Long-term comparison of laparoscopy-assisted distal gastrectomy and open distal gastrectomy in advanced gastric cancer

Background

The use of laparoscopy-assisted distal gastrectomy (LADG) in advanced gastric cancer (AGC) remains a controversial topic, mainly because of doubts about its oncologic validity. To date, literature on the prognosis for AGC after LADG is scarce. This study evaluated the procedure’s long-term benefits compared with those of the conventional, open distal gastrectomy (ODG).

Methods

This study involved 201 patients, 66 of whom underwent LADG, with a mean follow-up period of 49.2 months, from January 1999 to March 2010. A clear set of criteria was used to select patients (including no evidence of lymph node metastasis) and surgeons (subject to their experience). Survival outcomes were assessed by Kaplan–Meier analysis and log-rank testing. The postoperative recovery and complications of the patients also were monitored.

Results

No significant difference was observed between LADG and ODG in terms of overall survival or disease-specific survival. The corresponding 5-year survival rates for individual tumor node metastasis stages also were comparable in each group. The number of lymph nodes harvested was similar in the two groups, although the operation time was significantly shorter for ODG. The postoperative hospital stay was shorter for LADG patients (average stay of 8.4 vs. 18.1 days in the ODG group; p < 0.001), and the postoperative complication rate was almost half that for ODG (13.6 vs. 25.0 %; p = 0.048).

Conclusion

The combination of the long- and short-term data indicates that LADG should be considered as a feasible alternative to ODG for the treatment of AGC. Its widespread integration requires the accumulation of similar results across multiple centers worldwide.     

Placental transport of bile acids: analysis of bile acids in maternal serum and urine, umbilical cord blood, and amniotic fluid

To investigate the role of placental transport of bile acids in fetal bile acid metabolism, such as with regard to synthesis of the unusual bile acids (1 beta- and 6 alpha-hydroxylated and unsaturated bile acids), we measured the concentrations of bile acids in umbilical cord blood, amniotic fluid, maternal serum and maternal urine at delivery by means of gas chromatography-mass spectrometry. Serum and urine from healthy nonpregnant women were used as controls. We detected large amounts of unusual bile acids, especially hyocholic acid and 3 beta-hydroxy-delta 5 bile acids, in amniotic fluid and umbilical cord blood. The concentration of total bile acids in maternal serum was less than that of control serum and umbilical cord blood, and the concentration of total bile acids in maternal urine was higher than that of control urine and amniotic fluid. In conclusion, the fetus synthesized large amounts of unusual bile acids, and these compounds were transported from fetus to mother by placental transfer. We suggest that pregnant women may excrete large amounts of bile acids into the urine to control serum concentration of bile acids in fetus.     

Acetazolamide assisted Tc-99m MAG3 renography to assess renal blood flow reserve

OBJECTIVE: The present study examines whether or not baseline and acetazolamide (ACZ) Tc-99m MAG3 renography can assess renal blood flow reserve. METHODS: Renography proceeded for 50 min after sequential injections of 370 MBq Tc-99m MAG3 for baseline renography and 10 min after a 1,000 mg injection of ACZ for ACZ renography. Effective renal plasma flow of renal cortex (cERPF) in each kidney and the percentage change in cERPF of those parameters (deltaERPF) were obtained before and after the administration of ACZ in 10 subjects without hypertension or diabetes (normal group), in 10 with essential hypertension (hypertensive group) and in 10 who had Type 2 diabetes with hypertension (diabetic group). A placebo test was performed in the 10 without hypertension or diabetes using distilled water instead of ACZ (placebo group). RESULTS: The placebo test performed in the 10 without hypertension or diabetes using distilled water instead of ACZ indicated that the parameter variance between the two types of renogram was below 3.2%. The cERPF of baseline and ACZ Tc-99m MAG3 renography and deltaERPF in the normal, hypertensive and diabetic groups were 89 +/- 10 and 110 +/- 10 ml/min, 89 +/- 14 and 117 +/- 22 ml/min, 100 +/- 23 and 112 +/- 23 ml/min, respectively, and 24.5 +/- 13.5%, 26.0 +/- 9.7% and 12.3 +/- 11.1%, respectively. The difference in the cERPF value was significant in the normal and hypertensive groups whereas this did not change in the diabetic group before or after ACZ administration. CONCLUSIONS: We suggested that the deltaERPF determined by baseline and ACZ Tc-99m MAG3 renography is a useful parameter for assessing renal blood flow reserve.     

Ultrasonographic evaluation using the internal echo in normal and cirrhotic livers: Comparison of accuracy of gray-scale and binary black-and-white images and their intraobserver reproducibility and interobserver agreement

We attempt to determine the possibility of classifying normal and cirrhotic livers by their internal echo texture alone, without using such basic ultrasonographic information as shape and surface character of the liver. We also assessed intraobserver reproducibility and interobserver agreement obtained using this classification to ascertain the diagnostic usefulness of the method. In this evaluation, we used both regional magnified B-mode images and binary black-and-white images, both derived from conventional B-mode images obtained from 10 patients with normal livers and 10 with cirrhotic livers. These 20 echograms were randomly divided into two groups and evaluated independently on two occasions by 12 observers who used the unaided eye and took only internal echo texture into consideration. Accuracy in distinguishing between normal and cirrhotic livers ranged from 41.7 percent to 100 percent. The intraobserver correlation coefficient r1 between evaluations of the regional magnified B-mode images was 0.63, while that for the binary black-and-white images was 0.80. Agreement between the decisions of the 12 observers in the first and second evaluations of the binary black-and-white images showedk values between 0 and 1.0 for binary black-and-white images and between −0.32 and 0.29 for regional magnified B-mode images. Subjective evaluation of normal and cirrhotic livers based on internal echo texture alone was possible: intraobserver correlation was good; and unexpectedly, agreement with black-and-white images was greater than that with the regional magnified B-mode images.     

Acute portal hypertension associated with liver resection. Analysis of early postoperative death

Changes in portal pressure before and after hepatic resection were monitored in 65 patients. Significant increases in portal pressure, from 226 +/- 13 mm saline to 277 +/- 16 mm saline were noted in 17 cirrhotics undergoing major hepatic resection. In 14 noncirrhotics undergoing major resection of the liver, pressure in the portal vein changed significantly from 198 +/- 10 mm saline to 226 +/- 9 mm saline. Conversely, there were no differences in the 26 cirrhotic and eight noncirrhotic individuals who underwent minor hepatic resection. Clinical analysis of these patients showed that acute portal hypertension induced by liver resection was not linked to increases in early postoperative death.     

Prognostic study of intramucosal carcinoma of the stomach with DNA aneuploidy

Cell nuclear DNA content was microspectophotometrically measured in 70 patients with a gastric carcinoma lesion of less than 4.0 cm in diameter and with mucosal or minimal submucosal invasion. Two groups were prepared; low ploidy and high ploidy, according to the degree of dispersion on the DNA histogram. Twenty-four cases of high ploidy were reviewed from the aspects of clinicopathology and prognosis and the findings compared with data on 46 of low ploidy. The high ploidy group was characterized by an elevated lesion and a differentiated carcinoma while the low ploidy group had a depressed lesion and an undifferentiated carcinoma Postoperative recurrence was confirmed in none of the low ploidy cases and 2/24 of the high ploidy cases. The five and ten-year survival rates of the patients with high ploidy were 100 per cent and 91.1 per cent, respectively. Compared to the findings that patients with submucosal carcinoma of high ploidy survived at a rate of only 64.8 per cent in the 5-year follow-up, efforts should be directed toward a higher detection of gastric carcinoma with aneuploidy at the stage limited to within the intramucosal layer. Endoscopic treatment for early gastric carcinoma is not recommended, especially for a differentiated carcinoma, even if the invasion is confined to the mucosa, since it may include aneuploid carcinoma.     

Relationship between perfusion pressure and myocardial microcirculation in the beating empty or spontaneously fibrillating heart

The influence of graded perfusion pressure (30, 60, and 90 mmHg) at cardiopulmonary bypass were studied on beating empty hearts (BEH) or spontaneously fibrillating hearts (SFH) in the normothermic state. The adequacy and distribution of coronary flow and the myocardial oxygen consumption (MVO₂) were examined using the tracer microsphere technique in twelve mongrel dogs. In the SFH, the left ventricular (LV) endocardium (ENDO)/epicardium (EPI) flow ratio indicated significant decrease at 30 and 60 mmHg (0.83±0.05 and 0.86±0.06, p<0.005, respectively), but was recovered to control value at 90 mmHg (1.01±0.13). In the BEH, these low perfusion pressures did not result in an abnormal flow distribution in the LV (1.03±0.03 at 30 mmHg). The flow distribution to the right ventricle (RV) relatively increased in both the BEH and the SFH (p<0.001). The ENDO/EPI ratio of the RV did not decrease at 30 mmHg in both groups (1.11±0.03 in BEH and 1.16±0.08 in SFH). Coronary blood flow and MVO₂ were significantly higher in the SFH than in the BEH. Coronary blood flow increased significantly with increase in the perfusion pressure, in both groups. The MVO₂ was constant in the BEH, regardless of the perfusion pressure, but increased in the SFH at increasing pressure. These results show that in the SFH, subendocardial underperfusion of the LV is induced at the perfusion pressure of 30 and 60 mmHg.     

Outbreak of tuberculosis in a 2000-year-old Chinese population.

The molecular identification of Mycobacterium tuberculosis DNA in ancient human remains has been achieved mainly in mummies with macroscopic changes but not in the skeletons without bone tuberculosis. Using polymerase chain reaction studies, we identified mycobacterial DNA in 2000-year-old human skeletons without pathological changes. Our findings suggest that these people suffered from an outbreak of tuberculosis. Molecular examinations for mycobacterial DNA in the bone marrow of skeletons may contribute to the clarification of ancient diseases in old human populations.