The "Scarless Ab-Lift": A Novel Method for the Treatment of Skin Laxity with Rectus Muscle Diastasis.

BACKGROUND: Pregnancy and vaginal delivery result in irreversible damage to the abdominal wall and skin. In the article, we present a new method for treating major skin laxity, rectus muscle diastasis, and umbilical hernia. METHODS: A 38-year-old woman with rectus muscle diastasis, umbilical hernia, and major skin laxity was treated with the scarless ab-lift procedure. The extent of diastasis before the surgery, on day 5 after surgery, and 3 months after surgery were measured. Skin laxity was evaluated 5 days and 3 months after surgery. RESULTS: The rectus muscle diastasis was restored on day 5 after surgery and remained unchanged 3 months later. Only minor supraumbilical folding was visible on day 5, and this disappeared after 3 months. The patient had only mild postoperative pain on day 5, and peroral non-steroid anti-inflammatory analgesics provided sufficient relief. Three months after surgery, she was without pain. No sensory defects were noted on the mobilized skin, and no seroma developed. CONCLUSION: The scarless ab-lift is a minimally invasive method that completely restores the abdominal wall and skin integrity in patients with rectus muscle diastasis and skin laxity after pregnancy. NO LEVEL ASSIGNED: This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Does leptin cause proximal gastric cancer in the obese? The role of serum leptin in the etiology of proximal gastric cancer.

OBJECTIVES: The aim of the present study was to determine the correlation between obesity, serum levels of leptin and proximal gastric cancer. METHODS: Sixty-four gastric cancer patients operated on with curative intent were included in the study. We determined the correlation between the preoperative serum levels of leptin and the tumor's location. RESULTS: Serum leptin levels were correlated significantly with the proximal third location (p=0.04), gastric outlet obstructing tumors (p<0.0001), CRP levels (p=0.03) and BMI (p<0.0001). Patients with high serum levels of leptin had significantly more intestinal types of gastric cancer (p=0.033) and better differentiation (p=0.009). The linear regression model determined the proximal tumor location (beta: 0.467; p=0.045), BMI (beta: 0.657; p=0.001), high preoperative serum albumin (beta: 0.563; p=0.016) and the presence of pyloric stenosis (beta: 0.525; p=0.006) as related significantly to serum leptin levels. The Cox proportional hazard model identified age (HR: 0.003; 95 % CI: 0-0.794; p=0.041), preoperative serum levels of leptin (HR: 0.125; 95 % CI: 0.018-0.887; p=0.037) and the number of extracted LNs (HR: 0.001; 95 % CI: 0-0.677; p=0.038) as independent prognostic factors. CONCLUSIONS: Serum levels of leptin were significantly elevated in patients with proximal gastric cancer, suggesting that the leptin's effect might be due to its systemic secretion. This might explain the higher incidence of proximal gastric cancer in obese patients. Elevated serum leptin levels were an independent prognostic factor.

The Contribution of the Hunger Hormone Leptin in the Aetiology of Postoperative Anorexia after Laparoscopic and Open Gastrectomy in Gastric Cancer Patients.

BACKGROUND: Laparoscopic surgery produces lesser postoperative inflammation with a smaller cytokine and leptin response, and might thus reduce postoperative anorexia compared with open surgery. The aim of the present study was to determine the role of serum leptin in postoperative anorexia after laparoscopic gastric cancer surgery. METHODS: Fifty-four consecutive patients with adenocarcinoma of the stomach were operated on either with open or laparoscopic surgery. Correlations were determined between the serum levels of leptin, clinico-pathological characteristics, serum haemoglobin, and albumin. RESULTS: Serum leptin levels on day seven were correlated significantly to gender (p = 0.004), body mass index (BMI) (p = 0.002), and tumour grade (p = 0.033). In the patients with C-reactive protein (CRP) < 100 mg/L (n = 46) the leptin levels on day seven were significantly lower after the laparoscopic operation (p = 0.042) and in patients with lower BMI (p = 0.001). The linear regression model determined a significant correlation between the relative concentration of leptin on day seven and laparoscopic surgery (Beta-0.688; p < 0.0001), gender, BMI, location of the tumour, T stage, N stage, perioperative therapy, tumour grade, perineural invasion, Lauren histological type, and ulceration. In patients with CRP levels below 100 mg/mL, the serum level of albumin on day seven after surgery was significantly higher in patients after laparoscopic surgery. CONCLUSION: Laparoscopic surgery produced significantly lower relative leptin concentrations on day seven, and higher serum albumin levels in the subgroup with CRP levels below 100 mg/L at discharge. These results suggested that laparoscopic gastric cancer surgery might reduce postoperative leptin response, leading to a better nutritional status at discharge compared with open surgery.

East meets West: the initial results of laparoscopic gastric cancer resections with Eastern principles in a single Western centre - a propensity score-matched study.

BACKGROUND: We compared the initial experience of totally laparoscopic gastric cancer surgery with Eastern principles with the results of propensity score-matched counterparts operated with open surgery. METHODS: From 1163 patients stored in our database, 62 PSM patients were selected for this study. The quality control was assured with video documentation and standardisation of the procedures. RESULTS: According to the distribution of age, comorbidities, and general health, patients in the LG and OG were well-balanced. Most of the patients in both groups had advanced gastric cancer (69.3%). In the OG, 67.8% of patients received a total gastrectomy, as well as 54.8% of patients in the LG. There was no significant difference in the postoperative mortality between groups. The recovery of bowel function was significantly faster, and postoperative pain was significantly decreased in the LG. Compared to the OG, the inflammatory response was significantly smaller in the LG. There was no significant difference in the overall survival between LG and OG patients. CONCLUSION: We have shown that laparoscopic gastrectomy with Eastern principles can be safely introduced in a high-volume Western centre with sufficient laparoscopic training. We have also shown that laparoscopy offers a significant faster bowel function recovery, less postoperative pain, and a smaller inflammatory response.

Surgical resection of synchronous liver metastases in gastric cancer patients. A propensity score-matched study.

BACKGROUND: The aim of the study was to determine the value of synchronous liver resection in patients with oligo-metastatic gastric cancer and the prognostic factors in these patients. PATIENTS AND METHODS: We compared the results of 21 gastric patients with liver metastases and synchronous liver resection (LMR) to 21 propensity score-matched patients with gastric cancer and liver metastases in whom liver resection was not performed (LM0) and to a propensity score-matched control group of 21 patients without liver metastases and stage III and IV resectable gastric cancer (CG). RESULTS: The overall 5-year survival of LMR, LM0 and CG were 14.3%, 0%, and 19%, respectively (p = 0.002). Five-year survival was 47.5% for well-differentiated tumour compared to 0% in patients with moderate or poor tumour differentiation (p = 0.006). In addition, patients with R0 resection and TNM stage N0-1 had a significantly better survival compared to patients with TNM N stage N2-3 (5-year survival: 60% for N0-1 vs. 7.7% for N2-3; p = 0.007). CONCLUSIONS: The results presented in the study support synchronous liver resections in gastric patients and provide additional criteria for patient selection.

Impact of perioperative treatment on survival of resectable gastric cancer patients after D2 lymphadenectomy: a single European centre propensity score matching analysis.

Background To determine the effects of perioperative treatment of gastric cancer patients, we conducted an analysis with propensity score matched patient groups to determine the role of perioperative chemotherapy in patients after D2 lymphadenectomy. Patients and methods From our database of 1563 patients, 482 patients were selected with propensity score matching and divided into two balanced groups: 241 patients in the surgery only group and 241 patients in the perioperative group. The long-term results of treatment were compared between the two groups. Results Most of the included patients received radio-chemotherapy with capecitabine (n = 111; 46%) and perioperative chemotherapy with epirubicin, oxalliplatin and capecitabine (n = 91; 37.7%). 92.9% of the patients received a D2 lymph node dissection. Perioperative morbidity was similar between surgery only (18.3%) and perioperative treatment groups (20.7%) (p = 0.537). The perioperative mortality was not influenced by perioperative treatment. A pathological response was observed in 12.5% of patients. The overall 5-year and median survivals were significantly higher in the perioperative treatment group (50.5%; 51.7 moths) compared to surgery only group (41.8%; 34.9 months; p = 0.038). The subgroup analysis revealed that only patients with the TNM stages T3 (p = 0.028), N2 (p = 0.009), N3b (p = 0.043), and UICC stages IIIb (p = 0.003) and IIIc (p = 0.03) significantly benefit from perioperative treatment. Conclusions Perioperative treatment in radically resected gastric cancer patients after D2 lymphadenectomy was beneficial in stages IIIb and IIIc. The effects of perioperative treatment in lower stages could be negated by the effects of the radical surgery in lower stages and in higher stages by the biology of the disease.

Outcomes of the Surgical Treatment for Adenocarcinoma of the Cardia - Single Institution Experience.

BACKGROUND: Adenocarcinomas at the cardia are biologically aggressive tumors with poor long-term survival following curative resection. For resectable adenocarcinoma of the cardia, mostly esophagus extended total gastrectomy or esophagus extended proximal gastric resection is performed; however, the surgical approach, transhiatal or transthoracic, is still under discussion. Postoperative morbidity, mortality and long-term survival were analyzed to evaluate the potential differences in clinically relevant outcomes. PATIENTS AND METHODS: Of altogether 844 gastrectomies performed between January 2000 and December 2016, 166 were done for the adenocarcinoma of the gastric cardia, which we analyzed with using the Cox proportional hazards model. RESULTS: 136 were esophagus extended total gastrectomy and 125 esophagus extended proximal gastric resection. A D2 lymphadenectomy was performed in 88.2%, splenectomy in 47.2%, and multivisceral resections in 12.4% of patients. R0 resection rate was 95.7%. The mean proximal resection margin on the esophagus was 42.45 mm. It was less than 21 mm in 9 patients. Overall morbidity regarding Clavien-Dindo classification (> 1) was altogether 28.6%. 15.5% were noted as surgical and 21.1% as medical complications. The 30-day mortality was 2.2%. The 5-year survival for R0 resections was 33.4%. Multivisceral resection, depth of tumor infiltration, nodal stage, and curability of the resection were identified as independent prognostic factors. CONCLUSIONS: Transhiatal approach for resection of adenocarcinoma of the cardia is a safe procedure for patients with Siewert II and III regarding the postoperative morbidity and mortality; moreover, long-term survival is comparable to transthoracic approach. The complications associated with thoracoabdominal approach can therefore be avoided with no impact on the rate of local recurrence.

Impact Factors for Perioperative Morbidity and Mortality and Repercussion of Perioperative Morbidity and Long-term Survival in Pancreatic Head Resection.

BACKGROUND: The focus of the present study was to reveal any impact factors for perioperative morbidity and mortality as well as repercussion of perioperative morbidity on long-term survival in pancreatic head resection. PATIENTS AND METHODS: In a retrospective study, clinic-pathological factors of 240 patients after pancreatic head (PD) or total resection were analyzed for correlations with morbidity, 30- and 90-day mortality, and long-term survival. According to Clavien-Dindo classification, all complications with grade II and more were defined as overall complications (OAC). OAC, all surgical (ASC), general (AGC) and some specific types of complications like leaks from the pancreatoenteric anastomosis (PEA) or pancreatic fistula (PF, type A, B and C), leaks from other anastomoses (OL), bleeding (BC) and abscesses (AA) were studied for correlation with clinic-pathological factors. RESULTS: In the 9-year period, altogether 240 patients had pancreatic resection. The incidence of OAC was 37.1%, ASC 29.2% and AGC 15.8%. ASC presented themselves as PL, OL, BC and AA in 19% (of 208 PD), 5.8%, 5.8%, and 2.5% respectively. Age, ASA score, amylase on drains, and pancreatic fistulas B and C correlated significantly with different types of complications. Overall 30- and 90-day mortalities were 5 and 7.9% and decreased to 3.5 and 5% in P2. CONCLUSIONS: High amylase on drains and higher mean age were independent indicators of morbidity, whereas PL and BC revealed as independent predictor for 30-day mortality, and physical status, OAC and PF C for 90-day mortality.

Simultaneous Pure Laparoscopic Resection of Primary Colorectal Cancer and Synchronous Liver Metastases: A Single Institution Experience with Propensity Score Matching Analysis.

BACKGROUND: The aim of the study was to compare the outcome of pure laparoscopic and open simultaneous resection of both the primary colorectal cancer and synchronous colorectal liver metastases (SCLM). PATIENTS AND METHODS: From 2000 to 2016 all patients treated by simultaneous resection were assessed for entry in this single center, clinically nonrandomized trial. A propensity score matching was used to compare the laparoscopic group (LAP) to open surgery group (OPEN). Primary endpoints were perioperative and oncologic outcomes. Secondary endpoints were overall survival (OS) and disease-free survival (DFS). RESULTS: Of the 82 patients identified who underwent simultaneous liver resection for SCLM, 10 patients underwent LAP. All these consecutive patients from LAP were matched to 10 comparable OPEN. LAP reduced the length of hospital stay (P = 0.044) and solid food oral intake was faster (P = 0.006) in this group. No patient undergoing the laparoscopic procedure experienced conversion to the open technique. No difference was observed in operative time, blood loss, transfusion rate, narcotics requirement, clinical risk score, resection margin, R0 resections rate, morbidity, mortality and incisional hernias rate. The two groups did not differ significantly in terms of the 3-year OS rate (90 vs. 75%; P = 0.842) and DFS rate (60 vs. 57%; P = 0.724). CONCLUSIONS: LAP reduced the length of hospital stay and offers faster solid food oral intake. Comparable oncologic and survival outcomes can be achieved. LAP is beneficial for well selected patients in high volume centers with appropriate expertise.

Can flow cytometry reinvent the sentinel lymph node concept in gastric cancer patients?

BACKGROUND: The focused sentinel lymph node (SLN) concept we proposed previously relied on real time-quantitative polymerase chain reaction (RT-qPCR) to detect tumor cells, which is too elaborate for intraoperative use. Therefore, we evaluated flow cytometry for intraoperative detection of tumor cells in SLNs. METHODS: Sixty-five consecutive gastric cancer patients were included. SLN analysis was carried out for a single SLN from each patient, using the molecular methods of RT-qPCR (first 30 patients) and flow cytometry (final 35 patients). All LNs underwent hematoxylin and eosin staining and immunohistochemical examination. RESULTS: Extraction of the SLN from a high-risk station was an important determinant for accurate prediction of LN metastases. For RT-qPCR, the sensitivity and specificity of detection were 72.7% and 81.8%, respectively, and for flow cytometry, 36.8% and 100%, respectively. When only high-risk SLNs were analyzed and specimens with <10% viability of leukocytes were excluded, the sensitivity and specificity of flow cytometry were 60% and 100%, respectively. Multivariate analysis identified significant predictors for LN metastases as the molecular method of SLN analysis (P = 0.021; 95% confidence interval [CI]: 1.304-24.284) and lymphovascular invasion (P = 0.002; 95% CI: 2.142-28.555). In subgroup analysis of high-risk SLNs, only RT-qPCR was a significant predictor for LN metastases (P = 0.016; 95% CI: 1.581-91.084). CONCLUSIONS: Flow cytometry of high-risk SLNs, excluding specimens with low cell viability is a rapid, cost-effective, widely obtainable, and highly specific method for SLN metastases detection although it lacks the necessary sensitivity. Therefore, it cannot be recommended as a stand-alone method for the detection of LN metastases during operations.

Does Negative-Pressure Wound Therapy for the Open Abdomen Benefit the Patient? A Retrospective Cohort Study.

OBJECTIVE: Negative-pressure wound therapy (NPWT) is the most modern and sophisticated method of temporary abdominal closure. The aim of the study was to determine the significant predictors for mortality in patients with NPWT. SETTING: University Clinical Centre Maribor, Slovenia MATERIALS AND METHODS:: The authors performed a retrospective cohort study of all patients treated with NPWT between January 1, 2011, and December 31, 2014. RESULTS: In the univariate analysis, the type of wound closure, more than 7 NPWT changes, the total days with NPWT, and time to wound closure were significantly associated with death of the patient. In the multivariate analysis, only the number of more than 7 NPWT changes was found as a significant predictor for death (P = .038). CONCLUSIONS: Negative-pressure wound therapy is a method of choice for the treatment of open abdomen if there is a clear indication. However, clinicians should try all measures to remove the NPWT system and close the abdomen as soon as possible because prolonged use is associated with significantly higher mortality.

CA19-9 serum levels predict micrometastases in patients with gastric cancer.

BACKGROUND: We explored the prognostic value of the up-regulated carbohydrate antigen (CA19-9) in node-negative patients with gastric cancer as a surrogate marker for micrometastases. PATIENTS AND METHODS: Micrometastases were determined using reverse transcription quantitative polymerase chain reaction (RT-qPCR) for a subgroup of 30 node-negative patients. This group was used to determine the cut-off for preoperative CA19-9 serum levels as a surrogate marker for micrometastases. Then 187 node-negative T1 to T4 patients were selected to validate the predictive value of this CA19-9 threshold. RESULTS: Patients with micrometastases had significantly higher preoperative CA19-9 serum levels compared to patients without micrometastases (p = 0.046). CA19-9 serum levels were significantly correlated with tumour site, tumour diameter, and perineural invasion. Although not reaching significance, subgroup analysis showed better five-year survival rates for patients with CA19-9 serum levels below the threshold, compared to patients with CA19-9 serum levels above the cut-off. The cumulative survival for T2 to T4 node-negative patients was significantly better with CA19-9 serum levels below the cut-off (p = 0.04). CONCLUSIONS: Preoperative CA19-9 serum levels can be used to predict higher risk for haematogenous spread and micrometastases in node-negative patients. However, CA19-9 serum levels lack the necessary sensitivity and specificity to reliably predict micrometastases.

Could the immune response in the sentinel lymph nodes of gastric cancer patients be the key to tailored surgery?

BACKGROUND: Precise detection of downstream, nonsentinel lymph node metastases is the key to implementation of the sentinel lymph node concept in gastric cancer. To overcome the problem of complex lymphatic drainage, micrometastases, and skip metastases, we investigated the feasibility of tumor cell detection in sentinel lymph nodes, using flow cytometry as well as studied immune suppression in the sentinel lymph node as a potential marker of downstream lymph node metastases. METHODS: In 21 patients with gastric cancer, the sentinel lymph nodes extracted during operation subjected to frozen sections and flow cytometry. The tumor cells were defined with the cell surface markers CEACAM and EpCAM. Simultaneously, the cell densities of different subsets of T cells were determined. RESULTS: The sensitivity and specificity of the determination of nodal status with flow cytometry for tumor cell detection was 100% and 63%, respectively, as seen in frozen sections. Correlations with nonsentinel lymph node metastases were seen for CD127(low)CD25(high) and CD45(neg)CD127(low)CD25(high) cell densities, relative proportion of CD45RA(neg)CD127(low)CD25(high) cells, frozen sections results, lymphangial invasion, and tumor size (P ≤ .043 each). Multivariate analysis identified the relative proportions of CD45RA(neg)CD127(low)CD25(high) cells as the only significant predictor for downstream nonsentinel lymph node metastases (P = .028; 95% confidence interval, 1.107-5.780). The predictive value of combined detection of flow cytometry tumor cells and the relative proportion of CD45RA(neg)CD127(low)CD25(high) cells for nodal stage determination was 91%. CONCLUSION: Combined detection of tumor cells and CD45RA(neg)CD127(low)CD25(high) cells in sentinel lymph nodes with flow cytometry predicts accurately nonsentinel lymph node metastases.

Prediction of liver metastases after gastric cancer resection with the use of learning vector quantization neural networks.

OBJECTIVE: The aim of our study was to determine whether learning vector quantization neural networks could be used to predict liver metastases after a gastric cancer surgery. BACKGROUND: The prediction of tumor recurrence is invaluable for tailoring specific treatment and follow-up strategies for gastric cancer patients. At present, it is still impossible to make reliable predictions of tumor progression. The use of complex mathematical models such as neural networks has already been implemented for the study of various pathophysiological mechanisms, but to date they have never been used for predicting liver metastases after gastric cancer resection. METHODS: A total of 213 patients operated for gastric cancer between 1999 and 2005 were included in our study. They were stratified in a model development (140 patients) and validation group (73 patients). With the use of an auxiliary regression network, seven clinicopathological variables were selected to predict liver metastases. RESULTS: Forty-one patients developed liver metastases (19.2%). The longest follow-up was 2,754 days. Most liver metastases occurred in the first 799 days after discharge. All predictions were compared to actual recurrences with a two by two contingence table. The determined sensitivity and specificity for the development sample were 71 and 96.1%, respectively. The values for the test sample were 66.7 and 97.1%, respectively. The significance of the model was determined using various post-hoc tests, which all confirmed the effectiveness of our model. CONCLUSION: The presented model exhibited a high negative predictive value and reasonable high sensitivity for liver metastases. To improve sensitivity, the inclusion of more patients and perhaps biological markers is still necessary.

The validity of clinical risk score for patients undergoing liver resection for colorectal metastases.

BACKGROUND/AIMS: The purpose of this study was to examine the validity of the clinical risk score (CRS) for a selection of patients for surgery. METHODOLOGY: In the period of January 1996 to June 2007, 169 patients underwent their first surgical and/or local ablative therapy for CRLM. This study assesses five preoperative prognostic criteria which define the CRS (nodal status of the primary tumor, the disease-free interval, the number of hepatic metastases, the preoperative CEA level, and the size of the largest metastasis). In the present study was analyzed the calculated CRS with respect to patient's postoperative survival. RESULTS: An individual CRS was found to be predictive of survival. CRS stratified into two groups (CRS scores 0-2 and 3-5) were also found to be predictive of survival, with 5-year survival rates of 41% and 13%, respectively. CRS stratified into three groups (CRS scores 0-1; 2-3 and 4-5) were found predictive of survival as well, with 5-year survival rates of 72.7%, 21% and 4.6%, respectively. CONCLUSIONS: Immediate hepatic resection is reasonable in patients with CRS 0 to 1. In patients with CRS 2 to 3, chemotherapy may be required in addition to hepatic resection. In patients with CRS 4 to 5, hepatic resection is probably reasonable only if there is a response to chemotherapy.

Irregularity test for very short electrocardiogram (ECG) signals as a method for predicting a successful defibrillation in patients with ventricular fibrillation.

A significant proportion of patients with ventricular fibrillation (VF) can only be defibrillated after a period of chest compressions and ventilation before the defibrillation attempt. In these patients, unsuccessful defibrillations increase the duration of heart arrest and reduce the possibility of a successful resuscitation, which could be avoided if a reliable prediction for the success of defibrillation could be made. A new method is presented for estimating the irregularity in very short electrocardiographic (ECG) recordings that enables the prediction of a successful defibrillation in patients with VF. This method is based on a recently developed determinism test for very short time series. A slight modification shows that the method can be used to determine relative differences in irregularity of the studied signals. In particular, ECG recordings of VF from patients who could be successfully defibrillated are characterized by a higher level of irregularity, indicating a chaotic nature of the dynamics of the heart, which is in agreement with previous studies on long ECG recordings showing that cardiac chaos was prevalent in healthy heart, whereas in severe congestive heart failure, a decrease in the chaotic behavior was observed.