Can Proximal Gastrectomy with Double-Tract Reconstruction Replace Total Gastrectomy? A Propensity Score Matching Analysis.

BACKGROUND: This retrospective cohort study compared proximal gastrectomy (PG) with double-tract reconstruction (DTR) versus total gastrectomy (TG) with Roux-en-Y reconstruction in terms of clinical outcomes. METHODS: All consecutive patients with upper early gastric cancer (EGC) who underwent PG-DTR or TG in 2008-2016 were selected. TG patients who matched PG-DTR patients in age, sex, body mass index, clinical stage, and ASA score were selected by propensity score matching. Groups were compared in terms of clinicopathological characteristics, clinical outcomes, early (≤ 30 days), late (> 30 days), and severe (Clavien-Dindo grade ≥ III) postoperative complications, 1-year reflux morbidity, recurrence, and mortality. RESULTS: Of 322 patients, 52 underwent PG-DTR. A matching TG group of 52 patients was selected. The PG-DTR group had smaller tumors (p = 0.02), smaller proximal and distal resection margins (p = 0.01, p < 0.01), and fewer retrieved lymph nodes (p < 0.01). PG-DTR associated with shorter times to diet and hospital stay (both p = 0.02). Groups did not differ in early (11.3 vs. 19.2%, p = 0.19), late (1.9 vs. 5.7%, p = 0.31), or severe complication rates (7.7 vs. 13.5%, p = 0.34). At 1 year, the groups did not differ in reflux symptoms (Visick score) or endoscopic esophagitis (Los Angeles Classification). There were no recurrences. Five-year overall survival rates were 100 and 81.6% (p = 0.02), respectively. CONCLUSION: PG-DTR associated with better clinical outcomes and survival. Complication and reflux rates were similar. PG-DTR may be suitable for upper EGC.

Tumor localization using radio-frequency identification clip marker: experimental results of an ex vivo porcine model.

PURPOSE: With the widespread use of minimally invasive surgery, tumor detection is becoming more difficult. We present the experimental results of a radio-frequency identification (RFID) lesion detection system in an ex vivo porcine model. METHODS: The efficacy and feasibility of a newly developed RFID lesion detection system were examined. It was applied to the stomach and colon of pigs weighing 40 kg. The RFID clip was attached to the upper and lower mucosal sides of the stomach. Colon specimens with thin and thick walls were used. The clipped sites were marked on the serosa by a pin. The longest distance from the pin the RFID tag could be detected was measured 25 times in each direction. RESULTS: In the upper gastric wall, the RFID tag detection distance was 4.5 ± 0.9 mm, 5.6 ± 0.7 mm, 12.5 ± 0.7 mm, and 5.3 ± 0.5 mm in the four directions, respectively (right, left, upper, and lower). In the antrum, the RFID tag detection distance was 5.8 ± 0.7 mm, 6.9 ± 0.5 mm, 5.6 ± 0.5 mm, and 3.7 ± 0.5 mm in the four directions. In the thin colon, the RFID tag detection distance was 6.3 ± 0.5 mm, 5.0 ± 0.5 mm, 9.7 ± 0.7 mm, and 6.4 ± 0.4 mm in the four directions. In the thick colon, the RFID tag detection distance was 3.5 ± 0.8 mm, 6.6 ± 0.5 mm, 8.4 ± 0.6 mm, and 9.8 ± 0.5 mm in the four directions. The area of detection was smallest for the antrum (83.7 mm2) and similar for the other sites (150.6, 154.7 and 157.7 mm2 for the upper body, thin colon, and thick colon, respectively). CONCLUSIONS: The distance at which the RFID tag was detected was usually within 10 mm. These results indicate the feasibility of the clinical application of the add-on clip and RFID tag as a marker for identifying the location of various gastrointestinal tumors.

Atraumatic Liver Retraction Using Nelaton Catheters During Totally Laparoscopic Gastrectomy.

This study introduces a novel technique for liver retraction during laparoscopic gastrectomy and assesses its impact on postoperative recovery. This study included 139 patients in whom Nelaton catheters (n=57) or Nathanson retractors (n=82) were used for liver retraction. Serum liver enzyme levels were measured preoperatively and on the first, second, third, fifth, and seventh postoperative days. Clinicopathologic features and postoperative recovery variables between the 2 groups were compared. The aspartate aminotransferase, alanine aminotransferase, and C-reactive protein levels were significantly lower (P<0.001, P<0.001, and P=0.007, respectively), and the day of first flatus, the day of initiating a soft diet, and the length of hospital stay were shorter in the Nelaton catheter U-shaped retractor group than those seen in the Nathanson retractor group (P=0.035, P=0.002, and P=0.024, respectively). Atraumatic liver retraction with Nelaton catheters is recommended in laparoscopic gastrectomy.

Risk factors for lymph node metastasis in mucosal gastric cancer and re-evaluation of endoscopic submucosal dissection.

PURPOSE: The selection of the appropriate treatment strategy for patients with mucosal gastric cancer (MGC) remains controversial. In the present study, we aimed to determine the risk factors for lymph node (LN) metastasis in MGC and reassess the role of endoscopic submucosal dissection (ESD). METHODS: We examined 1,191 MGC patients who underwent curative gastrectomy between January 2005 and December 2014. We determined the clinicopathologic risk factors for LN metastasis among the MGC patients. RESULTS: Among 1,191 patients with MGC, 42 patients (3.5%) had LN metastasis. Univariate analysis indicated that age ≤ 50 years (P = 0.045), tumor invasion to the muscularis mucosa (P < 0.001), tumor size > 2 cm (P = 0.014), presence of ulceration (P = 0.01), diffuse type as per Lauren classification (P = 0.005), and undifferentiated-type histology (P = 0.001) were associated with LN metastasis. Moreover, multivariate analysis indicated that tumor invasion to the muscularis mucosa (P = 0.001; odds ratio [OR], 4.909), presence of ulceration (P = 0.036; OR, 1.982), and undifferentiated-type histology (P = 0.025; OR, 4.233) were independent risk factors for LN metastasis. In particular, LN metastasis was observed in some MGC cases with indications for ESD, including absolute indications (1 of 179, 0.6%) and expanded indications (9 of 493, 1.8%). CONCLUSION: Although MGC patients can be treated via ESD, we recommend that they undergo a more aggressive treatment strategy if they have tumor invasion to the muscularis mucosa, ulceration, or undifferentiated-type histology in the final pathology report.

Necrotizing soft tissue infection: analysis of the factors related to mortality in 30 cases of a single institution for 5 years.

PURPOSE: Necrotizing soft tissue infection is the infection of the soft tissue with necrotic changes. It is rare, but results in high mortality. We analyzed the characteristics of patients, prognosis, and mortality factors after reviewing 30 cases of a single hospital for 5 years. METHODS: From January 2009 to December 2013, 30 patients diagnosed with necrotizing fasciitis or Fournier's gangrene in Pusan National University Hospital were enrolled for this study. The following parameters were analyzed retrospectively: demographics, infection site, initial laboratory finding, initial antibiotics, isolated microorganisms, number of surgeries, time to first operation, length of intensive care unit, and total hospital stays. RESULTS: The overall mortality rate was 23.3%. Mean body mass index (BMI) of the survival group (24.7 ± 5.0 kg/m(2)) was significantly higher than the nonsurvival group (22.0 ± 1.4 kg/m(2), P = 0.029). When BMI was less than 23 kg/m(2), the mortality rate was significantly higher (P = 0.025). Two patients (6.7%) with chronic kidney disease requiring hemodialysis died (P = 0.048). Initial WBC count (>13×10(3)/µL), CRP (>26.5 mg/dL), and platelet (PLT) count (<148×10(3)/µL) were found to have negative impact on the prognosis of necrotizing soft tissue infection. Factors such as potassium level, blood urea nitrogen (>27.6 mg/dL), serum creatinine (>1.2 mg/dL) that reflected kidney function were significant mortality factors. CONCLUSION: Patients with low BMI or abnormal values of WBC count, CRP, and PLT count reflecting the degree of infection or abnormal renal function will need more intensive care.

Comparison Between Billroth-II with Braun and Roux-en-Y Reconstruction After Laparoscopic Distal Gastrectomy.

PURPOSE: This study aims to compare the effectiveness of Billroth-II with Braun and Roux-en-Y reconstruction after laparoscopic distal gastrectomy. METHODS: From April 2010 to August 2012, 66 patients underwent laparoscopic distal gastrectomy (Billroth-II with Braun reconstruction, 26; Roux-en-Y, 40). The patients' data were collected prospectively and reviewed retrospectively. RESULTS: The mean operation and reconstruction times were statistically shorter for Billroth-II with Braun reconstruction than Roux-en-Y (198.1 ± 33.0 vs. 242.3 ± 58.1 min, p = 0.001). One case of postoperative stricture was observed in each group. One case each of intra-abdominal abscess and delayed gastric emptying occurred in the Billroth-II with Braun group. At 1 year postoperatively, gastric residue and reflux esophagitis were not significantly different between the groups. Gastritis and bile reflux were more frequently observed in the Billroth-II with Braun group (p = 0.004 and p < 0.001, respectively). At 2 years postoperatively, gastric residue was not significantly different, but gastritis, bile reflux, and esophagitis were more frequent in the Billroth-II with Braun group (p = 0.029, p < 0.001, and p = 0.036, respectively). CONCLUSION: The postoperative effectiveness of Roux-en-Y reconstruction may be superior to Billroth-II with Braun reconstruction after laparoscopic distal gastrectomy.

Duodenal stump fistula after gastrectomy for gastric cancer: risk factors, prevention, and management.

PURPOSE: A duodenal stump fistula is one of the most severe complications after gastrectomy for gastric cancer. We aimed to analyze the risk factors for this problem, and to identify the methods used for its prevention and management. METHODS: We retrospectively reviewed the clinical data of 716 consecutive patients who underwent curative gastrectomy with a duodenal stump for gastric cancer between 2008 and 2013. RESULTS: A duodenal stump fistula occurred in 16 patients (2.2%) and there were 2 deaths in this group. Univariate analysis revealed age >60 years (odds ratio [OR], 3.09; 95% confidence interval [CI], 0.99-9.66), multiple comorbidities (OR, 4.23; 95% CI, 1.50-11.92), clinical T stage (OR, 2.91; 95% CI, 1.045-8.10), and gastric outlet obstruction (OR, 8.64; 95% CI, 2.61-28.61) to be significant factors for developing a duodenal stump fistula. Multivariate analysis identified multiple comorbidities (OR, 3.92; 95% CI, 1.30-11.80) and gastric outlet obstruction (OR, 5.62; 95% CI, 1.45-21.71) as predictors of this complication. CONCLUSION: Multiple comorbidities and gastric outlet obstruction were the main risk factors for a duodenal stump fistula. Therefore, preventive methods and aggressive management should be applied for patients at high risk.

Various features of laparoscopic tailored resection for gastric submucosal tumors: a single institution's results for 168 patients.

BACKGROUND: Laparoscopic resection is a standard procedure for gastric submucosal tumors. Herein, we analyzed the features of various laparoscopic approaches. METHODS: Between January 2007 and November 2013, 168 consecutive patients who underwent laparoscopic resection for gastric submucosal tumors were enrolled. Patients' demographics and clinicopathologic and perioperative data were reviewed retrospectively. RESULTS: Among the 168 patients, exogastric wedge resection was performed in 99 cases (58.9%), single-port intragastric resection was performed in 30 cases (17.9%), eversion technique was used in 17 cases (10.1%), transgastric resection was performed in 8 cases (4.8%), and single-port wedge resection was performed in 6 cases (3.6%). The remaining cases underwent single-port exogastric wedge resection, laparoscopic and endoscopic cooperative surgery, or major resection. Mean age was 56.8 ± 13.3 years, and body mass index was 24.0 ± 3.2 kg/m(2). Mean operation time was 96.1 ± 58.9 min; laparoscopic proximal gastrectomy had the longest operation time (3 cases, 291.7 ± 129.0 min). In contrast, the laparoscopic eversion technique had the shortest operation time (82.6 ± 32.8 min). Pathologic data revealed a mean tumor size of 2.9 ± 1.2 cm (with a range of 0.8-8.0 cm). Tumors were most common on the body (98 cases, 58.3%), followed by the fundus (44 cases, 26.2%). Exophytic growth occurred in 39 cases (23.2%), endophytic growth occurred in 89 cases (53.0%), and dumbbell-type growth occurred in 40 cases (23.8%). Gastrointestinal stromal tumors occurred in 130 cases (77.4%), and schwannomas occurred in 23 (13.7%). Thirteen patients had postoperative complications (delayed gastric emptying in 5, stricture in 3, bleeding in 3, others in 2). The mean follow-up period was 28.8 ± 20.8 months, and there were three recurrences (1.8%) at 6, 19 and 31 months after the initial surgery. CONCLUSIONS: For gastric submucosal tumors with appropriate locations and growth types, laparoscopic tailored resection which facilitates safer and more precise resection can be good alternative treatment option.

Effect of extramucin pools in gastric cancer patients.

PURPOSE: Mucinous gastric adenocarcinoma (MGC) is defined by the World Health Organization as a gastric adenocarcinoma with >50% extracellular mucin pools within the tumors. In this study, we attempted to analyze the clinicopathologic features of patients pathologically diagnosed as gastric cancer with lower than 50% tumor volume of extracellular mucin pool adenocarcinoma (LEMPC). We compared MGC versus nonmucinous gastric adenocarcinoma (NMGC). We were used in abbreviations LEMPC for NMGC including extracellular mucin pool. METHODS: Files of 995 patients with gastric cancer NMGC (n = 935), MGC (n = 20), LEMPC (n = 40) who underwent curative resection at Pusan National University Yangsan Hospital from December 2008 to December 2013 were retrospectively analyzed. All pathologic reports after curative resection and evaluated clinicopathologic features were reviewed to identify the effect of extracellular mucin pools in gastric cancer. RESULTS: Compared with the NMGC patients, the clinicopathological features of MGC patients were as follows: more frequent open surgery, larger tumor size, more advanced T stage and N stage, more positive lymph node metastasis, and perineural invasion. LEMPC patients showed similar features compared with NMGC patients. MGC and LEMPC patients showed similar clinicopathological features, except T stage and lymph node metastasis. CONCLUSION: LEMPC can be thought of as a previous step of MGC. It is reasonable to consider LEMPC patients in the diagnostic criteria of MGC, and to adequately treat.

Intracorporeal esophagojejunostomy using the double stapling technique after laparoscopic total gastrectomy: A retrospective case-series study.

AIM: To introduce a simple and safe anvil insertion technique to esophagus during laparoscopic total gastrectomy (LTG). METHODS: Between July 2010 and December 2012, 58 consecutive patients with early gastric cancer underwent LTG were enrolled. We performed a simple and safe Roux-en-Y esophagojejunostomy using the double stapling technique to all patients. Then patients' characteristics, perioperative outcome and histopathologic data were analyzed retrospectively. RESULTS: The mean age and body mass index were 59.3 ± 9.7 years and 22.7 ± 2.6 kg/m(2). The mean operation, reconstruction and anvil insertion times (from gastric incision to linear stapling) were 251.8 ± 57.0, 43.1 ± 2.8 and 4.2 ± 1.9 min, respectively. Intraoperative blood loss was 204.6 ± 156.3 mL and there was no open conversion. The postoperative complications were in 8 cases (delayed gastric emptying in 4 cases, pulmonary complication in 2 cases, pancreatitis in 1 case, anastomotic stricture in 1 case). Anastomotic stricture occurred after discharge and was recovered by endoscopic intervention. The patients were discharged at a mean of 9.6 ± 2.0 d after surgery. Neither leakage nor bleeding from the esophagojejunostomy occurred postoperatively. The mean proximal margin of specimen was 2.7 ± 2.8 cm CONCLUSION: Roux-en Y esophagojejunostomy using the double stapling technique is simple and rapid, and it may offer a solid, alternative reconstruction method for LTG or proximal gastrectomy.

Risk factors for delayed gastric emptying caused by anastomosis edema after subtotal gastrectomy for gastric cancer.

BACKGROUND/AIMS: Delayed gastric emptying (DGE) is one of the most troublesome complications after subtotal gastrectomy for gastric cancer. We evaluated operative and perioperative variables to assess for independent risk factors of DGE caused by anastomosis edema. METHODOLOGY: The study retrospectively reviewed clinical data of 382 consecutive patients who underwent subtotal gastrectomy for gastric cancer between 2009 and 2011 at a single institution. RESULTS: Delayed gastric emptying had occurred in twelve patients (3.1%). Univariate analysis revealed high body mass index (>25kg/m2), open gastrectomy, and Billroth II or Roux-en Y reconstructions to be significant factors for delayed gastric emptying. Multivariate analysis identified high body mass index and open gastrectomy as predictors of delayed gastric emptying. CONCLUSIONS: To avoid delayed gastric emptying, surgeons should take care in creating the gastrointestinal anastomosis, particularly in patients with high BMI or in cases of open gastrectomy.

Single-incision intragastric resection for upper and mid gastric submucosal tumors: a case-series study.

PURPOSE: Laparoscopic gastric wedge resection is a standard treatment for removing gastric submucosal tumors (SMTs). So far, however, there have been few reports of single-incision laparoscopic intragastric wedge resection. Our aim was to describe this procedure and our experience with it. METHODS: From January 2010 to December 2013, a total of 21 consecutive patients with gastric SMTs underwent single-incision intragastric resection at our institution. Their clinicopathologic data were analyzed retrospectively. RESULTS: The patients consisted of nine men and 12 women with a mean age of 51.9 ± 12.9 years (22-69 years). Their mean body mass index was 22.6 ± 2.0 kg/m(2). Mean tumor size was 2.4 ± 0.7 cm, with the following anatomic distribution: esophagogastric junction in three patients, fundus in twelve, upper body in three, and lower body in two. Mean operating time was 68.6 ± 12.0 minutes. There were no conversions to open surgery and no major intraoperative complications. Time to resumption of water intake was 1.4 ± 0.5 days. Mean hospital stay was 4.9 ± 1.7 days. There were no recurrences or deaths during the mean 19-month follow-up. CONCLUSION: Single-incision intragastric wedge resection is a feasible and safe procedure. It is especially efficient for treating small endophytic gastric SMTs located on the upper and mid portion of the stomach.

Solitary Peutz-Jeghers-type appendiceal hamartomatous polyp growing into the terminal ileum.

Solitary Peutz-Jeghers type hamartomatous polyp is rare. It is considered to be related to a variant Peutz-Jeghers syndrome (PJS) and may be a separate disease entity. A 50-year-old man was referred to our hospital with a diagnosis of intussusception in the terminal ileum and underwent segmental ileal resection with appendectomy. We identified a 3.5-cm diameter polyp arising from the appendix with ingrowth into the terminal ileum. The polyp was confirmed to be a hamartomatous polyp of Peutz-Jeghers-type, histologically. However, the patient had no characteristic manifestations of PJS such as mucocutaneous pigmentation and family history. There are few reports of appendiceal hamartomatous polyp in PJS patients and solitary appendiceal hamartomatous polyp is even rarer. Also, rather than telescoping, ours is the first reported intussuscepted lesion, to the best of our knowledge.

Mucin expression in gastric cancer: reappraisal of its clinicopathologic and prognostic significance.

CONTEXT: The clinical validity of mucin expression in gastric cancer is debated. Whereas several reports demonstrate a correlation between mucin expression and prognosis, others deny such an association. OBJECTIVES: This survival analysis study aims to elucidate the prognostic significance of mucin expression in gastric cancer. DESIGN: A retrospective survival analysis was done with 412 cases of gastric cancer characterized on the basis of MUC immunohistochemistry using MUC2, MUC5AC, MUC6, and CD10 antibodies; the cases were divided into those with a gastric, an intestinal, or a null mucin phenotype based on the predominant mucin. RESULTS: There was no association between mucin expression and survival when considering overall gastric cancers or the advanced gastric cancer subtype. However, early gastric cancers with a gastric mucin phenotype showed longer survival than those with an intestinal mucin phenotype (P = .01) or a null phenotype (P = .01). In particular, MUC5AC-positive early gastric cancers resulted in longer survival than did those that did not express MUC5AC (P = .009). The loss of MUC5AC expression was identified as an independent, poor prognostic factor in early gastric cancers using the Cox regression proportional hazard model (hazard ratio, 3.50; P = .045). CONCLUSIONS: MUC5AC expression is significantly associated with patient survival and can be used to predict outcomes in the gastric cancers, especially in the early gastric cancers.

Validation of circulating miRNA biomarkers for predicting lymph node metastasis in gastric cancer.

We validated candidate biomarkers using circulating miRNAs by analyzing serum miRNA concentrations from patients with gastric cancer (GC) to predict lymph node (LN) metastasis. In a pilot study, serum levels of miR-21, miR-27a, miR-106b, miR-146a, miR-148a, miR-223, and miR-433 were compared in 10 healthy donors, 16 LN-positive patients with GC, and 15 LN-negative patients with GC. Then, we compared the level of three miRNAs (miR-21, miR-146a, and miR-148a) with the total of 79 GC patients with or without LN metastasis. In the pilot study, miR-21, miR-27a, miR-106b, miR-146a, miR-148a, and miR-223 concentrations from LN-positive patients with GC were significantly different from those of LN-negative patients with GC (P < 0.001, P = 0.003, P = 0.033, P < 0.001, P <0.001, and P = 0.017, respectively). In the validation study, levels of miR-21, miR-146a, and miR-148a increased as pN stage increased (P < 0.001, P = 0.001, and P < 0.001, respectively). Levels of the miRNAs were significantly different between pN0 and pN0 in the pT1 group (P = 0.013, P = 0.004, and P = 0.035, respectively) and among clinical stages (P = 0.001, P = 0.002, and P < 0.001, respectively). No differences in miRNA levels were observed by pT stage, Lauren's classification, sex, or age. Serum concentrations of miR-21, miR-146a, and miR-148a were closely associated with GC pN stage. These serum miRNA levels could be biomarker candidates to predict the presence of LN metastasis.

Characterization of antigenic determinants in ApxIIA exotoxin capable of inducing protective immunity to Actinobacillus pleuropneumoniae challenge.

Actinobacillus pleuropneumoniae is the causative agent of porcine pleuropneumonia. Among the virulence factors of the pathogen, ApxIIA, a bacterial exotoxin, is expressed by many serotypes and presents a plausible target for vaccine development. We characterized the region within ApxIIA that induces a protective immune response against bacterial infection using mouse challenge model. Recombinant proteins spanning the length of ApxIIA were produced and antiserum to the full-length ApxIIA was induced in mice. This antiserum recognized fragments #2, #3 and #5 with high binding specificity, but showed poor recognition for fragments #1 and #4. Of the antisera induced in mice by injection of each fragments, only the antiserum to fragment #4 failed to efficiently recognize the full-length antigen, although the individual antisera recognized their cognate antigens with almost equal efficiency. The protective potency of the immunogenic proteins against a challenge injection of bacteria in vivo correlated well with the antibody titer. Fragment #5 induced the highest level of protective activity, comparable to that by the full-length protein. These results support the use of fragment #5 to produce a vaccine against A. pleuropneumoniae challenge, since the small antigen peptide is easier to handle than is the full-length protein and can be expressed efficiently in heterologous expression systems.

Is there any synergic effect for coadministration of mitomycin C and halofuginone on the skin wound healing?

OBJECTIVE: This study compared the potencies of the antifibrotic agents mitomycin C (MMC) and halofuginone (HFN) and investigated whether coadministration of these agents produces synergic effects in an animal skin wound model. SUBJECTS AND METHODS: Twenty male Sprague-Dawley rats were used for this study. After a full-thickness excisional wound was made on the dorsum of each rat, each rat was treated with topical mitomycin, intraperitoneal HFN, or both. Wound surface areas were measured over time, and histologic analysis was performed after wounds healed completely. RESULTS: The groups treated with MMC alone, HFN alone, and a combination of the two all exhibited delayed wound healing compared with the untreated group. Histologically, fibrosis and matrix metalloproteinase-2 expression were significantly inhibited in the treated groups. However, there were no gross or histologic differences between the MMC-treated group, the HFN-treated group, and the combination-treatment group. CONCLUSIONS: Both MMC and HFN inhibited excessive fibrosis. However, there was no significant difference in the antifibrotic effects of MMC and HFN on surgically induced skin wounds. Moreover, combination treatment with both MMC and HFN failed to confer an additional antifibrotic effect on skin wounds when compared with treatment with MMC or HFN alone.

Coagulase-positive staphylococcal necrotizing fasciitis subsequent to shoulder sprain in a healthy woman.

Necrotizing fasciitis (NF) is a deep infection of the subcutaneous tissue that progressively destroys fascia and fat; it is associated with systemic toxicity, a fulminant course, and high mortality. NF most frequently develops from trauma that compromises skin integrity, and is more common in patients with predisposing medical conditions such as diabetes mellitus, atherosclerosis, alcoholism, renal disease, liver disease, immunosuppression, malignancy, or corticosteroid use. Most often, NF is caused by polymicrobial pathogens including aerobic and anaerobic bacteria. NF caused by Staphylococcus aureus as a single pathogen, however, is rare. Here we report a case of NF that developed in a healthy woman after an isolated shoulder sprain that occurred without breaking a skin barrier, and was caused by Staphylococcus aureus as a single pathogen.

Double stapling Roux-en-Y reconstruction in a laparoscopy-assisted distal gastrectomy.

PURPOSE: The purpose of this study is to introduce the technical details of double stapling Roux-en-Y (R-Y) reconstruction and evaluate its short-term results. METHODS: Twenty-three patients who underwent a laparoscopy assisted distal gastrectomy with R-Y reconstruction between May 2007 and December 2008 were enrolled in this study. This investigation analyzed the clinicopathological data, the surgical data, and the postoperative outcome. RESULTS: There were 14 males and 9 females, and the mean age was 60.1 years (range, 51-66 years). The mean number of the retrieved lymph nodes was 37.3 (range, 17-67), and stage IA in 22 patients and stage IB in 1 patient. The total operation time was 198.3 min (range, 165-210 min), the intracorporeal operation time was 118.0 min (range, 95-130 min), and the extracorporeal operation time was 80.2 min (range, 70-90 min). The mean length of the incision was 3.5 cm (range, 3.2-3.8 cm). There was no leakage, stricture, or Roux stasis syndrome, and 3 cases (13%) of remnant gastritis occurred postoperatively. CONCLUSIONS: Double stapling R-Y anastomosis can be performed easily, quickly, and safely, and it is particularly useful in a laparoscopy-assisted distal gastrectomy. This method is advantageous in terms of the operation time and the cost effectiveness.

Lymph node metastasis from intestinal-type early gastric cancer: experience in a single institution and reassessment of the extended criteria for endoscopic submucosal dissection.

BACKGROUND: Given the increasing use of endoscopic resection as a therapeutic modality for cases of early gastric cancer (EGC), it is very important to define strict criteria for the use of endoscopic mucosal resection and endoscopic submucosal dissection. To date, the criteria are almost entirely based on Japanese literature evaluating the risk of lymph node (LN) metastasis in patients with EGC. OBJECTIVE: To analyze our own experience with the factors affecting LN metastasis and to reappraise the extended criteria for endoscopic submucosal dissection. DESIGN: Retrospective, single-center study. SETTING: University teaching hospital. PATIENTS: This study involved 478 patients who underwent gastrectomy with LN dissection (n = 270, mucosal [m] EGC; n = 208, submucosal [sm] EGC). INTERVENTION: Gastrectomy with LN dissection. MAIN OUTCOME MEASUREMENTS: LN metastasis. RESULTS: Overall, 12.6% (60/478) of patients with EGCs presented with LN metastasis (mEGC, 3.0% [8/270], smEGC, 25.0% [52/208]). Increased size, macroscopic type (elevated), depth of invasion, and lymphovascular invasion were associated with LN metastasis. In 270 cases of mEGC, there was no relationship between clinicopathologic features and LN metastasis. In the smEGC group, size, depth of invasion, and lymphovascular emboli were associated with an increased risk of LN metastasis. Significantly, LN metastasis was noted in EGCs falling within established extended endoscopic submucosal dissection criteria, that is, intestinal-type mucosal cancer of any size without ulcer and no lymphovascular emboli (2/146 [1.4%]) or < or =3 cm with no lymphovascular emboli and irrespective of the presence of ulceration (2/126 [1.6%]) or intestinal-type submucosal cancer (sm1, <500 microm) without lymphovascular invasion and measuring < or =3 cm in size (3/20 [15.0%]). LIMITATIONS: Retrospective review of a single-center study. CONCLUSION: We recommend that more centers survey their experiences of LN metastasis in cases of EGC to refine the criteria for endoscopic submucosal dissection as a therapeutic modality of intestinal-type EGC.