Parameters affecting improvement of excessive daytime sleepiness in obstructive sleep apnea patients.

OBJECTIVES: Obstructive sleep apnea (OSA) is a sleep-related breathing disorder caused by repetitive obstruction of the upper airway; this impairs gaseous exchange, resulting in hypoxia, hypercapnia, and frequent arousals. Excessive daytime sleepiness (EDS) is a common daytime symptom of OSA. EDS manifests as fatigue and impaired attention, leading to poor performance at work and falling asleep while driving, which is a major socioeconomic problem. Therefore, it is important to properly treat EDS and accurately predict the response to treatment. However, few studies have compared OSA patients showing and not showing improvement in EDS. Therefore, this study aimed to objectively analyze and compare EDS improvement and non-improvement groups. SUBJECTS AND METHODS: We retrospectively reviewed the medical records of 57 OSA patients with EDS. Patients were divided into two groups according to the improvement in EDS after positive airway pressure (PAP) device treatment. We analyzed differences in clinical records including patients' age, sex, history of smoking, hypertension, diabetes, myocardial infarction, and cerebrovascular disease between the two groups. Systolic, diastolic blood pressure, blood test including blood glucose, total cholesterol, high- and low-density lipoprotein cholesterol, and triglyceride levels were also analyzed. Polysomnography (PSG) data, PAP device treatment compliance and scores of questionnaires related to various psychiatric symptoms, subjective sleep quality between the two groups were also analyzed. RESULTS: There was no statistically significant difference in age, gender, or past medical history between the two groups. Systolic and diastolic blood pressure, and blood test results, were also not significantly different. Among the questionnaires related to various psychiatric symptoms, the groups showed statistically significant differences in Social Avoidance and Distress Scale (SADS) and Fear of Negative Evaluation (FNE) scores (P = 0.001 and 0.020, respectively). The group differences in the scores on the other questionnaires were not significantly different. Among the PSG items, significant group differences were observed in the percentage of stage 2 non-REM sleep (N2%, P = 0.023), apnea index (AI, P = 0.005), apnea-hypopnea index (AHI, P = 0.023), and frequency of 3 % oxygen desaturation (ODI3, P = 0.001). No obesity-related parameters showed significant group differences. The percentage of days on which a PAP device was used (out of 90 days; PAP%) and percentage of days on which a PAP device was used for >4 h (Time4%) did not differ significantly. CONCLUSIONS: The SADS, FNE, AI, AHI, N2%, and ODI3 parameters differed significantly between the EDS improvement and non-improvement groups. These parameters may help clinicians treat and predict the prognosis of patients suffering with EDS.

Clinical significance of pathologic subtype in curatively resected ampulla of vater cancer.

BACKGROUND: Ampullary cancer is considered to have a better prognosis than cancers of the distal bile duct and pancreas, and recent publications emphasize the prognostic importance of the histologic differentiation of the intestinal and pancreatobiliary types of ampullary cancer. The aims of this study were to identify those factors that affect recurrence after curative resection and to investigate differences between the clinicopathologic features of these two pathologic subtypes. PATIENTS AND METHODS: The medical records of patients that underwent pancreatoduodenectomy for ampullary carcinoma from February 1995 to March 2009 at our institute were retrospectively reviewed. One hundred and four patients that underwent curative resection for ampullary carcinoma were enrolled in this study. One pathologist reviewed all pathologic reports and histopathologic findings. Data on clinicopathologic factors and disease free and overall survival were analyzed. RESULTS: The 3- and 5-year disease free survival rates of the 104 study subjects were 62.2% and 57.7%, respectively, and overall survival rates were 69.4% and 60.1%, respectively. Multivariate analysis showed that an advanced T stage (P = 0.049), the presence of lymph node metastasis (P = 0.003), poor differentiation (P = 0.039), and the pancreatobiliary type (P = 0.022) significantly increased the risk of recurrence. Furthermore, the pancreatobiliary type was found to be more associated with an advanced T stage (P = 0.009), regional lymph node metastasis (P = 0.007), and perineural invasion (P = 0.026) than the intestinal type. In addition, pathologic subtype analysis showed that Carcinoembryonic antigen (CEA) level and lymph node metastasis were important predictors of recurrence in patients with the intestinal (P = 0.013) and pancreatobiliary types, respectively (P = 0.003). CONCLUSIONS: An advanced T stage, nodal metastasis, poor differentiation, and the pancreaticobiliary type were found to be independent predictors of recurrence after curative resection of ampullary carcinoma by multivariate analysis. In addition, the pancreatobiliary type tended to present in a more advanced T stage and more frequently with regional lymph node involvement and perineural invasion than the intestinal type. Furthermore, CEA level and lymph node metastasis were found to be independent predictors of recurrence for the intestinal and pancreatobiliary types, respectively.

Clinicopathologic analysis of adenosquamous/squamous cell carcinoma of the gallbladder.

BACKGROUNDS AND OBJECTIVES: Adenosquamous/squamous cell carcinoma (AS/SCC) of the gallbladder is rarely encountered and accounts for 1.4-10.6% of all gallbladder carcinomas (GBCs). This study was conducted to investigate the clinicopathologic features of AS/SCC of gallbladder. METHODS: The authors retrospectively reviewed 16 cases of pathologically proven AS/SCC of the gallbladder among 404 patients who underwent surgery for GBC from October 1994 to March 2009. Forty-eight conventional GBC patients were selected as controls after matching for age and gender. RESULTS: Mean patient age was 60.2 years and half were male. Tumor stages in the case group were significantly more advanced than the control group (P < 0.001). R0 resection rates in cases and controls were 50% and 81.2% (P = 0.022). Overall 1-year survival in the case group was significantly poorer than in the control group (18.8% vs. 87.3%, P < 0.001). However, no significant difference in disease-free survival rates was found between cases and controls after R0 resection (P = 0.072). CONCLUSIONS: AS/SCC of the gallbladder is often diagnosed at an advanced stage, which results in non-curative surgical resection and a poorer prognosis than conventional GBC. However, curative surgical resection of AS/SCC of the gallbladder might result in disease-free survival rates that are comparable with those of conventional GBC.

Conversion of oximes to carbonyl compounds with 2-nitro-4,5-dichloropyridazin-3(2H)-one.

Conversion of oximes to the carbonyl compounds has been demonstrated with use of 2-nitro-4,5-dichloropyridazin-3(2H)-one (2) under microwave irradiated conditions. Fourteen aliphatic and aromatic oximes converted to their corresponding aldehydes and ketones in good to excellent yields. It is noteworthy that the reaction is conducted under neutral, mild, and eco-friendly condition.

TBAF-assisted copper-catalyzed N-arylation and benzylation of benzazoles with aryl and benzyl halides under the ligand/base/ solvent-free conditions.

TBAF-assisted N-arylation and benzylation of benzazoles such as 1H-benzimidazole, 1H-indole, and 1H-benzotriazole with aryl and benzyl halides have been demonstrated under the ligand/base/solvent-free conditions. In the presence of CuBr2 and TBAF (n-Bu4NF), the azoles underwent N-arylation and benzylation with aryl and benzyl halides smoothly in moderate to good yields. It is noteworthy that the reaction is conducted under the ligand/base/solvent-free conditions.

What is an adequate extent of resection for T1 gallbladder cancers?

OBJECTIVE: The purpose of this study was to analyze clinicopathologic and surgical features and to determine what should be an adequate extent of resection for T1 gallbladder cancers. SUMMARY BACKGROUND DATA: Simple cholecystectomy offers adequate treatment for T1a cancers; however, it remains debatable whether T1b cancers should be treated by simple cholecystectomy or by radical resection. METHODS: Two hundred ninety patients with gallbladder cancer underwent surgical resection. A retrospective analysis was conducted on 52 patients with pathologic stage T1 (27 [52%] with T1a and 25 [48%] with T1b). Clinicopathologic features, extents of resection, and survival rates were investigated retrospectively. RESULTS: No lymph node metastasis or lymphovascular or perineural infiltration was observed in those with T1a disease, but 2 of the 25 patients with T1b disease (3.8%) had lymph node metastasis and 1 patient (1.9%) had lymphatic infiltration. Twenty-one of the 52 study subjects (40.3%) underwent simple cholecystectomy. No peritoneal dissemination occurred regardless of the surgical method (laparoscopy or open surgery). Of the 23 radically resected patients (44.2%) in T1b group, 6 patients (11.5%) underwent cholecystectomy and hepatoduodenal lymph node dissection (CholeLN), and 17 patients (32.7%) underwent CholeLN combined with wedge resection of IVb and V segments of liver, common bile duct resection, or pancreaticoduodenectomy. No difference in locoregional recurrence, metastasis, or survival rate was observed regardless of combined resection of an adjacent organ. The overall survival rate for all patients was 96.2%, and for T1a and T1b these were 96.3% and 96%, respectively. CONCLUSION: When early gallbladder carcinoma is suspected on the basis of imaging findings, further evaluation of the depth of invasion by endoscopic ultrasonography or intraoperative frozen biopsy is advised. Then, if the disease stage is determined to be T1a, laparoscopic or open cholecystectomy alone is curative, and if T1b, cholecystectomy with hepatoduodenal lymph node dissection without combined resection of an adjacent organ is recommended.

Surgical resection of metastasis to the pancreas.

PURPOSE: Metastasis to the pancreas is rare, and the benefit of resection for pancreatic metastasis is poorly defined. The aim of this study was to review our experiences of the operative management of metastasis to the pancreas. METHODS: Between 1995 and 2009, 11 patients (8 men and 3 women; median age, 54 years) were admitted to our institution with a metachronously metastatic lesion to the pancreas and later underwent pancreatic resection. The clinical features and outcomes of treatments were examined. RESULTS: The primary cancers were renal cell carcinoma (RCC, n = 7), carcinoid tumor (n = 2), rectal cancer and leiomyosarcoma. Six patients underwent distal pancreatectosplenectomy, 3 pancreaticoduodenectomy and 2 patients underwent enucleation for small RCC. One patient died of metastatic RCC at 53 months after surgery and ten patients remain alive; four patients without disease at 7 to 69 months postoperatively, and the other six with disease at 11 to 68 months. Median postoperative survival of all patients was 34 months. CONCLUSION: Patients with a low surgical risk should be considered for pancreatic metastasectomy if curative resection is possible. Primary cancer type, which is associated with survival benefit, would be the best candidate for surgical resection of metastases to the pancreas.

Clinical validation of the ISGPF classification and the risk factors of pancreatic fistula formation following duct-to-mucosa pancreaticojejunostomy by one surgeon at a single center.

BACKGROUND: Postoperative pancreatic fistula remains a troublesome complication after pancreatoduodenectomy (PD), and many authors have suggested factors that affect pancreatic leakage after PD. The International Study Group on Pancreatic Fistula (ISGPF) published a classification, but the new criteria adopted have not been substantially validated. The aims of this study were to validate the ISGPF classification and to analyze the risk factors of pancreatic leakage after duct-to-mucosa pancreatojejunostomy by a single surgeon. METHODS: All patient data were entered prospectively into a database. The risk factors for pancreatic fistula were analyzed retrospectively for 247 consecutive patients who underwent conventional pancreatoduodenectomy or pylorus-preserving pancreatoduodenectomy between June 2005 and March 2009 at the Samsung Medical Center by a single surgeon. Duct-to-mucosa pancreatojejunostomy was performed on all patients. The ISGPF criteria were used to define postoperative pancreatic fistula. RESULTS: Conventional pancreatoduodenectomy was performed in 84 patients and pylorus-preserving pancreatoduodenectomy in 163. Postoperative complications occurred in 144 (58.3%) patients, but there was no postoperative in-hospital mortality. Pancreatic fistula occurred in 105 (42.5%) [grade A, 82 (33.2%); grade B, 9 (3.6%); grade C, 14 (5.7%)]. However, no difference was evident between the no fistula group and the grade A fistula group in terms of clinical findings, including postoperative hospital stays (11 versus 12 days, respectively, p = 0.332). Mean durations of hospital stay in the grade B and C fistula groups were significantly longer than in the no fistula group (21 and 28.5 days, respectively; p < 0.001). Multivariate analysis revealed that a soft pancreas and a long operation time (>300 min) were individually associated with pancreatic fistula formation of grades B and C. CONCLUSIONS: Although the new ISGPF classification appears to be sound in terms of postoperative pancreatic leakage, grade A fistulas lack clinical implications; thus, we are of the opinion that only grade B and C fistulas should be considered in practice. A soft pancreatic texture and an operation time exceeding 300 min were found to be risk factors of grade B and C pancreatic fistulas.

Management of bleeding from pseudoaneurysms following pancreaticoduodenectomy.

AIM: To review the clinical course and the management of pseudoaneurysms post-pancreaticoduodenectomy. METHODS: Medical records of 907 patients who underwent pancreaticoduodenectomies from January 1995 to May 2007 were evaluated retrospectively. The clinical course, management strategy, and outcome of ruptured pseudoaneurysms cases were analyzed. RESULTS: Twenty-seven (3.0%) of 907 cases had post-operative hemorrhage from ruptured pseudoaneurysms. Pancreatic fistula was evident in 12 (44%) cases. Sentinel bleeding appeared in 21 (77.8%) cases. Of the 27 cases, 11 (41%) cases demonstrated bleeding pseudoaneurysm of the ligated gastroduodenal artery, 8 (30%) of the right, proper, common hepatic artery, 2 (7%) of the right gastric artery, and 4 (15%) of the peripancreatic arteries. The remaining two patients died due to sudden-onset massive hemorrhage and pseudoaneurysm rupture was suspected. Emergent operation was performed on 2 cases directly without angiography. Angiography was attempted in 23 cases. Eighteen (78.2%) cases succeeded to hemostasis; the five failed cases were explored. After embolization of the hepatic artery, five cases developed liver abscesses or infarction and a single case of hepatic failure expired. Gastroduodenal artery embolization with common hepatic artery stent insertion was performed to enhance hepatic artery flow in a single case and was successfully controlled. CONCLUSION: Bleeding pseudoaneurysms are among the most serious and fatal complications following pancreaticoduodenectomy. Diagnostic angiography has been preferred over endoscopy and is rapidly becoming the standard therapeutic treatment for bleeding pseudoaneurysms.

Prognostic factors and adjuvant chemoradiation therapy after pancreaticoduodenectomy for pancreatic adenocarcinoma.

BACKGROUND: The aim of this study was to determine prognostic factors for survival after resection of pancreatic adenocarcinoma (PC) and to compare outcomes after surgery alone versus surgery plus adjuvant therapy. METHODS: We performed a retrospective review of 219 patients who underwent pancreaticoduodenectomy for PC with curative intent between 1995 and 2007. Data were collected prospectively. Postoperative adjuvant chemoradiation therapy (CRT) consisted of fluorouracil or gemcitabine-based chemotherapy; the median radiation dose was 45 Gy. RESULTS: The 3- and 5-year overall survival (OS) rates were 24.3% and 14.2%, respectively. Median OS was 14.0 months [95% confidence interval (CI), 12-16 months]. Patients with metastatic lymph nodes experienced improved median survival (16 vs 10 months; P < 0.001) and 3-year OS (3-year OS 28% vs 8%) after adjuvant CRT compared with those who had no CRT. Patients who underwent non-curative resection had the same effect (median OS, 13 vs 8 months; P = 0.037). Lymph node metastasis and non-curative resection showed no significance on multivariate analysis. Poor differentiation [risk ratio (RR) = 2.10; P < 0.001] and tumor size >3 cm (RR = 1.57; P = 0.018) were found to be adverse prognostic factors; adjuvant CRT had borderline significance (RR = 0.70; P = 0.087). CONCLUSIONS: Adjuvant CRT benefited a subset of patients with resected PC, particularly those with lymph node metastasis and those undergoing non-curative resection. Multivariate analysis demonstrated that patients with tumors larger than 3 cm and poor differentiation had poor prognosis.

Carcinoma of the middle bile duct: is bile duct segmental resection appropriate?

AIM: To compare survival between bile duct segmental resection (BDSR) and pancreaticoduodenectomy (PD) for treating distal bile duct cancers. METHODS: Retrospective analysis was conducted for 45 patients in a BDSR group and for 149 patients in a PD group. RESULTS: The T-stage (P < 0.001), lymph node invasion (P = 0.010) and tumor differentiation (P = 0.005) were significant prognostic factors in the BDSR group. The 3- and 5-year overall survival rates for the BDSR group and PD group were 51.7% and 36.6%, respectively and 46.0% and 38.1%, respectively (P = 0.099). The BDSR group and PD group did not show any significant difference in survival when this was adjusted for the TNM stage. The 3- and 5-year survival rates were: stage Ia [BDSR (100.0% and 100.0%) vs PD (76.9% and 68.4%) (P = 0.226)]; stage Ib [BDSR (55.8% and 32.6%) vs PD (59.3% and 59.3%) (P = 0.942)]; stage IIb [BDSR (19.2% and 19.2%) vs PD (31.9% and 14.2%) (P = 0.669)]. CONCLUSION: BDSR can be justified as an alternative radical operation for patients with middle bile duct in selected patients with no adjacent organ invasion and resection margin is negative.

Prognostic factors for primary duodenal adenocarcinoma.

BACKGROUND: The aim of this study was to review the clinical features of primary duodenal adenocarcinoma (PDA) patients and to identify factors that influence survival. The natural history of PDA and the factors that affect patient outcome remain poorly defined. METHODS: The authors reviewed the medical records of 53 patients treated for PDA from January 1995 to May 2007. RESULTS: Altogether, 28 of the 53 patients (resectability 52.8%) underwent curative resection and 25 (47.2%) surgical palliation (bypass surgery or biopsy). Overall, the 3- and 5-year survival rates were 34.4% and 28.6%, respectively. Survival was significantly higher for patients who underwent curative resection (median survival 39 months; 3- and 5-year survivals 52.9% and 44.1%, respectively) than for those who underwent palliative surgery (median survival 8 months; 3-year survival 0%) (p < 0.001). T stage (p = 0.032) and nodal metastasis (p = 0.002) had significant negative effects on the survival of patients who underwent curative resection according to univariate analysis. However, multivariate analysis revealed that only nodal metastasis (p = 0.015) was significantly associated with survival. CONCLUSIONS: The resectability of PDA was associated with increased survival, and metastasis to lymph nodes was found to be associated with reduced survival of patients with PDA. Findings indicate that an aggressive surgical approach should be pursued.