Treatment and Outcome of Patients with Gastric Remnant Cancer After Resection for Peptic Ulcer Disease

Background

To study the pathology, treatment, and outcome of patients with gastric remnant cancer (GRC) after resection for peptic ulcer disease (PUD).

Methods

Review of a prospective gastric cancer database identified patients with GRC after gastrectomy for PUD. Clinicopathologic and treatment-related variables were obtained. Multivariate analysis was performed for factors associated with disease-specific survival (DSS).

Results

From January 1985 to April 2010, 4402 patients with gastric adenocarcinoma were treated at our institution and 105 patients (2.4%) had prior gastrectomy for PUD. Prior resections were most often Billroth II (N = 97, 92%). The median time from initial resection to development of GRC was 32 years (3–60 years), and the majority of tumors were located at the gastrointestinal anastomosis (N = 72, 69%). Median DSS was 1.3 years (0.6–2.1 years). Patients who had resection had a significantly better outcome than patients who did not have resection (median DSS 5 vs 0.35 years, P < .0001). Factors associated with DSS on multivariate analysis included advanced T-stage (HR 16.5 (CI 2.2–123.4), P = .0006) and lymph node metastasis (HR 1.1 (CI 1.0–1.2), P < .0001). Stage-specific survival following R0 resection was similar to patients with conventional gastric cancer.

Conclusions

Patients have a lifetime risk for the development of GRC following resection for PUD. As with conventional gastric cancer, determinants of survival of patients with GRC include advanced T stage and nodal metastasis. Patients with GRC amenable to curative resection exhibit the best DSS and have stage-specific outcomes similar to patients with conventional gastric cancer.     

Evolution of surgical management of gallbladder carcinoma and impact on outcome: results from two decades at a single-institution

BackgroundThe surgical approach to gallbladder cancer (GBCA) has evolved in recent years, but the impact on outcomes is unknown. This study describes differences in presentation, surgery, chemotherapy strategy, and survival for patients with GBCA over two decades at a tertiary referral center.MethodsA single-institution database was queried for patients with GBCA who underwent surgical evaluation and exploration and was studied retrospectively. Univariate logistic regression was used to assess the relationship between time and treatment. Univariate Cox proportional hazard regression assessed the association between year of diagnosis and survival.ResultsFrom 1992 to 2015, 675 patients with GBCA were evaluated and 437 underwent exploration. Complete resection rates increased over time (p < 0.001). In those submitted to complete resection (n = 255, 58.4%), more recent years were associated with lower likelihood of bile duct resection and major hepatectomy but greater odds of neoadjuvant and adjuvant chemotherapy (p < 0.05). No significant association was found between year of diagnosis and OS or RFS (p > 0.05) for patients with complete resection.ConclusionOver the study period, GBCA treatment evolved to include fewer biliary and major hepatic resections with no apparent adverse impact on outcome. Further prospective trials, specifically limited to GBCA, are needed to determine the impact of adjuvant chemotherapy.     

Comparison of visual acuity, refractive results and complications of femtosecond laser with mechanical microkeratome in LASIK

AIM:To compare the outcomes of laser in situ keratomileusis (LASIK) performed with a femtosecond laser (Femtec, Technolas Perfect Vision GmbH, Germany) versus a mechanical microkeratome (Hansatome, Bausch and Lomb, USA) for the correction of myopia and astigmatism.METHODS: In this retrospective study, patients who had undergone LASIK using the 80-kHz Femtec femtosecond laser were compared to age- and refraction-matched patients in whom the Hansatome microkeratome was used. Refractive and visual results 1 month and 3 months postoperatively, and complication rates were compared between the two groups.RESULTS:A total of 280 eyes were analyzed (140 in each group).At 3 months postoperatively in the Femtec vs Hansatome group, spherical equivalent refraction was within ±1.00D of emmetropia in 140 vs 138 eyes (P=0.498), the cylinder was within ±0.50D in 137 vs 139 eyes (P=0.622), and the UDVA was 20/20 or better in 136 vs 137 eyes (P=0.724), respectively. There was no statistically significant difference in the complication rates between the two groups (P=0.099).CONCLUSION:LASIK performed both with Femtec femtosecond laser and Hansatome microkeratome achieved satisfactory refractive and visual results at 3 months postoperatively, without significant differences in efficacy, safety, and complication rates between the two procedures.     

Blood Lactate Levels Differ Significantly Between Surviving and Nonsurviving Patients Within the Same Risk-Adjusted Classification for Congenital Heart Surgery (RACHS-1) Group After Pediatric Cardiac Surgery

This study aimed to examine the association between lactate levels in the first hours after surgery for congenital heart defects and the results of Risk-Adjusted Classification for Congenital Heart Surgery (RACHS-1) scoring and to evaluate serial lactate levels over time to determine whether they can serve as a supplementary tool for postoperative assessment within the same RACHS-1 group of patients. A retrospective cohort study was performed using data retrieved from a clinical database of 255 children who had surgery for congenital heart defects between 1999 and 2001 at Sheba Medical Center. Lactate levels were measured postoperatively four times (mg/dL units). The last sample was taken at the end of the surgical procedure, and lactate levels were measured at admission to the pediatrics critical care unit, then 6 and 12 h after admission. The lactate level was measured via arterial blood gases. A total of 27 deaths occurred, yielding a mortality rate of 7.4% when Norwood operations were excluded and 10.16% when they were included. The mean initial postoperative lactate level was significantly lower for survivors (42.2 ± 32.0 mg/dL) than for nonsurvivors (85.4 ± 54.1 mg/dL) (p < 0.01). The serial mean lactate levels decreased progressively for all surviving patients (r ² = 0.96) compared with nonsurvivors (r ² = 0.02). The lactate levels correlated with the RACHS-1 subgroups at each time point (r ² > 0.96 for all). The Pearson correlations between postoperative lactate levels (last lactate measurement taken in the operating room) and cardiopulmonary bypass (CPB) duration (r = 0.549), clamp duration (r = 0.586), and the inotropic score (r = 0.466) (p < 0.001 for all) were significantly positive. The correlations between the maximum lactate levels (during the first 12 postoperative hours) and CPB duration (r = 0.496), clamp duration (r = 0.509), and the inotropic score (r = 0.633) (p < 0.001 for all) were extremely positive. The early elevation of lactate levels in RACHS-1 subgroups 1 to 3 were highly correlated with poor prognosis and death (p < 0.03). In addition, the lactate levels differed significantly between survivors and nonsurvivors within the same RACHS-1 subgroup. The survivors in RACHS-1 subgroups 1 to 3 had lower mean lactate levels than the nonsurvivors in this group (P = 0.011), and this also held true for the survivors and nonsurvivors in RACHS-1 subgroups 4 to 6 (P = 0.026). Lactate levels differed significantly between survivors and nonsurvivors within the same RACHS-1 subgroup. This combination allows the targeting of appropriately intensive interventions and therapies toward the sickest patients.     

Instability of Doppler cerebral blood flow in monochorionic twins.

OBJECTIVE: The purpose of this study was to evaluate Doppler flow velocity changes in cerebral vessels of monochorionic twins with twin-twin transfusion syndrome (TTTS). METHODS: Repeated Doppler umbilical and cerebral blood flow studies were performed in 7 twin pairs with TTTS. Eight monochorionic twin pairs and 11 dichorionic twin pairs served as control groups. The following Doppler parameters were assessed: umbilical artery pulsatility index (PI), middle cerebral artery (MCA) PI, cerebroplacental ratio, delta PI between the umbilical artery and MCA, and peak systolic velocity (PSV) in the MCA. RESULTS: Significant variations in PSV in the MCA and cerebral indices were found in the study group of monochorionic twins with TTTS. Periods of high PSV with low PI in the MCA were followed by lower PSV in the same fetus. Repeated measurements in the comparison groups were stable without significant variations. The delta cerebroplacental ratio was significantly higher in the study group (0.38 versus 0.09 and 0.19 in the comparison groups; P < .02). CONCLUSIONS: Significant changes in Doppler flow velocity and indices suggest instability of cerebral blood flow with episodes of "hyperperfusion" in monochorionic twins with TTTS. Further studies are needed to elucidate the relationship of these transient changes to neurologic sequelae in the neonate.     

Asystole after the first dose of ceftriaxone

The incidence of ceftriaxone-related hypersensitivity skin reactions is between 1% and 3%, whereas anaphylaxis is rare. To the best of our knowledge, the following case is the first report of asystole after the administration of single-dose ceftriaxone. A 55-year-old man was admitted to our emergency department because of high fever, abdominal pain, dysuria, and weakness. To determine the cause of his fever, blood and urine cultures were obtained. Then, an infusion of 1 g ceftriaxone was started slowly. One minute later, cardiac arrest occurred. The rhythm was asystole. Cardiopulmonary resuscitation and tracheal intubation were performed immediately, and the ceftriaxone infusion was discontinued. Within 20 minutes, circulation was restored. The time of onset was suggestive of ceftriaxone-induced anaphylaxis. The patient was discharged in good clinical condition on the 10th day of admission. Emergency physicians should be mindful of the possibility of anaphylaxis and asystole that could occur with the first dose of ceftriaxone and should also make sure to offer receiving detailed informed patient consent, too.