Safety and feasibility of pure laparoscopic extended cholecystectomy: comparison with the open technique in a propensity analysis at a single center.

BACKGROUND: The aim of this study was to validate the safety and feasibility of pure laparoscopic extended cholecystectomy (LEC) by comparing the outcome with that of open extended cholecystectomy (OEC). Moreover, on the basis of our experience, we also aimed to investigate the learning curve of pure LEC. METHODS: This single-center study enrolled patients who were diagnosed primary gallbladder cancer with pathologically confirmed and underwent R0 resection with curative intent between January 2016 and December 2019. A total of 31 patients who underwent OEC and 17 patients who underwent LEC were selected. Propensity score matching analysis was performed in a 1:1 ratio using the nearest-neighbor matching method, and clinical information was retrospectively collected from medical records and analyzed. RESULTS: The postoperative hospital stay was statistically shorter in the LEC group (7 days) than in the OEC group (12 days). The overall surgical complication rate did not differ between the two groups. The 1- and 3-year disease-free survival rates were 82.4% and 82.4% in the OEC group and 94.2% and 71.5% in the LEC group, respectively (P = 0.94). Considering the correlation between the number of cumulative cases and the operation time and between the number of cumulative cases and the number of retrieved lymph nodes in the LEC group, as the cases were accumulated, both the operation time and the number of retrieved lymph nodes had a statistically significant correlation with the number of cases. CONCLUSIONS: LEC showed a significant advantage in terms of achieving shorter postoperative hospital stay and similar results to OEC with respect to overall complications and pathological outcomes. The present results confirm that laparoscopy can be considered a safe treatment for primary gallbladder cancer in selected patients.

Clinicopathological Differences in T2 Gallbladder Cancer According to Tumor Location.

We aimed to identify clinicopathological differences and factors affecting survival outcomes of stage T2a and T2b gallbladder cancer (GBC) and validate the oncological benefits of regional lymphadenectomy and hepatic resection in these patients. This single-center study enrolled patients who were diagnosed with pathologically confirmed T2 GBC and underwent curative resection between January 1995 and December 2017. Eighty-two patients with T2a and 50 with T2b GBCs were identified, and clinical information was retrospectively collected from medical records and analyzed. Five-year overall survival rates were 96.8% and 80.7% in T2a and T2b groups, respectively (P = .007). Three- and 5-year survival rates among all patients with T2 GBC without and with lymph node metastasis were 97.2% and 94.4% and 81.3% and 81.3%, respectively (P = .029). There was no difference in survival rates between the 2 groups according to whether hepatic resection was performed (P = .320). However, in the T2b group, those who underwent hepatic resection demonstrated a better survival rate than those who did not (P = .029). The T2b group had more multiple recurrence patterns than the T2a group, and the lymph nodes were the most common site in both groups. Multivariate analysis revealed that lymph node metastasis, vascular invasion, and tumor location were significant independent prognostic factors. Hepatic resection was not always necessary in patients with peritoneal-side GBC. Considering clinicopathological features and recurrence patterns, a systematic treatment plan, including radical resection and adjuvant treatment, should be established for hepatic-side GBC.

Development and validation of novel scoring system for the prediction of disease recurrence following resection of colorectal liver metastasis.

BACKGROUND: The aim of this study was to identify predictive factors for the recurrence of colorectal cancer liver metastasis (CRLM) and then to develop a corresponding novel scoring system that should improve the sensitivity of predicting recurrence in patients with CRLM. METHODS: A total of 295 consecutive CRLM patients were enrolled in our institution between January 2002 and December 2015. Multivariate analyses were performed to identify the variables associated with disease recurrence and established the novel scoring system based on it. RESULTS: The scoring system considered seven variables: synchronosity, CA19-9 level, number of liver metastasis, largest size of liver metastasis, resection margin of hepatic lesion, neutrophil-to-lymphocyte ratio and prognostic nutritional index. The area under the curve of ROC was 0.824 (95% confidence interval 0.767-0.882); the sensitivity of our scoring system was 87.9%, specificity was 66.7%, positive predictive value was 20.6%, and negative predictive value was 20.9%. CONCLUSION: For patients with CRLM undergoing curative hepatic resection, our novel scoring system would improve the sensitivity for prediction of disease recurrence in Case of CRLM patients.

Prognostic markers affecting the early recurrence of hepatocellular carcinoma with liver cirrhosis after curative resection.

BACKGROUND: Early recurrence is associated with poor prognosis after curative resection for hepatocellular carcinoma. Thus, we studied which factors, including this inflammation-based scoring system, affect disease recurrence in single hepatocellular carcinoma patients with liver cirrhosis. METHODS: A total of 430 consecutive hepatocellular carcinoma patients were enrolled in our institution between January 2002 and December 2015. Survival rate, univariate, and multivariate analyses were performed to identify the variables associated with recurrence and early recurrence especially. RESULTS: The overall survival rate was significantly lower in the early recurrence group than in the non-early recurrence group (P<0.001). According to the multivariate analysis, protein induced by vitamin K absence or antagonist (PIVKA) greater than 200 (P=0.035), neutrophil-to-lymphocyte ratio greater than 2.0 (P<0.001), elevated Glasgow prognostic score (P=0.003), tumor size greater than 5 cm (P=0.002), and the presence of lymphovascular invasion (P=0.002) were significantly different among the groups and affected the early recurrence of hepatocellular carcinoma. The patients were categorized into five levels of risk for early recurrence according to the number of independent risk factors, and patients with no risk factors were set as the reference group. CONCLUSION: Neutrophil-to-lymphocyte ratio, Glasgow prognostic score, and serum level of PIVKA offer significant prognostic information associated with early recurrence following single lesion hepatocellular carcinoma patients with liver cirrhosis after curative resection.

Prognostic impact of the combination of the neutrophil-to-lymphocyte ratio and serum carbohydrate antigen 19-9 in patients with pancreas head cancer.

BACKGROUND: This study aimed to evaluate the clinical value of the combination of a traditional prognostic factor with a systemic inflammation-based prognostic factor in patients undergoing curative resection for pancreas head cancer diagnosed as pancreatic ductal adenocarcinoma. METHODS: From January 2005 to December 2015, 198 patients were enrolled. Various clinicopathological factors potentially associated with survival and recurrence were evaluated in this study. RESULTS: The selected cut-off values for the test prognostic factors with sufficient sensitivity and specificity were 2.8 for the neutrophil-to-lymphocyte ratio (NLR) and 70 U/mL for serum carbohydrate antigen 19-9 (CA19-9). Kaplan-Meier survival analysis demonstrated that the 5-year survival rate in patients with a high NLR and CA19-9 was 21.8% compared with 79.8% for patients with a low NLR and CA19-9. The 5-year disease-free survival rate in patients with a high NLR and CA19-9 was 0% compared with 33.9% for patients with a low NLR and CA19-9. Patients with high NLRs and high CA19-9 were more likely to have an early recurrence and multiple relapse patterns. CONCLUSION: Preoperative NLR and serum CA19-9 offer significant prognostic information for survival following curative resection of pancreas head cancer diagnosed as pancreatic ductal adenocarcinoma.

Early postoperative delirium after hemiarthroplasty in elderly patients aged over 70 years with displaced femoral neck fracture.

PURPOSE: Postoperative delirium is a risk factor for worse outcome after hip fracture surgery in elderly patients. Postoperative delirium is associated with anesthesia, postoperative pain, and patient factors. We investigated the incidence, predictors, and prognostic implications of post-operative delirium after hemiarthroplasty (HA) in elderly patients with femoral neck fracture. PATIENTS AND METHODS: A total of 356 consecutive patients aged >70 years who underwent HA for femoral neck fracture were enrolled. Diagnosis of delirium was made by a psychiatrist based on patient status and an objective scoring system. The patients were divided into 2 categories according to the HA onset time (immediate [≤24 h after surgery] vs delayed delirium [>24 h after surgery]) and its incidence, predictors and mortality were evaluated. RESULTS: Postoperative delirium was diagnosed in 110 patients (30.9%) during hospitalization. Immediate and delayed delirium occurred in 59 (53.6%), and 51 (46.4%) patients, respectively. The independent predictors of immediate delirium included age (odds ratio [OR] 1.47, 95% CI 0.98-2.23, p=0.066), and general anesthesia (OR 2.25, 95% CI 1.17-4.43, p=0.015). The independent predictors of delayed delirium were parkinsonism (OR 5.75, 95% CI 1.66-19.96, p=0.006), intensive care unit stay (OR 1.85, 95% CI 0.97-3.56, p=0.064), and higher American Society of Anesthesiologists grade (OR 2.33, 95% CI 0.90-6.07, p=0.083). On Kaplan-Meier survival analysis, the 2-year survival rate was significantly lower in the immediate delirium group than those in the delayed and control groups (71.0% vs 83.6% vs 87.8%, respectively; p=0.031). CONCLUSION: Immediate and delayed delirium after HA for femoral neck fracture had different predictors and immediate delirium was associated with worse prognosis.

Rubiarbonone C inhibits platelet-derived growth factor-induced proliferation and migration of vascular smooth muscle cells through the focal adhesion kinase, MAPK and STAT3 Tyr705 signalling pathways.

BACKGROUND AND PURPOSE: The proliferation and migration of vascular smooth muscle cells (VSMCs) induced by platelet-derived growth factor (PDGF) are important steps in cardiovascular diseases, including neointimal lesion formation, myocardial infarction and atherosclerosis. Here, we evaluated the rubiarbonone C-mediated signalling pathways that regulate PDGF-induced VSMC proliferation and migration. EXPERIMENTAL APPROACH: Cell proliferation and migration were measured in cells treated with rubiarbonone C followed by PDGF BB using the MTT assay, [3 H]-thymidine incorporation, flow cytometry and wound-healing migration assay, MMP gelatin zymography, a fluorescence assay for F-actin. Western blotting of molecules including MAPK, focal adhesion kinase (FAK) and STAT3 and an immunofluorescence assay using anti-PCNA and -STAT3 antibodies were performed to evaluate rubiarbonone C signalling pathway(s). The medial thickness of the carotid artery was evaluated using a mouse carotid ligation model. KEY RESULTS: Rubiarbonone C inhibited PDGF-induced VSMC proliferation and migration and diminished the ligation-induced increase in medial thickness of the carotid artery. In PDGF-stimulated VSMCs rubiarbonone C decreased the following: (i) levels of cyclin-dependent kinases, cyclins, PCNA and hyperphosphorylated retinoblastoma protein; (ii) levels and activity of MMP2 and MMP9; (iii) activation of MAPK; (iv) F-actin reorganization, by reducing FAK activation; (v) activation of STAT3. CONCLUSIONS AND IMPLICATIONS: These findings suggest that rubiarbonone C inhibits the proliferation and migration of VSMCs by inhibiting the FAK, MAPK and STAT3 signalling pathways. Therefore, rubiarbonone C could be a good candidate for the treatment of cardiovascular disease.

Experience of hemostasis in tracheal bleeding very close to the carina by the bronchial blocker: a case report.

Massive hemoptysis is respiratory compromise which should be managed as a life-threatening condition. In our case, the bronchial blocker played a role in hemostasis of tracheal bleeding very close to the carina and prevented further spillage into the contralateral lung. Right-sided one-lung isolation in an 87-year-old female, who received cardiopulmonary resuscitation due to myocardial infarction, was requested due to hemoptysis. Right-sided bronchial bleeding was suspected on auscultation, but esophageal and tracheal bleeding due to violent intubation with a stylet was also considered. We attempted one-lung isolation with the bronchial blocker. The bronchial blocker was inadvertently advanced to the left mainstem bronchus, but the inflated balloon of the bronchial blocker compressed the site of bleeding, which was within 1 cm proximal and left posterior to the carina. Tracheal bleeding stopped, and we confirmed that hemostasis was achieved with the balloon of the bronchial blocker using a fiberoptic bronchoscope.

Anesthetic experience in a clinically euthyroid patient with hyperthyroxinemia and suspected impairment of T4 to T3 conversion: a case report.

We report an anesthetic experience in a clinically euthyroid patient with hyperthyroxinemia (elevated free thyroxine, fT4 and normal 3, 5, 3'-L-triiodothyronine, T3) and suspected impairment of conversion from T4 to T3. Despite marked hyperthyroxinemia, this patient's perioperative hemodynamic profile was suspected to be the result of hypothyroidism, in reference to the presence of T4 to T3 conversion disorder. We suspected that pretreatment with antithyroid medication before surgery, surgical stress and anesthesia may have contributed to the decreased T3 level after surgery. She was treated with liothyronine sodium (T3) after surgery which restored her hemodynamic profile to normal. Anesthesiologists may be aware of potential risk and caveats of inducing hypothyroidism in patients with euthyroid hyperthyroxinemia and T4 to T3 conversion impairment.

Pericardial tamponade caused by massive fluid resuscitation in a patient with pericardial effusion and end-stage renal disease -A case report-.

Pericardial tamponade can lead to significant hemodynamic derangement including cardiac arrest. We experienced a case of pericardial tamponade in a patient with end-stage renal disease. Hemodynamic changes occurred by unexpectedly aggravated pericardial effusion during surgery for iatrogenic hemothorax. We quickly administered a large amount of fluids and blood products for massive bleeding and fluid deficit due to hemothorax. Pericardial effusion was worsened by massive fluid resuscitation, and thereby resulted in pericardial tamponade. Hemodynamic parameters improved just after pericardiocentesis, and the patient was transferred to the intensive care unit.

The effect of heated breathing circuit on body temperature and humidity of anesthetic gas in major burns.

BACKGROUND: Cold and dry gas mixtures during general anesthesia cause the impairment of cilliary function and hypothermia. Hypothermia and pulmonary complications are critical for the patients with major burn. We examined the effect of heated breathing circuit (HBC) about temperature and humidity with major burned patients. METHODS: Sixty patients with major burn over total body surface area 25% scheduled for escharectomy and skin graft were enrolled. We randomly assigned patients to receiving HBC (HBC group) or conventional breathing circuit (control group) during general anesthesia. The esophageal temperature of the patients and the temperature and the absolute humidity of the circuit were recorded every 15 min after endotracheal intubation up to 180 min. RESULTS: There was no significant difference of the core temperature between two groups during anesthesia. The relative humidity of HBC group was significantly greater compared to control group (98% vs. 48%, P < 0.01). In both groups, all measured temperatures were significantly lower than that after intubation. CONCLUSIONS: The use of HBC helped maintain airway humidity, however it did not have the effect to minimize a body temperature drop in major burns.

Effect of the bevel direction of puncture needle on success rate and complications during internal jugular vein catheterization.

OBJECTIVE: Artery puncture and hematoma formation are the most common immediate complications during internal jugular vein catheterization. This study was performed to assess whether the bevel-down approach of the puncture needle decreases the incidence of posterior venous wall damage and hematoma formation during internal jugular vein catheterization. DESIGN: Prospective, randomized, controlled study. SETTING: A university-affiliated hospital. PATIENTS: Three hundred thirty-eight patients for scheduled for thoracic surgery requiring central venous catheterization in the right internal jugular vein. INTERVENTIONS: Patients requiring internal jugular vein catheterization were enrolled and randomized to either the bevel-down group (n = 169) or the bevel-up group (n = 169). All patients were placed in the Trendelenburg position with the head turned to the left. After identifying the right internal jugular vein with ultrasound imaging, a double-lumen central venous catheter was inserted using the modified Seldinger technique. Venous entry of the needle was recognized by return of venous blood during needle advance or withdrawal. The internal jugular vein was assessed cross-sectionally and longitudinally after catheterization to identify any complications. A p value of <.05 was considered to be statistically significant. MEASUREMENTS AND MAIN RESULTS: There was no difference in the incidence of the puncture-on-withdrawal between the two groups (37 of 169 in the bevel-down group and 25 of 169 in the bevel-up group). However, the incidence of posterior hematoma formation was lower in the bevel-down group (six of 169 vs. 17 of 169, p = .031). Additionally, there was less incidence of the posterior hematoma formation associated with puncture-on-withdrawal in the bevel-down group (six of 37 vs. 11 of 25, p = .034). CONCLUSIONS: The bevel-down approach of the right internal jugular vein may decrease the incidence of posterior venous wall damage and hematoma formation compared with the bevel-up approach, which implicates a reduced probability of carotid artery puncture with the bevel-down approach during internal jugular vein catheterization.

Tracheal laceration during intubation of a double-lumen tube and intraoperative fiberoptic bronchoscopic evaluation through an LMA in the lateral position -A case report-.

A 76-year-old, 148-cm woman was scheduled for right upper lobectomy. A 32 Fr left-sided double lumen tube was placed using a conventional technique. Despite several attempts under fiberoptic bronchoscope-guidance, we could not locate the double lumen tube properly. We thus decided to proceed with the bronchial tube in the right mainstem bronchus. During surgery, 8-cm-long laceration was noted on the posterolateral side of the trachea. To check the possibility of laceration of the proximal trachea, the double lumen tube was changed to an LMA for use as a conduit for fiberoptic bronchoscopic evaluation in the lateral position. A plain endotracheal tube with the cuff modified and collapsed was re-intubated after evaluation. And then she was transferred to SICU.