Influence of the Enhanced Recovery After Surgery Protocol on Postoperative Inflammation and Short-term Postoperative Surgical Outcomes After Colorectal Cancer Surgery

Purpose

Many studies have shown that the enhanced recovery after surgery (ERAS) protocols improve postoperative surgical outcomes. The purpose of this study was to observe the effects on postoperative inflammatory markers and to explore the effects of a high degree of compliance and the use of epidural anesthesia on inflammation and surgical outcomes.

Methods

Four hundred patients underwent colorectal cancer surgery at 2 hospitals during 2 different periods, namely, from January 2006 to December 2009 and from January 2017 to July 2017. Data related to the patient’s clinicopathological features, inflammatory markers, percentage of compliance with elements of the ERAS protocol, and use of epidural anesthesia were collected from a prospectively maintained database.

Results

The complication rate and the length of hospital stay (LOS) were less in the ERAS group than in the conventional group (P = 0.005 and P ≤ 0.001, respectively). The postoperative white blood cell count and the duration required for leukocytes to normalize were reduced in patients following the ERAS protocol (P ≤ 0.001). Other inflammatory markers, such as lymphocyte count (P = 0.008), neutrophil/lymphocyte ratio (P = 0.032), and C-reactive protein level (P ≤ 0.001), were lower in the ERAS protocol group. High compliance ( ≥ 70%) was strongly associated with the complication rate and the LOS (P = 0.008 and P ≤ 0.001, respectively).

Conclusion

ERAS protocols decrease early postoperative inflammation and improves short-term postoperative recovery outcomes such as complication rate and the LOS. High compliance ( ≥ 70%) with the ERAS protocol elements accelerates the positive effects of ERAS on surgical outcomes; however, the effect on inflammation was very small.

Effects of PrObiotics on the Symptoms and Surgical ouTComes after Anterior REsection of Colon Cancer (POSTCARE): A Randomized, Double-Blind, Placebo-Controlled Trial

We investigated microbiota changes following surgical colon cancer resection and evaluate effects of probiotics on microbiota and surgical recovery. This randomized double-blind trial was performed at four medical centers in South Korea. Of 68 patients expected to undergo anterior sigmoid colon cancer resection, 60 were eligible, of whom 29 and 31 received probiotics and placebo, respectively, for four weeks, starting at one week preoperatively. Third- and/or fourth-week information on anterior resection syndrome (ARS), inflammatory markers, and quality of life was obtained. Stool sample analysis was conducted after randomization and bowel preparation and at three and four postoperative weeks. Bacteria were categorized into Set I (with probiotic effects) and II (colon cancer-associated). The probiotic group’s ARS score showed an improving trend (p = 0.063), particularly for flatus control (p = 0.030). Serum zonulin levels significantly decreased with probiotics. Probiotic ingestion resulted in compositional changes in gut microbiota; greater increases and decreases in Set I and II bacteria, respectively, occurred with probiotics. Compositional increase in Set I bacteria was associated with reduced white blood cells, neutrophils, neutrophil-lymphocyte ratio, and zonulin. Bifidobacterium composition was negatively correlated with zonulin levels in the probiotic group. Probiotics improved postoperative flatus control and modified postoperative changes in microbiota and inflammatory markers.

Evaluation of satisfaction with three different cervical cancer screening modalities: clinician-collected Pap test vs. HPV test by self-sampling vs. HPV test by urine sampling

OBJECTIVE

Human papillomavirus testing by self-sampling and urine sampling might be alternatives to Papanicolaou test (Pap test) for cervical cancer screening (CCS), and may increase compliance and adherence thereto. The present study aimed to explore satisfaction and preferences for cervical screening modalities among Korean women.

METHODS

In total, 732 women aged between 20 and 69 years responded to a questionnaire designed to survey the women's perceived satisfaction for the 3 CCS modalities: clinician-collected Pap test, self-collected vaginal sampling (self-sampling) and urine sampling.

RESULTS

Overall satisfaction was significantly higher with both the self-sampling and urine sampling than the clinician-collected Pap test (odds ratio [OR]=2.01; 95% confidence interval [CI]=1.48-3.00 and OR=2.47; 95% CI=1.75-3.48, respectively). Psychological distress, including embarrassment, pain, anxiety, discomfort, and stress, with self-sampling and urine sampling were significantly lower than that with the Pap test. 52% of participants reported preferences for self-sampling in the next screening round.

CONCLUSIONS

Korean women were more likely to report satisfaction with alternative modalities (self-sampling and urine sampling) for CCS in comparison to the Pap test. This suggests that self-collected modalities may help with improving CCS uptake rates by eliminating burden related with the Pap test. However, further studies for test accuracy and cost-effective analysis of the alternative modalities should be conducted in order to apply CCS.

Estimating age group-dependent sensitivity and mean sojourn time in colorectal cancer screening

OBJECTIVE

In evaluating the efficacy of cancer screening programmes, sojourn time (duration of the preclinical detectable phase) and sensitivity of the screening test are the two key parameters. Studies suggest that in breast cancer screening, both parameters may vary depending on age at the time of screening, but few studies have examined other cancers. We expanded an existing probability model for periodic screening by performing simultaneous estimation of age group-dependent and sensitivity at preclinical onset time, and tested the expanded model using data from the Korean National Colorectal Cancer Screening Programme.

METHODS

Simulation studies were conducted to assess the performance of the proposed probability model. The method was then applied to the analysis of 376,542 participants aged 50 or over who underwent fecal occult blood testing (FOBT) as part of the National Colorectal Cancer Screening Programme between 2004 and 2007. Age group-dependent mean sojourn time and screening sensitivity of FOBT for colorectal cancer were derived using maximum likelihood estimation.

RESULTS

The method performed well in terms of bias, standard deviation, and coverage probability. National Colorectal Cancer Screening Programme data results indicated that the sensitivity of FOBT to detect colorectal cancer increases with age, while mean sojourn time decreases with age (approximately 4.3 years for participants aged 50-54, 3.9 years at age 55-59, 3.4 years at age 60-64, and 3.6 years at age 65-69, with corresponding sensitivity estimates around 41%, 47%, 45%, and 51%, respectively).

CONCLUSION

Simulation studies showed that the proposed stochastic model considering both mean sojourn time and sensitivity yields highly accurate results.

Budget Impact of the Accreditation Program for Clinical Laboratories on Colorectal Cancer Screening via Fecal Immunochemical Testing: Results from the National Cancer Screening Program in Korea

Background

False-positive fecal immunochemical test (FIT) results in the National Cancer Screening Program (NCSP) for colorectal cancer may lead to unnecessary procedures, such as colonoscopies, increasing the medical costs. We estimated reductions in the cost of National Health Insurance according to the accreditation status of screening facilities participating in the NCSP for colorectal cancer.

Methods

We used data collected between 2007 and 2010 from NCSP and the Korea Central Cancer Registry to identify patients with colorectal cancer. We also ascertained the history of the accreditation of each facility by the Korean Laboratory Accreditation Program (KLAP). Budget impact was defined as a reduction in medical costs achieved when the false-positive rate of the non-accredited facilities decreased relative to that of the accredited facilities.

Results

A total of 3,285 screening facilities participated in the NCSP. Of these, 196 were accredited by the KLAP. The false-positive rate of the accredited facilities was 2.47%, and that of the non-accredited facilities was 6.83%. Medical costs were estimated to be reduced by approximately 19 million US dollars (USD), and the cost of detecting one case of colorectal cancer was estimated to decrease from 9,212 USD to 7,332 USD if the false-positive rate of non-accredited facilities were decreased to that of the accredited facilities. Clinics were estimated to have the largest associated cost reduction.

Conclusions

Quality assurance in clinical laboratories could lower false-positive rates and prevent the use of unnecessary procedures, ensuring patient safety and increasing the cost-effectiveness of FIT screening in the NCSP for colorectal cancer.

Clinical implications of systemic inflammatory response markers as independent prognostic factors in colorectal cancer patients

Purpose

Cancer-related inflammation affects many aspects of malignancy. We confirm the effects of early postoperative systemic inflammation on cancer prognosis.

Materials and Methods

Six hundred consecutive patients underwent surgery for colorectal cancer from 2006 to 2009. Measurements of white blood cells, neutrophils, lymphocytes, monocytes, and platelet counts were performed preoperatively, daily until the fourth postoperative day, and subsequently every two days. Patients were divided into three groups based on the days spent on the leukocyte count to drop below 10,000/mm³ after surgery.

Results

Preoperative white blood cell (WBC) counts correlated with stage of disease. In univariate survival analyses, tumor, node, metastasis (TNM) stage, and monocyte count were associated with cancer-free survival. In addition, cancer-free survival outcomes were worse in patients who required more than four days for the normalization of WBC count. A TNM stage greater than II and the neutrophil lymphocyte ratio were associated with the duration of overall survival. In a multivariate analysis of these significant variables, TNM stage, an interval longer than four days for normalization of WBC counts and monocyte count independently associated with cancer-free survival.

Conclusion

Postoperative early inflammatory phase and preoperative monocyte count correlate with poor colon cancer prognosis. We can conclude that preoperative and postoperative inflammatory response and period unfavorably affect the metastatic microenvironment.

Can high serum anti-Müllerian hormone levels predict the phenotypes of polycystic ovary syndrome (PCOS) and metabolic disturbances in PCOS patients?

OBJECTIVE

To evaluate correlations between serum anti-Müllerian hormone (AMH) levels, phenotypes of polycystic ovary syndrome (PCOS), obesity, and metabolic parameters in patients with PCOS.

METHODS

A total of 175 patients with PCOS were diagnosed according to the Rotterdam Consensus were included. Exclusion criteria were age over 40, FSH>25 mIU/mL, and 17a-OHP>1.5 ng/mL. The Phenotypes of PCOS were divided into a severe form (oligo-anovulation, ANOV/hyperandrogenism/polycystic ovary morphology [PCOM]; n=59) and a mild form without HA (ANOV/PCOM, n=105). The serum AMH levels were classified into 3 groups (<5 vs. 5-10 vs. >10 ng/mL). Obesity was defined as body mass index (BMI) ≥25 kg/m(2) (n=34).

RESULTS

The mean age was 25.9±5.7 year and mean AMH level was 10.1±5.4 ng/mL. The BMI (kg/m(2)) was higher in group 1 (24.2±6.3) than in group 2 (21.9±4.3, p=0.046) or group 3 (21.6±3.3, p=0.019). There was no difference among the three groups in age, menstrual interval, antral follicle counts, androgens, or other metabolic parameters. The obesity group showed significantly lower AMH (7.7±3.9 ng/mL vs. 10.7±5.6 ng/mL), p=0.004) and low-density lipoprotein levels (93.1±21.2 mg/dL vs. 107.5±39.3 mg/dL, p=0.031), and showed higher total T (0.74±0.59 ng/mL vs. 0.47±0.36 ng/mL, p=0.001), free T (2.01±1.9 vs. 1.04±0.8 pg/mL, p=0.0001), and free androgen index (6.2±7.9 vs. 3.5±3.0, p=0.003). After controlling for age factors and BMI, the serum AMH levles did not show any significant correlations with other hormonal or metabolic parmeters.

CONCLUSION

For PCOS patients under the age 40, serum AMH is not negatively correlated with age. High serum AMH levels can not predict the phenotype of PCOS and metabolic disturbances in PCOS patients in the non-obese group. Further study might be needed to define the relation more clearly.

The epidemiology of psychiatric disorders among women with breast cancer in South Korea: analysis of national registry data

OBJECTIVE

Population-based data on the epidemiology of psychiatric disorders in patients with breast cancer are lacking. Because the National Health Insurance (NHI) Program in South Korea is a compulsory social insurance system covering the entire Korean population, the NHI is a good source of information for epidemiological studies. In the present study, we examined the incidence of psychiatric disorders among Korean women newly diagnosed with breast cancer using the NHI Corporation (NHIC) database.

METHODS

Data were collected for adult women newly diagnosed with breast cancer using the claim database and cancer registration files of the NHIC from 2005 to 2008. We analysed data for women diagnosed with psychiatric disorders over a 5-year period, from 2004 (at least 1 year before the cancer registration date) to 2009 (at least 1 year after the cancer registration date).

RESULTS

We identified 6536 patients with psychiatric disorders among 42 190 women with breast cancer. The most prevalent psychiatric disorder was anxiety disorder (N = 2518). The incidence rates of anxiety disorders, depressive disorders, sleep disorders and adjustment disorders were 27.08, 22.41, 10.57 and 4.35 cases per 1000 person-year, respectively.

CONCLUSION

The incidence rates of psychiatric disorders in Korean women with breast cancer from the nationwide database were much lower than found by previous reports using screening tools. The finding implicates that psychiatric disorders among breast cancer patients tend to be underdiagnosed and undertreated in actual clinical practice. Our epidemiological findings provide important information for establishing a national strategy of cancer care to detect and manage psychiatric problems.

The expression of multiple proteins as prognostic factors in colorectal cancer: cathepsin D, p53, COX-2, epidermal growth factor receptor, C-erbB-2, and Ki-67

BACKGROUND/AIMS

A single gene mutation alone cannot explain the poor prognosis of colorectal cancer. This study aimed to establish a correlation between the expression of six proteins and the prognosis of colorectal cancer patients.

METHODS

Tissue samples were collected from 266 patients who underwent surgery for colorectal cancer at our institution from January 2006 to December 2007. The expression of six proteins were determined using immunohistochemical staining of specimens.

RESULTS

Cathepsin D, p53, COX-2, epidermal growth factor receptor, c-erbB-2, and Ki-67 expression were detected in 38.7%, 60.9%, 37.6%, 35.7%, 30.1%, and 74.4% of the samples, respectively. The expression of cathepsin D was significantly correlated with reduced cancer-free survival (p=0.036) and colorectal cancer-specific survival (p=0.003), but the other expression levels were not. In a multivariate analysis, cathepsin D expression was found to be an independent prognostic factor for poorer colorectal cancer-specific survival (hazard ratio, 8.55; 95% confidence interval, 1.07 to 68.49). Furthermore, patients with tumors expressing four or more of the proteins had a significantly decreased cancer-free survival rate (p=0.006) and colorectal cancer-specific survival rate (p=0.002).

CONCLUSIONS

Patients with cathepsin D positivity had a poorer outcome than patients who were cathepsin D-negative. Thus, cathepsin D may provide an indicator for appropriate intensive follow-up and adjuvant chemotherapy.

Factors associated with gout in South Koreans: analysis using the National Health Insurance Corporation and the National Health Screening Exam databases

The aim of this study was to identify the factors associated with gout among South Koreans. A case control study of gout patients newly diagnosed between January 1, 2007, and December 31, 2008, and matching controls was conducted using the nationwide database (National Health Insurance Corporation and National Health Screening Exam (NHSE) database), which included the health-care records of 48.1 million individuals. Of 495,998 newly diagnosed patients, we included 18,123 who were ≥40 years old and had an NHSE before diagnosis of gout. To elucidate the factors associated with gout, multivariate conditional logistic analyses were performed. Gout was associated with drinking ≥1/week (p < 0.001), drinking ≥1 bottle of soju/session (p < 0.001), high body mass index (BMI) (p < 0.001), high blood pressure (p < 0.001), high total cholesterol (p < 0.001), proteinuria (multivariate odds ratio (OR) = 1.75; 95 % confidence interval (CI) = 1.53-2.00), and an elevated uric acid (multivariate OR = 1.54; 95 % CI = 1.22-1.94). Exercise frequency was not significantly associated with gout. Prediabetic blood sugar level (100-125 mg/dL) was associated with gout in the univariate analysis, but not in the multivariate analysis. Diabetic blood sugar level (≥126 mg/dL) was associated with a decreased odds of gout (multivariate OR = 0.79; 95 % CI = 0.73-0.86). Our nationwide South Korean study showed that frequent and excessive alcohol consumption, high BMI, high blood pressure, high total cholesterol, proteinuria, and high uric acid are associated with gout.

The effect of a radiographic solid fusion on clinical outcomes after minimally invasive transforaminal lumbar interbody fusion

BACKGROUND CONTEXT

The correlation between radiographic solid fusion and favorable clinical outcome has not been fully established. Many surgeons believe that patients who achieve a radiographic solid fusion will exhibit a more positive clinical outcome than those getting an unsuccessful fusion. To our knowledge, there is no study that has evaluated whether a solid fusion influences clinical outcome after minimally invasive lumbar fusion.

PURPOSE

This study was designed to evaluate the effect of radiographic solid fusion on clinical outcome after minimally invasive transforaminal lumbar interbody fusion (TLIF).

STUDY DESIGN

We conducted a retrospective study by comparing the prospectively collecting data.

PATIENT SAMPLE

The sample comprises 66 patients who had achieved a solid fusion or nonunion at least 2 years after minimally invasive TLIF for the treatment of low-grade spondylolisthesis or degenerative segmental instability.

OUTCOME MEASURES

The outcome measures were visual analog scale (VAS) for back pain and radiating leg pain, Oswestry Disability Index (ODI), functional scale (defined as a modified method of Whitecloud et al.), and radiographic fusion status.

METHODS

Two independent spine surgeons reviewed the completed medical records and radiographic data of 66 patients who had undergone minimally invasive TLIF by one surgeon at an institution. Clinical outcome was evaluated using VAS, ODI, and functional scale. The radiographic fusion status was assessed using flexion-extension lateral radiographs and computed tomography scans. Comparison and correlation analyses were performed to examine the relationship between fusion status and clinical outcome.

RESULTS

There were 51 (77%) patients in the solid fusion (control) group and 15 patients in the nonunion group. The improvement from baseline with regard to VAS scores for back and leg pain as well as ODI scores was significant in both groups (all, p<.0001), with patients in the control group reporting significantly better improvement of back pain scores than those in nonunion group (p=.04). Conversely, the improvement of VAS scores for leg pain and ODI scores was comparable between two groups. Forty-one patients (80%) in the control group and 13 (87%) in the nonunion group demonstrated an excellent or good result in the final functional scale as well. The presence of radiographic solid fusion positively, but not strongly, correlated with the improvement of VAS scores for back pain (r=0.255, p=.039).

CONCLUSIONS

At least 2 years after minimally invasive TLIF, better reduction of back pain was noted in patients who achieved a radiographic solid fusion as opposed to those with nonunion. However, there was no clear evidence that radiographic solid fusion was associated with better clinical outcome scores or improvement in leg pain than nonunion.

Prognostic value of CEA and CA 19-9 tumor markers combined with cytology from peritoneal fluid in colorectal cancer

BACKGROUND

Early diagnosis and management of peritoneal metastases from colorectal cancer patients are difficult clinical challenges. The aims of this study were to evaluate the clinical significance of tumor markers and cytology in peritoneal effusions (PE) and peritoneal irrigation fluid (PI) and to determine their value as prognostic indicators in this disease.

METHODS

Two hundred thirty-four consecutive patients who underwent abdominal surgery for colorectal cancer from January 2006 to December 2007 were included, and tumor markers and cytology in PE and PI were analyzed prospectively.

RESULTS

The incidence of free cancer cells retrieved from peritoneal samples was 7.9%. Cytology was positive in 40.0% by Papanicolaou and Giemsa staining, 73.3% by hematoxylin and eosin staining of cell blocks, and 66.7% by carcinoembryonic antigen (CEA) and calretinin immunohistochemistry. Multivariate analysis revealed that peritoneal CEA and cancer antigen (CA) 19-9 in PI were correlated with peritoneal metastasis and cytology. Level of peritoneal fluid CEA was statistically significantly correlated with recurrence and peritoneal metastatic recurrence in patients with negative peritoneal cytology. Cytology, peritoneal CEA, and peritoneal CA 19-9 showed correlations with cancer-free survival and overall survival.

CONCLUSIONS

These correlations demonstrate the importance of continuous follow-up of peritoneal metastasis if there is positive cytology or an increase in CEA and CA 19-9 in peritoneal fluid.

Smoking, alcohol and gastric cancer risk in Korean men: the National Health Insurance Corporation Study

We investigated the risk of gastric cancer by subsite in relation to cigarette smoking and alcohol in a large population-based cohort of 669 570 Korean men in an insurance plan followed for an average 6.5 years, yielding 3452 new cases of gastric cancer, of which 127 were cardia and upper-third gastric cancer, 2409 were distal gastric cancer and 1007 were unclassified. A moderate association was found between smoking, cardia and upper-third (adjusted relative risk (aRR) 2.2; 95% confidence interval (CI) 1.4-3.5) and distal cancers (aRR=1.4; 95% CI=1.3-1.6). We also found a positive association between alcohol consumption and distal (aRR=1.3; 95% CI=1.2-1.5) and total (aRR=1.2; 95% CI=1.1-1.4) gastric cancer. Combined exposure to high levels of tobacco and alcohol increased the risk estimates further; cardia and upper-third gastric cancers were more strongly related to smoking status than distal gastric cancer.British Journal of Cancer (2007) 97, 700-704. doi:10.1038/sj.bjc.6603893 www.bjcancer.com Published online 17 July 2007.

The survival rate and prognostic factors in 26 perforated colorectal cancer patients

PURPOSE

The treatment for perforated colorectal cancer is not easy and the prognosis for this disease is not so predictable. There are some controversies about performing radical operations because colorectal cancer perforation was considered as an advanced stage disease due to the possibility of tumor cell dissemination through the perforation site.

METHODS

We selected and enrolled 26 patients with perforated colorectal cancers among the 1,227 patients who underwent operation for colorectal cancer. These cases were retrospectively analyzed by using their medical records and clinicopathological data.

RESULTS

Twenty-eight cases (2.3%) with perforated colorectal cancers were studied and the overall operative mortality rate was 11%. The overall 5-year survival rate was 57.8% when excluding the operative mortality. The overall 5-year cancer-free survival rate was 52.8%. There were significant differences in the survival rate and the cancer-free survival rate between the stages (p=0.008 and p<0.001, respectively). A univariate analysis of the prognostic factors revealed that the number of the metastatic lymph nodes (p=0.018) and the perforation proximal to the cancer (p=0.005) were significantly correlated to worse survival, and the higher number of the metastatic lymph nodes was correlated to a poorer cancer-free survival rate (p<0.001).

CONCLUSION

For the perforated colorectal cancers, the stage, the perforation proximal to the cancer, and the number of the metastatic lymph nodes were correlated, with the survival and the cancer-free survival as factors of a poor prognosis. The surgical approach selected for perforated colorectal cancer should be in line with the principles of an appropriate cancer operation because the clinical pathway of perforated colorectal cancer is similar to that of uncomplicated colorectal cancer.