Chylous Ascites After Gastric Cancer Surgery: Risk Factors and Treatment Results

Purpose@#Although chylous ascites is a frequent complication of radical gastrectomy for gastric cancer, proper diagnostic criteria and optimal treatment strategies have not been established. This study aimed to identify the clinical features of chylous ascites and evaluate the treatment outcomes. @*Materials and Methods@#We retrospectively analyzed the data of patients who underwent radical gastrectomy between 2013 and 2019. Diagnosis was made when milky fluid or elevated triglyceride levels (≥100 mg/dL) appeared in the drains without a preceding infection. The clinical features, risk factors, and treatment outcomes were assessed according to the initial treatment modalities for fasting and non-fasting groups. @*Results@#Among the 7,388 patients who underwent radical gastrectomy for gastric cancer, 156 (2.1%) experienced chylous ascites. The median length of hospital stay was longer in patients with chylous ascites than in those without (median [interquartile range]: 8.0 [6.0–12.0] vs. 6.0 [5.0–8.0], P<0.001). Low body mass index (adjusted odds ratio [aOR]=0.9; P<0.001), advanced gastric cancer (aOR=1.51, P=0.024), open surgery (reference: laparoscopic surgery; aOR=1.87, P=0.003), and extent of surgical resection (reference: subtotal gastrectomy, total gastrectomy, aOR=1.5, P=0.029; proximal gastrectomy, aOR=2.93, P=0.002) were associated with the occurrence of chylous ascites. The fasting group (n=12) was hospitalized for a longer period than the non-fasting group (n=144) (15.0 [12.5–19.5] vs. 8.0 [6.0–10.0], P<0.001). There was no difference in grade III complication rate (16.7% vs. 4.2%, P=0.117) or readmission rate (16.7% vs. 11.1%, P=0.632) between the groups. @*Conclusions@#A fat-controlled diet and medication without fasting provided adequate initial treatment for chylous ascites after radical gastrectomy for gastric cancer.

Intracorporeal modified delta-shaped gastroduodenostomy during 2-port distal gastrectomy:technical aspects and short-term outcomes

Purpose@#Surgeons have become increasingly interested in reduced-port gastrectomy to minimize trauma while maintaining oncologic safety. Although gastroduodenostomy has the benefits of better nutritional outcomes and fewer postoperative complications than other types of reconstruction, gastroduodenostomy is not a preferred option for reducedport distal gastrectomy because of technical difficulties. In this study, we describe our intracorporeal modified deltashaped gastroduodenostomy technique, which is easily applicable during 2-port distal gastrectomy. @*Methods@#We retrospectively reviewed our database of 30 consecutive patients with gastric cancer who underwent 2-port distal gastrectomy with intracorporeal modified delta-shaped gastroduodenostomy from October 2016 to May 2021. In this reduced-port approach, we used a Tropian Single port (TROPIAN TECH) via a 25-mm transumbilical incision and a 12-mm port at the right flank. All anastomoses were performed using a 60-mm endolinear stapler. We used 3 additional sutures to provide proper traction and support for the anastomosis. @*Results@#Mean ± standard deviation of operation time was 148.9 ± 34.7 minutes; reconstruction time was 13.2 ± 4.6 minutes; estimated blood loss was 29.3 ± 44.4 mL; and length of hospital stay was 4.5 ± 1.2 postoperative days. A total of 11 patients (36.7%) had a Clavien-Dindo grade I or grade II complication, and there were no grade IIIa or higher complications. @*Conclusion@#Intracorporeal modified delta-shaped gastroduodenostomy was safely performed via a 2-port approach, resulting in acceptable surgical outcomes and no major complications.

XperCT-guided Intra-cisterna Magna Injection of Streptozotocin for Establishing an Alzheimer’s Disease Model Using the Cynomolgus Monkey (Macaca fascicularis)

Till date, researchers have been developing animal models of Alzheimer’s disease (AD) in various species to understand the pathological characterization and molecular mechanistic pathways associated with this condition in humans to identify potential therapeutic treatments. A widely recognized AD model that mimics the pathology of human AD involves the intracerebroventricular (ICV) injection with streptozotocin (STZ).However, ICV injection as an invasive approach has several limitations related to complicated surgical procedures. Therefore, in the present study, we created a customized stereotaxic frame using the XperCT-guided system for injecting STZ in cynomolgus monkeys, aiming to establish an AD model. The anatomical structures surrounding the cisterna magna (CM) were confirmed using CT/MRI fusion images of monkey brain with XperCT, the c-arm cone beam computed tomography. XperCT was used to determine the appropriate direction in which the needle tip should be inserted within the CM region. Cerebrospinal fluid (CSF) was collected to confirm the accurate target site when STZ was injected into the CM.Cynomolgus monkeys were administered STZ dissolved in artificial CSF once every week for 4 weeks via intracisterna magna (ICM) injection using XperCT-guided stereotactic system. The molecular mechanisms underlying the progression of STZ-induced AD pathology were analyzed two weeks after the final injection. The monkeys subjected to XperCT-based STZ injection via the ICM route showed features of AD pathology, including markedly enhanced neuronal loss, synaptic impairment, and tau phosphorylation in the hippocampus. These findings suggest a new approach for the construction of neurodegenerative disease models and development of therapeutic strategies.

Impaired Hand Dexterity Function in a Non-human Primate Model with Chronic Parkinson’s Disease

ymptoms of Parkinson’s disease (PD) caused by loss of dopaminergic neurons are accompanied by movement disorders, including tremors, rigidity, bradykinesia, and akinesia. Non-human primate (NHP) models with PD play an essential role in the analysis of PD pathophysiology and behavior symptoms. As impairments of hand dexterity function can affect activities of daily living in patients with PD, research on hand dexterity function in NHP models with chronic PD is essential. Traditional rating scales previously used in the evaluation of animal spontaneous behavior were insufficient due to factors related to subjectivity and passivity. Thus, experimentally designed applications for an appropriate apparatus are necessary. In this study, we aimed to longitudinally assess hand dexterity function using hand dexterity task (HDT) in NHP-PD models. To validate this assessment, we analyzed the alteration in Parkinsonian tremor signs and the functionality of presynaptic dopaminergic neuron using positron emission tomography imaging of dopamine transporters in these models. In addition, a significant inverse correlation between HDT and DAT level was identified, but no local bias was found. The correlation with intention tremor signs was lower than the resting tremor. In conclusion, the evaluation of HDT may reflect behavioral symptoms of NHP-PD models. Furthermore, HDT was effectively used to experimentally distinguish intention tremors from other tremors.

Assessment of Hand Motor Function in a Non-human Primate Model of Ischemic Stroke

Ischemic stroke results from arterial occlusion and can cause irreversible brain injury. A non-human primate (NHP) model of ischemic stroke was previously developed to investigate its pathophysiology and for efficacy testing of therapeutic candidates; however, fine motor impairment remains to be well-characterized. We evaluated hand motor function in a cynomolgus monkey model of ischemic stroke. Endovascular transient middle cerebral artery occlusion (MCAO) with an angiographic microcatheter induced cerebral infarction. In vivo magnetic resonance imaging mapped and measured the ischemia-induced infarct lesion. In vivo diffusion tensor imaging (DTI) of the stroke lesion to assess the neuroplastic changes and fiber tractography demonstrated three-dimensional patterns in the corticospinal tract 12 weeks after MCAO. The hand dexterity task (HDT) was used to evaluate fine motor movement of upper extremity digits. The HDT was modified for a home cage-based training system, instead of conventional chair restraint training. The lesion was localized in the middle cerebral artery territory, including the sensorimotor cortex. Maximum infarct volume was exhibited over the first week after MCAO, which progressively inhibited ischemic core expansion, manifested by enhanced functional recovery of the affected hand over 12 weeks after MCAO. The total performance time decreased with increasing success rate for both hands on the HDT. Compensatory strategies and retrieval failure improved in the chronic phase after stroke. Our findings demonstrate the recovery of fine motor skill after stroke, and outline the behavioral characteristics and features of functional disorder of NHP stroke model, providing a basis for assessing hand motor function after stroke.

Prognostic Impact of Extended Lymph Node Dissection versus Limited Lymph Node Dissection on pN0 Proximal Advanced Gastric Cancer: a Propensity Score Matching Analysis

PURPOSE: Splenic hilar lymph node dissection (LND) during total gastrectomy is regarded as the standard treatment for proximal advanced gastric cancer (AGC). This study aimed to investigate whether splenic hilar LND or D2 LND is essential for proximal AGC of pT2-4aN0M0 stage. MATERIALS AND METHODS: Data of curative total gastrectomies (n=370) performed from 2000 to 2010 for proximal AGC of pT2-4aN0 stage were retrospectively reviewed. Clinicopathological characteristics and long-term outcomes were compared using propensity score matching between patients who underwent splenectomy (n=43) and those who did not (n=327) and between patients who underwent D2 LND (n=122) and those who underwent D1+ LND (n=248). RESULTS: Tumors of larger size and a more advanced T stage and significantly lower overall and relapse-free survival (P<0.001) were observed in the splenectomy group than in the 2 spleen-preserving groups. Before propensity score matching, worse overall and relapse-free survival (P<0.001) was observed in the splenectomy group than in the non-splenectomy group. After matching, although the overall survival became similar (P=0.123), relapse-free survival was worse in the splenectomy group (P=0.021). Compared with D1+ LND, D2 LND had no positive impact on the overall (P=0.619) and relapse-free survival (P=0.112) after propensity score matching. CONCLUSIONS: Splenic hilar LND with or without splenectomy may not have an oncological benefit for patients with pathological AGC with no LN metastasis.

Prognostic Evaluation of Neurological Assessment of the Neuro-Oncology Scale in Glioblastoma Patients

BACKGROUND: The aims of this study were to investigate the role of the Neurological Assessment of Neuro-Oncology (NANO) scale in predicting the prognosis of patients with glioblastoma, and compare these results to predicted data of the Karnofsky Performance Scale (KPS), and Eastern Cooperative Oncology Group (ECOG)/World Health Organization (WHO) performance status. Additionally, we examined other prognostic factors in glioblastoma patients. METHODS: The medical records of 76 patients with a new diagnosis of histologically ascertained glioblastoma in the period from January 2002 to December 2015 at the authors' institution were retrospectively reviewed. Clinical factors, including epidemiologic, radiologic, and therapeutic values were reviewed as well as the performance status assessed by the KPS, ECOG/WHO performance status, and NANO scale. RESULTS: The mean overall survival was 19.8 months (95% confidence interval 15.2–25.4 months). At initial diagnosis, the mean value [±standard deviation (SD)] of KPS score, ECOG/WHO performance status, and NANO scale were 81 (±7.4), 1.3 (±0.6), and 7.3 (±3.8), respectively. Multivariate analysis for predicting survival showed odds ratios of KPS score, ECOG/WHO performance status, and NANO scale were 2.502 (≥80 vs. < 80; p=0.024), 1.691 (0–1 vs. 2–5; p=0.047), and 2.763 (0–7 vs. 8–23; p=0.020), respectively. At the time of progression, the mean value (±SD) of KPS score, ECOG/WHO performance status, and NANO scale were 69 (±8.2), 1.6 (±0.7), and 11.4 (±4.2), respectively; multivariate analysis for predicting survival showed that the odd ratios for KPS score, ECOG/WHO performance status, and NANO scale were 2.007 (≥80 vs. < 80; p=0.035), 1.321 (0–1 vs. 2–5; p=0.143), and 3.182 (0–7 vs. 8–23; p=0.002), respectively. CONCLUSION: The NANO scale provided a more detailed and objective measure of neurologic function than that currently used for predicting the prognosis of glioblastoma patients, especially at the time of progression.

Acute Cholecystitis Associated with Gallbladder Metastasis of Gastric Cancer / 대한췌담도학회지

Gastric cancer mainly spreads to the liver, peritoneum, and lymph nodes and rarely metastasizes to the gallbladder. The prognosis of gastric cancer with metastasis to the gallbladder is reported to be very poor, and presentation with cholecystitis is a prognostic factor. Herein, we present a case of gastric cancer with metastasis to the gallbladder, accompanied by acute cholecystitis.

Neuroendocrine Tumors in the Stomach, Duodenum, and Pancreas Accompanied by Novel MEN1 Gene Mutation / 대한소화기학회지

Multiple endocrine neoplasia type 1 (MEN1) syndrome is a relatively rare disease, characterized by the occurrence of multiple endocrine tumors in the parathyroid and pituitary glands as well as the pancreas. Here, we report a case of MEN1 with neuroendocrine tumors (NETs) in the stomach, duodenum, and pancreas. A 53-year-old man visited our hospital to manage gastric NET. Five years prior to his visit, he had undergone surgery for incidental meningioma. His brother had pancreatic nodules and a history of surgery for adrenal adenoma. His brother's daughter also had pancreatic nodules, but had not undergone surgery. The lesion was treated by endoscopic submucosal dissection and diagnosed as a grade 1 NET. Another small NET was detected in the second duodenal portion, resected by endoscopic submucosal dissection, which was also diagnosed as a grade 1 NET. During evaluation, three nodules were detected in the pancreas, and no evidence of pituitary, parathyroid tumors, or metastasis was observed. After surgery, the pancreatic lesions were diagnosed as NETs, with the same immunohistochemical patterns as those of the stomach and duodenum. Genetic testing was performed, and a heterozygous mutation was detected in the MEN1 gene, which is located on 11q13.

Tuberculous Osteomyelitis of the First Metatarsophalangeal Joint Misdiagnosed as Gouty Arthritis

A-43-year-old man visited our clinic due to pain and swelling of his left first metatarsophalangeal (MTP) joint since 6-months ago. He was diagnosed as gouty arthritis at private clinic and took hypouricemic agent, but he had progressive pain and swelling. There was swelling, erythema and tenderness and ulceration at base of the left first MTP joint. His laboratory results showed elevated C-reactive protein and normal serum uric acid level. The plain radiograph of foot showed bone destruction of left first MTP joint. MRI revealed joint space narrowing, soft tissue swelling and subchondral cyst. He underwent excisional biopsy and histology demonstrated chronic granulomatous inflammation with caseation necrosis. Tissue polymerase chain reaction for mycobacterium tuberculosis was positive. He was diagnosed as tuberculous osteomyelitis. He started on quadruple anti-tuberculous therapy and his symptom was improved. Early diagnosis and anti-tuberculosis therapy could lead to improve outcomes.

Acute Transverse Myelitis in a Patient with Rheumatoid Arthritis Treated with Intravenous Immunoglobulin / 대한내과학회지

Acute transverse myelitis (ATM) is a heterogeneous syndrome characterized by acute spinal cord dysfunction resulting in paresis and sensory and autonomic impairment below the level of the lesion. The etiology of ATM includes parainfectious, paraneoplastic, drug-induced, systemic autoimmune disorders, and acquired demyelinating diseases. ATM is very rare in patients with rheumatoid arthritis (RA). A 79-year-old woman with RA, a recurring peptic ulcer, and congestive heart failure presented with acute weakness of both upper and lower extremities. She was diagnosed with ATM based on the results of laboratory and radiological tests. ATM is usually treated with high-dose glucocorticoid. However, we treated her with intravenous immunoglobulin (IVIG) considering the adverse events of high-dose glucocorticoid, and she improved. We report a case of ATM in a patient with RA successfully treated with IVIG.

The Effect of Surgical Scrub in Orthopaedic Surgery / 대한정형외과학회잡지

PURPOSE: Two antiseptic solutions were investigated for their effect on bacterial growth inhibition. MATERIALS AND METHODS: A total of 38 patients were included in this study, who visited Daegu Catholic Medical Center from August 2, 2011 to September 2, 2011. Bacterial culture was performed at the pre-scrub, post-scrub, and postoperation; patients were divided into two groups according to use of povidone iodine (3.75%) and povidone iodine with Softa-Man(R) as antiseptic agents at the surgical. RESULTS: Comparison between the antiseptic solutions showed a significant difference for the presence of gram positive cocci (p=0.034), however, no difference was observed for the presence of gram positive bacilli (p=0.838). As the scrub time increased, the positive detection ratio of bacteria decreased (p=0.000), and decreased significantly at more than 120 seconds. However, positive detection ratio of bacteria increased significantly at more than 300 seconds in cases with povidone iodine only (p=0.014). Glove wearing time did not have a significant influence on the positive detection ratio of bacteria, and no significant difference was observed between the antiseptic solutions (p=0.143). CONCLUSION: Considering the positive detection ratio of bacteria when using povidone iodine only, the appropriate scrub time should be between 4 and 5 minutes. When using both antiseptics, at least 2 minutes of scrub time is needed.

Effect of gingival health promotion and oral hygiene improvement for children using vibratory toothbrushes / 대한구강보건학회지

OBJECTIVES: The purpose of this study was to evaluate the effect of periodontal health promotion and oral hygiene in children using a vibrating toothbrush. METHODS: Forty-seven volunteers aged between 7-15 years participated in this study at local care centers from January to February 2013. A vibratory toothbrush for children was designed with the bristles operating on a self-vibration system that separated the head-neck part of the toothbrush from the handle. The toothbrush was designed with the aim of massaging the gingiva and reducing gingival inflammation. The papillary marginal attachment (PMA) index and O'Leary plaque index were measured by oral examinations before and at 4 weeks after brushing with the vibrating toothbrush. RESULTS: The PMA index and O'Leary plaque index were reduced from 39.20 to 25.42 (P<0.001) and from 5.56 to 2.78 (P<0.001), respectively. CONCLUSIONS: These results suggested that vibrating toothbrushes designed for children can be helpful in promoting gingival health and improving oral hygiene.

A Case of Vancomycin Resistant Enterococcal Urinary Tract Infection and Pseudomembranous Colitis Co-Infection / 대한신장학회지

Infections are the second leading cause of mortality among patients with end-stage renal disease (ESRD). Recently, colonization or infection with vancomycin-resistant enterococci (VRE) is increasing in prevalence at many institutions and is often reported in dialysis patients. Enterococci are generally considered to be of low pathogenicity but may cause urinary tract infection, bacteremia, endocarditis or meningitis in debilitated patients. Three cases of VRE peritonitis in patients on CAPD were reported, but there was no report of VRE urinary tract infection (UTI) in hemodialysis patients in Korea. We present a case of VRE UTI with pseudomembranous colitis (PMC) in an ESRD patient with anal VRE colonization. The VRE UTI was treated successfully with linezolid.

A Case of Severe Acute Renal Failure Due to Sodium Bromate Intoxication / 대한신장학회지

Bromate is an oxidizing agent used as a permanent wave neutralizer. Accidental or deliberate ingestion of bromate has rarely been reported, but is potentially severe. We report a 36-year-old female hairdresser, who was admitted due to nausea and vomiting after ingestion of sodium bromate. The patient was successfully treated with hemodialysis therapy and renal function recovered without any complication. The clinicians must remember that early therapeutic measures, including hemodialysis, should be taken as soon as possible to prevent irreversible hearing loss and renal failure.

A Case of Adult Minimal Change Nephrotic Syndrome Associated with Thin Basement Membrane Nephropathy / 대한신장학회지

Thin basement membrane nephropathy (TBMN) is characterized by persistent hematuria, mild proteinuria, normal renal function and family history of hematuria. Many studies report that TBMN commonly occurs together with other glomerular diseases such as minimal change nephrotic syndrome, membranous nephropathy, IgA nephropathy and focal segmental glomerulosclerosis. Especially, the case of TBMN with minimal change nephrotic syndrome has been rare. We report a case of adult minimal change nephrotic syndrome with TBMN in a 44-year-old female with general edema and microscopic hematuria. On renal biopsy, electron microscopic examination demonstrated diffuse thinning of glomerular basement membrane with the thickness less than 250nm and diffuse foot process effacement. Treatment with corticosteroid resulted in complete remission of proteinuria.

A Case of Inferior Vena Cava Thrombosis and Acute Pancreatitis in a Patient with Ulcerative Colitis / 대한소화기학회지

A 21-year-old man admitted complaining of sudden severe epigastric pain for 1 day. He had been diagnosed as ulcerative colitis (UC) and taking mesalazine for two months. UC was in nearly complete remission at admission. He never drank an alcohol, and serum amylase was 377 IU/L. CT scan showed inferior vena cava (IVC) thrombosis in addition to mild acute pancreatitis. To evaluate the cause of acute pancreatitis and IVC thrombosis, magnetic resonance cholangiopancreatogram (MRCP), endoscopic ultrasonogram (EUS), lower extremity Doppler ultrasonogram (US) and blood test of hypercoagulability including factor V, cardiolipin Ab, protein C, protein S1, antithrombin III, and anti phospholipids antibody were performed. There was no abnormality except mild acute pancreatitis and IVC thrombosis in all the tests. He was recommended to stop taking mesalazine and start having anticoagulation therapy. After all symptoms disappeared and amylase returned normal, rechallenge test with mesalazine was done. Flare-up of abdominal pain occurred and the elevation of serum amylase was observed. Ulcerative colitis came to complete remission with short-term steroid monotherapy. Acute pancreatitis and IVC thrombosis were completely resolved after 3-month anticoagulation therapy with no more mesalazine. We postulated that IVC thrombosis occurred due to hypercoagulable status of UC and intra-abdominal inflammation caused by mesalazine-induced pancreatitis.

A Case of Systemic Lupus Erythematosus Involving the Kidneys in a Patient with IgA Nephropathy / 대한류마티스학회지

Renal involvement in systemic lupus erythematosus (SLE) is a typical manifestation of the disease. The occurrence of non-lupus nephritis, especially IgA nephropathy (IgAN), in patients with SLE has rarely been reported. We describe the case of a 21-year-old woman who was diagnosed with IgAN and subacute necrotizing lymphadenitis, and her renal lesion biopsy was typical of lupus nephritis (ISN/RPS Class III). Although IgAN and lupus nephritis share some common physiopathological characteristics, their laboratory, histopathologic findings, and the extra-renal clinical manifestations are different and support a different pathogenesis. Our case highlights the importance of a renal biopsy in patients with lupus and urinary alterations despite underlying IgAN. A correct diagnosis would permit the most appropriate immunosuppressive treatments to be considered.

A Patient Diagnosed as Autoimmune Pancreatitis 6 Years after Onset of Jaundice / 대한소화기학회지

The clinical manifestations of autoimmune pancreatitis (AIP) are diffuse pancreatic swelling, diffuse irregular narrowing of the main pancreatic duct, and increased serum IgG or positive serum autoantibody. Clinically, AIP can be improved dramatically with oral steroid therapy. In this report, we describe a 62-year-old woman diagnosed as autoimmune pancreatitis six years after onset of jaundice, who presented with uncontrolled blood glucose levels. The laboratory tests revealed obstructive jaundice, and the computed tomography of the pancreas showed pancreatic swelling. After six years of onset, she was diagnosed with AIP and successfully treated with steroid treatment.

Virologic response to adefovir dipivoxil monotherapy is not durable in HBeAg-positive, lamivudine-resistant chronic hepatitis B patients / 대한간학회지

BACKGROUNDS/AIMS: It has been shown that adefovir dipivoxil is an effective antiviral agent in the treatment of chronic hepatitis B (CHB), not only in wild-type hepatitis B virus (HBV) infection, but also in lamivudine-resistant (LAMV-R) cases. However, little is known about the durability of the virologic response to adefovir in LAMV-R CHB patients. METHODS: Fifteen HBV e-antigen (HBeAg)-positive, LAMV-R CHB patients showed a virologic response to adefovir monotherapy. These patients received additional adefovir for at least a further 12 months. The virologic relapse rate after discontinuation of adefovir was evaluated. In addition, predictive factors associated with virologic relapse were investigated. RESULTS: The median level of serum HBV DNA before adefovir administration was 7,457,840 IU/mL (range 107,920-99,524,960 IU/mL). The median duration of adefovir treatment was 30 months (range 14-46 months). During a median follow-up period of 14 months after discontinuation of adefovir, the 1-, 2-, 3-, 6-, and 12-month cumulative relapse rates were 26.7%, 53.3%, 73.3%, 80%, and 80%, respectively. High pretreatment HBV DNA levels were found to be the only factor that was predictive of off-therapy relapse. CONCLUSIONS: Our data suggest that the adefovir-monotherapy-induced virologic response is not durable in most patients with LAMV-R HBeAg-positive CHB, especially in those with a high pretreatment HBV DNA level.