New anti-mesenteric delta-shaped stapled anastomosis: Technical report with short-term postoperative outcomes in patients with Crohn’s disease

BACKGROUND Medical treatment for Crohn’s disease(CD)has continuously improved,which has led to a decrease in surgical recurrence rates.Despite these advancements,25%of patients will undergo repeat intestinal surgery.Recurrence of CD com-monly occurs on the mesentery side of the anastomosis site.AIM To compare the new anti-mesenteric side-to-side delta-shaped stapled anasto-mosis(DSA)with the conventional stapled functional end-to-end anastomosis(CSA).METHODS This retrospective study included CD patients who underwent ileo-ileal or ileo-colic anastomosis between January 2020 and December 2023.The DSA technique employed a stapler to maintain the concept of anti-mesentery side-to-side ana-stomosis by performing a 90°vertical closure of the open window compared with the CSA technique.At the corner where the open window is closed,the DSA avoids forming a pouch and creates an anastomosis resembling a delta shape within the intestinal lumen.We compared demographics,preoperative condition,operative findings,and operative outcomes for the two techniques.RESULTS The study included 175 patients,including 92 in the DSA group and 83 in the CSA group.The two groups were similar in baseline characteristics,preoperative medical treatment,and operative findings except for the Montreal classification location.The 30-days postoperative complication rate was signi-ficantly lower in the DSA group compared with the CSA group(16.3%vs 32.5%,P=0.009).Ileus incidence was significantly lower in the DSA group than in the CSA group(4.3%vs 14.5%,P=0.033),and the hospital stay was shorter in the DSA group than in the CSA group(5.67±1.53 days vs 7.39±3.68 days,P=0.001).CONCLUSION The DSA technique was feasible and showed comparable postoperative outcomes with lower short-term complic-ations compared with the CSA technique.Further studies on CD recurrence and long-term complications are warranted.

Short-term and long-term outcomes of laparoscopic vs open ileocolic resection in patients with Crohn's disease: Propensityscore matching analysis

BACKGROUND Laparoscopic ileocolic resection(LICR)is the preferred surgical approach for primary ileocolic Crohn’s disease(CD)because it has greater recovery benefits than open ICR(OICR).AIM To compare short-and long-term outcomes in patients who underwent LICR and OICR.METHODS Patients who underwent ICR for primary CD from 2006 to 2017 at a single tertiary center specializing in CD were included.Patients who underwent LICR and OICR were subjected to propensity-score matching analysis.Patients were propensityscore matched 1:1 by factors potentially associated with 30-d perioperative morbidity.These included demographic characteristics and disease-and treatment-related variables.Factors were compared using univariate and multivariate analyses.Long-term surgical recurrence-free survival(SRFS)in the two groups was determined by the Kaplan-Meier method and compared by the log-rank test.RESULTS During the study period,348 patients underwent ICR,211 by the open approach and 137 laparoscopically.Propensity-score matching yielded 102 pairs of patients.The rate of postoperative complication was significantly lower(14%versus 32%,P=0.003),postoperative hospital stay significantly shorter(8 d versus 13 d,P=0.003),and postoperative pain on day 7 significantly lower(1.4 versus 2.3,P<0.001)in propensity-score matched patients who underwent LICR than in those who underwent OICR.Multivariate analysis showed that postoperative complications were significantly associated with preoperative treatment with biologics[odds ratio(OR):3.14,P=0.01]and an open approach to surgery(OR:2.86,P=0.005).The 5-and 10-year SRFS rates in the matched pairs were 92.9%and 83.3%,respectively,with SRFS rates not differing significantly between the OICR and LICR groups.The performance of additional procedures was an independent risk factor for surgical recurrence[hazard ratio(HR):3.28,P=0.02].CONCLUSION LICR yielded better short-term outcomes and postoperative recovery than OICR,with no differences in long-term outcomes.LICR may provide greater benefits in selected patients with primary CD.

Cumulative incidence and risk factors for pouch adenomas associated with familial adenomatous polyposis following restorative proctocolectomy

BACKGROUND The emergence of restorative total proctocolectomy has significantly reduced the lifetime colorectal cancer risk associated with familial adenomatous polyposis(FAP).However,adenomas may develop in the ileal pouch over time and may even progress to carcinoma.We evaluated the cumulative incidence,time to development,and risk factors associated with ileal pouch adenoma.AIM To evaluate the cumulative incidence,time to development,and risk factors associated with pouch adenoma.METHODS In this retrospective,observational study conducted at a tertiary center,95 patients with FAP who underwent restorative proctocolectomy at our center between 1989 and 2018 were consecutively included.The mean follow-up period was 88 mo.RESULTS Pouch adenomas were found in 24(25.3%)patients,with a median time of 52 mo to their first formation.Tubular adenomas were detected in most patients(95.9%).There were no high-grade dysplasia or malignancies.Of the 24 patients with pouch adenomas,13 had all detected adenomas removed.Among the 13 patients who underwent complete adenoma removal,four(38.5%)developed recurrence.Among 11(45.8%)patients with numerous polyps within the pouch,seven(63.6%)exhibited progression of pouch adenoma.The cumulative risks of pouch adenoma development at 5,10,and 15 years after pouch surgery were 15.2%,29.6%,and 44.1%,respectively.Severe colorectal polyposis(with more than 1000 polyps)was a significant risk factor for pouch adenoma development(hazard ratio,2.49;95% confidence interval:1.04-5.96;P=0.041).CONCLUSION Pouch adenomas occur at a fairly high rate in association with FAP after restorative proctocolectomy,and a high colorectal polyp count is associated with pouch adenoma development.

Selective inhibition of cell growth by activin in SNU-16 cells

AIM： To investigate whether activin regulates the cell proliferation of human gastric cancer cell line SNU-16 through the mRNA changes in activin receptors, Smads and p21^CIP1/WAF1. METHODS： The human gastric cancer cell lines were cultured, RNAs were purified, and RT-PCRs were carried out with specifically designed primer for each gene. Among them, the two cell lines SNU-5 and SNU-16 were cultured with activin A for 24, 48 and 72 h. The cell proliferation was measured by MTT assay. For SNU-16, changes in ActRIA, ActRIB, ActRIIA, ActRIIB, Smad2, Smad4, Smad7, and p21^CIP1/WAF1 mRNAs were detected with RT-PCR after the cells were cultured with activin A for 24, 48 and 72 h. RESULTS： The proliferation of SNU-16 cells was down regulated by activin A whereas other cells showed no change. Basal level of inhibin/activin subunits, activin receptors, Smads, and p21^CIP1/WAF1 except for activin βB mRNAs was observed to have differential expression patterns in the human gastric cancer cell lines, AGS, KATO III, SNU-1, SNU-5, SNU-16, SNU-484, SNU-601, SNU-638, SNU-668, and SNU-719. Interestingly, significantly higher expressions of ActR IIA and IIB mRNAs were observed in SNU-16 cells when compared to other cells. After activin treatment, ActR IA, IB, and IIA mRNA levels were decreased whereas ActR IIB mRNA level increased in SNU-16 cells. Smad4 mRNA increased for up to 48 h whereas Smad7 mRNA increased sharply at 24 h and returned to the initial level at 48 h in SNU-16 cells. In addition, expression of the p21^CIP1/WAF1 the mitotic inhibitor, peaked at 72 h after activin treatment in SNU-16 cells. CONCLUSION： Our results suggest that inhibition of cell growth by activin is regulated by the negative feedback effect of Smad7 on the activin signaling pathway, and is mediated through p21^CIP1/WAF1 activation in SNU-16 cells.

Cost-effective screening using a two-antibody panel for detecting mismatch repair deficiency in sporadic colorectal cancer

BACKGROUND The microsatellite instability(MSI)test and immunohistochemistry(IHC)are widely used to screen DNA mismatch repair(MMR)deficiency in sporadic colorectal cancer(CRC).For IHC,a two-antibody panel of MLH1 and MSH2 or four-antibody panel of MLH1,MSH2,PMS2,and MSH6 are used.In general,MSI is known as a more accurate screening test than IHC.AIM To compare two-and four-antibody panels of IHC in terms of accuracy and cost benefit on the basis of MSI testing for detecting MMR deficiency.METHODS We retrospectively analyzed patients with CRC who underwent curative surgery between 2015 and 2017 at a tertiary referral center.Both IHC with four antibodies and MSI tests were routinely performed.The sensitivity and specificity of a fourand two types of two-antibody panels(PMS2/MSH6 and MLH1/MSH2)were compared on the basis of MSI testing for detecting MMR deficiency.RESULTS High-frequency MSI was found in 5.5%(n=193)of the patients(n=3486).The sensitivities of the four-and two types of two-antibody panels were 97.4%,92.2%,and 87.6%,respectively.The specificities of the three types of panels did not differ significantly(99.6%for the four-antibody and PMS2/MSH6 panels,99.7%for the MLH1/MSH2 panel).Based on Cohen's kappa statistic(κ),four-and twoantibody panels were in almost perfect agreement with the MSI test(κ>0.9).The costs of the MSI test and the four-and two-antibody panels of IHC were approximately$200,$160,and$80,respectively.CONCLUSION Considering the cost of the four-antibody panel IHC compared to that of the twoantibody panel IHC,a two-antibody panel of PMS2/MSH6 might be the best choice in terms of balancing cost-effectiveness and accuracy.