Proper preparation to reduce endoscopic reexamination due to food residue after distal gastrectomy for gastric cancer

Background

Reducing food residue by proper preparation methods before endoscopy after distal gastrectomy can increase the quality of examination and decrease patient discomfort. We evaluated the risk factors for food residue and proper methods of preparation for endoscopy after distal gastrectomy.

Methods

Follow-up endoscopy with questionnaires was performed on 1,001 patients who underwent distal gastrectomy at Asan Medical Center between December 2010 and July 2011.

Results

Endoscopic examination failed in 94 patients (9.4 %) as a result of large amounts of food residue. Rates of failure were significantly higher in patients who ate a regular diet rather than a soft diet at last dinner before examination (13.9 vs. 6.1 %, p = 0.050), and in those who ate lunch rather than not eating lunch on the day before examination (14.6 vs. 7.7 %, p = 0.020). Multivariate analysis showed that the rate of failed examination was lower in patients who had a history of abdominal surgery (p = 0.011), those who ate a soft (p < 0.001) or liquid (p = 0.003) diet as a last meal rather than a regular diet, those who underwent Billroth I rather than Billroth II reconstruction (p = 0.035), patients with longer fasting time (p = 0.009), and those with a longer gastrectomy-to-endoscopy time interval (p < 0.001).

Conclusions

Patients who undergo follow-up endoscopy after surgery should fast more than 18 h and ingest a soft or liquid diet on the day before examination.     

Selection Criteria for Postmastectomy Radiotherapy in T1–T2 Tumors with 1 to 3 Positive Lymph Nodes

Background

Postmastectomy radiotherapy (PMRT) is well established in patients with ≥4 positive axillary lymph nodes (ALN); indications in 1 to 3 positive ALN remains controversial. We examined clinicopathologic criteria used for PMRT selection and compared locoregional recurrence (LRR), recurrence-free survival (RFS), and overall survival (OS) among patients with and without PMRT.

Methods

Between 1995 and 2006, a total of 1,331 patients with T1–T2 tumors and 1 to 3 positive ALN underwent mastectomy. We excluded T3/T4 tumors and neoadjuvant chemotherapy; we analyzed 1,087 patients (924 without PMRT, 163 with PMRT). Chi square testing compared clinicopathologic features between groups. The Kaplan–Meier method and Cox regression analysis examined the association between PMRT and LRR, RFS, and OS.

Results

PMRT patients were more likely to be ≤50 years old (p = 0.001) and to have larger tumors (p = 0.01), disease of a higher histologic grade (p = 0.03), lymphovascular invasion (LVI) (p < 0.0001), a greater number of positive ALN (p < 0.0001), extranodal invasion (p < 0.0001), and macroscopic ALN metastases (p < 0.0001). With a median follow-up of 7 years, PMRT and no-PMRT groups were similar in LRR (p = 0.57), RFS (p = 0.70), and OS (p = 0.28). On multivariate analysis of the no-PMRT group, age ≤50 years (p = 0.002) and presence of LVI (p < 0.0001) were associated with LRR. Stratified by age and LVI, patients ≤50 years old and with LVI had the highest 5-year LRR, 10.1 versus 1.1 %, than in patients >50 years old without LVI (p < 0.001).

Conclusions

By using clinicopathologic features, clinicians delivered PMRT to a select group of patients with T1–T2 tumors and 1 to 3 positive ALN, resulting in similarly low rates of 5-year LRR. Among patients not receiving PMRT, age ≤50 years and LVI were associated with increased LRR rates and warrant PMRT consideration.     

The Effects of Surgical Cytoreduction Prior to Imatinib Therapy on the Prognosis of Patients with Advanced GIST

Background

Baseline tumor size is one of important prognostic factors for imatinib therapy in patients with advanced gastrointestinal stromal tumor (GIST). The purpose of this study was to determine whether surgical cytoreduction before imatinib therapy can improve the prognosis.

Methods

A total of 249 patients with advanced GIST were reviewed retrospectively. Patients were categorized into two groups according to the degree of initial cytoreduction: 35 patients with ≥75 % of initial tumor bulk removed (cytoreduction group) and the other 214 patients (no cytoreduction group). The median follow-up was 44.0 months.

Results

Patients in the cytoreduction group were younger, in better performance, showed more initially metastatic disease, peritoneal metastases, but fewer liver metastases. The baseline tumor size when starting imatinib became significantly reduced in the cytoreduction group, which made significant difference between the two groups. By multivariate analyses, mutational status, tumor size, and granulocyte count at presentation were associated with progression-free survival. Age and tumor size were associated with overall survival. However, initial cytoreduction was not significantly related to the prognosis.

Conclusions

Cytoreduction before imatinib therapy appears not to improve the prognosis. Imatinib therapy should still represent the initial treatment for advanced GIST.     

Elevated Galectin-3 Precedes the Development of CKD

Galectin-3, a profibrotic mediator, is linked to the development of renal fibrosis in animal models and inversely correlates with GFR in humans, but whether galectin-3 predicts incident kidney disease is unknown. Here, we assessed renal outcomes for 2450 Framingham Offspring participants who attended examination 6 (1995–1998) and had follow-up data at examination 8 (2005–2008). Renal outcomes of interest included rapid decline in renal function (≥3 ml/min per 1.73 m² per year decline in estimated GFR [eGFR]), CKD (eGFR < 60 ml/min per 1.73 m²), and albuminuria (albumin-to-creatinine ratio ≥17 mg/g in men or ≥25 mg/g in women). We used multivariable logistic regression models to evaluate associations between galectin-3 with incident renal outcomes at examination 8. During a mean follow-up of 10.1 years, GFR declined rapidly in 241 (9.2%) participants, incident CKD developed in 277 (11.3%), and albuminuria developed in 194 (10.1%). Higher plasma levels of galectin-3 were associated with rapid decline in eGFR (per 1-SD log-galectin-3; adjusted odds ratio [OR], 1.49; 95% confidence interval [CI], 1.28 to 1.73]) and a higher risk of incident CKD (OR, 1.47; 95% CI, 1.27 to 1.71), but not with the risk of incident albuminuria. The addition of galectin-3 to clinical predictors improved the C-statistic (0.837–0.845; P=0.02) but did not reach predefined thresholds for clinically significant improvements to risk prediction based on reclassification indices. In conclusion, elevated levels of plasma galectin-3 are associated with increased risks of rapid GFR decline and of incident CKD in the community, which calls for further study in higher-risk groups.CKD is a major worldwide public health problem^1–6 that may result in progressive deterioration in kidney function,⁷ substantial morbidity,^8–10 and increased mortality from both cardiovascular¹¹ and noncardiovascular causes.¹² Because of the lack of early clinical signs or symptoms and the poor sensitivity of currently available biomarkers (serum creatinine and urinary protein), CKD is typically detected at an advanced stage. However, when detected early, kidney function decline may be slowed or even reversed and these secondary complications averted.^13–15 Hence, there is a pressing clinical need for novel biomarkers that identify at-risk individuals at the earliest possible stage.Galectin-3 is a β-galactoside–binding lectin that has emerged as a key regulator of inflammation and fibrosis.¹⁶ Galectin-3 is strongly linked to the development of organ fibrosis in rodent models: Galectin-3 knockout mice are resistant to the development of fibrosis, whereas infusion of recombinant galectin-3 induces TGF-β−dependent tissue fibroblast proliferation and collagen deposition.^17,18 In addition, upregulation of galectin-3 has been implicated in fibrosis of multiple organs, including the liver,^19,20 lung,²¹ and heart.¹⁷ Galectin-3 has also been linked to the development of renal fibrosis,^22,23 as well as fibrosis attenuation via matrix remodeling,²⁴ indicating a context-dependent role.Progressive CKD is characterized by the development of tubulointerstitial fibrosis.²⁵ Galectin-3 expression and secretion by macrophages have previously been shown to promote the development of tubulointerstitial fibrosis in mouse models.²³ We believe galectin-3 merits study as a renal biomarker on the basis of this association with renal fibrosis, as well as strong cross-sectional correlations with GFR identified in studies of patients with heart failure and in the general population.^26–30 We hypothesized that higher plasma galectin-3 levels would be associated with an increased risk of incident CKD in the general population, defined as estimated GFR (eGFR) < 60 ml/min per 1.73 m² or incident albuminuria. We also considered whether galectin-3 is associated with rapid decline in kidney function, as assessed by decline in eGFR during the follow-up period. To address these questions, we assessed prospective relations of galectin-3 and these outcomes in unselected participants from the Framingham Heart Study (FHS).     

The Reproducibility Of Urodynamic Studies Of Neurogenic Bladders In Spinal Cord Injury

Abstract

Objective: To evaluate the reproducibility (test-retest reliability) of urodynamic studies in neurogenic bladders of subjects with spinal cord injuries (SCI).

Design: Retrospective case series.

Setting: Urology department of a major rehabilitation center.

Subjects: Fifty individuals with SCI who had urodynamic studies performed from February 2000 to April 2000.

Main outcome measures: Two trials (Time 1 and Time 2) of urodynamic studies done 5 minutes apart, with the following collected: bladder volume at first sensation, maximum cystometric capacity, presence of uninhib ited contractions, opening pressure, maximum detrusor pressure, duration of bladder contraction, volume voided, and post-void residual (PVR) volume. The corresponding data were then compared. Statistical analysis was performed using the Lin’s concordance correlation coefficient and kappa.

Results: Analysis of the data showed statistically significant levels of agreement between Time 1 and Time 2 with regard to the various corresponding parameters for both the filling and voiding phases. For 3 of the most important parameters-the opening pressure, maximum detrusor pressure, and duration of contraction-the Lin’s concordance correlation coefficient (r_c) was .86 (95% Cl, .78-.95; ρ < .0005), .91 (95% Cl, .86-.96; ρ < .0005), and .97 (95% Cl, .95 -.99, ρ < .0005), respectively.

Conclusion: The study demonstrates good short-term intrasubject reproducibility of urodynamic studies in individuals with SCI.