Feasibility of a Clinical Pathway With Early Oral Intake and Discharge for Laparoscopic Gastrectomy

BACKGROUND AND AIMS

Although some studies have reported the safety of early oral intake after gastrectomy, it still remains controversial. This study focused on the feasibility of a clinical pathway with early oral intake and discharge setting for exclusively laparoscopic distal gastrectomy.

MATERIALS AND METHODS

A clinical pathway was applied to 403 patients until December 2014. In the protocol, patients are allowed to take a sip of water and a soft diet on the first and second days after the operation, respectively, and the discharge day is set as the fifth to seventh day after the operation. Clinicopathological variables were prospectively collected, and risk factors for discharge variances were analyzed.

RESULTS

The completion rate of the clinical pathway was 76.9%. There were five re-admissions (1.2%). The overall morbidity rate was 18% ( n = 72), and major complications (Clavien-Dindo IIIa or greater) occurred in 13 patients (3%). Complications were the causes for discharge variances in 68 cases (73%), while the attending surgeons' judgment was the cause in 25 cases (27%). On multivariate analysis, age (odds ratio = 2.23, 95% confidence interval = 1.38-3.60, p = 0.001) and operative time (odds ratio = 2.38, 95% confidence interval = 1.45-3.98, p = 0.001) were independent risk factors for discharge variances.

CONCLUSION

A high completion rate of a clinical pathway with early oral intake and discharge setting for laparoscopic distal gastrectomy was achievable with an acceptably low re-admission rate. Laparoscopic distal gastrectomy is recommended as a first step for a clinical pathway with an early oral intake and discharge protocol.

Risk factors for parastomal hernia after abdominoperineal resection for rectal cancer

INTRODUCTION

This study was designed to identity risk factors for parastomal hernia occurring after abdominoperineal resection for rectal cancer.

METHODS

The study group was comprised of 158 patients with rectal cancer who underwent abdominoperineal resection in our department from January 1990 through December 2014. Twelve variables were studied as risk factors for parastomal hernia.

RESULTS

Parastomal hernia developed in 27 patients, including 19 patients who underwent colostomy creation via an intraperitoneal route and 8 patients who underwent colostomy creation via an extraperitoneal route. On univariate analysis, a BMI ≥25 kg/m² was significantly related to the development of parastomal hernia (P = 0. 018), and an ASA physical status ≥2 was slightly but not significantly related to parastomal hernia (P = 0. 076). Multivariate analysis showed that a BMI ≥25 kg/m² was an independent risk factor (odds ratio = 2.9698; P = 0. 016).

CONCLUSION

Patients with a BMI ≥25 kg/m² should be instructed about lifestyle modifications to control preoperative bodyweight and to reduce abdominal pressure.

The clinical significance of cysteine dioxygenase type 1 methylation in Barrett esophagus adenocarcinoma

Methylation of cysteine dioxygenase type 1 (CDO1) gene, a tumor suppressor gene, has been studied in various cancers; however, there is no information regarding Barrett esophagus cancer. In this study, the clinical significance of CDO1 methylation in Barrett esophagus adenocarcinoma (BEA) was clarified. CDO1 gene promoter methylation was analyzed for DNA from the patient's specimens using quantitative methylation-specific polymerase chain reaction. Thirty-eight BEA patients who underwent resection were identified between 2000 and 2014. Hypermethylation of CDO1 gene was demonstrated to be frequently recognized even at early stage in BEA by quantitative methylation-specific polymerase chain reaction. In BEA, there is a robust prognostic difference between stage I and stage II/III/IV with regard to 5-year relapse-free survival (P = 0.0016) and 5-year overall survival (P = 0.0024), and the tumor size separated by 7 cm was also a prognostic factor. There was significant difference in CDO1 gene methylation according to the tumor size (P = 0.036). BEA patients with CDO1 gene methylation were shown marginally significantly poorer prognosis (P = 0.054) than otherwise patients. In conclusion, higher CDO1 gene methylation was seen in BEA at earlier stage than in squamous cell carcinoma, and it may account for aggressive phenotype of BEA.

The novel BMI-1 inhibitor PTC596 downregulates MCL-1 and induces p53-independent mitochondrial apoptosis in acute myeloid leukemia progenitor cells

Disease recurrence is the major problem in the treatment of acute myeloid leukemia (AML). Relapse is driven by leukemia stem cells, a chemoresistant subpopulation capable of re-establishing disease. Patients with p53 mutant AML are at an extremely high risk of relapse. B-cell-specific Moloney murine leukemia virus integration site 1 (BMI-1) is required for the self-renewal and maintenance of AML stem cells. Here we studied the effects of a novel small molecule inhibitor of BMI-1, PTC596, in AML cells. Treatment with PTC596 reduced MCL-1 expression and triggered several molecular events consistent with induction of mitochondrial apoptosis: loss of mitochondrial membrane potential, BAX conformational change, caspase-3 cleavage and phosphatidylserine externalization. PTC596 induced apoptosis in a p53-independent manner. PTC596 induced apoptosis along with the reduction of MCL-1 and phosphorylated AKT in patient-derived CD34⁺CD38^low/− stem/progenitor cells. Mouse xenograft models demonstrated in vivo anti-leukemia activity of PTC596, which inhibited leukemia cell growth in vivo while sparing normal hematopoietic cells. Our results indicate that PTC596 deserves further evaluation in clinical trials for refractory or relapsed AML patients, especially for those with unfavorable complex karyotype or therapy-related AML that are frequently associated with p53 mutations.

Analysis of serum corticosteroid-induced alkaline phosphatase isoenzyme in dogs with hepatobiliary diseases

OBJECTIVE

To reveal the relationship between canine corticosteroid-induced alkaline phosphatase isoenzyme activity and hepatobiliary diseases.

MATERIALS AND METHODS

Retrospective analysis of the relationship between serum corticosteroid-induced alkaline phosphatase activity and diagnosis, serum cortisol concentration and alanine transferase activity in dogs with hepatobiliary diseases. Dogs with a history of glucocorticoid administration were excluded.

RESULTS

Seventy-two dogs with hepatobiliary diseases were analysed. The serum corticosteroid-induced alkaline phosphatase concentration was increased in dogs with hepatobiliary diseases. There was no correlation between serum cortisol concentration and serum corticosteroid-induced alkaline phosphatase percentage or activity.

CLINICAL SIGNIFICANCE

Dogs with hepatobiliary disease can exhibit high serum alkaline phosphatase activity even if the dogs have not been administrated glucocorticoids and the serum cortisol concentration is normal.

Comparison of Survival Times for Dogs with Pituitary-Dependent Hyperadrenocorticism in a Primary-Care Hospital: Treated with Trilostane versus Untreated

Background

Although pituitary‐dependent hyperadrenocorticism (PDH) is one of the most common endocrinopathies in dogs, the effects of withholding treatment on survival time in dogs with PDH remain unclear.

Hypothesis/Objectives

The purpose of this study was to clarify the effects of treatment in dogs with PDH by comparing survival times between dogs treated with trilostane and untreated dogs.

Animals

Forty‐three dogs diagnosed with PDH at a primary‐care hospital in Japan between June 2009 and January 2014.

Methods

Retrospective cohort study. The medical records of dogs with PDH treated with trilostane (n = 17) or left untreated (n = 26) were reviewed retrospectively. Survival analysis at 2 years after diagnosis of PDH was performed.

Results

Median survival time for the trilostane group was not reached (95% confidence interval [CI], 443 days–not applicable) and was significantly longer than the 506 days (95% CI, 292–564 days; P = .016) for the untreated group. Multivariate Cox proportional hazards analysis (including age at diagnosis, basal cortisol concentration at diagnosis, and treatment group) only identified assignment to the untreated group (hazard ratio, 5.01; 95% CI, 1.63–15.44) as associated with increased mortality.

Conclusions and Clinical Importance

The results of this retrospective cohort study suggest that withholding treatment for dogs with PDH might be associated with a higher risk of death. This represents the largest study to date to report survival times of untreated dogs with PDH.

A unified theory of bone healing and nonunion

This article presents a unified clinical theory that links established facts about the physiology of bone and homeostasis, with those involved in the healing of fractures and the development of nonunion. The key to this theory is the concept that the tissue that forms in and around a fracture should be considered a specific functional entity. This ‘bone-healing unit’ produces a physiological response to its biological and mechanical environment, which leads to the normal healing of bone. This tissue responds to mechanical forces and functions according to Wolff’s law, Perren’s strain theory and Frost’s concept of the “mechanostat”. In response to the local mechanical environment, the bone-healing unit normally changes with time, producing different tissues that can tolerate various levels of strain. The normal result is the formation of bone that bridges the fracture – healing by callus. Nonunion occurs when the bone-healing unit fails either due to mechanical or biological problems or a combination of both. In clinical practice, the majority of nonunions are due to mechanical problems with instability, resulting in too much strain at the fracture site. In most nonunions, there is an intact bone-healing unit. We suggest that this maintains its biological potential to heal, but fails to function due to the mechanical conditions. The theory predicts the healing pattern of multifragmentary fractures and the observed morphological characteristics of different nonunions. It suggests that the majority of nonunions will heal if the correct mechanical environment is produced by surgery, without the need for biological adjuncts such as autologous bone graft.

Cite this article: Bone Joint J 2016;98-B:884–91.

Transplantation of Restored Kidneys From Unrelated Donors After Resection of Renal Cell Carcinoma: Results From 10 Patients

PURPOSE

To relieve the chronic shortage of donor kidneys, we conducted a prospective kidney transplantation trial using kidneys removed from 10 unrelated patients (51 to 79 years of age) who had undergone nephrectomy for small renal cell carcinoma (1.5 to 3.9 cm) of low-to-moderate complexity based on RENAL (radius, exophytic/endophytic properties, nearness of tumor to the collecting system or sinus in millimeters, anterior/posterior location relative to polar lines) nephrometry (objective description helpful for operative indication and planning).

METHODS

Donors were selected from among 15 patients who opted to undergo nephrectomy for small renal cell carcinoma. A total of 76 dialysis patients 34 to 85 years of age who agreed to undergo restored kidney transplantation were recruited as transplant candidates.

RESULTS

In stage 1 (5 cases), high-risk patients were selected without human leukocyte antigen testing, and accelerated acute rejection occurred in 4 of 5 recipients. This trial was subsequently extended with human leukocyte antigen testing, and an additional 5 patients were enrolled in stage 2. Eight recipients, including 4 recipients with a history of renal transplantation, experienced rejection; 1 patient resumed dialysis 35 months after transplantation. The most recent serum creatinine levels ranged from 1.10 to 3.19 mg/dL in the 9 recipients with functioning grafts and from 0.84 to 4.68 mg/dL in the 10 donors. No tumor recurrence was noted at 32 to 58 months after surgery in either the recipients or the donors.

CONCLUSIONS

Restored kidney transplantation using kidneys with a small renal tumor seems suitable for carefully selected high-risk recipients and, in particular, elderly kidneys can also function well. Avoiding cancer transmission, fair recipient selection, close follow-up, and a well-organized tracking system warrant further study.

Prognostic value of tropomyosin-related kinases A, B, and C in gastric cancer

PURPOSE

Tropomyosin-related kinase (Trk) receptors play critical roles in tumor development and are considered attractive targets for cancer therapy. We investigated correlations of the expression of TrkA, TrkB, and TrkC with clinicopathological features and outcomes in gastric cancer.

METHODS

Tumor samples were obtained from 221 patients with gastric cancer who underwent gastrectomy between 2003 and 2007. The expression of TrkA, TrkB, and TrkC was analyzed using immunohistochemical staining. The relationship of their expression to clinicopathological factors and outcomes was assessed.

RESULTS

High expression of TrkA, TrkB, or TrkC was significantly associated with histopathology (p = 0.022, p < 0.001, and p < 0.001). High expression of TrkA was significantly correlated with variables related to tumor progression, including lymph node metastasis (p = 0.024) and distant metastasis or recurrence (p < 0.001). Distant metastasis or recurrence was found in a significantly higher proportion of patients with high expression of TrkC than in those with low expression (p = 0.036). High expression of TrkA was significantly associated with poorer relapse-free survival (RFS) in univariate analysis (p = 0.001). High expression of TrkA or TrkC was significantly associated with poorer disease-specific survival (DSS) in univariate analysis (p < 0.001 and p = 0.008). In multivariate analysis, TrkA was an independent predictor of RFS [hazard ratio (HR), 2.294; 95 % confidence interval (CI), 1.309-4.032; p = 0.004] and DSS (HR, 2.146; 95 % CI, 1.195-3.861; p = 0.011). Expression of TrkB was not associated with RFS or DSS in univariate analysis.

CONCLUSIONS

Our results demonstrated that TrkA expression was associated with tumor progression and poor survival, and was an independent predictor of poor outcomes in gastric cancer patients.

Crystallization of high-quality protein crystals using an external electric field

The effect of a 20 kHz external electric field on the quality of tetragonal hen egg white (HEW) lysozyme crystals was investigated using X-ray diffraction rocking-curve measurements. The full width at half-maximum was found to be larger for high-order reflections but smaller for low-order reflections. In particular, it was revealed that a large amount of local strain is accumulated in tetragonal HEW lysozyme crystals grown under an applied field at 20 kHz. Comparison with previous results obtained for crystals grown with an applied field at 1 MHz [Koizumi, Uda, Fujiwara, Tachibana, Kojima & Nozawa (2013).J. Appl. Cryst.46, 25–29] indicated that improvement of the protein crystal quality could be achieved by selection of an appropriate frequency for the applied electric field, which has a significant effect on the growth of the solid.

Biomechanical evaluation of interfragmentary compression at tibia plateau fractures in vitro using different fixation techniques: a CONSORT-compliant article

Reliable osteosynthesis of intraarticular fractures depends on lasting interfragmentary compression. Its amount differs in the applied fixation method. The interfragmentary compression of cancellous and cortical lag screws and angle stable locking plates was quantified in an osteoporotic and non-osteoporotic synthetic human bone model.A split fracture of the lateral tibia plateau (AO/OTA type 41-B1.1) was mimicked by an osteotomy in right adult synthetic human tibiae with hard or soft cancellous bone. Specimens were fixed with either two 6.5 mm cancellous, four 3.5 mm cortical lag screws, or 3.5 mm LCP proximal lateral tibia plate preliminary compresed by a reduction clamp (n = 5 per group). A pressure sensor film was used to register the interfragmentary compression. One-way analysis of variance (ANOVA) with Bonferroni post hoc correction was performed for statistical analysis (p < 0.05).Interfragmentary compression under reduction clamp was 0.59 ± 0.12 MPa in the non-osteoporotic and 0.55 ± 0.14 MPa in the osteoporotic group. The locking plate itself maintained the compression in non-osteoporotic (0.53 ± 0.11 MPa) and osteoporotic bone (0.50 ± 0.14 MPa). Four 3.5 mm cortical lag screws provided a compression of 1.69 ± 0.65 MPa in non-osteoporotic bone, being not significantly different to the osteoporotic bone group (1.43 ± 0.47 MPa, P = 1.0). Two 6.5 mm cancellous lag screws showed a significantly higher compression in non-osteoporotic (2.1 ± 0.59 MPa) compared to osteoporotic (0.77 ± 0.21 MPa, P < 0.01) bone.Angle stable locking plates maintained the compression preliminarily applied by a reduction clamp. Two 6.5 mm cancellous lag screws are especially suited for non-osteoporotic bone, whereas four 3.5 mm cortical screws exhibited comparable compression in both bone qualities.

Thy28 protects against anti-CD3-mediated thymic cell death in vivo

Apoptotic cell death plays a pivotal role in the development and/or maintenance of several tissues including thymus. Deregulated thymic cell death is associated with autoimmune diseases including experimental autoimmune encephalomyelitis (EAE), a prototype murine model for analysis of human multiple sclerosis. Because Thy28 expression is modulated during thymocyte development, we tested whether Thy28 affects induction of EAE as effectively as antigen-induced thymocyte deletion using Thy28 transgenic (TG) mice. Thy28 TG mice showed partial resistance to anti-CD3 monoclonal antibody (mAb)-induced thymic cell death in vivo, as assessed by annexin V-expression and loss of mitochondrial membrane potential. The resistance to anti-CD3 mAb-induced cell death in Thy28 TG mice appeared to correlate with a decreased c-Jun N-terminal kinase phosphorylation and reduced down-regulation of Bcl-xL. Moreover, thymic hyperplasia was detected in Thy28 TG mice, although thymocyte development was unaltered. Development of peripheral lymphoid tissues including spleen and lymph nodes was also unaltered. Thy28 TG spleen T cells showed an increased production of IFN-γ, but not IL-17, in response to both anti-CD3 and anti-CD28 mAbs. Finally, Thy28 TG mice displayed accelerated induction of EAE as assessed by disease incidence, clinical score, and pathology following immunization with myelin oligodendrocyte glycoprotein compared with control WT mice. These findings suggest that modulation of Thy28 expression plays a crucial role in the determination of thymic cell fate, which may contribute to the development of EAE through proinflammatory cytokine production.