Feasibility of a novel laparoscopic technique with unidirectional knotless barbed sutures for the primary closure of duodenal ulcer perforation.

BACKGROUND: Laparoscopic primary repair is one of the main procedures used for perforated gastric ulcers, and this technique requires reproducible and secure suturing. The aim of this study was to investigate the safety and efficacy of a novel continuous suture method with barbed sutures during laparoscopic repair for perforated peptic ulcers. PATIENTS AND METHODS: Clinical data from 116 consecutive patients undergoing laparoscopic repair for perforated peptic ulcers were collected between November 2009 and October 2015. Continuous suturing with 15-cm-long unidirectional absorbable barbed sutures was used for laparoscopic repair in the study group, termed group V (n = 51). Patients who underwent laparoscopic repair with conventional interrupted sutures were defined as group C (n = 65). The complication and operative data were compared between groups. RESULTS: Although there was no difference between group V and group C in the overall complication rate (15.7% vs. 24.6%; p = 0.259), the complication rate related to suturing was lower (3.9% vs. 15.4%; p = 0.04) in group V. Group V showed rates of 0% for leakage, 2% for intra-abdominal fluid collection, and 2% for stricture; the corresponding rates in group C were 3.1, 7.7, and 4.6%, respectively. Regarding operative data, the total operation time (V vs. C, 87.7 min vs. 131.2 min), total suture time (7.1 min vs. 25.3 min), and suture time per stitch (1.2 min vs. 6.2 min) were significantly shorter in group V than in group C (p < 0.001). CONCLUSION: The use of a continuous suture technique with unidirectional barbed sutures is as safe as the conventional suture technique and allows easier and faster suturing in the repair of perforated peptic ulcers.

Overexpression of Neuron-Specific Enolase as a Prognostic Factor in Patients with Gastric Cancer.

PURPOSE: Enolase is a cytoplasmic enzyme that catalyzes the conversion of 2-phosphoglycerate to phosphoenolpyruvate in the glycolytic pathway. The aim of this study was to investigate whether the overexpression of neuron-specific enolase (NSE) can serve as a prognostic factor in patients with gastric cancer (GC). MATERIALS AND METHODS: To assess its prognostic value in GC, NSE expression was measured by immunohistochemistry in a clinically annotated tissue microarray comprising of 327 human GC specimens. Cytoplasmic NSE expression was scored from 0 to 4, reflecting the percentage of NSE-positive cells. RESULTS: In terms of histology as per the World Health Organization criteria (P=0.340), there were no differences between the NSE overexpression (NSE-OE) and NSE underexpression (NSE-UE) groups. The NSE-OE group showed a significantly lower rate of advanced GC (P<0.010), lymph node metastasis (P=0.010), advanced stage group (P<0.010), cancer-related death (P<0.010), and cancer recurrence (P<0.010). Additionally, a Kaplan-Meier survival analysis revealed that the NSE-OE group had longer cumulative survival times than the NSE-UE group (log-rank test, P<0.010). However, there were no significant differences in the serum levels of NSE expression in patients with GC and healthy volunteers (P=0.280). CONCLUSIONS: Patients with NSE overexpressing GC tissues showed better prognostic results, implying that NSE could be a candidate biomarker of GC.

Experimental Demonstration of Four-Dimensional Photonic Spatial Entanglement between Multi-core Optical Fibres.

Fibre transport of multi-dimensional photonic quantum states promises high information capacity per photon without space restriction. This work experimentally demonstrates transmission of spatial ququarts through multi-core optical fibres and measurement of the entanglement between two fibres with quantum state analyzers, each composed of a spatial light modulator and a single-mode fibre. Quantum state tomography reconstructs the four-dimension entangled state that verifies the nonlocality through concurrences in two-dimensional subspaces, a lower bound of four-dimensional concurrence and a Bell-type CGLMP inequality.

Cooccurrence of Metastatic Papillary Thyroid Carcinoma and Salmonella Induced Neck Abscess in a Cervical Lymph Node.

Cervical lymph node metastasis is common in patients with papillary thyroid carcinoma (PTC). Salmonella species are rarely reported as causative agents in focal infections of the head and neck. The cooccurrence of lymph node metastasis from PTC and a bacterial infection is rare. This report describes a 76-year-old woman with a cervical lymph node metastasis from PTC and Salmonella infection of the same lymph node. The patient presented with painful swelling in her left lateral neck region for 15 days, and neck ultrasonography and computed tomography showed a cystic mass along left levels II-IV. The cystic mass was suspected of being a metastatic lymph node; modified radical neck dissection was performed. Histopathological examination confirmed the presence of PTC in the resected node and laboratory examination of the combined abscess cavity confirmed the presence of Salmonella Typhi. Following antibiotic sensitivity testing of the cultured Salmonella Typhi, she was treated with proper antibiotics. Cystic lesions in lymph nodes with metastatic cancer may indicate the presence of cooccurring bacterial infection. Thus, culturing of specimen can be option to make accurate diagnosis and to provide proper postoperative management.

A Case of Advanced Gastric Cancer with Para-Aortic Lymph Node Metastasis from Co-Occurring Prostate Cancer.

An 84-year-old man was diagnosed with two synchronous adenocarcinomas, a Borrmann type IV advanced gastric adenocarcinoma in his antrum and a well-differentiated Borrmann type I carcinoma on the anterior wall of the higher body of his stomach. Pre-operatively, computed tomography of the abdomen revealed the presence of advanced gastric cancer with peri-gastric and para-aortic lymph node (LN) metastasis. He planned for palliative total gastrectomy owing to the risk of obstruction by the antral lesion. We performed a frozen biopsy of a para-aortic LN during surgery and found that the origin of the para-aortic LN metastasis was from undiagnosed prostate cancer. Thus, we performed radical total gastrectomy and D2 LN dissection. Post-operatively, his total prostate-specific antigen levels were high (227 ng/mL) and he was discharged 8 days after surgery without any complications.

Unsuspected Duplicated Gallbladder in a Patient Presenting with Acute Cholecystitis.

Duplicated gallbladder (GB) is a rare congenital disease. Surgical management of a duplicated GB needs special care because of concurrent bile duct anomalies and the risk of injuring adjacent arteries during surgery. An 80-year-old man visited an emergency room with right upper quadrant abdominal pain. Computed tomography (CT) revealed cholecystitis with a 2-bodied GB. Because of this unusual finding, magnetic resonance choledochopancreatography was performed to detect possible biliary anomalies. The 2 GB bodies were unified at the neck with a common cystic duct, a so-called V-shaped duplicated GB. The patient's right posterior hepatic duct joined the common bile duct (CBD) near the cystic duct. The patient underwent laparoscopic cholecystectomy without adjacent organ injury, and was discharged uneventfully. Surgeons should carefully evaluate the patient preoperatively and select adequate surgical procedures in patients with suspected duplicated GB because of the risk of concurrent biliary anomalies.

Relationship between low body mass index and morbidity after gastrectomy for gastric cancer.

PURPOSE: This study aimed to evaluate the association between low body mass index (BMI) and morbidity after gastric cancer surgery. METHODS: A total of 1,805 patients were included in the study. These subjects had undergone gastric cancer surgery at a single institution between January 1997 and December 2013. Clinicopathologic and morbidity data were analyzed by dividing the patients into 2 groups: underweight patients (BMI < 18.5 kg/m(2)) and nonunderweight patients (BMI ≥ 18.5 kg/m(2)). RESULTS: The overall complication rate as determined by our study was 24.4%. Pulmonary complications occurred more frequently in the underweight group (UWG) than in the non-UWG (10.5% vs. 3.8%, respectively; P = 0.012). Multivariate analysis revealed two independent factors responsible for postoperative pulmonary complications-weight of the patients (UWG vs. non-UWG, 10.8% vs. 3.8%; P < 0.007) and stage of gastric cancer (early stage vs. advanced stage, 3.1% vs. 6.8%; P < 0.023). Multivariate analysis revealed that underweight (UWG vs. non-UWG, 10.8% vs. 3.8%, respectively, P < 0.007) and advanced cancer stage (early stage vs. advanced stage, 3.1% vs. 6.8%, respectively, P = 0.023) were significant risk factors for postoperative pulmonary complications. CONCLUSION: We concluded that underweight patients had a higher pulmonary complication rate. Additionally, underweight and advanced cancer stage were determined to be independent risk factors for the development of postoperative pulmonary complications.

Comparison of Learning Curves for Major and Minor Laparoscopic Liver Resection.

BACKGROUND: Because laparoscopic liver resection (LLR) has a steep learning curve, analyzing experience is important for trainees. Several authors have described the learning curve of LLR, without comparing the learning curves between major and minor LLR. METHODS: Perioperative data were retrieved from the medical records of 170 consecutive patients who underwent LLR by a single surgeon at a tertiary hospital. Learning curves were generated and compared between major and minor LLR using cumulative sum control charts and the moving average. RESULTS: Major and minor LLR was performed in 96 and 74 patients, respectively. The learning curves showed a steady state after case 50 for major LLR. Because of discordant results in minor LLR, subgroup analyses were performed, showing competency in LLR after cases 25 and 35 for left lateral sectionectomy and tumorectomy, respectively. Transfused red blood cell volume (0.6 versus 2.2 packs, P < .001) decreased after achievement of competence in major LLR. Blood loss exceeding 500 mL (odds ratio 2.395, 95% confidence interval 1.096-5.233, P = .028) was independently associated with LLR failure. CONCLUSIONS: The number of cases required to accomplish LLR differed according to the extent of resection. Extensive blood loss was independently associated with LLR failure.

Comparison of perioperative and oncologic outcomes between open and laparoscopic liver resection for intrahepatic cholangiocarcinoma.

BACKGROUND: Laparoscopic liver resection (LLR) has become an essential method for treating malignant liver tumors. Although the perioperative and oncologic outcomes of LLR in patients with hepatocellular carcinoma have been reported, there are few reports of LLR for intrahepatic cholangiocarcinoma (IHCC). METHODS: Patients who underwent liver resection for T1 or T2 IHCC between March 2010 and March 2015 in Gyeongsang National University Hospital were enrolled. They were divided into open (n = 23) and laparoscopic (n = 14) approaches, and the perioperative and oncologic outcomes were compared. RESULTS: The Pringle maneuver was less frequently used (p = 0.015) and estimated blood loss was lesser (p = 0.006) in the laparoscopic group. There were no significant differences in complication rate (p = 1.000), hospital stay (p = 0.371), tumor size (p = 0.159), lymph node metastasis (p = 0.127), and the number of retrieved lymph nodes (p = 0.553). The patients were followed up for a median of 21 months. The 3-year overall survival (OS) and recurrence-free survival (RFS) rates were 74.7 and 55.2 %, respectively. No differences were observed in the 3-year OS (75.7 vs 84.6 %, p = 0.672) and RFS (56.7 vs 76.9 %, p = 0.456) rates between the open and laparoscopic groups, even after the groups were divided into patients that received liver resection with or without lymph node dissection. CONCLUSION: LLR for IHCC is a treatment modality that should be considered as an option alongside open liver resection in selected patients.

A case of gallbladder cancer combined with ectopic individual opening of pancreatic and bile ducts to the duodenal bulb.

Ectopic opening of the pancreatic and bile ducts (EOPBD) into the duodenal bulb is an extremely rare congenital anomaly with unknown clinical implications. We presented a case of gallbladder cancer with EOPBD into the duodenal bulb. A 57-year-old male was referred to our hospital with intermittent right upper abdominal pain. Endoscopic retrograde cholangiopancreatography and magnetic resonance cholangiopancreatography showed individual EOPBD into the duodenal bulb with no papillary structure, and a focal nodular lesion in the gallbladder. A follow-up abdominal computed tomography scan 9 months later revealed a slight increase in the size of the fundal nodule, which was suspected as gallbladder cancer. An intraoperative frozen biopsy identified the nodular lesion as adenocarcinoma involving the cystic duct, and the patient underwent radical cholecystectomy including bile duct resection with hepaticojejunostomy. EOPBD is an extremely rare condition that can be associated with gallbladder malignancy as well as benign disease. Clinicians should follow up carefully and consider surgical treatment for suspected malignant lesions.

Multi-core fiber interferometer using spatial light modulators for measurement of the inter-core group index differences.

We demonstrate an experimental technique to generate and measure arbitrary superpositions of core modes in a multi-core fiber. Two spatial light modulators couple the fundamental mode of a single-mode fiber with multiple-core modes of the MCF to constitute a Mach-Zehnder-type multi-path interferometer. The phase tunability of each path is verified by comparing two-, three-, and four-path interference patterns with the theory. Interference fringes in the wavelength domain estimates the inter-core group index differences with a resolution of 10(-5) using a fiber length of 1 m.

Impact of tumor size on subclinical central lymph node metastasis in papillary thyroid microcarcinoma depends on age.

BACKGROUND: The aim of this study is to evaluate whether the associations between clinicopathologic factors of papillary thyroid microcarcinoma (PTMC), especially tumor size, and subclinical central lymph node metastasis (LNM) are dependent on patient age. METHODS: The medical records of 428 patients who underwent thyroid surgery for PTC measuring ≤1 cm were reviewed. All patients were clinically lymph node negative and underwent thyroidectomy with unilateral or bilateral central lymph node dissection. Univariate and multivariate analyses were performed to identify clinicopathologic factors associated with central LNM. RESULTS: Central LNM was identified in 96 of 428 (22.4%) patients. Mean tumor size was significantly greater in patients with than without central LNM (0.74 ± 0.22 cm vs. 0.64 ± 0.23 cm, P = 0.001). Tumor size > 0.5 cm was significantly predictive of central LNM. Subgroup analysis according to age groups showed that tumor size was an independent predictor of subclinical central LNM only in patients aged ≥45 years. CONCLUSIONS: Factors predictive of central LNM in patients with PTMC differed by age. PTMC size was an independent predictor of subclinical central LNM only in patients aged ≥45 years.

Prognostic importance of ultrasound BI-RADS classification in breast cancer patients.

OBJECTIVE: We investigated the prognostic importance of pre-operative Breast Imaging Reporting and Data System classification in ultrasound imaging. METHODS: Histopathological differences and disease-free survival were analyzed in Breast Imaging Reporting and Data System classification subgroups. Univariate and multivariate analyses were used to identify the prognostic factors. RESULTS: We identified 531 invasive breast cancer patients eligible for this study. Most patients classified as Breast Imaging Reporting and Data System 5 had large tumors and a higher rate of lymph node metastasis. However, hormonal receptor or HER-2 status did not differ according to Breast Imaging Reporting and Data System classification. During a median post-operative follow-up of 42.0 months, 43 patients were diagnosed with a disease-specific event. Disease-free survival was significantly lower in patients with Breast Imaging Reporting and Data System 5 than in patients with Breast Imaging Reporting and Data System 3-4. Subgroup analysis of patients with invasive breast cancer of Stage I showed that Breast Imaging Reporting and Data System 5 was an independent negative prognostic indicator of disease-free survival (hazard ratio 9.195; 95% confidence interval, 1.175-71.955; P = 0.035). CONCLUSIONS: Breast Imaging Reporting and Data System classification might be considered as prognostic factors especially in Stage I breast cancer. Further confirmatory studies are needed.

A noble method for intraoperative fine localization during laparoscopic gastric local resection: endoscopic submucosal cutting and light transmission.

BACKGROUND: The main requirements when performing laparoscopic local resection for early mucosal tumors of the stomach are a clearly defined cancer-free margin and precise tumor localization. In this study, a novel method for precise intraoperative tumor localization and appropriate resection in a porcine model is introduced: endoscopic submucosal cutting and light transmission (ESCLT). METHODS: A total of 15 cases of laparoscopic local resection were performed in 6 pigs. The size of the target lesions was approximately 20 mm. The imaginary lesions were located in the high body anterior wall, posterior wall, lower body posterior wall, angle, and antrum anterior wall of the stomach. Mucosal marking around the lesions, mucosal precutting surrounding the marking, and submucosal cutting along the precutting line using white light endoscopy were sequentially performed. Next, an endoscopic light source was placed directly in front of the lesion. Exact oval-shaped submucosal cutting margins were identified via laparoscopy. Laparoscopic local resection was performed after the minimal distance from the stapler line to the submucosal cutting line was confirmed. The sizes of the mucosal marking, submucosal cutting line, and the entire resected mucosa and serosa were measured. RESULTS: The procedure was completed successfully in all pigs. Local resection was completed on all of the lesions. The mean endoscopic and laparoscopic procedure times were 26.1 and 12.7 min, respectively. The mean size of the resected specimens was: (i) marking lesion, 22 × 19.5 mm; (ii) submucosal cutting line, 26.7 × 23.2 mm; (iii) entire resected mucosa, 37 × 31 mm; and (iv) entire resected serosa, 41.7 × 33.1 mm. There was no intraoperative morbidity. CONCLUSION: ESCLT provides a precise and useful method of intraoperative tumor localization during laparoscopic local resection of the stomach in terms of minimizing the resection of normal stomach tissue and guaranteeing adequate mucosal safety margins.

Synthesis of carbon nanotube-nickel nanocomposites using atomic layer deposition for high-performance non-enzymatic glucose sensing.

A useful strategy has been developed to fabricate carbon-nanotube-nickel (CNT-Ni) nanocomposites through atomic layer deposition (ALD) of Ni and chemical vapor deposition (CVD) of functionalized CNTs. Various techniques, including scanning electron microscopy (SEM), transmission electron microscopy (TEM), and X-ray photoelectron spectroscopy (XPS), were used to characterize the morphology and the structure of as-prepared samples. It was confirmed that the products possess uniform Ni nanoparticles that are constructed by finely controlled deposition of Ni onto oxygen or bromine functionalized CNT surface. Electrochemical studies indicate that the CNT-Ni nanocomposites exhibit high electrocatalytic activity for glucose oxidation in alkaline solutions, which enables the products to be used in enzyme-free electrochemical sensors for glucose determination. It was demonstrated that the CNT-Ni nanocomposite-based glucose biosensor offers a variety of merits, such as a wide linear response window for glucose concentrations of 5 µM-2 mM, short response time (3 s), a low detection limit (2 µM), high sensitivity (1384.1 µA mM(-1) cm(-2)), and good selectivity and repeatability.

Decreased expression of heat shock protein 20 in colorectal cancer and its implication in tumorigenesis.

Heat shock protein 20 (HSP20), which is a member of the small heat shock protein family, is known to participate in many pathological processes, such as asthma, intimal hyperplasia, and insulin resistance. However, the function of HSP20 in cancer development is not yet fully understood. In this study, we identified HSP20 as a down-regulated protein in 20 resected colorectal cancer (CRC) specimens compared with their paired normal tissues. Because HSP20 proteins were barely detectable in HCT-116 cells (a human colorectal cancer cell line), recombinant adenovirus encoding HSP20 (Ad-HSP20) was used to induce HSP20 overexpression in HCT-116 cells. Infection of Ad-HSP20, but not control adenovirus (Ad-GFP), reduced viability, and induced massive apoptosis in a time-dependent manner. The forced expression of HSP20 enhanced caspase-3/7 activity and down-regulated the anti-apoptotic Bcl-xL and Bcl-2 mRNA and protein levels. In addition, immunohistochemical analysis of 94 CRC specimens for HSP20 protein showed that reduced HSP20 expression was related to advanced TNM stage, lymph node metastasis, and tumor recurrence. Our study shows, for the first time, that expression of the HSP20 protein has a pro-death role in colorectal cancer cells. Therefore, HSP20 may have value as a prognostic tumor marker and its overexpression might be a novel strategy for CRC therapy.

Surgical strategy for colonic intussusception caused by a giant colonic lipoma: a report of two cases and a review of the literature.

A colon lipoma is a remarkably rare tumor. In most cases, the tumors are asymptomatic and small in size, need to be differentiated from malignant tumors, and do not need any special treatment. Selection of the right surgical strategy depends on the status of bowel, as well as the size and the location of tumor. We encountered two patients with giant submucosal lipomas that had induced intussusceptions: one with a lipoma in the transverse colon and the other with a lipoma in the ascending colon. The diagnoses were made by using histological examinations. We report the clinical features, diagnoses, and treatments of, as well as our experience with, these two uncommon cases, and we present a review of the literature on this subject.

OCT-1 overexpression is associated with poor prognosis in patients with well-differentiated gastric cancer.

Octamer transcription factor-1 (OCT-1) is a well-known transcription factor that is reportedly overexpressed in intestinal metaplasia and gastric carcinoma in the intestine. In this study, we investigated OCT-1 overexpression as a prognostic factor for gastric cancer. The association between OCT-1 overexpression (detected using immunohistochemistry) and clinicopathological features including survival was evaluated. In vitro gain-of-function approaches were utilized to assess the function of OCT-1 in malignancy. Analysis of OCT-1 expression in patients with gastric cancer with well-differentiated carcinoma as per the World Health Organization classification showed that OCT-1 overexpression was correlated with advanced tumor invasion (58.8 % of patients with advanced tumor invasion vs. 21.2 % of patients with early tumor invasion; p<0.01), lymph node metastasis (63.9 % of patients with metastasis vs. 24.1 % of those without; p=0.015), and cancer recurrence (83.3 % of patients with recurrence vs. 25.4 % of those without; p<0.01), as well as a lower survival rate (62.8 vs. 87.9 Mo; p<0.01). However, there were no significant differences in the levels of OCT-1 expression in gastric cancer patients with other carcinoma types (p>0.05). Furthermore, we found that the proliferation rate of OCT-1-overexpressing MKN-45 cells was higher than that of the control cells. OCT-1 overexpression may be a marker for poor prognosis in patients with well-differentiated gastric adenocarcinoma.

Prognostic importance of baseline neutrophil to lymphocyte ratio in patients with advanced papillary thyroid carcinomas.

Inflammation is associated with several tumor development and progression. However, these associations are not clear in well-differentiated thyroid carcinomas. We assessed whether NLR is a useful prognostic marker in patients with papillary thyroid carcinomas (PTC). The medical records of all patients who underwent thyroid surgery at a single institution between March 2005 and September 2012 were retrospectively evaluated; as a control group, patients who underwent routine health examinations in 2012 were also evaluated. Differences in mean NLR among patient groups were assessed, and clinical characteristics according to NLR quartile were evaluated in patients with PTC. The association between NLR and disease-free survival (DFS) in PTC patients was determined. NLR was significantly higher in the groups with than without thyroid nodules, but did not differ significantly in patients with benign and malignant thyroid nodules. Mean NLR was significantly higher in patients with solid or mixed thyroid than in patients with cystic nodules (1.75 ± 0.92 vs. 1.65 ± 0.74, p = 0.004). Patient follow-up ranged from 6 to 99 months. At 5-year follow-up, 11 patients had disease-specific events. We found that 5-year DFS rate was significantly worse in stages III and IV patients with NLR ≥1.5 than NLR <1.5 (94.1 vs. 99.3 %, p = 0.013). The univariate Cox hazard proportional hazard model for DFS revealed that higher NLR was independently correlated with poorer prognosis (hazard ratio 8.76; 95 % confidence interval 1.09-70.27, p = 0.041). Higher NLR may be a negative prognostic marker for DFS in patients with PTC, especially those with stages III and IV.

Feasibility of the trans-umbilical route compared with the trans-oral route in gastric upper body endoscopic submucosal dissection: a porcine model.

BACKGROUND: Total gastrectomy is performed for early gastric cancer in the upper body of the stomach because of the high complication rate of endoscopic submucosal dissection (ESD). The aims of the present animal study in pigs were to verify: (1) the feasibility of the trans-umbilical route compared with the trans-oral route in gastric upper body ESD; (2) the non-inferiority of single port laparoscopic lymph node dissection (LLND) compared with multiport LLND; and (3) the safety of 2-basin LLND (upper greater and lesser curvature). METHODS: We separated the pigs (~40 kg each) into two groups: conventional and experimental (n = 5 per group). We performed ESD in the fundus and upper body anterior wall (UBAW) via the trans-oral route and multiport LLND in the conventional group, and via the trans-umbilical route and single port LLND in the experimental group. RESULTS: The completion rates, tissue weights, and specimen diameters of both routes showed no statistical differences in either the fundus or the UBAW. The operative time was shorter with the trans-umbilical route than with the trans-oral route in both areas (p < 0.05). In LLND, there were no differences in surgical outcomes between the multiport and single port groups. Intraoperative perforation was seen in the trans-oral route group (n = 1). Delayed perforation was observed in 30 % of the ESD sites. CONCLUSIONS: The trans-umbilical route is feasible and has lower complication rates than the trans-oral route in gastric upper body ESD. Additionally, single port LLND is not inferior to multiport LLND, and one-side-basin dissection is safer than two-side.