Developing an Institutional Protocol Guideline for Laparoscopy-Assisted Distal Gastrectomy

Background  The technical difficulty of lymph node dissection in laparoscopy-assisted distal gastrectomy (LADG) remains a barrier for extending the indication for this modality and limits its widespread clinical practice. The aim of this study was to evaluate our institutional guidelines for LADG, limiting the indications for this modality to only clinical stage T1N0 or T1N1 gastric cancer. Methods  From January 2002 to October 2006, a total of 294 cases of LADG and 664 cases of open distal gastrectomy (ODG) for clinical T1N0 or T1N1 gastric cancer were performed at the National Cancer Center, Korea. The two groups’ clinicopathologic characteristics, surgical outcome, morbidity, and survival were compared. Results  The mean operating time for the LADG group was significantly longer than that for the ODG group (265.8 ± 56.3 vs. 171.4 ± 43.1 minutes, P < .001). The mean number of retrieved lymph nodes in the LADG group was higher than that of the ODG group (39.5 ± 14.7 vs. 37.2 ± 12.9, P = .017). The postoperative hospital stay was shorter in the LADG group (8.0 ± 3.3 vs. 10.5 ± 4.1 days, P < .001). The complications rate was lower for the LADG group than that for the ODG group (6.8% vs. 11.3%, P = .032). The overall survival rate was not significantly different between the two groups (P = .880). Conclusions  Before considering expanding the indications for LADG, developing a carefully thought-out guideline and conducting an audit are mandatory.     

Surgical Complications and the Risk Factors of Laparoscopy-Assisted Distal Gastrectomy in Early Gastric Cancer

Background Information on surgical complications of laparoscopy-assisted distal gastrectomy (LADG) and their risk factors is limited in the literature despite increasing popularity of this procedure. This study was performed to identify the surgical complications and their associated risk factors of LADG in early gastric cancer. Methods LADG was performed in 347 gastric cancer patients from January 2002 to December 2006 at the Korean National Cancer Center by four surgeons with ample experience of open gastric surgery before LADG. LADG indications for cases of gastric cancer at our institution are preoperatively diagnosed cT1N0 or cT1N1, except in cases with an absolute indication for endoscopic resection. Lymph node dissection of more than D1 + β was performed in all patients. Intraoperative and postoperative complications were reviewed and their risk factors were retrospectively analyzed by prospective database information. Results Forty complications occurred in 34 patients (9.8%), but there was no mortality. Intraoperative complications occurred in nine patients (2.6%), and open conversion was performed in eight (2.3%) of these patients. Early and late postoperative complications occurred in 21 (6.1%) and 10 (2.9%) patients, respectively. The most serious complication was vascular injury resulting in bleeding or organ ischemia, which occurred in seven patients. Degree of lymph node dissection and surgical inexperience were found to be risk factors of surgical complication (P = .023, odds ratio 2.832, 95% confidence interval 1.155–6.946 vs. P = .028, odds ratio 2.975, 95% confidence interval 1.127–7.854). Conclusions Lymph node dissection during LADG should be performed cautiously to prevent surgical complications like vascular injuries, especially during the surgeon’s early learning period.     

Metabolic Dysfunction-Associated Fatty Liver Disease Predicts Long-term Mortality and Cardiovascular Disease

Background/AimsWe investigated the effect of metabolic dysfunction-associated fatty liver disease (MAFLD) on future mortality and cardiovascular disease (CVD) using a prospective community-based cohort study.MethodsIndividuals from two community-based cohorts who were 40 to 70 years old were prospectively followed for 16 years. MAFLD was defined as a high fatty liver index (FLI ≥60) plus one of the following conditions overweight/obesity (body mass index ≥23 kg/m²), type 2 diabetes mellitus, or ≥2 metabolic risk abnormalities. Nonalcoholic fatty liver disease (NAFLD) was defined as FLI ≥60 without any secondary cause of hepatic steatosis.ResultsAmong 8,919 subjects (age 52.2±8.9 years, 47.7% of males), 1,509 (16.9%) had MAFLD. During the median follow-up of 15.7 years, MAFLD independently predicted overall mortality after adjustment for confounders (hazard ratio [HR], 1.33; 95% confidence interval [CI], 1.05 to 1.69) but NAFLD did not (HR, 1.20; 95% CI, 0.94 to 1.53). MAFLD also predicted CVD after adjustment for age, sex, and body mass index (HR, 1.35; 95% CI, 1.13 to 1.62), which lost its statistical significance by further adjustments. Stratified analysis indicated that metabolic dysfunction contributed to mortality (HR, 1.51; 95% CI, 1.21 to 1.89) and CVD (HR, 1.27; 95% CI, 1.02 to 1.59). Among metabolic dysfunctions used for defining MAFLD, type 2 diabetes mellitus in MAFLD increased the risk of both mortality (HR, 2.07; 95% CI, 1.52 to 2.81) and CVD (HR, 1.42; 95% CI, 1.09 to 1.85).ConclusionsMAFLD independently increased overall mortality. Heterogeneity in mortality and CVD risk of subjects with MAFLD may be determined by the accompanying metabolic dysfunctions.     

Induction of Apoptosis Signaling by Glycoprotein of Capsosiphon fulvescens in Human Gastric Cancer (AGS) Cells

Capsosiphon fulvescens is a well-known green sea algae that has been touted in recent years as a potential anticancer drug. In this study, C. fulvescens glycoprotein (Cf-GP) showed proapoptotic signaling in AGS cells. An MTS assay indicated that Cf-GP inhibited the proliferation of AGS cell lines in a dose-dependent manner. Cells were treated with Cf-GP and the expression of proteins associated with apoptosis was examined by Western blotting. Based on the Western blot, expression of Cf-GP-activated caspase-cascade and PARP, which is a substrate of caspase-3 and -8, and proteins of the Bcl-2 family was observed. Cf-GP treatment stimulated the release of cytochrome C and apoptotic protease activating factor-1 from mitochondria to the cytosol. Cf-GP inhibited the growth of AGS cells through induction of sub-G1 phase arrest. We confirmed that sub-G1-phase arrest was associated with a decrease in the expression of cyclin D, cyclin E, Cdk2, Cdk4, and Cdk6, and an increase in the protein levels of p21 and p27. As a result, the increased sub-G1 ratio appears to be inhibited by cell proliferation. Therefore, we can confirm apoptosis in the AGS cells. Our results suggest that Cf-GP could be a potential source of biofunctional material that shows anticancer effects in human gastrointestinal cancer.     

The correlation of left atrial volume index to the level of N-terminal pro-BNP in heart failure with a preserved ejection fraction

Background: Patients with heart failure with a preserved ejection fraction (HFPEF) have high N‐terminal pro‐B‐type natriuretic peptide (NT‐pro‐BNP) level and a high ratio of early transmitral inflow to diastolic velocity of the mitral annulus (E/E′) derived from tissue Doppler imaging (TDI). Because left atrial volume indexed to body surface area (LAVI) is believed to reflect chronic diastolic dysfunction, we assessed the ability of LAVI and E/E′ ratio to predict NT‐pro‐BNP level in patients with HFPEF. Methods: One hundred forty‐eight patients with HFPEF (ejection fraction ≥ 50%, NT‐pro‐BNP ≥ 100 pg/ml) underwent conventional echocardiography including LAVI and E/E′ ratio, which were compared with NT‐pro‐BNP level. Results: In the overall patient population, modest correlations were found between NT‐pro‐BNP level and peak systolic TDI (S′) (P = 0.009), LAVI (P = 0.009), and E/E′ ratio (P = 0.017). However, in patients with E/E′ ratio ≥13, LAVI was the most important predictor of NT‐pro‐BNP level (P < 0.001), whereas in those with E/E′ ratio <13 it was S′ (P < 0.001) in multivariate analysis. Conclusion: In patients with HFPEF evidenced by high NT‐pro‐BNP level, LAVI correlates with NT‐pro‐BNP level in the setting of elevated E/E′ ratio. However, in the setting of low E/E′ ratio, LAVI does not seem to be associated with NT‐pro‐BNP level.