Comparison between the mesenteric fixation method (MEFIX) and conventional methods at preventing the occurrence of Petersen's hernia: a study protocol for a multicenter randomized controlled trial

BACKGROUND

Petersen's hernia, which occurs after Billroth-II (B-II) or Roux-en-Y (REY) anastomosis, can be reduced by defect closure. This study aims to compare the incidence of bowel obstruction above Clavien-Dindo classification grade III due to Petersen's hernia between the mesenteric fixation method and the conventional methods after laparoscopic or robotic gastrectomy.

METHODS

This study was designed as prospective, single-blind, non-inferiority randomized controlled multicenter trial in Korea. Patients with histologically diagnosed gastric cancer of clinical stages I, II, or III who underwent B-II or REY anastomosis after laparoscopic or robotic gastrectomy are enrolled in this study. Participants who meet the inclusion criteria are randomly assigned to two groups: a CLOSURE group that underwent conventional Petersen's defect closure method and a MEFIX group that underwent the mesenteric fixation method. The primary endpoint is the number of patients who underwent surgery for bowel obstruction caused by Petersen's hernia within 3 years after laparoscopic or robotic gastrectomy.

DISCUSSION

This trial is expected to provide high-level evidence showing that the MEFIX method can quickly and easily close Petersen's defect without increased postoperative complications compared to the conventional method.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05105360. Registered on November 3, 2021.

Reappraisal of optimal reconstruction after distal gastrectomy - a study based on the KLASS-07 database

BACKGROUNDS

This study aimed to compare the incidence of bile reflux, quality of life (QoL), and nutritional status among Billroth II (BII), Billroth II with Braun anastomosis (BII-B), and Roux-en-Y (RY) reconstruction after laparoscopic distal gastrectomy (LDG).

MATERIALS AND METHODS

We reviewed the prospective data of 397 patients from a multicentre database who underwent LDG for gastric cancer between 2018 and 2020 at 20 tertiary teaching hospitals in Korea. Postoperative endoscopic findings, QoL surveys using the European Organization for Research and Treatment of Cancer questionnaire (C30 and STO22), and nutritional and surgical outcomes were compared among groups.

RESULTS

In endoscopic findings, bile reflux was the lowest in the RY group ( n =67), followed by the BII-B ( n =183) and BII groups ( n =147) at 1 year (3.0 vs. 67.8 vs. 84.4%, all P <0.05). The anti-reflux capability of BII-B was statistically better than that of BII, but not as perfect as that of RY. From the perspective of QoL, BII-B was not inferior to RY, but better than BII reconstruction in causing fewer STO22 reflux symptoms at 6 and 12 months. However, only RY caused fewer C30 nausea symptoms than BII at 6 and 12 months, but not BII-B. Nutritional status and morbidities were similar among the three groups, and the operative time did not differ between the BII-B and RY groups.

CONCLUSIONS

BII-B cannot substitute for RY in preventing bile reflux, shortening the operative time, or reducing morbidities. Regarding short-term QoL, BII-B was sufficient to reduce STO22 reflux symptoms but failed to reduce C30 nausea symptoms postoperatively.

Perioperative risk and benefit of antiplatelet therapy in patients undergoing non-cardiac surgery within 1 year after percutaneous coronary intervention with second-generation drug-eluting stents

Background

Antiplatelet therapy (APT) in patients undergoing non-cardiac surgery (NCS) after percutaneous coronary intervention (PCI) is still on debate due to its opposite effects which are to prevent from cardiovascular events and to cause bleeding. There is no apparent consensus on how to determine perioperative APT strategy within 1 year after PCI. Therefore, we investigated the risk and benefit of APT in NCS within 1 year after PCI.

Methods

Patients undergoing NCS after PCI with second-generation drug-eluting stents are retrospectively included from multicenter cohort of 8 medical centers in Korea. Perioperative clinical event within 30 days after NCS was recorded. Net adverse clinical event (NACE) including all cause death, major adverse cardiac event (MACE, a composite of cardiac death, myocardial infarction, and stent thrombosis) and major bleeding were evaluated. To overcome bias, propensity score covariate adjustment was performed using logistic regression analysis to generate propensity scores for patients of both APT strategies.

Results

Total 1130 patients (median age 69 years, female 30.5%) undergoing NCS within 1 year after PCI were eligible in the cohort. Study population included 55.1% patients suffered from ACS and 22.5% underwent complex PCI. NCS included 45.8% intermediate-to-high risk surgery and 10.7% urgent or emergent surgery. APT was continued during NCS in 62.7% of the patients. More patients continued DAPT (48% vs. 32%, p&lt;0.001) among the patients who underwent NCS within 6 months after PCI than those who underwent NCS after 6 months. There were 49 NACE (4.3%), 16 MACE (1.4%) and 23 major bleeding events (2.0%), respectively. Continuing APT was associated with a lower risk of NACE (Adjusted hazard ratio [HR], 0.49; 95% confidence interval [CI], 0.27–0.89; p=0.020)) and MACE (Adjusted HR, 0.35; 95 CI, 0.12–0.96; p=0.042). Subgroup analysis showed a tendency that continuing APT might be favorable than discontinuing APT in terms of MACE in patients who were diagnosed with ACS, underwent complex PCI, or underwent NCS within 6 months after PCI.

Conclusions

About two thirds of the patients were continuing APT during NCS. Our findings may support a careful consideration of APT continuation for some of the patients who are undergoing NCS within 1 year after PCI.

Funding Acknowledgement

Type of funding sources: None.

Gastric Malignant Peripheral Nerve Sheath Tumor in Type 1 Neurofibromatosis

Gastric malignant peripheral nerve sheath tumors (MPNSTs) are extremely rare spindle cell sarcomas that arise within the peripheral nerves of the gastrointestinal tract. MPNST can present as a mass that may or may not be accompanied by obstruction or bleeding. Type 1 neurofibromatosis (NF) is an autosomal dominant genetic disorder with an incidence of 1 in 2,500-3,000. Plexiform neurofibromas in Type 1 NF can undergo a malignant transformation to MPNSTs. Approximately half of the incidence of MPNST is associated with the NF-1 gene. MPNST behaves aggressively, and radical excisional surgery is important for treatment. Recurrence and metastasis are significant, even after a radical excision. Despite multidisciplinary treatment, the five-year survival rate is only 30-50%. This paper reports the case of a 47-year-old man with Type 1 NF who presented with hemorrhage of a gastric subepithelial lesion. He underwent surgery under the suspicion of a gastrointestinal stromal tumor, but it was diagnosed as MPNST after confirming the histopathological appearance and immunohistochemical profiles. In addition, the large mass invaded the spleen and diaphragm. Radical surgery was performed, and additional chemotherapy was administered. This paper reports the experience of a patient with NF 1 with advanced MPNST discovered due to a subepithelial lesion.

A Huge Malignant Gastric Gastrointestinal Stromal Tumor in a Young Patient

Malignant gastrointestinal stromal tumors (GISTs) are rare neoplasms originating from the gastrointestinal tract that rarely occur in patients below 40 years of age. To our knowledge, there have been no previous reports of satellite and metastatic nodules in GIST. We present a case of a young patient with a huge malignant gastric GIST accompanied by spontaneous bleeding and satellite and metastatic nodules, successfully treated surgically, without preoperative chemotherapy administration. A 28-year-old man was admitted to Haeundae Paik Hospital with melena. A huge bulging gastric mass with ulceration and bleeding was observed on endoscopy. A subepithelial lesion on the stomach body, abutting the pancreatic body and tail, with regional lymph node enlargement was confirmed by EUS and CT. Radical total gastrectomy was performed, the invasion surrounding the pancreatic tail and spleen were surgically dissected, and enlarged lymph nodes around the celiac trunk and the common hepatic artery were removed. The pathology results showed a malignant GIST with two satellite nodules and a metastatic tumor nodule at the left paracardial lymph node site. After complete resection of the malignant GIST, adjuvant chemotherapy with imatinib was initiated. Follow-up CT and endoscopy performed 6 months after surgery confirmed no recurrence of the disease.

Long-Term Survival Outcomes of Elderly Patients Treated With S-1 or Capecitabine Plus Oxaliplatin for Stage II or III Gastric Cancer: A Multicenter Cohort Study

Purpose

Materials and Methods

Results

Conclusions

Gastric Neuroendocrine Tumor Mimicking Gastrointestinal Stromal Tumor: A Case Report

Gastric neuroendocrine tumors (NETs) are rare lesions that arise from enterochromaffin-like cells of the gastric mucosa. Gastric NETs are classified into 3 types of NETs and poorly differentiated neuroendocrine cancers. Most gastric NETs usually present as hemispherical, yellowish, polypoid lesions with a central depression and often as subepithelial tumors (SETs) because they are confined within the submucosal layer. Here, we report a case of gastric NET presenting as SET mimicking a gastrointestinal stromal tumor (GIST). Endoscopy revealed a 2.3-cm-sized SET with intact surface mucosa, and endoscopic ultrasonography showed a homogeneous hypoechoic lesion with a well-circumscribed margin. Typical features of gastric NET, such as yellowish mucosal changes or central ulceration, were not observed. GIST was suspected, and a laparoscopic wedge resection was performed. The final diagnosis was gastric NET with grade 2 differentiation.

Long-Term Survival of Two Patients with Liver Metastases from Advanced Gastric Cancer Treated with Radiofrequency Ablation and Chemotherapy

Liver metastasis from gastric cancer has a very poor prognosis. Herein, we present two cases of liver metastases (synchronous and metachronous) from advanced gastric cancer. In the first case, the patient underwent radical subtotal gastrectomy. Liver metastases occurred 6 months after surgery while the patient was receiving adjuvant chemotherapy, but two hepatic tumors were successfully removed by radiofrequency ablation (RFA). In the second case, liver metastases occurred 15 months after surgery for gastric cancer. The patient also received RFA for one hepatic tumor, and other suspicious metastatic tumors were treated with systemic chemotherapy. Although these case presentations are limited for the efficacy of RFA treatment with systemic chemotherapy for hepatic metastases from gastric cancer, our findings showed long-term survival (overall survival for 108 and 67 months, respectively) of the affected patients, without recurrence. Therefore, we suggest that RFA treatment with systemic chemotherapy could be an effective alternative treatment modality for hepatic metastases from gastric cancer.

Appropriate Number of Adjuvant Chemotherapy Cycles for Patients with Stage 2 or 3 Gastric Cancer After Curative Gastrectomy: A Multicenter Cohort Study

BACKGROUND

Few studies have presented evidence pertaining to the adequate minimum number of adjuvant chemotherapy (AC) cycles required to achieve an oncologic benefit for gastric cancer.

METHODS

From January 2012 to December 2013, data from patients who underwent curative radical gastrectomy and consequently received AC for pathologic stage 2 or 3 gastric cancer at 27 institutions in South Korea were analyzed.

RESULTS

The study enrolled 925 patients, 661 patients (71.5%) who completed 8 cycles of AC and 264 patients (28.5%) who did not. Compared with the mean disease-free survival (DFS) of the patients who completed 8 AC cycles (69.3 months), the mean DFS of patients who completed 6 AC cycles (72.4 months; p = 0.531) and those who completed 7 AC cycles (63.7 months; p = 0.184) did not differ significantly. However, the mean DFS of the patients who completed 5 AC cycles (48.2 months; p = 0.016) and those who completed 1-4 AC cycles (62.9 months; p = 0.036) was significantly lower than the DFS of those who completed 8 AC cycles. In the multivariate Cox proportional hazards analysis, the mean DFS was significantly affected by advanced stage, large tumor size, positive vascular invasion, and number of completed AC cycles (1-5 cycles: hazard ratio 1.45; 95% confidence interval 1.01-2.08; p = 0.041).

CONCLUSION

The current multicenter observational cohort study showed that the mean DFS for 6 or 7 AC cycles was similar to that for 8 AC cycles as an adjuvant treatment for gastric cancer.

Amifampridine to treat Lambert-Eaton myasthenic syndrome

Lambert-Eaton myasthenic syndrome (LEMS) is a presynaptic autoimmune disabling neuromuscular disease caused by antibodies against presynaptic voltage-gated calcium channels. It reduces the quantal release of acetylcholine (Ach), causing muscle weakness, reduced or absent reflex and dysautonomia. About half of LEMS patients have associated small cell lung cancer. For symptomatic treatment, amifampridine (3,4-diaminopyridine [3,4-DAP]) is ideal because it increases the release of Ach at the presynaptic membrane. Since the first use of 3,4-DAP in LEMS patients in the 1980s, 136 LEMS patients were treated with amifampridines in the open-label studies and 208 patients in the eight randomized studies. These studies showed that amifampridine is the most effective drug for symptomatic treatment in LEMS. Now, 3,4-DAPP (3,4-DAP phosphate) is approved for adult LEMS patients and 3,4-DAP for pediatric patients. The recommended dose is 80 mg a day, divided 3 or 4 times a day. Side effects are usually mild, and the most frequently reported are paresthesia.

The pattern of postoperative quality of life following minimally invasive gastrectomy for gastric cancer: a prospective cohort from Korean multicenter robotic gastrectomy trial

Purpose

Quality of life (QOL) has become important in the trend of emphasizing patient satisfaction. This study aimed to evaluate the QOL in patients who underwent laparoscopic or robotic gastrectomy for gastric cancer.

Methods

A prospective trial was performed involving patients who underwent laparoscopic or robotic gastrectomy for primary gastric cancer at 11 hospitals in Korea. Within this comparative trial, QOL, postoperative pain, and long-term complications were exanimated. The quality-of-life questionnaire (QLQ)-C30 and QLQ-STO22 developed by the European Organization for Research and Treatment of Cancer were used for the QOL survey. We compared the data after dividing it into several types of characteristics as follows; device (robotic or laparoscopic), operation type, pathological stage, and sex. Biased components were extracted by logistic regression analysis. Propensity score matching was applied to the data set with the biased components.

Results

In total, 434 patients (211 for laparoscopic surgery and 223 for robotic surgery) were enrolled, out of which 321 patients who responded to both preoperative and postoperative surveys were selected for analysis. Robotic gastrectomy was not different from laparoscopic gastrectomy with respect to postoperative QOL. Distal gastrectomy showed better scores than total gastrectomy in terms of role functioning, social functioning, fatigue, nausea/vomiting, pain, dyspnea, constipation, financial difficulties, dysphagia, eating restrictions, anxiety, taste, and body image. Male patients showed better scores on the 19 scales compared to female patients.

Conclusion

Robotic and laparoscopic approaches for gastric cancer surgery did not differ from each other with respect to QOL. Distal gastrectomy resulted in better QOL than total gastrectomy.

Reducing Malignant Ascites and Long-Term Survival in a Patient with Recurrent Gastric Cancer Treated with a Combination of Docetaxel and Mistletoe Extract

Recurrent gastric cancer with peritoneal seeding is associated with poor overall survival. A 71-year-old man with advanced gastric cancer underwent radical total gastrectomy (stage IIIb, T4b N1 M0). Abdomino-pelvic computed tomography performed 7 months after surgery revealed increased ascites with enhanced peritoneal thickening. He was diagnosed with peritoneal seeding and received second-line chemotherapy (irinotecan). However, he refused chemotherapy due to the side effects (general weakness, nausea, and vomiting) after 1 cycle. He started receiving alternative therapy with Viscum album extract (VAE) (mistletoe) instead of chemotherapy. Malignant ascites gradually decreased after mistletoe therapy. So we started third-line chemotherapy (docetaxel) with VAE. The patient achieved good health with complete response postoperatively 32 months after combination treatment and survived over 60 months after surgery without disease progression. We report a case of recurrent gastric cancer that was successfully treated with a combination of docetaxel monotherapy and long-term mistletoe extract treatment.

Signet Ring Cell Carcinoma Mimicking Gastric Gastrointestinal Stromal Tumor: A Case Report

The presentation of submucosal gastric cancer, especially signet ring cell carcinoma, is rare. The submucosal tumor (SMT) is covered with normal mucosa, and confirmation is difficult through endoscopic biopsy; thus, histologic diagnosis is important to determine the appropriate treatment method. Here, we report a case of gastric signet ring cell carcinoma mimicking gastrointestinal stromal tumor (GIST). A 2-cm-sized SMT suspected of being a GIST on preoperative endoscopic ultrasonography and computed tomography was suspected to be cancerous during surgery. The frozen diagnosis of the resected mass (obtained via wedge resection) showed a carcinoma with signet ring feature, and additional frozen diagnosis of one enlarged lymph node revealed metastatic cancer. Therefore, subtotal gastrectomy with lymph node dissection was performed. This case report suggests that preoperative histologic diagnosis of high-risk SMT might be useful, although the tumor had typical features of GIST on preoperative imaging. Overall, if a tumor is suspected of being a gastric carcinoma during surgery and the differential diagnosis between gastric carcinoma and GIST is uncertain, a careful surgical approach should be considered to account for the possibility of adenocarcinoma.

Long-term Efficacy of S-1 Monotherapy or Capecitabine Plus Oxaliplatin as Adjuvant Chemotherapy for Patients with Stage II or III Gastric Cancer after Curative Gastrectomy: a Propensity Score-Matched Multicenter Cohort Study

Purpose

To compare long-term disease-free survival (DFS) between patients receiving tegafur/gimeracil/oteracil (S-1) or capecitabine plus oxaliplatin (CAPOX) adjuvant chemotherapy (AC) for gastric cancer (GC).

Materials and Methods

This retrospective multicenter observational study enrolled 983 patients who underwent curative gastrectomy with consecutive AC with S-1 or CAPOX for stage II or III GC at 27 hospitals in Korea between February 2012 and December 2013. We conducted propensity score matching to reduce selection bias. Long-term oncologic outcomes, including DFS rate over 5 years (over-5yr DFS), were analyzed postoperatively.

Results

The median and longest follow-up period were 59.0 and 87.6 months, respectively. DFS rate did not differ between patients who received S-1 and CAPOX for pathologic stage II (P=0.677) and stage III (P=0.899) GC. Moreover, hazard ratio (HR) for recurrence did not differ significantly between S-1 and CAPOX (reference) in stage II (HR, 1.846; 95% confidence interval [CI], 0.693–4.919; P=0.220) and stage III (HR, 0.942; 95% CI, 0.664–1.337; P=0.738) GC. After adjustment for significance in multivariate analysis, pT (4 vs. 1) (HR, 11.667; 95% CI, 1.595–85.351; P=0.016), pN stage (0 vs. 3) (HR, 2.788; 95% CI, 1.502–5.174; P=0.001), and completion of planned chemotherapy (HR, 2.213; 95% CI, 1.618–3.028; P<0.001) were determined as independent prognostic factors for DFS.

Conclusions

S-1 and CAPOX AC regimens did not show significant difference in over-5yr DFS after curative gastrectomy in patients with stage II or III GC. The pT, pN stage, and completion of planned chemotherapy were prognostic factors for GC recurrence.

Actual compliance to adjuvant chemotherapy in gastric cancer

Purpose

This study aims to investigate the actual compliance with chemotherapy and analyze several factors affecting the compliance in patients with gastric cancer.

Methods

From February 2012 to December 2014, we collected data of patients with gastric cancer who received adjuvant chemotherapy (TS-1 monotherapy or XELOX: capecitabine/oxaliplatin) in Korea.

Results

We collected data of 1,089 patients from 31 institutions. The completion rate and dose reduction rate by age (≥60 years vs. <60 years) were 57.5% vs. 76.8% (P < 0.001) and 17.9% vs. 21.3% (P = 0.354); by body mass index (BMI) (≥23 kg/m²vs. <23 kg/m²) were 70.2% vs. 63.2% (P = 0.019) and 19.2% vs. 19.9% (P = 0.987), respectively. The compliance by American Society of Anesthesiologists physical status (ASA PS) classification was as follows: completion rate was 74.4%, 62.8%, and 60% (P = 0.001) and the dose reduction rate was 18.4%, 20.7%, and 17.8% (P = 0.946) in ASA PS classification I, II, and III, respectively. The completion rate of TS-1 and XELOX was 65.9% vs. 70.3% (P = 0.206) and the dose reduction rate was 15.7% vs. 33.6% (P < 0.001). Furthermore, the completion rate of chemotherapy by surgical oncologists and medical oncologists was 69.5% vs. 63.2% (P = 0.028) and the dose reduction rate was 17.4% vs. 22.3% (P = 0.035), respectively.

Conclusion

The compliance was lower in patients who were older than 60 years, had BMI <23 kg/m², and had higher ASA PS classification. Furthermore, the patients showed higher compliance when they received chemotherapy from surgical oncologists rather than from medical oncologists.

A feasibility study of laparoscopic total gastrectomy for clinical stage I gastric cancer: a prospective multi-center phase II clinical trial, KLASS 03

BACKGROUND

With improved short-term surgical outcomes, laparoscopic distal gastrectomy has rapidly gained popularity. However, the safety and feasibility of laparoscopic total gastrectomy (LTG) has not yet been proven due to the difficulty of the technique. This single-arm prospective multi-center study was conducted to evaluate the use of LTG for clinical stage I gastric cancer.

METHODS

Between October 2012 and January 2014, 170 patients with pathologically proven, clinical stage I gastric adenocarcinoma located at the proximal stomach were enrolled. Twenty-two experienced surgeons from 19 institutions participated in this clinical trial. The primary end point was the incidence of postoperative morbidity and mortality at postoperative 30 days. The severity of postoperative complications was categorized according to Clavien-Dindo classification, and the incidence of postoperative morbidity and mortality was compared with that in a historical control.

RESULTS

Of the enrolled patients, 160 met criteria for inclusion in the full analysis set. Postoperative morbidity and mortality rates reached 20.6% (33/160) and 0.6% (1/160), respectively. Fifteen patients (9.4%) had grade III or higher complications, and three reoperations (1.9%) were performed. The incidence of morbidity after LTG in this trial did not significantly differ from that reported in a previous study for open total gastrectomy (18%).

CONCLUSIONS

LTG performed by experienced surgeons showed acceptable postoperative morbidity and mortality for patients with clinical stage I gastric cancer.

Long-Term Survival of a Patient with Adenocarcinoma of the Esophagogastric Junction with a Portal Vein Tumor Thrombosis Who Underwent Palliative Total Gastrectomy: A Case Report

Portal vein tumor thrombosis (PVTT) with advanced gastric cancer is very rare; when it occurs, it exhibits aggressive growth and carries a poor prognosis. In addition, definitive treatment has not been established due to insufficient data. Herein, we report a case of PVTT associated with an adenocarcinoma of the esophagogastric junction that was successfully controlled by means of a palliative total gastrectomy without surgical resection of the PVTT and administration of palliative continuous doxifluridine.

Three-Port Versus Five-Port Laparoscopic Distal Gastrectomy for Early Gastric Cancer Patients: A Propensity Score Matched Case-Control Study

AIM

The aim of this study was to evaluate the feasibility and safety of three-port laparoscopic distal gastrectomy (TP-LDG) as a reduced port laparoscopic gastrectomy.

MATERIALS AND METHODS

We retrospectively identified 146 patients preoperatively diagnosed with early gastric cancer who underwent five-port laparoscopic distal gastrectomy (FP-LDG) or TP-LDG between May 2013 and July 2016. A propensity score matching analysis was used to create patient groups (48 patients in each group) matched for sex, age, body mass index, previous abdominal surgery history, and American Society of Anesthesiologist score. The short-term surgical outcomes between TP-LDG and FP-LDG were compared.

RESULTS

The TP-LDG group had a statistically shorter umbilical wound length [3.4 (range, 3.0-4.0) cm vs. 3.9 (range, 3.7-4.0) cm, p = .000], shorter operative time [230 (range, 190-310) min vs. 250 (range, 180-320) min, p = .036], and lower estimated blood loss [68 (range, 20-180) mL vs. 80 (range, 40-150) mL, p = .005] compared to that in the FP-LDG group. However, there was no specific superiority regarding inflammatory profiles. Complication rates were also similar (8.4% TP-LDG vs. 12.6% FP-LDG, p = .504).

CONCLUSIONS

TP-LDG is a feasible and safe surgical procedure for the patients with early gastric cancer and provides the benefit of better cosmesis.

A Case of Advanced Gastric Cancer Concomitant with Pyogenic Liver Abscess in the Patient with Subtotal Gastrectomy

The hematogenous spreading of an infectious pathogen via the portal vein from a mucosal injury in the gastrointestinal tract has been considered as one of the pathologic mechanisms of pyogenic liver abscess. Several studies have presented the association between colorectal cancer and pyogenic liver abscess. However, the cases of stomach cancer concomitant with pyogenic liver abscess have rarely been reported in the world. Herein, we present a case of advanced gastric cancer concomitant with pyogenic liver abscess in a patient who previously underwent subtotal gastrectomy due to peptic ulcer perforation.

Osteoporotic fractures in patients with systemic lupus erythematosus and end stage renal disease

Background The incidence of end stage renal disease (ESRD) in patients with systemic lupus erythematosus (SLE) is rising. However, the relationship between osteoporotic fractures and SLE in the setting of ESRD remains uninvestigated. The purpose of this study was to compare the frequency of incident osteoporotic fractures in patients with ESRD with and without SLE, to identify risk factors for fractures in patients with SLE and ESRD, and to examine the contribution of these fractures to mortality. Methods Retrospective cohort study of patients with SLE ( n = 716) and a 5% random sample of controls without SLE ( n = 4176) in the United States Renal Data System (USRDS) from years 2006-2008 enrolled in Medicare Part D. Results Fractures occurred in 10.6% ( n = 76) of patients with SLE and ESRD and 12.1% ( n = 507) of patients with ESRD without SLE ( p = 0.24). Older age (adjusted relative risk 1.02, 95% confidence interval 1.01-1.04) was associated with an increased risk for fracture in patients with SLE and ESRD. In multivariable analyses, vertebral and hip fractures more than doubled the risk for mortality. Conclusions The frequency of osteoporotic fractures in patients with SLE and ESRD is similar to the general population of patients with ESRD. Vertebral and hip fractures are significant contributors to mortality in patients with SLE and ESRD. Fracture prevention, in particular, for elderly patients with SLE and ESRD, should be considered. Summary SLE is not an independent risk factor for fractures in patients with ESRD. However, among patients with SLE and ESRD, vertebral and hip fractures are significant contributors to mortality.

Alcohol Consumption, High-Density Lipoprotein Cholesterol, Antithrombin III, and Body Mass Index Are Associated with Great Saphenous Vein Reflux in the Thigh

BACKGROUND

Venous valvular reflux is the main cause of chronic venous dysfunction. However, the etiology of valvular reflux is not completely understood. We conducted this study to investigate new risk factors for venous reflux of the great saphenous vein (GSV) in the thigh.

METHODS

We studied 139 consecutive patients (278 legs) who underwent Doppler ultrasonography at our hospital between March 2015 and February 2016 for leg discomfort with visible varicosities, edema, skin changes, or venous ulcer in the legs. Continuous variables included age, body mass index (BMI), hematological and blood chemistry parameters, smoking (pack-years), and alcohol consumption (days). Nominal variables included sex, comorbidities, smoking status, alcohol drinking status, and specific antibodies. The relationship of GSV reflux with pregnancy and number of children was investigated in 184 legs of 92 patients among 96 female patients.

RESULTS

On logistic regression analysis, independent factors determining GSV reflux were BMI (B = 0.126, P = 0.012), high-density lipoprotein (HDL) cholesterol level (B = 0.029, P = 0.025), duration of alcohol consumption (B = 1.237 E^-4, P = 0.016), and antithrombin III level (B = -0.036, P = 0.011).

CONCLUSIONS

In this study, the factors determining GSV reflux were higher HDL cholesterol level, longer duration of alcohol consumption, lower antithrombin III level, and higher BMI.

Prognostic Discrepancy of the 6th and 7th UICC N Classification for Lymph Node Staging in Gastric Cancer Patients after Curative Resection

BACKGROUND

The validity of N classification of the 7th edition of the American Joint Committee on Cancer/Union Internationale contre le Cancer (AJCC/UICC) tumor-node-metastasis (TNM) staging system is still under debate. The purpose of this study was to evaluate the prognostic efficacy of the 7th edition of the AJCC/UICC TNM staging system (focusing on N stage), in comparison with the 6th edition, at a single Eastern institution.

METHODS

We analyzed 1,435 patients with gastric cancer who underwent curative resection performed from September 1998 to August 2003 at the Memorial Jin-Pok Kim Korea Gastric Cancer Center. We analyzed the survival rate of the patients according to the AJCC/UICC 6th and 7th editions, and compared each stage, focusing on N stage.

RESULTS

Significant differences in the 5-year survival rates were observed between the 6th and the 7th AJCC/UICC staging system. In the 6th edition staging system, the Kaplan-Meier curves discriminated each N stage significantly. In contrast, there was no difference in terms of survival curves for N stage according to the 7th edition, especially between N1 and N2: the Kaplan-Meier plots of survival curves between N1 (77.0%) and N2 (78.1%) stages overlapped significantly (p < 0.05).

CONCLUSION

Although the 7th UICC staging system is a more detailed and sophisticated system in the T category, there was no prognostic significance between the pN1 and pN2 stages according to our data. Therefore, we suggest establishing a new UICC staging system taking into consideration the application of the N stage.

Simultaneous robotic subtotal gastrectomy and right hemicolectomy for synchronous adenocarcinoma of stomach and colon

Simultaneous laparoscopy-assisted resection for synchronous stomach and colon cancers has been reported frequently; however, robot-assisted gastrectomy and colectomy for these conditions are rarely reported. We report the successful use of robotic surgery for synchronous cancers of the stomach and colon. A 71-year-old woman with no specific medical history was diagnosed with early gastric cancer at the gastric angle and right colon cancer after undergoing esophagogastroduodenoscopy and colonofiberoscopy. Abdomino-pelvic computed tomography revealed that the stomach and colon lesions were limited to the mucosa without any lymph nodes or distant metastasis, which suggested the clinical stage for both cancers as T1N0M0. We performed robot-assisted radical subtotal gastrectomy and simultaneous right hemicolectomy through six ports. All procedures were successful without any perioperative complications. A 36-month postoperative follow-up of the patient at the outpatient department revealed no evidence of recurrence. We consider that concurrent robot-assisted subtotal gastrectomy and colectomy are technically feasible and safe.

Simultaneous robotic low anterior resection and prostatectomy for adenocarcinoma of rectum and prostate: initial case report

Background

We report a case of synchronous rectal and prostate cancer treated successfully with simultaneous da Vinci robotic-assisted low anterior resection of the rectum and robotic-assisted laparoscopic radical prostatectomy to address both cancers.

Case presentation

Recently, minimally invasive surgical techniques using da Vinci robot^® system (Intuitive Surgical, Sunnyvale, USA) were introduced as curative surgical modality of prostate and rectal malignancies. Herein, we report an initial case of simultaneous robotic low anterior resection and robotic prostatectomy for adenocarcinoma of rectum and prostate sharing a considerable number of port sites.

Conclusion

Simultaneous robotic-assisted low anterior resection could be performed with robotic-assisted radical prostatectomy safely and effectively in synchronous rectal and prostate cancer.

Who may benefit from robotic gastrectomy?: A subgroup analysis of multicenter prospective comparative study data on robotic versus laparoscopic gastrectomy

AIMS

Robotic gastrectomy for gastric cancer has been proven to be a feasible and safe minimally invasive procedure. However, our previous multicenter prospective study indicated that robotic gastrectomy is not superior to laparoscopic gastrectomy. This study aimed to identify which subgroups of patients would benefit from robotic gastrectomy rather than from conventional laparoscopic gastrectomy.

METHODS

A prospective multicenter comparative study comparing laparoscopic and robotic gastrectomy was previously conducted. We divided the patients into subgroups according to obesity, type of gastrectomy performed, and extent of lymph node dissection. Surgical outcomes were compared between the robotic and laparoscopic groups in each subgroup.

RESULTS

A total of 434 patients were enrolled into the robotic (n = 223) and laparoscopic (n = 211) surgery groups. According to obesity and gastrectomy type, there was no difference in the estimated blood loss (EBL), number of retrieved lymph nodes, complication rate, open conversion rate, and the length of hospital stay between the robotic and laparoscopic groups. According to the extent of lymph node dissection, the robotic group showed a significantly lower EBL than did the laparoscopic group after D2 dissection (P = 0.021), while there was no difference in EBL in patients that did not undergo D2 dissection (P = 0.365).

CONCLUSION

Patients with gastric cancer undergoing D2 lymph node dissection can benefit from less blood loss when a robotic surgery system is used.

A Giant Retroperitoneal Liposarcoma Encasing the Entire Left Kidney and Adherent to Adjacent Structures: A Case Report

Retroperitoneal liposarcoma is a rare tumor. The dimension and weight of liposarcoma are variable; those over 20 kg are called ‘giant liposarcoma’. Herein, we report giant retroperitoneal liposarcoma measuring 45 cm in diameter and 25 kg in weight encasing the entire left kidney and adherent to adjacent structures. A 71-year-old woman presented for a regular checkup. Image study revealed a huge mass probably indicative of retroperitoneal liposarcoma encasing the entire left kidney and adherent to adjacent structures. We performed an organ-preserving surgical removal. The pathologic report was liposarcoma. At postoperative month 16, a follow-up CT revealed a locally recurrent tumor. The patient underwent surgical removal of the newly discovered mass. After the second surgery, the patient underwent regular follow-up CT for approximately 12 months, and to date, there has been no evidence of tumor recurrence. High-grade liposarcoma shows sensitivity to radiation therapy. However, the toxic effect of radiation therapy limits this option by treatment modality. The use of chemotherapy is also controversial. As a result, complete resection is the gold standard treatment. Here, we report a giant retroperitoneal liposarcoma encasing the entire left kidney and adherent to adjacent structures, describe successful organ-preserving surgical removal and discuss prognosis.

Gastric Schwannoma Mimicking Malignant Gastrointestinal Stromal Tumor Exhibiting Increased Fluorodeoxyglucose Uptake

A schwannoma is a kind of neurogenic tumor that rarely occurs in the gastrointestinal tract. Gastric schwannomas make up 0.2% of all gastric neoplasms. Gastrointestinal stromal tumors (GIST) are the most common mesenchymal tumors and up to 60-70% of GIST occur in the stomach. Schwannoma and GIST are similar in clinical features, so they are difficult to differentiate preoperatively. Differential diagnosis of these two submucosal tumors is important because of the malignant potential of GIST and the relatively benign course of gastric schwannomas. We report a 49-year-old woman who was diagnosed after operation with a gastric schwannoma, which was suspected a malignant GIST by fluorine-18-fluorodeoxyglucose positron emission computed tomography imaging.

The Prognostic Value of Circumferential Resection Margin Involvement in Patients with Extraperitoneal Rectal Cancer

The prognostic influence of circumferential resection margin (CRM) status in extraperitoneal rectal cancer probably differs from that of intraperitoneal rectal cancer because of its different anatomical and biological behaviors. However, previous reports have not provided the data focused on extraperitoneal rectal cancer. Therefore, the aim of this study was to examine the prognostic significance of the CRM status in patients with extraperitoneal rectal cancer. From January 2005 to December 2008, 248 patients were treated for extraperitoneal rectal cancer and enrolled in a prospectively collected database. Extraperitoneal rectal cancer was defined based on tumors located below the anterior peritoneal reflection, as determined intraoperatively by a surgeon. Cox model was used for multivariate analysis to examine risk factors of recurrence and mortality in the 248 patients, and multivariate logistic regression analysis was performed to identify predictors of recurrence and mortality in 135 patients with T3 rectal cancer. CRM involvement for extraperitoneal rectal cancer was present in 29 (11.7%) of the 248 patients, and was the identified predictor of local recurrence, overall recurrence, and death by multivariate Cox analysis. In the 135 patients with T3 cancer, CRM involvement was found to be associated with higher probability of local recurrence and mortality. In extraperitoneal rectal cancer, CRM involvement is an independent risk factor of recurrence and survival. Based on the results of the present study, it seems that CRM involvement in extraperitoneal rectal cancer is considered an indicator for (neo)adjuvant therapy rather than conventional TN status.

The Prognostic Value of Circumferential Resection Margin Involvement in Patients with Extraperitoneal Rectal Cancer

The prognostic influence of circumferential resection margin (CRM) status in extraperitoneal rectal cancer probably differs from that of intraperitoneal rectal cancer because of its different anatomical and biological behaviors. However, previous reports have not provided the data focused on extraperitoneal rectal cancer. Therefore, the aim of this study was to examine the prognostic significance of the CRM status in patients with extraperitoneal rectal cancer. From January 2005 to December 2008, 248 patients were treated for extraperitoneal rectal cancer and enrolled in a pro-spectively collected database. Extraperitoneal rectal cancer was defined based on tumors located below the anterior peritoneal reflection, as determined intraoperatively by a surgeon. Cox model was used for multivariate analysis to examine risk factors of recurrence and mortality in the 248 patients, and multivariate logistic regression analysis was performed to identify predictors of recurrence and mortality in 135 patients with T3 rectal cancer. CRM involvement for extraperitoneal rectal cancer was present in 29 (11.7%) of the 248 patients, and was the identified predictor of local recurrence, overall recurrence, and death by multivariate Cox analysis. In the 135 patients with T3 cancer, CRM involvement was found to be associated with higher probability of local recurrence and mortality. In extraperitoneal rectal cancer, CRM involvement is an independent risk factor of recurrence and survival. Based on the results of the present study, it seems that CRM involvement in extraperitoneal rectal cancer is considered an indicator for (neo)adjuvant therapy rather than conventional TN status.

Novel strategy for a bispecific antibody: induction of dual target internalization and degradation

Activation of the extensive cross-talk among the receptor tyrosine kinases (RTKs), particularly ErbB family-Met cross-talk, has emerged as a likely source of drug resistance. Notwithstanding brilliant successes were attained while using small-molecule inhibitors or antibody therapeutics against specific RTKs in multiple cancers over recent decades, a high recurrence rate remains unsolved in patients treated with these targeted inhibitors. It is well aligned with multifaceted properties of cancer and cross-talk and convergence of signaling pathways of RTKs. Thereby many therapeutic interventions have been actively developed to overcome inherent or acquired resistance. To date, no bispecific antibody (BsAb) showed complete depletion of dual RTKs from the plasma membrane and efficient dual degradation. In this manuscript, we report the first findings of a target-specific dual internalization and degradation of membrane RTKs induced by designed BsAbs based on the internalizing monoclonal antibodies and the therapeutic values of these BsAbs. Leveraging the anti-Met mAb able to internalize and degrade by a unique mechanism, we generated the BsAbs for Met/epidermal growth factor receptor (EGFR) and Met/HER2 to induce an efficient EGFR or HER2 internalization and degradation in the presence of Met that is frequently overexpressed in the invasive tumors and involved in the resistance against EGFR- or HER2-targeted therapies. We found that Met/EGFR BsAb ME22S induces dissociation of the Met-EGFR complex from Hsp90, followed by significant degradation of Met and EGFR. By employing patient-derived tumor models we demonstrate therapeutic potential of the BsAb-mediated dual degradation in various cancers.

Metachronous Liver Metastasis Resulting from Early Gastric Carcinoma after Subtotal Gastrectomy Following Endoscopic Resection: A Case Report

Hepatic metastasis of early gastric cancer (EGC) following subtotal gastrectomy with lymphadenectomy is rare. We report the case of a 61-year-old male patient who was diagnosed with EGC that was initially treated using endoscopic submucosal dissection (ESD) and subsequently underwent laparoscopic subtotal gastrectomy. Histopathological examination of the patient's ESD specimen showed a moderately differentiated tubular adenocarcinoma invading the submucosa without lymphatic invasion. The deep margin of the specimen was positive for adenocarcinoma, and he subsequently underwent laparoscopic distal gastrectomy. The patient developed liver metastasis 15 months after the operation and then underwent liver resection. Histology of the resected specimen confirmed the diagnosis of two foci of metastatic adenocarcinoma originating from stomach cancer. Immunohistochemical analysis of the specimen demonstrated overexpression of human epidermal growth factor receptor 2. The patient was treated with trastuzumab in combination with chemotherapy consisting of capecitabine and cisplatin. Twenty-four months after the operation, the patient remained free of recurrence.

Synchronous triple primary cancers occurring in the stomach, kidney, and thyroid

We report an unusual case of synchronous triple primary cancer of the stomach, kidney, and thyroid in a 50-year-old male patient. Initial esophagogastroduodenoscopy with biopsy for the medical check-up revealed poorly differentiated adenocarcinoma. We performed an abdominal/pelvic computed tomography scan for staging and incidentally found a 1.7-cm exophytic hypervascular mass in the left kidney. Thyroid ultrasonography showed suspicious malignant nodules suspicious with multiple lymph nodes (LNs) metastasis in the right side of the neck. Subsequent fine needle aspiration biopsy of a nodule and a LN was performed. Cytologic report revealed papillary thyroid carcinoma with lateral LNs metastasis. Our integrate oncology team performed radical subtotal gastrectomy, partial nephrectomy, and total thyroidectomy with modified radical neck dissection. The postoperative pathologic finding was well-differentiated gastric adenocarcinoma (T1N0M0; stage 1A), renal cell carcinoma (T1aN0M0; stage 1), and papillary thyroid carcinoma (T4bN1bM0; stage 4B). He received postoperative a radio-active iodine ablation and is doing well with no recurrence.

Two cases of advanced gastric carcinoma mimicking a malignant gastrointestinal stromal tumor

Gastric cancer that mimics a submucosal tumor is rare. This rarity and the normal mucosa covering the protuberant tumor make it difficult to diagnosis with endoscopy. We report two cases of advanced gastric cancer that mimicked malignant gastrointestinal stromal tumors preoperatively. In both cases, the possibility of cancer was not completely ruled out. In the first case, a large tumor was suspected to be cancerous during surgery. Therefore, total gastrectomy with lymph node dissection was performed. In the second case, the first gross endoscopic finding was of a Borrmann type II advanced gastric cancer-like protruding mass with two ulcerous lesions invading the anterior wall of the body. Therefore, subtotal gastrectomy with lymph node dissection was performed. Consequently, delayed treatment of cancer was avoided in both cases. If differential diagnosis between malignant gastrointestinal stromal tumor and cancer is uncertain, a surgical approach should be carefully considered due to the possible risk of adenocarcinoma.

Integration of reverse transcriptase loop-mediated isothermal amplification with an immunochromatographic strip on a centrifugal microdevice for influenza A virus identification

A novel centrifugal microdevice which could perform reverse transcriptase loop-mediated isothermal amplification (RT-LAMP) and immunochromatographic strip (ICS) based amplicon detection was demonstrated for simple and cost-effective influenza A virus identification. The proposed centrifugal microdevice consists of the sample and running buffer loading reservoirs, the RT-LAMP chamber, and the ICS for detecting gene expression. The entire process could be completed sequentially and automatically by simply controlling the rotation speed and by optimizing the microfluidic design. Monoplex and multiplex RT-LAMP reactions targeting H1 and/or M gene were executed at 66 °C for 40 min, and the resultant amplicons were successfully analysed on the ICS within 15 min. Influenza A H1N1 virus was subtyped by detecting H1 and M gene on the ICS even with 10 copies of viral RNAs. Highly specific and multiplex viral typing of the integrated RT-LAMP-ICS microdevice was also demonstrated. The combination of the rapid isothermal amplification with the simple colorimetric detection on a strip in a single centrifugal microdevice will provide an advanced genetic analysis platform in the field of on-site pathogen diagnostics.

Factors related to morbidity in elderly gastric cancer patients undergoing gastrectomies

Purpose

The prevalence of gastric cancer in the elderly is increasing. The purpose of this study was to clarify factors related to morbidity following gastric cancer surgery in elderly patients.

Materials and Methods

For this study, data from 411 patients who underwent curative gastrectomies with lymph node dissections between March 2010 and January 2013 were retrospectively studied using a prospectively designed database. Patients were divided into 2 groups (<70 years vs. ≥70 years). For each group, perioperative factors were analyzed to determine if they were associated with postoperative morbidity and mortality.

Results

Comorbidities were more prevalent in the elderly group (≥70 years). Intraoperative and postoperative transfusions were also more frequently required in the elderly group. There was no significant difference in the number of retrieved lymph nodes between the 2 groups (44.3 vs. 46.6 nodes). In a comparison of the elderly versus non-elderly groups, the postoperative morbidity rates were 22.7% versus 8.9% (P<0.001) and the postoperative mortality rates were 4.2% versus 0% (P=0.002), respectively. Of the possible non-surgical complications, pulmonary problems were predominately found in the elderly group (P<0.001). Surgical complications were evenly distributed between the 2 groups (P=0.463). Postoperative morbidity was significantly associated with older age and postoperative transfusion. Multivariate analysis showed that higher body mass index (BMI) and postoperative transfusion were important factors associated with postoperative complications in the elderly group.

Conclusions

Pulmonary complications were frequently problematic in elderly patients. Higher BMI and postoperative transfusion were significant risk factors for postoperative complications in elderly patients with gastric cancer.

Delayed rupture of the iliac artery after percutaneous angioplasty

Rupture of the iliac artery during percutaneous angioplasty is a life-threatening condition that requires prompt diagnosis and treatment to rescue the patient. Recently, percutaneous angioplasty has become an outpatient procedure, but there is no reliable guideline for observation time in the hospital after percutaneous angioplasty. We describe a 67-year-old man with bilateral lesions in the iliac artery who experienced a delayed rupture of the iliac artery 2 days after percutaneous balloon angioplasty and placement of a self-expandable stent. The patient was successfully treated by endovascular intervention with a stent graft. In our department, percutaneous angioplasty is not performed in an outpatient clinic, and all patients are admitted to the hospital and observed for at least 3 days after percutaneous angioplasty. Because our patient was in the hospital when the iliac artery ruptured, prompt diagnosis and treatment were possible. Moreover, because appropriately sized stent grafts were prepared in the hospital, timely endovascular treatment could be performed, and the patient recovered successfully. From this case, we conclude that observing patients for a sufficient time in the hospital and preparing appropriately sized stent grafts are 2 important factors for the safety of patients who undergo percutaneous angioplasty.

Effect of multiple invasive foci on breast cancer outcomes according to the molecular subtypes: a report from the Korean Breast Cancer Society

BACKGROUND

In this study, the prognostic impact of the presence of the multifocal or multicentric tumor (MMT) and its association with molecular subtypes were investigated.

PATIENTS AND METHODS

We investigated the breast cancer metastasis and survival in patients with multifocal or multicentric invasive foci in the same breast. The study population includes 2882 patients in the Seoul National University Hospital Breast Care Center (SNUHBCC) dataset and 41 179 patients in Korean Breast Cancer Registry (KBCR) dataset.

RESULTS

From SNUHBCC dataset, we observed a significant role of MMT in developing distant metastasis and death when the tumors were triple-negative subtype. This subtype-specific prognostic importance of MMT in overall survival was also seen in KBCR dataset (HR, 1.32; 95% CI, 1.02-1.69). In tumors <2 cm, the hazard ratios (HRs) for node metastasis and death were similar along the tumor size change in triple-negative subtype, while other subtypes showed a stepwise increment, suggesting the biologic importance of small invasive foci in this subtype.

CONCLUSIONS

Our results demonstrate the prognostic importance of MMT in patients with triple-negative breast cancers. Small additional invasive foci in triple-negative breast cancer patients should be considered as clinically relevant tumor deposits.

Comparison of cystatin C- and creatinine-based estimation of glomerular filtration rate according to glycaemic status in Type 2 diabetes

AIMS

The influence of hyperglycaemia on the performance of glomerular filtration rate (GFR) estimating equations remains to be determined. We compared the performance of creatinine-based GFR with cystatin C-based GFR in patients with Type 2 diabetes according to glycaemic status.

METHODS

In a cross-sectional study of 210 patients with Type 2 diabetes, we staged glycaemic status by HbA(1c) tertiles [HbA(1c) ≤ 75 mmol/mol (9.0%) (n = 70), HbA(1c) 76-95 mmol/mol (9.1-10.8%) (n = 70), HbA(1c) >95 mmol/mol (10.8%) (n = 70)] and measured GFR. Isotopic GFR was measured using renal dynamic imaging with (99m) Tc-diethylene-triamine-penta-acetic acid. Estimated GFR (eGFR) was measured using creatinine-based formulae (Cockcroft-Gault-eGFR, the Modification of Diet in Renal Disease equation-eGFR and the Chronic Kidney Disease Epidemiology Collaboration formula-eGFR) and a cystatin C-based formula (cystatin C-eGFR).

RESULTS

The isotopic GFR of all patients was 93.1 ± 34.1 ml min(-1) 1.73 m(-2). All methods for estimating GFR underestimated isotopic GFR [Cockcroft-Gault-eGFR (68.8 ± 38.6 ml min(-1) 1.73 m(-2) ) (P < 0.05), Modification of Diet in Renal Disease-eGFR (74.8 ± 31.3 ml min(-1) 1.73 m(-2) ) (P < 0.05), Chronic Kidney Disease Epidemiology Collaboration-eGFR (72.9 ± 26.6 ml min(-1) 1.73 m(-2)) (P < 0.05) and cystatin C-eGFR (83.5 ± 33.2 ml min(-1) 1.73 m(-2)) (P < 0.05)]. In all patient groups, cystatin C-eGFR was less biased and more accurate than the creatinine-based formulae, especially in the group with HbA(1c) > 95 mmol/mol (10.8%) where there was no difference between cystatin C-eGFR and isotopic GFR.

CONCLUSIONS

Performance of cystatin C-eGFR was superior to creatinine-based GFR in patients with Type 2 diabetes with HbA(1c) >95 mmol/mol (10.8%).

Risk factors of circumferential resection margin involvement in the patients with extraperitoneal rectal cancer

Purpose

Currently, circumferential resection margins (CRM) are used as a clinical endpoint in studies on the prognosis of rectal cancer. Although the concept of a circumferential resection margin in extraperitoneal rectal cancer differs from that in intraperitoneal rectal cancer due to differences in anatomical and biologic behaviors, previous reports have provided information on CRM involvement in all types of rectal cancer including intraperitoneal lesions. Therefore, the aim of this study was to analyze risk factors of CRM involvement in extraperitoneal rectal cancer.

Methods

From January 2005 to December 2008, 306 patients with extraperitoneal rectal cancer were enrolled in a prospectively collected database. Multivariate logistic regression analysis was used to identify predictors of CRM involvement.

Results

The overall rate of CRM involvement was found to be 16.0%. Multivariate analysis showed that male sex, larger tumor size (≥4 cm), stage higher than T3, nodal metastasis, tumor perforation and non-sphincter preserving proctectomy (NSPP) were risk factors for CRM involvement.

Conclusion

Male sex, larger tumor size (≥4 cm), advanced T stage, nodal metastasis, tumor perforation, and NSPP are significant risk factors of CRM involvement in extraperitoneal rectal cancer. Given that postoperative chemoradiotherapy is recommended for patients with a positive CRM, further oncologic studies are warranted to ascertain which patients with these risk factors would require adjuvant therapy.

Intra-arterial tirofiban infusion for partial recanalization with stagnant flow in hyperacute cerebral ischemic stroke

Early reocclusion is a major concern associated with poor clinical outcomes in patients with an ischemic cerebral stroke. This occurs most frequently in patients with partial initial recanalization. This study focuses on partial recanalization with stagnant antegrade flow after intravenous (IV) tPA or spontaneously, treated with the administration of intra-arterial (IA) tirofiban. Three patients with initial M1 occlusion on diagnostic studies had an occluded segment that was recanalized with stagnant flow after IV tPA or spontaneously. In all cases, IA tirofiban was administrated. We evaluated the distal blood flow and the degree of vascular narrowing in the pre and post-procedure angiography and at follow-up in addition to the clinical status. In all patients, severe vascular narrowing with stagnation of blood flow was detected in the initial M1. After infusion of IA tirofiban, improvement of the distal blood flow was achieved rapidly within 40 minutes in all patients. The severe vascular narrowing resolved rapidly in two patients without residual stenosis. In one patient, moderate vascular narrowing was still present. The median baseline National Institutes of Health Stroke Scale (NIHSS) scores were 18 and the median post-procedural NIHSS scores were 2 at two weeks. No intracerebral hemorrhage occurred in any of the patients. Treatment with IA tirofiban was safe and effective in patients with partial initial recanalization. It can be suggested that detection of any partial recanalization is time for administration of glycoprotein IIb-IIIa receptor inhibitor in hyperacute ischemic stroke.

Transport and metabolism of the antitumour drug candidate 2'-benzoyloxycinnamaldehyde in Caco-2 cells

The transport and metabolism of the antitumour drug candidate 2'-benzoyloxycinnamaldehyde (BCA) was characterized in Caco-2 cells. BCA disappeared rapidly from the donor side without being transported to the receiver side during its absorptive transport across Caco-2 cells. Its metabolites 2'-hydroxycinnamaldehyde (HCA) and o-coumaric acid (OCA) were formed in both the donor and the receiver sides. HCA, in a separate study, also disappeared rapidly from the donor side, mostly being converted to its oxidative metabolite OCA during its absorptive transport across Caco-2 cells. OCA was transported rapidly in the absorptive direction across Caco-2 cells with a P(app) of 25.4 +/- 1.0 x 10(-6) cm s(-1) (mean +/- standard deviation (SD), n = 3). OCA was fully recovered from both the donor and the receiver side throughout the time-course of this study. Formation of HCA from BCA was inhibited almost completely by bis(p-nitrophenyl)phosphate (BNPP), a selective inhibitor of carboxylesterases (CES), and phenylmethylsulfonyl fluoride (PMSF), a broad specificity inhibitor of esterases in Caco-2 cells, suggesting that this hydrolytic biotransformation was likely mediated predominantly by CES. Conversion of HCA to OCA was inhibited significantly by isovanillin, a selective inhibitor of aldehyde oxidase (AO). Inhibitors for xanthine oxidase (XO) and aldehyde dehydrogenase (ALDH), which are known to be involved in the oxidation of aldehydes to carboxylic acids, did not have a significant effect on the biotransformation of HCA to OCA in Caco-2 cells. In summary, the present work demonstrates that BCA is hydrolysed rapidly to HCA, followed by subsequent oxidation to OCA, in Caco-2 cells. The results provide a mechanistic understanding of the poor absorption and low bioavailability of BCA after oral administration.

Anatomic and Functional Evaluation of Bifurcation Lesions Undergoing Percutaneous Coronary Intervention

Background— We sought to investigate the mechanism of geometric changes after main branch (MB) stent implantation and to identify the predictors of functionally significant “jailed” side branch (SB) lesions.

Methods and Results— Seventy-seven patients with bifurcation lesions were prospectively enrolled from 8 centers. MB intravascular ultrasound was performed before and after MB stent implantation, and fractional flow reserve was measured in the jailed SB. The vessel volume index of both the proximal and distal MB was increased after stent implantation. The plaque volume index decreased in the proximal MB (9.1�3.0 to 8.4�2.4 mm 3 /mm, P =0.001), implicating plaque shift, but not in the distal MB (5.4�1.8 to 5.3�1.7 mm 3 /mm, P =0.227), implicating carina shifting to account for the change in vessel size (N=56). The mean SB fractional flow reserve was 0.71�0.20 (N=68) and 43% of the lesions were functionally significant. Binary logistic-regression analysis revealed that preintervention % diameter stenosis of the SB (odds ratio=1.05; 95% CI, 1.01 to 1.09) and the MB minimum lumen diameter located distal to the SB ostium (odds ratio=3.86; 95% CI, 1.03 to 14.43) were independent predictors of functionally significant SB jailing. In patients with ≥75% stenosis and Thrombolysis In Myocardial Infarction grade 3 flow in the SB, no difference in poststent angiographic and intravascular ultrasound parameters was found between SB lesions with and without functional significance.

Conclusions— Both plaque shift from the MB and carina shift contribute to the creation/aggravation of an SB ostial lesion after MB stent implantation. Anatomic evaluation does not reliably predict the functional significance of a jailed SB stenosis.

Clinical Trial Registration: http://www.clinicaltrials.gov. Unique Identifier: NCT00553670.

Wide thumb and the first web reconstruction using a neurovascularised instep free flap

Deformed hands result in palmar defects of the thumb. The sensate instep free flap can be used for wide palmar coverage of the thumb. Three hands with palmar defects of the thumb extended to the first web space underwent soft-tissue reconstruction using a neurovascular instep free flap. These flaps provided sensate coverage with static two-point discrimination values of 8-15 mm. Key pinch strengths of reconstructed thumbs were nearly half of those on the normal side. Donor foot morbidity was minimal with no hyperkeratosis. The neurovascular instep free flap supplies sensate, similar pliable and tough glabrous skin to the palmar surface of the thumb extended to the first web area.

Genetic polymorphisms of the bovine fatty acid binding protein 4 gene are significantly associated with marbling and carcass weight in Hanwoo (Korean Cattle)

The objective of this study was to investigate an association between polymorphisms in the FABP4 gene and phenotypic variation for marbling and carcass weight (CWT) in a population of Hanwoo steers. We re-sequenced 4.3 kb of the FABP4 gene region in 24 Hanwoo bulls and identified 16 SNPs and 1 microsatellite polymorphism. Of these 16 SNPs, three SNPs [g.2774G>C (intron I), g.3473A>T (intron II) and g.3631G>A (exon III, creating a p.Met >Val amino acid substitution)] were genotyped in 583 steers to assess their association with carcass traits. The g.3473A allele showed a significant increasing effect on CWT (P = 0.01) and the g.3631G allele was associated with higher marbling score (P = 0.006). One haplotype of these three SNPs (CAG) was significantly associated with CWT (P = 0.02) and marbling score (P = 0.05) and could potentially be of value for marker assisted selection in Hanwoo cattle. The CAG haplotype effect for CWT was larger (11.14 +/- 5.03 kg) than the largest single locus effect of g.3473A>T (5.01 +/- 2.2 kg).

A novel modification of double stapling technique in Billroth I anastomosis

Although the double-stapling technique has been used as a safe procedure in gastroduodenostomy, creating anastomosis with a circular stapler on the linear stapler line can be vulnerable for anastomotic leakage and ischemia. Therefore, we tried to modify the double-stapling technique to avoid stapling on the staple line.