Prognosis of spread through air spaces in invasive mucinous lung adenocarcinoma after curative surgery.

INTRODUCTION: The purpose of this study is to investigate the prognostic impact of spread through air spaces (STAS) in invasive mucinous adenocarcinoma (IMA). MATERIALS AND METHODS: From 2015 to 2019, patients who underwent complete resection of IMA were extracted from the prospective database. Multivariable Cox-regression analysis and inverse probability of treatment weight (IPTW) - adjusted log-rank test for 5-year recurrence-free survival (RFS) were performed. RESULTS: STAS was observed in 39.1% (53 out of 133). The STAS (+) group shows larger tumor size (2.9 ± 2.4 cm vs 3.8 ± 2.4 cm, p = 0.031) and higher incidence of lympho-vascular invasion (6 [7.5%] vs 18 [34.0%], p < 00.001) compared to the STAS (-) group. The 5-year RFS was 66.1% in the STAS (+) group and 91.8% in the STAS (-) group (p < 00.001), and the incidence of locoregional recurrence was significantly higher in the STAS (+) group than the STAS (-) group (1 [1.2%] vs 12 [22.6%], p < 00.001). Multivariable analysis revealed that STAS was associated with poor prognosis for all-recurrence (hazard ratio 2.81, 95% confidence interval 1.01-7.81, p = 0.048). After IPTW adjustment, 5-year RFS was 66.3% in the STAS (+) group and 92.9% in the STAS (-) group (p = 0.007), and risk for locoregional recurrence was greater in the STAS (+) group than the STAS (-) group (1.1 [0.9%] vs 20.8 [16.6%], p < 00.001). CONCLUSIONS: STAS showed negative prognostic impact on all-recurrence, especially due to locoregional recurrence, after curative resection of IMA.

The Optimal Treatment Strategy for Postoperative Anastomotic Leakage After Esophagectomy: a Comparative Analysis Between Endoscopic Vacuum Therapy and Conventional Treatment.

BACKGROUND: We compared the clinical outcomes between endoscopic vacuum therapy (EVT) and conventional treatment (CT) for the management of post-esophagectomy anastomotic leakage. METHODS: A retrospective review of the medical records of patients who underwent esophagectomy with esophagogastrostomy from November 2003 to August 2021 was conducted. Thirty-four patients who developed anastomotic leakage were analyzed according to whether they underwent CT (n = 13) or EVT (n = 21). RESULTS: The median time to complete healing was significantly shorter in the EVT group than in the CT group (16 [4-142] days vs. 70 [8-604] days; p = 0.011). The rate of clinical success was higher in the EVT group (90.5%) than in the CT group (66.7%, p = 0.159). A subgroup analysis showed more favorable outcomes for EVT in patients with thoracic leakage, including a higher clinical success rate (p = 0.037), more rapid complete healing (p = 0.004), and shorter hospital stays (p = 0.006). However, the results were not significantly different in patients with cervical leakage. Anastomotic strictures occurred in 3 EVT patients (14.3%) and 5 CT patients (50.0%) (p = 0.044), and the EVT group showed a trend towards improved freedom from anastomotic strictures (p = 0.105). CONCLUSIONS: EVT could be considered as an adequate treatment option for post-esophagectomy anastomotic leakage. EVT might have better clinical outcomes compared to CT for managing anastomotic leakage after transthoracic esophagogastrostomy, and further studies are needed to evaluate the effectiveness of EVT in patients who undergo cervical esophagogastrostomy.

Comparison between percutaneous transhepatic gallbladder drainage and upfront laparoscopic cholecystectomy in patients with moderate-to-severe acute cholecystitis: a propensity score-matched analysis.

Purpose: In the Tokyo Guidelines 2018 (TG18), emergency laparoscopic cholecystectomy is recognized as a crucial early treatment option for acute cholecystitis. However, early laparoscopic intervention in patients with moderate-to-severe acute cholecystitis or those with severe comorbidities may increase the risk of complications. Therefore, in the present study, we investigated the association between early laparoscopic cholecystectomy and percutaneous transhepatic gallbladder drainage (PTGBD) in moderate-to-severe acute cholecystitis patients. Methods: We retrospectively analyzed 835 TG18 grade II or III acute cholecystitis patients who underwent laparoscopic cholecystectomy at 4 tertiary medical centers in the Republic of Korea. Patients were classified into 2 groups according to whether PTGBD was performed before surgery, and their short-term postoperative outcomes were analyzed retrospectively. Results: The patients were divided into 2 groups, and 1:1 propensity score matching was conducted to establish the PTGBD group (n = 201) and the early laparoscopic cholecystectomy group (n = 201). The PTGBD group experienced significantly higher rates of preoperative systemic inflammatory response syndrome (24.9% vs. 6.5%, P < 0.001), pneumonia (7.5% vs. 3.0%, P = 0.045), and cardiac disease (67.2% vs. 57.7%, P = 0.041) than the early operation group. However, there was no difference in biliary complication (hazard ratio, 1.103; 95% confidence interval, 0.519-2.343; P = 0.799) between the PTGBD group and early laparoscopic cholecystectomy group. Conclusion: In most cases of moderate-to-severe cholecystitis, early laparoscopic cholecystectomy was relatively feasible. However, PTGBD should be considered if patients have the risk factor of underlying disease when experiencing general anesthesia.

Surgical outcomes of thoracoscopic thymectomy via the single-port subxiphoid approach versus the unilateral intercostal approach.

OBJECTIVES: The purpose of this study was to explore the safety and feasibility of video-assisted thoracic surgery (VATS) total thymectomy via the single-port subxiphoid approach compared with the intercostal approach. METHODS: From January 2018 to May 2022, patients who underwent VATS total thymectomy via the subxiphoid or unilateral intercostal approach and diagnosed with Masaoka-Koga stage I-II, non-myasthenic thymoma were included in this study. Perioperative outcomes, immediate and long-term pain evaluations were compared in a propensity score-matching analysis. RESULTS: In total, 95 patients were included and underwent the subxiphoid approach (n = 37) and the intercostal approach (n = 58). Propensity score yielded 2 well-matched cohorts of 30 patients and there was no significant demographical imbalance between the 2 groups. Compared with the intercostal approach, the subxiphoid group demonstrated favourable perioperative outcomes including the intraoperative blood loss (P = 0.025) and the median duration of hospital stay (P = 0.083). The immediate and long-term pain evaluations revealed that the subxiphoid group reported lower visual analogue scales at postoperative 24 h and lower total doses of fentanyl bolus infusions during hospitalization (P = 0.004 and 0.018, respectively), along with lower long-term neuropathic pain scale scores (P = 0.005) than patients in the intercostal group. CONCLUSIONS: VATS thymectomy via the single-port subxiphoid approach showed favourable perioperative outcomes compared to the intercostal approach. Moreover, the subxiphoid approach seemed both to cause minimal immediate postoperative pain and to have advantages in reducing long-term neuropathic pain compared with the intercostal approach.

Alteration of the fecal microbiome in patients with cholecystectomy: potential relationship with postcholecystectomy diarrhea - before and after study.

BACKGROUND: Bile acid (BA) is a crucial determinant of the gut microbiome, and cholecystectomy can alter the physiology of BA. Physiological changes in BA resulting from cholecystectomy can also influence the gut microbiome. We aimed to identify the specific taxa associated with perioperative symptoms, including postcholecystectomy diarrhea (PCD), and to evaluate the effect of cholecystectomy on the microbiome by investigating the fecal microbiome of patients with gallstones. METHODS: We analyzed the fecal samples of 39 patients with gallstones (GS group) and 26 healthy controls (HC group) to evaluate their gut microbiome. We also collected fecal samples from GS group 3 months postcholecystectomy. Symptoms of patients were evaluated before and after cholecystectomy. Further, 16S ribosomal RNA amplification and sequencing were performed to determine the metagenomic profile of fecal samples. RESULTS: The microbiome composition of GS differed from that of HC; however, the alpha diversity was not different. No significant microbiome alterations were observed before and after cholecystectomy. Moreover, GS group showed a significantly lower Firmicutes to Bacteroidetes ratio before and after cholecystectomy than the HC group (6.2, P< 0.05). The inter-microbiome relationship was lower in GS than in HC and tended to recover 3 months after surgery. Furthermore, ~28.1% ( n =9) of patients developed PCD after surgery. The most prominent species among PCD (+) patients was Phocaeicola vulgatus. Compared with the preoperative state, Sutterellaceae , Phocaeicola , and Bacteroidals were the most dominant taxa among PCD (+) patients. CONCLUSION: GS group showed a different microbiome from that of HC; however, their microbiomes were not different 3 months after cholecystectomy. Our data revealed taxa-associated PCD, highlighting the possibility of symptom relief by restoring the gut microbiome.

Investigation of Immunostimulatory Effects of Heat-Treated Lactiplantibacillus plantarum LM1004 and Its Underlying Molecular Mechanism.

Postbiotics are defined as probiotics inactivated by heat, ultraviolet radiation, sonication, and other physical or chemical stresses. Postbiotics are more stable than probiotics, and these properties are advantageous for food additives and pharmacological agents. This study investigated the immunostimulatory effects of heat-treated Lactiplantibacillus plantarum LM1004 (HT-LM1004). Cellular fatty acid composition of L. plantarum LM1004 isolated form kimchi was analyzed by gas chromatography-mass spectrometry detection system. The nitric oxide (NO) content was estimated using Griess reagent. Immunostimulatory cytokines were evaluated using enzyme-linked immunosorbent assay. Relative protein expressions were evaluated by western blotting. Phagocytosis was measured using enzyme-labelled Escherichia coli particles. L. plantarum LM1004 showed 7 kinds of cellular fatty acids including palmitic acid (C16:0). The HT-LM1004 induced release of NO and upregulated the inducible NO synthase in RAW 264.7 macrophage cells. Tumor necrosis factor-α and interleukin-6 levels were also increased compared to control (non-treated macrophages). Furthermore, HT-LM1004 modulated mitogen-activated protein kinase (MAPK) subfamilies including p38 MAPK, extracellular signal-regulated kinase 1/2, and c-Jun N-terminal kinase. Therefore, these immunostimulatory effects were attributed to the production of transcriptional factors, such as nuclear factor kappa B (NF-κB) and the activator protein 1 family (AP-1). However, HT-LM1004 did not showed significant phagocytosis of RAW 264.7 macrophage cells. Overall, HT-LM1004 stimulated MAPK/AP-1 and NF-κB expression, resulting in the release of NO and cytokines. These results will contribute to the development of diverse types of food and pharmacological products for immunostimulatory agents with postbiotics.

Comparison of Short-Term Surgical Outcomes According to Immediately Postoperative Serum Glucose Level in Non-Diabetic Pancreatic Resection Patients.

The adequate regulation of postoperative serum glucose level (SGL) is widely accepted; however, the effects for non-diabetic patients who underwent major pancreatic surgery have not yet been established. We discerned the relevance of the immediately postoperative SGL to short-term postoperative outcomes from major pancreatic surgery in non-diabetic patients. Between January 2007 and December 2016, 2259 non-diabetic patients underwent major pancreatic surgery at four tertiary medical centers in Republic of Korea. Based on a SGL of 200 mg/dL, patients were classified into two groups by averaging the results of four SGL tests taken on the first day after surgery, and their short-term postoperative outcomes were analyzed. A 1:1 propensity score matching method was conducted to establish the high SGL group (n = 568) and the normal SGL group (n = 568). The high SGL group experienced a significantly higher rate of level C complications in the Clavien-Dindo classification (CDc) than the normal SGL group (24.1% vs. 16.5%, p = 0.002). Additionally, an SGL of more than 200 mg/dL was associated with a significantly high risk of complications above level C CDc after adjusting for other risk factors (hazard ratio = 1.324, 95% confidence interval = 1.048-1.672, p = 0.019). The regulation of SGL of less than 200 mg/dL in non-diabetic patients early after major pancreatic surgery could be helpful for reducing postoperative complications.

Development of Nomograms for Predicting Prognosis of Pancreatic Cancer after Pancreatectomy: A Multicenter Study.

Surgical resection is the only curative treatment for pancreatic ductal adenocarcinoma (PDAC). Currently, the TNM classification system is considered the standard for predicting prognosis after surgery. However, the prognostic accuracy of the system remains limited. This study aimed to develop new predictive nomograms for resected PDAC. The clinicopathological data of patients who underwent surgery for PDAC between 2006 and 2015 at five major institutions were retrospectively reviewed; 885 patients were included in the analysis. Cox regression analysis was performed to investigate prognostic factors for recurrence and survival, and statistically significant factors were used for creating nomograms. The nomogram for predicting recurrence-free survival included nine factors: sarcopenic obesity, elevated carbohydrate antigen 19-9, platelet-to-lymphocyte ratio, preoperatively-identified arterial abutment, estimated blood loss (EBL), tumor differentiation, size, lymph node ratio, and tumor necrosis. The nomogram for predicting overall survival included 10 variables: age, underlying liver disease, chronic kidney disease, preoperatively found portal vein invasion, portal vein resection, EBL, tumor differentiation, size, lymph node metastasis, and tumor necrosis. The time-dependent area under the receiver operating characteristic curve for both nomograms exceeded 0.70. Nomograms were developed for predicting survival after resection of PDAC, and the platforms showed fair predictive performance. These new comprehensive nomograms provide information on disease status and are useful for determining further treatment for PDAC patients.

Prognostic Role of Circulating Tumor Cells in the Pulmonary Vein, Peripheral Blood, and Bone Marrow in Resectable Non-Small Cell Lung Cancer.

Background: Studies of the prognostic role of circulating tumor cells (CTCs) in early-stage non-small cell lung cancer (NSCLC) are still limited. This study investigated the prognostic power of CTCs from the pulmonary vein (PV), peripheral blood (PB), and bone marrow (BM) for postoperative recurrence in patients who underwent curative resection for NSCLC. Methods: Forty patients who underwent curative resection for NSCLC were enrolled. Before resection, 10-mL samples were obtained of PB from the radial artery, blood from the PV of the lobe containing the tumor, and BM aspirates from the rib. A microfabricated filter was used for CTC enrichment, and immunofluorescence staining was used to identify CTCs. Results: The pathologic stage was stage I in 8 patients (20%), II in 15 (38%), III in 14 (35%), and IV in 3 (8%). The median number of PB-, PV-, and BM-CTCs was 4, 4, and 5, respectively. A time-dependent receiver operating characteristic curve analysis showed that PB-CTCs had excellent predictive value for recurrence-free survival (RFS), with the highest area under the curve at each time point (first, second, and third quartiles of RFS). In a multivariate Cox proportional hazard regression model, PB-CTCs were an independent risk factor for recurrence (hazard ratio, 10.580; 95% confidence interval, 1.637-68.388; p<0.013). Conclusion: The presence of ≥4 PB-CTCs was an independent poor prognostic factor for RFS, and PV-CTCs and PB-CTCs had a positive linear correlation in patients with recurrence.

The value of drain fluid amylase as a predictor of postoperative pancreatic fistula after pancreaticogastrostomy.

BACKGROUND: Drain fluid amylase is commonly used as a predictor of pancreatic fistula after pancreaticoduodenectomy (PD). This study aimed to determine the ideal cut-off value of drain fluid amylase on postoperative day 1 (DFA1) for predicting pancreatic fistula after pancreaticogastrostomy (PG). METHODS: Prospective data of 272 consecutive patients undergoing PG between 2010 and 2020 was collected and analysed to determine the postoperative pancreatic fistula (POPF) risk factors. RESULTS: The incidence of POPF was 143 cases (52.6%). The median DFA1 in patients with POPF was significantly higher than that of patients with NO-POPF (5483 versus 311, P < 0.001). DFA1 correlated with POPF in the area under the curve (AUC) of 0.84 (P < 0.001). When DFA1 was 2300 U/L, Youden index was the highest, with a sensitivity of 72.7% and a specificity of 82.9%. Logistic regression analysis showed that DFA1 ≥ 2300 U/L was an independent predictor of POPF (P < 0.001; OR: 12.855; 95% CI: 7.019-23.544). The AUC of DFA1 and clinically relevant postoperative pancreatic fistula (CR-POPF) was 0.674 (P < 0.001). CONCLUSION: DFA1 ≥ 2300 U/L can be used as an independent predictor of POPF after PG. DFA1 ≥ 3000 U/L can predict the occurrence of CR-POPF, when DFA1 ≥ 3000 U/L, the patients should be observed closely active for complications.

The differential prognostic impact of spread through air spaces in early-stage lung adenocarcinoma after lobectomy according to the pT descriptor.

OBJECTIVES: We evaluated the differential prognostic impact of spread through air spaces (STAS) in early-stage lung adenocarcinoma after lobectomy according to the pT descriptor. METHODS: The study population included 506 patients who underwent lobectomy with mediastinal lymph node dissection for pT1b, pT1c, and pT2a adenocarcinoma between 2011 and 2016. We divided the study population into 2 groups according to STAS status, ie, STAS (+) versus STAS (-), and stratified them according to the pT descriptor. A Cox proportional hazard model and inverse probability of treatment weight-adjusted Kaplan-Meier curves were used to evaluate the prognostic impact of STAS on recurrence-free survival (RFS) and its independency in each stratum. RESULTS: Multivariable Cox proportional hazard regression analysis demonstrated that in pT1b and pT1c strata, STAS (+) patients had a 7.02-fold and 2.89-fold greater risk of recurrence than STAS (-) patients, respectively. However, in the pT2a stratum, STAS did not affect RFS. And the RFS of the STAS (+) pT1b/c strata was similar to that of the pT2a stratum. In the pT1b/c strata, inverse probability of treatment weighting-adjusted Kaplan-Meier curves also showed that RFS was significantly worse when STAS was present. Furthermore, the risks for locoregional and distant recurrence were both greater when STAS was present. CONCLUSIONS: The presence of STAS increased the risk of recurrence independently from other poor prognostic factors in patients with pT1b/cN0M0 adenocarcinoma who underwent lobectomy, but not in pT2a patients. The presence of STAS in pT1b/cN0M0 adenocarcinoma was associated with a similar risk of recurrence to that of pT2aN0M0 adenocarcinoma.

Atrophy of remnant pancreas after pancreatoduodenectomy: Risk factors and effects on quality of life, nutritional status, and pancreatic function.

BACKGROUND: Factors aggravating remnant pancreas atrophy following pancreatoduodenectomy and the effects of atrophy have not been extensively studied. This study aimed to evaluate the clinical factors affecting remnant pancreas atrophy and assess the effects of atrophy on quality of life, nutritional status, and pancreatic exocrine and endocrine functions. METHODS: Data collected prospectively from 122 patients who completed 12 months of follow-up, including computed tomography and the quality-of-life questionnaire, were analyzed. Pancreas volume was measured using a computed tomography volumetry program. Endocrine and exocrine functions were evaluated. RESULTS: Malignancy and adjuvant chemoradiotherapy were associated with severity of atrophy. At 12 postoperative months, quality-of-life scores and nutritional indexes were mostly not associated with atrophy, but stool elastase level decreased significantly and incidence of new-onset diabetes mellitus was higher in the severe atrophy group. Postprandial 2-hour blood glucose and glycosylated hemoglobin levels were also higher in this group. CONCLUSIONS: Remnant pancreas atrophy was more severe in patients with malignant disease who received adjuvant chemoradiotherapy and was associated with pancreatic exocrine and endocrine functions. More careful monitoring and active management of exocrine and endocrine deficiencies are necessary for patients who underwent pancreatoduodenectomy for malignant disease and received chemoradiotherapy.

Impact of Bilateral Subcostal Plus Lateral Transversus Abdominis Plane Block on Quality of Recovery After Laparoscopic Cholecystectomy: A Randomized Placebo-Controlled Trial.

BACKGROUND: Previous research has not evaluated the potential effect of transversus abdominis plane (TAP) block on quality of recovery following laparoscopic cholecystectomy. Therefore, we investigated whether addition of the bilateral subcostal and lateral TAP (bilateral dual TAP [BD-TAP]) blocks to multimodal analgesia would improve the quality of recovery as assessed with the Quality of Recovery-40 (QoR-40). METHODS: Patients age 18 to 60 years who were scheduled to undergo elective laparoscopic cholecystectomy were randomized to the BD-TAP or control group. The BD-TAP group received the BD-TAP block with multimodal analgesia under general anesthesia, using 0.25% ropivacaine, and the control group was treated with the same method, except that they received the sham block using 0.9% normal saline. Both groups had the same multimodal analgesia regimen, consisting of intravenous dexamethasone, propacetamol, ibuprofen, and oxycodone. The primary outcome was the QoR-40 score at 24 hours after surgery. Data were analyzed using the independent t test, Mann-Whitney U test, χ2 test, and Fisher exact test. RESULTS: Thirty-eight patients in each group were recruited. The mean QoR-40 score decreased by 13.6 (95% confidence interval [CI], 8.3-18.8) in the BD-TAP group and 15.6 (95% CI, 6.7-24.5) in the control group. The postoperative QoR-40 score at 24 hours after surgery did not differ between the 2 groups (BD-TAP group, median [interquartile range], 170.5 [152-178]; control group, 161 [148-175]; median difference, 3 [95% CI, -5 to 13]; P = .427). There were no differences between the 2 groups in the pain dimension of the QoR-40: 30.5 (95% CI, 27-33) in the BD-TAP group and 31 (95% CI, 26-32) in the control group; median difference was 0 (95% CI, -2 to 2); P = .77. CONCLUSIONS: Our results indicate that the BD-TAP block does not improve the quality of recovery or analgesic outcomes following laparoscopic cholecystectomy. Our results do not support the routine use of the BD-TAP block for this surgery.

Prognostic Significance of the Extranodal Extension of Regional Lymph Nodes in Stage III-N2 Non-Small-Cell Lung Cancer after Curative Resection.

The present study investigated the prognostic role of extranodal extension (ENE) in stage III-N2 non-small-cell lung cancer (NSCLC) following curative surgery. From January 2005 to December 2018, pathologic stage III-N2 disease was diagnosed in 371 patients, all of whom underwent anatomic pulmonary resection accompanied by mediastinal lymph node dissection. This study included 282 patients, after excluding 89 patients who received preoperative chemotherapy or incomplete surgical resection. Their lymph nodes were processed; after hematoxylin and eosin staining, histopathologic slides of the metastatic nodes were reviewed by a designated pathologist. Predictors of disease free survival (DFS), including age, sex, operation type, pathologic T stage, nodal status, visceral pleural invasion, perioperative treatment, and the presence of ENE, were investigated. Among the 282 patients, ENE was detected in 85 patients (30.1%). ENE presence was associated with advanced T stage (p = 0.034), N2 subgroups (p < 0.001), lymphatic invasion (p = 0.001), and pneumonectomy (p = 0.002). The multivariable analysis demonstrated that old age (p < 0.001), advanced T stage (p = 0.012), N2 subgroups (p = 0.005), and ENE presence (p = 0.005) were significant independent predictors of DFS. The DFS rate at five years was 21.4% in patients who had ENE and 43.4% in patients who did not have ENE (p < 0.001). The presence of ENE, coupled with tumor-node-metastasis staging, should be recognized as a meaningful prognostic factor in stage III-N2 NSCLC patients.

The diagnostic and prognostic values of inflammatory markers in intraductal papillary mucinous neoplasm.

BACKGROUND: Intraductal papillary mucinous neoplasm (IPMN) is an broad-spectrum disease from benign to malignant. Inflammatory markers are known as prognostic predictors in various diseases. The purpose of this study was to determine the predictive value of inflammatory markers for prognosis in IPMN. METHODS: From April 1995 to December 2016, patients who underwent pancreatectomy with pathologically confirmed IPMN at four tertiary centers were enrolled. Patients with a history of pancreatitis or cholangitis, and other malignancies were excluded. Neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), and advanced lung cancer inflammation index (ALI) were calculated. RESULTS: Of all, ninety-eight patients (26.8%) were diagnosed as invasive IPMN. The NLR and PLR were significantly elevated in invasive IPMN than in non-invasive disease (2.0 vs 1.8, p = 0.004; 117.1 vs 107.4, p = 0.009, respectively). ALI was significantly higher in non-invasive IPMN than in invasive disease (58.1 vs 45.9, p < 0.001). In multivariate analysis, only NLR showed significant association among the inflammatory markers studied (p = 0.044). In invasive IPMN, the five-year recurrence-free survival rate for NLR less than 3.5 was superior to the rest (59.1 vs 42.2, p = 0.023). CONCLUSION: NLR may help to rightly select IPMN patients who will require surgery and may serve as a useful prognostic factor.

Prognostic significance of tumor spread through air spaces in patients with stage IA part-solid lung adenocarcinoma after sublobar resection.

OBJECTIVES: The purpose of this study was to assess the clinicopathologic implications of tumor spread through air spaces (STAS) in patients with stage IA part-solid lung adenocarcinoma after sublobar resection. MATERIALS AND METHODS: Medical records of patients with stage IA part-solid adenocarcinoma who underwent curative pulmonary resection between February 2009 and December 2016 were retrospectively reviewed. The clinicopathological features of STAS and its influence on postoperative recurrence and survival were investigated. RESULTS: Among the 115 patients with stage IA part-solid adenocarcinoma who underwent wedge resection, 20 (17.4 %) had STAS. The multivariable analysis showed presence of STAS [HR (hazard ratio), 9.447; p = 0.002) and a larger invasive component size (HR, 1.097; p = 0.034) were independent risk factors for recurrence. The 5-year freedom from recurrence rates were 62.4 % and 97.9 % in cases with and without STAS, respectively (p < 0.001), and the 5-year disease-free survival rates were 58.5 % and 97.9 % in cases with and without STAS, respectively (p < 0.001). The presence of STAS was associated with old age (p = 0.030), male gender (p = 0.023), acinar predominant histologic pattern (p = 0.004), presence of micropapillary pattern (p < 0.001), lymphovascular invasion (p < 0.001) and larger invasive component (p < 0.001). CONCLUSION: STAS could be an important prognostic factor in patients with stage IA part-solid lung adenocarcinoma after sublobar resection. Effective preoperative evaluation and postoperative surveillance may help improve the outcome of patients with small part-solid nodules, particularly when accompanied by STAS.

Predictive Factors for Lymph Node Metastasis in Clinical Stage I Part-Solid Lung Adenocarcinoma.

BACKGROUND: Accurate clinical staging of tumors with a small solid portion is essential for developing an appropriate treatment plan. This study evaluated predictive factors for lymph node (LN) metastasis in patients with clinical stage I part-solid lung adenocarcinoma. METHODS: Medical records of patients with clinical stage I part-solid adenocarcinoma who underwent anatomic pulmonary resection with systematic node evaluation between January 2009 and June 2018 were retrospectively reviewed. To identify predictive factors for LN metastasis, univariate and multivariable logistic regression analyses were performed. RESULTS: Among the 593 patients in this study, the overall prevalence of LN metastasis was 3.7% (n = 22), which included 3.0% (n = 18) of patients with N1 LN metastasis and 1.5% (n = 9) of patients with N2 LN metastasis. Combined N1 and N2 nodal involvement was observed in 5 patients. Nodal metastasis was not observed in tumors with a solid portion sized 1.1 cm or smaller. The nodal metastasis rates in cT1b, cT1c, and cT2a tumors were 5.5% (13 of 237), 7.1% (6 of 84), and 13.6% (3 of 22), respectively. According to the multivariable analysis, predictive factors included the size of the solid portion (P = .015) and the high maximum standardized uptake value (SUVmax) of the primary tumor (P = .044). CONCLUSIONS: Large solid portion and high SUVmax of the primary tumor were predictive factors of LN metastasis in patients with clinical stage I part-solid lung adenocarcinoma. Systematic LN evaluation should be performed, especially in those who have a large solid portion and high SUVmax of the primary tumor.

National survey of Korean hepatobiliary-pancreatic surgeons on attitudes about the enhanced recovery after surgery protocol.

BACKGROUNDS/AIMS: The purpose of this study was to investigate attitudes regarding the Enhanced Recovery After Surgery (ERAS) protocol of hepato-biliary-pancreatic (HBP) surgeons in Korea and the extent to which they use the protocol for perioperative management. METHODS: An online survey was conducted among members of the Korean Association of Hepato-Biliary-Pancreatic Surgery (KAHBPS) for eight weeks beginning on August 2019. The questionnaire, which was written in Korean, was based on the latest ERAS guidelines. Total responses were collected from 127 surgeons. RESULTS: Of the 127 total respondents, the largest proportion (44.9%) were working in Seoul. In terms of established in-hospital clinical pathways (CP), 19.7% of the participating surgeons had and followed a CP in pancreaticoduodenectomy (PD) and 21.3% in hepatectomy. Regarding the ERAS protocol for each surgery, four items (18.2%) regarding PD and seven items (35.0%) related to hepatectomy were followed by more than 50% of respondents. CONCLUSIONS: ERAS guidelines are one of the consensuses for better recovery in perioperative management of patients undergoing major surgeries and encompass the overall process of patient recovery including patient education, pain control, physiologic balance, and perioperative nutrition. A novel project is needed to successfully implement an evidence-based enhanced recovery strategy.

Comparative Analysis on Machine Learning and Deep Learning to Predict Post-Induction Hypotension.

Hypotensive events in the initial stage of anesthesia can cause serious complications in the patients after surgery, which could be fatal. In this study, we intended to predict hypotension after tracheal intubation using machine learning and deep learning techniques after intubation one minute in advance. Meta learning models, such as random forest, extreme gradient boosting (Xgboost), and deep learning models, especially the convolutional neural network (CNN) model and the deep neural network (DNN), were trained to predict hypotension occurring between tracheal intubation and incision, using data from four minutes to one minute before tracheal intubation. Vital records and electronic health records (EHR) for 282 of 319 patients who underwent laparoscopic cholecystectomy from October 2018 to July 2019 were collected. Among the 282 patients, 151 developed post-induction hypotension. Our experiments had two scenarios: using raw vital records and feature engineering on vital records. The experiments on raw data showed that CNN had the best accuracy of 72.63%, followed by random forest (70.32%) and Xgboost (64.6%). The experiments on feature engineering showed that random forest combined with feature selection had the best accuracy of 74.89%, while CNN had a lower accuracy of 68.95% than that of the experiment on raw data. Our study is an extension of previous studies to detect hypotension before intubation with a one-minute advance. To improve accuracy, we built a model using state-of-art algorithms. We found that CNN had a good performance, but that random forest had a better performance when combined with feature selection. In addition, we found that the examination period (data period) is also important.

Correction to: Stepwise Disease Progression Model of Subsolid Lung Adenocarcinoma with Cystic Airspaces.

In the original article there are errors in Fig. 3. Following is the corrected figure.