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Defecation is a complex process and up to 25% of the population suffer from symptoms of defecatory dysfunction. For functional testing, diagnostics, and therapy of anorectal disorders, it is important to know the optimal defecation position. is The aim of this study was to evaluate defecation pressure patterns in side lying, seated and squatting defecation positions in normal subjects using a simulated stool device called Fecobionics. The Fecobionics expulsion parameters were assessed in an interventional study design conducted from May 29 to December 9 2019. Subjects were invited to participate in the study through advertisement at The Chinese University of Hong Kong. The Fecobionics device consisted of a core containing pressure sensors at the front (caudal end) and rear (cranial end) and a polyester-urethane bag spanning most of the core length which also contained sensors. The Fecobionics bag was distended to 50 ml in the rectum of normal subjects (no present and past symptoms of defecatory disorders, no prior abdominal surgery, medication or chronic diseases). Studies were done in side lying (left lateral recumbent position), seated (hip flexed 90°) and squatting position (hip flexed 25°). Pressure endpoints including the rear-front pressure diagram and defecation indices were compared between positions. Twelve subjects (6 females/6 males, mean age 26.3 ± 2.6 [19.0–48.0] years) were included and underwent the planned procedures. The resting anal pressure for side lying and seated positions were 33.1 ± 4.1 cmH2O and 37.1 ± 4.0 cmH2O (p > 0.3). The anal squeeze pressure for side lying and seated positions were 98.4 ± 6.9 cmH2O and 142.3 ± 16.4 cmH2O (p 0.5). Rear-front pressure diagrams and distensibility indices demonstrated distinct differences in pressure patterns between the side lying position group and the other positions. The delay in expelling the Fecobionics device in the lying position was associated with dyssynergic pressure patterns on the device. Quantitative differences were not found between the seated and squatting position. Trial Registration http://www.clinicaltrials.gov Identifier: NCT03317938.

Highlights • Non-cirrhotic non malignant acute mescenteric thrombosis could lead to massive bowel ischaemia and is challenging to manage. • Conventional PV or SMV exploration is associated with significant blood lost, physiological disturbances and may need repeated procedures. • Catheter directed thrombolysis and thrombectomy provide minimal invasive option to restore patency of PV or SMV. • Literature review found high success rate and favourable outcome. • Catheter directed therapy should be the first line therapy., Aim To present two cases of acute non-cirrhotic and non-malignant mesenteric vein thrombosis (MVT) treated with early transcatheter thrombectomy and thrombolysis with tissue plasminogen activator (tPA) and to review the literature on transcatheter thrombectomy and thrombolytic therapy of such condition. Methods Two cases of acute MVT treated with transhepatic transcatheter thrombectomy and thrombolysis in addition to systemic anticoagulation upon diagnosis are presented. In addition, a Pubmed literature search was undertaken using keywords acute mesenteric vein thrombosis, thrombolysis and thrombectomy. The inclusion criteria were studies examining the impacts of transcatheter thrombolysis and thrombectomy in the management of acute MVT. Results Early transcatheter thrombectomy and thrombolysis achieves technical success in both patients and result in nearly complete recanalization of the venous system, with no recurrent thrombosis to date in follow up. Both patients do not require extensive bowel resection despite extensive thrombus on presentation. However, both patients develop intra-abdominal bleeding requiring blood transfusion and embolization of the transcatheter tract. Conclusion Catheter-directed first approach provides a minimal invasive approach for management of non-malignant and non-cirrhotic acute mesenteric thrombosis. It offers the benefits of rapid venous recanalization and avoid massing bowel resection despite extensive thrombosis. Subsequent progression into chronic MVT was also reduced. However, the procedure could lead to bleeding from puncture site and hence embolization of the catheter tract is advised during catheter removal.

Background and Aims: It is unclear whether obesity is associated with the development of inflammatory bowel disease despite compelling data from basic science studies. We therefore examined the association between obesity and risk of Crohn's disease (CD) and ulcerative colitis (UC). Methods: We conducted pooled analyses of 5 prospective cohorts with validated anthropometric measurements for body mass index (BMI) and waist-hip ratio and other lifestyle factors. Diagnoses of CD and UC were confirmed through medical records or ascertained using validated definitions. We used Cox proportional hazards modeling to calculate pooled multivariable-adjusted HRs (aHRs) and 95% confidence intervals (CIs). Results: Among 601,009 participants (age range, 18-98 years) with 10,110,018 person-years of follow-up, we confirmed 563 incident cases of CD and 1047 incident cases of UC. Obesity (baseline BMI ≥30 kg/m 2) was associated with an increased risk of CD (pooled aHR, 1.34; 95% CI, 1.05-1.71, I 2 = 0%) compared with normal BMI (18.5 to 2). Each 5 kg/m 2 increment in baseline BMI was associated with a 16% increase in risk of CD (pooled aHR, 1.16; 95% CI, 1.05-1.22; I 2 = 0%). Similarly, with each 5 kg/m 2 increment in early adulthood BMI (age, 18-20 years), there was a 22% increase in risk of CD (pooled aHR, 1.22; 95% CI, 1.05-1.40; I 2 = 13.6%). An increase in waist-hip ratio was associated with an increased risk of CD that did not reach statistical significance (pooled aHR across quartiles, 1.08; 95% CI, 0.97-1.19; I 2 = 0%). No associations were observed between measures of obesity and risk of UC. Conclusions: In an adult population, obesity as measured by BMI was associated with an increased risk of older-onset CD but not UC.

Background Whether bisphenol A (BPA) exposure is a contributing factor to benign prostatic hyperplasia (BPH) remains unclear. This study evaluated the association between chronic BPA exposure and BPH risk, and explored whether this association was modified by alcohol drinking. Methods This study included a total of 650 BPH cases and 650 controls recruited from the same hospital in Hong Kong during 2011-2016. Chronic BPA exposure level was estimated by a validated cumulative BPA exposure index (CBPAI). We performed unconditional logistic regression model to examine the association of BPH risk with potential sources of BPA exposure via oral intake and CBPAI. We further tested the interactions between CBPAI and alcohol consumption habits on BPH risk. Results A positive exposure-response relationship was observed between CBPAI and BPH risk. Frequent BPA exposure via oral intake of foods heated in a plastic box/bag (odds ratio [OR] = 3.52, 95% confidence interval [CI]: 1.51-8.22), cooling water in a plastic bottle (OR = 2.65, 95% CI: 1.33-5.27), or using a plastic cup to contain hot water (OR = 4.14, 95% CI: 1.02-16.89), was significantly associated with increased BPH risk. Compared with nonalcohol drinkers, alcohol drinkers was insignificantly associated with BPH risk (OR = 1.10, 95% CI: 0.77-1.57), but it demonstrated a more remarkable positive gradient between CBPAI exposure and BPH risk among alcohol drinkers, indicating an additive interaction between CBPAI and alcohol on BPH risk (synergy index = 4.24, 95% CI: 1.21-14.94). Conclusions Chronic oral BPA exposure increased BPH risk with a positive exposure-response relationship among Hong Kong Chinese, and alcohol drinking amplified the effect of BPA on BPH. Hence, minimizations of containing food or water/beverage in plastic containers and drinking alcohol are recommended in the community to mitigate BPH risk. Future larger and designated studies are warranted.

BACKGROUND Most patients who have undergone low anterior resection suffer from bowel dysfunction postoperatively. This condition is referred to as low anterior resection syndrome (LARS). The aim was to study defecatory patterns in LARS patients compared to a primary control group of fecal incontinence (FI) patients and normal subjects (NS) with the Fecobionics device. METHODS Fecobionics expulsion parameters were assessed in an interventional study design. The Fecobionics probe contained pressure sensors at the front, rear, and inside the bag. The bag was distended until urge sensation in rectum in 11 LARS patients (5F/6M, 63.2 ± 2.9 years), 11 FI subjects (7F/4M, 64.4 ± 2.5 years), and 11 NS (7F/4M, 63.6 ± 3.0 years). Defecation indices were computed from the Fecobionics data. All subjects had high-resolution anorectal manometry (ARM) and balloon expulsion test (BET) done. Symptoms were evaluated with LARS and Wexner scores. KEY RESULTS The LARS score in the LARS patients was 39.0 ± 0.6. The Wexner score in the LARS, FI, and NS groups was 14.2 ± 0.7, 10.1±1.0, and 0.0 ± 0.0 (p

The aim of this study was to determine the clinical safety and feasibility of a novel single-port flexible robot for Transoral Robotic Surgery (TORS).This was a prospective phase II / IDEAL stage 2 clinical trial of both benign and malignant lesions of the head and neck. The primary endpoint included conversion rates and perioperative complications within 30 days following surgery. The study was registered on www.ClinicalTrials.gov (NCT03010813). The Fisher's exact test and Mann-Whitney U test were used to compare categorical, and non-parametric data for the trial. A p value0.05 was considered to be statistically significant. Statistical analysis was performed with SPSS 20.0 (IBM Corp., Armonk, New York) RESULTS: Twenty-one patients safely underwent TORS with the da Vinci SP (Intuitive Surgical Inc., Sunnyvale, CA) demonstrating the feasibility of access to the nasopharynx, oropharynx, larynx and hypopharynx. There were no conversions of the robotic surgical system. There were no serious adverse events or adverse events related to the use of the robot at 30-day follow-up for all patients.In a prospective Phase II clinical trial, a novel single-port flexible robotic system appears safe and feasible to use for transoral endoscopic head and neck surgery to access the nasopharynx, oropharynx, larynx and hypopharynx.

Purpose Dynamic capabilities (DC) have been linked to firm competitive advantage, but the ways in which firms can create and build these DC are still not clear. The purpose of this paper is to propose a model with organizational learning (OL) and supply chain orientation (SCO) as antecedents of dynamic logistics capabilities and firm performance as the outcome. The study tests this model on a sample of logistics service firms. Design/methodology/approach Partial least squares structural equation modeling was used to analyze the data collected from 103 logistics firms drawn from the Chartered Institute of Logistics and Transportation of Hong Kong. Findings Results show that OL directly enhances DC and indirectly through SCO. The relationship between OL and SCO is stronger than the relationship between OL and DC. DC are positively related to logistics firm performance. Research limitations/implications The study relied on perceptual and self-reported data from senior management. Relationships among variables may also be inflated by common method variance but efforts were taken to reduce this threat. Practical implications Logistics firms should promote a learning culture in the organization. Organization learning enhances a firm’s willingness to change and innovate. It also helps employees to gain a better understanding of clients’ supply chains and possibilities. SCO helps the firm to direct its reconfiguration and renewal efforts where the returns are the highest. Originality/value There is scant empirical research on the antecedents of DC outside of manufacturing and knowledge-intensive services. The study focused on the logistics services industry. SCO, a necessary strategic orientation for firms in the supply chain, has not been empirically investigated in the previous research. This study addressed these gaps in the literature and contributes to the understanding of the factors giving rise to DC.

This is a preclinical cadaveric study to investigate the feasibility of transcervical esophagectomy using a novel single-port robotic surgical system. A 40-mm cervical incision was created over left supraclavicular fossa. The novel da Vinci® SP™ Surgical System was introduced through a wound retraction port. The mobilization of esophagus was performed using da Vinci SP from cervical, thoracic to abdominal segments. Lymph nodes were dissected en bloc with esophagus. The transcervical esophagectomy with complete mobilization of the cervical, thoracic, and abdominal esophagus was completed in 60 min. The procedure was completed using the novel da Vinci SP Surgical System, which was introduced via the cranial side over the left cervical incision. No additional port was used for retraction and dissection, and the esophageal hiatus could be reached after complete transcervical dissection. This preclinical study demonstrated that transcervical esophagectomy is technically feasible and can be completed with the novel da Vinci SP Surgical System without additional ports or assistance. This will serve as an important step to the performance of robotic transcervical esophagectomy without the necessity of one-lung ventilation.

BACKGROUND AND OBJECTIVES This study aimed to find the advantages of robotic natural orifice specimen extraction surgery (NOSES) for middle and low rectal cancer, compared with traditional laparoscopic low anterior resection (LAR). METHODS Patients receiving robotic NOSES or traditional laparoscopic LAR were retrospectively enrolled from 2013-10 to 2019-06, with middle and low rectal cancer, maximum diameter ≤ 5 cm, pT1-3 or ypT1-3 stage, no distant metastases. The baseline of the two groups was balanced using the propensity score matching method. Surgical quality, postoperative recovery, and long-term oncological outcomes were compared. RESULTS Totally 137 eligible patients with robotic NOSES and 137 matched patients with traditional laparoscopic LAR were enrolled. Robotic NOSES had a significantly lower open conversion rate (0 vs. 4.4%, p = .030), less intraoperative hemorrhage (50 ml vs. 80 ml, p

Purpose: This study was performed to evaluate the outcome of implementation of transanal total mesorectal excision (TaTME) for low rectal cancer in a regional hospital and in comparison to laparoscopic (Lap) TME.Methods: Consecutive patients with low rectal cancer of which the lowest border of the tumour was located beween 1 and 5 cm from the puborectalis who underwent TME at North District Hospital between January 2013 and December 2019 were included. Clinical, operative, and pathologic outcomes were compared between Lap TME and TaTME. The primary end point was complication profile.Results: Thirty-five patients underwent Lap TME and 45 patients underwent TaTME for low rectal cancer. The conversion rate of the TaTME group was significantly lower than that of the Lap TME group (4.4% vs. 20%, P=0.029), but the operating time was longer (259 minutes vs. 219 minutes, P=0.009). The tumour location was significantly lower in the TaTME group, but the distal resection margins were adequate and not different between both groups. The TaTME group had higher incidence rates of prolonged ileus and urinary tract infection, but the other complications were similar between the two groups. The resection margin positivity rates of the TaTME and Lap TME groups were 2.2% and 5.7%, respectively (P=0.670). At a median follow up of 39 months, no abnormal early recurrence was detected.Conclusion: It is technically feasible and oncologically safe to perform TaTME in a medium-volume colorectal unit. Patients with difficult pelvic anatomy can benefit by reducing the risk of conversion and margin positivity rate.

Fecal continence is maintained by several mechanisms including anatomical factors, anorectal sensation, rectal compliance, stool consistency, anal muscle strength, mobility, and psychological factors. The homeostatic balance is easily disturbed, resulting in symptoms including fecal incontinence and constipation. Current technologies for assessment of anorectal function have limitations. Overlap exist between data obtained in different patient groups, and there is lack of correlation between measurements and symptoms. This review describes a novel technology named Fecobionics for assessment of anorectal physiology. Fecobionics is a simulated stool, capable of dynamic measurements of a variety of variables during defecation in a single examination. The data facilitate novel analysis of defecatory function as well as providing the foundation for modeling studies of anorectal behavior. The advanced analysis can enhance our physiological understanding of defecation and future interdisciplinary research for unraveling defecatory function, anorectal sensory-motor disorders, and symptoms. This is a step in the direction of improved diagnosis of anorectal diseases.

Fecal incontinence (FI) is characterized by involuntary loss of rectal content. Up to 9.5% of Americans younger than 70 years suffer from FI.1 The pathophysiology has many causes and is not well understood and diagnosed.

OBJECTIVE This longitudinal study mapped distinct trajectories of fear of cancer recurrence (FCR) over 12 months among patients with breast (BC) or colorectal (CRC) cancer, and examined if metacognition, indirectly via attentional bias, intrusive thoughts and avoidance (hallmarks of cognitive attentional syndrome; CAS) predicted FCR trajectory membership. METHODS Two hundred and seventy BC (n = 163) or CRC (n = 107) patients were assessed at 8-weeks, 3-, 6-, and 12-months postsurgery on a measure of FCR (FCRI-SF). Metacognition (MCQ-30), Intrusive and Avoidant Thoughts (CIES-R) and attentional bias (dot-probe tasks) were assessed at baseline. Latent growth mixture modeling identified FCR trajectories. Fully-adjusted Multinomial Logistic Regression identified whether direct and indirect effects of metacognition through CAS determined FCR trajectory membership. RESULTS Three distinct FCR trajectories were identified, namely, low-stable (62.4%), high-stable (29.2%), and recovery (8.3%). Negative beliefs about worry, cognitive confidence, and age predicted FCR trajectories (χ2 (6) = 38.31, P

Objective There is a need for an improved biomarker for colorectal cancer (CRC) and advanced adenoma. We evaluated faecal microbial markers for clinical use in detecting CRC and advanced adenoma. Design We measured relative abundance of Fusobacterium nucleatum ( Fn ), Peptostreptococcus anaerobius ( Pa ) and Parvimonas micra ( Pm ) by quantitative PCR in 309 subjects, including 104 patients with CRC, 103 patients with advanced adenoma and 102 controls. We evaluated the diagnostic performance of these biomarkers with respect to faecal immunochemical test (FIT), and validated the results in an independent cohort of 181 subjects. Results The abundance was higher for all three individual markers in patients with CRC than controls (p Fn in patients with advanced adenoma than controls (p=0.022). The marker Fn , when combined with FIT, showed superior sensitivity (92.3% vs 73.1%, p Conclusions This study identified marker Fn as a valuable marker to improve diagnostic performance of FIT, providing a complementary role to detect lesions missed by FIT alone. This simple approach may improve the clinical utility of the current FIT, and takes one step further towards a non-invasive, potentially more accurate and affordable diagnosis of advanced colorectal neoplasia.

Psychometric evaluation with tools such as the faecal incontinence quality of life scale is an essential component of clinical assessment. Currently, there is no translated Traditional Chinese version of the scale. A validated translated version may help to improve the quality of healthcare received in countries with Chinese minorities (0.5, 1.2 and 4.0 % of the UK, USA and Australian population, respectively) as well as local population of Hong Kong. The purpose of this study is to validate the Traditional Chinese version of the faecal incontinence quality of life scale (FIQL). The FIQL questionnaire was translated into Traditional Chinese Language followed by linguistic validation. It was then tested on 55 patients with faecal incontinence and 93 controls in the colorectal outpatients clinic. Faecal incontinence severity index was also used for the assessment of disease severity. Internal consistency was good/excellent for all scales (Cronbach’s alpha >0.70, between 0.71 and 0.93). The intra-class correlation indicated a high stability over time with coefficients ranging between 0.78 and 0.90. Test and retest of all four scales found no significant differences of mean scores between baseline and retest. The mean faecal incontinence quality of life scale scores of all four domains improved significantly after treatment of 10 patients whose faecal incontinence severity index scores decreased by 50 % of their pre-treatment scores, hence indicating good sensitivity. This study demonstrates the linguistic and psychometric validity of the traditional Chinese version of the faecal incontinence quality of life scale.

The effects of doping InAs quantum dots (QDs) with Si on charge carrier dynamics and recombination in the InAs/GaAs QD solar cells (QDSCs) with AlAs cap layers was investigated. Non-radiative and radiative recombination paths in the doped cells were identified by changes in emission intensity, long-wavelength photovoltage (PV) as well as time-resolved PV and photoluminescence (PL) measurements. We find that the reduction of long-wavelength PV and PL with n-doping is due to the electron population of the QD ground states (GSs) and shrinkage of the depletion layer. The time constants, derived from the time-resolved PV, grow non-monotonically with increasing of the doping density in the QDs due to redistribution of electrostatic potential in the intrinsic region of p-i-n diode and electron population of EL2 defect states of GaAs barriers. We also find that the GS emission from the InAs QDs decreases with n-doping. The results show that PL traces depend on carrier dynamic in the top QD layers populated partially with electrons from ionized impurities, whereas PV transients were found to be strongly dependent on recombination via QD and defect states located outside the depletion layer. We conclude that the non-radiative recombination of photogenerated electrons and holes via defects is suppressed due to the spatial separation by the local electric fields in and around doped AlAs/InAs QDs, as the potential profile of the intrinsic region is modulated spatially by built-in charges. The interpretation of experimental data suggests limiting mechanisms in the InAs/GaAs QDSCs operation and sheds light on possible approaches for their further improvement.

Background The mechanism of defaecation and continence is a complex process involving several factors. Identifying the cause of faecal incontinence is often difficult. Assessment of patients currently involve functional assessment with high-resolution anorectal manometry (HR-ARM) and anatomical assessment using Endoanal ultrasound (EAUS) scan, providing limited information. EndoFLIP (Functional Lumen Imaging Probe) allows additional assessment of anal canal distensibility.1 2 Aim To compare anal canal function using EndoFLIP between faecally incontinent patients (FI) and asymptomatic subjects (AS). Methods All subjects were assessed using HR-ARM, EAUS and EndoFLIP. Using the EndoFLIP, continuous ramp distension was carried out up to 5=bag vol. In second ramp distension, the 5=volume was maintained while the subjects were asked to squeeze their anus. Anal competence of the narrowest area of the anal canal was evaluated using three distinct parameters derived from the EndoFLIP data. Mann-Whitney’s U test was used for statistical analysis. Results Sixteen FI patients (2M/14F, Mean age 61.38 years, SEM +3.34) and 9 AS (3M/6F, Mean age 57.9 years, SEM +3.69) were assessed. The median yield pressure (the pressure when the diameter increased from baseline) was significantly lower in the FI group at 22.99 cmH20 (17.67–45.49 cmH20) compared to 55.95 cmH20 (36.56–64.82 cmH20) in asymptomatic subjects. There was no significant difference in the distensibility between the FI group 0.18 (0.17–0.35) mm/cmH20 compared to AS group 0.23 (0.12–0.39) mm/cmH20 calculated as the change in diameter divided by the change in distension pressure. The squeeze strength was significantly higher in the AS group 167.3 (62.0–270.8) mm.cmH20 compared to FI group 23.6 (8.1–86.1) mm.cmH20. Conclusions EndoFLIP demonstrated that FI patient‘s anal sphincters yielded at a lower pressure and had lower squeeze strength than in asymptomatic subjects, which may be clinically more relevant than squeeze pressures alone.

Background Defecation is a complex process. Defecatory disorders may be assessed using rectal balloon expulsion test (BET), high-resolution anorectal manometry (HR-ARM) and defecography. We have developed a Fecobionics device that integrates several current tests1 to assess pressures, orientation and bending all at once by the patient bedside. The Fecobionics probe is 10 cm long, 12 mm in diameter with 8 cm long inflatable bag and pressure sensors at each end. It contains two gyroscopes to measure the orientation and bending during defaecation. Aim To characterise physiological expulsion parameters in asymptomatic subjects using Fecobionics. Methods Fecobionics was inserted into the rectum and subjects were asked to sit on a commode. The bag was filled with fluid until subjects had the sensation to defaecate. Patients were asked to expel the Fecobionics. Time to expulsion, pressures and bending angles were assessed during the expulsion. This was compared to conventional 5=BET and HR-ARM. Results Eight subjects (6F/2M, 50 years (25–77)) were assessed. Defaecation urge was felt at 32±=. Five subjects expelled Fecobionics in one attempt. The expulsion time for Fecobionics and BET were 32.2±6.3 and 15.7±3.3 s respectively (p Conclusions It was possible to obtain reliable data under physiological conditions using Fecobionics. Five defecatory phases could be defined by the pressure signature. Orientation and bending could also be assessed.

BACKGROUND Measurement of DNA derived from different tissues in the circulating DNA pool can provide important information regarding the presence of many pathological conditions. However, existing methods involving genome-wide bisulfite sequencing are relatively expensive and may present challenges for large-scale analysis. METHODS Through identifying differentially methylated regions in the liver and colon compared with other tissues, we identified 2 markers and developed corresponding droplet digital PCR assays. Plasma concentrations of liver-derived and colon-derived DNA were measured for 13 liver transplant recipients, 40 liver cancer patients, and 62 colorectal cancer (CRC) patients (27 with and 35 without liver metastases). RESULTS In liver transplant recipients, the fractional concentration of liver-derived DNA measured using the liver-specific methylation marker and donor-specific alleles showed good correlation (Pearson R = 0.99). In liver cancer patients, the concentration of liver-derived DNA correlated positively with the maximal dimension of the tumor (Spearman R = 0.74). In CRC patients with and without liver metastasis, the plasma concentrations of colon-derived DNA (median, 138 copies/mL and 4 copies/mL, respectively) were increased compared with the 30 healthy controls (26 had undetectable concentrations). The absolute concentration of liver-derived DNA provided a better differentiation between CRC patients with and without liver metastasis compared with the fractional concentration (area under ROC curve, 0.85 vs 0.75). CONCLUSIONS Quantitative analysis of plasma DNA with tissue-specific methylation patterns using droplet digital PCR is applicable for the investigation of cancers and assessing organ transplantation. This approach is useful for differentiating patients with and without metastases to other organs.

Patients with nonalcoholic fatty liver disease (NAFLD) and family history of colorectal cancer (CRC) are at higher risks but how they should be screened remains uncertain. Hence, we evaluated the cost-effectiveness of CRC screening among patients with NAFLD and family history by different strategies. A hypothetical population of 100,000 subjects aged 40-75 years receive: (i) yearly fecal immunochemical test (FIT) at 50 years; (ii) flexible sigmoidoscopy (FS) every 5 years at 50 years; (iii) colonoscopy 10 yearly at 50 years; (iv) colonoscopy 10 yearly at 50 years among those with family history/NAFLD and yearly FIT at 50 years among those without; (v) colonoscopy 10 yearly at 40 years among those with family history/NAFLD and yearly FIT at 50 years among those without and (vi) colonoscopy 10 yearly at 40 years among those with family history/NAFLD and colonoscopy 10 yearly at 50 years among those without. The incremental cost-effectiveness ratio (ICER) was studied by Markov modeling. It was found that colonoscopy, FS and FIT reduced incidence of CRC by 49.5, 26.3 and 23.6%, respectively. Using strategies 4, 5 and 6, the corresponding reduction in CRC incidence was 29.9, 30.9 and 69.3% for family history, and 33.2, 34.7 and 69.8% for NAFLD. Compared with no screening, strategies 4 (US$1,018/life-year saved) and 5 (US$7,485) for family history offered the lowest ICER, whilst strategy 4 (US$5,877) for NAFLD was the most cost-effective. These findings were robust when assessed with a wide range of deterministic sensitivity analyses around the base case. These indicated that screening patients with family history or NAFLD by colonoscopy at 50 years was economically favorable.

Background & Aims We compared the accuracy of a qualitative fecal immunochemical test (FIT) in identifying patients with proximal vs distal advanced neoplasia and evaluated whether analysis of 2 specimens performed better than analysis of 1 specimen. Distal advanced neoplasia was defined as colorectal cancer (CRC), any colorectal adenoma ≥10 mm in diameter, high-grade dysplasia, or a lesion with villous or tubulovillous histologic characteristics in a location distal to the splenic flexure, including the descending colon, the rectosigmoid, and the rectum. Methods We collected data from 5343 subjects (50−70 years old) who received 2 FITs (Hemosure; cutoff value, 10 μg hemoglobin/g feces) before colonoscopy in an invitational CRC screening program in Hong Kong from 2008 through 2012. We calculated the FIT's sensitivity, specificity, positive predictive value (PPV), and negative predictive value in detecting colorectal neoplasia. Results Of the participants, 13.6%, 12.2%, and 6.0% had distal, proximal, and synchronous distal or proximal neoplasia, respectively. Advanced neoplasia was detected in 291 subjects (5.4%); 22 (0.4%) had CRC. FIT detected distal advanced adenoma with 39.7% sensitivity (95% confidence interval [CI], 32.0%−48.0%) vs proximal advanced adenoma with 25.0% sensitivity (95% CI, 17.3%−34.6%; P = .014), distal advanced neoplasia with 40.0% sensitivity (95% CI, 32.5%−47.9%) vs proximal advanced neoplasia with 27.9% sensitivity (95% CI, 20.0%−37.4%; P = .039), and any distal adenoma ≥10 mm, irrespective of other lesion characteristics, with 39.5% sensitivity (95% CI, 31.0%−48.7%) vs proximal adenoma with 25.3% sensitivity (95% CI, 16.5%−36.6%; P = .038). The specificity of FIT in detecting CRC was similar between the proximal and distal colon. FIT detected distal lesions with higher PPV than proximal lesions. One FIT detected advanced neoplasia with 31.8% sensitivity (95% CI, 25.9%−38.4%) and 92.4% specificity (95% CI, 91.6%−93.2%), whereas 2 FITs detected advanced neoplasia with 34.1% sensitivity (95% CI, 28.0%−40.8%; P = .617) and 91.9% specificity (95% CI, 91.0%−92.7%; P = .327). FIT detected distal advanced neoplasia with greater sensitivity and higher PPV than proximal advanced neoplasia. Conclusions In an analysis of data from subjects who underwent CRC screening in Hong Kong, FIT detected distal advanced neoplasia with higher sensitivity than proximal advanced neoplasia. Analysis of 1 vs 2 specimens by FIT identified advanced neoplasia with similar test characteristics.

Aim The aim of the present study was to assess patients' understanding of their informed consent to surgery preoperatively. Appropriate completeness of essential items in the written consent form was also verified. Patients and Methods An audit was conducted from March to May 2013 at a university teaching hospital. All participants were adult surgical patients. Operations were confined to major category on elective basis performed under general anaesthesia. The first part of the audit consisted of a structured questionnaire with five questions concerning their understanding and perception of the surgery. In the second part of the audit, the completeness of all fundamental items entered into the standardized written consent form was verified. Results A total of 100 surgical patients were studied, with a median age of 61 years (range: 22–89). A total of 99 per cent of participants could state the correct name and site of the procedure, and 92 per cent could state the mode of anaesthesia. Only 39 per cent of patients received an information leaflet regarding the operation, of which 80 per cent claimed this could enhance their understanding of the procedure. Only 70 per cent of them could recall the potential surgical risks. Most essential items were completed in the consent forms. Witnesses were involved only in 24 per cent of cases. Illegible surgeons' handwriting was observed in 6 per cent of consent documents. Conclusions Most patients could understand the nature and site of the operation they were going to receive. The provision of relevant information to our patients preoperatively was insufficient. Patients had limited recall of the potential surgical risks. There is room for improvement in the present informed consent process.

Background Certain subgroups have higher rates of false fecal immunochemical test (FIT) results, yet few studies have addressed this topic. Objective To identify demographic factors associated with false-positive and false-negative FIT results in colorectal cancer screening. Design Retrospective database review of prospectively collected data. Setting A bowel cancer screening center in Hong Kong invited participants for colorectal cancer screening (2008-2012). Patients Study participants who underwent both FIT and colonoscopy in the first year (n = 4482) and underwent colonoscopy after negative FIT results for 3 consecutive years (n = 857). Main Outcome Measurements The diagnostic accuracy and predictive values of FIT according to participant characteristics. Results The sensitivity, specificity, positive predictive values, and negative predictive values for advanced neoplasia were 33.1%, 91.9%, 19.0%, and 96.0%, respectively. Participants 66 to 70 years of age had higher sensitivity, whereas older age, smoking, and use of aspirin/nonsteroidal anti-inflammatory drugs were associated with lower specificity. The rates of false-positive and false-negative results were 8.1% and 66.9%, respectively. Older age (66-70 years; adjusted odds ratio [AOR] 1.95; 95% confidence interval [CI], 1.35-2.81; P P = .020), and the presence of polypoid adenoma (AOR 1.71; 95% CI, 1.14-2.57; P = .009) were associated with false-positive results. Younger participants (AOR for elderly participants 0.31) and the use of aspirin/nonsteroidal anti-inflammatory drugs (AOR 4.44) in participants with 1 FIT with negative results and the absence of high-grade dysplasia (AOR for presence 0.41) were associated with false-negative results. Limitations Self-referred participants who received one type of qualitative FIT. Conclusion These findings could be used to target screening more toward those with a higher risk of false-negative results and those with a lower risk of false-positive results for earlier colonoscopy.

Flexible sigmoidoscopy (FS) and colonoscopy are two commonly used screening tools for colorectal cancer (CRC), and FS mainly detects distal lesions. Colonoscopy resource is limited, yet there is no definite evidence on when flexible sigmoidoscopy is suitable as a screening alternative. This study evaluated the optimal cut-off score from a validated risk stratification system which best predicts proximal advanced neoplasia (PAN) by comparing the sensitivity, specificity and relative risk of PAN according to various cut-off scores. 5819 asymptomatic subjects aged between 50 and 70years (average age 57.7years, standard deviation (SD) 4.9) received colonoscopy between 2008 and 2014 in Hong Kong. Their prevalence of PAN was evaluated according to a prediction tool for colorectal neoplasia based on age, gender, smoking status, family history of CRC, body mass index (BMI) and diabetes (ranging from 0 to 6). One binary logistic regression model was performed with PAN as the outcome variable and the risk score as the variable tested for association. In multivariate regression analysis, risk score ⩾3 was associated with significantly higher risk of PAN (3.4-9.1%; AOR=3.18-8.09, p0.001) when compared with those scoring 0. Risk scores 0-2 were associated with either insignificant or lower risks of PAN compared to the overall risk. Applying FS for screening those who scored 0-2 and colonoscopy for those who scored ⩾3 led to a very small proportion of PAN being missed (1.60%), whilst maintaining a high level of specificity (81.9%). Clinicians may use this scoring system to inform subjects and facilitate their choice between colonoscopy and FS.

Objectives Influence of environmental exposures on prostate cancer remains largely unclear. We aimed to document the associations of occupational and environmental risk factors with prostate cancer in Hong Kong using a case-control study. Methods We consecutively recruited 431 incident prostate cancer cases and 402 controls to obtain information on occupational and environmental exposures using a standard questionnaire, including smoking, dietary habits, family cancer history, night shift work, use of detergents and pesticide, and lifetime usage of food containers. We developed a new assessment tool of environmental BPA exposure and created a novel cumulative BPA exposure index (CBPAI). Odds ratio and 95% confidence interval (95% CI) was performed using multiple logistic regression analysis. Results Family history of prostate cancer was more common in cases (9.5%) than controls (3.0%), showing an adjusted OR of 3.68 (95% CI: 1.85–7.34). Weekly consumption of deep fried food and picked vegetable was associated with an excessive prostate cancer risk by 85% (95% CI: 15%–195%) and 87% (7%–228%). Night shift work was hazardous (OR=1.76, 95% CI: 1.07–2.89) but habitual green tea drinking was protective (OR=0.56, 95% CI: 0.34–0.91). A positive exposure-response relationship with CPBAI and prostate cancer was observed. Conclusions This study demonstrated an overall picture of occupational and environmental risk factors to prostate cancer among Hong Kong Chinese men. Furthermore, this study provided the first epidemiological evidence on carcinogenicity of BPA on human prostate thus added breakthrough data into the literature. Funding Health and Medical Research Fund (Ref. No. 11121091), Hong Kong Special Administrative Region, China.

The aim of this study was to describe the early results of a phase 1 safety and feasibility clinical trial of the first clinical use of a novel robot for transoral robotic surgery (TORS)—the da Vinci SP (Intuitive Surgical Inc., Sunnyvale, CA, USA). Study design of this study is prospective clinical trial. The methods used in this study are prospective innovation, development, exploration, assessment, and long-term study phase 1 clinical trial. Early results of six patients underwent TORS with the da Vinci SP (Intuitive Surgical Inc., Sunnyvale, CA, USA) demonstrate access the nasopharynx, oropharynx, larynx, and hypopharynx. There were no conversions of the robotic surgical system. There were no serious adverse events or adverse events related to the use of the robot at 30-day follow-up for all six patients. The early results of this safety and feasibility trial of the da Vinci SP (Intuitive Surgical Inc., Sunnyvale, CA, USA) clearly demonstrate that the device is safe and that it is feasible in performing TORS to access the nasopharynx, oropharynx, larynx, and hypopharynx. Electronic supplementary material The online version of this article (doi:10.1007/s00405-017-4729-y) contains supplementary material, which is available to authorized users.

Background: Environmental exposures are contributing factors to prostate cancer etiology, but these remain unclear. We aimed to document the associations between environmental risk factors and prostate cancer in Chinese, with special reference to bisphenol A (BPA). Methods: We recruited 431 newly diagnosed prostate cancer cases and 402 age-matched controls from Prince of Wales Hospital in Hong Kong. We obtained each participant's clinical data and epidemiological information on chronic BPA exposure and other environmental risk factors (e.g., dietary habits, occupation and shift work) using a standard questionnaire. A new assessment tool of environmental BPA exposure was developed and replicated. Multiple logistic regression analysis was performed to examine odds ratio (OR) and 95% confidence interval (95% CI) for the association of prostate cancer with a novel cumulative BPA exposure index (CBPAI) and other environmental risk factors. Results: Weekly consumption of deep fried food (OR=1.85, 95% CI: 1.15–2.95) and pickled vegetable (OR=1.87, 95% CI: 1.07–3.28) was significantly associated with excessive prostate cancer risk. Prostate cancer was positively associated with nightshift work (OR=1.76, 95% CI: 1.07–2.89) and it was negatively associated with green tea drinking (OR=0.56, 95% CI: 0.34–0.91). There was a positive exposure-response relationship between CBPAI and prostate cancer, with the greatest and significant risk in the high versus reference category (OR=1.57, 95% CI: 1.01–2.44). Conclusions: Frequent consumption of deep fried food and pickled vegetable, non-habitual green tea drinking and nightshift work are the contributing risk factors to prostate cancer in Hong Kong Chinese. More importantly, this study provides the first epidemiological evidence on carcinogenicity of BPA on the human prostate. Keywords: Prostate cancer, Environmental exposures, Bisphenol A, Epidemiology

The objective of this study was to compare the level of adherence to colorectal cancer (CRC) screening programs among screening participants offered vs. not offered informed choices on screening modality.We recruited 10,606 screening participants aged 50-70 years, including 6,397 subjects who were offered a choice of yearly fecal immunochemical test (FIT) for up to 3 years vs. one colonoscopy, and 4,209 subjects who were offered either FIT or colonoscopy without choice. They were prospectively followed up for 3 years. The proportion of screening participants who returned their specimens in all subsequent years (FIT group) and the attendance rate of scheduled endoscopy appointment (colonoscopy group) were compared between those with vs. without choice.The adherence rate with FIT was 97.6%, 84.1%, and 72.6% in the first 3 years of follow-up, respectively, among those who were offered a choice. The adherence rate with FIT was 97.5%, 78.4%, and 62.8%, respectively, among those without choices. The proportion of subjects attending colonoscopy was 95.7% (choice offered) and 90.6% (no choice). From binary logistic regression analysis, participants who were offered informed choice were significantly more likely to adhere to the program when compared with those without test choices (odds ratio (OR)=2.54, 95% confidence interval (CI): 2.30-2.82, P0.001). The respective adjusted OR for the FIT and colonoscopy groups was 1.60 (95% CI: 1.42-1.80, P0.001) and 2.53 (95% CI: 1.94-3.31, P0.001).This study found that patients who were offered an informed choice for screening had higher adherence rates than patients who were not offered a choice in real-life practices, suggesting that providing screening test options for CRC screening is preferred.

Purpose: Detecting microRNA (miRNA) in stool is a novel approach for colorectal cancer (CRC) screening. This study aimed to identify stool-based miRNA as noninvasive biomarkers for detection of CRC and adenoma. Experimental Design: A miRNA expression array covering 667 human miRNAs was performed on five pairs of CRC and two pairs of advanced adenoma tissues. The most upregulated miRNAs were validated in 40 pairs of CRC tissues, 16 pairs of advanced adenoma tissues, and 424 stool samples, including 104 CRCs, 169 adenomas, 42 inflammatory bowel diseases (IBD), and 109 healthy controls. miRNA levels were followed-up after removal of lesions. Results: In an array analysis, miR-31 and miR-135b were the most upregulated miRNAs in CRC and advanced adenoma as compared with their adjacent normal tissues (>13-fold increase). In stool samples, level of miR-135b was significantly higher in subjects with CRC (P < 0.0001) or adenomas (P < 0.0001), but not in patients with IBD compared with controls. miR-135b showed a significant increasing trend across the adenoma to cancer sequence (P < 0.0001). Levels of miR-31 were not significantly different among groups. The sensitivity of stool mR-135b was 78% for CRC, 73% for advanced adenoma, and 65% for any adenoma, respectively, with a specificity of 68%. No significant difference in the miR-135b level was found between proximal and distal colorectal lesions. Stool miR-135b dropped significantly upon removal of CRC or advanced adenoma (P < 0.0001). Conclusion: Stool-based miR-135b can be used as a noninvasive biomarker for the detection of CRC and advanced adenoma. Clin Cancer Res; 20(11); 2994–3002. ©2014 AACR.

Objective To compare long-term oncologic outcomes between laparoscopic and open surgery for rectal cancer and to identify independent predictors of survival. Background Few randomized trials comparing laparoscopic and open surgery for rectal cancer have reported long-term survival data. Methods Data from the 3 randomized controlled trials comparing curative laparoscopic (n=136) and open surgery (n=142) for upper, mid, and low rectal cancer conducted at the Prince of Wales Hospital, Hong Kong, between September 1993 and August 2007 were pooled together for this analysis. Survival and disease status were updated to February 2012. Survival was calculated using the Kaplan-Meier method, and independent predictors of survival were determined using the Cox regression analysis. Results The demographic data of the 2 groups were comparable. The median follow-up time of living patients was 124.5 months in the laparoscopic group and 136.6 months in the open group. At 10 years, there were no significant differences in locoregional recurrence (5.5% vs. 9.3%; P=0.296), cancer-specific survival (82.5% vs. 77.6%; P=0.443), and overall survival (63.0% vs. 61.1%; P=0.505) between the laparoscopic and open groups. There was a trend toward lower recurrence rate at 10 years in the laparoscopic group than in the open group among patients with stage III cancer (P=0.078). The Cox regression analysis showed that stage III cancer, lymphovascular permeation, and blood transfusion, but not the operative approach, were independent predictors of poorer cancer-specific survival. Conclusions This pooled analysis with a follow-up of more than 10 years confirms the long-term oncologic safety of laparoscopic surgery for rectal cancer.

INTRODUCTION: Defecation is a complex process that can be easily disturbed. Defecatory disorders may be diagnosed using specialized investigation, including anorectal manometry (ARM) and the balloon expulsion test (BET). Recently, we developed a simulated stool named Fecobionics that integrates several tests and assesses pressures, orientation, and bending during evacuation. The aim was to evaluate the feasibility and performance of Fecobionics for assessing defecatory physiology in normal subjects. METHODS: Physiological expulsion parameters were assessed in an interventional study design. The 10-cm-long Fecobionics probe contained pressure sensors at the front and rear and inside a bag and 2 motion processor units. The bag was distended in the rectum of 20 presumed normal subjects (15 female/5 male) until urge to defecate. ARM-BET was also performed. Three subjects used +2 minutes to evacuate BET, and 1 subject had a high fecal incontinence score. Therefore, the normal group consisted of 16 subjects (13 female/3 male aged 25–78 years). RESULTS: All subjects reported that Fecobionics evacuation was similar to normal defecation. Fecobionics expulsion pressure signatures demonstrated 5 phases, reflecting rectal pressure, anal relaxation, and anal passage. Preload-afterload loop diagrams demonstrated clockwise contraction cycles. The expulsion duration for BET and Fecobionics was 16 ± 2 and 23 ± 5 seconds (P > 0.2), respectively. The duration of the Fecobionics and BET expulsions was associated (P < 0.001). The change in bending of Fecobionics during defecation was 40 ± 3°. DISCUSSION: Fecobionics obtained reliable data under physiological conditions. Agreement was found for comparable variables between ARM-BET and Fecobionics but not for other variables. The study suggests that Fecobionics is safe and effective in evaluation of key defecatory parameters.

Background We investigated the feasibility of adding FOLFOXIRI to neoadjuvant chemoradiotherapy for patients (pts) with high risk rectal adenocarcinoma (T3-4 +/- node positivity, threatened margin and/or sphincter involvement). Methods Eligible patients were treated with 4 cycles of modified FOLFOXIRI (D1: CPT-11 165mg/m2, D1: oxaliplatin 85mg/m2, D1-2 200mg/m2 leucovorin, D1-2 5FU 400mg/m2 30min, then D1-2 5FU 600mg/m2 over 22hrs, with GCSF support), followed by capecitabine (825mg/m2 b.d) given concurrently during pre-operative radiotherapy (CRT, 50.4 Gy, 28 fr, 5 wks). Pts underwent surgery at planned 8-10 weeks after CRT, followed by adjuvant chemo. The primary endpoints were pathologic complete response rate (pCR) and objective response rate (ORR, RECIST ver 1.1). Results 40 eligible pts were enrolled (median age 60 yrs; male:female=82%:18%), 1 pt was excluded before starting treatment. Baseline stage distribution was stage II (10.2%), IIIB (64.1%) and IIIC (25.7%). Of the 39 pts evaluated for response (ITT), ORR to FOLFOXIRI was 38.5% (15 PRs, 24 SDs); ORR to CRT was 64.1% (25 PRs, 9 SDs, 1 PD, 4NA). Total of 28 pt (out of 38 evaluated, 73.7%) had a reduced overall TNM stage. Of the 27 pts who underwent surgery (18.5% had permanent stoma), pCR rate was 25.9%, 26 pts had negative and 1 pt had close margin, respectively. At median follow-up of 30.2 months, the 2-yr overall survival and relapse-free rates were 79.3% and 82.8%, respectively. The top three most common grade 3-4 toxicities: (1) To FOLFOXIRI were diarrhea (12%), neutropenia (7.7%) and hyponatremia (5.1%); (2) To CRT – diarrhea (2.5%), RT-dermatitis (2.5%) and rectal hemorrhage (2.5%). No treatment-related deaths or perioperative mortality were encountered. Conclusions In summary, neoadjuvant FOLFOXIRI followed by Cape-RT for high risk rectal cancer is feasible and the pCR rate compares favorably with the historic rate of 13.8% with CRT alone (Yeung et al. Hong Kong Med J 2016;22) This strategy is being evaluated in a randomized study. Clinical trial identification NCT01941641. Legal entity responsible for the study The Chinese University of Hong Kong. Funding Hong Kong Research Grant Council General Research Fund 471613. Disclosure All authors have declared no conflicts of interest.