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.

Trends in laparoscopic anti-reflux surgery: a Korea nationwide study.

BACKGROUND: In 2014, the results derived from the nationwide data of the Korean Anti-reflux Surgery Study (KARS) demonstrated short-term feasibility and safety of anti-reflux surgery. This study aimed to update the longer-term safety and feasibility of laparoscopic anti-reflux surgery up to 1-year follow-up with the KARS nationwide cohort. METHODS: The data of 310 patients with GERD who received anti-reflux surgery up to 2018 were analyzed. Baseline patient characteristics, postoperative symptom resolution, and postoperative complications were evaluated at postoperative 3 months and 1 year using the questionnaire designed by KARS. We divided the patients into two groups according to the operation period (up to and after 2014) to identify changes in the trends of the characteristics of surgical patients and operative qualities. RESULTS: The typical preoperative symptoms were present in 275 patients (91.7%), and atypical symptoms were present in 208 patients (71.0%). Ninety-seven (35.5%) and 124 patients (46.1%) had inadequate PPI responses and hiatal hernia, respectively. At postoperative 1 year, typical and atypical symptoms were either completely or partially controlled in 90.3% and 73.5.0% of patients, respectively. Moderate-to-severe dysphagia, inability to belch, gas bloating, and flatulence at postoperative 1 year were identified in 23.5%, 29.4%, 23.2%, and 22.0% of patients, respectively. The number of surgical patients continuously increased from 2011 to 2018 in Korea. The proportion of patients with hiatal hernia and comorbidities increased (p < 0.01, p = 0.053), and the operation time decreased significantly (p < 0.01) in the late period (2015-2018) as compared with the early period (2011-2014). Symptom control and complication rate were equivalent between the two periods. CONCLUSIONS: Anti-reflux surgery was effective with > 90% of typical symptom resolution and posed a comparable postoperative complication rate with those in Western studies with mid-term to long-term follow-up. This result supports the feasibility and safety of anti-reflux surgery as a treatment for GERD in the Korean population.

Comparison of surgical outcomes among different methods of esophagojejunostomy in laparoscopic total gastrectomy for clinical stage I proximal gastric cancer: results of a single-arm multicenter phase II clinical trial in Korea, KLASS 03.

BACKGROUND: Laparoscopic distal gastrectomy for early gastric cancer has been widely accepted, but laparoscopic total gastrectomy has still not gained popularity because of technical difficulty and unsolved safety issue. We conducted a single-arm multicenter phase II clinical trial to evaluate the safety and the feasibility of laparoscopic total gastrectomy for clinical stage I proximal gastric cancer in terms of postoperative morbidity and mortality in Korea. The secondary endpoint of this trial was comparison of surgical outcomes among the groups that received different methods of esophagojejunostomy (EJ). METHODS: The 160 patients of the full analysis set group were divided into three groups according to the method of EJ, the extracorporeal circular stapling group (EC; n = 45), the intracorporeal circular stapling group (IC; n = 64), and the intracorporeal linear stapling group (IL; n = 51). The clinicopathologic characteristics and the surgical outcomes were compared among these three groups. RESULTS: There were no significant differences in the early complication rates among the three groups (26.7% vs. 18.8% vs. 17.6%, EC vs. IC vs. IL; p = 0.516). The length of mini-laparotomy incision was significantly longer in the EC group than in the IC or IL group. The anastomosis time was significantly shorter in the EC group than in the IL group. The time to first flatus was significantly shorter in the IL group than in the EC group. The long-term complication rate was not significantly different among the three groups (4.4% vs. 12.7% vs. 7.8%; EC vs. IC vs. IL; p = 0.359), however, the long-term incidence of EJ stenosis in IC group (10.9%) was significantly higher than in EC (0%) and IL (2.0%) groups (p = 0.020). CONCLUSIONS: The extracorporeal circular stapling and the intracorporeal linear stapling were safe and feasible in laparoscopic total gastrectomy, however, intracorporeal circular stapling increased EJ stenosis.

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.

Minimization of Wound With the Assistance of a Needle Grasper in Single-Incision Laparoscopic Appendectomy.

Background. Technical difficulties and pain from large wounds have prevented the widespread use of single-incision laparoscopic appendectomy (SILA). This study aimed to evaluate the efficacy of our newly developed needle grasper (Endo Relief)-assisted SILA (NASILA). Methods. For NASILA, about a 12-mm umbilical incision was made, and a glove port was introduced. A needle grasper was then introduced through a 2.5-mm wound on the suprapubic area. For SILA, a 2.5-cm transumbilical wound was made. The medical records of patients who underwent SILA or NASILA from June 2017 to September 2017 were retrospectively reviewed. Operative and short-term postoperative outcomes and results of telephone interviews for scars were compared. Results. A total of 49 patients in the SILA group (male: 40.8%) and 12 in the NASILA group (male: 50.0%) were included. Appendicitis status (not perforated:perforated without abscess:perforated with abscess) was significantly different between the 2 groups (SILA vs NASILA, 30:18:1 vs 4:6:2, P = .027). Additional trocars were inserted in 9 patients (18.4%) of the SILA group. The operative time was significantly shorter (43.3 ± 33.6 vs 54.1 ± 15.6 minutes, P = .012), and the highest numerical pain intensity score during the first 24 hours after surgery was significantly lower (2.4 ± 0.7 vs 3.0 ± 0.9, P = .038) in the NASILA group than in the SILA group. Hospital stay, postoperative complications, and complaint of scar were not significantly different between the 2 groups. Conclusions. NASILA was not inferior to SILA regarding cosmetic results. Operative convenience is higher in NASILA than in SILA, and the smaller surgical wound in NASILA minimizes postoperative pain.

Bacterial culture and antibiotic susceptibility in patients with acute appendicitis.

PURPOSE: Essential treatment of acute appendicitis is surgical resection with the use of appropriate antibiotics. In order to effectively treat acute appendicitis, it is important to identify the microorganism of acute appendicitis and evaluate the effective antibiotics. METHODS: A total of 694 patients who underwent appendectomy for acute appendicitis and had positive microbial result between 2006 and 2015 were recruited. For microbial assessment, luminal contents of the appendix were swabbed after appendectomy. In patients with periappendiceal abscess, the specimens were obtained from abscess fluid. The patient characteristics, operative data, use of antibiotics, the results of microbiology, and postoperative morbidities including surgical site infection (SSI) were retrospectively reviewed. RESULTS: The mean age was 38.2 (± 19.8) years, and 422 patients (60.8%) were male. Most of the operations were performed by conventional laparoscopy (83.1%), followed by single-port laparoscopy (11.8%). The most common microorganism was Escherichia coli (64.6%), which was susceptible to amoxicillin/clavulanate, ciprofloxacin, most cephalosporins, piperacillin/tazobactam, and imipenem. The second most common microorganism was Pseudomonas aeruginosa (16.4%), which was resistant to amoxicillin/clavulanate and cefotaxime. The rate of postoperative morbidity was 8.6%, and the most common type was superficial SSI (6.2%), followed by ileus (1.2%), gastroenteritis (0.7%), and organ/space SSI (0.3%). P. aeruginosa (odds ratio = 2.128, 95% confidence interval 1.077-4.206, P = 0.030) was the only significant microorganism associated with SSI according to multivariate analysis adjusting for other clinical factors. CONCLUSIONS: In perforated appendicitis, the use of empirical antibiotics seems to be safe. In some cases of Pseudomonas infection, adequate antibiotics should be considered.

Multicenter Prospective Comparative Study of Robotic Versus Laparoscopic Gastrectomy for Gastric Adenocarcinoma.

OBJECTIVE: To compare short-term surgical outcomes including financial cost of robotic and laparoscopic gastrectomy. BACKGROUND: Despite a lack of supporting evidence, robotic surgery has been increasingly adopted as a minimally invasive modality for the treatment of gastric cancer because of its assumed technical superiority over conventional laparoscopy. METHODS: A prospective, multicenter comparative study was conducted. Patients were matched according to the surgeon, extent of gastric resection, and sex. The primary endpoint was morbidity and mortality. Outcomes were analyzed on an intention-to-treat and per-protocol basis. RESULTS: A total of 434 patients were enrolled for treatment with either robotic (n = 223) or laparoscopic (n = 211) gastrectomy for intention-to-treat analysis, and a total of 370 patients (n = 185 per treatment) were compared in per-protocol analysis. Results were similar between both analyses. In per-protocol analysis, both groups showed similar overall complication rates (robotic = 11.9% vs laparoscopic = 10.3%) and major complication rates (robotic = 1.1% vs laparoscopic = 1.1%) with no operative mortality in either group. Patients treated with robotic surgery showed significantly longer operative time (robotic = 221 minutes vs laparoscopic = 178 minutes; P < 0.001) and significantly higher total costs (robotic = US$13,432 vs laparoscopic = US$8090; P < 0.001), compared with those who underwent laparoscopic gastrectomy. No significant differences between groups were noted in estimated blood loss, rates of open conversion, diet build-up, or length of hospital stay. CONCLUSIONS: The use of robotic systems is assumed to provide a technically superior operative environment for minimally invasive surgery. However, our analysis of perioperative surgical outcomes indicated that robotic gastrectomy is not superior to laparoscopic gastrectomy. Clinical trials identification: NCT01309256.

Preoperative Body Mass Index May Determine the Prognosis of Advanced Gastric Cancer.

Radical gastrectomy followed by adjuvant chemotherapy for advanced gastric cancer causes serious nutritional impairment. Our study evaluated the clinical impact of body mass index (BMI) on the long-term outcomes of advanced gastric cancer (stage II and III). We analyzed 211 cases of stage II and III gastric cancer between January 2005 and December 2010 at Chung-Ang University Hospital, Seoul, Korea. Patients were divided into four groups according to BMI: underweight, normal, overweight, and obese. In addition, we divided patients into two groups: BMI-High (BMI ≥ 23 kg/m2) vs. BMI-Low (BMI < 23 kg/m2). We assessed age, sex, tumor location, lymph node (LN) involvement, operation method, initial cancer stage, recurrence, and survival between the two groups. There was significant difference in overall survival (OS) between the underweight group and the other groups (P = 0.005). The survival of the BMI-High group was better than that of the BMI-Low group. The rate of cancer-related death in the BMI-High group was significantly lower than that in the BMI-Low group (cancer-related death: BMI-Low 27% vs. BMI-High 12.6%, P = 0.022). Our findings suggest that preoperative BMI may have an influence on the long-term outcomes of advanced gastric cancer after radical surgery and chemotherapy.

Aberrant loss of dickkopf-3 in gastric cancer: can it predict lymph node metastasis preoperatively?

BACKGROUND: Dickkopf-3 (DKK3) may act as a tumor suppressor as it is down-regulated in various types of cancer. This study assessed the DKK3 protein expression in gastric cancer and its potential value as a prognostic marker. METHODS: DKK3 expression was evaluated by immunohistochemistry in 158 gastric cancer samples from patients who underwent gastrectomy from 2002 to 2008. Clinicopathological parameters and survival data were analyzed. RESULTS: Loss of DKK3 expression was found in 64 of 158 (40.5%) samples, and it was associated with advanced T stage (p < 0.001), lymph node metastasis (p < 0.001), UICC TNM stage (p < 0.001), tumor location (p = 0.029), lymphovascular invasion (p = 0.035), and perineural invasion (p = 0.032). Patients without DKK3 expression in tumor cells had a significantly worse disease-free and overall survival than those with DKK3 expression (p < 0.001, and p = 0.001, respectively). TNM stage (p = 0.028 and p < 0.001, respectively) and residual tumor (p < 0.001 and p = 0.003, respectively) were independent predictors of disease-free and overall survival. Based on the preoperative clinical stage assessed by computed tomography (CT), loss of DKK3 expression was predominantly associated with worse prognosis in patients with clinically node-negative advanced gastric cancer (AGC). The combination of DKK3 expression status and CT increased the accuracy of CT staging for predicting lymph node involvement from 71.5 to 80.0% in AGC patients. CONCLUSION: Loss of DKK3 protein expression was significantly associated with poor survival in patients with gastric cancer and was strongly correlated with the TNM stage. DKK3 might be a potential biomarker of lymph node involvement that can improve the predictive power of CT.

Intraoperative systemic lidocaine for pre-emptive analgesics in subtotal gastrectomy: a prospective, randomized, double-blind, placebo-controlled study.

BACKGROUND: Pre-emptive intravenous lidocaine infusion is known to improve postoperative pain in abdominal surgery. We assessed the effect of intravenous lidocaine infusion in patients who underwent subtotal gastrectomy. METHODS: We conducted a double-blind, placebo-controlled study with patients undergoing subtotal gastrectomy for early gastric cancer divided into 2 groups: 1 group received intravenous lidocaine infusion preoperatively and throughout surgery, and the other received normal saline infusion (placebo). We assessed postoperative outcomes, including pain scores on a visual analogue scale (VAS), administration frequency of patient-controlled analgesia (PCA) and the amount of consumed fentanyl. Postoperative nausea and vomiting, length of hospital stay (LOS), time to return to regular diet and patient satisfaction at discharge were evaluated. RESULTS: There were 36 patients in our study. Demographic characteristics were similar between the groups. The VAS pain scores and administration frequency of PCA were significantly lower in the lidocaine group until 24 hours after surgery, and fentanyl consumption was significantly lower in this group until 12 hours postoperatively compared with the placebo group. The total amount of consumed fentanyl and the total administration frequency of PCA were significantly lower in the lidocaine than the control group. No significant differences were detected in terms of nausea and vomiting, return to regular diet, LOS and patient satisfaction, and there were no reported side-effects of lidocaine. CONCLUSION: Intravenous lidocaine infusion reduces pain during the postoperative period after subtotal gastrectomy.

CONTEXTE: Administrée à titre préventif, la perfusion intraveineuse de lidocaïne améliorerait la douleur postopératoire dans la chirurgie abdominale. Nous avons mesuré l'effet d'une perfusion intraveineuse de lidocaïne chez des patients soumis à une gastrectomie subtotale. MÉTHODES: Nous avons réalisé une étude à double insu avec témoins sous placebo auprès de patients soumis à une gastrectomie subtotale pour un cancer de l'estomac au premier stade. Les patients ont été répartis en 2 groupes : l'un a reçu une perfusion intraveineuse de lidocaïne en préopératoire et tout au long de la chirurgie, tandis que l'autre a reçu une perfusion de solution physiologique (placebo). Nous avons évalué les résultats postopératoires, y compris les scores de douleur sur une échelle analogique visuelle, la fréquence d'administration d'analgésie contrôlée par les patients (ACP) et la quantité de fentanyl utilisée. Les nausées et vomissements postopératoires, la durée du séjour hospitalier, l'intervalle avant la reprise d'une alimentation régulière et la satisfaction du patient au moment de son congé ont aussi été consignés. RÉSULTATS: Notre étude a regroupé 36 patients. Les caractéristiques démographiques étaient similaires entre les groupes. Les scores de douleur à l'échelle analogique visuelle et la fréquence d'administration de l'ACP ont été significativement moindres dans le groupe sous lidocaïne jusqu'à 24 heures après la chirurgie et la prise de fentanyl a aussi été significativement moindre dans ce groupe jusqu'à 12 heures après la chirurgie, comparativement au groupe témoin. La quantité totale de fentanyl utilisée et la fréquence totale d'administration de l'ACP ont été significativement plus faibles dans le groupe sous lidocaïne que dans le groupe témoin. Aucune différence significative n'a été observée pour ce qui est des nausées et vomissements, du retour à une alimentation régulière, de la durée du séjour hospitalier et de la satisfaction des patients et on n'a rapporté aucun effet secondaire associé à la lidocaïne. CONCLUSION: La perfusion de lidocaïne intraveineuse atténue la douleur durant la période postopératoire après une gastrectomie subtotale.

The occurrence of Hospital-Acquired Pneumonia is independently associated with elevated Stress Hyperglycaemia Ratio at admission but not elevated blood glucose.

BACKGROUND: The association between stress-induced hyperglycaemia (SIH) and increased infection rates in hospitalised subjects is well-known. It is less clear if SIH at admission independently drives new-onset infections. We assessed the relationship between early exposure at admission to both the Stress Hyperglycaemia Ratio (SHR) and Blood Glucose (BG) with Hospital-Acquired Pneumonia (HAP). METHODS: This observational retrospective study included those with length-of-stay > 1 day, BG within 24 h of admission and recent haemoglobin A1c. SIH was defined as BG ≥ 10 mmol/L, or SHR ≥ 1.1, measured at both admission and as a 24-hour maximum. Multivariable analyses were adjusted for length-of-stay, age, mechanical ventilation, and chronic respiratory disease. RESULTS: Of 5,339 eligible subjects, 110 (2.1%) experienced HAP. Admission SHR ≥ 1.1 was independently associated with HAP (OR 3.04, 95% CI 1.98-4.68, p < 0.0001) but not BG ≥ 10 mmol/L (OR 0.65, 95% CI 0.41-1.03, p = 0.0675). The association with SHR strengthened using maximum 24-hour values (OR 3.37, 95% CI 2.05-5.52, p < 0.0001) while BG ≥ 10 mmol/L remained insignificant (OR 0.96, 95% CI 0.63-1.46, p = 0.86). Of those experiencing HAP 40 (36.4%) occurred in subjects with no recorded BG ≥ 10 mmol/L but SHR ≥ 1.1. CONCLUSION: SIH at admission defined as SHR ≥ 1.1, but not the conventional marker of BG ≥ 10 mmol/L, was independently associated with the subsequent onset of HAP, commonly at BG < 10 mmol/L.

Exploring objective factors to predict successful outcomes after laparoscopic Nissen fundoplication.

BACKGROUND: Currently, the reported parameters that predict the resolution of symptoms after surgery are largely subjective and unreliable. Considering that fundoplication rebuilds the structural integrity of the lower esophageal sphincter (LES), the authors focused on searching for objective and quantitative predictors for the resolution of symptoms based on the anatomical issues and whether an antireflux barrier can be well established or not. MATERIALS AND METHODS: The authors reviewed the prospectively collected data of 266 patients with gastroesophageal reflux disease (GERD) who had undergone laparoscopic Nissen fundoplication (LNF). All patients were diagnosed with GERD using preoperative esophagogastroduodenoscopy, 24-h ambulatory esophageal pH monitoring, and high-resolution esophageal manometry. The patients received GERD symptom surveys using the validated Korean Antireflux Surgery Group questionnaire twice: preoperatively and 3 months after the surgery. RESULTS: After excluding patients with insufficient follow-up data, 152 patients were included in the analysis. Multivariate logistic regression analyses revealed that a longer length of the LES and lower BMI determined better resolution of typical symptoms after LNF (all P <0.05). Regarding atypical symptoms, higher resting pressure of LES and DeMeester score greater than or equal to 14.7 were associated with better resolution after the surgery (all P <0.05). After LNF, typical symptoms improved in 34 out of 37 patients (91.9%) with a length of LES >greater than .05 cm, BMI less than 23.67 kg/m 2 , and atypical symptoms were resolved in 16 out of 19 patients (84.2%) with resting pressure of LES greater than or equal to 19.65 mm Hg, DeMeester score greater than or equal to 14.7. CONCLUSION: These results show that the preoperative length and resting pressure of LES is important in the objective prediction of symptom improvement after LNF.

Convenience of Adding a Needle Grasper in Single-Incision Laparoscopic Distal Gastrectomy With Billroth I Anastomosis for Clinical Early Gastric Cancer.

PURPOSE: To overcome the technical difficulties of single-incision laparoscopic distal gastrectomy (SILDG), needle grasper (Endo ReliefTM)-assisted SILDG (NASILDG) was developed. Here, we compared the operative convenience and postoperative outcomes between SILDG and NASILDG. MATERIALS AND METHODS: A needle grasper was inserted into the right upper abdomen and used in the NASILDG. We retrospectively reviewed patients who underwent D1 + dissection and delta-shaped Billroth I anastomosis with SILDG or NASILDG performed by a single surgeon between September 2015 and August 2018. RESULTS: The SILDG (male, 50.0%) and NASILDG (male, 60.0%) groups included 10 and 15 patients, respectively. The operative time without combined operation and anastomosis was significantly shorter in the NASILDG group. Early complications and scar characteristics were not significantly different between the two groups. CONCLUSIONS: By adding a needle grasper, SILDG became more convenient without decreasing cosmetic results. NASILDG could be a recommended method to reduce the technical difficulty of SILDG.

Dysbiotic change in gastric microbiome and its functional implication in gastric carcinogenesis.

Although there is a growing interest in the role of gastric microbiome on the development of gastric cancer, the exact mechanism is largely unknown. We aimed to investigate the changes of gastric microbiome during gastric carcinogenesis, and to predict the functional potentials of the microbiome involved in the cancer development. The gastric microbiome was analyzed using gastric juice samples from 88 prospectively enrolled patients, who were classified into gastritis, gastric adenoma, or early/advanced gastric cancer group. Differences in microbial diversity and composition were analyzed with 16S rRNA gene profiling, using next-generation sequencing method. Metagenomic biomarkers were selected using logistic regression models, based on relative abundances at genus level. We used Tax4Fun to predict possible functional pathways of gastric microbiome involved in the carcinogenesis. The microbial diversity continuously decreased in its sequential process of gastric carcinogenesis, from gastritis to gastric cancer. The microbial composition was significantly different among the four groups of each disease status, as well as between the cancer group and non-cancer group. Gastritis group was differently enriched with genera Akkermansia and Lachnospiraceae NK4A136 Group, whereas the cancer group was enriched with Lactobacillus and Veillonella. Predictive analysis of the functional capacity of the microbiome suggested enrichment or depletion of several functional pathways related to carcinogenesis in the cancer group. There are significant changes in the diversity and composition of gastric microbiome during the gastric carcinogenesis process. Gastric cancer was characterized with microbial dysbiosis, along with functional changes potentially favoring carcinogenesis.

Rib and pericardium invaded huge abdominal mass in young woman: A case report with literature review.

RATIONALE: Desmoid fibromatosis is a rare benign tumor, but due to its rarity and diverse clinical course, treatment guidelines have not been established. However, since a good prognosis can be expected, an accurate diagnosis and appropriate treatment are required. We describe a rare case of desmoid fibromatosis on young female that presented as huge abdominal mass. PATIENTS CONCERNS: A 28-year-old female with left upper abdominal pain 1 month ago was referred. DIAGNOSES: Abdominal computed tomography and magnetic resonance imaging revealed a heterogeneous soft tissue mass approximately 29 × 17 cm in size in the left abdomen with abdominal wall invasion and pathological fracture in costochondral junction of the left 8th to 10th ribs. INTERVENTIONS: Surgical resection was performed. OUTCOMES: 33 × 23 × 6 cm sized tumorous mass showed proliferation of bland fibromatosis and myofibroblast with nuclear ß-catenin expression on pathological examination. Desmoid fibromatosis arising from intra-abdominal soft tissue with ribs and pericardium invasion was diagnosed. LESSONS: The mainstay of treatment of symptomatic desmoid fibromatosis is surgical resection, and in the case of abdominal tumor, it can be more dangerous when it invades adjacent organ. We report a case that required additionally multidisciplinary approach for surgery and postoperative treatment of huge abdominal desmoid tumor which infiltrate bone and pericardium beyond abdominal cavity.

Risk factors and clinical outcomes of postgastrectomy sarcopenia newly developed after curative resection for gastric cancer.

ABSTRACT: This study aimed to investigate the risk factors and clinical impact of newly developed sarcopenia after surgical resection on the prognosis of patients undergoing curative gastrectomy for gastric cancer (GC).The clinicopathological data of 573 consecutive patients with GC who underwent curative gastrectomy were reviewed. Their skeletal muscle mass and abdominal fat volume were measured using abdominal computed tomography.Forty six of them (8.0%) were diagnosed with preoperative sarcopenia. Among the 527 patients without sarcopenia, 57 (10.8%) were diagnosed with postgastrectomy sarcopenia newly developed 1 year after curative gastrectomy. Female sex, weight loss, proximal location of the tumor and differentiated tumor were significant risk factors of postgastectomy sarcopenia newly developed after curative gastrectomy. There was a significant difference in the 5-year overall survival among the preoperative sarcopenic, nonsarcopenic, and postgastrectomy sarcopenic groups (P = .017). Especially, there was a significant difference between nonsarcopenic and postgastrectomy sarcopenic groups (P = .009). However, there was no significant difference in the 5-year disease-free survival among the groups (P = .49).Since newly developed sarcopenia after surgical resection had an influence on the overall survival, patients with high sarcopenia risks after curative gastrectomy may require early nutritional support.

Low PARP-1 expression level is an indicator of poor prognosis in patients with stage II and III gastric cancer.

Purpose: This study aimed to investigate the relationship between DNA damage response (DDR) related protein expression and clinical outcomes of patients with stage II and III gastric cancer undergoing gastrectomy. Materials and Methods: From January 2005 to December 2017, 217 gastrectomized patients with stage II and III gastric cancer were analyzed for disease-free and overall survival (DFS and OS, respectively) based on their DDR expression status. We performed the immunohistochemical assessment of MLH1, MSH2, at-rich interaction domain 1 (ARID1A), poly adenosine diphosphate-ribose polymerase 1 (PARP-1), breast cancer susceptibility gene 1 (BRCA1), and ataxia-telangiectasia mutated (ATM) using formalin-fixed paraffin-embedded (FFPE) samples. Results: Among the 217 patients studied, the most common DDR gene whose expression was suppressed was high PARP-1 (n = 120, 55.3%), followed by ATM (n = 62, 28.6%), ARID1A (n = 45, 20.7%), MLH1 (n = 33, 15.2%), BRCA1 (n = 25, 11.5%), and MSH2 (n = 9, 4.1%). The low-expression PARP-1 group exhibited a significantly shorter 5-year OS rate than the high-expression PARP-1 group (48.1% vs. 62.7%; HR 1.519, 95% CI = 1.011-2.283, P = 0.044). In the multivariate OS analysis, TNM stage (II vs. III) (HR = 5.172, P < 0.001), low PARP-1 expression (HR = 1.697, P = 0.013) and adjuvant chemotherapy (HR = 0.382, P < 0.001) were the only significant prognostic factors. Conclusions: Low PARP-1 expression level could be an indicator of poor prognosis in gastrectomized patients with stage II and III gastric cancer.

Impact of the Deep Neuromuscular Block on Oncologic Quality of Laparoscopic Surgery in Obese Gastric Cancer Patients: A Randomized Clinical Trial.

BACKGROUND: Obesity can hinder laparoscopic procedures and impede oncological safety during laparoscopic cancer surgery. Deep neuromuscular block (NMB) reportedly improves laparoscopic surgical conditions, but its oncological benefits are unclear. We aimed to evaluate whether deep NMB improves the oncologic quality of laparoscopic cancer surgery in obese patients. STUDY DESIGN: We conducted a double-blinded, parallel-group, randomized, phase 3 trial at 9 institutions in Korea. Clinical stage I and II gastric cancer patients with a BMI at or above 25 kg m -2 were eligible and randomized 1:1 ratio to the deep or moderate NMB groups, with continuous infusion of rocuronium (0.5-1.0 and 0.1-0.5 mg kg -1 h -1, respectively). The primary endpoint was the number of retrieved lymph nodes (LNs). The secondary endpoints included the surgeon's surgical rating score (SRS) and interrupted events. RESULTS: Between August 2017 and July 2020, 196 patients were enrolled. Fifteen patients were excluded, and 181 patients were finally included in the study. There was no significant difference in the number of retrieved LNs between the deep (N = 88) and moderate NMB groups (N = 93; 44.6 ± 17.5 vs 41.5 ± 16.9, p = 0.239). However, deep NMB enabled retrieving more LNs in patients with a BMI at or above 28 kg/m2 than moderate NMB (49.2 ± 18.6 vs 39.2 ± 13.3, p = 0.026). Interrupted events during surgery were lower in the deep NMB group than in the moderate NMB group (21.6% vs 36.6%; p = 0.034). The SRS was not influenced by NMB depth. CONCLUSION: Deep NMB provides potential oncologic benefits by retrieving more LNs in patients with BMI at or above 28 kg/m2 during laparoscopic gastrectomy.

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: Tegafur/gimeracil/oteracil (S-1) and capecitabine plus oxaliplatin (CAPOX) are standard adjuvant chemotherapies (ACs) administered after gastrectomy to patients with stage II or III gastric cancer. However, the efficacy of AC in elderly patients remains unclear. The objective of this retrospective multicenter cohort study was to compare the efficacies of S-1 and CAPOX AC in patients aged ≥70 years. Materials and Methods: Nine hundred eighty-three patients who were treated with AC using S-1 (768 patients) or CAPOX (215 patients) were enrolled in this study. Each patient underwent AC after curative gastrectomy for stage II or III gastric cancer at one of 27 hospitals in the Republic of Korea between January 2012 and December 2013. Relapse-free survival (RFS) and overall survival (OS) were analyzed according to AC regimen and age group. Results: Of the 983 patients, 254 (25.8%) were elderly. This group had a similar RFS (P=0.099) but significantly poorer OS (p=0.003) compared with the non-elderly group. Subgroup analysis of the non-elderly group revealed no AC-associated differences in survival. Subgroup analysis of the elderly group revealed significantly better survival in the S-1 group than in the CAPOX group (RFS, P<0.001; OS, P<0.001). Multivariate analysis revealed that the CAPOX regimen was an independent poor prognostic factor for RFS (hazard ratio [HR], 1.891; 95% confidence interval [CI], 1.072-3.333; P=0.028) and OS (HR, 2.970; 95% CI, 1.550-5.692; P=0.001). Conclusions: This multicenter observational cohort study found significant differences in RFS and OS between S-1 and CAPOX AC among patients with gastric cancer aged ≥70 years.

Comparison of postoperative pain after needle grasper-assisted single-incision laparoscopic appendectomy versus single-incision laparoscopic appendectomy: a prospective randomized controlled trial (PANASILA trial).

PURPOSE: This study was performed to compare the efficacies of newly developed needle grasper-assisted (Endo Relief) single-incision laparoscopic appendectomy (NASILA) and single-incision laparoscopic appendectomy (SILA). METHODS: This study enrolled 110 patients with acute appendicitis without periappendiceal abscess, diagnosed using computed tomography, who were randomized to the SILA (n = 54) and NASILA groups (n = 56) between December 2017 and August 2018 (6 patients withdrawn). The NASILA technique entailed a small umbilical incision for the glove port (equivalent to that for a 12-mm trocar), and a 2.5-mm suprapubic incision for the needle grasper. RESULTS: The SILA and NASILA groups included 49 (male, 61.2%) and 55 (male, 54.5%) patients, respectively. Age, body mass index, abdominal surgical history, symptom duration, and use of patient-controlled analgesia did not differ significantly between the 2 groups. The main wound size was significantly smaller in the NASILA group than in the SILA group (1.8 ± 0.4 cm vs. 2.2 ± 0.4 cm, P < 0.001). The operative time and estimated blood loss did not differ significantly between both groups. The immediate postoperative pain score, i.e., the primary endpoint, was significantly lower in the NASILA group than in the SILA group (2.33 ± 0.98 vs. 2.82 ± 1.29, P = 0.031). The complaints for scar status 1 month postoperatively did not differ significantly between the groups. CONCLUSION: NASILA could attenuate postoperative pain by minimizing the size of the surgical wound; further, NASILA may not be inferior to SILA in terms of cosmetic results.