Tumour size is related to the curability of signet ring cell early gastric cancer with endoscopic submucosal dissection: A retrospective single centre study

Background

Endoscopic submucosal dissection is applied in selected cases of signet ring cell early gastric cancer. However, factors related to curability of signet ring cell early gastric cancer with this method have not been fully evaluated. Our aim was to evaluate factors related to incomplete resection in signet ring cell early gastric cancer with endoscopic submucosal dissection.

Methods

A retrospective analysis was performed on a total of 126 consecutive patients with signet ring cell early gastric cancer who had undergone endoscopic submucosal dissection at the Severance Hospital in Korea, between March 2007 and March 2012. The clinical outcomes were reviewed and factors related to incomplete resection were analysed.

Results

Multivariate analysis showed that large tumour size was the only significant factor related to incomplete resection (P = 0.006; hazard ratio, 1.040; 95% confidence interval, 1.101–1.084). In addition, large tumour size was the only significant factor related to endoscopic size underestimation (P < 0.001; hazard ratio, 1.391; 95% confidence interval, 1.221–1.586). The rate of endoscopic size underestimation was significantly higher in tumours with a size ≥20 mm (P < 0.001).

Conclusions

To improve the curability of signet ring cell early gastric cancer with endoscopic submucosal dissection, larger tumours (especially tumour with a size ≥20 mm) should be resected with a larger margin.     

Feasibility of the Short Hospital Stays after Laparoscopic Appendectomy for Uncomplicated Appendicitis

Purpose

The aim of this study was to evaluate the feasibility of short hospital stays after laparoscopic appendectomy for uncomplicated appendicitis.

Materials and Methods

The records of 142 patients who underwent laparoscopic appendectomy for uncomplicated appendicitis from January 2010 to December 2012 were analyzed retrospectively. Patients were allocated to an early (<48 hours) or a late (>48 hours) group by postoperative hospital stay. Postoperative complications and readmission rates in the two groups were evaluated and compared.

Results

Overall mean patient age was 50.1 (±16.0) years, and mean hospital stay was 3.8 (±2.8) days. Fifty-four patients (group E, 38.0%) were discharged within 48 hours of surgery, and 88 patients (group L, 62.0%) stayed more than 48 hours. Overall complication rates were similar in the two groups (14.8% vs. 21.6%, p=0.318), and wound complications (13.0% vs. 12.5%), postoperative bowel obstruction (1.9% vs. 2.3%), and abdominal pain (1.9% vs. 3.4%) were not significantly different.

Conclusion

Patients that undergo laparoscopic appendectomy due to uncomplicated appendicitis may be safely discharged within 48 hours. Further study should be conducted to determine the optimal length of hospital stay after laparoscopic appendectomy to reduce hospital costs.     

Multidisciplinary Team Approach for Identifying Potential Candidate for Transcatheter Aortic Valve Implantation

Purpose

We sought to evaluate the clinical usefulness of decision making by a multidisciplinary heart team for identifying potential candidates for transcatheter aortic valve implantation (TAVI) in patients with symptomatic severe aortic stenosis.

Materials and Methods

The multidisciplinary team consisted of two interventional cardiologists, two cardiovascular surgeons, one cardiac imaging specialist, and two cardiac anesthesiologists.

Results

Out of 60 patients who were screened as potential TAVI candidates, 31 patients were initially recommended as appropriate for TAVI, and 20 of these 31 eventually underwent TAVI. Twenty-two patients underwent surgical aortic valve replacement (AVR), and 17 patients received only medical treatment. Patients who underwent TAVI and medical therapy were older than those who underwent surgical AVR (p<0.001). The logistic Euroscore was significantly highest in the TAVI group and lowest in the surgical AVR group (p=0.012). Most patients in the TAVI group (90%) and the surgical AVR group (91%) had severe cardiac symptoms, but only 47% in the medical therapy group had severe symptoms. The cumulative percentages of survival without re-hospitalization or all-cause death at 6 months for the surgical AVR, TAVI, and medical therapy groups were 84%, 75%, and 28%, respectively (p=0.007, by log-rank).

Conclusion

TAVI was recommended in half of the potential candidates following a multidisciplinary team approach and was eventually performed in one-third of these patients. One-third of the patients who were initially considered potential candidates received surgical AVR with favorable clinical outcomes.     

Incidence and Risk Factors of Postoperative Nausea and Vomiting in Patients with Fentanyl-Based Intravenous Patient-Controlled Analgesia and Single Antiemetic Prophylaxis

Purpose

We evaluated the incidence and risk factors of postoperative nausea and vomiting (PONV) in patients with fentanyl-based intravenous patient-controlled analgesia (IV-PCA) and single antiemetic prophylaxis of 5-hydroxytryptamine type 3 (5 HT₃)-receptor antagonist after the general anesthesia.

Materials and Methods

In this retrospective study, incidence and risk factors for PONV were evaluated with fentanyl IV-PCA during postoperative 48 hours after various surgeries.

Results

Four hundred-forty patients (23%) of 1878 had showed PONV. PCA was discontinued temporarily in 268 patients (14%), mostly due to PONV (88% of 268 patients). In multivariate analysis, female, non-smoker, history of motion sickness or PONV, long duration of anesthesia (>180 min), use of desflurane and intraoperative remifentanil infusion were independent risk factors for PONV. If one, two, three, four, five, or six of these risk factors were present, the incidences of PONV were 18%, 19%, 22%, 31%, 42%, or 50%. Laparoscopic surgery and higher dose of fentanyl were not risk factors for PONV.

Conclusion

Despite antiemetic prophylaxis with 5 HT₃-receptor antagonist, 23% of patients with fentanyl-based IV-PCA after general anesthesia showed PONV. Long duration of anesthesia and use of desflurane were identified as risk factors, in addition to risk factors of Apfel''s score (female, non-smoker, history of motion sickness or PONV). Also, intraoperative remifentanil infusion was risk factor independent of postoperative opioid use. As the incidence of PONV was up to 50% according to the number of risk factors, risk-adapted, multimodal or combination therapy should be applied.     

Early Feeding Is Feasible after Emergency Gastrointestinal Surgery

Purpose

This study was undertaken to assess the feasibility of early feeding in patients that have undergone emergency gastrointestinal (GI) surgery.

Materials and Methods

The authors retrospectively reviewed 84 patients that underwent emergency bowel resection and/or anastomosis from March 2008 to December 2011. Patients with severe shock, intestinal ischemia, sustained bowel perforation, or short bowel syndrome were excluded. Patients were divided into the early (group E; n=44) or late (group L; n=40) group according to the time of feeding commencement. Early feeding was defined as enteral feeding that started within 48 hours after surgery. Early and late feeding groups were compared with respect to clinical data and surgical outcomes.

Results

The most common cause of operation was bowel perforation, and the small bowel was the most commonly involved site. No significant intergroup differences were found for causes, sites, or types of operation. However, length of stay (LOS) in the intensive care unit (1 day vs. 2 days, p=0.038) and LOS in the hospital after surgery were significantly greater (9 days vs. 12 days, p=0.012) in group L than group E; pulmonary complications were also significantly more common (13.6% vs. 47.5%, p=0.001) in group L than group E.

Conclusion

After emergency GI surgery, early feeding may be feasible in patients without severe shock or bowel anastomosis instability.     

Small bowel volvulus with a jejunal trichobezoar

Background

Small bowel volvulus caused by a jejunal trichobezoar is an extremely rare and life-threatening emergency in children.

Case characteristics

An 8-year-old girl with abdominal pain and persistent bilious vomiting.

Observation

The abdominal computed tomography scan showed a solitary intraluminal mass and a whirl sign, suggesting the small bowel volvulus. Emergency laparoscopic exploration revealed the rotated segment of small bowel loops by a jejunal trichobezoar.

Outcome

Satisfactory recovery after surgery.

Message

Trichobezoars should be considered in the differential diagnosis of abdominal pain and projectile vomiting in children.     

Effects of Transglutaminase 2 Inhibition on Ventilator-Induced Lung Injury

This study was performed to examine the role of transglutaminase 2 (TG2) in ventilator-induced lung injury (VILI). C57BL/6 mice were divided into six experimental groups: 1) control group; 2) lipopolysaccharide (LPS) group; 3) lung protective ventilation (LPV) group; 4) VILI group; 5) VILI with cystamine, a TG2 inhibitor, pretreatment (Cyst+VILI) group; and 6) LPV with cystamine pretreatment (Cyst+LPV) group. Acute lung injury (ALI) score, TG2 activity and gene expression, inflammatory cytokines, and nuclear factor-κB (NF-κB) activity were measured. TG2 activity and gene expression were significantly increased in the VILI group (P < 0.05). Cystamine pretreatment significantly decreased TG2 activity and gene expression in the Cyst+VILI group (P < 0.05). Inflammatory cytokines were higher in the VILI group than in the LPS and LPV groups (P < 0.05), and significantly lower in the Cyst+VILI group than the VILI group (P < 0.05). NF-κB activity was increased in the VILI group compared with the LPS and LPV groups (P < 0.05), and significantly decreased in the Cyst+VILI group compared to the VILI group (P = 0.029). The ALI score of the Cyst+VILI group was lower than the VILI group, but the difference was not statistically significant (P = 0.105). These results suggest potential roles of TG2 in the pathogenesis of VILI.

Graphical Abstract

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Relationship between Tetrahydrobiopterin and Portal Hypertension in Patients with Chronic Liver Disease

Tetrahydrobiopterin (BH4) is an essential cofactor in NO synthesis by endothelial nitric oxide synthase (eNOS) enzymes. It has been previously suggested that reduced intrahepatic BH4 results in a decrease in intrahepatic NO and contributes to increased hepatic vascular resistance and portal pressure in animal models of cirrhosis. The main aim of the present study was to evaluate the relationship between BH4 and portal hypertension (PHT). One hundred ninety-three consecutive patients with chronic liver disease were included in the study. Liver biopsy, measurement of BH4 and hepatic venous pressure gradient (HVPG) were performed. Hepatic fibrosis was classified using the Laennec fibrosis scoring system. BH4 levels were determined in homogenized liver tissues of patients using a high performance liquid chromatography (HPLC) system. Statistical analysis was performed to evaluate the relationship between BH4 and HVPG, grade of hepatic fibrosis, clinical stage of cirrhosis, Child-Pugh class. A positive relationship between HVPG and hepatic fibrosis grade, clinical stage of cirrhosis and Child-Pugh class was observed. However, the BH4 level showed no significant correlation with HVPG or clinical features of cirrhosis. BH4 concentration in liver tissue has little relation to the severity of portal hypertension in patients with chronic liver disease.

Graphical Abstract

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Evidence-Based,Pharmacological Treatment Guideline for Depression in Korea,Revised Edition

This paper aims to introduce, summarize, and emphasize the importance of the ''Evidence-Based, Pharmacological Treatment Guideline for Depression in Korea, Revised Edition''. The guideline broadly covers most aspects of the pharmacological treatment of patients in Korea diagnosed with moderate to severe major depression according to the DSM-IV TR. The guideline establishment process involved determining and answering a number of key questions, searching and selecting publications, evaluating recommendations, preparing guideline drafts, undergoing external expert reviews, and obtaining approval. A guideline adaptation process was conducted for the revised edition. The guideline strongly recommends pharmacological treatment considered appropriate to the current clinical situation in Korea, and should be considered helpful when selecting the appropriate pharmacological treatment of patients diagnosed with major depressive disorder. Therefore, the wide distribution of this guideline is recommended.     

Clinically Useful Diagnostic Tool of Contrast Enhanced Ultrasonography for Focal Liver Masses: Comparison to Computed Tomography and Magnetic Resonance Imaging

Background/Aims

To evaluate the diagnostic value of contrast (SonoVue®) enhancement ultrasonography (CEUS) and to compare this method with computed tomography (CT) and magnetic resonance imaging (MRI) in evaluating liver masses.

Methods

CEUS (n=50), CT (n=47), and MRI (n=43) were performed on 50 liver masses in 48 patients for baseline mass characterization. The most likely impression for each modality and the final diagnosis, based on the combined biopsy results (n=14), angiography findings (n=36), and clinical course, were determined. The diagnostic value of CEUS was compared to those of CT and MRI.

Results

The final diagnosis of the masses was hepatocellular carcinoma (n=43), hemangioma (n=3), benign adenoma (n=2), eosinophilic abscess (n=1), and liver metastasis (n=1). The overall diagnostic agreement with the final diagnosis was substantial for CEUS, CT, and MRI, with κ values of 0.621, 0.763, and 0.784, respectively. The sensitivity, specificity, and accuracy were 83.3%, 87.5%, and 84.0%, respectively, for CEUS; 95.0%, 87.5%, and 93.8%, respectively, for CT; and 94.6%, 83.3%, and 93.0%, respectively for MRI. After excluding the lesions with poor acoustic sonographic windows, the sensitivity, specificity, and accuracy for CEUS were 94.6%, 87.5%, and 93.3%, respectively, with a κ value of 0.765.

Conclusions

If an appropriate acoustic window is available, CEUS is comparable to CT and MRI for the diagnosis of liver masses.