Comparison of Laparoscopic and Open Gastrectomy for Patients With Gastric Cancer Treated With Neoadjuvant Chemotherapy: A Multicenter Retrospective Study Based on the Korean Gastric Cancer Association Nationwide Survey

Purpose@#Despite scientific evidence regarding laparoscopic gastrectomy (LG) for advanced gastric cancer treatment, its application in patients receiving neoadjuvant chemotherapy remains uncertain. @*Materials and Methods@#We used the 2019 Korean Gastric Cancer Association nationwide survey database to extract data from 489 patients with primary gastric cancer who received neoadjuvant chemotherapy. After propensity score matching analysis, we compared the surgical outcomes of 97 patients who underwent LG and 97 patients who underwent open gastrectomy (OG). We investigated the risk factors for postoperative complications using multivariate analysis. @*Results@#The operative time was significantly shorter in the OG group. Patients in the LG group had significantly less blood loss than those in the OG group. Hospital stay and overall postoperative complications were similar between the two groups. The incidence of Clavien– Dindo grade ≥3 complications in the LG group was comparable with that in the OG group (1.03% vs. 4.12%, P=0.215). No statistically significant difference was observed in the number of harvested lymph nodes between the two groups (38.60 vs. 35.79, P=0.182). Multivariate analysis identified body mass index (odds ratio [OR], 1.824; 95% confidence interval [CI], 1.029–3.234; P=0.040) and extent of resection (OR, 3.154; 95% CI, 1.084–9.174; P=0.035) as independent risk factors for overall postoperative complications. @*Conclusions@#Using a large nationwide multicenter survey database, we demonstrated that LG and OG had comparable short-term outcomes in patients with gastric cancer who received neoadjuvant chemotherapy.

Early Clinical Outcomes of the Morbidly Obese Patients Who Underwent Laparoscopic Sleeve Gastrectomy by Gastric Cancer Surgeons: the Analysis of Fifty Consecutive Cases

Purpose@#The number of bariatric surgeries performed at our tertiary hospital has gradually increased since the national health insurance began to cover their expenses in January of 2019. This study examined the early surgical outcomes of laparoscopic sleeve gastrectomy (LSG) performed by experienced gastric cancer surgeons. @*Materials and Methods@#We retrospectively reviewed and analyzed data from 50 patients who underwent LSG between November of 2018 and April of 2020 at the Asan Medical Center by 1 of 5 experienced surgeons each of whom performed approximately 100–300 cases of gastrectomy annually. The age, body mass index (BMI), weight, presence of comorbidities, operation time, hospital stay after surgery, postoperative complications, postoperative excess weight loss (EWL), and resolution of comorbidities were examined. @*Results@#The mean age, BMI, and weight were 37.29±9.77 years, 37.12 kg/m2, and 102.00 kg, respectively. The mean operation time and postoperative length of hospital stay were 109.59±35.88 and 5.06±1.20 days, respectively. Two patients (4.00%) had early postoperative complications and postoperative leakage; bleeding and stenosis were not reported. The EWL after 1 and 6 months of operation was 26.55% and 60.34%, respectively. The resolution of diabetes, hypertension, and dyslipidemia after 6 months of operation was 88.89%, 54.54%, and 50.00%, respectively. @*Conclusion@#LSG is safe and effective when performed by an experienced gastric cancer surgeon; however, a long-term follow-up of patients is required.

Impact of Esophagojejunal Reconstruction without Division of the Mesentery for Total Laparoscopic Total Gastrectomy

Purpose@#This study aimed to compare the surgical outcomes of total laparoscopic total gastrectomy without mesentery division (LTG without MD) and conventional total laparoscopic total gastrectomy (CLTG), as well as evaluate the appropriate method for esophagojejunostomy (EJ) reconstruction after total laparoscopic total gastrectomy (TLTG). @*Materials and Methods@#We retrospectively analyzed data from 301 consecutive patients who underwent TLTG for upper or middle third gastric cancer between January 2016 and May 2019. After propensity score matching, 95 patients who underwent LTG without MD and 95 who underwent CLTG were assessed. Data on clinical characteristics and surgical outcomes, including operation time, length of postoperative hospital stay, pathological findings, and postoperative complications were analyzed. @*Results@#The LTG without MD group showed a shorter time to first flatus (3.26±0.80 vs.3.62±0.81 days, P=0.003) and a shorter time to soft diet (2.80±2.09 vs. 3.52±2.20 days, P=0.002). The total EJ-related complications in the LTG without MD group were comparable to those in the CLTG group (9.47% vs. 3.16%, P=0.083). EJ-related leakage (6.32% vs. 3.16%, P=0.317) and EJ-related stricture (3.16% vs. 1.05%, P=0.317) rates were not significantly different between the LTG without MD and CLTG groups. No significant differences were found between the two groups in terms of other early surgical outcomes such as early complications, late complications, hospital stay, and readmission rate. @*Conclusions@#LTG without MD is a safe surgical treatment for upper or middle third gastric cancer. LTG without MD may be an alternative procedure for EJ anastomosis during TLTG.

Validation of the ACS NSQIP Surgical Risk Calculator for Patients with Early Gastric Cancer Treated with Laparoscopic Gastrectomy

Purpose@#The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) risk calculator is useful in predicting postoperative adverse events. However, its accuracy in specific disorders is unclear. We validated the ACS NSQIP risk calculator in patients with gastric cancer undergoing curative laparoscopic surgery. @*Materials and Methods@#We included 207 consecutive early gastric cancer patients who underwent laparoscopic gastrectomy between January 2018 and January 2019. The preoperative characteristics and risks of the patients were reviewed and entered into the ACS NSQIP calculator. The estimated risks of postoperative outcomes were compared with the observed outcomes using C-statistics and Brier scores. @*Results@#Most of the patients underwent distal gastrectomy with Roux-en-Y reconstruction (74.4%). We did not observe any cases of mortality, venous thromboembolism, urinary tract infection, renal failure, or cardiac complications. The other outcomes assessed were complications such as pneumonia, surgical site infections, any complications requiring re-operation or hospital readmission, the rates of discharge to nursing homes/rehabilitation centers, and the length of stay. All C-statistics were <0 and the highest was for pneumonia (0.65; 95% confidence interval: 0.58–0.71). Brier scores ranged from 0.01 for pneumonia to 0.155 for other complications. Overall, the risk calculator was inconsistent in predicting the outcomes. @*Conclusions@#The ACS NSQIP surgical risk calculator showed low predictive ability for postoperative adverse events after laparoscopic gastrectomy for patients with early gastric cancer. Further research to adjust the risk calculator for these patients may improve its predictive ability.

Portomesenteric Vein Thrombosis after Laparoscopic Sleeve Gastrectomy: A Case Report

Portomesenteric vein thrombosis is an uncommon but potentially life-threatening complication associated with laparoscopic sleeve gastrectomy. We present the case of a 26-year-old male who underwent an uneventful laparoscopic sleeve gastrectomy and presented on postoperative day 14 with portomesenteric vein thrombosis. The patient was treated conservatively with IV heparinization, followed by an oral anticoagulant agent. He was discharged in stable condition without further problems. A high index of suspicion for the disease is required not to miss or delay the diagnosis of portomesenteric vein thrombosis which could lead to a fatal outcome. All patients should be screened beforehand for underlying hypercoagulability before surgery.

Predicting Successful Conservative Surgery after Neoadjuvant Chemotherapy in Hormone Receptor-Positive, HER2-Negative Breast Cancer

PURPOSE: This study aimed to determine whether clinicopathological factors are potentially associated with successful breast-conserving surgery (BCS) after neoadjuvant chemotherapy (NAC) and develop a nomogram for predicting successful BCS candidates, focusing on those who are diagnosed with hormone receptor (HR)-positive, human epidermal growth factor receptor 2 (HER2)-negative tumors during the pre-NAC period. METHODS: The training cohort included 239 patients with an HR-positive, HER2-negative tumor (≥3 cm), and all of these patients had received NAC. Patients were excluded if they met any of the following criteria: diffuse, suspicious, malignant microcalcification (extent >4 cm); multicentric or multifocal breast cancer; inflammatory breast cancer; distant metastases at the time of diagnosis; excisional biopsy prior to NAC; and bilateral breast cancer. Multivariate logistic regression analysis was conducted to evaluate the possible predictors of BCS eligibility after NAC, and the regression model was used to develop the predicting nomogram. This nomogram was built using the training cohort (n=239) and was later validated with an independent validation cohort (n=123). RESULTS: Small tumor size (p < 0.001) at initial diagnosis, long distance from the nipple (p=0.002), high body mass index (p=0.001), and weak positivity for progesterone receptor (p=0.037) were found to be four independent predictors of an increased probability of BCS after NAC; further, these variables were used as covariates in developing the nomogram. For the training and validation cohorts, the areas under the receiver operating characteristic curve were 0.833 and 0.786, respectively; these values demonstrate the potential predictive power of this nomogram. CONCLUSION: This study established a new nomogram to predict successful BCS in patients with HR-positive, HER2-negative breast cancer. Given that chemotherapy is an option with unreliable outcomes for this subtype, this nomogram may be used to select patients for NAC followed by successful BCS.

Immunohistochemical Study for Expression of cFos, pERK1/2 and pAkt Proteins in a Macrosphere Animal Model for Permanent Focal Brain Ischemic Injury

PURPOSE: Recently, a new animal model for permanent focal brain ischemia using macrospheres was developed wherein the hypothalamic area was free from ischemic injury. The purpose of this study was to evaluate spatiotemporal changes in the expressions of cFos, pERK, and pAkt proteins in the macrosphere model. METHOD: Three or four macrospheres were injected into the internal carotid artery after ligation of the external carotid artery to induce permanent focal brain ischemic injury. RESULT: Twenty-four hours after macrosphere injection, 2,3,5-Triphenyltetrazlium (TTC) staining showed a marked ischemic injury in the blood supply territory of the middle cerebral artery, for example, the cerebral cortex and striatum. Furthermore, TUNEL staining revealed apoptotic cell death in the ischemic injury region of the cerebral cortex and striatum. Expression of the cFos protein was significant in the penumbral zone, but not in the ischemic core of the cortex and striatum, two and six hours after ischemic insult. A transient prominent expression of the pERK1/2 protein was noted in the penumbral zone of the cortex and striatum two hours after injection of macrospheres. In contrast, there was a strong immunoreactivity for the pAkt protein in the ischemic core, but not in the penumbral zone of the cortex and striatum, six hours after ischemic injury. CONCLUSION: The above results suggest that early expressions of cFos, pERK1/2, and pAkt proteins take part in different signaling cascades for cell survival or death in macrosphere animal model of permanent focal brain ischemic injury.

Plasma Homocysteine Level and Blood Coagulation Factors in Acute Ischemic Cerebral Stroke

PURPOSE: We studied the plasma homocysteine level and coagulation factors such as fibrinogen and antithrombin III (ATIII) in acute cerebral infarction (ACI). METHODS: We enrolled 222 patients who visited our emergency department from March 1, 2003, to August 31, 2003. The ACI patient group included those who visited the emergency department within 24 hours due to cerebral infarction symptoms and included 115 patients the control group included those visited the emergency department due to minor trauma (CRAMS score>9) and include 56 patients in the homocysteine control group and 51 in the fibrinogen and ATIII group. ACI patient group was subclassified according to great artery, small artery, or cardioembolic cerebral infarction. RESULTS: The plasma homocysteine level, the fibrinogen, and ATIII were 16.3+/-7.9 micrommol, 283.2+/-60.1 mg/dl, 87.3+/-25.8%, respectively, in the ACI patient group and 9.6+/-4.0 micrommol, 245.3+/-62.2 mg/dl, 109.8+/-14.7% in the control group. The values of plasma homocysteine and fibrinogen in the was higher than it was in the control group. The value of ATIII in the ACI patient group was lower than it was in the control group. In according to cerebral infarction type, no differences were observed in the plasma homocyteine, fibrinogen, and ATIII. CONCLUSION: In cases of acute cerebral infarction, fibrinogen and ATIII have no statistical usefulness in classifying the type of cerebral infarction. However, the value of plasma homocysteine, fibrinogen, and ATIII have statistical usefulness in deciding on the existence or nonexistence of an acute cerebral infarction.

Expressions of the pERK1/2 and the cFos Proteins at an Early Stage of Transient Global Ischemia-reperfusion Injury in the Hippocampus of Rats

PURPOSE: This study was to evaluate temporal changes in the expressions of the phosphorylated extracellular-regulated kinase1/2 (pERK1/2), the phosphorylated MAPK/ERK kinase1/2 (pMEK1/2) and the cFos proteins in the hippocampus of rats following transient global ischemia. METHODS: Transient global ischemia was induced in the forebrains of Sprague-Dawley rats by using a 4-vessel occlusion for 20 min under anesthetic condition. Hematoxyline-eosin staining showed typical microscopic findings that represented neuronal cell death in hippocampal CA1 regions 5 days after transient global ischemia. Four-vessel occlusion-reperfusion produced ischemic injury in major forebrain structures, such as the striatum, the cortex and the hippocampus, in the finding of triphenyltetrazolium chloride (TTC) staining. RESULTS: A high density of pERK1/2 immunoreactivity existed in the pyramidal-cell layers of the CA2-3 regions and in the granular-cell layers of the dentate gyrus 5 min after ischemia. Following ischemia, expression of the pMEK1/2 protein showed temporal changes similar to that of the pERK1/2 protein. A significant expression of the cFos protein was noted in the pyramidal-cell layers of the CA2-3 regions and in the granular-cell layers of the dentate gyrus 2 hours after global ischemia. CONCLUSION: Intracellular signaling cascades of the ERK or the cFos protein take part in early cellular events in the hippocampus of rats in response to ischemic insult.