Is the ISGPS definition of pancreatic fistula applicable after gastrectomy?

BACKGROUND: Pancreatic fistula is one of the most common and potentially fatal surgical complications after radical gastrectomy. The purpose of this study was to assess the validity of extrapolating the definition of pancreatic fistula by the International Study Group on Pancreatic Surgery to include situations surrounding gastric cancer surgery. METHODS: The clinicopathological data of 443 patients who underwent elective gastrectomy with suprapancreatic lymph node dissection (D1+, D2, or D2+ dissection) without pancreatic resection were reviewed. The relationship between postoperative pancreas-related complications (PPRC) and laboratory data, including drain fluid amylase levels on postoperative day 1 (dAmy1) and day 3 (dAmy3), were investigated. RESULTS: Twenty-four patients (5.4%) developed PPRC of ≥ grade II according to Clavien-Dindo classification. Among them, 15 patients had dAmy3 levels ≥ 375 IU/L, while all 24 patients had dAmy1 levels ≥ 375 IU/L. None of the patients with dAmy1 levels < 375 IU/L developed PPRC. The area under the curve of dAmy1 and dAmy3, calculated by drawing receiver operating characteristic curves, were 0.896 and 0.791, respectively. Univariate and multivariate analyses demonstrated that both dAmy1 and dAmy3 were significant predictors of PPRC; however, dAmy1 (p < 0.001) was more strongly correlated with PPRC than dAmy3 (p = 0.049). CONCLUSIONS: DAmy1 is more sensitive than dAmy3 as an indicator of pancreatic fistula after gastric cancer surgery.

[A case of juvenile gastric polyposis with gastric cancer successfully treated by laparoscopic total gastrectomy -review of 36 reported cases in Japan].

A 43-year-old woman was suffering from epigastric pain. Her gastroscopy revealed polyposis of the stomach, and her biopsy revealed a hyperplastic polyp. During the 18-month follow-up, the polyps proliferated, and the patient was referred to our institute for further investigation and treatment. A juvenile gastric polyposis diagnosis was made. She refused to have the surgery despite the fact that it was necessary due to the anemia and hypoalbuminemia she was experiencing. Endoscopic biopsy results revealed gastric cancer at a follow-up visit 2 years and 3 months later; thus, a laparoscopic total gastrectomy was performed. Pathological examination revealed adenocarcinomas that were scattered and well-differentiated, with hyperplastic polyps in the background. No lymph node metastasis was found. Despite the fact that juvenile gastric polyposis is a pathologically benign disease, there have been numerous case reports of surgery being performed due to anemia, hypoalbuminemia, or gastric cancer associated with the disease. When gastric cancers are discovered in cases of juvenile gastric polyposis, they are usually in an early stage, making them a good candidate for laparoscopic total gastrectomy.

A case of pulmonary leiomyosarcoma achieving long-term survival after multiple metastasectomies.

A 58-year-old man who underwent lower lobectomy of the right lung for primary pulmonary leiomyosarcoma (PPL) 4 years ago presented with epigastric pain and was diagnosed with small bowel intussusception caused by an intestinal mass. Partial resection of the small intestine was performed, and pathological examination revealed metastatic leiomyosarcoma. Masses in the left adrenal gland, subcutaneous tissue of the left upper arm, right pleura, jejunum, right trapezius muscle, and right adrenal gland were subsequently detected in the following 4 years. Resection was performed for each tumor, which was histologically confirmed as metastatic leiomyosarcoma. However, 1 month after the last surgery, multiple systemic metastases were found, thus, he is currently undergoing chemotherapy. The patient has been alive for 8 years and 4 months after the first operation for PPL. PPL is an extremely rare disease with no established treatment strategy for recurrences. Aggressive metastasectomy may be beneficial in selected cases.

The Amount and Concentration of Drain Amylase Together Predict Postoperative Pancreatic Fistula after Gastric Cancer Surgery More Accurately than the Concentration Alone.

INTRODUCTION: The drain amylase concentration (dAmy-C) is a useful marker for predicting pancreatic fistula after gastric cancer surgery. However, dAmy-C might be reduced in cases of high drainage volume. Therefore, we hypothesized that we could accurately assess the amount of amylase leaked from the pancreas by multiplying dAmy-C by the daily drainage volume. In this study, we investigated the clinical utility of the amount of drain amylase (A-dAmy: concentration × volume) for predicting pancreatic fistula. We investigated the clinical utility of the combination of dAmy-C and A-dAmy for predicting pancreatic fistula. METHODS: We investigated patients who underwent gastrectomy for gastric cancer at Yodogawa Christian Hospital between 2012 and 2020. The optimal cutoff levels of dAmy-C and A-dAmy on postoperative day 1 for predicting Clavien-Dindo (CD) grade II or higher pancreatic fistula was calculated using receiver operating characteristic (ROC) curves. We calculate the positive predictive value and negative predictive value for predicting pancreatic fistula using these cutoff levels. RESULTS: A total of 448 patients were eligible for analysis. Twenty-two patients experienced CD grade II or higher pancreatic fistula. ROC curves identified 1,615 IU/L as the optimal cutoff level of dAmy-C, predicting pancreatic fistula. When the simple cutoff level of dAmy-C was 1,600 IU/L, the positive predictive value for was 22.8%, and the negative predictive value was 99.7%. ROC curves identified 177.52 IU as the optimal cutoff level of A-dAmy predicting pancreatic fistula. When the simple cutoff level of A-dAmy was 177 IU, the positive predictive value was 21.2%, and the negative predictive value was 99.7%. Using these two cutoff levels together, the positive predictive value was 34.4%, and the negative predictive value was 99.7%. CONCLUSION: A-dAmy could predict and exclude pancreatic fistula after gastrectomy as with dAmy-C. The combination of dAmy-C and A-dAmy predict pancreatic fistula more accurately than dAmy-C alone.

Optimal Timing to Assess Drain Amylase Concentration after Elective Gastrectomy.

PURPOSE: While the amylase concentration of the drainage fluid (dAmy) has been reported to be a predictor of postoperative pancreas-related complications (PPRC), the optimal timing for its measurement has not been fully investigated. MATERIALS AND METHODS: The clinicopathological data of 387 patients who underwent elective gastrectomy for gastric cancer were reviewed. Laboratory data, including dAmy on postoperative days 1 (dAmy1) and 3 (dAmy3), and serum C-reactive protein (sCRP) concentrations on postoperative days 1 (sCRP1) and 3 (sCRP3) were compared between patients with PPRC and without PPRC. RESULTS: Nineteen of the 387 patients (4.9%) developed PPRC. The optimal cutoff values of dAmy1, dAmy3, sCRP1, and sCRP3 were 1514 IU/L, 761 IU/L, 8.32 mg/dL, and 15.15 mg/dL, respectively. The area under the curve of dAmy1 was greater than that of dAmy3 (0.915 vs. 0.826), and that of sCRP3 was greater than that of sCRP1 (0.820 vs. 0.659). In the multivariate analysis, dAmy1 (P<0.001) and sCRP3 (P=0.004) were significant predictors of PPRC, while dAmy3 (P=0.069) and sCRP1 (P=0.831) were not. Thirteen (41.9%) of 31 patients with both dAmy1 ≥1,545 IU/L and sCRP3 ≥15.15 mg/dL had PPRC ≥Clavien-Dindo II. In contrast, among 260 patients with both dAmy1 <1,545 IU/L and sCRP3 <15.15 mg/dL, none developed PPRC. CONCLUSIONS: dAmy1 was more useful than dAmy3 in predicting PPRC. The combination of dAmy1 and sCRP3 may be a useful criterion for the removal of drains on postoperative day 3.

The Combined Use of Drainage Amylase Concentration and Serum C-reactive Protein as Predictors of Pancreas-Related Complications after Elective Gastrectomy.

INTRODUCTION: Postoperative pancreas-related complications (PPRC) can cause critical conditions, including sepsis and intra-abdominal bleeding. Thus, it is important to identify patients who are at risk of clinically significant PPRC as early as possible in the postoperative period. Some authors have reported the use of amylase concentration of the drainage fluid (dAmy) to predict PPRC. However, the positive predictive value of dAmy alone is not sufficient. OBJECTIVE: The aim of this study is to evaluate the predictive value of combined use of dAmy and serum C-reactive protein (sCRP) for PPRC. METHODS: The clinicopathological data of 327 patients who underwent elective gastrectomy for gastric cancer were reviewed. There were 18 patients who developed PPRC. Univariate and multivariate analyses were conducted to identify the risk factors of PPRC. Receiver operating characteristic curves were used to identify the cut-off values of dAmy and sCRP on postoperative day 3 (dAmy3 and sCRP3) to predict the risk of PPRC. RESULTS: In the multivariate analysis, splenectomy alone correlated with PPRC. The cut-off values of dAmy3 and sCRP3 were 761 IU/L and 15.15 mg/dL, respectively. Among the 17 patients with both dAmy3 and sCRP3 above the thresholds, 10 (58.8%) had PPRC with Clavien-Dindo classification (CD) ≥II and 7 (41.2%) had PPRC with CD ≥III. In contrast, among the 236 patients with both parameters below the thresholds, 233 (98.7%) did not develop PPRC, and only 1 (0.4%) had PPRC with CD ≥III. CONCLUSIONS: Splenectomy correlates with PPRC, which is consistent with results from large clinical trials. A combined use of dAmy3 and sCRP3 can be useful in predicting the risks of PPRC.

Validity of Laparoscopic Gastrectomy in the Elderly.

OBJECTIVES: This study aimed to investigate the validity of laparoscopic gastric cancer surgery in elderly patients. METHODS: A total of 202 patients who underwent laparoscopic gastrectomy for gastric cancer between January 2007 and December 2016 were divided into an elderly group (age ≥75 years, n = 36) and a control group (age < 75 years, n = 166). The patients' clinicopathological data were reviewed. RESULTS: The overall morbidity rate was relatively higher in the elderly group (16.7 vs. 11.4%, p = 0.389), whereas the incidence of serious complications ≥grade III according to the Clavien-Dindo classification did not increase significantly in the elderly group (8.3 vs. 7.8%, p = 0.920). Univariate and multivariate analyses revealed that age ≥75 years was not a significant predictive factor of postoperative morbidity (p = 0.568). There was no significant difference in the 5-year overall survival rate of patients with pathological stage I gastric cancer between the groups (97.1 vs. 96.1%, p = 0.704; hazard ratio, 0.669; 95% confidence interval, 0.036-3.692). CONCLUSIONS: Laparoscopic gastrectomy has an acceptable morbidity rate in elderly patients, and the long-term outcome of patients with stage I gastric cancer was similar to that of the control group.

Postoperative morbidity in elderly patients after gastric cancer surgery.

BACKGROUND: Elderly patients have a high risk of adverse outcomes after surgery. Therefore, it is essential to determine the predictive factors for postoperative morbidity in elderly patients undergoing gastric cancer surgery. METHODS: A total of 544 patients who underwent elective gastrectomy for gastric cancer at Yodogawa Christian Hospital between January 2007 and December 2015 were divided into the elderly group (age ≥70 years, n=282) and a control group (age <70 years, n=262). Clinicopathological data from all patients were reviewed. RESULTS: The overall morbidity rates were 24.8% in the elderly group and 13.4% in the control group, indicating a significant difference (P<0.001). The incidence rates of anastomotic leakage (4.6% vs. 1.5%, P=0.039) and cardiovascular complications (2.5% vs. 0%, P=0.01) were significantly higher in the elderly group. A multivariate analysis revealed that a blood loss of ≥320 mL was an independent predictive factor of overall morbidity (P=0.004). A blood loss of ≥219 mL (P=0.025) and American Society of Anesthesiologists (ASA) physical status of 3/4 (P=0.006) were associated with anastomotic leakage and postoperative cardiovascular complications, respectively. CONCLUSIONS: The overall morbidity rate was significantly higher among elderly patients and an intraoperative blood loss of ≥320 mL was a significant predictive factor. In particular, anastomotic leakage and cardiovascular complications were seen with greater frequency among those with a higher blood loss volume and ASA physical status, respectively.

[Early Surgery for Acute Cholecystitis Complicated with Gallbladder Cancer].

The present study involved 6 patients who had urgent surgery for acute cholecystitis(AC)complicated with gallbladder cancer(GBC)in our hospital from January 2014 to December 2016. We analyzed the clinical outcome of early surgery for AC complicated with GBC. According to Tokyo Guidelines 2013, the AC severity was classified as Mild 1 case, Moderate 5 cases. Only one patient was diagnosed with GBC before the operation for AC. The others were during or after the laparoscopic cholecystectomy. Histopathologically, all patients had Stage II disease or greater. Two patients had adjunctive radical operation with the wedge resection of the gallbladder bed, lymphadenectomy and bile duct resection, and they survived without recurrence for 28 months and 12 months, respectively. Of the 3 patients without any additional surgery, 2 patients died in several months after the operation. In consideration of the concurrence of GBC, early surgery for AC must be decided carefully.

Impact of Gastric Cancer Surgery in Elderly Patients.

OBJECTIVES: This study aimed to investigate the validity of gastric cancer surgery in elderly patients. METHODS: A total of 544 patients who underwent elective gastrectomy for gastric cancer were divided into an elderly group (age ≥75 years, n = 171) and a control group (age <75 years, n = 373). The clinicopathological data of the patients were reviewed. RESULTS: The overall morbidity rate (26.3 vs. 16.1%, p = 0.005) and the incidence rate of anastomotic leakage (6.4 vs. 1.6%, p = 0.003) were significantly higher in the elderly group. The proportion of patients who had severe complications (≥grade IIIa) was relatively higher in the elderly group (10.5 vs. 5.7%); however, the difference was not significant (p = 0.074). A stage-matched survival analysis revealed no significant differences between the groups (stage I: p = 0.978; stage II: p = 0.964; stage III: p = 0.199). For the pathological stages II and III, the overall survival of the patients in the elderly group who received adjuvant chemotherapy for >3 months was significantly better than that of the patients who received it for ≤3 months or did not receive it (p = 0.023). CONCLUSIONS: An aggressive treatment strategy should be adopted in selected elderly patients with gastric cancer.

[Granulomatosis with Polyangiitis Complicated with Gastrointestinal Perforation: A Case Report and Review of Literature].

  A 51-year-old man was detected nasal bleeding, multiple pulmonary nodule and mass, urinalysis abnormality, renal involvement and high titer of proteinase 3-anti-neutrophil cytoplasmic antibody (PR3-ANCA), and was suspected of granulomatosis with polyangiitis and initiated with steroid pulse therapy. On the day after the start of steroid pulse therapy, generalized peritonitis due to ileal perforation occurred, and emergency ileectomy and peritonitis surgery were performed. Induction therapy with steroid pulse therapy, plasma exchange and intravenous cyclophosphamide therapy (IVCY) and maintenance therapy with glucocorticoid and azathioprine led to good therapeutic outcomes. Gastrointestinal perforation in GPA is a rare complication, and we examined the clinical features, treatment contents, and prognosis of GPA with gastrointestinal perforation from this case and previous reports. Lung involvements were complicated in all reported cases. Gastrointestinal perforations in GPA were frequent in the small intestine, occurred just before and immediately after the start of treatment, and were severe involvement with poor prognosis because of the high mortality rate (46.7%). The frequency of ear, nose and upper respiratory tract lesions in the surviving group was significantly higher than in the dead group (survival 87.5%, death 28.3%, P = 0.041). IVCY were more frequently used in the surviving group (62.5%) than the death group (16.7%), but it was not significantly. GPA complicated with gastrointestinal perforation is a severe condition with poor prognosis, but there is a possibility to improve prognosis by early diagnosis and early initiation of strong treatment.

Outcomes of Consistent Conservative Management for Acute Cholecystitis Followed by Delayed Cholecystectomy.

OBJECTIVE: This study's objective was to assess outcomes of a totally conservative strategy for acute cholecystitis (AC) followed by delayed elective cholecystectomy. PATIENTS AND METHODS: Consecutive patients who underwent cholecystectomy for AC were divided into the Emergent and Elective cholecystectomy groups. Patients in the elective cholecystectomy group were divided into early, medium, and late groups according to time from symptoms onset. RESULTS: The success rate for conservative management reached 97.2%. Increased blood loss and a higher conversion rate were significantly associated with the emergent group. Patients in the late group had significantly lower operative time and tended to have lower blood loss and less frequent conversion to open surgery than those in the early and medium groups. CONCLUSIONS: Most AC cases could be managed conservatively, and elective cholecystectomy was performed safely regardless of the time. Elective cholecystectomy carried out in late phase was likely to be associated with decreased surgical difficulty.

Is the Glasgow Prognostic Score Applicable to Both Early- and Advanced-Stage Gastric Cancers?

BACKGROUND: The Glasgow prognostic score (GPS) has been reported as a sensitive prognostic marker for gastric cancer. This study aimed to investigate whether the GPS is equally applicable to patients with early-stage and advanced-stage gastric cancers. METHODS: Patients (n = 544) who underwent elective gastrectomy for gastric cancer between 2007 and 2015 were retrospectively studied. GPSs of 2, 1, and 0 were allocated to patients with both an elevated C-reactive protein level (> 1.0 mg/dL) and hypoalbuminemia (< 3.5 mg/dL), patients with only one of these abnormalities, and patients with neither abnormality, respectively. The prognostic factors relevant to patients with early-stage (pStage I, n = 304) and advanced-stage (pStage II, III, and IV, n = 240) gastric cancer were analyzed through univariate and multivariate analyses. RESULTS: In the early-stage group, only the serum carbohydrate antigen (CA) 19-9 level (P = 0.037) was a significant prognostic factor in the multivariate analysis; the GPS was not significant (P = 0.095). In the advanced-stage group, an American Society of Anesthesiologists physical status of 3 or 4 (P = 0.032), elevated carcinoembryonic antigen (CEA) (P = 0.043) and CA19-9 (P = 0.045) levels, a GPS 1 - 2 (P = 0.017), and type 4 tumor (P = 0.020) correlated significantly with worse overall survival. CONCLUSIONS: GPS is a simple and useful prognostic score for patients with advanced-stage, but is not applicable to early-stage patients.

Outcome of Gastric Cancer Surgery in Patients with Chronic Kidney Disease.

BACKGROUND: The influence of chronic kidney disease (CKD) on the outcome of gastric cancer surgery has rarely been reported. METHODS: Retrospectively collected clinicopathological data on patients who underwent elective gastrectomy between January 2007 and December 2014 were analyzed (n = 500). The patients were divided into 2 groups based on the preoperative estimated glomerular filtration rate (eGFR): a non-CKD group (eGFR ≥60 ml/min/1.73 m2, n = 392) and a CKD group (eGFR <60 ml/min/1.73 m2, n = 108). Short- and long-term results of the surgery were compared. RESULTS: There was no significant difference between the 2 groups in terms of the overall morbidity rate (p = 0.215), and in any kind of postoperative complication, including infectious and cardiovascular complications. Additionally, there was no significant difference in the morbidity rate irrespective of the type of gastrectomy and the extent of lymph node dissection. The 3-year relapse-free survival rates in the non-CKD and CKD groups were 92.1 and 92.0%, respectively, in stage I disease (p = 0.640), 81.4 and 73.7%, respectively, in stage II disease (p = 0.825), and 35.9 and 31.9%, respectively, in stage III disease (p = 0.784). CONCLUSION: CKD did not affect the short- and long-term outcomes in patients after gastric cancer surgery.

Current role of percutaneous transhepatic gallbladder aspiration: from palliative to curative management for acute cholecystitis.

BACKGROUND: The present study assessed conservative management of acute cholecystitis (AC) with a focus on percutaneous transhepatic gallbladder aspiration (PTGBA). METHODS: Consecutive 275 patients with AC who underwent PTGBA were reviewed. Patients aged ≥80 years and/or with American Society of Anesthesiologists score III to IV and/or performance status 3 to 4 were defined as high risk. Patients were classified according to duration from symptom onset to first PTGBA: within 3 days (early PTGBA) or over 3 days (late PTGBA). They were also classified according to duration from first PTGBA to surgery: within 30 days (early surgery) or over 30 days (late surgery). RESULTS: A total of 263 patients (95.6%) showed recovery after PTGBA. There were no significant differences in operating time, blood loss, operating procedure, conversion rate to open surgery, postoperative complications, or postoperative hospital stay between the early and late PTGBA groups or between the early and late surgery groups. No significant complications associated with PTGBA or surgery were observed, including in those at high risk. CONCLUSIONS: Percutaneous transhepatic gallbladder aspiration can be a useful alternative for most patients with AC, including those at high risk. Elective cholecystectomy can be performed safely regardless of the timing of PTGBA or surgery.

Intestinal perforation management using T-tube drainage.

In cases of small bowel perforation with gross contamination, enterostomy has traditionally been the treatment of choice. An 86-year-old woman was diagnosed with perforative peritonitis. Emergency laparotomy revealed a small bowel perforation with gross contamination, and a T-tube enterostomy was performed. The T-tube was used for intestinal decompression for the first few days and was then accompanied by enteral feeding. When oral intake was sufficient, the T-tube was removed. The abdominal wall's fistula healed within 2 days of removal. Except for wound infection, the patient developed no postoperative complications. Under specific circumstances, a T-tube enterostomy can be an effective alternative for a traditional enterostomy. Its advantages include less or no anastomotic leakage, easier management of fluid and electrolyte levels, postoperative enteral feeding from the tube, a shorter operative time and no need for a second operation to close the stoma.

[A case of undifferentiated gastric cancer that recurred with portal vein tumor thrombus].

A 69-year-old man with a malignant tumor of the stomach underwent distal gastrectomy with partial resection of the abdominal wall, transverse colon, and lateral segment of the liver. Based on a detailed pathological examination of the resected specimen, a diagnosis of undifferentiated gastric cancer was established. Six months after the operation, during postoperative adjuvant chemotherapy with S-1, diagnostic imaging, including CT and positron emission tomography (PET), revealed a portal vein tumor thrombus and diffusely spreading metastases in the posterior segment of the liver. Despite chemotherapy with S-1/CDDP, the metastatic tumors continued to grow rapidly. The patient died 10 months after the operation. On autopsy, the portal vein tumor thrombus was observed to be composed of undifferentiated cancer cells invading into the liver parenchyma through hepatic sinusoids, with the metastatic tumors replacing 60% or more of the entire liver.

Comparison of laparoscopic sigmoidectomy with and without preservation of the superior rectal artery: a single-institution retrospective study.

INTRODUCTION: The inferior mesenteric artery is usually divided during the resection of sigmoid colon cancers. However, this sometimes results in an insufficient blood supply to the anastomosis, leading to anastomotic leakage. We conducted a retrospective analysis to determine the feasibility and potential benefits of preserving the superior rectal artery (SRA). METHODS: Fifty-seven patients underwent SRA-preserving sigmoidectomy with D2 or D3 lymph node dissection (group A) between June 2008 and May 2012. These patients were compared with 35 patients who underwent sigmoidectomy without preservation of the SRA (group B) during the same period. RESULTS: The amount of blood loss, the number of harvested lymph nodes, and the postoperative morbidity rate did not differ significantly between the groups. There were no cases of anastomotic leakage in group A and there was one in group B, but this difference was not significant. The 3-year relapse-free survival rates also did not differ significantly between the two groups, irrespective of lymph node status. CONCLUSION: Sigmoidectomy with SRA preservation can be performed without compromising the quality of lymph node dissection and relapse-free survival. No advantage of preserving the SRA could be demonstrated, but it is noteworthy that no anastomotic leakage was noted among the 57 patients in group A.

Role of percutaneous transhepatic gallbladder aspiration in the early management of acute cholecystitis.

OBJECTIVE: Early cholecystectomy is currently the gold standard treatment for acute cholecystitis (AC). However, the acceptability and safety of this strategy remain in dispute. The aim of this study was to clarify the role of percutaneous transhepatic gallbladder aspiration (PTGBA) in the early management of AC in a single center. METHODS: A total of 147 consecutive patients who were treated with PTGBA for AC from 2008 to 2012 were included in the study. The therapeutic outcomes and adverse events were evaluated. RESULTS: A single PTGBA was adequate for 96 (65.3%) patients with AC. Of the remaining 51 patients, 43 (29.3%) showed an improvement after repeated PTGBA and/or percutaneous transhepatic gallbladder drainage (PTGBD), while semi-emergency cholecystectomy was needed in eight patients. Although five patients experienced adverse events (intra-abdominal hemorrhage in two, bile leakage in two and gallbladder hemorrhage in one), no patient died of treatment-related complications. Subsequently, 87 (59.2%) patients underwent cholecystectomy after PTGBA (a single PTGBA in 48 and repeated PTGBA and/or PTGBD in 39 patients). No significant differences were observed in the conversion rate from laparoscopic surgery to open cholecystectomy, operative time or intraoperative hemorrhage volume between the two groups. CONCLUSIONS: The present study demonstrated the safety and acceptability of treatment with PTGBA for AC at our center. This elective treatment strategy may be a useful alternative option in the treatment of AC.