Quality of life after laparoscopic vs open sphincter-preserving resection for rectal cancer

AIM: To compare quality of life (QoL) outcomes in Chinese patients after curative laparoscopic vs open surgery for rectal cancer. METHODS: Eligible Chinese patients with rectal cancer undergoing curative laparoscopic or open sphincterpreserving resection between July 2006 and July 2008 were enrolled in this prospective study. The QoL outcomes were assessed longitudinally using the validated Chinese versions of the European Organization for Research and Treatment of Cancer QLQ-C30 and QLQCR38 questionnaires before surgery and at 4, 8, and 12 mo after surgery. The QoL scores at the different time points were compared between the laparoscopic and open groups. A higher score on a functional scale indicated better functioning, whereas a higher score on a symptom scale indicated a higher degree of symptoms.RESULTS: Seventy-four patients (49 laparoscopic and 25 open) were enrolled. The two groups of patients were comparable in terms of sociodemographic data, types of surgery, tumor staging, and baseline mean QoL scores. There was no significant decrease from baseline in global QoL for the laparoscopic group at different time points, whereas the global QoL was worse compared to baseline beginning at 4 mo but returned to baseline by 12 mo for the open group (P = 0.019, Friedman test). Compared to the open group, the laparoscopic group had significantly better physical (89.9±1.4 vs 79.2±3.7, P = 0.016), role (85.0±3.4 vs 63.3±6.9, P = 0.005), and cognitive (73.5±3.4 vs 50.7±6.2, P = 0.002) functioning at 8 mo, fewer micturition problems at 4-8 mo (4 mo: 32.3±4.7 vs 54.7±7.1, P = 0.011; 8 mo: 22.8±4.0 vs 40.7±6.9, P = 0.020), and fewer male sexual problems from 8 mo onward (20.0±8.5 vs 76.7±14.5, P = 0.013). At 12 mo after surgery, no significant differences were observed in any functional or symptom scale between the two groups, with the exception of male sexual problems, which remained worse in the open group (29.2±11.3 vs 80.0±9.7, P = 0.026). CONCLUSION: Laparoscopic sphincter-preserving resection for rec     

Effects of hexahydrocurcumin in combination with 5-fluorouracil on dimethylhydrazine-induced colon cancer in rats

AIM: To investigate the effects of hexahydrocurcumin (HHC), and its combination with 5-fluorouracil (5-FU) on dimethylhydrazine (DMH)-induced colon cancer in rats.METHODS: Male Wistar rats weighing 100-120 g were used as subject models. Aberrant crypt foci (ACF), early preneoplastic lesions of colon cancer, were induced by subcutaneous injection of DHM (40 mg/kg) twice a week for two weeks. After the first DMH injection, rats were treated daily with vehicle (n = 12), curcumin (CUR) (50 mg/kg) (n = 12), HHC (50 mg/kg) orally (n = 12), and treated weekly with an intraperitoneal injection of 5-FU (50 mg/kg) (n = 12), or a combination of 5-FU plus CUR (n = 12) and HHC (n = 12) at the same dosage(s) for 16 wk. The total number of ACF and large ACF were assessed. Cyclooxygenase (COX)-1 and COX-2 expression were detected by immunohistochemistry in colon tissues. The quantitative data of both COX-1 and COX-2 expression were presented as the percentage of number of positive-stained cells to the total number of cells counted. Apoptotic cells in colon tissues were also visualized using the dUTP-biotin nick end labeling method. Apoptotic index (AI) was determined as the percentage of labeled nuclei with respect to the total number of nuclei counted.RESULTS: The total number of ACF was highest in the DMH-vehicle group (1558.20 ± 17.37), however, the number of ACF was significantly reduced by all treatments, 5-FU (1231.20 ± 25.62 vs 1558.20 ± 17.37, P < 0.001), CUR (1284.20 ± 25.47 vs 1558.20 ± 17.37, P < 0.001), HHC (1086.80 ± 53.47 vs 1558.20 ± 17.37, P < 0.001), DMH-5-FU + CUR (880.20 ± 13.67 vs 1558.20 ± 17.37, P < 0.001) and DMH-5-FU + HHC (665.80 ± 16.64 vs 1558.20 ± 17.37, P < 0.001). Interestingly, the total number of ACF in the combined treatment groups, the DMH-5-FU + CUR group (880.20 ± 13.67 vs 1231.20 ± 25.62, P < 0.001; 880.20 ± 13.67 vs 1284.20 ± 25.47, P < 0.001) and the DMH-5-FU + HHC group (665.80 ± 16.64 vs 1231.20 ± 25.62, P < 0.001; 665.80 ± 16.64 vs 1086.80 ± 53.47, P < 0.001) were significantly reduced as compared to 5-FU or each treatment alone. Large ACF were also significantly reduced in all treatment groups, 5-FU (111.00 ± 7.88 vs 262.20 ± 10.18, P < 0.001), CUR (178.00 ± 7.33 vs 262.20 ± 10.18, P < 0.001), HHC (186.60 ± 21.51 vs 262.20 ± 10.18, P < 0.001), DMH-5-FU + CUR (122.00 ± 5.94 vs 262.20 ± 10.18, P < 0.001) and DMH-5-FU + HHC (119.00 ± 17.92 vs 262.20 ± 10.18, P < 0.001) when compared to the vehicle group. Furthermore, in the DMH-5-FU + CUR and DMH-5-FU + HHC groups the formation of large ACF was significantly reduced when compared to CUR (122.00 ± 5.94 vs 178.00 ± 7.33, P < 0.005) or HHC treatment alone (119.00 ± 17.92 vs 186.60 ± 21.51, P < 0.001), however, this reduction was not statistically different to 5-FU monotherapy (122.00 ± 5.94 vs 111.00 ± 7.88, P = 0.217; 119.00 ± 17.92 vs 111.00 ± 7.88, P = 0.619, respectively). The levels of COX-1 protein after all treatments were not different from normal rats. A marked increase in the expression of COX-2 protein was observed in the DMH-vehicle group. Over-expression of COX-2 was not significantly decreased by 5-FU treatment alone (95.79 ± 1.60 vs 100 ± 0.00, P = 0.198). However, over-expression of COX-2 was significantly suppressed by CUR (77.52 ± 1.68 vs 100 ± 0.00, P < 0.001), HHC (71.33 ± 3.01 vs 100 ± 0.00, P < 0.001), 5-FU + CUR (76.25 ± 3.32 vs 100 ± 0.00, P < 0.001) and 5-FU + HHC (68.48 ± 2.24 vs 100 ± 0.00, P < 0.001) in the treated groups compared to the vehicle group. Moreover, CUR (77.52 ± 1.68 vs 95.79 ± 1.60, P < 0.001), HHC (71.33 ± 3.01 vs 95.79 ± 1.60, P < 0.001), 5-FU + CUR treatments (76.25 ± 3.32 vs 95.79 ± 1.60, P < 0.001) and 5-FU + HHC (68.48 ± 2.24 vs 95.79 ± 1.60, P < 0.001) markedly decreased COX-2 protein expression more than 5-FU alone. Furthermore, the AI in all treated groups, 5-FU (38.86 ± 4.73 vs 23.56 ± 2.12, P = 0.038), CUR (41.78 ± 6.92 vs 23.56 ± 2.12, P < 0.001), HHC (41.06 ± 4.81 vs 23.56 ± 2.12, P < 0.001), 5-FU + CUR (49.05 ± 6.75 vs 23.56 ± 2.12, P < 0.001) and 5-FU + HHC (53.69 ± 8.59 vs 23.56 ± 2.12, P < 0.001) significantly increased when compared to the DMH-vehicle group. However, the AI in the combination treatments, 5-FU + CUR (49.05 ± 6.75 vs 41.78 ± 6.92, P = 0.192; 49.05 ± 6.75 vs 38.86 ± 4.73, P = 0.771) and 5-FU + HHC (53.69 ± 8.59 vs 41.06 ± 4.81, P = 0.379; 53.69 ± 8.59 vs 38.86 ± 4.73, P = 0.245) did not reach significant levels as compared with each treatment alone and 5-FU monotherapy, respectively.CONCLUSION: The combined effects of HHC with 5-FU exhibit a synergistic inhibition by decreasing ACF formation mediated by down-regulation of COX-2 expression.     

Protective effects of D-002 on experimentally induced gastroesophageal reflux in rats

AIM:To investigate the effects of beeswax alcohols(D-002)on the esophageal damage induced by gastroesophageal reflux(GER)in rats.METHODS:Sixty male rats were randomized into six groups(10 rats/group):a negative control and five groups with experimentally induced GER:a positive vehicle control,three treated with D-002(25,100 and 200mg/kg,respectively),and one with omeprazole 10 mg/kg.All treatments were given by gastric gavage.One hour after dosing,GER was produced by simultaneous ligation of the pyloric end and the forestomach.Esophageal lesions index(ELI),gastric secretion volume and acidity,and esophageal malondialdehyde(MDA)and sulfhydryl(SH)group concentrations were measured.Statistical significance was considered at P<0.05.RESULTS:As compared to the negative control,the positive control group exhibited increased ELI(5.2±0.33 vs 0±0,P=0.0003),gastric secretion volume(2.69±0.09 vs 0.1±0.0,P=0.0003)and acidity(238±19.37 vs 120.0±5.77,P=0.001),and esophageal concentrations of MDA(2.56±0.1 vs 1.76±0.28,P=0.001)and SH groups(1.02±0.05 vs 0.56±0.08,P=0.0003).D-002(25,100 and 200 mg/kg)reduced ELI(3.36±0.31,2.90±0.46 and 2.8±0.23,respectively)vs the positive control(5.2±0.33)(P=0.004;P=0.002;P=0.001,respectively).There were no significant changes in acidity with D-002 treatment,and only the highest dose reduced the volume of the gastric secretion(1.92±0.25)vs the positive control(2.69±0.09,P=0.013).D-002(25,100 and 200 mg/kg)lowered the esophageal MDA(2.05±0.16,1.98±0.22and 1.93±0.22,respectively)(P=0.01;P=0.03;P=0.03,respectively)and SH group concentration(0.87±0.06,0.79±0.08 and 0.77±0.06,respectively)(P=0.04;P=0.04;P=0.02)vs the positive control(2.56±0.10 and 1.02±0.05,respectively).Omeprazole decreased ELI(2.54±0.47),gastric secretion volume(1.97±0.14)and acidity(158.5±22.79),esophageal MDA(1.87±0.13)and SH group(0.72±0.05)concentrations vs the positive control(P=0.002;P=0.001;P=0.02;P=0.003;P=0.002,respectively).CONCLUSION:Acute oral administration of D-002 decreased macroscopic esophageal lesions and oxidative stress in rats with experimentally induced GER,without modifying gastric secretion acidity.     

Eradication rate and histological changes after Helicobacter pylori eradication treatment in gastric cancer patients following subtotal gastrectomy

AIM: To investigate the eradication rate and histological changes after Helicobacter pylori(H. pylori) eradication treatment following subtotal gastrectomy for gastric cancer.METHODS: A total of 610 patients with H. pylori infection who had undergone surgery for either early or advanced gastric adenocarcinoma between May 2004 and December 2010 were retrospectively studied. A total of 584 patients with proven H. pylori infection after surgery for gastric cancer were enrolled in this study. Patients received a seven day standard triple regimen as first-line therapy and a 10 d bismuthcontaining quadruple regimen as second-line therapy in cases of eradication failure. The patients underwent an esophagogastroduodenoscopy(EGD) between six and 12 mo after surgery, followed by annual EGDs. A further EGD was conducted 12 mo after confirming the result of the eradication and the histological changes. A gastric biopsy specimen for histological examination and Campylobacter-like organism testing was obtained from the lesser and greater curvature of the corpus of the remnant stomach. Histological changes in the gastric mucosa were assessed using the updated Sydney system before eradication therapy and at follow-up after 12 mo.RESULTS: Eradication rates with the first-line and second-line therapies were 78.4%(458/584) and 90%(36/40), respectively, by intention-to-treat analysis and 85.3%(458/530) and 92.3%(36/39), respectively, by per-protocol analysis. The univariate and multivariate analyses revealed that Billroth Ⅱ surgery was an independent factor predictive of eradication success in the eradication success group(OR = 1.53, 95%CI: 1.41-1.65, P = 0.021). The atrophy and intestinal metaplasia(IM) scores 12 mo after eradication were significantly lower in the eradication success group than in the eradication failure group(0.25 ± 0.04 vs 0.47 ± 0.12, P = 0.023; 0.27 ± 0.04 vs 0.51 ± 0.12, P = 0.015, respectively). The atrophy and IM scores 12 mo after successful eradication were significantly lower in the Billroth Ⅱ group than in the Billroth I group(0.13 ± 0.09 vs 0.31 ± 0.12, P = 0.029; 0.32 ± 0.24 vs 0.37 ± 0.13, P = 0.034, respectively).CONCLUSION: Patients with H. pylori following subtotal gastrectomy had a similar eradication rate to patients with an intact stomach. H. pylori eradication is recommended after subtotal gastrectomy.     

Expression profile of polyunsaturated fatty acids in colorectal cancer

AIM:To investigate the relationship between the metabolism of polyunsaturated fatty acids(PUFAs)andtumor-associated factors for predicting the outcome of colorectal carcinoma(CRC)in Chinese patients.METHODS:Fresh-frozen malignant and normal tissues from 82 Chinese patients with CRC were analyzed for PUFA composition using gas-liquid chromatography.The levels of vascular endothelial growth factor(VEGF),cyclooxygenase-2(COX-2),prostaglandin E2 and platelet-derived growth factor(PDGF)were measured by enzyme-linked immunosorbent assay,and the levels of VEGF,p53 and Ki-67 were measured by immunohistochemistry.RESULTS:In malignant tissue,compared with normal tissue,the levels of totalω-6 PUFAs(24.64%±3.41%vs 26.77%±3.37%,P=0.00)and linoleic acid(LA)(15.46%±3.51%vs 18.30%±2.83%,P0.01)were lower,whereas the levels of totalω-3 PUFAs(1.58%±0.74%vs 1.35%±0.60%,P0.01)and dihomo-gamma-linolenic acid(DGLA)(1.32%±0.69%vs 0.85%±0.29%,P0.01)were significantly higher.The ratios of arachidonic acid(AA)/LA(0.53±0.22 vs0.42±0.19,P0.01)and AA/totalω-6 PUFAs(0.31±0.09 vs 0.27±0.10,P0.01)were also significantly higher in malignant tissue.The levels of PDGF(353.10±148.85 pg/m L vs 286.09±104.91 pg/m L,P0.01),COX-2(125.21±70.29 ng/m L vs 67.06±42.22 ng/m L,P0.01)and VEGF(357.11±128.76 pg/m L vs211.38±99.47 pg/m L,P0.01)were also higher in malignant tissue compared to normal tissue.COX-2was inversely correlated with LA(R=-0.3244,P0.05)and positively correlated with AA/totalω-6 PUFAs(R=0.3083,P0.05)and AA/LA(R=0.3001,P0.05).The tissue level of LA was highest in poorly differentiated tumors(19.9%±6.3%,P0.05),while the ratio of AA/ω-3 PUFAs was lowest in these tumors(10.8±2.6,P0.05).In VEGF-positive tumors,the level of LA was higher(16.2%±3.7%vs 13.9%±2.7%,P0.01),while the AA/ω-3PUFA,AA/ω-6 PUFA,and AA/LA ratios were lower than in VEGF-negativetumors(5.0±1.8 vs 6.7±3.3,0.30±0.09 vs 0.34±0.09,0.50±0.21 vs 0.61±0.21,P0.01).CONCLUSION:The metabolism of PUFAs may playan important role in the evolution of inflammationdriven tumorigenesis in CRC and may be considered apotential marker for prognosis.     

Poor prognosis for hepatocellular carcinoma with transarterial chemoembolization pre-transplantation:Retrospective analysis

AIM: To investigate whether transarterial chemoembolization(TACE) before liver transplantation(LT) improves long-term survival in hepatocellular carcinoma(HCC) patients.METHODS: A retrospective study was conducted among 204 patients with HCC who received LT from January 2002 to December 2010 in PLA General Hospital. Among them, 88 patients received TACE before LT. Prognostic factors of serum α-fetoprotein(AFP), intraoperative blood loss, intraoperative blood transfusion, disease-free survival time, survival time with tumor, number of tumor nodules, tumor size, tumor number, presence of blood vessels and bile duct invasion, lymph node metastasis, degree of tumor differentiation, and preoperative liver function were determined in accordance with the Child-TurcottePugh(Child) classification and model for end-stage liver disease. We also determined time of TACE before transplant surgery and tumor recurrence and metastasis according to different organs. Cumulative survival rate and disease-free survival rate curves were prepared using the Kaplan-Meier method, and the logrank and χ2 tests were used for comparisons.RESULTS: In patients with and without TACE before LT, the 1, 3 and 5-year cumulative survival rate was 70.5% ± 4.9% vs 91.4% ± 2.6%, 53.3% ± 6.0% vs 83.1% ± 3.9%, and 46.2% ± 7.0% vs 80.8% ± 4.5%, respectively. The median survival time of patients with and without TACE was 51.857 ± 5.042 mo vs 80.930 ± 3.308 mo(χ2 = 22.547, P < 0.001, P < 0.05). The 1, 3 and 5-year disease-free survival rates for patients with and without TACE before LT were 62.3% ± 5.2% vs98.9% ± 3.0%, 48.7% ± 6.7% vs 82.1% ± 4.1%, and 48.7% ± 6.7% vs 82.1% ± 4.1%, respectively. The median survival time of patients with and without TACE before LT was 50.386 ± 4.901 mo vs 80.281 ± 3.216 mo(χ2 = 22.063, P < 0.001, P < 0.05). TACE before LT can easily lead to pulmonary or distant metastasis of the primary tumor. Although there was no significant difference between the two groups, the chance of metastasis of the primary tumor in the group with TACE was significantly higher than that of the group without TACE.CONCLUSION: TACE pre-LT for HCC patients increased the chances of pulmonary or distant metastasis of the primary tumor, thus reducing the long-term survival rate.     

Esophagogastroduodenoscopy with conscious sedation does not interfere with catheter-based 24-h pH monitoring

AIM:To investigate the impact of esophagogastroduodenoscopy with conscious sedation on the subsequent 24-h catheter-based pH monitoring.METHODS:Fifty patients with extra-esophageal symptoms of gastroesophageal reflux disease undergoing ambulatory dual-probe 24-h pH monitoring were enrolled from March 2010 to August 2011.All of the data were collected prospectively and analyzed retrospectively.Thirty-six patients(72%,group A) underwent pH monitoring shortly after esophagogastroduodenoscopy(EGD) with conscious sedation,and 14 patients(28%,group B) underwent pH monitoring without conscious sedation.The 24-h pH data from two time periods were analyzed:the first 4 h(Period Ⅰ) and the remaining time of the study(Period Ⅱ).RESULTS:The mean age of the patients was 49.6 ± 12.5 years;20 patients(40%) were men.The baseline data,including age,sex,body mass index,reflux esophagitis,the Reflux Symptom Index,and the Reflux Findings Score,were comparable between the two groups.The percentage of total time with a pH < 4 and the frequency of acid reflux during Period Ⅰ were not significantly different between the two groups,as measured using both pharyngeal(0.03% ± 0.10% vs 0.07% ± 0.16%,P = 0.32;and 0.07 ± 0.23 episodes/h vs 0.18 ± 0.47 episodes/h,P = 0.33,respectively) and esophageal probes(0.96% ± 1.89% vs 0.42% ± 0.81%,P = 0.59;and 0.74 ± 1.51 episodes/h vs 0.63 ± 0.97 episodes/h,P = 0.49,respectively).The percentage of total time with a pH < 4 and the frequency of acid reflux were also not significantly different between Periods I and Ⅱ in group A patients,as measured using both pharyngeal(0.03% ± 0.10% vs 0.23% ± 0.85%,P = 0.21;and 0.07 ± 0.23 episodes/h vs 0.29 ± 0.98 episodes/h,P = 0.22,respectively) and esophageal probes(0.96% ± 1.89% vs 1.11% ± 2.57%,P = 0.55;and 0.74 ± 1.51 episodes/h vs 0.81 ± 1.76 episodes/h,P = 0.55,respectively).CONCLUSION:EGD with conscious sedation does not interfere with the results of subsequent 24-h pH monitoring in patients with extra-esophageal symptoms of gast     

Protective role of hydrogen-rich water on aspirin-induced gastric mucosal damage in rats

AIM: To investigate the role of the hydrogen-rich water(HRW) in the prevention of aspirin-induced gastric mucosal injury in rats. METHODS: Forty male rats were allocated into four groups: normal control group, HRW group, aspirin group, and HRW plus aspirin group. The protective efficacy was tested by determining the gastric mucosal damage score. Malondialdehyde(MDA), superoxide dismutase(SOD), myeloperoxidase(MPO), interleukin(IL)-06 and tumor necrosis factor(TNF)-α in gastric tissues were evaluated. The serum levels of IL-1β and TNF-α were also detected. Histopathology of gastric tissues and localization of Cyclooxygenase 2(COX-2) were detected using hematoxylin and eosin staining and immunohistochemistry, respectively. RESULTS: Pretreatment with HRW obviously reduced aspirin-induced gastric damage scores(4.04 ± 0.492 vs 2.10 ± 0.437, P < 0.05). The oxidative stress levels of MDA and MPO in the gastric tissues increased significantly in the aspirin-treated group compared with the HRW group(2.43 ± 0.145 vs 1.79 ± 0.116 nmol/mg prot, P < 0.05 and 2.53 ± 0.238 vs 1.40 ± 0.208 U/g tissue, P < 0.05, respectively). HRW could obviously elevated the SOD levels in the gastric tissues(37.94 ± 8.44 vs 59.55 ± 9.02 nmol/mg prot, P < 0.05). Pretreatment with HRW significantly reduced IL-06 and TNF-α in the gastric tissues(46.65 ± 5.50 vs 32.15 ± 4.83 pg/mg, P < 0.05 and 1305.08 ± 101.23 vs 855.96 ± 93.22 pg/mg, P < 0.05), and IL-1β and TNF-α in the serum(505.38 ± 32.97 vs 343.37 ± 25.09 pg/mL, P < 0.05 and 264.53 ± 28.63 vs 114.96 ± 21.79 pg/mL, P < 0.05) compared to treatment with aspirin alone. HRW could significantly decrease the COX-2 expression in the gastric tissues(staining score: 8.4 ± 2.1 vs 2.9 ± 1.5, P < 0.05). CONCLUSION: HRW pretreatment alleviated the aspirin-induced gastric lesions by inhibiting the oxidative stress, inflammatory reaction and reducing the COX-2 in the gastric tissues.     

High-fibre diet and Lactobacillus paracasei B21060 in symptomatic uncomplicated diverticular disease

AIM:To investigate in symptomatic uncomplicated diverticular disease the efficacy of symbiotics associated with a high-fibre diet on abdominal symptoms.METHODS:This study was a multicentre,6-mo randomized,controlled,parallel-group intervention with a preceding 4-wk washout period.Consecutive outpatients with symptomatic uncomplicated diverticular disease,aged 40-80 years,evaluated in 4 Gastroenter-ology Units,were enrolled.Symptomatic uncomplicated diverticular disease patients were randomized to two treatment arms A or B.Treatment A(n = 24 patients) received 1 symbiotic sachet Flortec(Lactobacillus paracasei B21060) once daily plus high-fibre diet for 6 mo.Treatment B(n = 21 patients) received high-fibre diet alone for 6 mo.The primary endpoint was regression of abdominal symptoms and change of symptom severity after 3 and 6 mo of treatment.RESULTS:In group A,the proportion of patients with abdominal pain 24 h decreased from 100% at baseline to 35% and 25% after 3 and 6 mo,respectively(P 0.001).In group B the proportion of patients with this symptom decreased from 90.5% at baseline to 61.9% and 38.1% after 3 and 6 mo,respectively(P = 0.001).Symptom improvement became statistically significant at 3 and 6 mo in group A and B,respectively.The proportion of patients with abdominal pain 24 h decreased from 60% to 20% then 5% after 3 and 6 mo,respectively in group A(P 0.001) and from 33.3% to 9.5% at both 3 and 6 mo in group B(P = 0.03).In group A the proportion of patients with abdominal bloating significantly decreased from 95% to 60% after 3 mo,and remained stable(65%) at 6-mo follow-up(P = 0.005) while in group B,no significant changes in abdominal bloating was observed(P = 0.11).After 6 mo of treatment,the mean visual analogic scale(VAS) values of both short-lasting abdominal pain(VAS,mean ± SD,group A:4.6 ± 2.1 vs 2.2 ± 0.8,P = 0.02;group B:4.6 ± 2.9 vs 2.0 ± 1.9,P = 0.03) and abdominal bloating(VAS,mean ± SD,group A:5.3 ± 2.2 vs 3.0 ± 1.7,P = 0.005;group B:5.3 ± 3.2 vs 2.3 ± 1.9,P = 0.006) decreased in both groups,whilst the VAS values of prolonged abdominal pain decreased in the Flortec group,but remained unchanged in the high-fibre diet group(VAS,mean ± SD,group A:6.5 ± 1.5 vs 4.5 ± 2.1,P = 0.052;group B:4.5 ± 3.8 vs 5.5 ± 3.5).CONCLUSION:A high-fibre diet is effective in relievingabdominal symptoms in symptomatic uncomplicated diverticular disease.This treatment may be implemented by combining the high-fibre diet with Flortec.     

Quality of life after three kinds of esophagectomy for cancer

AIM:To evaluate quality of life(QOL) following Ivor Lewis,left transthoracic,and combined thoracoscopic/laparoscopic esophagectomy in patients with esophageal cancer.METHODS:Ninety patients with esophageal cancer were assigned to Ivor Lewis(n = 30),combined thoracoscopic/laparoscopic(n = 30),and left transthoracic(n = 30) esophagectomy groups.The QOL-core 30 questionnaire and the supplemental QOL-esophageal module 18 questionnaire for patients with esophageal cancer,both developed by the European Organization for Research and Treatment of Cancer,were used to evaluate patients' QOL from 1 wk before to 24 wk after surgery.RESULTS:A total of 324 questionnaires were collected from 90 patients;36 postoperative questionnaires were not completed because patients could not be contacted for follow-up visits.QOL declined markedly in all patients at 1 wk postoperatively:preoperative and 1-wk postoperative global QOL scores in the Ivor Lewis,combined thoracoscopic/laparoscopic,and left transthoracic groups were 80.8 ± 9.3 vs 32.0 ± 16.1(P 0.001),81.1 ± 9.0 vs 53.3 ± 11.5(P 0.001),and 83.6 ± 11.2 vs 46.4 ± 11.3(P 0.001),respectively.Thereafter,QOL recovered gradually in all patients.Patients who underwent Ivor Lewis esophagectomy showed the most pronounced decline in QOL;global scores were lower in this group than in the combined thoracoscopic/laparoscopic(P 0.001) and left transthoracic(P 0.001) groups at 1 wk postoperatively and was not restored to the preoperative level at 24 wk postoperatively.QOL declined least in patients undergoing combined thoracoscopic/laparoscopic esophagectomy,and most indices had recovered to preoperative levels at 24 wk postoperatively.In the Ivor Lewis and combined thoracoscopic/laparoscopic groups,pain and physical function scores were 78.9 ± 18.5 vs 57.8 ± 19.9(P 0.001) and 59.3 ± 16.1 vs 70.2 ± 19.2(P = 0.02),respectively,at 1 wk postoperatively and 26.1 ± 28.6 vs 9.5 ± 15.6(P = 0.007) and 88.4 ± 10.5 vs 95.8 ± 7.3(P = 0.003),respectively,at 24 wk postoperatively.Scores in the left transthoracic esophagectomy group fell between those of the other two groups.CONCLUSION:Compared with Ivor Lewis and left transthoracic esophagectomies,combined thoracoscopic/laparoscopic esophagectomy enables higher postoperative QOL,making it a preferable surgical approach for esophageal cancer.     

Three-dimensional vs two-dimensional video assisted thoracoscopic esophagectomy for patients with esophageal cancer

AIM: To define the benefits of three-dimensional video-assisted thoracoscopic esophagectomy(3D-VATE)over 2D-VATE for esophageal cancer.METHODS: A total of 93 patients with esophageal cancer including 45 patients receiving 3D-VATE and48 receiving 2D-VATE were evaluated. Data related to patient and cancer characteristics, operating time,intraoperative bleeding, morbidity and mortality,postoperative inflammatory markers, Numerical Rating Scale for postoperative pain, Constant-Murley rating system for shoulder recovery and oxygenation index(OI) were collected. All medical records were retrieved from a prospectively maintained oncological database at our institution. A retrospective study was performed to compare the short-term surgical outcomes between the two groups.RESULTS: No significant differences were found between the two groups in either morbidity or mortality(P = 0.328). An enhanced surgical recovery was noted in the 3D group as indicated by shortened thoracoscopic operation time(3D vs 2D: 68 ± 13.79 min vs 83 ± 13min, P 0.01), minor intraoperative blood loss(3D vs 2D: 68.2 ± 10.7 ml vs 89.8 ± 10.4 ml, P 0.01),earlier chest tube removal(3D vs 2D: 2.67 ± 1.01 vs3.75 ± 1.15 d, P 0.01), shorter length of hospital stay(3D vs 2D: 9.07 ± 2.00 vs 10.85 ± 3.40 d, P 0.01), lower in-hospital expenses(3D vs 2D: 74968.4± 9637.8 vs 86211.1 ± 8519.7 RMB, P 0.01), lower pain intensity(P 0.01) and faster recovery of the left shoulder function(P 0.01). Better preservation of the pulmonary function was also found in the 3D group as the decline of the OI post operation was significantly lower than that of the 2D group(P 0.01). Changes of postoperative inflammatory markers, including procalcitonin [postoperative days(PODs) 4 and 7: P 0.01], peripheral granulocytes(PODs 1, 4 and 7: P 0.01) and hypersensitive C-reactive protein(POD 4: P 0.01) in 3D-VATE patients were less than those in the 2D group. Moreover, utilization of the 3D technique extended the dissection of the thoracic lymph nodes(P 0.01), with better exposure of nodes in the left recurrent laryngeal nerve(P = 0.031).CONCLUSION: 3D-VATE could be a more viable technique over 2D-VATE in terms of short-term outcomes for patients with esophageal cancer.     

Lower esophageal sphincter relaxation is impaired in older patients with dysphagia

AIM: To characterize the effects of age on the mechanisms underlying the common condition of esophageal dysphagia in older patients, using detailed manometric analysis. METHODS: A retrospective case-control audit was performed on 19 patients aged ≥ 80 years (mean age 85 ± 0.7 year) who underwent a manometric study for dysphagia (2004-2009). Data were compared with 19 younger dysphagic patients (32 ± 1.7 years). Detailed manometric analysis performed prospectively included basal lower esophageal sphincter pr...     

Anorectal functional outcome after repeated transanal endoscopic microsurgery

AIM:To evaluate the status of anorectal function after repeated transanal endoscopic microsurgery(TEM).METHODS:Twenty-one patients undergoing subtotal colectomy with ileorectal anastomosis were included.There were more than 5 large( 1 cm) polyps in the remaining rectum(range:6-20 cm from the anal edge).All patients,19 with villous adenomas and 2 with low-grade adenocarcinomas,underwent TEM with submucosal endoscopic excision at least twice between 2005 and 2011.Anorectal manometry and a questionnaire about incontinence were carried out at week 1 before operation,and at weeks 2 and 3 and 6 mo after the last operation.Anal resting pressure,maximum squeeze pressure,maximum tolerable volume(MTV) and rectoanal inhibitory reflexes(RAIR) were recorded.The integrity and thickness of the internal anal sphincter(IAS) and external anal sphincter(EAS) were also evaluated by endoanal ultrasonography.We determined the physical and mental health status with SF-36 score to assess the effect of multiple TEM on patient quality of life(QoL).RESULTS:All patients answered the questionnaire.Apart from negative RAIR in 4 patients,all of the anorectal manometric values in the 21 patients were normal before operation.Mean anal resting pressure decreased from 38 ± 5 mmHg to 19 ± 3 mmHg(38 ± 5 mmHg vs 19 ± 3 mmHg,P = 0.000) and MTV from 165 ± 19 mL to 60 ± 11 mL(165 ± 19 mL vs 60 ± 11 mL,P = 0.000) at month 3 after surgery.Anal resting pressure and MTV were 37 ± 5 mmHg(38 ± 5 mmHg vs 37 ± 5 mmHg,P = 0.057) and 159 ± 19 mL(165 ± 19 mL vs 159 ± 19 mL,P = 0.071),respectively,at month 6 after TEM.Maximal squeeze pressure decreased from 171 ± 19 mmHg to 62 ± 12 mmHg(171 ± 19 mmHg vs 62 ± 12 mmHg,P = 0.000) at week 2 after operation,and returned to normal values by postoperative month 3(171 ± 19 vs 166 ± 18,P = 0.051).RAIR were absent in 4 patients preoperatively and in 12(2 = 4.947,P = 0.026) patients at month 3 after surgery.RAIR was absent only in 5 patients at postoperative month 6(2 = 0.141,P = 0.707).Endosonography demonstrated that IAS disruption occurred in 8 patients,and 6 patients had temporary incontinence to flatus that was normalized by postoperative month 3.IAS thickness decreased from 1.9 ± 0.6 mm preoperatively to 1.3 ± 0.4 mm(1.9 ± 0.6 mm vs 1.3 ± 0.4 mm,P = 0.000) at postoperative month 3 and increased to 1.8 ± 0.5 mm(1.9 ± 0.6 mm vs 1.8 ± 0.5 mm,P = 0.239) at postoperative month 6.EAS thickness decreased from 3.7 ± 0.6 mm preoperatively to 3.5 ± 0.3 mm(3.7 ± 0.6 mm vs 3.5 ± 0.3 mm,P = 0.510) at month 3 and then increased to 3.6 ± 0.4 mm(3.7 ± 0.6 mm vs 3.6 ± 0.4 mm,P = 0.123) at month 6 after operation.Most patients had frequent stools per day and relatively high Wexner scores in a short time period.While actual fecal incontinence was exceptional,episodes of soiling were reported by 3 patients.With regard to the QoL,the physical and mental health status scores(SF-36) were 56.1 and 46.2(50 in the general population),respectively.CONCLUSION:The anorectal function after repeated TEM is preserved.Multiple TEM procedures are useful for resection of multi-polyps in the remaining rectum.     

Prevalence of functional dyspepsia and its subgroups in patients with eating disorders

AIM: To study the prevalence of functional dyspepsia (FD) (Rome III criteria) across eating disorders (ED), obese patients, constitutional thinner and healthy volunteers.METHODS: Twenty patients affected by anorexia nervosa, 6 affected by bulimia nervosa, 10 affected by ED not otherwise specified according to diagnostic and statistical manual of mental disorders, 4th edition, nine constitutional thinner subjects and, thirty-two obese patients were recruited from an outpatients clinic devoted to eating behavior disorders. Twenty-two healthy volunteers matched for age and gender were enrolled as healthy controls. All participants underwent a careful clinical examination. Demographic and anthropometric characteristics were obtained from a structured questionnaires. The presence of FD and, its subgroups, epigastric pain syndrome and postprandial distress syndrome (PDS) were diagnosed according to Rome III criteria. The intensity-frequency score of broader dyspeptic symptoms such as early satiety, epigastric fullness, epigastric pain, epigastric burning, epigastric pressure, belching, nausea and vomiting were studied by a standardized questionnaire (0-6). Analysis of variance and post-hoc Sheffè tests were used for comparisons.RESULTS: 90% of patients affected by anorexia nervosa, 83.3% of patients affected by bulimia nervosa, 90% of patients affected by ED not otherwise specified, 55.6% of constitutionally thin subjects and 18.2% healthy volunteers met the Postprandial Distress Syndrome Criteria (χ², P < 0.001). Only one bulimic patient met the epigastric pain syndrome diagnosis. Postprandial fullness intensity-frequency score was significantly higher in anorexia nervosa, bulimia nervosa and ED not otherwise specified groups compared to the score calculated in the constitutional thinner group (4.15 ± 2.08 vs 1.44 ± 2.35, P = 0.003; 5.00 ± 2.45 vs 1.44 ± 2.35, P = 0.003; 4.10 ± 2.23 vs 1.44 ± 2.35, P = 0.002, respectively), the obese group (4.15 ± 2.08 vs 0.00 ± 0.00, P < 0.001; 5.00 ± 2.45 vs 0.00 ± 0.00, P < 0.001; 4.10 ± 2.23 vs 0.00 ± 0.00, P < 0.001, respectively) and healthy volunteers (4.15 ± 2.08 vs 0.36 ± 0.79, P < 0.001; 5.00 ± 2.45 vs 0.36 ± 0.79, P < 0.001; 4.10 ± 2.23 vs 0.36 ± 0.79, P < 0.001, respectively). Early satiety intensity-frequency score was prominent in anorectic patients compared to bulimic patients (3.85 ± 2.23 vs 1.17 ± 1.83, P = 0.015), obese patients (3.85 ± 2.23 vs 0.00 ± 0.00, P < 0.001) and healthy volunteers (3.85 ± 2.23 vs 0.05 ± 0.21, P < 0.001). Nausea and epigastric pressure were increased in bulimic and ED not otherwise specified patients. Specifically, nausea intensity-frequency-score was significantly higher in bulimia nervosa and ED not otherwise specified patients compared to anorectic patients (3.17 ± 2.56 vs 0.89 ± 1.66, P = 0.04; 2.70 ± 2.91 vs 0.89 ± 1.66, P = 0.05, respectively), constitutional thinner subjects (3.17 ± 2.56 vs 0.00 ± 0.00, P = 0.004; 2.70 ± 2.91 vs 0.00 ± 0.00, P = 0.005, respectively), obese patients (3.17 ± 2.56 vs 0.00 ± 0.00, P < 0.001; 3.17 ± 2.56 vs 0.00 ± 0.00, P < 0.001 respectively) and, healthy volunteers (3.17 ± 2.56 vs 0.17 ± 0.71, P = 0.002; 3.17 ± 2.56 vs 0.17 ± 0.71, P = 0.001, respectively). Epigastric pressure intensity-frequency score was significantly higher in bulimic and ED not otherwise specified patients compared to constitutional thin subjects (4.67 ± 2.42 vs 1.22 ± 1.72, P = 0.03; 4.20 ± 2.21 vs 1.22 ± 1.72, P = 0.03, respectively), obese patients (4.67 ± 2.42 vs 0.75 ± 1.32, P = 0.001; 4.20 ± 2.21 vs 0.75 ± 1.32, P < 0.001, respectively) and, healthy volunteers (4.67 ± 2.42 vs 0.67 ± 1.46, P = 0.001; 4.20 ± 2.21 vs 0.67 ± 1.46, P = 0.001, respectively). Vomiting was referred in 100% of bulimia nervosa patients, in 20% of ED not otherwise specified patients, in 15% of anorexia nervosa patients, in 22% of constitutional thinner subjects, and, in 5.6% healthy volunteers (χ², P < 0.001).CONCLUSION: PDS is common in eating disorders. Is it mandatory in outpatient gastroenterological clinics to investigate eating disorders in patients with PDS?     

Intravenous iron supplementation may be superior to observation in acute isovolemic anemia after gastrectomy for cancer

AIM:To determine whether the application of postoperative intravenous(IV)-iron for acute isovolemic anemia after gastrectomy for cancer may be effective.METHODS:Among 2078 gastric cancer patients who underwent surgery between February 2007 and August2009 at the National Cancer Center Korea,368 patients developed post-operative anemia[hemoglobin-(Hb)-level<9 g/dL]within the first postoperative week.Patients requiring transfusions were excluded.IV-iron was administered to 63 patients(iron group).Sixty patients were observed without treatment(observation group).The clinical outcomes of the groups were compared concerning clinicopathologic data,morbidity,and changes in Hb levels using Fisher’s exact test,Student’s t-test and the Z-test.RESULTS:The initial Hb level was higher in the iron group than in the observation group(7.3±1.0 g/dL vs8.4±0.5 g/dL,P<0.001).The slope of the changes in the Hb level was significantly higher in the iron group than in the observation group(0.648±0.054 vs 0.349±0.038,P<0.001).The Hb level 1 and 3 mo postoperatively increased from 10.7±1.3 to 11.9±1.3g/dL in the iron group(P=0.033)and from 10.1±1.0to 10.8±1.4 g/dL in the observation group(P<0.001).The postoperative hospital stay was significantly longer in the iron group than in the observation group(10.5±6.8 d vs 7.6±5.5 d,P=0.011).There were no significant differences in the major and surgical complications between the groups(6.3%vs 13.3%,P=0.192;9.5%vs 3.3%,P=0.164).CONCLUSION:IV-iron supplementation may be an effective treatment for post-operative isovolemic postgastrectomy anemia and may be a better alternative than observation.     

Endoscopic findings in patients with Schatzki rings: Evidence for an association with eosinophilic esophagitis

AIM: To investigate endoscopic findings in patients with Schatzki rings (SRs) with a focus on evidence for eosinophilic esophagitis (EoE).METHODS: We consecutively approached all adult patients scheduled for elective outpatient upper endoscopy for a variety of indications at the German Diagnostic Clinic, Wiesbaden, Germany between July 2007 and July 2010. All patients with endoscopically diagnosed SRs, defined as thin, symmetrical, mucosal structures located at the esophagogastric junction, were prospectively registered. Additional endoscopic findings, clinical information and histopathological findings with a focus on esophageal eosinophilia (≥ 20 eosinophils/high power field) were recorded. The criteria for active EoE were defined as: (1) eosinophilic tissue infiltration ≥ 20 eosinophils/hpf; (2) symptoms of esophageal dysfunction; and (3) exclusion of other causes of esophageal eosinophilia. Gastroesophageal reflux disease was excluded by proton pump inhibitor treatment prior to endoscopy. The presence of ≥ 20 eosinophils/hpf in esophageal biopsies in patients that did not fulfil the criteria of EoE was defined as esophageal hypereosinophilia.RESULTS: A SR was diagnosed in 171 (3.3%; 128 males, 43 females, mean age 66 ± 12.9 years) of the 5163 patients that underwent upper gastrointestinal-endoscopy. Twenty of the 116 patients (17%) from whom esophageal biopsies were obtained showed histological hypereosinophilia (≥ 20 eosinophils/hpf). Nine of these patients (8 males, 1 female, mean age 49 ± 10 years) did not fulfill all diagnostic criteria of EoE, whereas in 11 (9%) patients with ≥ 20 eosinophils/hpf, a definite diagnosis of EoE was made. Three of the 11 patients (27%) with definite EoE had no suspicious endoscopic features of EoE. In contrast, in the 25 patients in whom EoE was suspected by endoscopic features, EoE was only confirmed in 7 (28%) patients. Patients with EoE were younger (mean age 41.5 ± 6.5 vs 50.5 ± 11.5 years, P = 0.012), were more likely to have a history of allergies (73% vs 29%, P = 0.007) and complained more often of dysphagia (91% vs 34%, P = 0.004) and food impaction (36% vs 6%, P = 0.007) than patients without EoE. Endoscopically, additional webs were found significantly more often in patients with EoE than in patients without EoE (36% vs 11%, P = 0.04). Furthermore, the SR had a tendency to be narrower in patients with EoE than in those without EoE (36% vs 18%, P = 0.22). The percentage of males (73% vs 72%, P = 1.0) and frequency of heartburn (27% vs 27%, P = 1.0) were not significantly different in both groups. The 9 patients with esophageal hypereosinophilia that did not fulfil the diagnostic criteria of EoE were younger (mean age 49 ± 10 years vs 58 ± 6 years, P = 0.0008) and were more likely to have a history of allergies (78% vs 24%, P = 0.003) than patients with < 20 eosinophils/hpf. Predictors of EoE were younger age, presence of dysphagia or food impaction and a history of allergies.CONCLUSION: A significant proportion of patients with SRs also have EoE, which may not always be suspected according to other endoscopic features.