Primary Versus Delayed Primary Incision Closure in Contaminated Abdominal Surgery: A Meta-Analysis.

BACKGROUND: Debates still exist whether delayed primary incision closure (DPC) could bring more benefits to patients suffering contaminated abdominal surgery. So, we want to determine whether DPC has advantage over primary incision closure (PC) in contaminated abdominal surgery. METHODS: Embase, Medline, and the Cochrane Library databases were searched for eligible studies from January 1, 1980 to August 6, 2017. Bibliographies of potential eligibility were also retrieved. The primary outcome was the rate of surgical site infection (SSI) and the second outcome was length of hospital stay (LOS). A systematic review and meta-analysis of RCTs were performed. RESULTS: Twelve studies were included in the final quantitative synthesis. Of the 12 studies included, five were from third world countries (i.e., India and Pakistan), and all of these demonstrated an improvement in SSI rate with DPC. When the fixed-effect model used, compared with PC, SSI was significantly reduced in DPC with a risk ratio of 0.64 (0.51-0.79) (P < 0.0001), and a significant difference in LOS between DPC and PC was also identified with a mean difference of 0.39 (0.17-0.60) (P = 0.0004). Although the random-effect model was used, no significant difference in SSI between DPC and PC was observed with a risk ratio of 0.65 (0.38-1.12) (P = 0.12), and no significant difference in LOS between DPC and PC was found with a mean difference of 1.19 (-1.03 to 3.41) (P = 0.29). CONCLUSIONS: DPC may be the preferable choice in contaminated abdominal surgeries, especially in patients with high risk of infection, and particularly in resource constrained environments. In addition, more high-quality studies with well design are needed to provide clear evidence.

Role of surgical resection for patients with recurrent or metastatic gastrointestinal stromal tumors: A systematic review and meta-analysis.

BACKGROUND: The role of surgical resection for patients with recurrent or metastatic gastrointestinal stromal tumors is still controversial. This meta-analysis aims to investigate the clinical outcomes of surgery combined with tyrosine kinase inhibitors among patients with recurrent or metastatic gastrointestinal stromal tumors. METHODS: We systematically searched PubMed, EMBASE, the Cochrane Library and Wanfangdata without language restriction. Random effect models were used to estimate pooled hazard ratio and the corresponding 95% confidence intervals. Subgroup analyses, sensitivity analysis and trim and fill analysis were also performed. RESULTS: A total of 1416 patient from 9 studies were finally enrolled in this meta-analysis. The summary results showed that surgery combined with tyrosine kinase inhibitors showed a tendency of a longer overall survival compared with tyrosine kinase inhibitors treatment alone (HR by random-effects model 0.68, 95% CI 0.54-0.85, I2 = 44.7%) and improved progress-free survival (HR by random-effects model 0.50,95% CI, 0.33-0.76, I2 = 17.9%). The trim and fill analysis and sensitive analysis indicated the relatively robust result. CONCLUSION: Surgery combined with tyrosine kinase inhibitors therapy is associated with a better overall survival and progression free survival for patients with recurrent or metastatic gastrointestinal stromal tumors as compared with TKIs treatment alone.

Prognoses in patients with primary gastrointestinal neuroendocrine neoplasms based on the proposed new classification scheme.

AIM: The aim of this study is to investigate the clinicopathological characteristics, as well as explore the prognostic accuracy of the proposed new classification in gastrointestinal NENs (GI-NENs) patients. METHODS: Patients diagnosed with GI-NENs were retrospectively indentified from existing databases of the pathological institute at our institution from January 2009 to November 2015. RESULTS: We identified 414 patients with GI-NENs, 250 cases were diagnosed as neuroendocrine tumor G1 (NET G1), 25 as neuroendocrine tumor G2 (NET G2), 53 as neuroendocrine tumor G3 (NET G3), 55 as neuroendocrine carcinoma G3 (NEC G3), and 31 as mixed adenoneuroendocrine carcinoma (MANEC); the overall survival (OS) rate at three years were 94.9%, 91.7%, 74.3%, 62.7% and 38.1%, respectively. The difference in progression-free survival (PFS) duration among the patients with NET G1, NET G2, NET G3, NEC G3, and MANEC was statistically significant (P < 0.001). However, the PFS of NEC G3 and MANEC was low and similar (P = 0.090). In multivariate analysis of patients with GI-NENs, surgical margin, comorbidity, proposed new classification and tumor location were useful predictors of OS (P < 0.05). CONCLUSION: Our findings suggest that the proposed new classification can accurately reflect the clinical outcome, together with surgical margin, comorbidity, and tumor location may be meaningful prognostic factors for the OS of GI-NENs.

Comparison Analysis of Three Different Types of Minimally Invasive Procedures for Gastrointestinal Stromal Tumors ≤5 cm.

OBJECTIVE: This study aimed to evaluate the safety, feasibility, and prognosis of three different types of minimally invasive procedures for treating gastric gastrointestinal stromal tumors (GISTs) ≤5 cm. MATERIALS AND METHODS: The clinical data, perioperative conditions, and the follow-up results of patients who underwent laparoscopic resection (LAP), laparoscopic and endoscopic cooperative surgery (LECS), or endoscopic submucosal dissection (ESD) for gastric GISTs ≤5 cm were retrospectively collected and analyzed. RESULTS: A total of 91 patients were enrolled in this study, and the number of cases who underwent LAP, LECS, and ESD was 30, 15, and 46, respectively. Compared with patients in the LAP and LECS group, patients in the ESD group had a smaller tumor size (P < .001, <.05, respectively.) and a higher percentage of intragastric growth pattern (all P value <.01). Significant differences were found in operative time and intraoperative blood loss among the three groups (P < .001). The operative time and intraoperative blood loss in ESD group were significantly less than that in LECS and LAP groups. No statistical difference was found in the postoperative recovery and complications among the three groups, such as nasogastric tube retention, anal exhaust time, oral intake, postoperative complication, and tumor recurrence. CONCLUSIONS: Minimally invasive surgery for gastric GISTs ≤5 cm is safe and feasible. The final choice regarding a minimally invasive approach should be based on the tumor size, tumor location, pattern of tumor growth, and experience of laparoscopic surgeons.

[FAP Expression and Its Association with the Prognosis of Gastric Stromal Tumors].

OBJECTIVES: To determine the association of FAP expression with the prognosis of gastric stromal tumors (GSTs). METHODS: Paraffin-embedded GSTs samples were collected from January 2010 to December 2013 in the department of pathology of our hospital. FAP expression was examined by immunohistochemistry staining. Its correlations with clinical pathological characteristics and prognosis of GSTs were analyzed. RESULTS: A total of 98 cases were included in this study. FAP was expressed in the cytoplasm of GSTs cells, with a positive rate of 42.9%. No FAP expression was found in normal gastric tissues. No differences of FAP expression were found in patients with different gender, age and tumor mitotic counts (P >0.05). Tumor diameter and risk classification were associated with FAP expression (P <0.05). Higher levels of FAP expression were found in larger and higher risk tumors. No significant correlations between FAP expression and routine immunohistochemical markers were found. Log-rank univariate survival analysis showed that mitotic counts, tumor size, postoperative IM and FAP expression were associated with recurrence free survival of GSTs patients with intermediate-high risks (P <0.05). Cox multivariate survival analysis showed that mitotic counts, tumor size, postoperative IM and FAP were independent predictors for the prognosis of GSTs patients with intermediate-high risks (P <0.05). CONCLUSION: FAP is expressed in the cytoplasm of gastric GIST cells, but not in normal gastric tissues. FAP is a predictor for the prognosis of GSTs patients with intermediate-high risks.

[Associations of Preoperative Platelet-to-lymphocyte Ratio and Derived Neutrophil-to-lymphocyte Ratio with thePrognosis of Gastrointestinal Stromal Tumor].

OBJECTIVES: To determine the associations of preoperative platelet-to-lymphocyte ratio (PLR) and derived neutrophil-to-lymphocyte ratio (d-NLR) with the prognosis of gastrointestinal stromal tumor (GIST). METHODS: GIST patients with surgical treatment from June 2005 to February 2015 in West China Hospital of Sichuan University were enrolled in the study. The results of blood routine tests of the patients within one week prior to surgery and their clinical data were extracted. The patients were divided into high-PLR/d-NLR (PLR#>153.075, d-NLR#>1.245) and low-PLR/d-NLR (PLR≤153.075, d-NLR≤1.245) groups according to the optimal cutoff values of the receiver operating characteristic (ROC) curves. Recurrence-free survival (RFS) rates were calculated using Kaplan-Meier method. COX regression analyses were performed to identify factors associated with RFS for GIST patients without imatinib treatment. [WTHZ]. RESULTS: [WTBZ]Regardless of imatinib treatment, the patients with high PLR and d-NLR had shorter RFS than those with low PLR and d-NLR. Tumor diameter, location, mitotic counts, preoperative PLR and d-NLR were identified as factors associated with RFS in the univariate analyses. The multivariate analysis identified tumor diameter [≥5 cm, hazard ratio (HR): 4.295, 95% confidence interval (CI): 1.772-10.413, P=0.001], non-stomach (HR:2.247, 95%CI: 1.200-4.209; P=0.011), mitotic counts (>5/50 HPF: HR:4.678, 95%CI: 2.364-9.257; P<0.001) and high d-NLR (HR:2.549, 95%CI: 1.159-5.606; P=0.1020) as independent factors predicting the prognosis of GIST. The patients with high PLR or high d-NLR had shorter RFS than those with low PLR/d-NLR. [WTHZ]. CONCLUSION: [WTBZ]Preoperative d-NLR is an independent predictor of RFS in GIST. PLR and d-NLR can be used in predicting the recurrence risk of GIST.

Preoperative imatinib mesylate (IM) for huge gastrointestinal stromal tumors (GIST).

BACKGROUND: Preoperative imatinib mesylate (IM) treatment has not yet been standardized. Here, we aim to further explore such therapy on patients with gastrointestinal stromal tumors (GIST) retrospectively. METHODS: Patients experiencing preoperative IM were identified from January 2009 to February 2015. RESULTS: A total of 28 GIST patients were identified. The patients received preoperative IM treatment for a median length of 13.5 months, ranging from 5 to 37 months. PR and SD were observed in 24 (85.7%) and 4 (15.3%) patients, respectively. The tumor shrinkage occurred predominantly within 6 to 12 months, and slight tumor shrinkage could be observed after 12 months in certain patients. Nineteen patients (67.9%) received surgery, and R0 resection was acquired in 18 (94.7%) patients. The initial mean maximum diameter was 10.5 (5.2 to 19.0) cm and decreased to 5.9 (2.7 to 19.0) cm after preoperative treatment with a median length of 12 (ranging from 5 to 36) months (P < 0.001) in patients receiving operations. Three in 7 cases of rectum GIST underwent abdominoperineal resection, and four others adopted sphincter-sparing resection. Partial gastrectomy was performed in four patients. CONCLUSIONS: IM prior to surgery can effectively prevent tumor rupture and facilitate surgery with low surgical morbidity for GIST patients. Tumor shrinkage following IM occurred predominantly within 6 to 12 months, and slight tumor shrinkage could be observed after 12 months in certain patients. In selected patients, prolonged exposure to IM is seemingly advisable under close radiological surveillance.

Neuroendocrine tumors of colon and rectum: validation of clinical and prognostic values of the World Health Organization 2010 grading classifications and European Neuroendocrine Tumor Society staging systems.

BACKGROUND/AIMS: This study evaluated and compared the clinical and prognostic values of the grading criteria used by the World Health Organization (WHO) and the European Neuroendocrine Tumors Society (ENETS). Moreover, this work assessed the current best prognostic model for colorectal neuroendocrine tumors (CRNETs). RESULTS: The 2010 WHO classifications and the ENETS systems can both stratify the patients into prognostic groups, although the 2010 WHO criteria is more applicable to CRNET patients. Along with tumor location, the 2010 WHO criteria are important independent prognostic parameters for CRNETs in both univariate and multivariate analyses through Cox regression (P<0.05). METHODS: Data from 192 consecutive patients histopathologically diagnosed with CRNETs and had undergone surgical resection from January 2009 to May 2016 in a single center were retrospectively analyzed. CONCLUSIONS: Findings suggest that the WHO classifications are superior over the ENETS classification system in predicting the prognosis of CRNETs. Additionally, the WHO classifications can be widely used in clinical practice.

A lower dosage of imatinib in patients with gastrointestinal stromal tumors with toxicity of the treatment.

This study investigated the efficiency and safety of imatinib in the lower dose (300 mg/d) in patients with gastrointestinal stromal tumor (GIST) who cannot tolerate imatinib in the standard dose (400 mg/d).Steady-state imatinib trough concentration (Cmin) values in 18 patients with GIST who were taking 300 mg/d or 400 mg/d imatinib were measured. The clinical features, toxicity data, and follow-up data were collected.Around 18 patients with GIST were investigated in which 9 patients received 300 mg/d imatinib. The mean imatinib Cmin value of the 18 patients was 1841 ng/mL (1018-3897 ng/mL). The difference between the patients treated with 400 mg/d (n=9) and those treated with 300 mg/d (n = 9), which have imatinib Cmin values of 2122±1003 ng/mL and 1559±478 ng/mL, respectively, was not significant (P = 0.148). In total, 12 of the 18 patients had complete resection of the primary tumor, 8 of whom received postoperative imatinib 300 mg/d. After the average follow-up of 15.4 months, no recurrence was documented. Of the 6 patients with unresected GIST, 1 received imatinib 300 mg/d for 13 months. The tumor size of this patient continued to decrease. In contrast to patients treated with imatinib 400 mg/d, patients treated with imatinib 300 mg/d notably exhibited lesser drug-related side effects.Patients with GIST who exhibited intolerance to the standard dose of imatinib (400 mg/d), a lower dose of 300 mg/d could provide not only sufficient plasma Cmin and good disease control but also the alleviation of the side effects.

Surgical treatment and prognosis of gastric neuroendocrine neoplasms: a single-center experience.

BACKGROUND: Gastric neuroendocrine neoplasms (G-NENs) are uncommon, and data on their management is limited. We here investigated the clinicopathological characteristics, surgical and survival outcomes in G-NENs among Chinese. Moreover, we will discuss their prognostic value. METHODS: From existing databases of the West China Hospital, we retrospectively identified 135 consecutive patients who were surgically treated and pathologically diagnosed as G-NENs from January 2009 to August 2015. RESULTS: This entire cohort comprised 98 males and 37 females, with a median age of 60 years. Twenty-five patients underwent endoscopic resection, while 110 patients underwent open/laparoscopic surgery. Thirty-nine patients had neuroendocrine tumor G1 (NET G1), seven patients had neuroendocrine tumor G2 (NET G2), 69 patients had neuroendocrine carcinoma G3 (NEC G3) and 20 patients had mixed adenoneuroendocrine carcinoma (MANEC). The median survival was not achieved for both NET G1 and NET G2 versus 19 months (range 3-48) for NEC G3 and 10.5 months (range 3-45) for MANEC. The 3-year survival rates for stage I, II, III, and IV were 91.1 %, 78.6 %, 51.1 % and 11.8 %, respectively (P < 0.001). As for the prognostic analysis, both surgical margin and the newly updated World Health Organization (WHO) classification were independent predictors of overall survival (OS). CONCLUSIONS: G-NENs are a kind of rare tumors, and patients with NET G3 and MANEC have unfavorable prognosis even surgically treated. Moreover, surgical margin and the new 2010 WHO criteria are closely associated with OS for G-NENs.

[Characteristics of Clinicopathology and Genotype in 179 Cases with Gastrointestinal Stromal Tumor].

OBJECTIVE: To analyze the characteristics of the clinicopathology and genotypes in patients with gastrointestinal stromal tumor (GIST). METHODS: The clinicopathological and genotypic data of 179 patients with GIST, who underwent treatment and genetic testing in the Hostital of West China from September 2009 to February 2009 were collected retrospectively. RESULTS: The tumor sites of the cases were located in stomach (88 cases, 49.2%), small intestine (70 cases, 39.1%), colorectum (7 cases, 3.9%) and the other sites (14 cases, 7.8%) respectively. 94.4%, 74.9% and 93.3% of GIST patients were positive for CD117, CD34 and DOG-1 immunophenotypes respectively. C-kit and PDGFRα mutations were found in 151 cases (84.4%) and 8 cases (4.5%) except for the wild types of the rest 20 cases (11.2%). Among all the c-kit mutation, 92.2% mutation types in exon 11 were deletion mutation, point mutation and hybrid mutations, and in exon 9 the mutation types were just involving A502_Y503dup (n = 6) and Y403_F504ins (n = 14), while the mutation type were K642Q in exon 13 (n = 1) and N822K in 17 (n = 2). There were 6 patients with the mutation types of PDGFRα in exon 18, and 3 of them were type of D842V. In the GIST genotyping, DOG-1 positive rate in PDGFRα mutation patients were significantly lower than that in c-kit mutation and wild type patients (P = 0.007). In the various type of c-kit mutations, the positive rate of CD34 in point mutation patients were significantly lower than that in other mutation types (P < 0.001). The rate of high-risk patients in point mutation and insertion mutation patients were lower than that in deletion mutation and deletion + insertion mutation patients (P = 0.006). CONCLUSION: The most common localizaions of GISTs are the stomach and small intestine. The most frequent mutation type of GIST is c-kit exon 11. The individualized treatment is required for GIST patients because its high mutation rate and types.

Treatment and Prognoses in Patients With Primary Gastrointestinal Stromal Tumors ≥10  cm: A Single-Institution Experience in China.

Data on treatments and specific outcomes of primary gastrointestinal stromal tumors (GISTs) ≥10  cm are limited. We here report the treatments and survival outcomes concerning a subgroup of primary giant GISTs. Data of 83 consecutive patients with primary GISTs ≥10  cm in a single institution were retrospectively collected. Fifty-eight patients underwent surgery before imatinib mesylate (IM) treatment (Group A), 10 underwent surgical resection following IM therapy (Group B), whereas 15 patients took IM as drug therapy alone (Group C). The baseline clinical characteristics were similar among the 3 groups. However, a lower proportion in Group A had metastatic disease at the time of diagnosis or surgery compared with Groups B and C (8.6% vs 40.0% vs 40.0%, P < 0.05). The median follow-up duration was 21.5 months. No statistically significant differences were observed on progression-free survival (PFS) among the groups. However, patients in Group B showed significantly better overall survival (OS) compared with those in Group C (P = 0.044). Multivariate analysis showed that patients treated with adjuvant IM were associated with better PFS (hazard ratio [HR] 3.01; 95% confidence interval [CI] 1.13-7.97; P = 0.027) and OS (HR 29.11; 95% CI 3.32-125.36; P = 0.004). The subgroup with mitotic count >10/50 high-power fields (HPF) showed worse PFS (HR 3.50; 95% CI 1.19-10.25; P = 0.022) and OS (HR 20.04; 95% CI 1.67-143.79; P = 0.018) than that of mitotic count ≤5/50 HPF. Clinical treatment patterns for primary giant GISTs are different, and the outcomes of different interventions vary. The optimal treatments for these subgroup of patients still require further long-term investigation. Moreover, mitotic count and adjuvant IM are closely associated with PFS and OS in giant GISTs.

Kepler-16: a transiting circumbinary planet.

We report the detection of a planet whose orbit surrounds a pair of low-mass stars. Data from the Kepler spacecraft reveal transits of the planet across both stars, in addition to the mutual eclipses of the stars, giving precise constraints on the absolute dimensions of all three bodies. The planet is comparable to Saturn in mass and size and is on a nearly circular 229-day orbit around its two parent stars. The eclipsing stars are 20 and 69% as massive as the Sun and have an eccentric 41-day orbit. The motions of all three bodies are confined to within 0.5° of a single plane, suggesting that the planet formed within a circumbinary disk.