Long-term outcomes after laparoscopy-assisted gastrectomy for advanced gastric cancer: a large-scale multicenter retrospective study

Background

Recently, the number of laparoscopic procedures for gastric cancer has increased rapidly. Laparoscopic surgery is reported to have many advantages over open gastrectomy with oncologic safety in early gastric cancer. However, there were few reports on long-term outcomes of laparoscopy-assisted gastrectomy (LAG) for advanced gastric cancer (AGC). The aim of this study was to investigate long-term survival outcomes after LAG for AGC.

Methods

The data of 1,485 patients who underwent LAG between April 1998 and December 2005 by ten surgeons at ten hospitals were collected retrospectively. Among them, 239 patients who were diagnosed with AGC on final pathologic examination were enrolled in the present study to investigate long-term clinical outcomes.

Results

The ratio of male to female patients was 151:88 and the mean age was 57.1?years. One hundred ninety-three subtotal gastrectomies, 41 total gastrectomies, and 5 proximal gastrectomies were performed. D1?+?α, D1?+?β, and D2 lymph node dissections were performed for 14, 62, and 163 cases, respectively. The median follow-up period was 55.4?months. The overall 5-year survival rate of the 239 AGC patients was 78.8% and the disease-specific 5-year survival rate was 85.6%. The 5-year survival rates of the TNM staging system’s (7th ed.) stages were 90.5% (stage Ib, n?=?86), 86.4% (stage IIa, n?=?53), 78.3% (stage IIb, n?=?44), 52.8% (stage IIIa, n?=?24), 52.9% (stage IIIb, n?=?24), and 37.5% (stage IIIc, n?=?8) (p?Conclusion The long-term survival outcome rates of LAG for AGC in the present study were comparable to those previously reported for open gastrectomy. Based on the present results, a well-designed phase III trial comparing LAG and open gastrectomy for AGC will be needed to affirm the validity of LAG for AGC.     

Novel technique for intraoperative tumor localization during totally laparoscopic distal gastrectomy: endoscopic autologous blood tattooing

Background

Knowledge of the intraoperative location of lesions is a prerequisite for deciding the proper extent of gastric resection or the choice of anastomosis technique during totally laparoscopic distal gastrectomy (TLDG) for early gastric cancer (EGC). In this study we introduce a novel tumor localization method for TLDG: endoscopic blood tattooing.

Methods

Twenty-three consecutive patients scheduled for TLDG for EGC were enrolled in this prospective study. The day before surgery, 2–3?ml of autologous blood was injected into the gastric muscle layer at 3–4?cm proximal to the lesion during endoscopy.

Results

The study subjects consisted of 15 males and 8 females with a mean age of 61?±?10.4?years. During surgery, the endoscopic blood tattooed sites were successfully identified in all 23 patients. No complications associated with the procedure occurred, and no patient had microscopic residual tumor cells at the proximal resection margin, with a mean proximal margin length of 3.3?±?2.7?cm. Eighteen patients underwent TLDG with Billroth II anastomosis, four patients with Roux-en-Y gastrojejunostomy, and one patient with laparoscopic total gastrectomy. At final pathologic examinations, 20 patients were of stage IA and 3 were of stage IB according to the UICC TNM classification (6th ed.).

Conclusions

Endoscopic blood tattooing provides a simple and useful means of localizing lesions during TLDG for EGC. Although the superiority of this technique over other localization methods needs to be evaluated further, the authors recommend endoscopic blood tattooing as an alternative to other intraoperative localization methods for laparoscopic surgery for EGC.     

N-acetylcysteine attenuates ventilator-induced lung injury in an isolated and perfused rat lung model

N-acetylcysteine (NAC) suppresses the generation of reactive oxygen species (ROS) that are implicated in ventilator-induced lung injury (VILI). We thus hypothesised that NAC attenuates VILI. VILI was induced by mechanical ventilation with a tidal volume (Vt) of 15mlkg(-1) in isolated and perfused rat lung. NAC was administered in the perfusate prior to the onset of mechanical ventilation. A group ventilated with low Vt of 5mlkg(-1) served as control. Haemodynamics, lung injury indices, inflammatory responses and activation of apoptotic pathways were determined upon completion of the mechanical ventilation. There was an increase in lung permeability and lung weight gain after mechanical ventilation with high Vt, compared to low Vt. The levels of inflammatory cytokines including interleukin-1β (IL-1β), tumour necrosis factor-α (TNF-α) and macrophage inflammatory protein-2 (MIP-2) increased in lung lavage fluids; the concentrations of H(2)O(2) were higher in lung lavage fluids, and the expression of myeloperoxidase (MPO), JNK, P38, pAKT and caspase-3 in lung tissue was greater in the high Vt than in the low Vt group. The concentrations of glutathione (GSH) in lung tissue were higher in low Vt than those in high Vt. The administration of NAC increased GSH, attenuated ROS, cytokines, MPO, JNK, pAKT and caspase-3 and lung permeability associated with decreased activation of nuclear factor-κB. VILI is associated with inflammatory responses including the generation of ROS, cytokines and the activation of mitogen-activated protein kinase cascade. The administration of NAC attenuates the inflammatory responses, apoptosis and VILI in the isolated, perfused rat lung model.     

Hepatic resection using a liver-hanging maneuver and Glissonean pedicle transection for hepatocellular carcinoma in a patient with situs inversus totalis: report of a case

Situs inversus totalis is a rare congenital anomaly in which the major abdominal organs are located as a mirror image of their normal positions. This poses much difficulty for surgeons. We describe how we performed the liver-hanging maneuver (LHM) for hepatocellular carcinoma (HCC) in a 59-year-old man with situs inversus totalis, to resolve the difficulty of the mirror-image location of his liver. The HCC was located in the right lateral sector. Although segmentectomy of segment 7 would normally be considered minimal for a curative treatment of HCC, this was relatively complicated in this patient. Thus, we performed an extended right lateral sectionectomy using the LHM to achieve a simple transection. The hepatic hilum was dissected using the Glissonean pedicle transection method. The operation time and intraoperative blood loss were 6 h 45 min and 471 ml, respectively. No blood product transfusion was required. The LHM and the hilar Glissonean pedicle approach proved effective for resolving the difficulties of performing surgery in a mirror image for HCC in a patient with situs inversus totalis.     

Misexpression of Dickkopf-1 in endothelial cells, but not in chondrocytes or hypertrophic chondrocytes, causes defects in endochondral ossification

Developing cartilage serves as a template for long-bone development during endochondral ossification. Although the coupling of cartilage and bone development with angiogenesis is an important regulatory step for endochondral ossification, the molecular mechanisms are poorly understood. One possible mechanism involves the action of Dickkopf (DKK), which is a family of soluble canonical Wnt antagonists with four members (DKK1-4). We initially observed opposite expression patterns of Dkk1 and Dkk2 during angiogenesis and chondrocyte differentiation: downregulation of Dkk1 and upregulation of Dkk2. We examined the in vivo role of Dkk1 and Dkk2 in linking cartilage/bone development and angiogenesis by generating transgenic (TG) mice that specifically express Dkk1 or Dkk2 in chondrocytes, hypertrophic chondrocytes, or endothelial cells. Despite specific expression pattern during cartilage development, chondrocyte- and hypertrophic chondrocyte-specific Dkk1 and Dkk2 TG mice showed normal developmental phenotypes. However, Dkk1 misexpression in endothelial cells resulted in defects of endochondral ossification and reduced skeletal size. The defects are caused by the inhibition of angiogenesis in developing bone and subsequent inhibition of apoptosis of hypertrophic chondrocytes and cartilage resorption.     

Surgical treatment of temporal bone chondroblastoma

BACKGROUND: Temporal bone chondroblastoma is a rare primary bone tumor that affects the floor of the middle cranial fossa. This tumor is known to have high recurrence rate after curettage, and wide resection is therefore recommended. However, the literature provides little information regarding long-term results after wide resection of temporal bone chondroblastoma. METHODS: Four cases of surgically treated temporal bone chondroblastoma underwent long-term follow-up. RESULTS: Four patients, 3 males and 1 female, with mean age of 34, were surgically treated at the neurosurgery department of Keio University Hospital. Two patients were treated for recurrent tumor and the other two for new disease. In all cases the tumor mainly involved the mandibular fossa with variable degree of infiltration into tympanic and petrous parts. The tumor was totally removed via zygomatic approach in all patients. In 3 patients, the mandibular condyle was removed to expose the tumor. These patients had temporary malocclusion and restricted motion postoperatively, which resolved within 3 to 12 months with conservative treatment. All patients have no recurrence to date with a mean follow-up period of 9 years. CONCLUSION: Temporal bone chondroblastoma was removed totally with skull base surgical technique and no recurrence has occurred for 6 to 13 years postoperatively. We found that removal of the mandibular head does not cause permanent problems of mastication in patients with normal dentures.     

The anatomical basis for reverse first to fifth dorsal metacarpal arterial flaps

This study discusses the anatomical basis for reverse first to fifth dorsal metacarpal arterial flaps. The arterial pattern and size of the first to fifth dorsal metacarpal arteries were examined in 20 fresh cadaver hands. Their connections to the palmar arterial system at the metacarpal head were observed, and the location, number and diameter of skin perforators from each dorsal metacarpal artery were measured. The first to fourth dorsal metacarpal arteries were found in all specimens; the fifth dorsal metacarpal artery was found in 19 of our 20 specimens. The mean diameters of the first to fifth arteries at their bifurcation site were 0.6, 0.8, 0.5, 0.4 and 0.2 mm, respectively. Each artery gave off four to eight skin perforators (diameter: 0.1-0.3 mm) between the metacarpal head and base. The first to third dorsal metacarpal arteries consistently connected to the palmar arterial system, and connections between the fourth and fifth dorsal metacarpal arteries and the palmar system were found in 65% and 40% of specimens.     

Reduced Field-of-View Diffusion-Weighted Magnetic Resonance Imaging of the Pancreas: Comparison with Conventional Single-Shot Echo-Planar Imaging

ObjectiveTo investigate the image quality (IQ) and apparent diffusion coefficient (ADC) of reduced field-of-view (FOV) di-ffusion-weighted imaging (DWI) of pancreas in comparison with full FOV DWI.ResultsOn qualitative analysis, reduced FOV DWI showed better anatomic structure visualization (2.76 ± 0.79 at b = 0 s/mm² and 2.81 ± 0.64 at b = 400 s/mm²), lesion conspicuity (3.11 ± 0.99 at b = 0 s/mm² and 3.15 ± 0.79 at b = 400 s/mm²), IQ score (8.51 ± 2.05 at b = 0 s/mm² and 8.79 ± 1.60 at b = 400 s/mm²), and higher clinical utility (3.41 ± 0.64), as compared to full FOV DWI (anatomic structure, 2.18 ± 0.59 at b = 0 s/mm² and 2.56 ± 0.47 at b = 500 s/mm²; lesion conspicuity, 2.55 ± 1.07 at b = 0 s/mm² and 2.89 ± 0.86 at b = 500 s/mm²; IQ score, 7.13 ± 1.83 at b = 0 s/mm² and 8.17 ± 1.31 at b = 500 s/mm²; clinical utility, 3.14 ± 0.70) (p < 0.05). Artifacts were significantly improved on reduced FOV DWI (2.65 ± 0.68) at b = 0 s/mm² (full FOV DWI, 2.41 ± 0.63) (p < 0.001). On quantitative analysis, there were no significant differences between the 2 DWI sequences in ADCs of various pancreatic lesions and parenchyma (p > 0.05). ADCs of adenocarcinomas (1.061 × 10^-3 mm²/s ± 0.133 at reduced FOV and 1.079 × 10^-3 mm²/s ± 0.135 at full FOV) and neuroendocrine tumors (0.983 × 10^-3 mm²/s ± 0.152 at reduced FOV and 1.004 × 10^-3 mm²/s ± 0.153 at full FOV) were significantly lower than those of parenchyma (1.191 × 10^-3 mm²/s ± 0.125 at reduced FOV and 1.218 × 10^-3 mm²/s ± 0.103 at full FOV) (p < 0.05).ConclusionReduced FOV DWI of the pancreas provides better overall IQ including better anatomic detail, lesion conspicuity and subjective clinical utility.     

The unrecognized epidemic of blunt carotid arterial injuries: early diagnosis improves neurologic outcome.

OBJECTIVE: To determine the benefit of screening for blunt carotid arterial injuries (BCI) in patients who are asymptomatic. SUMMARY BACKGROUND DATA: Blunt carotid arterial injuries have the potential for devastating complications. Published studies report 23% to 28% mortality rates, with 48% to 58% of survivors having permanent severe neurologic deficits. Most patients have neurologic deficits when the injury is diagnosed. The authors hypothesized that screening patients who are asymptomatic and instituting early therapy would improve neurologic outcome. METHODS: The Trauma Registry of the author's Level I Trauma Center identified patients with BCI from 1990 through 1997. Beginning in August 1996, the authors implemented a screening for BCI. Arteriography was used for diagnosis. Patients without specific contraindications were anticoagulated. Endovascular stents were deployed in the setting of pseudoaneurysms. RESULTS: Thirty-seven patients with BCI were identified among 15,331 blunt-trauma victims (0.24%). During the screening period, 25 patients were diagnosed with BCI among 2902 admissions (0.86%); 13 (52%) were asymptomatic. Overall, eight patients died, and seven of the survivors had permanent severe neurologic deficits. Excluding those dying of massive brain injury and patients admitted with coma and brain injury, mortality associated with BCI was 15%, with severe neurologic morbidity in 16% of survivors. The patients who were asymptomatic at diagnosis had a better neurologic outcome than those who were symptomatic. Symptomatic patients who were anticoagulated showed a trend toward greater neurologic improvement at the time of discharge than those who were not anticoagulated. CONCLUSIONS: Screening allows the identification of asymptomatic BCI and thereby facilitates early systemic anticoagulation, which is associated with improved neurologic outcome. The role of endovascular stents in the treatment of blunt traumatic pseudoaneurysms remains to be defined.