Laparoscopic resection for submucosal tumors near the esophagogastric junction: feasibility and short-term outcome.

BACKGROUND: Minimally invasive surgery has proved to be effective and efficient in the management of gastric submucosal tumors (SMT). However, confronting a SMT near the esophagogastric junction (EGJ) is still challenging because of the potentially devastating risks of stenosis or leakage. This study evaluated the safety, feasibility, and oncological efficacy of laparoscopic resection for SMTs located near the EGJ. METHODS: From December 2008 to November 2011, we enrolled a total of 19 patients diagnosed with gastric SMTs located near the EGJ who underwent laparoscopic surgery. The clinicopathological characteristics and surgical outcomes of the 19 patients were recorded and reviewed retrospectively. RESULTS: All 19 patients underwent laparoscopic resections of their gastric SMTs without complications during the study period. There were 9 men and 10 women, with a mean age of 63.3 ± 15.1 years (range 33-86 years). The operative duration was 187.8 ± 58.9 minutes (range 90-310 minutes). Intraoperative localization included endoscopy (n = 3), tattooing (n = 2), and combined modalities (n = 1). The exogastric (n = 12) and transgastric methods (n = 7) were used. The histopathology showed 10 gastrointestinal stromal tumors, 7 leiomyomas, 1 hyperplastic polyp, and 1 lipoma. The postoperative courses for all cases were uneventful. The mean follow-up period was 16.7 ± 9.4 months, with no recurrence noted. CONCLUSIONS: Laparoscopic resections for gastric SMTs near the EGJ are safe and feasible, with satisfactory oncological outcomes in the short term.

Validation of a computer-based bronchoscopy simulator developed in Taiwan.

BACKGROUND/PURPOSE: Conventional training in bronchoscopy may increase patient's discomfort and procedure-related morbidity. Computer-based bronchoscopy simulator (CBBS) permits the acquisition and evaluation of the necessary skills through a realistic bronchoscopic experience. This study was conducted to validate the use of a CBBS system developed in Taiwan as a learning and assessment tool. METHODS: Twenty novice bronchoscopists and 10 expert bronchoscopists were enrolled as subjects in this prospective study. The 20 novice bronchoscopists were randomized into two groups, which received conventional bronchoscopic training or CBBS training and then completed a satisfaction survey. Subsequently, the novices who received CBBS training underwent an observational performance trial and the results were compared with those of expert bronchoscopists. All 10 expert bronchoscopists completed a realism survey and observational trial after CBBS performance. RESULTS: The satisfaction survey showed that the CBBS training program significantly increased participants' satisfaction (p = 0.002) and interest in learning (p < 0.001). The realism survey by the 10 expert bronchoscopists indicated that CBBS provides a favorable degree of realism with regard to the mechanical and visual parameters examined. Analysis of the performance results showed that the following parameters were capable of differentiating the participants by level of expertise: total procedure time (p = 0.002), percentage of bronchial segments entered (p = 0.012), percentage of bronchial segments identified (p < 0.001), percentage of repeated bronchial segments entered (p = 0.004), percentage of pathologies identified (p < 0.001), number of times that the bronchoscope tip collided with airway walls (p = 0.013), and number of times oral instruction was needed (p = 0.01). CONCLUSION: CBBS is a valid training method that increases interest in learning and provides a favorable degree of virtual realism. It can also distinguish various levels of competence at actual bronchoscopy and may have a useful role in the bronchoscopic training curriculum.

Effects of obesity surgery on the metabolic syndrome.

HYPOTHESIS: Individuals with the metabolic syndrome (MS), a clustering of risk factors (high levels of triglycerides and serum glucose, low level of high-density-lipoprotein cholesterol, high blood pressure, abdominal obesity) defined by the Third Report of the National Cholesterol Education Program Expert Panel of Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) (ATPIII), are at high risk of developing coronary heart disease and type 2 diabetes mellitus and may benefit from surgically induced weight loss. DESIGN: Prospectively controlled clinical study. SETTING: A tertiary referral center. PATIENTS: From December 1, 1999, to March 31, 2002, 645 consecutive morbidly obese patients were enrolled in a surgically supervised weight loss program, and the efficacy of weight loss 1 year after surgery was examined. INTERVENTION: Laparoscopic weight reduction surgery. MAIN OUTCOME MEASURES: Prevalence of the MS as defined by the ATPIII (>3 of the following): waist circumference greater than 102 cm in men and 88 cm in women; serum triglyceride level of at least 150 mg/dL (1.70 mmol/L); high-density lipoprotein cholesterol level less than 40 mg/dL (1.04 mmol/L) in men and 50 mg/dL (1.30 mmol/L) in women; blood pressure of at least 130/85 mm Hg; and serum glucose level of at least 110 mg/dL (6.11 mmol/L). RESULTS: Of 645 individuals, 337 (52.2%) met the ATPIII definition of the MS. Individuals with the MS had significant differences in age (31.5 years vs 28.1 years), sex (127 [37.7%] of 337 men vs 81 [26.3%] of 308 women), and many metabolic abnormalities compared with patients without the MS. Laparoscopic vertical banded gastroplasty was performed in 528 patients (81.9%) and laparoscopic gastric bypass in 117 (18.1%). A significant decrease in weight was found in both groups, but individuals who underwent laparoscopic gastric bypass lost significantly more weight (mean +/- SD, 38.4 +/- 14.4 kg vs 35.1 +/- 16.8 kg) and achieved a lower body mass index (29.3 +/- 4.8 vs 32.0 +/- 5.4) than individuals who underwent laparoscopic vertical banded gastroplasty. Substantial mean weight reduction (31.9%) of patients with the MS resulted in a substantial reduction of systolic (11.0 mm Hg) and diastolic (11.4 mm Hg) blood pressure and levels of glucose (46.1 mg/dL [2.56 mmol/L]), triglycerides (196.6 mg/dL [2.22 mmol/L]), and total cholesterol (33.7 mg/dL [0.88 mmol/L]) 1 year after surgery. These improvements resulted in a 95.6% resolution of the MS 1 year after surgery. There was no difference between operations (laparoscopic vertical banded gastroplasty or laparoscopic gastric bypass) in the resolution rate of the MS 1 year after surgery (95.0% vs 98.4%, respectively). CONCLUSION: The MS is prevalent in 52.2% of morbidly obese individuals enrolling in an obesity surgery program. Significant weight reduction 1 year after surgery markedly improved all aspects of the MS and resulted in a cure rate of 95.6%. Obesity surgery performed by laparoscopic surgery is recommended for obese patients with the MS.

Clinicopathologic characteristics and prognoses of gastric cancer in patients with a positive familial history of cancer.

BACKGROUND: There is a significant association between a positive family history of cancer and gastric cancer risk; however, the clinicopathologic characteristics and prognoses of gastric cancer patients with a positive family history of cancer are not clear. GOALS: To define the clinicopathologic characteristics and prognoses of gastric cancer patients with a positive family history of cancer. STUDY: We reviewed 548 patients with pathologically confirmed primary gastric cancer who had undergone a gastrectomy between 1990 and 1996. The average age was 59.7 years, and the male-to-female ratio was 1.7. The familial cancer histories of these patients were reviewed, and the various clinicopathologic characteristics of those patients with a positive family history of cancer were compared with those with a negative history. RESULTS: Among this cohort, 74 (13.5%) patients had a positive family history of cancer in their primary or secondary relatives. The most common cancer was gastric cancer in 29 patients, followed by colorectal cancer in 10 and lung cancer in 7. Patients with a positive family history of cancer were associated with bigger tumors, and more patients received a total gastrectomy than did patients with a negative family history. Immunopathologic study disclosed a higher rate of p53 overexpression but not of neu or c-met in patients with a positive family history of cancer. There were no differences in the mean age, gender, site, depth of invasion, or TNM stage. The survival curve of patients with a positive family history of malignancy was similar to that of patients without a family cancer history. CONCLUSION: Patients with gastric cancer with a positive family history of cancer appeared to have bigger tumors with a higher rate of p53 overexpression, and more patients required a total gastrectomy compared with those with a negative family history. This study suggests a genetic component in the aggressiveness of gastric cancer and indicates that higher caution should be exercised with people who have a positive family history of cancer.

Reappraisal of the new UICC staging system for gastric cancer: problem in lymph node stage.

BACKGROUND/AIMS: The International Union Against Cancer (UICC) TNM staging system defined a new system for classifying gastric cancer, based on the number of metastatic nodes (1997). However, the advantage of the new system is still a matter of debate. The aim of the present study is to compare the new system with the old one (1987), which is based on the location of positive lymph nodes. METHODOLOGY: We analyzed the survival of 608 patients with curative resection of their gastric cancer. The average number of resected and involved lymph nodes for each resected patient was 31.4 and 7.7. Comparison of these two systems was carried out to determine which classification was more effective. The prognostic value of different lymph node staging systems was also analyzed. RESULTS: One hundred and thirty-five patients (22.2%) had different N classification and 109 (17.9%) had different TNM staging. There was a significant stepwise decrease of slope of survival curve for each stage, but the new system did not cleanly separate stage II with IIIa at 3 years and stage IIIb with IV at 5 years. Although different lymph node staging systems were able to predict survival, the ratio rather than the number of involved nodes had a more cleanly separated stepwise decrease of slope of survival curve. CONCLUSIONS: The new UICC staging system is not better than the old system for the staging of gastric cancer. The reason is that the category of node number seems not to be appropriate and will be influenced by the extent of lymph node dissection. To overcome this problem, the frequency of involved nodes can be adopted instead of the number.