Laparotomic radical hysterectomy versus minimally invasive radical hysterectomy using vaginal colpotomy for the management of stage IB1 to IIA2 cervical cancer: Survival outcomes

This study compared survival outcomes for patients with stage IB1 to IIA2 (International Federation of Gynecology and Obstetrics stage 2009) cervical cancer who underwent open radical hysterectomy (ORH) versus those who underwent minimally invasive radical hysterectomy (MIRH) using vaginal colpotomy (VC).Data for 550 patients who were diagnosed with cervical cancer at our institution during the period August 2005 to September 2018 was retrospectively reviewed. Of these, 116 patients who underwent radical hysterectomy (RH) were selected after applying the exclusion criteria. All MIRH patients underwent VC. Clinicopathological characteristics and survival outcomes between the ORH and MIRH groups were compared using appropriate statistical testing.Ninety one patients were treated with ORH and 25 with MIRH during the study period. Among the MIRH patients, 18 underwent laparoscopy-assisted radical vaginal hysterectomy and 7 underwent laparoscopic RH. Preoperative conization was performed more frequently in MIRH patients than in ORH patients (44% vs 22%, respectively, P = .028). The incidence of lymph node invasion was higher in the ORH group than in MIRH group (37.4% vs 12.0% respectively; P = .016). Following RH, ORH patients underwent adjuvant treatment more frequently than MIRH patients (71.4% vs 56.0%, respectively, P = .002). There were no significant differences between ORH and MIRH patients for either progression-free survival (PFS) (91.3% vs 78.7%, respectively; P = .220) or 5-year overall survival (OS) (96.6% vs 94.7%, respectively, P = .929). In univariate analysis, lympho-vascular space invasion was the only clinicopathological feature associated with decreased PFS. No other clinicopathological factors was significantly associated with PFS or OS in univariate and multivariate analyses.Despite a higher incidence of unfavorable prognostic factors in ORH patients, their survival outcomes were not different to those of MIRH patients with VC.     

Diabetes mellitus risk after hysterectomy: A population-based retrospective cohort study

We explored whether hysterectomy with or without bilateral oophorectomy was associated with the increasing incidence of diabetes mellitus (DM) in an East Asian population. This was a retrospective population-based cohort study that analyzed DM risk in Taiwanese women, using a health insurance research database of 1998 to 2013 containing nearly 1 million people. We identified 7088 women aged 30 to 49 years who had undergone hysterectomy with or without oophorectomy. The comparison group included 27,845 women without a hysterectomy who were randomly selected from the population and matched to women in the hysterectomy group by age (exact year) and year of the surgery. DM comorbidities were identified. The incidence and hazard ratios for DM were calculated with Cox proportional hazard regression models. The median ages of patients in the hysterectomy and comparison groups were both approximately 44 years. After a median 7.1 years of follow-up, the incidence of DM was 40% higher in the hysterectomized women as compared with the comparisons (9.12 vs 6.78/1000 person-years, P < .001), with an adjusted hazard ratio (aHR) of 1.37 (95% confidence interval [CI] = 1.23 –1.52). However, the DM risk was not increased in the women with hysterectomy plus oophorectomy (aHR=1.28, 95% CI = 0.93–1.76). Furthermore, among women aged 30 to 39 years, 40 to 49 years, the risk in hysterectomized women was higher than the comparisons (aHR = 1.75, 95% CI = 1.27–2.41; aHR = 1.33, 95% CI = 1.19–1.49, respectively). Our study provides essential and novel evidence for the association between hysterectomy and DM risk in women aged 30 to 49 years, which is relevant to these women and their physicians. Physicians should be aware of the increased DM risk associated with hysterectomy and take this into consideration when evaluating a patient for a hysterectomy. The current results might help gynecologists prevent DM and encourage diagnostic and preventive interventions in appropriate patients.     

Long-term effects of endoscopic papillary large balloon dilation in patients with challenging bile duct calculi: A retrospective observational study

Endoscopic papillary large balloon dilation (EPLBD) can be used to treat challenging common bile duct stones. No previous studies have reported intractable cases treated either by EPLBD or mechanical lithotripter use. We aimed to evaluate and compare the long-term effects of EPLBD with mechanical lithotripter use.This retrospective cohort study reviewed data from 153 patients admitted to the Eastern Chiba Medical Center from April 2014 to March 2020, presenting with common bile duct calculi that could not be removed using a basket or balloon catheter. Patients were divided into groups depending on whether the treatment was performed using a mechanical lithotripter or EPLBD. The primary outcome was the recurrence rate of common bile duct calculi, and the secondary outcome was the rate of postoperative adverse events. The Wilcoxon test was used to compare the 2 groups. Statistical significance was set at P < .05.The median age of patients included in the lithotripter and EPLBD groups were 73 years and 83 years, respectively (P = .006), while the sex ratio (male:female) in the groups was 18:13 and 55:67, respectively. The EPLBD group showed a statistically larger median bile duct diameter (13 mm [range: 8–24 mm] vs 11 mm [range: 5–16 mm]; P < .001), larger maximal calculus diameter (median, 13.5 mm [range: 8–25 mm] vs 11 mm [range: 7–16 mm]; P < .001), and shorter median cumulative treatment time after reaching the duodenal papilla (35.5 minutes [range: 10–176 minutes] vs 47 minutes [range: 22–321 minutes]; P = .026) in comparison to the lithotripter group. There was no significant difference in the rate of adverse events between the EPLBD and the mechanical lithotripter groups. The recurrence rate was significantly lower (P = .014) in the EPLBD group.EPLBD increases therapeutic efficacy and reduces treatment duration for patients in whom calculus removal is difficult, without increasing the frequency of adverse events. No serious adverse events were observed. Additionally, EPLBD appears to reduce the risk of long-term recurrence. Future studies are needed to evaluate long-term outcomes in younger patients.     

Modalities of Invasive Arterial Pressure Monitoring in Critically Ill Patients: A Prospective Observational Study

Few studies assessed modalities of invasive arterial pressure monitoring (IAPM). We evaluated effects on measured values of various combinations of transducer level, catheter access site, and patient position.Prospective observational study in consecutive adults admitted to a French intensive care unit in 2009 to 2011 and fulfilling our inclusion criteria. Four combinations (B–E) of transducer level, catheter access site, and patient position were compared with a reference combination (A) (A: patient supine with all catheters in the same plane and a single transducer level (M) for zero point reference (Z) aligned on the phlebostatic axis; B: 45° head-of-bed elevation with M and Z aligned on the phlebostatic axis; C: 45° head-of-bed elevation with M aligned on the catheter access site and Z on the phlebostatic axis; D: 45° head-of-bed elevation with M and Z aligned on the catheter access site; and E: 45° head-of-bed elevation with M aligned on the phlebostatic axis and Z on the catheter access site).We included 103 patients, 68 men and 35 women, with a median age of 69 years (interquartile range [IQR], 56–78); at inclusion, 91 (88.3%) received mechanical ventilation, 45 (43.7%) catecholamines, and 66 (64.1%) sedation. The IAPM access site was femoral in 49 (47.6%) and radial in 54 (52.4%) patients, with 62 of 103 (60.2%) catheters on the right side. Measured absolute mean arterial pressure values were significantly higher with 3 study combinations (C–E) than with the reference combination (A). After adjustment, the differences versus A (median, 83 [IQR, 74–92] mm Hg) remained significant for D (median, 91 [IQR, 85–100] mm Hg, P < 0.001) and E (median, 88 [IQR, 77–99] mm Hg, P < 0.001). The difference versus A was not significant for B (median, 85 [IQR, 76–94] mm Hg, P = 0.21) or C (median, 90 [IQR, 84–100] mm Hg, P = 0.006).Several modalities used for zeroing and/or transducer leveling during IAPM may result in statistically and clinically significant overestimation of measured mean arterial pressure values. For patients in the 45° head-of-bed elevation position, aligning the Z on the phlebostatic axis provides values that are not significantly different from those obtained using the reference supine modality.     

Recognition of Anterior Peritoneal Reflections and Their Relationship With Rectal Tumors Using Rectal Magnetic Resonance Imaging

Our goal was to explore the factors influencing the visualization of anterior peritoneal reflections (APRs) using rectal MRI. We evaluated the usefulness of rectal MRI in measuring the distance from the anal verge to the APR and determining the relationship between the APR and the rectal tumor.Clinical and imaging data from 319 patients who underwent surgery after MRI examination between October 2010 and December 2013 were retrospectively analyzed. The distance from the anal verge to the APR and the relationship between the APR and the location of the rectal tumor was evaluated. analysis of variance, logistic regression, independent samples t tests, and Kappa tests were used for statistical analysis.The APR was visible in 283 of 319 cases using rectal MRI. The APR was more readily observed in patients who were older than 58 years (P = 0.046), in patients whose subcutaneous fat thicknesses were >22.2 mm (P = 0.004), in patients with nondistended bladders (P = 0.001), and in those with an anteversion of the uterus (P = 0.001). There was a significant difference between the distance from the anal verge to the APR between females (10.4 ± 1.1 cm) and males (10.0 ± 1.2 cm; P = 0.014). The accuracy in predicting tumor location with respect to the APR was 70%, 50%, 98.2%, respectively for patients with tumors located above, at, and below the APR (compared with the location determined during surgery).Most of the APRs were visible using rectal MRI, whereas certain internal factors influence visualization. Rectal MRI could be a useful tool for evaluating the distance from the anal verge to the APR and relationship between rectal tumors and the APR.     

Acute paraparesis syndrome after ruptured anterior communicating artery aneurysm

Here, we describe a series of 7 patients who presented with acute paraparesis due to anterior communicating artery aneurysm rupture. This study aimed to assess the clinical and radiological factors associated with acute paraparesis syndrome caused by subarachnoid hemorrhage (SAH).Between June 2005 and December 2012, our institution consecutively treated 210 patients with anterior communicating aneurysm rupture within 24 hours after ictus. We divided the patients into 2 groups based on the presence (n = 7) and absence (n = 203) of acute paraparesis after anterior communicating aneurysm rupture.Diffusion-weighted magnetic resonance imaging revealed high intensity in the medial aspects of the bilateral frontal lobes in 3 patients. The mean third ventricular distance at the time of admission was 9.2 mm (range, 8–12.5 mm), and the mean bicaudate distance was 33.9 mm (range, 24–39 mm). There was a significant difference in the bicaudate distance (P = .001) and third ventricle distance (P = .001) between the 2 groups. Acute hydrocephalus and global cerebral edema (GCE) were confirmed radiologically in all patients in the acute paraparesis group. The presence of acute hydrocephalus (P = .001) and GCE (P = .003) were significantly different between the groups.Acute paraparesis syndrome after SAH is transient and gradually improves if the patient does not develop severe vasospasm. The present study demonstrates that acute paraparesis after SAH is associated with acute hydrocephalus and GCE.     

Formula to estimate left atrial volume using antero-posterior diameter in patients with catheter ablation of atrial fibrillation

In patients undergoing atrial fibrillation (AF) ablation, an enlarged left atrium (LA) is a predictor of procedural failure as well as AF recurrence on long term. The most used method to assess LA size is echocardiography-measured diameter, but the most accurate remains computed tomography (CT).The aim of our study was to determine whether there is an association between left atrial diameters measured in echocardiography and the left atrial volume determined by CT in patients who underwent AF ablation.The study included 93 patients, of whom 60 (64.5%) were men and 64 (68.8%) had paroxysmal AF, who underwent AF catheter ablation between January 2018 and June 2019. Left atrial diameters in echocardiography were measured from the long axis parasternal view and the LA volume in CT was measured on reconstructed three-dimensional images.The LA in echocardiography had an antero-posterior (AP) diameter of 45.0 ± 6 mm (median 45; Inter Quartile Range [IQR] 41–49, range 25–73 mm), longitudinal diameter of 67.5 ± 9.4 (median 66; IQR 56–88, range 52–100 mm), and transversal diameter of 42 ± 8.9 mm (IQR 30–59, range 23–64.5 mm). The volume in CT was 123 ± 29.4 mL (median 118; IQR 103–160; range 86–194 mL). We found a significant correlation (r = 0.702; P < .05) between the AP diameter and the LA volume. The formula according to which the AP diameter of the LA can predict the volume was: LA volume = AP diam³ + 45 mL.There is a clear association between the left atrial AP diameter measured on echocardiography and the volume measured on CT. The AP diameter might be sufficient to determine the increase in the volume of the atrium and predict cardiovascular outcomes.     

Prospective evaluation of the efficacy of peroral endoscopic myotomy in patients with achalasia

Peroral endoscopic myotomy (POEM) is an endoscopic alternative to surgical myotomy in patients with achalasia. This study aimed to evaluate the efficacy and clinical outcomes of POEM.A total of 20 patients with achalasia who underwent POEM between October 2016 and November 2017 were prospectively recruited. The intraoperative esophagogastric junction distensibility index (mm²/mm Hg) was measured pre- and post-myotomy using an endoluminal functional lumen imaging probe. Clinical response was defined as Eckardt score ≤3. Health-related quality of life was measured by the 36-item short-form health survey score.POEM was successfully completed in all cases. The median procedure time was 68.5 minutes (range 50.0–120.0), and the median myotomy length was 13 cm (range 11–18). Major adverse events were encountered in 2 cases. Overall, clinical responses were observed in all patients during a median follow-up of 11.9 months (range 1.2–26.2). Postoperative esophagogastric junction distensibility index was significantly higher than baseline (from 1.3 [range 0.8–6.9] to 6.3 [range 25–19.2], P < .001). The median Eckardt scores were decreased after POEM (5 [range 2–11] to 1 [range 0–3], P < .001), and the 36-item short-form health survey score was also improved significantly after POEM (67.5 [range 34.5–93.9] to 85.7 [range 53.4–93.3], P = .004).POEM is an effective treatment for achalasia, based on the improvement of both symptoms and objective measures.Clinicaltrial.gov {"type":"clinical-trial","attrs":{"text":"NCT 02989883","term_id":"NCT02989883"}}NCT 02989883     

Efficacy and safety of acupuncture for urinary retention after hysterectomy: A systematic review and meta-analysis

Objective:The aim of this study was to evaluate the efficacy and safety of acupuncture in the treatment of urinary retention after hysterectomy in women.Methods:This research searched for 6 database documents, and the deadline is July 23, 2020. This study included a randomized controlled trial of women with urinary retention after hysterectomy. These randomized controlled trials compare acupuncture with bladder function training or other nonacupuncture treatments, and measure urodynamics, effectiveness (BR), and urinary tract infection rates (UIR). Four independent reviewers participated in data extraction and evaluation. Assess the risk of bias in each article, and conduct a meta-analysis according to the type of acupuncture. The result is expressed as a mean difference (MD) or relative risk (RR) with a 95% confidence interval (CI).Results:The meta-analysis contains 12 studies. Most studies indicate low risk or unknown risk, but the GRADE scores of the combined results show low or moderate levels. After the combined analysis, we found that acupuncture versus bladder function exercise and other nonacupuncture therapies can significantly improve the values of post voided residual urine (PVR) (MD = −25.29; 95% CI [−30.45 to −20.73]), maximal cystometric capacity (MD = 39.54; 95% CI [10.30–68.78]), bladder capacity for first voiding desire (MD = −61.98; 95% CI [−90.69 to −33.26]) and maximal flow rate (MFR) (MD = 7.58; 95% CI [5.19–9.97]). And compared with the control group, acupuncture still has advantages in BR (RR = 1.36; 95% CI [1.18–1.56]) and UIR (RR = 0.22; 95% CI [0.08–0.82]). These heterogeneities have been resolved through subgroup analysis, and their main sources are related to different intervention times, the time to start the intervention, and different PVR requirements.Conclusions:There is insufficient evidence that acupuncture can increase the patient''s MFR, BR, and UIR. However, acupuncture can effectively improve the PVR, maximal cystometric capacity, and bladder capacity for first voiding desire values of patients with urinary retention after hysterectomy. Although limited due to the quality and methodological limitations of the included studies, acupuncture can still be used as an effective and safe treatment for women with urinary retention after hysterectomy.Registration:The research has been registered and approved on the PROSPERO website. The registration number is CRD42019119238.     

Measurement of postpartum blood loss using a new two-set liquid collection bag for vaginal delivery: A prospective,randomized, case control study

Background:Postpartum hemorrhage (PPH) is a major obstetric complication, and the real-time measurement of blood loss is important in the management and treatment of PPH. We designed a new two-set liquid collection bag (TSLCB) for measuring postpartum blood loss in vaginal delivery. The aim of this study was to evaluate the effectiveness of the TSLCB in separating the blood from the amniotic fluid during vaginal delivery and in determining the accuracy of the measured postpartum blood loss.Methods:A prospective, randomized, case control study was conducted in the Women''s Hospital, Zhejiang University School of Medicine, from March 2018 to April 2018. Sixty single pregnant women with spontaneous labor at 37–41 weeks without maternal complications were randomly divided into the experimental and control groups. The TSLCB was used to evaluate separately the amount of blood and amniotic fluid. For the control group, visual estimation and traditional plastic blood-collecting consumables were used to estimate the amount of postpartum blood loss. The measured blood loss between the two groups was compared, and the association of the measured blood loss with various clinical lab indices and vital signs was investigated.Results:The TSLCB (the experimental group) improved the detection of the measured blood loss compared with visual estimation and the traditional method (the control group) (P < .05). In the experimental group, correlation analysis showed that the measured blood loss at delivery and within 24 h of delivery was significantly associated with the decreased hemoglobin level, red blood cell count, and hematocrit level of patients (r = −0.574, −0.455, −0.437; r = 0.-595, −0.368, −0.374; P < .05). In the control group, only the measured blood loss within 24 h of delivery was associated with the decreased hemoglobin level (r = −0.395, P < .05). No blood transfusion and plasma expanders were required in the treatment of PPH for both groups.Conclusions:The TSLCB can be used to accurately measure the postpartum blood loss in vaginal delivery by medical personnel.     

Sparing Sphincters and Laparoscopic Resection Improve Survival by Optimizing the Circumferential Resection Margin in Rectal Cancer Patients

The goal of rectal cancer treatment is to minimize the local recurrence rate and extend the disease-free survival period and survival. For this aim, obtainment of negative circumferential radial margin (CRM) plays an important role. This study evaluated predictive factors for positive CRM status and its effect on patient survival in mid- and distal rectal tumors.Patients who underwent curative resection for rectal cancer were included. The main factors were demographic data, tumor location, surgical technique, neoadjuvant therapy, tumor diameter, tumor depth, lymph node metastasis, mesorectal integrity, CRM, the rate of local recurrence, distant metastasis, and overall and disease-free survival. Statistical analyses were performed by using the Chi-squared test, Fisher exact test, Student t test, Mann–Whitney U test and the Mantel–Cox log-rank sum test.A total of 420 patients were included, 232 (55%) of whom were male. We observed no significant differences in patient characteristics or surgical treatment between the patients who had positive CRM and who had negative CRM, but a higher positive CRM rate was observed in patients undergone abdominoperineal resection (APR) (P < 0.001). Advanced T-stage (P < 0.001), lymph node invasion (P = 0.001) and incomplete mesorectum (P = 0.007) were encountered significantly more often in patients with positive CRM status. Logistic regression analysis revealed that APR (P < 0.001) and open resection (P = 0.046) were independent predictors of positive CRM status. Moreover, positive CRM was associated with decreased 5-year overall and disease-free survival (P = 0.002 and P = 0.004, respectively).This large single-institution series demonstrated that APR and open resection were independent predictive factors for positive CRM status in rectal cancer. Positive CRM independently decreased the 5-year overall and disease-free survival rates.     

Efficiency of minimal oblique resection of the uncinate process during an anterior cervical discectomy and fusion

Hypertrophy of the uncinate process (UP) can cause radiculopathy. Minimal UP resection is considered to remove the lesion while minimizing the risk of complications. This study aimed to elucidate the surgical results of minimal oblique resection of the UP. This study is a retrospective review of about sixty segments in 34 patients who underwent anterior cervical discectomy and fusion (ACDF) with minimal oblique uncinectomy between 2016 and 2018. The cross-sectional area of the UP was measured pre- and postoperatively. The interspinous distance, segmental Cobb angle, subsidence, fusion rate, surgical time, estimated blood loss, and postoperative complications were evaluated. The mean resected areas of the UP were 17.4 ± 8.7 mm² (25.9%) on the right and 17.3 ± 11.2 mm² (26.2%) on the left. The difference in interspinous distance in flexion-extension was 7.1 ± 3.2 and 1.6 ± 0.6 mm pre- and postoperatively, respectively (P = .000). The fusion rate after ACDF was 91.7% when measured according to segment (55/60) and 91.2% when measured according to patients (31/34). The difference in the segmental Cobb angle in flexion-extension was 8.3 ± 6.2° and 1.9 ± 0.3° pre and postoperatively, respectively (P = .000). Subsidence occurred in 4 (11.8%) patients and 5 (8.3%) segments. The average surgical time per segment was 68.8 ± 9.3 minute, and the estimated blood loss was 48.5 ± 25.0 mL. Postoperative complications comprised 1 case each of neck swelling, wound infection, pneumonia, and gastrointestinal bleeding. Our findings therefore revealed that minimal oblique uncinectomy during an ACDF can maintain the stability of the uncovertebral joint while sufficiently decompressing the neural foramen.     

Apex-to-Cupola Distance Following VATS Predicts Recurrence in Patients With Primary Spontaneous Pneumothorax

Our study sought to determine whether the size of the residual apical pleural space in young patients with primary spontaneous pneumothorax (PSP) following video-assisted thoracoscopic surgery is associated with the risk of recurrence.We retrospectively reviewed patients (≤30 years’ old) with primary spontaneous pneumothorax following thoracoscopic surgery (2002–2010) in a university-affiliated hospital. The size of residual apical pleural space was estimated by measuring the apex-to-cupola distance on a postoperative chest radiograph at 2 time windows: first between postoperative day (POD) 0 and 3, and second between POD 4 and 14.A total of 149 patients were enrolled with a median follow-up of 11.2 months (interquartile range, 0.95–29.5 months), of whom 141 (94.6%) were male with a mean age of 20 years. The postoperative recurrence rate was 11.4%. Comparing the characteristics between the patients with and without recurrent pneumothorax, the patients with recurrence were younger (18.2 + 2.4 vs 20.7 + 3.7 years, P = 0.008), with a lower rate of pleurodesis (35% vs1 69%, P = 0.037), longer apex-to-cupola distance at POD 0 to 3 (22.41 ± 19.56 vs 10.07 ± 10.83 mm, P < 0.001) and POD 4 to 14 (11.82 ± 9.75 vs 5.54 ± 8.38 mm, P = 0.005) than the patients without recurrence. In a multivariate logistic regression model for recurrent pneumothorax, age <18 years (P = 0.026, odds ratio [OR]: 4.694), apex-to-cupola distance at POD 0 to 3 >10 mm (P = 0.027, OR: 5.319), and no pleurodesis during VATS (P = 0.022, OR: 5.042) were independent risk factors for recurrent pneumothorax.The recurrence rate was not low (11.4%) in young patients with PSP following VATS. Residual apical pleural space with apex-to-cupola distance of 10 mm or greater at POD 0 to 3, younger age, and no pleurodesis would increase postoperative recurrence of primary spontaneous pneumothorax.     

Factors Associated With Oncologic Outcomes Following Abdominoperineal or Intersphincteric Resection in Patients Treated With Preoperative Chemoradiotherapy: A Propensity Score Analysis

Due to selection bias, the oncologic outcomes of APR and ISR have not been compared in an interpretable manner, especially in patients treated with preoperative CRT. To assess factors influencing oncologic outcomes in patients with locally advanced low rectal cancer treated with preoperative chemoradiotherapy (CRT) followed by abdominoperineal resection (APR) or intersphincteric resection (ISR).Between 2006 and 2011, 202 consecutive patients who underwent APR or ISR after preoperative CRT for locally advanced rectal cancer were enrolled in this study. The median follow-up period was 45.3 months (range: 5–85.2 months). Multivariate and propensity score matching (PSM) analyses were performed to reduce selection bias.Of the 202 patients, 40 patients (19.8%) underwent APR and 162 (80.2%) required ISR. In unadjusted analysis, patients undergoing APR had a higher 5-year local recurrence (P < 0.001) and distant metastasis rate (P = 0.01), respectively. However, the higher local recurrence rate for APR persisted even after PSM, and these findings were verified in the multivariate analyses. Moreover, patients with advanced tumors, as assessed by restaging magnetic resonance imaging and luminal circumferential involvement, had a significantly higher local recurrence rate after APR compared with ISR.This is the first PSM based analysis providing evidence of a worse oncologic outcome after APR compared with ISR. In addition, the results of the subgroup analysis suggest that a more radical modification of the current APR is required in cases of advanced cancer.     

Immune-related adverse events with immune checkpoint inhibitors: Special reference to the effects on the lungs

Immune checkpoint inhibitors (ICIs) have emerged as evolutionary treatments for malignant diseases. Although ICIs can cause immune-related adverse events (irAEs) in various organs, precise timing after ICI initiation has been scarcely reported. Elucidating the effects of irAEs, such as time to onset, involvement of major organs, influence on progression-free survival (PFS), and overall survival (OS), are critical issues for physicians. Furthermore, lung-irAE as a whole is not well known.We conducted a retrospective study of 156 patients who were treated with ICIs and compared 82 irAE patients with 74 non-irAE patients.This study clearly demonstrated that the preferred period after induction of ICIs was significantly longer in lung-irAE than in other major organs (skin, digestive tract, and endocrine). The effect of irAEs on PFS and OS was evident PFS in the irAE group (n = 82) (median 128 days, interquartile range [IQR] 62–269 days, P = .002) was significantly longer than that in the non-irAE group (n = 74) (median 53 days, IQR 33–151 days). Similarly, OS was significantly longer in the irAE group (median 578 days, IQR 274–1027 days, P = .007) than in the non-irAE group (median 464 days, IQR: 209–842 days). However, this positive effect of irAEs in the lungs was not proportional to the extent of severity.Lung-irAEs can occur at a later phase than non-lung-irAEs and seemed not to prolong OS and PFS. However, further studies are needed to support these findings.     

A Meta-analysis Reveals S-1-based Chemotherapy Improves the Survival of Patients With Advanced Gastric Cancer

The aim of this study was to compare the efficacy and safety of S-1-based therapy versus non-S-1-based therapy in advanced gastric cancer (AGC) patients.Eligible studies stratifying objective response rate (ORR), progression-free survival (PFS), overall survival (OS), and adverse events (AEs) in AGC patients were identified from Embase, Pubmed, Cochrane Library, and China National Knowledge Infrastructure databases. The STATA package (version 11.0) was used to pool the data from the eligible studies.Fifteen studies with 2973 AGC cases, of which 1497 (50.4%) received S-1-based therapy and 1476 (49.6%) received non-S-1-based therapy, were identified in the meta-analysis. AGC patients who had received S-1-based therapy had a higher median OS, median PFS, and ORR than those who had received 5-fluorouracil (FU)-based therapy (OS: hazard ratio [HR] 0.89, 95% confidence interval [CI] 0.80–0.98, P = 0.015; PFS: HR 0.88, 95% CI 0.80–0.98, P = 0.016; ORR: OR 1.25, 95% CI 1.08–1.45, P = 0.003, respectively). S-1-based therapy had similar efficacy to capecitabine-based therapy in terms of median OS (HR 1.14, 95% CI 0.91–1.41, P = 0.253), median PFS (HR 1.01, 95% CI 0.82–1.25, P = 0.927), and ORR (OR 0.84, 95% CI 0.63–1.12, P = 0.226). Subgroup analysis for grade 3 to 4 toxicity showed higher incidence of neutropenia (relative risk [RR] = 0.827, P = 0.006), nausea (RR = 0.808, P = 0.040), and lower diarrhea (RR = 1.716, P = 0.012) in 5-FU-based arm, and higher diarrhea (RR = 0.386, P = 0.007) in capecitabine-based arm.S-1-based chemotherapy is favorable to AGC patients with better clinical benefit than 5-FU-based chemotherapy and with equivalent antitumor compare with capecitabine-based therapy.     

Low Discrepancy Between Tissue Biopsy Plus Magnifying Endoscopy With Narrow-Band Imaging and Endoscopic Resection in the Diagnosis of Gastric Epithelial Neoplasia (STROBE)

Tissue biopsy is often not very accurate for the diagnosis of gastric epithelial neoplasia (GEN), and the results differ notably from endoscopic resection (ER) in terms of the pathological diagnosis. The aims of this study were to evaluate the diagnostic performances of biopsy, magnifying endoscopy with narrow-band imaging (ME-NBI), and biopsy plus ME-NBI for GEN.This study retrospectively analyzed 101 cases diagnosed as GEN using ER samples. The discrepancies between biopsy and ER, as well as between biopsy plus ME-NBI and ER in the diagnosis of GEN were evaluated. Factors that contributed to such discrepancies were analyzed. The sensitivity and specificity of biopsy and ME-NBI for the diagnosis of high-grade neoplasia (HGN) were determined.The discrepancy in the pathological diagnosis between biopsy and ER was 39.6% for GEN and 54.2% for HGN. The discrepancy between biopsy combined with ME-NBI and ER was 15.9% for GEN and 10.2% for HGN. Factors that undermined the diagnostic accuracy of biopsy included the lesion size (≤10 mm, odds ratio [OR] 1; 10–20 mm, OR 0.2, 95% confidence interval [CI] 0.1–0.7; >20 mm, OR 0.5, 95% CI 0.1–2.1, P = 0.03) and the number of biopsy fragments (OR 0.6, 95% CI 0.5–0.8, P = 0.001). The sensitivity and specificity for HGN were 45.8% (33.7%–58.3%) and 100% (87.5%–100%) for biopsy, and 88.1% (77.5%–94.1%) and 92.9% (81.0%–97.5%) for ME-NBI, respectively.In conclusion, biopsy-based diagnoses for GEN should be interpreted with caution. Biopsy combined with ME-NBI can contribute to the diagnosis of GEN, which improves diagnostic consistency with pathological result of ER specimens.     

Effects of Early Enteral Nutrition on Patients After Emergency Gastrointestinal Surgery: A Propensity Score Matching Analysis

Early postoperative enteral feeding has been demonstrated to improve the outcome of patients who underwent surgery for gastrointestinal (GI) malignancies, trauma, perforation, and/or obstruction. Thus, this study was conducted to assess the efficacy of early postoperative enteral nutrition (EN) after emergency surgery in patients with GI perforation or strangulation.The medical records of 484 patients, admitted between January 2007 and December 2012, were reviewed retrospectively. Patients were divided into 2 groups: the early EN (EEN, N = 77) group and the late EN (LEN, N = 407) group. The morbidity, mortality, length of hospital, and intensive care unit (ICU) stays were compared between the 2 groups. Propensity score matching was performed in order to adjust for any baseline differences.Patients receiving EEN had reduced in-hospital mortality rates (EEN 4.5% vs LEN 19.4%; P = 0.008), pulmonary complications (EEN 4.5% vs LEN 19.4%; P = 0.008), lengths of hospital stay (median: 14.0, interquartile range: 8.0–24.0 vs median: 17.0, interquartile range: 11.0–26.0, P = 0.048), and more 28-day ICU-free days (median: 27.0, interquartile range: 25.0–27.0 vs median: 25.0, interquartile range: 22.0–27.0, P = 0.042) than those receiving LEN in an analysis using propensity score matching. The significant difference in survival between the 2 groups was also shown in the Kaplan–Meier survival curve (P = 0.042). In a further analysis using the Cox proportional hazard ratio after matching on the propensity score, EEN was associated with reduced in-hospital mortality (hazard ratio, 0.03; 95% confidence interval, 0.01–0.49; P = 0.015).EEN is associated with beneficial effects, such as reduced in-hospital mortality rates, pulmonary complications, lengths of hospital stay, and more 28-day ICU-free days, after emergency GI surgery.     

Anti-Müllerian hormone level may predict successful pregnancy after adenomyomectomy in patients with infertility due to adenomyosis

We aimed to determine clinical factors predicting successful pregnancy by comparing pregnancy failure and success groups after adenomyomectomy. Additionally, we analyzed fertility outcomes after adenomyomectomy.The medical records of 43 patients who had undergone adenomyomectomy and received in vitro fertilization treatment from 2017 to 2020 were retrospectively reviewed. Patients were divided into pregnancy failure (n = 28) and pregnancy success (n = 15) groups. Patients’ demographic factors were evaluated and compared between the groups.The age of patients was higher (39.0 [32.0–45.0] vs. 37.0 [33.0–42.0] years, P = .006) whereas the level of anti-Müllerian hormone (anti-Müllerian hormone [AMH]; 0.54 [0.01–8.54] vs. 2.91 [0.34–7.92] ng/mL, P = .002) lower in the pregnancy failure group compared to the pregnancy success group. The operative time was longer (220.0 [68.0–440.0] vs. 175.0 [65.0–305.0] min, P = .048) while the estimated blood loss higher (750 [100–2500] vs. 500 [50–2000] mL, P = .016) in the pregnancy failure group compared to the pregnancy success group. No significant difference was observed in body mass index, symptoms, cancer antigen 125, preoperative uterine volume, or type of adenomyosis. In the multivariate analysis, age and AMH were significant predictive factors for successful pregnancy.Ovarian reserve (age and AMH) and disease severity might be predictive factors for successful pregnancy in patients who have undergone adenomyomectomy. Adenomyomectomy should be considered for women desiring pregnancy and having appropriate ovarian reserve. Our results would be beneficial for patients and clinicians before deciding on adenomyomectomy. Larger prospective studies are required to confirm our findings.     

Endovascular treatment for transplant renal artery stenosis: A retrospective cohort study

Transplant renal artery stenosis (TRAS) is the most common (1%–23%) vascular complication following kidney transplantation. The aim of this study was to review our experience with an endovascular approach to treat TRAS.We retrospectively reviewed kidney transplant recipients who underwent percutaneous transluminal angioplasty (PTA) due to TRAS in our institute from January 2009 to December 2015. We analyzed the patient''s baseline characteristics, postoperative renal function, blood pressure evolution, and the number of pre- and post-procedure antihypertensive drugs.A total of 21 patients (15 men, 6 women) were treated with the endovascular technique. The predominant presentation was graft dysfunction (76.2%). Stenosis or hemodynamic kinking was located at the anastomosis in 7 (33.3%) patients, proximal to the anastomosis in 13 (61.9%) patients, and distal the anastomosis in 1 (4.8%) patient. PTA without stent placement was performed in 7 patients (33.3%), and PTA with stent placement was performed in 14 patients (67.7%). Serum creatinine levels demonstrated no difference between the pre-procedure level and that on discharge day (1.61 mg/dl [0.47–3.29 mg/dl] vs 1.46 mg/dl [0.47–3.08 mg/dl]; P = .33). The glomerular filtration rate also showed no difference between the pre-procedure value and that on discharge day (53.6 ml/min [22.4–145.7 ml/min] vs 57.0 ml/min [17.56 –145 ml/min]; P = .084). Systolic blood pressure and diastolic blood pressure (DBP) varied from 137 mm Hg (120–160 mm Hg) and 84 mm Hg (70–100 mm Hg) pre-procedure to 129 mm Hg (90–150 mm Hg) and 79 mm Hg (60–90 mm Hg) at discharge, respectively (P = .124 and P = .07). The number of antihypertensive medications significantly decreased from 1.5 (0–6) pre-procedure to 0.5 (0–2) at discharge (P = .023). In our study, there were no technical failures, procedure-related complications or deaths. During the follow-up period, the free-from-reintervention rate was 100%, and graft failures occurred in 2 patients (9.5%) due to rejection.Endovascular procedures for TRAS show a high technical success rate with a low complication rate and a low reintervention rate. PTA showed a trend toward a positive impact on lowering serum creatinine, systolic blood pressure, and diastolic blood pressure and improving estimated glomerular filtration rate, and the number of antihypertensive medications could be significantly reduced after this procedure.