Immunotherapy for gastric cancer and liver metastasis: Is it time to bid farewell

Patients with metastatic gastric cancer have a grim prognosis. Palliative chemotherapy offers a limited survival improvement, but recent advancements in immunotherapy have sparked hope. However, the effectiveness of immunotherapy in patients with liver metastases remains debated. This article reviews a recent study by Liu et al and evaluates conflicting evidence on the impact of liver metastases on response to immunotherapy in metastatic gastric cancer. While some studies suggest no significant difference in treatment response based on liver involvement, others report varied response rates. The present study, a retrospective analysis of 48 patients by Liu et al, examines this issue and concludes that immunotherapy is less effective in patients with liver metastases. Despite methodological limitations and a small sample size, the study contributes to the ongoing discourse. The nuanced response to immunotherapy in certain patients underscores the importance of understanding the tumor microenvironment, immune cell infiltration, and the expression of immune checkpoints. Rather than dismissing immunotherapy for patients with gastric cancer and liver metastases, a shift towards personalized treatment strategies and a more profound understanding of tumor-specific biomarkers is essential. By unraveling the molecular intricacies of individual cases, clinicians may tailor more effective and customized treatments, offering a glimmer of hope for this challenging patient group.

Predictive utility of the Rockall scoring system in patients suffering from acute nonvariceal upper gastrointestinal hemorrhage

BACKGROUND

Acute non-variceal upper gastrointestinal bleeding (ANVUGIB) represents a significant clinical challenge due to its unpredictability and potentially severe outcomes. The Rockall risk score has emerged as a critical tool for prognostic assessment in patients with ANVUGIB, aiding in the prediction of rebleeding and mortality. However, its applicability and accuracy in the Chinese population remain understudied.

AIM

To assess the prognostic value of the Rockall risk score in a Chinese cohort of patients with ANVUGIB.

METHODS

A retrospective analysis of 168 ANVUGIB patients' medical records was conducted. The study employed statistical tests, including the t-test, χ 2 test, spearman correlation, and receiver operating characteristic (ROC) analysis, to assess the relationship between the Rockall score and clinical outcomes, specifically focusing on rebleeding events within 3 months post-assessment.

RESULTS

Significant associations were found between the Rockall score and various clinical outcomes. High Rockall scores were significantly associated with rebleeding events (r = 0.735, R 2 = 0.541, P < 0.001) and strongly positively correlated with adverse outcomes. Low hemoglobin levels (t = 2.843, P = 0.005), high international normalized ratio (t = 3.710, P < 0.001), active bleeding during endoscopy (χ 2 = 7.950, P = 0.005), large ulcer size (t = 6.348, P < 0.001), and requiring blood transfusion (χ 2 = 6.381, P = 0.012) were all significantly associated with rebleeding events. Furthermore, differences in treatment and management strategies were identified between patients with and without rebleeding events. ROC analysis indicated the excellent discriminative power (sensitivity: 0.914; specificity: 0.816; area under the curve: 0.933; Youden index: 0.730) of the Rockall score in predicting rebleeding events within 3 months.

CONCLUSION

This study provides valuable insights into the prognostic value of the Rockall risk score for ANVUGIB in the Chinese population. The results underscore the potential of the Rockall score as an effective tool for risk stratification and prognostication, with implications for guiding risk-appropriate management strategies and optimizing care for patients with ANVUGIB.

Effect of growth hormone on colonic anastomosis after intraperitoneal administration of 5-fluorouracil, bleomycin and cisplatin: An experimental study

BACKGROUND

Growth hormone (GH) plays a crucial role in wound healing and tissue repair in postoperative patients. In particular, colonic anastomosis healing following colorectal surgery is impaired by numerous chemotherapy agents.

AIM

To investigate whether GH can improve the healing of a colonic anastomosis following the adverse effects of intraperitoneal administration of 5-fluorouracil (5-FU), bleomycin and cisplatin.

METHODS

Eighty Wistar rats underwent laparotomy and a 1 cm-resection of the transverse colon, followed by an end-to-end anastomosis under general anesthesia. The rats were blindly allocated into four equal groups and administered a different daily intraperitoneal therapeutic regimen for 6 days. The control group (A) received normal saline. Group B received chemotherapy with 5-FU (20 mg/kg), bleomycin (4 mg/kg) and cisplatin (0.7 mg/kg). Group C received GH (2 mg/kg), and group D received the aforementioned combination chemotherapy and GH, as described. The rats were sacrificed on the 7th postoperative day and the anastomoses were macroscopically and microscopically examined. Body weight, bursting pressure, hydroxyproline levels and inflammation markers were measured.

RESULTS

All rats survived until the day of sacrifice, with no infections or other complications. A decrease in the body weight of group D rats was observed, not statistically significant compared to group A (P = 1), but significantly different to groups C (P = 0.001) and B (P < 0.01). Anastomotic dehiscence rate was not statistically different between the groups. Bursting pressure was not significantly different between groups A and D (P = 1.0), whereas group B had a significantly lower bursting pressure compared to group D (P < 0.001). All groups had significantly more adhesions than group A. Hydroxyproline, as a measurement of collagen deposition, was significantly higher in group D compared to group B (P < 0.05), and higher, but not statistically significant, compared to group A. Significant changes in group D were recorded, compared to group A regarding inflammation (3.450 vs 2.900, P = 0.016) and fibroblast activity (2.75 vs 3.25, P = 0.021). Neoangiogenesis and collagen deposition were not significantly different between groups A and D. Collagen deposition was significantly increased in group D compared to group B (P < 0.001).

CONCLUSION

Intraperitoneal administration of chemotherapy has an adverse effect on the healing process of colonic anastomosis. However, GH can inhibit the deleterious effect of administered chemotherapy agents and induce colonic healing in rats.

Transmembrane serine protease 4 expression in the prognosis of radical resection for biliary tract cancer

BACKGROUND

Recent advancements in biliary tract cancer (BTC) treatment have expanded beyond surgery to include adjuvant therapy, yet the prognosis remains poor. Identifying prognostic biomarkers could enhance the assessment of patients who have undergone radical resection for BTC.

AIM

To determine transmembrane serine protease 4 (TMPRSS4) utility as a prognostic biomarker of radical resection for BTC.

METHODS

Medical records of patients who underwent radical resection for BTC, excluding intrahepatic cholangiocarcinoma, were retrospectively reviewed. The associations between TMPRSS4 expression and clinicopathological factors, overall survival, and recurrence-free survival were analyzed.

RESULTS

Among the 85 patients undergoing radical resection for BTC, 46 (54%) were TMPRSS4-positive. The TMPRSS4-positive group exhibited significantly higher preoperative carbohydrate antigen 19-9 (CA19-9) values and greater lymphatic invasion than the TMPRSS4-negative group (P = 0.019 and 0.039, respectively). Postoperative overall survival and recurrence-free survival were significantly worse in the TMPRSS4-positive group (median survival time: 25.3 months vs not reached, P < 0.001; median survival time: 28.7 months vs not reached, P = 0.043, respectively). Multivariate overall survival analysis indicated TMPRSS4 positivity, pT3/T4, and resection status R1 were independently associated with poor prognosis (P = 0.032, 0.035 and 0.030, respectively). TMPRSS4 positivity correlated with preoperative CA19-9 values ≥ 37 U/mL and pathological tumor size ≥ 30 mm (P = 0.016 and 0.038, respectively).

CONCLUSION

TMPRSS4 is a potential prognostic biomarker of radical resection for BTC.

Assessment of perianal fistulizing Crohn's disease activity with endoanal ultrasound: A retrospective cohort study

BACKGROUND

Perianal fistulas pose dual challenges to Crohn's disease (CD) patients. Low patient compliance due to the complexity of existing examination methods plagues the treatment and follow-up management of perianal CD.

AIM

To determine the accuracy of endoanal ultrasound (EUS) and shear wave elastography (SWE) for evaluating perianal fistulizing CD (PFCD) activity.

METHODS

This was a retrospective cohort study. A total of 67 patients from August 2022 to December 2023 diagnosed with CD were divided into three groups: Non-anal fistula group (n = 23), low-activity perianal fistulas [n = 19, perianal disease activity index (PDAI) ≤ 4], high-activity perianal fistulas (n = 25, PDAI > 4) based on the PDAI. All patients underwent assessments including EUS + SWE, pelvic magnetic resonance [pelvic magnetic resonance imaging (MRI)], C-reactive protein, fecal calprotectin, CD activity index, PDAI.

RESULTS

The percentage of fistulas indicated by pelvic MRI and EUS was consistent at 82%, and there was good consistency in the classification of perianal fistulas (Kappa = 0.752, P < 0.001). Significant differences were observed in the blood flow Limberg score (χ 2 = 8.903, P < 0.05) and shear wave velocity (t = 2.467, P < 0.05) between group 2 and 3. Shear wave velocity showed a strong negative correlation with magnetic resonance novel index for fistula imaging in CD (Magnifi-CD) score (r = -0.676, P < 0.001), a weak negative correlation with the PDAI score (r = -0.386, P < 0.05), and a weak correlation between the Limberg score and the PDAI score (r = 0.368, P < 0.05).

CONCLUSION

EUS combined with SWE offers a superior method for detecting and quantitating the activity of perianal fistulas in CD patients. It may be the ideal tool to assess PFCD activity objectively for management strategies.

Clinical application value of long non-coding RNAs signatures of genomic instability in predicting prognosis of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) presents challenges due to its high recurrence and metastasis rates and poor prognosis. While current clinical diagnostic and prognostic indicators exist, their accuracy remains imperfect due to their biological complexity. Therefore, there is a quest to identify improved biomarkers for HCC diagnosis and prognosis. By combining long non-coding RNA (lncRNA) expression and somatic mutations, Duan et al identified five representative lncRNAs from 88 lncRNAs related to genomic instability (GI), forming a GI-derived lncRNA signature (LncSig). This signature outperforms previously reported LncSig and TP53 mutations in predicting HCC prognosis. In this editorial, we comprehensively evaluate the clinical application value of such prognostic evaluation model based on sequencing technology in terms of cost, time, and practicability. Additionally, we provide an overview of various prognostic models for HCC, aiding in a comprehensive understanding of research progress in prognostic evaluation methods.

Application value of dexmedetomidine in anesthesia for elderly patients undergoing radical colon cancer surgery

BACKGROUND

Colon cancer presents a substantial risk to the well-being of elderly people worldwide. With advancements in medical technology, surgical treatment has become the primary approach for managing colon cancer patients. However, due to age-related physiological changes, especially a decline in cognitive function, older patients are more susceptible to the effects of surgery and anesthesia, increasing the relative risk of postoperative cognitive dysfunction (POCD). Therefore, in the surgical treatment of elderly patients with colon cancer, it is of paramount importance to select an appropriate anesthetic approach to reduce the occurrence of POCD, protect brain function, and improve surgical success rates.

AIM

To explore the value of dexmedetomidine (Dex) in anesthesia for elderly patients undergoing radical colon cancer surgery.

METHODS

One hundred and seventeen patients with colon cancer who underwent elective surgery under general anesthesia were selected and divided into two groups: A and B. Group A received Dex before anesthesia induction, and B group received an equivalent amount of normal saline. Changes in the mini-mental state examination, regional cerebral oxygen saturation (rSO2), bispectral index, glucose uptake rate (GluER), lactate production rate (LacPR), serum S100β and neuron-specific enolase (NSE), POCD, and adverse anesthesia reactions were compared between the two groups.

RESULTS

Surgical duration, duration of anesthesia, and intraoperative blood loss were comparable between the two groups (P > 0.05). The overall dosage of anesthetic drugs used in group A, including propofol and remifentanil, was significantly lower than that used in group B (P < 0.05). Group A exhibited higher rSO2 values at the time of endotracheal intubation, 30 min after the start of surgery, and immediately after extubation, higher GluER values and lower LacPR values at the time of endotracheal intubation, 30 min after the start of surgery, immediately after extubation, and 5 min after extubation (P < 0.05). Group A exhibited lower levels of serum S100β and NSE 24 h postoperatively and a lower incidence of cognitive dysfunction on the 1st and 5th postoperative days (P < 0.05).

CONCLUSION

The use of Dex in elderly patients undergoing radical colon cancer surgery helps maintain rSO2 Levels and reduce cerebral metabolic levels and the incidence of anesthesia- and surgery-induced cognitive dysfunction.

Advancements in nutritional diagnosis and support strategies during the perioperative period for patients with liver cancer

Liver cancer represents a grave hepatic condition and constitutes a significant global health concern. Surgical resection remains the principal therapeutic modality for liver cancer. Nevertheless, perioperative malnutrition exerts a notable impact on patients with liver cancer, emerging as an independent risk factor for disease mortality and adverse outcomes. Hence, precise nutritional diagnosis and timely nutritional support hold the potential to enhance therapeutic efficacy and quality of life for liver cancer patients. This study represents a meticulous foray into the literature, extracting data from PubMed, Web of Science, and EMBASE databases, with a focus on the past 5 years. It scrutinizes the impact of malnutrition on patients undergoing liver cancer surgery, the etiological underpinnings of malnutrition within this patient cohort, the critical assessment of perioperative nutritional status, and the strategic approaches to nutritional support. Utilizing rigorous inclusion and exclusion criteria, the amassed scholarly works are meticulously synthesized, methodically organized, and categorically elaborated upon. Ultimately, the authors propose the incorporation of a multidisciplinary nutrition management team during the perioperative period, comprising nutritionists, pharmacists, physicians, nurses, psychologists, and rehabilitation therapists, among other specialized professionals. Together, they collaborate to devise and implement personalized nutritional support plans, monitor patients' nutritional status, and make necessary adjustments as required. Through comprehensive management and intervention, improvements in the nutritional status of liver cancer patients can be achieved, thereby enhancing surgical success rates and facilitating postoperative recovery. It is believed that this manuscript will offer valuable insights to advance the nutritional management during the perioperative phase of liver cancer, aiding in ameliorating patients' nutritional status and treatment outcomes.

Alteration of ascending colon mucosal microbiota in patients after cholecystectomy

BACKGROUND

Cholecystectomy is a successful treatment option for gallstones, although the incidence of colorectal cancer (CRC) has notably increased in post-cholecystectomy (PC) patients. However, it remains uncertain whether the altered mucosal microbiota in the ascending colon is related.

AIM

To investigate the potential correlation between gut microbiota and the surgical procedure of cholecystectomy.

METHODS

In total, 30 PC patients and 28 healthy controls underwent colonoscopies to collect mucosal biopsy samples. PC patients were divided based on their clinical features. Then, 16S-rRNA gene sequencing was used to analyze the amplicon, alpha diversity, beta diversity, and composition of the bacterial communities. Additionally, the Phylogenetic Investigation of Communities by Reconstruction of Unobserved States (PICRUSt) database, sourced from the Kyoto Encyclopedia of Genes and Genomes, was used to predict the functional capabilities of the bacteria.

RESULTS

PC patients were comparable with healthy controls. However, PC patients older than 60 years had a distinct composition compared to those under 60 years old. Bacteroidetes richness was considerably higher at the phylum level in PC patients. Bacteroides, Parabacteroides, and Bilophila were more abundant in the PC group than in the control group. Furthermore, PC patients exhibited greater enrichment in metabolic pathways, specifically those related to lipopolysaccharide biosynthesis and vancomycin group antibiotic production, than controls.

CONCLUSION

This study indicated that the mucosal microbiota in PC patients was altered, perhaps offering new perspectives on the treatment possibilities for CRC and diarrhea following cholecystectomy.

Nomogram predicting the prognosis of primary liver cancer after radiofrequency ablation combined with transcatheter arterial chemoembolization

BACKGROUND

The incidence and mortality rates of primary hepatocellular carcinoma (HCC) are high, and the conventional treatment is radiofrequency ablation (RFA) with transcatheter arterial chemoembolization (TACE); however, the 3-year survival rate is still low. Further, there are no visual methods to effectively predict their prognosis.

AIM

To explore the factors influencing the prognosis of HCC after RFA and TACE and develop a nomogram prediction model.

METHODS

Clinical and follow-up information of 150 patients with HCC treated using RFA and TACE in the Hangzhou Linping Hospital of Traditional Chinese Medicine from May 2020 to December 2022 was retrospectively collected and recorded. We examined their prognostic factors using multivariate logistic regression and created a nomogram prognosis prediction model using the R software (version 4.1.2). Internal verification was performed using the bootstrapping technique. The prognostic efficacy of the nomogram prediction model was evaluated using the concordance index (CI), calibration curve, and receiver operating characteristic curve.

RESULTS

Of the 150 patients treated with RFA and TACE, 92 (61.33%) developed recurrence and metastasis. Logistic regression analysis identified six variables, and a predictive model was created. The internal validation results of the model showed a CI of 0.882. The correction curve trend of the prognosis prediction model was always near the diagonal, and the mean absolute error before and after internal validation was 0.021. The area under the curve of the prediction model after internal verification was 0.882 [95% confidence interval (95%CI): 0.820-0.945], with a specificity of 0.828 and sensitivity of 0.656. According to the Hosmer-Lemeshow test, χ 2 = 3.552 and P = 0.895. The predictive model demonstrated a satisfactory calibration, and the decision curve analysis demonstrated its clinical applicability.

CONCLUSION

The prognosis of patients with HCC after RFA and TACE is affected by several factors. The developed prediction model based on the influencing parameters shows a good prognosis predictive efficacy.

Systemic immune-inflammation index combined with pediatric appendicitis score in assessing the severity and prognosis for paediatric appendicitis

BACKGROUND

Pediatric appendicitis is a common cause of abdominal pain in children and is recognized as a significant surgical emergency. A prompt and accurate diagnosis is essential to prevent complications such as perforation and peritonitis.

AIM

To investigate the predictive value of the systemic immune-inflammation index (SII) combined with the pediatric appendicitis score (PAS) for the assessment of disease severity and surgical outcomes in children aged 5 years and older with appendicitis.

METHODS

Clinical data of 104 children diagnosed with acute appendicitis were analyzed. The participants were categorized into the acute appendicitis group and chronic appendicitis group based on disease presentation and further stratified into the good prognosis group and poor prognosis group based on prognosis. The SII and PAS were measured, and a joint model using the combined SII and PAS was constructed to predict disease severity and surgical outcomes.

RESULTS

Significant differences were observed in the SII and PAS parameters between the acute appendicitis group and chronic appendicitis group. Correlation analysis showed associations among the SII, PAS, and disease severity, with the combined SII and PAS model demonstrating significant predictive value for assessing disease severity [aera under the curve (AUC) = 0.914] and predicting surgical outcomes (AUC = 0.857) in children aged 5 years and older with appendicitis.

CONCLUSION

The study findings support the potential of integrating the SII with the PAS for assessing disease severity and predicting surgical outcomes in pediatric appendicitis, indicating the clinical utility of the combined SII and PAS model in guiding clinical decision-making and optimizing surgical management strategies for pediatric patients with appendicitis.

Management of distal cholangiocarcinoma with arterial involvement: Systematic review and case series on the role of neoadjuvant therapy

BACKGROUND

The use of neoadjuvant therapy (NAT) in distal cholangiocarcinoma (dCCA) with regional arterial or extensive venous involvement, is not widely accepted and evidence is sparse.

AIM

To synthesise evidence on NAT for dCCA and present the experience of a high-volume tertiary-centre managing dCCA with arterial involvement.

METHODS

A systematic review was performed according to PRISMA guidance to identify all studies reporting outcomes of patients with dCCA who received NAT. All patients from 2017 to 2022 who were referred for NAT for dCCA at our centre were retrospectively collected from a prospectively maintained database. Baseline characteristics, NAT type, progression to surgery and oncological outcomes were collected.

RESULTS

Twelve studies were included. The definition of "unresectable" locally advanced dCCA was heterogenous. Four studies reported outcomes for 9 patients who received NAT for dCCA with extensive vascular involvement. R0 resection rate ranged between 0 and 100% but without survival benefit in most cases. Remaining studies considered either NAT in resectable dCCA or inclusive with extrahepatic CCA. The presented case series includes 9 patients (median age 67, IQR 56-74 years, male:female 5:4) referred for NAT for borderline resectable or locally advanced disease. Three patients progressed to surgery and 2 were resected. One patient died at 14 months with evidence of recurrence at 6 months and the other died at 51 months following recurrence 6 months post-operatively.

CONCLUSION

Evidence for benefit of NAT is limited. Consensus on criteria for uniform definition of resectability for dCCA is required. We propose using the established National-Comprehensive-Cancer-Network® criteria for pancreatic ductal adenocarcinoma.

Effects of fluid therapy combined with a preoperative glucose load regimen on postoperative recovery in patients with rectal cancer

BACKGROUND

Patients with rectal cancer undergoing radical resection often have poor postoperative recovery due to preoperative fasting and water deprivation and the removal of diseased tissue, and have a high risk of complications. Therefore, it is of great significance to apply appropriate rehydration regimens to patients undergoing radical resection of rectal cancer during the perioperative period to improve the postoperative outcomes of patients.

AIM

To analyze the effects of goal-directed fluid therapy (GDFT) with a preoperative glucose load regimen on postoperative recovery and complications in patients undergoing radical resection for rectal cancer.

METHODS

Patients with rectal cancer who underwent radical resection (n = 184) between January 2021 and December 2023 at our hospital were randomly divided into either a control group or an observation group (n = 92 in each group). Both groups received a preoperative glucose load regimen, and routine fluid replacement and GDFT were additionally implements in the control and observation groups, respectively. The operative conditions, blood levels of lactic acid and inflammatory markers, postoperative recovery, cognitive status, hemodynamic indicators, brain oxygen metabolism, and complication rates were compared between the groups.

RESULTS

The colloidal fluid dosage, total infusion, and urine volume, as well as time to first exhaust, time to food intake, and postoperative length of hospital stay, were lower in the observation group (P < 0.05). No significant differences were observed between the two groups in terms of operation time, bleeding volume, crystalloid liquid consumption, time to tracheal extubation, complication rate, heart rate, or mean arterial pressure (P > 0.05). Compared with the control group, in the observation group the lactic acid level was lower immediately after the surgery (P < 0.05); the Mini-Mental State Examination score was higher on postoperative day 3 (P < 0.05); the pulse pressure variability (PPV) was lower at 30 min after pneumoperitoneum (P < 0.05), though the differences in the PPV of the two groups was not significant at the remaining time points (P > 0.05); tumor necrosis factor-α and interleukin-6 levels were lower on postoperative day 3 (P < 0.05); and the left and right regional cerebral oxygen saturation was higher immediately after the surgery and 30 min after pneumoperitoneum (P < 0.05).

CONCLUSION

GDFT combined with the preoperative glucose load regimen is a safe and effective treatment strategy for improving postoperative recovery and risk of complications in patients with rectal cancer undergoing radical resection.

Survival prognostic analysis of laparoscopic D2 radical resection for locally advanced gastric cancer: A multicenter cohort study

BACKGROUND

With the development of minimally invasive surgical techniques, the use of laparoscopic D2 radical surgery for the treatment of locally advanced gastric cancer (GC) has gradually increased. However, the effect of this procedure on survival and prognosis remains controversial. This study evaluated the survival and prognosis of patients receiving laparoscopic D2 radical resection for the treatment of locally advanced GC to provide more reliable clinical evidence, guide clinical decision-making, optimize treatment strategies, and improve the survival rate and quality of life of patients.

AIM

To investigate the survival prognosis and influencing factors of laparoscopic D2 radical resection for locally advanced GC patients.

METHODS

A retrospective cohort study was performed. Clinicopathological data from 652 patients with locally advanced GC in our hospitals from December 2013 to December 2023 were collected. There were 442 males and 210 females. The mean age was 57 ± 12 years. All patients underwent a laparoscopic D2 radical operation for distal GC. The patients were followed up in the outpatient department and by telephone to determine their tumor recurrence, metastasis, and survival. The follow-up period ended in December 2023. Normally distributed data are expressed as the mean ± SD, and normally distributed data are expressed as M (Q1, Q3) or M (range). Statistical data are expressed as absolute numbers or percentages; the χ 2 test was used for comparisons between groups, and the Mann-Whitney U nonparametric test was used for comparisons of rank data. The life table method was used to calculate the survival rate, the Kaplan-Meier method was used to construct survival curves, the log rank test was used for survival analysis, and the Cox risk regression model was used for univariate and multifactor analysis.

RESULTS

The median overall survival (OS) time for the 652 patients was 81 months, with a 10-year OS rate of 46.1%. Patients with TNM stages II and III had 10-year OS rates of 59.6% and 37.5%, respectively, which were significantly different (P < 0.05). Univariate analysis indicated that factors such as age, maximum tumor diameter, tumor differentiation grade (low to undifferentiated), pathological TNM stage, pathological T stage, pathological N stage (N2, N3), and postoperative chemotherapy significantly influenced the 10-year OS rate for patients with locally advanced GC following laparoscopic D2 radical resection for distal stomach cancer [hazard ratio (HR): 1.45, 1.64, 1.45, 1.64, 1.37, 2.05, 1.30, 1.68, 3.08, and 0.56 with confidence intervals (CIs) of 1.15-1.84, 1.32-2.03, 1.05-1.77, 1.62-2.59, 1.05-1.61, 1.17-2.42, 2.15-4.41, and 0.44-0.70, respectively; P < 0.05]. Multifactor analysis revealed that a tumor diameter greater than 4 cm, low tumor differentiation, and pathological TNM stage III were independent risk factors for the 10-year OS rate in these patients (HR: 1.48, 1.44, 1.81 with a 95%CI: 1.19-1.84). Additionally, postoperative chemotherapy emerged as an independent protective factor for the 10-year OS rate (HR: 0.57, 95%CI: 0.45-0.73; P < 0.05).

CONCLUSION

A maximum tumor diameter exceeding 4 cm, low tumor differentiation, and pathological TNM stage III were identified as independent risk factors for the 10-year OS rate in patients with locally advanced GC following laparoscopic D2 radical resection for distal GC. Conversely, postoperative chemotherapy was found to be an independent protective factor for the 10-year OS rate in these patients.

Construction of a predictive model for gastric cancer neuroaggression and clinical validation analysis: A single-center retrospective study

BACKGROUND

This study investigated the construction and clinical validation of a predictive model for neuroaggression in patients with gastric cancer. Gastric cancer is one of the most common malignant tumors in the world, and neuroinvasion is the key factor affecting the prognosis of patients. However, there is a lack of systematic analysis on the construction and clinical application of its prediction model. This study adopted a single-center retrospective study method, collected a large amount of clinical data, and applied statistics and machine learning technology to build and verify an effective prediction model for neuroaggression, with a view to providing scientific basis for clinical treatment decisions and improving the treatment effect and survival rate of patients with gastric cancer.

AIM

To investigate the value of a model based on clinical data, spectral computed tomography (CT) parameters and image omics characteristics for the preoperative prediction of nerve invasion in patients with gastric cancer.

METHODS

A retrospective analysis was performed on 80 gastric cancer patients who underwent preoperative energy spectrum CT at our hospital between January 2022 and August 2023, these patients were divided into a positive group and a negative group according to their pathological results. Clinicopathological data were collected, the energy spectrum parameters of primary gastric cancer lesions were measured, and single factor analysis was performed. A total of 214 image omics features were extracted from two-phase mixed energy images, and the features were screened by single factor analysis and a support vector machine. The variables with statistically significant differences were included in logistic regression analysis to construct a prediction model, and the performance of the model was evaluated using the subject working characteristic curve.

RESULTS

There were statistically significant differences in sex, carbohydrate antigen 199 expression, tumor thickness, Lauren classification and Borrmann classification between the two groups (all P < 0.05). Among the energy spectrum parameters, there were statistically significant differences in the single energy values (CT60-CT110 keV) at the arterial stage between the two groups (all P < 0.05) and statistically significant differences in CT values, iodide group values, standardized iodide group values and single energy values except CT80 keV at the portal vein stage between the two groups (all P < 0.05). The support vector machine model with the largest area under the curve was selected by image omics analysis, and its area under the curve, sensitivity, specificity, accuracy, P value and parameters were 0.843, 0.923, 0.714, 0.925, < 0.001, and c:g 2.64:10.56, respectively. Finally, based on the logistic regression algorithm, a clinical model, an energy spectrum CT model, an imaging model, a clinical + energy spectrum model, a clinical + imaging model, an energy spectrum + imaging model, and a clinical + energy spectrum + imaging model were established, among which the clinical + energy spectrum + imaging model had the best efficacy in diagnosing gastric cancer nerve invasion. The area under the curve, optimal threshold, Youden index, sensitivity and specificity were 0.927 (95%CI: 0.850-1.000), 0.879, 0.778, 0.778, and 1.000, respectively.

CONCLUSION

The combined model based on clinical features, spectral CT parameters and imaging data has good value for the preoperative prediction of gastric cancer neuroinvasion.

Treatment strategy and therapy based on immune response in patients with gastric cancers

In this editorial, we highlight the significance of a retrospective study "Analysis of the impact of immunotherapy efficacy and safety in patients with gastric cancer and liver metastasis" performed by Liu et al. The authors utilized data collected from gastric cancer (GC) patients and assessed immunotherapy effectiveness and survival status. They found significant differences in treatment response. Because immunotherapy seems to be a beneficial strategy for advanced GC patients, stratification of the data based on metastasis status may further improve treatment strategies.

Primary coexisting adenocarcinoma of the colon and neuroendocrine tumor of the duodenum: A case report and review of the literature

BACKGROUND

Neuroendocrine tumors (NETs) arise from the body's diffuse endocrine system. Coexisting primary adenocarcinoma of the colon and NETs of the duodenum (D-NETs) is a rare occurrence in clinical practice. The classification and treatment criteria for D-NETs combined with a second primary cancer have not yet been determined.

CASE SUMMARY

We report the details of a case involving female patient with coexisting primary adenocarcinoma of the colon and a D-NET diagnosed by imaging and surgical specimens. The tumors were treated by surgery and four courses of chemotherapy. The patient achieved a favorable clinical prognosis.

CONCLUSION

Coexisting primary adenocarcinoma of the colon and D-NET were diagnosed by imaging, laboratory indicators, and surgical specimens. Surgical resection combined with chemotherapy was a safe, clinically effective, and cost-effective treatment.

Lone-Star retractor perineal exposure method for laparoscopic abdominal perineal resection of rectal cancer

BACKGROUND

The abdominal perineal resection (APR), historically referred to as Mile's procedure, stands as a time-honored surgical intervention for rectal cancer management. Advancements in surgical techniques and the advent of neoadjuvant therapies have significantly improved the rate of sphincter preservation among patients afflicted with rectal cancer, including those with ultralow rectal cancer. Despite these improvements, APR maintains its irreplaceable role in the clinical landscape, particularly for cases involving low rectal cancer with encroachment on the external anal sphincter or levator ani muscles. Optimal perineal exposure stands as a pivotal phase in APR, given that the precision of this maneuver is directly correlated with both the safety of the surgery and the patient's subsequent long-term prognosis.

AIM

To evaluate the value of Lone-Star retractor (LSR) perineal exposure method in the treatment for laparoscopic APR of rectal cancer.

METHODS

We reviewed the records of 38 patients with rectal cancer at Anqing Municipal Hospital from January 2020 to December 2023, including 20 patients who underwent the APR procedure with a LSR perineal exposure method (LSR group) and 18 patients who underwent the APR procedure with a conventional perineal exposure method (control group). In the LSR group, following incision of the skin and subcutaneous tissue, the LSR was placed and dynamically adjusted according to the surgical plane to fully expose the perineal operative field.

RESULTS

A total of 38 patients underwent laparoscopic APR, none of whom were found to have distant metastasis upon intraoperative exploration. Perineal blood loss, the postoperative hospital stays and the wound pain scores in the LSR group were significantly lower than those in the control group. A single surgeon completed the perineal operation significantly more often in the LSR group than in the control group (P < 0.05). The incidence of infection via the perineal incision in the LSR group was significantly lower than that in the control group (P < 0.05). No cases of distant metastasis or local recurrence were found among the patients at the postoperative follow-up.

CONCLUSION

The application of the LSR technique might be helpful for performing perineal exposure during APR for rectal cancer and could reduce the incidence of perineal complications, shorten the postoperative hospital stay, improve postoperative pain, and allow one surgeon to perform the perineal operation.

Clinical significance of peripheral blood immune cells in patients with gastric cancer after surgery

BACKGROUND

Gastric cancer is one of the most common malignant tumors worldwide, and surgical resection is one of the main ways to treat gastric cancer. However, the immune status of postoperative patients is crucial for prognosis and survival, and immune cells play an important role in this process. Therefore, it is helpful to understand the immune status of postoperative patients by evaluating the levels of peripheral blood immune cells, especially total T cells (CD3+), helper T cells (CD3+CD4+), and suppressor T cells (CD3+CD8+), and its relationship to survival.

AIM

To analyzed the immune cells in peripheral blood of patients with gastric cancer after surgery, detect the levels of total T cells, helper T cells and suppressor T cells.

METHODS

A total of 58 patients with gastric cancer who received surgical treatment were included in the retrospective study. Flow cytometry was used to detect the level of peripheral blood immune cells and analyze the correlation between total T cells, helper T cells and inhibitory T cells. To explore the relationship between these immune markers and patient survival.

RESULTS

The results showed that the levels of total T cells, helper T cells, and suppressor T cells changed in patients after gastric cancer surgery. There was a significant positive correlation between total T cells, helper T cells and suppressor T cells (r = 0.35, P < 0.01; r = 0.56, P < 0.01). However, there was a negative correlation between helper T cells and suppressor T cells (r = -0.63, P < 0.01). Follow-up showed that the survival rate of patients in the high-level total T cell group was significantly higher than that in the low-level group (28.87 ± 24.98 months vs 18.42 ± 16.21 months). The survival curve shows that the curve of patients in the high-level group is shifted to the upper right, and that of the low-level group is shifted downward. There was no significant difference between the levels of helper T cells and suppressor T cells and patient survival time.

CONCLUSION

By detecting peripheral blood immune cells with flow cytometry, we can initially evaluate the immune status of patients after gastric cancer surgery and initially explore its relationship with patient survival.

Problems with repairing gut sphincters malfunctions

Correcting a gut sphincter malfunction is a difficult problem. Because each sphincter has two opposite functions, that of closure and opening, repairing one there is a risk of damaging the other. Indeed, widening a narrow sphincter, such as lower esophageal sphincter (LES) and anal sphincter, may cause gastroesophageal reflux and fecal incontinence, respectively, whereas narrowing a wide sphincter, may cause a difficult transit. All the corrective treatments for difficult or retrograde transit concerning LES and anal sphincter with their unwanted consequences have been analyzed and discussed. To overcome the drawbacks of sphincter surgical repairs, researchers have devised devices capable of closing and opening the gut lumen, named artificial sphincters (ASs). Their function is based on various mechanisms, e.g., hydraulic, magnetic, mechanical etc, operating through many complicated components, such as plastic cuffs, balloons, micropumps, micromotors, connecting tubes and wires, electromechanical clamps, rechargeable batteries, magnetic devices, elastic bands, etc. Unfortunately, these structures may facilitate the onset of infections and induce a local fibrotic reaction, which may cause device malfunctioning, whereas the compression of the gut wall to occlude the lumen may give rise to ischemia with erosions and other lesions. Some ASs are already being used in clinical practice, despite their considerable limits, while others are still at the research stage. In view of the adverse events of the ASs mentioned above, we considered applying bioengineering methods to analyze and resolve biomechanical and biological interaction problems with the aim to conceive and build efficient and safe biomimetic ASs.

Establishment of predictive models and determinants of preoperative gastric retention in endoscopic retrograde cholangiopancreatography

BACKGROUND

Study on influencing factors of gastric retention before endoscopic retrograde cholangiopancreatography (ERCP) background: With the wide application of ERCP, the risk of preoperative gastric retention affects the smooth progress of the operation. The study found that female, biliary and pancreatic malignant tumor, digestive tract obstruction and other factors are closely related to gastric retention, so the establishment of predictive model is very important to reduce the risk of operation.

AIM

To analyze the factors influencing preoperative gastric retention in ERCP and establish a predictive model.

METHODS

A retrospective analysis was conducted on 190 patients admitted to our hospital for ERCP preparation between January 2020 and February 2024. Patient baseline clinical data were collected using an electronic medical record system. Patients were randomly matched in a 1:4 ratio with data from 190 patients during the same period to establish a validation group (n = 38) and a modeling group (n = 152). Patients in the modeling group were divided into the gastric retention group (n = 52) and non-gastric retention group (n = 100) based on whether gastric retention occurred preoperatively. General data of patients in the validation group and modeling group were compared. Univariate and multivariate logistic regression analyses were performed to identify factors influencing preoperative gastric retention in ERCP patients. A predictive model for preoperative gastric retention in ERCP patients was constructed, and calibration curves were used for validation. The receiver operating characteristic (ROC) curve was analyzed to evaluate the predictive value of the model.

RESULTS

We found no statistically significant difference in general data between the validation group and modeling group (P > 0.05). The comparison of age, body mass index, hypertension, and diabetes between the two groups showed no statistically significant difference (P > 0.05). However, we noted statistically significant differences in gender, primary disease, jaundice, opioid use, and gastrointestinal obstruction between the two groups (P < 0.05). Multivariate logistic regression analysis showed that gender, primary disease, jaundice, opioid use, and gastrointestinal obstruction were independent factors influencing preoperative gastric retention in ERCP patients (P < 0.05). The results of logistic regression analysis revealed that gender, primary disease, jaundice, opioid use, and gastrointestinal obstruction were included in the predictive model for preoperative gastric retention in ERCP patients. The calibration curves in the training set and validation set showed a slope close to 1, indicating good consistency between the predicted risk and actual risk. The ROC analysis results showed that the area under the curve (AUC) of the predictive model for preoperative gastric retention in ERCP patients in the training set was 0.901 with a standard error of 0.023 (95%CI: 0.8264-0.9567), and the optimal cutoff value was 0.71, with a sensitivity of 87.5 and specificity of 84.2. In the validation set, the AUC of the predictive model was 0.842 with a standard error of 0.013 (95%CI: 0.8061-0.9216), and the optimal cutoff value was 0.56, with a sensitivity of 56.2 and specificity of 100.0.

CONCLUSION

Gender, primary disease, jaundice, opioid use, and gastrointestinal obstruction are factors influencing preoperative gastric retention in ERCP patients. A predictive model established based on these factors has high predictive value.

Efficiency and safety of laparoscopic left hemihepatectomy: A study of intrathecal vs extrathecal Glissonean pedicle techniques

BACKGROUND

Selective hemihepatic vascular occlusion is utilized in both right and left hemihepatectomies to preserve blood supply to the intact lobe, maintain hemodynamic stability, and mitigate surgical risks. While this technique encompasses both intrathecal and extrathecal Glissonean pedicle transection methods, there is a lack of systematic comparative reports on these two approaches.

AIM

To retrospectively analyze the clinical data of patients with hepatocellular carcinoma (HCC) undergoing laparoscopic anatomical hepatectomy in our hospital to explore the feasibility, safety, and short- and long-term efficacy of extrathecal and intrathecal Glissonean pedicle transection methods in laparoscopic left hemihepatectomy.

METHODS

A retrospective study was performed to analyze the clinical data of 49 HCC patients who underwent laparoscopic left hemihepatectomy from January 2019 to December 2022 in our hospital. These patients were divided into extrathecal Glissonean pedicle transection (EGP) group (n = 24) and intrathecal Glissonean pedicle transection (IGP) group (n = 25) according to the different approaches used for selective hemihepatic vascular occlusion. The perioperative indicators, liver function indexes, complications, and follow-up findings were compared between these two groups.

RESULTS

The surgeries were smooth in both groups, and no perioperative death was noted. The hepatic pedicle transection time and the operation time were (16.1 ± 2.3) minutes and (129.6 ± 19.0) minutes, respectively, in the EGP group, which were significantly shorter than those in the IGP group [(25.5 ± 2.4) minutes and (184.8 ± 26.0) minutes, respectively], both P < 0.01. There were no significant differences in intraoperative blood loss, time to anal exhaust, hospital stay, drain indwelling time, and postoperative liver function between the two groups (all P > 0.05). The incidence of postoperative complications showed no significant difference [16.67% (4/24) vs 16.0% (4/25), P > 0.05). All the 49 HCC patients were followed up after surgery (range: 11.2-53.3 months; median: 36.4 months). The overall survival rate and disease-free survival rate were not significantly different (both P > 0.05).

CONCLUSION

Both extrathecal and intrathecal Glissonean pedicle approaches are effective and safe hepatic inflow occlusion techniques in laparoscopic left hemihepatectomy for HCC. However, the extrathecal approach simplifies the hepatic pedicle transection, shortens the operation time, and increases the surgical efficiency, making it a more feasible technique.

Machine learning in predicting postoperative complications in Crohn's disease

Crohn's disease (CD) is a chronic inflammatory bowel disease of unknown origin that can cause significant disability and morbidity with its progression. Due to the unique nature of CD, surgery is often necessary for many patients during their lifetime, and the incidence of postoperative complications is high, which can affect the prognosis of patients. Therefore, it is essential to identify and manage postoperative complications. Machine learning (ML) has become increasingly important in the medical field, and ML-based models can be used to predict postoperative complications of intestinal resection for CD. Recently, a valuable article titled "Predicting short-term major postoperative complications in intestinal resection for Crohn's disease: A machine learning-based study" was published by Wang et al. We appreciate the authors' creative work, and we are willing to share our views and discuss them with the authors.

Innovative integration of lung ultrasound and wearable monitoring for predicting pulmonary complications in colorectal surgery: A prospective study

BACKGROUND

Postoperative pulmonary complications (PPCs) are common in patients who undergo colorectal surgery. Studies have focused on how to accurately diagnose and reduce the incidence of PPCs. Lung ultrasound has been proven to be useful in preoperative monitoring and postoperative care after cardiopulmonary surgery. However, lung ultrasound has not been studied in abdominal surgeries and has not been used with wearable devices to evaluate the influence of postoperative ambulation on the incidence of PPCs.

AIM

To investigate the relationship between lung ultrasound scores, PPCs, and postoperative physical activity levels in patients who underwent colorectal surgery.

METHODS

In this prospective observational study conducted from November 1, 2019 to August 1, 2020, patients who underwent colorectal surgery underwent daily bedside ultrasonography from the day before surgery to postoperative day (POD) 5. Lung ultrasound scores and PPCs were recorded and analyzed to investigate their relationship. Pedometer bracelets measured the daily movement distance for 5 days post-surgery, and the correlation between postoperative activity levels and lung ultrasound scores was examined.

RESULTS

Thirteen cases of PPCs was observed in the cohort of 101 patients. The mean (standard deviation) peak lung ultrasound score was 5.32 (2.52). Patients with a lung ultrasound score of ≥ 6 constituted the high-risk group. High-risk lung ultrasound scores were associated with an increased incidence of PPCs after colorectal surgery (logistic regression coefficient, 1.715; odds ratio, 5.556). Postoperative movement distance was negatively associated with the lung ultrasound scores [Spearman's rank correlation coefficient (r), -0.356, P < 0.05].

CONCLUSION

Lung ultrasound effectively evaluates pulmonary condition post-colorectal surgery. Early ambulation and respiratory exercises in the initial two PODs will reduce PPCs and optimize postoperative care in patients undergoing colorectal surgery.

New anti-mesenteric delta-shaped stapled anastomosis: Technical report with short-term postoperative outcomes in patients with Crohn's disease

BACKGROUND

Medical treatment for Crohn's disease (CD) has continuously improved, which has led to a decrease in surgical recurrence rates. Despite these advancements, 25% of patients will undergo repeat intestinal surgery. Recurrence of CD commonly occurs on the mesentery side of the anastomosis site.

AIM

To compare the new anti-mesenteric side-to-side delta-shaped stapled anastomosis (DSA) with the conventional stapled functional end-to-end anastomosis (CSA).

METHODS

This retrospective study included CD patients who underwent ileo-ileal or ileo-colic anastomosis between January 2020 and December 2023. The DSA technique employed a stapler to maintain the concept of anti-mesentery side-to-side anastomosis by performing a 90° vertical closure of the open window compared with the CSA technique. At the corner where the open window is closed, the DSA avoids forming a pouch and creates an anastomosis resembling a delta shape within the intestinal lumen. We compared demographics, preoperative condition, operative findings, and operative outcomes for the two techniques.

RESULTS

The study included 175 patients, including 92 in the DSA group and 83 in the CSA group. The two groups were similar in baseline characteristics, preoperative medical treatment, and operative findings except for the Montreal classification location. The 30-days postoperative complication rate was significantly lower in the DSA group compared with the CSA group (16.3% vs 32.5%, P = 0.009). Ileus incidence was significantly lower in the DSA group than in the CSA group (4.3% vs 14.5%, P = 0.033), and the hospital stay was shorter in the DSA group than in the CSA group (5.67 ± 1.53 days vs 7.39 ± 3.68 days, P = 0.001).

CONCLUSION

The DSA technique was feasible and showed comparable postoperative outcomes with lower short-term complications compared with the CSA technique. Further studies on CD recurrence and long-term complications are warranted.