Identifying the best candidates for reduced port gastrectomy.

BACKGROUND: Previous studies have focused on the non-inferiority of RPG compared with conventional port gastrectomy (CPG); however, we assumed that some candidates might derive more significant benefit from RPG over CPG. METHODS: We retrospectively analyzed the clinicopathological and perioperative parameters of 1442 patients with gastric cancer treated by gastrectomy between 2009 and 2022. The C-reactive protein level on postoperative day 3 (CRPD3) was used as a surrogate parameter for surgical trauma. Patients were grouped according to the extent of gastrectomy [subtotal gastrectomy (STG) or total gastrectomy (TG)] and lymph node dissection (D1+ or D2). The degree of surgical trauma, bowel recovery, and hospital stay between RPG and CPG was compared among those patient groups. RESULTS: Of 1442 patients, 889, 354, 129, and 70 were grouped as STGD1+, STGD2, TGD1+, and TGD2, respectively. Compared with CPG, RPG significantly decreased CRPD3 only among patients in the STGD1+ group (CPG: n = 653, 84.49 mg/L, 95% CI 80.53-88.45 vs. RPG: n = 236, 70.01 mg/L, 95% CI 63.92-76.09, P < 0.001). In addition, the RPG method significantly shortens bowel recovery and hospital stay in the STGD1+ (P < 0.001 and P < 0.001), STGD2 (P < 0.001 and P < 0.001), and TGD1+ (P = 0.026 and P = 0.007), respectively. No difference was observed in the TGD2 group (P = 0.313 and P = 0.740). CONCLUSIONS: The best candidates for RPG are patients who undergo STGD1+, followed by STGD2 and TG D1+, considering the reduction in CRPD3, bowel recovery, and hospital stay.

A 3-year follow-up study of uncut Roux-en-Y reconstruction: clinical results and outcomes.

BACKGROUND: The goal of this study was to identify the clinical outcomes of uncut Roux-en-Y reconstruction in patients who underwent totally laparoscopic distal gastrectomy (TLDG) over 3-year follow-up. METHODS: From January 2016 to December 2017, 269 patients who underwent TLDG were enrolled in the study and analyzed retrospectively. They were classified into two groups according to the reconstruction method: uncut Roux-en-Y reconstruction (uncut RY) (n = 154) and Billroth II with Braun anastomosis (B-II/Braun) (n = 115). Postoperative endoscopic findings (residual food, bile reflux, gastritis, and esophagitis) and nutritional status (body weight, serum hemoglobin, total protein, and albumin levels) were assessed every 6 months for 3 years. RESULTS: Residual food was less frequent in the uncut RY group in the 6th month after TLDG (p = 0.022), but there were no differences between the two groups for the rest of the study period. The incidence of bile reflux and gastritis was low in the uncut RY group during all postoperative periods (all p < 0.001). In the B-II/Braun group, the frequency of reflux esophagitis was high in the 30th and 36th months after TLDG (both p < 0.001), and there were no differences between the two groups during the preceding periods. No significant differences were found with respect to nutritional status, such as body weight, serum hemoglobin, total protein, and albumin levels during all postoperative periods. CONCLUSIONS: Three-year follow-up outcomes showed that uncut RY can effectively reduce the incidence of bile reflux and gastritis in the remnant stomach compared to B-II/Braun after TLDG.

Direct endoscopic biopsy for subepithelial tumor larger than 20 mm after removal of overlying mucosa.

OBJECTIVE: An accurate diagnosis of a subepithelial tumor (SET) using endoscopic ultrasound (EUS) without tissue acquisition is difficult. Treatment plan for a SET may be influenced by endoscopic tissue diagnosis. We aimed to clarify the clinical outcomes of direct endoscopic biopsy for SET after removal of the overlying mucosa. METHODS: We evaluated the medical records of 15 patients. All patients underwent direct endoscopic biopsy for a SET larger than 20 mm (involving proper muscle layer) after removal of the overlying mucosa. The rate of achieving an accurate diagnosis and the treatment decision after the procedure were evaluated. RESULTS: The patients' mean age was 55.1 ± 14.7 years. The patient population predominantly comprised men (9/15, 60%). The mean tumor size was 24.3 ± 7.8 mm. The mean biopsy number was 3.5 ± 1.7. No major complications occurred with the procedure. The mean procedure time was 15 ± 7.4 min. An accurate diagnosis was achieved in 93.3% of patients (14/15). The main pathological diagnoses after direct endoscopic SET biopsy were leiomyoma (33.3%, 5/15) and ectopic pancreas (33.3%, 5/15) followed by gastrointestinal stromal tumor (GIST) (13.3%, 2/15) and schwannoma (13.3%, 2/15). The treatment plan was influenced by the result of biopsy in 80% of patients (9/15), and unnecessary surgical resection was avoided. CONCLUSIONS: Direct endoscopic SET biopsy after removal of the overlying mucosa using an endoscopic conventional snare was a useful diagnostic tool with high diagnostic accuracy and low risk of complications.

Risk factors associated with difficult gastric endoscopic submucosal dissection: predicting difficult ESD.

BACKGROUND AND STUDY AIM: Endoscopic submucosal dissection (ESD) is a widely accepted treatment for superficial gastric neoplasms. Difficult ESD can lead to complications, such as bleeding and perforation. To predict difficult ESD procedures, we analyzed the factors associated with difficult ESD. PATIENTS AND METHODS: The medical records of 1052 ESD procedures were retrospectively reviewed. Difficult ESD was defined by any one of three end points: longer procedure time (≥60 min), piecemeal resection, incomplete (R1) resection, or gastric wall perforation. To determine the factors associated with difficult ESD, clinical and pathologic features and endoscopic findings were analyzed. RESULTS: The rates of en bloc resection and curative (R0) resection were 93.3 and 92.4 %, respectively. The mean procedure time was 27.7 ± 16.7 min. After multivariate analysis, larger tumor size (≥20 mm) was an independent risk factor for longer procedure time (OR 4.1, P < 0.001), for piecemeal resection (OR 2.3, P = 0.003) and incomplete (R1) resection (OR 2.1, P = 0.005). Location of the lesion (upper third) was an independent risk factor for longer procedure time (OR 5.8, P < 0.001), for piecemeal resection (OR 4.1, P < 0.001) and incomplete (R1) resection (OR 4.5, P < 0.001). Submucosal fibrosis was an independent risk factor for longer procedure time (OR 9.7, P < 0.001), for piecemeal resection (OR 2.4, P < 0.001) and incomplete (R1) resection (OR 2.6, P < 0.001). Finally, submucosal invasive gastric cancer was an independent risk factor for piecemeal resection (OR 2.6, P = 0.008), for perforation (OR 19.3, P = 0.001) and for incomplete (R1) resection (OR 2.7, P = 0.001). CONCLUSIONS: Difficult ESD procedures are a function of the lesion size and location, submucosal fibrosis, and submucosal invasive cancer. When a difficult ESD procedure is expected, appropriate preparations should be considered, including consultation with more experienced endoscopists.

Factors associated with clinical failure of self-expandable metal stent for malignant gastroduodenal obstruction.

OBJECTIVE: Endoscopic self-expandable metal stent (SEMS) placement has emerged as an effective palliative treatment for inoperable malignant gastric outlet obstruction (GOO). In spite of successful stent placement, some patients complain of ongoing dysphagia and vomiting. Most reported data on SEMS to date are about technical success of different types of stents and low complication rates. The aim of this study was to evaluate the associated factors of clinical failure after endoscopic SEMS placement for inoperable malignant GOO. METHODS: A total 122 patients who underwent successful endoscopic SEMS placement for malignant GOO in an academic referral center were included in the analyses. We retrospectively evaluated variables associated with clinical outcomes after successful SEMS placement. RESULTS: The clinical success rate was 81.1%. The common causes of GOO were pancreatic (39%) and gastric cancers (32%). The mean length of the stents (± standard deviation) was 10.06 ± 2.42 cm. Multivariate analysis revealed that gallbladder cancer (p = 0.016, OR 6.486, 95% CI, 1.509-59.655), poor performance status (ECOG ≥ 3) (p = 0.001, OR 10.200, 95% CI, 2.435-42.721), the presence of carcinomatosis peritonei (p < 0.001, OR 35.714, 95% CI, 5.556-250.000) and the failure of endoscope passage (p = 0.039, OR 6.945, 95% CI, 1.101-43.818). CONCLUSION: Our results suggest that gallbladder cancer, poor performance status (ECOG ≥ 3) and the presence of carcinomatosis peritonei related with clinical failure of palliative SEMS placement.

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.

Congenital adhesion band causing small bowel obstruction: What's the difference in various age groups, pediatric and adult patients?

BACKGROUND: A congenital adhesion band is a rare condition, but may induce a small bowel obstruction (SBO) at any age. However, only a few sporadic case reports exit. We aimed to identify the clinical characteristics of congenital adhesion band manifesting a SBO stratified by age group between pediatric and adult patients. METHODS: The medical records of all patients with a SBO between Jan 1, 2009 and Dec 31, 2015 were retrospectively reviewed. Cases associated with previous surgical procedure and cases of secondary obstruction due to inflammatory processes or tumor and other systemic diseases were excluded. The patients were divided into two groups according to age below or above 18 years: pediatric and adult. The basic clinical characteristics were analyzed and compared between groups. RESULTS: Of 251 patients with a SBO, 15 (5.9%) met the inclusion criteria; 10 cases in pediatric group (mean age 17.9 ± 38.7 months) and 5 cases in adult group (mean age 60.0 ± 19.7 years). The pediatric group (66.6%) included 3 neonates, 5 infants, and 2 school children. They usually presented with bilious vomiting (50.0%) and abdominal distention (60.0%), and demonstrated a high rate of early operation (80.0%) and bowel resection (70.0%). In contrast, the adult group (33.3%) presented with abdominal pain (100%) in all cases and underwent a relatively simple procedure of band release using a laparoscopic approach (60%). However, group differences did not reach statistical significance. In addition, two groups did not differ in the time interval to the operation or in the range of the operation (p = 0.089 vs. p = 0.329). No significant correlation was found between the time interval to the operation and the necessity of bowel resection (p = 0.136). There was no mortality in either group. CONCLUSIONS: Congenital adhesion band is a very rare condition with diverse clinical presentations across ages. Unlike adult patients, pediatric patients showed a high proportion of early operation and bowel resection. A good result can be expected with an early diagnosis and prompt management regardless of age.

Risk factors associated with diagnostic discrepancy of gastric indefinite neoplasia: Who need en bloc resection?

BACKGROUND: Endoscopic forceps biopsy is insufficient for a definitive diagnosis of dysplastic lesions. It is difficult to decide clinical management of gastric indefinite neoplasia diagnosed by endoscopic forceps biopsy when early gastric cancer (EGC) is macroscopically suspected. The aim of this study was to discuss the final results of gastric indefinite neoplasia and associated clinical factors predictive of early gastric cancer. METHODS: The medical records of 119 patients who were diagnosed with gastric indefinite neoplasia by index forceps biopsy were retrospectively reviewed. The initial endoscopic findings were analyzed, and predictive factors of EGC were evaluated. RESULTS: The final pathologic diagnoses of 119 patients included early gastric cancer (n = 26, 21.8%), adenoma (n = 6, 5.0%) and non-neoplasm (n = 87, 73.1%). Univariate analysis showed that lesion size greater than 10 mm, surface nodularity and surface redness were associated risk factors. In the multivariate analysis, lesions diameter (p = 0.021, OR 11.401, 95% CI 1.432-90.759) and surface redness (p = 0.014, OR 3.777, 95% CI 1.306-10.923) were significant risk factors. CONCLUSIONS: Patients with gastric indefinite neoplasia with larger size (≥10 mm) and surface redness might need further diagnostic investigation rather than simple follow-up endoscopy.

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.

The application of enhanced recovery after surgery protocol after distal gastrectomy for patients with gastric cancer: a prospective randomized clinical trial.

BACKGROUND: This study aimed to evaluate the clinical outcomes and efficacy of enhanced recovery after surgery (ERAS) protocol in patients undergoing distal gastrectomy for gastric cancer (GC). METHODS: Patients were randomly assigned to the ERAS group (EG) and the conventional care group (CG) by stratified randomization according to age and sex. The primary endpoint was adjusted postoperative hospital stay, calculated using discharge criteria developed to evaluate recovery. Nutritional data and quality of life (QoL) (European Organisation for Research and Treatment of Cancer [EORTC] C30 and STO22) during the perioperative period were also analyzed. RESULTS: We enrolled 198 eligible patients with GC for the study between June 2017 and January 2019. A total of 147 patients were finally enrolled in this study (full analysis set) and were assigned to EG (n = 71) and CG (n = 76). First flatus was faster significantly in EG (3.6 ± 1.5 vs 4.1 ± 1.2 days, P = .019). EG showed a faster start of the sips and soft diet than CG (1.3 ± 0.7 vs 3.1 ± 0.4 days, P < .001; 2.4 ± 0.9 vs 5.2 ± 0.7 days, P < .001) according to the protocol. The recorded hospital stay was not significantly different; however, adjusted hospital stay was significantly shorter in EG than in CG (6.5 ± 3.1 vs 7.8 ± 2.1 days, P = .005). There was no difference in morbidity, and no mortality occurred in both groups. EG did not show significant superiority in nutritional outcome and QoL improvement, except for pain scale in EORTC-STO22. CONCLUSION: The application of the ERAS protocol could reduce the adjusted hospital stay without an increase in postoperative complications. There was no significant difference in long-term nutritional outcome and QoL of the 2 groups.

Helical Hybrid Nanostructure Based on Chiral M13 Bacteriophage via Evaporation-Induced Three-Dimensional Process.

The use of naturally sourced organic materials with chirality, such as the M13 bacteriophage, holds intriguing implications, especially in the field of nanotechnology. The chirality properties of bacteriophages have been demonstrated through numerous studies, particularly in the analysis of liquid crystal phase transitions, developing specific applications. However, exploring the utilization of the M13 bacteriophage as a template for creating chiral nanostructures for optics and sensor applications comes with significant challenges. In this study, the chirality of the M13 bacteriophage was leveraged as a valuable tool for generating helical hybrid structures by combining it with nanoparticles through an evaporation-induced three-dimensional (3D) printing process. Utilizing on the self-assembly property of the M13 bacteriophage, metal nanoparticles were organized into a helical chain under the influence of the M13 bacteriophage at the meniscus interface. External parameters, including nanoparticle shape, the ratio between the bacteriophage and nanoparticles, and pulling speed, were demonstrated as crucial factors affecting the fabrication of helical nanostructures. This study aimed to explore the potential of chiral nanostructure fabrication by utilizing the chirality of the M13 bacteriophage and manipulating external parameters to control the properties of the resulting hybrid structures.

Comparison between the mesenteric fixation method (MEFIX) and conventional methods at preventing the occurrence of Petersen's hernia: a study protocol for a multicenter randomized controlled trial.

BACKGROUND: Petersen's hernia, which occurs after Billroth-II (B-II) or Roux-en-Y (REY) anastomosis, can be reduced by defect closure. This study aims to compare the incidence of bowel obstruction above Clavien-Dindo classification grade III due to Petersen's hernia between the mesenteric fixation method and the conventional methods after laparoscopic or robotic gastrectomy. METHODS: This study was designed as prospective, single-blind, non-inferiority randomized controlled multicenter trial in Korea. Patients with histologically diagnosed gastric cancer of clinical stages I, II, or III who underwent B-II or REY anastomosis after laparoscopic or robotic gastrectomy are enrolled in this study. Participants who meet the inclusion criteria are randomly assigned to two groups: a CLOSURE group that underwent conventional Petersen's defect closure method and a MEFIX group that underwent the mesenteric fixation method. The primary endpoint is the number of patients who underwent surgery for bowel obstruction caused by Petersen's hernia within 3 years after laparoscopic or robotic gastrectomy. DISCUSSION: This trial is expected to provide high-level evidence showing that the MEFIX method can quickly and easily close Petersen's defect without increased postoperative complications compared to the conventional method. TRIAL REGISTRATION: ClinicalTrials.gov NCT05105360. Registered on November 3, 2021.

Application of the Falciform Ligament Patch for the Prevention of Duodenal Stump Leakage After Gastrectomy: Technical Report on a Case Series.

Background: Duodenal stump leakage (DSL) is a serious complication after gastrectomy. In this study, we developed a novel prevention technique using a falciform ligament patch (FLP) to prevent DSL among high-risk patients after gastrectomy. Materials and Methods: From January 2019 to July 2021, 14 patients who were judged to be at high risk for DSL during preoperative examinations or surgery were included in this retrospective study, and the FLP was applied to the duodenal stump. The falciform ligament was separated from the liver after duodenal transection during gastrectomy; the end part was used to cover the duodenal stump and was fixed using nonabsorbable polypropylene sutures. Results: In total, 14 patients who underwent FLP had one or two risk factors that were identified: 5 patients, gastric cancer duodenal invasion; 4 patients, gastric outlet obstruction (GOO); 1 patient, cancer involving the distal resection margin; 1 patient, duodenal gastrointestinal stromal tumor involving the distal resection margin; 1 patient, gastric cancer duodenal invasion and GOO; and 2 patients, cancer involving the distal resection margin and GOO. FLP construction was successful, and no patient developed complications of DSL. The average hospital stay was 11.9 days, and the patients were discharged without any morbidities after surgery. Conclusions: Therefore, the FLP can be used to prevent DSL among high-risk patients after gastrectomy.

Local Recurrence after Endoscopic Submucosal Dissection of Early Gastric Cancer.

Endoscopic submucosal dissection (ESD) is considered the treatment of choice for early gastric cancer (EGC) with a negligible risk of lymph node metastasis. Locally recurrent lesions on artificial ulcer scars are difficult to manage. Predicting the risk of local recurrence after ESD is important to manage and prevent the event. We aimed to elucidate the risk factors associated with local recurrence after ESD of EGC. Between November 2008 and February 2016, consecutive patients (n = 641; mean age, 69.3 ± 9.5 years; men, 77.2%) with EGC who underwent ESD at a single tertiary referral hospital were retrospectively analyzed to evaluate the incidence and factors associated with local recurrence. Local recurrence was defined as the development of neoplastic lesions at or adjacent to the site of the post-ESD scar. En bloc and complete resection rates were 97.8% and 93.6%, respectively. The local recurrence rate after ESD was 3.1%. The mean follow-up period after ESD was 50.7 ± 32.5 months. One case of gastric cancer-related death (0.15%) was noted, wherein the patient had refused additive surgical resection after ESD for EGC with lymphatic and deep submucosal invasion. Lesion size ≥15 mm, incomplete histologic resection, undifferentiated adenocarcinoma, scar, and the absence of erythema of the surface were associated with a higher risk of local recurrence. Predicting local recurrence during regular endoscopic surveillance after ESD is important, especially in patients with a larger lesion size (≥15 mm), incomplete histologic resection, surface changes of scars, and no erythema of the surface.

Clinical strategies for securing negative proximal margin in early gastric cancer.

Securing an appropriate proximal resection margin (PRM) is crucial for oncological safety in treating gastric cancer. This study investigated the clinicopathological characteristics of patients with incomplete PRM length of <2 cm in early gastric cancer. Clinicopathological data of 1,493 patients who underwent subtotal gastrectomy for early gastric cancer in 2012 to 2021 were retrospectively reviewed. Patients were divided into the PRM length of <2 cm and ≥2 cm groups based on pathological results. Univariate and multivariate analyses evaluated factors for incomplete PRM length. Factors related to patients with a relative PRM positive were also analyzed. The proportion of patients with a PRM length of <2 cm was 17.9% (267/1,493). Multivariate regression analysis revealed that age <50, preoperative endoscopic size of ≥3 cm, size discrepancy of ≥2 cm, and midbody tumor with a lesser curvature significantly contributed to the PRM length of <2 cm. Twenty-four patients had a relative PRM positive (24/1493, 1.6%). An incomplete PRM was the only risk factor for a positive relative PRM. Surgical treatment for early gastric cancer requires an accurate preoperative endoscopic tumor size and location evaluation. A more aggressive resection is recommended for patients with age <50, preoperative endoscopic size of ≥3 cm, size discrepancy of ≥2 cm, and midbody tumor with a lesser curvature.

Small bowel diaphragm disease with multiple cluster lesions in one segment of the small bowel mimicking an adhesion band: A case report.

RATIONALE: Small bowel diaphragm disease (SBDD) is a rare case, caused by long-term administration of nonsteroidal anti-inflammatory drugs (NSAIDs). The circumferential diaphragm in the lumen of small bowel causing mechanical obstruction is the characteristic finding. PATIENT CONCERNS: A 74-year-old male was transferred to Pusan National University Yangsan Hospital (PNUYH) due to abdominal pain lasting for 2 months. He was treated in the local medical center (LMC) with Levin tube insertion and Nil Per Os (NPO) but showed no improvement. DIAGNOSIS: According to abdomen-pelvis computed tomography (CT) result, small bowel obstruction due to the adhesion band was identified, showing dilatation of the small bowel with abrupt narrowing of the ileum. INTERVENTIONS: Laparoscopic exploration was done but failed to find an adhesion band. An investigation of the whole small bowel was done with mini-laparotomy. At the transitional zone, the intraluminal air could not pass so the segmental resection of small bowel including the transitional zone and end-to-end anastomosis was done. OUTCOMES: After surgery, every laboratory finding recovered to the normal range in 4 days, but the patient's ileus lasted for 8 days. The patient's symptoms were relieved after defecation, he was discharged on postoperative day 10. LESSONS: For patients who show mechanical obstruction without an operation history but with long-term administration of NSAIDs, the clinicians should suspect small bowel diaphragm disease.

Clinical experience of complex jejunal atresia.

PURPOSE: Small intestinal atresia is relatively common anomaly that causes intestinal obstruction in neonates. Although surgical interventions are usually successful, critical problems could raise in certain cases. This study aimed to identify the distinct clinical characteristics of complex cases of jejunal atresia by retrospective analysis. METHODS: Overall, 91 cases of small intestinal atresia, which occurred in infants between 2001 and 2010 at Pusan National University Children's Hospital, were reviewed retrospectively. The clinical characteristics of complex jejunal atresia were analyzed. RESULTS: Of the 91 small intestinal atresias, 11 cases of complex jejunal atresia were found: high jejunal atresia with distal deletion, 3; high jejunal atresia with distal multiple atresias, 4; jejunal atresia with distal apple peel appearance, 1; jejunal atresia with colonic atresia, 1; jejunoileal atresia with distal volvulus, 2. Short bowel syndrome was found in four patients and bowel-lengthening procedure was performed in all. Three patients presented with an adhesive intestinal obstruction during the early postoperative period. Postoperative mortality occurred in one patient with distal volvulus. CONCLUSIONS: From a surgical perspective, complex jejunal atresia can cause many critical problems after the correction operation. An aggressive and multidisciplinary approach is necessary for managing this condition.

Role of C-Reactive Protein, White Blood Cell Counts, and Serum Glucose Levels as Early Predictors of Infectious Complications After Laparoscopic Colorectal Surgery for Colorectal Cancer.

BACKGROUND: The early detection of infectious complications of colorectal surgery leads to better patient outcomes. This study aimed to assess the role of C-reactive protein (CRP), white blood cell count (WBC), and serum glucose in the early prediction of infectious complications of laparoscopic colorectal surgery. METHODS: Patients who underwent laparoscopic colorectal surgery were included and stratified into two groups: infectious complication (IC) or no infectious complication (non-IC). Serum levels were measured on postoperative days (PODs) 2 and 4. RESULTS: Analysis of 224 patients (IC group: 27, Non-IC group: 197) revealed higher CRP levels in IC group on POD 2 (P = .001). On POD 4, CRP levels and WBC counts were higher in IC group (P<.001, P = .011, respectively). The area under the curve (AUC) of the receiver operating characteristic (ROC) for CRP on PODs 2 and 4 were .743 and .907, respectively, and for WBC on POD 4 was .687. The cut-offs of CRP on PODs 2 and 4 were 156.2 mg/L and 91.3 mg/L, respectively; the cut-off of WBC was 7,220 cells/mm3. Sensitivity of CRP level ≥91.3 mg/L or WBC count ≥7,220 cells/mm3 was 96.3%; (cf. 88.9% for CRP alone), and specificity of CRP level ≥91.3 mg/L and WBC count ≥7,220 cells/mm3 was 93.4% (cf. 82.2% for CRP alone). DISCUSSION: The CRP level on postoperative day (POD) 2 and the combined CRP and WBC on POD 4 were meaningful in predicting infectious complications after laparoscopic colorectal surgery. However, serum glucose levels had a low predictive value for infectious complications.

Clinical outcomes of gastroduodenal neuroendocrine tumors according to their WHO grade: A single-institutional retrospective analysis.

The management of gastroduodenal neuroendocrine tumor (NET) has been controversial between radical surgical resection and local excision including endoscopic resection. A gastroduodenal NET grade (G), measured by their mitotic rate and Ki67 proliferation index, is important to predict prognosis. In this study, we aimed to compare the clinical outcomes of gastroduodenal NET according to grades in order to identify poor prognostic factors of gastroduodenal NETs. Fifty-four gastroduodenal NETs diagnosed between December 2008 and December 2020 in a tertiary referral hospital were retrospectively reviewed. The clinical outcomes of gastroduodenal NETs, according to tumor grades and factors associated with NET G2-3, were analyzed. A total of 52 gastroduodenal NET patients was enrolled. The mean follow-up period was 56.2 ± 40.1 months. The mean size of gastric and duodenal NET was 7.9 ± 11.0 mm and 9.8 ± 7.6 mm, respectively. During the study period, 72.7% (16/22) of gastric NETs and 83.3% (25/30) of duodenal NETS were G1. All G1 gastroduodenal NETs showed no lymph node or distant metastasis during the study periods. All G3 gastroduodenal NETs showed metastasis (one lymph node metastasis and 3 hepatic metastases). Among metastatic NETs, the smallest tumor size was a 13 mm gastric G3 NET. Factors associated with G2-3 NETs were larger tumor size, mucosal ulceration, proper muscle or deeper invasion, and lymphovascular invasion. A small-sized gastroduodenal NET confined to submucosa without surface ulceration may be suitable for endoscopic resection. After local resection of a gastroduodenal NET (G1) without lymphovascular and muscle proper invasion, follow-up examination without radical surgical resection can be recommended. G3 NETs may be treated by radical surgical resection, regardless of tumor size.