Clinical outcomes of gastric cancer surgery after liver transplantation

Purpose

De novo malignancy is common after liver transplantation (LT); however, there are limited reports on the clinical outcomes of gastric cancer surgery after LT. Our study aimed to investigate the feasibility and safety of gastric cancer surgery after LT.

Methods

Seventeen patients underwent gastric cancer surgery after LT at a single institution between January 2013 and June 2021. We retrospectively collected data on surgical complications, survival, and recurrence status of these cases.

Results

Fifteen patients (88.2%) underwent curative gastrectomy, with 10 open distal (66.7%) and 5 laparoscopic distal (33.3%) gastrectomies. Surgical and severe complication rates were 3 of 15 (20.0%) and 1 of 15 (6.7%), respectively. There were no significant differences between laparoscopic (33.3%) and open surgery (66.7%) in terms of operation time and complication rate. No surgery-related mortalities occurred. Immunosuppressants could be maintained without difficulty, and no suspicious acute rejection was identified during the perioperative period. There was 1 recurrence after curative surgery (recurrence rate, 6.7%), and the 5-year cancer-specific survival rate after curative surgery was 93.3%.

Conclusion

Laparoscopic gastrectomy can be safely done even after LT in terms of postoperative complications and graft safety.

CBCT based study to analyze and classify root canal morphology of maxillary molars - A retrospective study

OBJECTIVE

The study aims to evaluate maxillary molars' root and root canal morphology among the Saudi population using Cone-Beam Computed Tomography scanning (CBCT).

SUBJECTS AND METHODS

Retrospectively, the CBCT scans of 483 Saudi nationals were evaluated to identify the number of roots and root canals in maxillary first and second molars. The records were tabulated and classified according to Vertucci and a new system for root and canal classification given by Ahmed and Dummer. Fisher's exact test was used to analyze the data statistically. To check for symmetry, comparisons were made between all the maxillary first molars (MFM's) and maxillary second molars (MSM's) on opposing quadrants. Inter Observer variability was seen using Cohen's Kappa test.

RESULTS

MFM's presented with three roots with Type II Vertucci canal configuration (VC) commonly seen among them. MSM's had more variations in the number of roots and canals, although three roots and Type I VC were predominantly seen. When comparing the two genders statistically significant difference was observed in both maxillary molars at a 5% level using Fisher's exact test. Three roots with four canals (3R4C) were predominantly observed in the MFM's (85.6%) and three roots with three canals (3R3C) identified in 51.95% were more common than 3R4C (43.55%) in MSM's. Both the maxillary molars bilaterally, exhibited a high percentage of symmetry in root and canal configurations.

CONCLUSIONS

Identification of root canal morphology of molars would reduce the chances of root canal failures by making sure all canals are obturated. This study provides supplemental information about the root canals of maxillary molars in a Saudi Arabian subpopulation.

Awareness, knowledge, attitudes, and practices before the second wave of the COVID-19 pandemic in Saudi Arabia

OBJECTIVE

The COVID-19 outbreak was first reported in Wuhan City, China in early December 2019. It was declared a pandemic by WHO in March 2020. This study aimed at assessing the knowledge, awareness, and attitudes of the general population in Saudi Arabia towards COVID-19, as well as its adherence to preventive measures and its willingness to take the vaccine.

PATIENTS AND METHODS

This descriptive cross-sectional study involved an online sample of 7,188 participants (from five regions of Saudi Arabia) who completed a self-administered online-based questionnaire. They were recruited from 23 November 2020 to 29 November 2020 based on the nonprobability convenience sampling method. The self-administered questionnaire comprised four main sections: gathering information about participants' demographics, knowledge and awareness of COVID-19, participants' practices (hygiene and other) against infection, and vaccine acceptability.

RESULTS

More than half of the study participants were knowledgeable about COVID-19. The mean scores were 10.4 (SD=3.44, range: 0-18 - with high scores indicating better knowledge or awareness) for knowledge and 6.1 (SD=2.26, range: 0-11) for awareness, indicating a need for more educational campaigns to improve the level of knowledge and awareness among the Saudi Arabian population about COVID-19. The mean score for attitude was 5 (SD=1.67, range: 0-8 - from 0=very pessimistic to 8=very optimistic), indicating moderate optimism. As for practices, the mean score was 7.8 (SD=1.57, range: 0-10), indicating good practices to prevent or control infection. Concerning acceptability of the COVID-19 vaccine, 63.8% of the participants agreed to take the vaccine if it was proven to be 95% effective.

CONCLUSIONS

The findings of this study can help us designing effective measures against COVID-19 infections. Our results highlight the best practices adopted by the Saudi Arabian population, as well as those areas requiring improvement, including knowledge, attitudes, and practices against this disease.

Short-term Outcomes of Pylorus-Preserving Gastrectomy for Early Gastric Cancer: Comparison Between Extracorporeal and Intracorporeal Gastrogastrostomy

Purpose

This study aimed to compare the surgical and oncological outcomes between totally laparoscopic pylorus-preserving gastrectomy (TLPPG) with intracorporeal anastomosis and laparoscopy-assisted pylorus-preserving gastrectomy (LAPPG) with extracorporeal anastomosis.

Materials and Methods

A retrospective analysis was performed in 258 patients with cT1N0 gastric cancer who underwent laparoscopic pylorus-preserving gastrectomy using two different anastomosis methods: TLPPG with intracorporeal anastomosis (n=88) and LAPPG with extracorporeal anastomosis (n=170). The following variables were compared between the two groups to assess the postoperative surgical and oncological outcomes: proximal and distal margins, number of resected lymph nodes (LNs) in total and in LN station 6, operation time, postoperative hospital stay, and postoperative morbidity including delayed gastric emptying (DGE).

Results

The average length of the proximal margin was similar between the TLPPG and LAPPG groups (2.35 vs. 2.73 cm, P=0.070). Although the distal margin was significantly shorter in the TLPPG group than in the LAPPG group (3.15 vs. 4.08 cm, P=0.001), no proximal or distal resection margin-positive cases were reported in either group. The average number of resected LN was similar in both groups (36.0 vs. 33.98, P=0.229; LN station 6, 5.72 vs. 5.33, P=0.399). The operation time was shorter in the TLPPG group than in the LAPPG (200.17 vs. 220.80 minutes, P=0.001). No significant differences were observed between the two groups in terms of postoperative hospital stay (9.38 vs. 10.10 days, P=0.426) and surgical complication rate (19.3% vs. 22.9%), including DGE (8.0% vs. 11.8%, P=0.343).

Conclusions

The oncological safety and postoperative complications of TLPPG with intracorporeal anastomosis are similar to those of LAPPG with extracorporeal anastomosis.

Postoperative quality of life after gastrectomy in gastric cancer patients: a prospective longitudinal observation study

Purpose

The European Organization for Research and Treatment of Cancer quality of life (QOL) questionnaires (QLQ-C30, QLQ-OG25, and QLQ-STO22) are widely used for the assessment of gastric cancer patients. This study aimed to use these questionnaires to evaluate QOL in postgastrectomy patients.

Methods

We prospectively evaluated 106 patients with distal gastrectomy (DG), 57 with pylorus-preserving gastrectomy (PPG), and 117 with total gastrectomy (TG). Body weight and QOL questionnaires were evaluated preoperatively and postoperatively (at 3 weeks, and 3, 6, and 12 months).

Results

TG patients had significantly more weight loss than DG/PPG patients. Compared with DG, patients after PPG had less dyspnea (P = 0.008) and trouble with coughing (P = 0.049), but more severe symptoms of insomnia (P = 0.037) and reflux (P = 0.030) at postoperative 12 months. Compared with DG/PPG, TG was associated with worse body image, dysphagia, eating, and taste in both OG25 and STO22. Moreover, OG25 revealed worse QOL in the TG group with respect to odynophagia, eating with others, choked when swallowing, trouble talking, and weight loss. The QOL of patients who received chemotherapy was worse than those in the chemo-free group in both physical functioning and symptoms such as nausea/vomiting, appetite loss, and trouble with taste; however, these side effects would soon disappear after finishing chemotherapy.

Conclusion

PPG was similar to DG in terms of postoperative QOL and maintaining body weight, while TG was always inferior to both DG and PPG. Adjuvant chemotherapy can affect both body weight and QOL despite being reversible.

Preservation of hepatic branch of the vagus nerve reduces the risk of gallstone formation after gastrectomy

BACKGROUND

Injury to the vagus nerve has been proposed to be associated with occurrence of gallstones after gastrectomy. We investigated the effect of preservation of hepatic branch of the vagus nerve on prevention of gallstones during laparoscopic distal (LDG) and pylorus-preserving gastrectomy (LPPG).

METHODS

Preservation of the vagus nerve was reviewed of cT1N0M0 gastric cancer patients underwent LDG (n = 323) and LPPG (n = 144) during 2016-2017. Presence of gallstones was evaluated by ultrasonography (US) and computed tomography (CT). Incidences of gallstones were compared between the nerve preserved (h-DG, h-PPG) group and sacrificed (s-DG, s-PPG) group. Clinicopathological features were also compared.

RESULTS

The 3-year cumulative incidence of gallstones was lower in the h-DG (2.7%, n = 85) than the s-DG (14.6%, n = 238) (p = 0.017) and lower in the h-PPG (1.6%, n = 123) than the s-PPG (12.9%, n = 21) (p = 0.004). Overall postoperative complication rate was similar between the h-DG and s-DG (p = 0.861) as well as between the h-PPG and s-PPG (p = 0.768). The number of retrieved lymph nodes station #1 and 3-year recurrence-free survival were not significantly different between the preserved group and sacrificed group. Injury to the vagus nerve (p = 0.001) and high body mass index (BMI) (≥ 27.5 kg/m²) (p = 0.040) were found to be independent risk factors of gallstone formation in multivariate analysis.

CONCLUSIONS

Preservation of hepatic branch of the vagus nerve can be recommended for LDG as well as LPPG of early gastric cancer patients to reduce postoperative gallstone formation.

Postprandial Changes in Gastrointestinal Hormones and Hemodynamics after Gastrectomy in Terms of Early Dumping Syndrome

Purpose

This study aimed to examine the early postprandial changes in gastrointestinal (GI) hormones and hemodynamics in terms of early dumping syndrome after gastrectomy for gastric cancer.

Materials and Methods

Forty patients who underwent gastrectomy for gastric cancer and 18 controls without previous abdominal surgery were enrolled. Before and 20 minutes after liquid meal ingestion, blood glucose, glucagon-like peptide-1 (GLP-1), and GLP-2 concentrations and superior mesenteric artery (SMA) and renal blood flow were measured. The patients' heart rates were recorded at 5-minute intervals. All subjects were examined for dumping syndrome using a questionnaire based on Sigstad's clinical diagnostic index.

Results

The postprandial increases in blood glucose, GLP-1, and GLP-2 levels as well as SMA blood flow and heart rate were greater in patients who underwent gastrectomy than in controls (all P<0.010). Patients who underwent gastrectomy showed a significantly decreased renal blood flow (P<0.001). Among patients who underwent gastrectomy, distal gastrectomy was a significant clinical factor associated with a lower risk of early dumping syndrome than total gastrectomy (hazard ratio, 0.092; 95% confidence interval, 0.013–0.649; P=0.017). Patients who underwent total gastrectomy showed a greater postprandial increase in blood glucose (P<0.001), GLP-1 (P=0.030), and GLP-2 (P=0.002) levels as well as and heart rate (P=0.013) compared to those who underwent distal gastrectomy.

Conclusions

Early postprandial changes in GI hormones and hemodynamics were greater in patients who underwent gastrectomy than in controls, especially after total gastrectomy, suggesting that these changes play a crucial role in the pathophysiology of early dumping syndrome.

Clinical genomics expands the morbid genome of intellectual disability and offers a high diagnostic yield

Intellectual disability (ID) is a measurable phenotypic consequence of genetic and environmental factors. In this study, we prospectively assessed the diagnostic yield of genomic tools (molecular karyotyping, multi-gene panel and exome sequencing) in a cohort of 337 ID subjects as a first-tier test and compared it with a standard clinical evaluation performed in parallel. Standard clinical evaluation suggested a diagnosis in 16% of cases (54/337) but only 70% of these (38/54) were subsequently confirmed. On the other hand, the genomic approach revealed a likely diagnosis in 58% (n=196). These included copy number variants in 14% (n=54, 15% are novel), and point mutations revealed by multi-gene panel and exome sequencing in the remaining 43% (1% were found to have Fragile-X). The identified point mutations were mostly recessive (n=117, 81%), consistent with the high consanguinity of the study cohort, but also X-linked (n=8, 6%) and de novo dominant (n=19, 13%). When applied directly on all cases with negative molecular karyotyping, the diagnostic yield of exome sequencing was 60% (77/129). Exome sequencing also identified likely pathogenic variants in three novel candidate genes (DENND5A, NEMF and DNHD1) each of which harbored independent homozygous mutations in patients with overlapping phenotypes. In addition, exome sequencing revealed de novo and recessive variants in 32 genes (MAMDC2, TUBAL3, CPNE6, KLHL24, USP2, PIP5K1A, UBE4A, TP53TG5, ATOH1, C16ORF90, SLC39A14, TRERF1, RGL1, CDH11, SYDE2, HIRA, FEZF2, PROCA1, PIANP, PLK2, QRFPR, AP3B2, NUDT2, UFC1, BTN3A2, TADA1, ARFGEF3, FAM160B1, ZMYM5, SLC45A1, ARHGAP33 and CAPS2), which we highlight as potential candidates on the basis of several lines of evidence, and one of these genes (SLC39A14) was biallelically inactivated in a potentially treatable form of hypermanganesemia and neurodegeneration. Finally, likely causal variants in previously published candidate genes were identified (ASTN1, HELZ, THOC6, WDR45B, ADRA2B and CLIP1), thus supporting their involvement in ID pathogenesis. Our results expand the morbid genome of ID and support the adoption of genomics as a first-tier test for individuals with ID.

Excessively redundant umbilical skin as a potential early clinical feature of Morquio syndrome and FKBP14-related Ehlers-Danlos syndrome

Several umbilical abnormalities have been linked to and utilized to aid in the clinical diagnosis of certain syndromes. For instance, umbilical skin redundancy has long been recognized as a core feature of Rieger syndrome although its association with other disorders is unknown. In this article, we report for the first time the occurrence of this distinct clinical sign in association with two other syndromes: Morquio syndrome and FKBP14-related Ehlers-Danlos syndrome (EDS). Our observation is clinically significant because patients with Morquio syndrome are often diagnosed only after they develop typical skeletal manifestations, which reduces the efficacy of available enzyme replacement therapy, so the umbilical sign we report here can facilitate a much earlier diagnosis. In addition, the extreme rarity of FKBP14-related Ehlers-Danlos syndrome (EDS) can greatly delay the diagnosis of this condition unless it is recognized in the differential diagnosis of redundant umbilical skin as we argue in this report.