Gastric cancer with repeated metastasis in the colonic lumen: a case report and multi-surgical experience

Poorly differentiated gastric adenocarcinoma is commonly associated with lymph node metastasis, peritoneal spread, and liver metastasis but rarely with intraintestinal metastasis. Most patients with metastatic gastric carcinoma are unable to undergo surgical treatment and have a poor prognosis. A 42-year-old man with hunger-related abdominal pain was diagnosed as having gastric cancer. After the first surgery (distal partial gastrectomy) and the second surgery (gastric stump carcinoma (GSC) resection), the patient suffered repeated multiple intracolonic metastases and underwent three additional resection operations. The patient survived for 154 months after the first operation. In patients with gastric carcinoma that metastasizes to the colonic lumen, radical resection, if possible, can extend survival. Once patients develop extensive extraintestinal metastasis, radical resection cannot be performed, and patients often exhibit a poor prognosis.

Mapping O2 concentration in ex-vivo tissue samples on a fast PLIM macro-imager

O2 PLIM microscopy was employed in various studies, however current platforms have limitations in sensitivity, image acquisition speed, accuracy and general usability. We describe a new PLIM imager based on the Timepix3 camera (Tpx3cam) and its application for imaging of O2 concentration in various tissue samples stained with a nanoparticle based probe, NanO2-IR. Upon passive staining of mouse brain, lung or intestinal tissue surface with minute quantities of NanO2-IR or by microinjecting the probe into the lumen of small or large intestine fragments, robust phosphorescence intensity and lifetime signals were produced, which allow mapping of O2 in the tissue within 20 s. Inhibition of tissue respiration or limitation of O2 diffusion to tissue produced the anticipated increases or decreases in O2 levels, respectively. The difference in O2 concentration between the colonic lumen and air-exposed serosal surface was around 140 µM. Furthermore, subcutaneous injection of 5 µg of the probe in intact organs (a paw or tail of sacrificed mice) enabled efficient O2 imaging at tissue depths of up to 0.5 mm. Overall, the PLIM imager holds promise for metabolic imaging studies with various ex vivo models of animal tissue, and also for use in live animals.

To Err is Human, To Forget is Device-related: A Cautionary Note for Endoscopists

Background: In the United States, ∼5 million endoscopies are performed annually. Contaminated endoscopes account for more nosocomial infections than any other medical device, but the vast majority of such events go unreported. We found no reports in the literature or the FDA Manufacturer and User Facility Device Experience (MAUDE) database of the incident described below. Methods: During a colonoscopy, the operator noticed resistance while advancing a clipping wire through the channel. A balloon-tipped catheter sheath was then extruded into the colonic lumen. The sheath and endoscope were withdrawn without incident, and the procedure was completed with a different endoscope. According to equipment logs, the last time that type of balloon-tipped catheter was used occurred 20 days prior, resulting in 20 patients having potentially been exposed to an incompletely disinfected device. Interrogation of the endoscope with various inserts revealed that the presence of a retained sheath would allow passage of all types of guide wires, (snips, snares, etc), including the cleaning brush. The only device whose passage would have been prevented by a retained sheath was a vascular clipping device. A review of procedure notes and interviews of involved physicians revealed that such clippings were performed as recently as 2 days prior to the incident, thus reducing the number of potentially exposed to 2, plus the index. The county and state health departments were notified, a MAUDE report was filed, and patients were notified and offered free testing for bloodborne and enteric pathogens. Discussion: The root causes of the exposure included the absence of a closed-loop feedback for removable components (similar to an operating room sponge count), an inexperienced endoscopy technologist, and, in our opinion, a design flaw of the sheath that allows the sheath to enter the channel. Specifically, unlike other sheath brands, this brand lacks a large, irremovable warning flag that precludes channel entry (Fig. 1). Had we not been able to trace the use of each individual endoscope (n = 45) in the clinic and link each to specific patients, procedures, and reprocessing logs, we would have had no way to determine the extent of exposures. This incident, which we present as a cautionary tail to others, highlights (1) a possible equipment design flaw, (2) the importance of closed-loop feedbacks for removable components, (3) the criticality of detailed procedure notes along with granular cleaning and reprocessing logs traceable to every endoscope, and (4) the challenge of communicating risk of disease transmission to patients.Funding: NoneDisclosures: None

Colonic transendoscopic tube-delivered enteral therapy (with video): a prospective study

Background Colonic transendoscopic enteral tubing (TET) refers to colonic transendoscopic tube-delivered enteral therapy. Colonic TET has been successfully used for frequent colonic administration of drugs or multiple fecal microbiota transplantations (FMTs). This prospective observational study aimed to evaluate possible factors affecting methodology, feasibility and safety of colonic TET. Methods Patients who underwent colonic TET at our center from October 2014 to November 2018 were included. The feasibility, efficacy, and safety of TET were evaluated. Results In total, 224 patients were analyzed. The success rate of TET was 100%. The median retention time of TET tube within the colonic lumen was 8.5 (IQR 7–11) days in 158 patients with tube falling out spontaneously, and the maximum retention time was up to 28 days. These patients were divided into the short-retention group (≤ 8.5 days) and the long-retention group (> 8.5 days). Univariate and multivariate analysis demonstrated that the type of endoscopic clip (p = 0.001) was an independent factor for the retention time. The larger clips as well as a greater number of clips significantly affected the retention time (p = 0.013). No severe adverse event was observed during and after TET. Conclusions Colonic TET is a feasible, practical, and safe colon-targeted drug delivery technique with a high degree of patients’ satisfaction. Two to four large endoscopic clips are recommended to maintain stability of the TET tube within the colon for over 7 days.

Safety evaluation of preoperative stent insertion and clinical analysis on comparison of outcomes between preoperative stent insertion and emergency surgery in the treatment of obstructive left-sided colorectal cancer

Objective: To evaluate the safety of preoperative stent insertion and compare the short- and long-term outcomes between preoperative stent insertion and emergency surgery in the treatment of obstructive left-sided colorectal cancer. Methods: The clinical data of 302 patients who underwent surgery for obstructive left-sided colorectal cancer from January 2009 to May 2014 were retrospectively analyzed. They were divided into two groups according to whether to receive stenting for the success rate and complications of stent insertion in colonic lumen by colonoscope, and the number of cases of primary resection and anastomosis, and short-term complications such as incision infection, anastomotic leakage, spleen tear and abdominal abscess as well as mortality and survival rate during hospitalization were compared. Results: The success rate of endoscopic nitinol alloy memorial stent insertion in colonic lumen was 97.62%, and the overall incidence of complications was 14.5%, of which the incidence of serious complications (perforation, stent migration) was 4.76%. The primary anastomosis rate was significantly higher in the stent insertion group (85.71%) than that in the emergency surgery group (36.24%). The overall complication rate in the stent insertion group (14 cases) was significantly lower than that in the emergency surgery group (102 cases). There was no significant difference between survival curves (P>0.05). Conclusion: Preoperative stent insertion in colonic lumen by colonoscope for decompression is an ideal auxiliary method in the treatment of obstructive left-sided colorectal cancer, and may increase primary anastomosis rate, avoid neostomy, reduce short-term complications, and improve the long-term survival compared to emergency surgery. doi: https://doi.org/10.12669/pjms.36.3.1707 How to cite this:Han L, Song X, Yu B, Zhou M, Zhang L, Safety evaluation of preoperative stent insertion and clinical analysis on comparison of outcomes between preoperative stent insertion and emergency surgery in the treatment of obstructive left-sided colorectal cancer. Pak J Med Sci. 2020;36(3):---------. doi: https://doi.org/10.12669/pjms.36.3.1707 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Is Dientamoeba fragilis a Friend or a Foe? A Study from Istanbul on Patients and Healthy Individuals from Different Cohorts

Objective: Dientamoeba fragilis is an intestinal protozoan found in colonic lumen and it has been demonstrated that it can lead to various gastrointestinal and dermatological complaints. It has been discussed lately that D. fragilis can be found also in high prevalence among healthy individuals and could be a member of healthy gut microbiota. The aim of this study was to compare the prevalence of D. fragilis between patient and healthy-control groups from Istanbul, and to study clinical outcomes of the infection it causes on the patient group ,and patient characteristics. Method: Stool samples of 184 patients admitted to Acıbadem Health Group hospitals in Istanbul between 2016-2018, and 156 healthy controls were examined in the study. After microbiological and parasitological assessments of stool samples, DNA isolation was made followed by conventional PCR test using specific primers. Results: D. fragilis was detected in 15 of 184 (8.2%) patients and 42 of 156 (26.9%) controls, and the intergroup difference was significant (p<0.05). In the study group Salmonella spp. was detected in 3, and Rotavirus in 1 of the D. fragilis positive individuals. Six out of 15 D. fragilis positive individuals in the study group were women and their average age (n=24.3) was higher than other groups (p=0.25). Fifty-five of 57 (96.5%) D. fragilis positive individuals were in the pediatric age group. The leading complaints were diarrhea, anorexia and abdominal pain, while 3 of the 15 patients reported itching and urticaria. Conclusion: These preliminary results related to the metropolitan city of Istanbul tend to support the fact that D. fragilis may show pathogenic effects in some cases but it is more common among healthy individuals. Considering the similar results from different regions of the world, further studies are essential to unveil under which conditions D. fragilis is silent (friend) and acts as a pathogen (foe).

Oral Nutrition Modulates the Intestinal Barrier Following Cytotoxic Therapy Via the Microbiome

Reduced oral intake (ROI) is common in patients that have received cytotoxic therapy for hematologic malignancies. Here we examine the interplay between nutrition, intestinal bacteria and intestinal barrier function, focusing on preclinical mouse models. By 3 days following 9 Gy of total body irradiation (TBI), individually-housed C57BL/6 mice were observed to have an approximately 40-60% reduction in oral intake (Fig A), and 3 days later displayed marked changes in the microbiome by 16S deep sequencing, including an expansion of Bacteroides thetaiotaomicron (Fig B). These mice also had lost roughly 20% of their body weight (Fig C), and showed compromise of their intestinal barrier assayed by oral challenge with FITC-dextran (Fig M). We hypothesized that the ROI could be a driving factor behind the microbiome changes. To assess this, we limited the access of unirradiated mice to 2 grams of normal chow a day for 7 days (an approximately 50% reduction in oral intake) with unlimited water. Microbiome profiling by 16S sequencing showed many changes that were similar to those seen in irradiated mice, including an expansion of Bacteroides thetaiotaomicron (Fig D). Because Bacteroides thetaiotaomicron has been shown to utilize glycans derived from colonic mucin, we evaluated the consumption of porcine gastric mucin by intestinal bacteria in vitro with a colorimetric assay that quantifies polysaccharides. We found that following ROI, mice harbored intestinal bacteria that were significantly more efficient at utilizing mucin glycans (Fig E). Corroborating this, a histological characterization of the colonic mucus thickness following fixation with Carnoy's solution showed that after a week of ROI, unirradiated mice developed significant thinning of the colonic mucus layer (Fig F), though intestinal barrier function otherwise remained intact as assayed by FITC-dextran gavage (data not shown). We asked how ROI could favor mucolytic bacteria and hypothesized that ROI could reduce bacterial fermentation of dietary carbohydrates which largely results in production of short-chain fatty acids. Evaluating the pH of the colonic lumen showed that ROI led to a significant elevation in pH (Fig G). Ion-chromatography mass spectrometry of colonic stool samples showed a reduction in acetate, propionate, butyrate, and lactate following ROI, and interestingly an increase in succinate (Fig I). Corroborating this, RNA sequencing of intestinal bacteria following ROI demonstrated a downregulation of phosphoenolpyruvate carboxykinase, a metabolic enzyme that in Bacteroides species has been previously been found to be associated with conversion of succinate to propionate (Fig H). Finally, we evaluated in our ROI model the impact of administration of oral sugars by supplementing a well-absorbed sugar (glucose), and a poorly-absorbed prebiotic sugar in the drinking water of mice. We found that compared with glucose, supplementation with the prebiotic more effectively acidified the colonic lumen of normal mice (Fig J), and completely prevented thinning of the mucus layer in mice undergoing ROI (Fig K). Additionally, in mice following 9 Gy of total body irradiation, daily administration of the prebiotic was highly effective in preventing weight loss (Fig L) and nearly completely abrogated compromise of intestinal barrier function (Fig M). Conclusions: Reduced oral intake following cytotoxic therapy contributes to thinning of the colonic mucus layer, an effect that appears to be independent of the cytotoxic effects on the host and is rather mediated by changes in the intestinal microbiome, including reduced metabolism of organic acids. Strategies to restore colonic acidity with prebiotic sugars may successfully target this phenomenon with potential clinical benefits, particularly in preventing disruption to the intestinal barrier. Figure Figure. Disclosures Jenq: MicrobiomeDx: Consultancy; Seres Therapeutics, Inc.: Patents & Royalties; Ziopharm Oncology: Consultancy; Seres Therapeutics, Inc.: Membership on an entity's Board of Directors or advisory committees.

A New Surgical Device for Anterograde Intraoperative Rectal Washout

Background. Colorectal cancer is the fourth most diffuse cause of death in the world and local recurrence is associated with a reduced long-term life expectancy, with a reduced quality of life. Rectal washout at the anastomosis site leads to a statistically significant reduction of local recurrences. Methods. We developed the idea of a new laparoscopic stapler with an integrated washout system that could decontaminate the rectal stump before resection, without the need to enlarge the standard surgical incision or even to distort the incision site, closing the rectal stump just below the inferior part of the cancer, and then proceeding with the resection and stapling of the distal part of the tumor. Combined with these canonical functionalities, the new device, equipped with a patented washout system (patent number EP 3103401A1) will also allow to inject in the closed bowel a physiologic saline liquid. Results. In force of the mechanical action of the liquid injected, carcinogenic exfoliated cells eventually floating in the affected region of the colonic lumen will be expelled through the anal orifice. The intraoperative rectal washout, both in minimally invasive and in traditional open surgery, thus becomes a simple, effective, and reproducible procedure. Conclusions. We describe the technical features and the possible clinical applications of a potentially new surgical laparoscopic stapler coupled with an integrated irrigation system. We have patented the system and we are developing a prototype with the aim to start an experimental pilot study.