The effect of probiotics supplementation in postoperative cancer patients: a prospective pilot study

Purpose@#Microbiota manipulation through selected probiotics may be a promising tool to prevent cancer development as well as onset, to improve clinical efficacy for cancer treatments. The purpose of this study was to evaluate change in microbiota composition after-probiotics supplementation and assessed the efficacy of probiotics in improving quality of life (QOL) in postoperative cancer patients. @*Methods@#Stool samples were collected from 30 cancer patients from February to October 2020 before (group I) and after (group II) 8 weeks of probiotics supplementation. We performed 16S ribosomal RNA gene sequencing to evaluate differences in gut microbiota between groups by comparing gut microbiota diversity, overall composition, and taxonomic signature abundance. The health-related QOL was evaluated through the EORTC Quality of life Questionnaire Core 30 questionnaire. @*Results@#Statistically significant differences were noted in group II; increase of Shannon and Simpson index (P = 0.004 and P = 0.001), decrease of Bacteroidetes and Fusobacteria at the phylum level (P = 0.032 and P = 0.014, retrospectively), increased of beneficial bacteria such as Weissella (0.096% vs. 0.361%, P < 0.004), Lactococcus (0.023% vs. 0.16%, P < 0.001), and Catenibacterium (0.0% vs. 0.005%, P < 0.042) at the genus level. There was a significant improvement in sleep disturbance (P = 0.039) in group II. @*Conclusion@#Gut microbiota in cancer patients can be manipulated by specific probiotic strains, result in an altered microbiota. Microbiota modulation by probiotics can be considered as part of a supplement that helps to increase gut microbiota diversity and improve QOL in cancer patients after surgery.

Influence of the Enhanced Recovery After Surgery Protocol on Postoperative Inflammation and Short-term Postoperative Surgical Outcomes After Colorectal Cancer Surgery

Purpose@#Many studies have shown that the enhanced recovery after surgery (ERAS) protocols improve postoperative surgical outcomes. The purpose of this study was to observe the effects on postoperative inflammatory markers and to explore the effects of a high degree of compliance and the use of epidural anesthesia on inflammation and surgical outcomes. @*Methods@#Four hundred patients underwent colorectal cancer surgery at 2 hospitals during 2 different periods, namely, from January 2006 to December 2009 and from January 2017 to July 2017. Data related to the patient’s clinicopathological features, inflammatory markers, percentage of compliance with elements of the ERAS protocol, and use of epidural anesthesia were collected from a prospectively maintained database. @*Results@#The complication rate and the length of hospital stay (LOS) were less in the ERAS group than in the conventional group (P = 0.005 and P ≤ 0.001, respectively). The postoperative white blood cell count and the duration required for leukocytes to normalize were reduced in patients following the ERAS protocol (P ≤ 0.001). Other inflammatory markers, such as lymphocyte count (P = 0.008), neutrophil/lymphocyte ratio (P = 0.032), and C-reactive protein level (P ≤ 0.001), were lower in the ERAS protocol group. High compliance ( ≥ 70%) was strongly associated with the complication rate and the LOS (P = 0.008 and P ≤ 0.001, respectively). @*Conclusion@#ERAS protocols decrease early postoperative inflammation and improves short-term postoperative recovery outcomes such as complication rate and the LOS. High compliance ( ≥ 70%) with the ERAS protocol elements accelerates the positive effects of ERAS on surgical outcomes; however, the effect on inflammation was very small.

At Which Stage of Gastric Cancer Progression Do Levels of Carcinoembryonic Antigen and Carbohydrate Antigen 19-9 Increase? Application in Advanced Gastric Cancer Treatment

PURPOSE: Since there are no proven tumor markers that reflect the course of gastric cancer, carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA19-9) are commonly used alternatives. However, the degree of progression that corresponds to an increase in these markers, and the values of these markers at different cancer stages, remains unclear. MATERIALS AND METHODS: This study enrolled 1,733 gastric cancer patients who underwent surgery and whose pre-operative CEA and CA19-9 levels were known. Survival curves and mean values of the two markers were compared according to the degree of cancer progression: serosa-unexposed (SU), serosa-exposed (SE), direct invasion (DI), localized seeding (P1), and extensive seeding (P2). RESULTS: The 5-year overall survival rates at each stage differed significantly, except between DI and P1 patients (17.1% vs. 10.5%, P=0.344). The mean CEA values in SU, SE, DI, P1, and P2 patients were 5.80, 5.48, 13.36, 8.06, and 22.82, respectively. The CA19-9 values for these patients were 49.40, 38.97, 101.67, 73.77, and 98.57, respectively. The increase in CEA in P2 patients was statistically significant (P=0.002), and the increases in CA19-9 in DI and P2 patients were significant (P=0.025, 0.007, respectively). There was a fair correlation between the two markers in P2 patients (r=0.494, P<0.001). CONCLUSIONS: CA19-9 can be used to assess DI of gastric cancer into adjacent organs. Both markers are useful for predicting the presence of extensive peritoneal seeding.

The Impact of an Increased Application of Critical Pathway for Gastrectomy on the Length of Stay and Cost

PURPOSE: We developed a standardized critical pathway for gastric cancer surgery and then determined the increase of application, which resulted in an improvement in terms of measurable indices, such as hospital stay and cost. MATERIALS AND METHODS: A critical pathway was revised and used widely from the 2nd quarter of 2009. We collected clinical data, such as length of stay and complication rate, as clinical indices of quality prospectively. The total cost paid at the patient's discharge, as well as the daily hospital income, were calculated and compared by each quarter from January 2008 to December 2009. RESULTS: The application rate of critical pathway was 11.8% and 87.8% in 2008 and 2009, respectively. There were no perioperative deaths. There was no difference in the complication rates between 2008 and 2009 (P=0.45). However, the mean length of stay was significantly different between the 2 years (P<0.05). Although the total cost was not different, the daily hospital income was significantly higher in the latter year (P<0.05). CONCLUSIONS: An increase in the application of critical pathway for gastrectomy resulted in significant decreases in length of stay and increases in the daily hospital income without a compromise on the clinical indices.

Susceptibility of gastric cancer according to leptin and leptin receptor gene polymorphisms in Korea / 대한외과학회지

PURPOSE: Leptin plays an important role in the control of body weight and also has a growth-factor-like function in epithelial cells. Abnormal expression of leptin and leptin receptor may be associated with cancer development and progression. We evaluated the relationship among leptin and leptin receptors polymorphisms, body mass index (BMI), serum leptin concentrations, and clinicopathologic features with gastric cancer and determined whether they could be the risk factor of gastric cancer. METHODS: We measured the serum leptin concentrations of 48 Korean patients with gastric cancer and 48 age- and sex-matched controls. By polymerase chain reaction-restriction fragment length polymorphism, we investigated one leptin gene promoter G-2548A genotype and four leptin receptor gene polymorphisms at codons 223, 109, 343, and 656. RESULTS: There was no significant difference between the mean leptin concentrations of the patient and control groups, while BMI was significantly lower in gastric cancer cases (22.9 +/- 3.6 vs. 24.5 +/- 2.8 kg/m2, P = 0.021). There was significant association between the LEPR Lys109Arg genotype and gastric cancer risk, heterozygotes for GA genotype had been proved to increased the risk of gastric cancer, and its corresponding odds ratio was 2.926 (95% confidence interval, 1.248 to 6.861). CONCLUSION: Our results suggested that LEPR gene Lys109Arg polymorphism is associated with gastric cancer in Korean patients.

Mixed Exocrine and Endocrine Carcinoma in the Stomach: A Case Report

We report a rare case of the coexistence of a gastric small cell neuroendocrine carcinoma with a gastric adenocarcinoma. A 62-year-old man presented with epigastric soreness for 1 month. Esophagogastroduodenoscopy revealed a Borrmann type I tumor at the lesser curvature of the lower body of the stomach. The patient underwent a distal gastrectomy with D2 lymph node dissection and the resected specimen exhibited a 3.5x3.5 cm sized, fungating lesion. Two separated, not intermingling, lesions with non-adenocarcinoma components encircled by well differentiated adenocarcinoma components were identified microscopically. The non-adenocarcinoma component showed neuroendocrine features, such as a solid and trabecular pattern, and the tumor cells showed a high nuclear grade with minimal cytoplasm, indistinct nucleoli, and positive response for synaptophysin, CD56. The final pathological diagnosis was a gastric mixed exocrine-endocrine carcinoma (MEEC) composed of an adenocarcinoma and small cell neuroendocrine carcinoma of the collision type.

Expression of c-erbB2 and p53 in Curatively Resected Gastric Cancer: Correlation with Clinicopathologic Features and Prognosis

PURPOSE: We investigated the correlation between expression of c-erbB-2 and p53 proteins and clinicopathologic features of gastric cancer to reveal prognostic factors. METHODS: 125 patient records under going curative resection for gastric carcinoma at our institution from January 2000 to June 2003 were collected. Surgical specimens embedded in paraffin block were evaluated for p53 and c-erbB-2 protein as detected by immunohistochemistry. RESULTS: Samples from 30 cases (24.0%) of 125 patients with gastric adenocarcinomas demonstrated positive staining for c-erbB-2 and 72 patients (57.6%) showed positive nuclear staining for p53 protein. c-erbB-2 stained tumors were significantly associated with the depth of tumor invasion (P=0.022), lymph node metastasis (P=0.004) and lymphatic invasion (P=0.019). In a subgroup of patients with gastric carcinoma not exposed to serosa (n=91), expression of both c-erbB-2 and p53 significantly related with poor disease-free survival (OR=5.107) and survival (OR=4.449) in multivariate analysis. CONCLUSION: When patients with gastric adenocarcinoma showed expression of c-erbB-2 with p53, they were associated with aggressive pathologic features. In the subgroup of patients with gastric adenocarcinoma that did not involve serosa, expression of c-erbB-2 combined with p53 could become a predictive factor for recurrence and survival in multivariate analysis.

Management of Anastomotic Leakage after Gastrointestinal Surgery Using Fluoroscopy-guided Foley Catheter

PURPOSE: The aim of this study is to present cases of postoperative leakage after various types of gastrointestinal operations that were successfully managed with fluoroscopy-guided Foley catheter. METHODS: Fluoroscopy-guided Foley catheter insertion and drainage methods were performed in 13 leakage sites of 10 patients diagnosed as having leakage after gastrointestinal operations such as esophagectomy, gastrectomy and appendectomy. Under fluoroscopic guidance, a guide-wire was inserted into the leakage site where a Foley catheter was then introduced over the guide wire, inserted and ballooned. RESULTS: The median time for the procedures was 30 minutes (range: 20~260 minutes), with esophagus or stomach leakage sites requiring a longer procedure time than the appendiceal or duodenal stump. The indwelling Foley catheters were successfully removed after a median of 11 days (range: 8~44 days), and the opening of the enterocutaneous fistulas were spontaneously closed in eight out of 10 patients. CONCLUSION: The application of this method showed good results and could be a useful method to manage leakage after gastrointestinal surgery, especially in patients with leakage from the stump of the duodenum or appendix.

Gastric Cancer Susceptibility according to Methylenetetrahydrofolate Reductase and Thymidylate Synthase Gene Polymorphism

PURPOSE: The genetic polymorphism and intracellular activity of methylenetetrahydrofolate reductase (MTHFR) and thymidylate synthase (TS) is clinically associated with carcinogenesis and biological therapeutic effect in gastrointestinal malignancies. We aimed to elucidate the susceptibility of gastric cancer according to MTHFR and TS gene polymorphism. METHODS: This study was designed as a hospital-based case-control study in a single institute. The gastric cancer group (n=300) for the study was diagnosed at first time as tubular adenocarcinoma, and the control group (n=100) was diagnosed as no malignancy in the endoscopic biopsy. The genetic polymorphism of TS and MTHFR were confirmed by PCR. RESULTS: The MTHFR mutant type had a more than 2-fold increased risk of developing gastric cancer (RR: 2.341). But, only heterozygote type (677CT) revealed significantly higher susceptibility compared to wild type (RR: 2.581). In TS gene genotype, the mutant genotype rate (2R/3R and 3R/3R) was significantly higher in gastric cancer group compared to control group (P=0.008), and the mutant type had a more than 3-fold increased risk of developing gastric cancer (RR: 3.222). In combined MTHFR and TS, 677CT+2R/3R and 677CT+3R/3R there was more than a 3-fold increased risk rate of developing gastric cancer compared with other combinations (RR, 3.474 in 677CT with 2R/3R; RR, 3.895 in 677CT with 3R/3R). CONCLUSION: This study shows a significant association between the MTHFR and TS polymorphisms and susceptibility to gastric cancer, providing a genetic basis. The polymorphisms study of two genes could be applied as susceptibility markers, clinically, for gastric cancer.

Effect of Roux-en-Y Gastric Bypass on Body Weight, Ghrelin and PYY(3-36) in Diet-induced Obese Rats

PURPOSE: Obesity is considered an epidemic worldwide. Nonsurgical treatment such as dietary, physical and pharmacological therapies have limited success and thus, bariatric surgery is the ultimate option. Roux-en-Y gastric bypass (RYGB) is a bariatric procedure, which is a restrictive and malabsorptive procedure simultaneously. The purpose of this study was to develop surgical rat models of bariatric surgery and analyze the effect of gastric bypass on body weight, ghrelin and polypeptide YY(3-36) (PYY(3-36)) changes in rats. METHODS: RYGB, sleeve gastrectomy (SG) and sham operation were performed in diet-induced obese rats and compared to obese control and normal control rats. RESULTS: In RYGB group, 20.7+/-8.56% of weight loss was achieved on postoperative day 18 and maintained thereafter. This outcome was significant compared to SG (8.8+/-1.82%) and sham operated (6.2+/-2.45%) groups. When pre- and postoperative ghrelin levels were compared, there was a significant decrease in RYGB group (P<0.028); nonetheless, there was no difference in SG and sham operated groups. When pre- and postoperative PYY(3-36) levels were compared, there was a significant increase in RYGB (P<0.028), SG (P<0.031) and sham operated (P<0.031) groups. CONCLUSION: We developed surgical rat models of RYGB and SG. Those rats that underwent RYGB lost significant body weight and maintained the weight thereafter. The decrease in ghrelin and increase in PYY(3-36) may be associated with loss of appetite and delay in intestinal transit time with subsequent weight loss maintenance. In the future, this rat model would serve as a tool for further study on endocrine regulation of obesity.

Clinical Evaluation of Immediate Removal of Transurethral Catheter after Radical Gastrectomy: A Result of Feasibility Study

PURPOSE: Transurethral catheterization is restricted to fewer procedures and a limited time with an increase in enhanced recovery after surgery (ERAS) programs or fast-track surgical procedures. We aim to evaluate the feasibility of immediate removal of transurethral catheter in hemodymically stable patients undergoing radical gastrectomy prior to a prospective randomized control trial. METHODS: A total 63 gastric cancer patients undergoing elective radical gastrectomy were enrolled in a feasibility study. Patients were randomized to either the active group (immediate removal group) or control group (removal at postoperative day 1 group) with blinding, and 58 patients were finally included. Amount of residual and voiding urine, operative factors (operation time, infused fluid, urine output, and blood loss), first voiding discomfort level, urinary discomfort score, and urine analysis were measured. RESULTS: In the active group, the self-voiding volume and residual urine volume measured nearly equal (256 ml vs 244 ml) at 16 hours after transurethral catheter removal. The discomfort score of first self-voiding was lower in active group (P=0.041). Regarding urinary discomfort at postoperative day 2 and the urine analysis at postoperative day 5, there were no significant differences between the 2 groups. CONCLUSION: Immediate removal of the transurethral catheter could be feasible and safe in hemodynamically stable patients undergoing radical gastrectomy in aspects of ERAS programs. A prospective randomized controlled trial would be scheduled for acceptable evidence.

Outcomes of Modified FOLFOX-6 as First Line Treatment in Patients with Advanced Gastric Cancer in a Single Institution; Retrospective Analysis / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: Treatment options for patients with advanced gastric cancer remain limited. Few studies have investigated the efficacy and tolerability of the combination regimen of oxaliplatin and 5-fluorouracil with leucovorin for patients with advanced gastric cancer. The goal of this study was to examine the efficacy and toxicity of a modified FOLFOX-6 (mFOLFOX-6) regimen as a first-line chemotherapy regimen for patients with advanced gastric cancer. MATERIALS AND METHODS: From March, 2006, to December, 2007, 82 patients with advanced gastric cancer received 100 mg/m2 oxaliplatin and 100 mg/m2 leucovorin on the first day of treatment, followed by 2,400 mg/m2 of 5-fluorouracil on the first and second days of treatment every 2 weeks as a first-line treatment. RESULTS: The median age of the enrolled patients was 62 years (range; 30~75). Out of 82 patients, 34 cases (41.5%) were recurrent cases after curative resection, and the other 48 cases were unresectable or non-curative resectable cases. Their response was evaluated every 6 weeks. The overall response rate was 40.2%, with 2 (2.4%) complete response and 31 (37.8%) partial responses. The median time to progression (TTP) and overall survival (OS) time were 6.0 months (95% confidence interval [CI]: 4.69~7.31) and 13.0 months (7.99~18.0), respectively. The grade 3~4 hematologic toxicities observed included neutropenia (34.1%), thrombocytopenia (7.3%), and anemia (1.2%). The gastrointestinal toxicities observed included grade 3~4 nausea (9.8%) and vomiting (7.3%). Six patients (7.3%) experienced grade 3 neuropathy. No treatment-related deaths were recorded. CONCLUSION: The modified FOLFOX-6 regimen is effective and well tolerated as a first-line chemotherapy regimen for patients with advanced gastric cancer.

The Feasibility of Short Term Prophylactic Antibiotics in Gastric Cancer Surgery

PURPOSE: Most surgeons administer prophylactic antibiotics for 3 to 5 days postoperatively. However, the Center for Disease Control (CDC) guideline recommends antibiotic therapy for 24 hours or less in clean/uncontaminated surgery. Thus, we prospectively studied the use of short term prophylactic antibiotic therapy after gastric cancer surgery. MATERIALS AND METHODS: A total of 103 patients who underwent gastric cancer surgery between October 2007 and June 2008 were prospectively enrolled in a short term prophylactic antibiotics program. One gram of cefoxitin was administered 30 minutes before the incision, and one additional gram was administered intraoperatively for cases with an operation time over 3 hours. Postoperatively, one gram was administered 3 times, every 8 hours. Patients were checked routinely for fever. All cases received open surgery, and the surgical wounds were dressed and checked for Surgical Site Infection (SSI) daily. RESULTS: Of the 103 patients, 15 were dropped based on exclusion criteria (severe organ dysfunction, combined resection of the colon, etc). The remaining 88 patients were included in the short-term program of prophylactic antibiotic use. Of these patients, SSIs were detected in 8 (9.1%) and fever after 2 postoperative days was detected in 11 (12.5%). The incidence of SSIs increased with patient age, and postoperative fever correlated with operation time. CONCLUSIONS: Short term prophylactic antibiotic usage is feasible in patients who undergo gastric cancer surgery, and where there are no grave comorbidities or combined resection.

The Feasibility of Short Term Prophylactic Antibiotics in Gastric Cancer Surgery

PURPOSE: Most surgeons administer prophylactic antibiotics for 3 to 5 days postoperatively. However, the Center for Disease Control (CDC) guideline recommends antibiotic therapy for 24 hours or less in clean/uncontaminated surgery. Thus, we prospectively studied the use of short term prophylactic antibiotic therapy after gastric cancer surgery. MATERIALS AND METHODS: A total of 103 patients who underwent gastric cancer surgery between October 2007 and June 2008 were prospectively enrolled in a short term prophylactic antibiotics program. One gram of cefoxitin was administered 30 minutes before the incision, and one additional gram was administered intraoperatively for cases with an operation time over 3 hours. Postoperatively, one gram was administered 3 times, every 8 hours. Patients were checked routinely for fever. All cases received open surgery, and the surgical wounds were dressed and checked for Surgical Site Infection (SSI) daily. RESULTS: Of the 103 patients, 15 were dropped based on exclusion criteria (severe organ dysfunction, combined resection of the colon, etc). The remaining 88 patients were included in the short-term program of prophylactic antibiotic use. Of these patients, SSIs were detected in 8 (9.1%) and fever after 2 postoperative days was detected in 11 (12.5%). The incidence of SSIs increased with patient age, and postoperative fever correlated with operation time. CONCLUSIONS: Short term prophylactic antibiotic usage is feasible in patients who undergo gastric cancer surgery, and where there are no grave comorbidities or combined resection.

Near-Total Gastrectomy Preserving the Lower Esophageal Sphincter Followed by Jejunal Pouch Interposition as a Treatment for Upper Gastric Cancer

PURPOSE: Conventional total gastrectomy with Roux-en-Y esophagojejunostomy has certain limitations such as insufficient food reservoir and malabsorption of nutrients. Therefore, we performed reconstruction of the jejunal pouch interposition (JPI) after near-total gastrectomy preserving the lower esophageal sphincter (LES). We compared the technical feasibility, safety, and surgical outcome of this operation with conventional total gastrectomy accompanying with Roux-en-Y esophagojejunostomy. METHODS: From April 2003 to October 2005, 15 LES-preserving, near-total gastrectomies with JPI (LES-JPI group) were performed. The clinical features and surgical outcomes were retrospectively compared with 17 cases of conventional R-Y esophagojejunostomy. Statistical analysis was performed using Fisher's exact test for categorical data and an unpaired t-test for continuous data. RESULTS: Clinicopathological features of the LES-JPI and R-Y groups did not show differences excepting patient age (50.8+/-5.8 years vs. 62.8+/-12.4, respectively; P=0.002) and the depth of tumor invasion (T1-T2; 11~4 vs. 5~12; P=0.032). The operative outcomes for the two groups significantly differed in terms of operation time (676 vs. 484 min; P=0.008) and blood loss (424 vs. 336 ml; P=0.006). Postoperative gastrofiberscopic examination of all LES-JPI patients showed no esophageal reflux or strictures and intact LES. In addition, the LES-JPI group did not experience swallowing difficulty or stricture. CONCLUSION: LES-preserving total gastrectomy with JPI is a feasible and safe procedure for patients with upper gastric cancer.

Chemotherapeutic Responsibility according to Polymorphism of ERCC1, XRCC1 and GSTP1 in Gastric Cancer Patients Receiving Oxaliplatin Based Chemotherapy

PURPOSE: The platinum-based modified FOLFOX-6 has been reported as an acceptable chemotherapeutic regimen in treatment of advanced gastric cancer patients. The response rate and drug-induced toxicity of platinum-based chemoagents is different according to several gene polymorphism such as ERCC1, XRCC1 and GSTP1 genes, which were related with therapeutic mechanisms. We aimed to evaluate the effect of gene polymorphism and determine the possibility as prediction factor for responsibility in advanced and recurrent gastric cancer patients treated with modified FOLFOX-6 regimen. METHODS: This study was conducted with 55 patients. We sampled 20 ml of peripheral blood to isolate DNA from lymphocytes, and identified genotypes of 3 genes (ERCC1, XRCC1, GSTP1) by PCR-RFL of extracted DNA. Based on medical records, retrospective analysis was made on the patients' clinical characteristics. RESULTS: The overall response rate to modified FOLFOX-6 was 40.0% (22/55). In polymorphism of ERCC1 C8092A, the wild type (CC) showed a statistically significantly lower response rates to chemoagents than the mutant type (CA/AA). In the subtypes of ERCC1 C118T, however, the wild type (CC) showed statistically significantly lower hematological toxicity than the mutant type (CA/AA). But, there was no statistically significance in survival analysis. CONCLUSION: We suggest that ERCC1 gene polymorphism is clinically more adequate as a feasible factor for predicting the response rate and toxicity of modified FOLFOX-6 regimen in gastric cancer patients.

The Role of Preoperative Magnetic Resonance Imaging for Detecting the Extent of Disease and Predicting the Prognosis of Ductal Carcinoma In Situ / 한국유방암학회지

PURPOSE: Magnetic Resonance Imaging (MRI) is widely used for the preoperative staging of breast cancer. In this study, we investigated a role of preoperative breast MRI for detecting the extent of disease and predicting the prognosis of ductal carcinoma in situ (DCIS). METHODS: From January 2002 to April 2008, preoperative MRI was performed for evaluating the extent of disease in 26 patients with DCIS. The MRI findings, the modified Van Nuys scores and the clinicopathological results were reviewed. The accuracy of breast MRI was analyzed with respect to the detection of tumor multiplicity and disease extending into the nipple, and this was compared with that of mammography. RESULTS: For detecting multiple lesions, the sensitivity and specificity of breast MRI were 25.0% and 86.4%, respectively, and the results of mammography were 0.0% and 86.4%, respectively. The accuracy of breast MRI was 76.9% and that of mammography was 73.1%. For detecting tumor extension into the nipple, the sensitivity and specificity of breast MRI was 100.0% and 80.0%, respectively, and that for mammography was 0.0% and 92.0%. respectively. The accuracy of MRI was 80.8% and that for mammography was 88.5%. The MRI final assessment was not associated with the modified Van Nuys score (p=0.474). CONCLUSION: For detecting the disease extent of DCIS, preoperative breast MRI is not superior to mammography due to the low specificity and accuracy of MRI. MRI did not show a definite ability to predict the prognosis of DCIS in this study.

Is a Fast-track Critical Pathway Possible in Gastric Cancer Surgery?

PURPOSE: The postoperative hospital stay after gastric cancer surgery is usually 8 to 14 days. The main reason for a prolonged hospital stay may be the 3 to 4 day period of postoperative starvation. The aim of this study is to investigate the feasibility of a critical pathway for early recovery after gastric cancer surgery, and this pathway included early postoperative feeding. MATERIALS AND METHODS: One hundred three consecutive patients who underwent gastric resection and reconstruction for gastric cancer from October 2007 to June 2008 at St. Mary's Hospital were prospectively enrolled in a fast-track critical pathway. The pathway included minimal preoperative procedures, optimal pain relief, proper fluid administration, early mobilization and early enteral nutrition at postoperative 1 day. The exclusion criteria were determined preoperatively, intraoperatively and postoperatively. RESULTS: Of the 103 patients, 19 patients were excluded for preoperative (5), intraoperative (7) and postoperative (7) reasons. Eighty-four patients (81.6%) were included in the fast-track critical pathway. Sixty-eight (88.6%) of 84 patients were discharged at the planned 8 day after surgery during the initial period of the study, and the postoperative hospital stay was shortened up to 6 days during the more recent period. Postoperative complications occurred in 22 patients (26.2%), and these were gastrointestinal track-related complications in 6 cases (3 cases of ileus, 1 case of stasis and 2 cases of leakage) and infection-related complications in 8 cases. There was no statistical difference in the incidence of morbidity according to the clinic-operative features that included age, gender, stomach resection and lymphadenectomy. CONCLUSION: The fast-track critical pathway with using the available exclusion criteria was a valid option for patients who underwent gastric cancer surgery.

Candida Infection in a Patient with Gastric Carcinoma; 1 Case Report

Most gastric candida infections have been reported in immune-insufficient patients with peptic ulcer, but there have been few reports on gastric candidiasis with malignant ulcer in the stomach. We experienced a case of candida infection with gastric carcinoma in a 72-year-old female with diabetic mellitus. The endoscopic view showed multiple whitish necrotic plaques with a huge ulcer in the body of the stomach. The pathologic findings showed that budding yeast and pseudohyphae had infiltrated through the ulcerated stomach wall and the stomach wall contained tubular adenocarcinoma. After treatment with Fluconazole medication for 14 days, the patient underwent total gastrectomy along with D2 lymph node dissection. For the final pathologic results, there was no evidence of any remnant candidiasis, and the patient was discharged without specific complications. Through our experience and with reviewing articles about gastric candidiasis, we recommend that the gastric candidiasis that is accompanied with gastric malignancy should be treated before administering definite treatments for the gastric cancer.

Laparoscopic Treatment of Paraesophageal Hernia Complicated with Gastric Volvulus

Paraesophageal hernias are rare, accounting only for about 5% of all hiatal hernias but can sometimes lead to life-threatening complications such as bleeding, obstruction, incarceration, and strangulation. Accordingly, the surgical repair of paraesophageal hernia must be performed irrespectively of symptoms. Laparoscopic techniques of paraesophageal hernia offer several advantages compared with open techniques, including smaller incision, less traumatic handling of tissues, less postoperative pain. In this report, we describe a case of paraesophageal hernia complicated with gastric volvulus, which has been successfully repaired by the laparoscopic approach. A 79-year-old female was suffering from dysphagia, abdominal pain and intermittent vomiting for several months, and a paraesophageal hernia with partial gastric outlet obstruction due to gastric volvulus was diagnosed. The patient underwent the reduction of the hernia, dissection of the sac, crural repair and fundoplication via a laparoscopic approach. She recovered early and has been doing well on follow up with no recurrence.