Successful living donor liver transplantation between septuagenarians

We report a case of a 76-year-old female who underwent living donor right hepatectomy for her 75-year-old husband with recurrent hepatocellular carcinoma. With her voluntary decision, full medical and psychiatric assessment was performed. The operative time was 130 min in the donor and 399 min in the recipient. Both the donor and recipient had an uneventful recovery and were discharged on days 7 and 10, respectively with normal liver function. The couple has had no complication so far and is currently doing well in good health 26 months after living donor liver transplantation.

Pushing the frontiers of living donor right hepatectomy

Living donor right hepatectomy (LDRH) is currently the most common donor surgery in adult-to-adult living donor liver transplantation although the morbidity and mortality reported in living donors still contradicts the Hippocratic tenet of “do no harm”. Achieving low complication rates in LDRH remains a matter of major concern. Living donor surgery is performed worldwide as an established solution to the donor shortage. The aim of this study was to assess the current status of LDRH and comment on the future of the procedure; assessment was made from the standpoint of optimizing the donor selection criteria and reducing morbidity based on both the authors’ 8-year institutional experience and a literature review. New possibilities have been explored regarding selection criteria. The safety of living donors with unfavorable conditions, such as low remnant liver volume, fatty change, or old age, should also be considered. Abdominal incisions have become shorter, even without laparoscopic assistance; upper midline laparotomy is the primary incision used in more than 400 consecutive LDRHs in the authors’ institution. Various surgical techniques based on preoperative imaging technology of vascular and biliary anomalies have decreased the anatomical barriers in LDRH. Operative time has been reduced, with low blood loss. Laparoscopic or robotic LDRH has been tried in only a few selected donors. The LDRH-specific, long-term outcomes remain to be addressed. The follow-up duration of these studies should be long enough to address possible late complications. Donor safety, which is the highest priority, is ensured by three factors: preoperative selection, intraoperative surgical technique, and postoperative management. These three focus areas should be continuously refined, with the ultimate goal of zero morbidity.

Clinicopathological features and prognosis of combined hepatocellular carcinoma and cholangiocarcinoma after surgery

BACKGROUND

Combined hepatocellular carcinoma and cholangiocarcinoma (cHCC-CC) is a rare subtype of primary liver cancer consisting of both hepatocellular carcinoma (HCC) and cholangiocarcinoma (CC). Because of the rarity of this tumor, its feature is poorly understood. The present study aimed to evaluate the clinicopathological features and long-term prognosis of patients with cHCC-CC after surgery and to compare with those of the patients with stage-matched HCC and CC.

METHODS

The clinicopathological features of the patients who underwent surgery for cHCC-CC at our center during the period of 2001-2010 were retrospectively analyzed and compared with those of stage-matched HCC and CC patients. Cancer staging was performed according to the AJCC Cancer Staging Manual (6th ed.). Overall survival and disease-free survival were compared among the groups and prognostic factors of cHCC-CC were evaluated.

RESULTS

Significant differences were observed in clinicopathological features among 42 patients with cHCC-CC, 90 patients with HCC and 45 patients with CC. Similar to HCC patients, cHCC-CC patients had frequent hepatitis B virus antigen positivity, microscopic vessel invasion, cirrhosis and high level of serum alpha-fetoprotein. Similar to CC patients, cHCC-CC patients showed increased bile duct invasion and decreased capsule. The 1-, 3-, and 5-year overall survival and disease-free survival of patients with cHCC-CC were not significantly different from those with stage-matched patients with CC; but significantly poorer than those with HCC. In subanalysis of patients with stage II, the overall survival in patients with cHCC-CC or CC was significantly poorer than that in patients with HCC. We did not find the difference in patients with other stages. Univariate analysis of overall and disease-free survival of patients with cHCC-CC showed that the vascular invasion and intrahepatic metastasis were the significant predictive factors.

CONCLUSION

Patients with cHCC-CC showed similar clinicopathological features as those with HCC or CC, and patients with cHCC-CC or CC had a poorer prognosis compared with those with HCC, especially at matched stage II.

Kinetics of B, T, NK lymphocytes and isoagglutinin titers in ABO incompatible living donor liver transplantation using rituximab and basiliximab

BACKGROUND

The kinetics of isoagglutinin titers and lymphocyte subpopulations including B, T, and natural killer (NK) cells after ABO incompatible (ABO-I) living donor liver transplantation (LDLT) have not been evaluated.

METHODS

From January 2012 to July 2013, consecutive ABO-I LDLT patients were enrolled at the National Cancer Center. Our desensitizing protocol included rituximab, plasma exchanges, basiliximab, and intravenous immune globulin without splenectomy.

RESULTS

Twenty patients (14 males, 6 females) underwent ABO-I LDLT due to HCC (n=15) or liver cirrhosis (n=5). There was no hyperacute and antibody-mediated rejection. The isoagglutinin titers were effectively lowered less than 1:16 before operation. CD 19+ B cells were rapidly eliminated after rituximab and suppressed during 6months postoperatively. CD3+ and CD4+ T cells were elevated higher than CD8+ T cells. CD4/CD8 ratio was increased during first 1month postoperatively and decreased thereafter. CD16+CD56+ NK cells were lowered and restored after 4months of LDLT. Among 15 patients with HCC, 5 patients (33.3%) experienced early tumor recurrence (1/8 within Milan and 4/7 beyond Milan).

CONCLUSIONS

Our protocol showed effective results in preventing antibody-mediated rejection and suppressing B lymphocytes. Application to advanced hepatocellular carcinoma should be considered due to decreased natural immunity after ABO-I LDLT.

Long-term safety and efficacy of certolizumab pegol in the treatment of Crohn's disease: 7-year results from the PRECiSE 3 study

BACKGROUND

The efficacy and safety of certolizumab pegol (CZP) in moderate-to-severe Crohn's disease were demonstrated in two 26-week double-blind studies (PRECiSE 1 & 2).

AIM

To report the safety and efficacy outcomes of long-term, CZP therapy from PRECiSE 3, in which patients received treatment up to 7 years treatment.

METHODS

Patients completing PRECiSE 1 or 2 were eligible to enter PRECiSE 3 in which they received CZP 400 mg, open-label, every 4 weeks (without additional induction therapy) for up to 7 years, for up to 91 doses from study start. Safety (adverse events, including infections and malignancies) and efficacy (Harvey-Bradshaw Index, faecal calprotectin, C-reactive protein) were prospectively monitored. Remission was analysed using observed cases, last observation carried forward imputation and nonresponder imputation.

RESULTS

A total of 595 patients entered the study; 117 (20%) completed 7 years. Discontinuation rates were 29.2%, 13.6%, 16.1%, 7.9%, 5.0%, 4.5% and 3.9% (years 1-7 respectively). During 1920 patient-years of exposure to CZP, no new safety signals were observed. Incidence rates (new cases/100 patient-years) for serious infections and malignant neoplasms were 4.37 and 1.06 respectively. No lymphoproliferative malignancies were reported. Clinical remission rates were ≥68% at each year (observed cases); rates by last observation carried forward and nonresponder imputation were 58% and 45% at year 1, 56% and 26% at year 3 and 55% and 13% at year 7 respectively.

CONCLUSION

Certolizumab pegol was well tolerated in the long-term treatment of Crohn's disease, with sustained remission in some patients continuing in the study for up to 7 years. ClinicalTrials.gov identifier NCT00552058.

ABO-incompatible living donor liver transplantation without graft local infusion and splenectomy

BACKGROUND

Graft local infusion and splenectomy in ABO-incompatible (ABO-I) living donor liver transplantation (LDLT) are associated with high rates of operative complications.

METHODS

Consecutive ABO-I LDLT patients treated at the National Cancer Centre between January 2012 and February 2013 were identified. The protocol for ABO-I LDLT at the study centre included the administration of rituximab (300 mg/m(2)) at 2 weeks preoperatively, followed by plasma exchanges (target isoagglutinin titre: ≤ 1:8), basiliximab (20 mg on the day of surgery and on postoperative day 4), and i.v. immunoglobulin (0.8 g/kg on postoperative days 1 and 4) without graft local infusion or splenectomy.

RESULTS

Fifteen patients (11 men and four women) who underwent transplantation for liver cirrhosis (n = 3) or hepatocellular carcinoma (n = 12) were identified. These included 13 patients with hepatitis B virus infection, one with hepatitis C virus infection and one with alcoholic cirrhosis. The mean age, mean Model for End-stage Liver Disease (MELD) score and mean graft-to-recipient weight ratio (GRWR) of these patients was 51.8 years, 11.5 and 0.84, respectively. The median isoagglutinin titre before plasma exchange was 1:32 (range: 1:4 to 1:256). There were no hyperacute or antibody-mediated rejections. No bacterial or fungal infections were observed. Complications included herpes zoster viral infection in one patient, postoperative bleeding in one patient and extrahepatic biliary stricture in three patients.

CONCLUSIONS

This simplified ABO-I LDLT protocol showed good graft outcomes without immunologic failure or serious infections.

Effects of Dietary Fat Types on Growth Performance, Pork Quality, and Gene Expression in Growing-finishing Pigs

This study was performed to determine the effects of dietary fat sources, i.e., beef tallow, soybean oil, olive oil and coconut oil (each 3% in feed), on the growth performance, meat quality and gene expression in growing-finishing pigs. A total of 72 crossbred pigs (Landrace×Large White×Duroc) were used at 71±1 kg body weight (about 130 d of age) in 24 pens (320×150 cm) in a confined pig house (three pigs per pen) with six replicate pens per treatment. The growing diet was given for periods of 14±3 d and the finishing diet was given for periods of 28±3 d. The fat type had no significant effect either on growth performance or on chemical composition or on meat quality in growing-finishing pigs. Dietary fat type affected fatty acid composition, with higher levels of unsaturated fatty acids (UFAs) and monounsaturated fatty acids (MUFAs) in the olive oil group. Microarray analysis in the Longissimus dorsi identified 6 genes, related to insulin signaling pathway, that were differentially expressed among the different feed groups. Real time-PCR was conducted on the six genes in the longissimus dorsi muscle (LM). In particular, the genes encoding the protein kinase, cAMP-dependent, regulatory, type II, alpha (PRKAR2A) and the catalytic subunit of protein phosphatase 1, beta isoform (PPP1CB) showed the highest expression level in the olive oil group (respectively, p<0.05, p<0.001). The results of this study indicate that the type of dietary fat affects fatty acid composition and insulin signaling-related gene expression in the LM of pigs.

Clinical outcomes and risk factors of hepatitis B virus recurrence in patients who received prophylaxis with entecavir and hepatitis B immunoglobulin following liver transplantation

INTRODUCTION

Although entecavir (ETV) and hepatitis B immunoglobulin (HBIG) have widely been used for prophylaxis of hepatitis B virus (HBV) recurrence following liver transplantation (OLT), there have been few studies about clinical outcomes and risk factors of HBV recurrence.

MATERIALS AND METHODS

This study retrospectively assessed clinical outcomes and identified risk factors of post-transplant HBV recurrence in 154 patients who received prophylaxis with both ETV and HBIG after OLT.

RESULTS

The median follow-up duration was 28.0 months (range, 1.0-57.8). Post-transplant HBV recurrence occurred in 5 patients (3.2%) without any ETV-resistant mutants. The overall rates of HBV recurrence at 1, 2, and 4 years were 0.6%, 1.6%, and 6.2%, respectively. We found that recurrent hepatocellular carcinoma (HCC) was an independent risk factor of HBV recurrence (hazard ratio = 13.5, 95% confidence interval, 2.4-74.4; P = .006).

CONCLUSIONS

Prophylaxis with a combination of ETV and HBIG resulted in a low HBV recurrence rate following OLT without any emergence of ETV-resistant mutants. Recurrent HCC was an independent risk factor of HBV recurrence in patients who received prophylaxis with both ETV and HBIG for prophylaxis following OLT.

Fate and transport of radiocesium, radiostrontium and radiocobalt on urban building materials

Kinetics of (137)Cs, (60)Co and (85)Sr sorption on powdered building materials in aqueous suspensions at 20 °C for interaction times of 1, 7, 14 and 28 days were studied. The (137)Cs distribution coefficient (Kd) values for all building materials except limestone practically did not change during 28 days of sorption. The Kd ((85)Sr) was several orders of magnitude lower than for (60)Co. The highest values were observed for asphalt and granite. An effective method to study the radionuclide distribution in depth of building materials using layer-by-layer sanding was developed. Using the developed method, the (137)Cs, (60)Co and (85)Sr distribution with depth of selected building materials at different air humidity, time and temperature was studied. Relative humidity (RH) was found to influence significantly the (85)Sr depth distribution in the case of granite (unlike (137)Cs and (60)Co). While (85)Sr penetrated to 0.5 mm in depth of granite at RH 30%, at RH 87% the depth of (85)Sr penetration to granite reached up to 7 mm.

Laparoscopic versus open surgery for stage I rectal cancer: long-term oncologic outcomes

BACKGROUND

Laparoscopic resection is increasingly being performed for rectal cancer. However, few data are available to compare long-term outcomes after open versus laparoscopic surgery for early-stage rectal cancer.

METHODS

Included in this retrospective study were 160 patients who underwent surgery for stage I rectal cancer between 2001 and 2008. Perioperative outcomes, overall survival (OS), and disease-free survival (DFS) were compared for open versus laparoscopic surgery.

RESULTS

Altogether, 85 patients were treated using open surgery and 80 with laparoscopic surgery. Postoperative mortality (0 vs. 1.3%; p = 1.00), morbidity (31.3 vs. 25.0%; p = 0.38), and harvested lymph nodes (22.5 vs. 20.0; p = 0.84) were similar for the two groups. However, operating time was longer (183.8 vs. 221.0 min; p = 0.008), volume of intraoperative bleeding was less (200.0 vs. 150.0 ml; p = 0.03), time to first bowel movement was shorter (3.54 vs. 2.44 days; p < 0.001), rate of superficial surgical-site infection was lower (7.5 vs. 0%; p = 0.03), and postoperative hospital stay was shorter (11.0 vs. 8.0 days; p < 0.001) in the laparoscopy group than in the open surgery group. At 5 years, there was no difference in OS (98.6 vs. 97.1%; p = 0.41) or DFS (98.2 vs. 96.4%; p = 0.30) between the open and laparoscopy groups.

CONCLUSIONS

Long-term outcomes of laparoscopic surgery for stage I rectal cancer were comparable to those of open surgery. Laparoscopic surgery, however, produced more favourable short-term outcomes than open surgery.

Selection and outcomes of living donors with a remnant volume less than 30% after right hepatectomy

The evidence for defining a safe minimal remnant volume after living donor hepatectomy is insufficient. The aim of this study was to evaluate the outcomes of living donors with a remnant/total volume ratio (RTVR) < 30% after right hepatectomy according to the following selection criteria: the preservation of the middle hepatic vein (MHV), an age < 50 years, and no or mild fatty changes in healthy adults. All living donors who underwent right hepatectomy preserving the MHV at our institution between January 2005 and September 2011 were divided into 2 groups: group A with an RTVR < 30% and group B with an RTVR ≥ 30%. Perioperative data, complications by the Clavien classification, and outcomes with at least 15.1 months' follow-up were compared. Twenty-eight donors were enrolled in group A, and 260 were enrolled in group B. The estimated liver volume was strongly correlated with the actual graft weight (R(2)  = 0.608, P < 0.001). The calculated donation liver volume and the RTVR were significantly different between the 2 groups (P = 0.03 and P < 0.001, respectively). The peak postoperative aspartate aminotransferase levels, alanine aminotransferase levels, and international normalized ratios did not differ between the 2 groups. The peak total bilirubin level was higher for group A versus group B (P = 0.04). The hospital stay was longer for group A versus group B (P < 0.001). All donors recovered completely, and there were no significant differences in overall complications between the 2 groups. In conclusion, right hepatectomy preserving the MHV with an RTVR < 30% can be safely indicated for carefully selected living donors less than 50 years old with no or mild fatty changes.

Clinical characteristics of patients with tuberculosis-destroyed lung

SETTING

Multicentre study.

OBJECTIVE

To define the clinical characteristics of patients with tuberculosis (TB) destroyed lung due to past TB.

DESIGN

We reviewed patients with TB-destroyed lung between May 2005 and June 2011.

RESULTS

A total of 595 patients from 21 hospitals were enrolled. The mean age was 65.63 ± 0.47 (mean ± standard error); 60.5% were male. The mean number of lobes involved was 2.59 ± 0.05. Pleural thickening was observed in 54.1% of the patients. Mean forced vital capacity (FVC), forced expiratory volume in 1 s (FEV(1)), FEV(1)/FVC, bronchodilator response and number of exacerbations per year were respectively 2.06 ± 0.03 l (61.26% ± 0.79), 1.16 ± 0.02 l (49.05% ± 0.84), 58.03% ± 0.70, 5.70% ± 0.34, and 0.40 ± 0.04. The number of lobes involved was significantly correlated with FVC and FEV(1), and with the number of exacerbations per year. Use of long-acting muscarinic antagonists or long-acting beta-2 agonists plus inhaled corticosteroids resulted in bronchodilatory effects. Multivariable regression analysis showed that age, initial FEV(1) (%) and number of exacerbations during follow-up were independent factors affecting change in FEV(1).

CONCLUSION

Decreased lung function with exacerbation, and progressive decline of FEV(1) were observed in patients with TB-destroyed lung.

GenoType® MTBDRplus assay detection of drug-resistant tuberculosis in routine practice in Korea

SETTING

Korea is an intermediate-burden country with high rates of tuberculosis (TB) drug resistance.

OBJECTIVE

To evaluate the performance of the GenoType® MTBDRplus (MTBDR) assay in diagnosing drug-resistant TB in routine practice in Korea.

DESIGN

The MTBDR assay was performed on 428 samples, and the results were retrospectively compared with the results of conventional drug susceptibility testing (DST). The interval between treatment and diagnosis of drug resistance was also compared.

RESULTS

The sensitivity, specificity and positive and negative predictive values of the MTBDR assay were respectively 96.6%, 98.9%, 93.4% and 99.5% for the detection of rifampicin (RMP) resistance; 93.8%, 98.3%, 92.7% and 98.6% for isoniazid (INH) resistance; and 91.1%, 99.2%, 99.4% and 98.7% for multidrug-resistant TB (MDR-TB). The median interval between the start of anti-tuberculosis chemotherapy and the reporting of results was 88.9 days for conventional DST and 19.8 days for MTBDR using clinical specimens.

CONCLUSION

The specificity of the MTBDR assay in detecting MDR-TB was very high, although the sensitivity in detecting INH resistance and MDR-TB was not optimal (<95%). Although the turnaround time in detecting drug resistance was dramatically reduced with MTBDR compared to conventional DST, more effort is needed to shorten the turnaround time.

(18)F-FDG-PET/CT predicts early tumor recurrence in living donor liver transplantation for hepatocellular carcinoma

The prognosis including (18)F-fluorodeoxyglucose positron emission tomography/computed tomography ((18)F-FDG-PET/CT) for the early recurrence for hepatocellular carcinoma (HCC) after living donor liver transplantation (LDLT) was not well established. Consecutive patients who underwent (18)F-FDG-PET/CT and subsequent LDLT for HCC from March 2005 to June 2011 were enrolled. The 191 patients with a median follow-up of 26.1 months were evaluated. There were 20 patients (10.5%) with early recurrence (≤6 months), 18 patients (9.4%) with late recurrence (>6 months), and 153 patients (80.1%) with no recurrence. Fifty-five patients (28.8%) displayed increased PET/CT tumor uptake. Three-year overall and disease-free survival for PET/CT-positive patients were 65.5% and 57.1%, respectively, while PET/CT-negative patients showed respective values of 89.8% and 86.8% (P = 0.001 vs. P < 0.001). Tumor variables associated with PET/CT-positive finding were preoperative AFP level, Milan, UCSF criteria, maximum tumor size, total tumor size, differentiation, vascular invasion, and serosal invasion. PET/CT-positive status was identified as an independent prognostic factor for disease-free survival influencing early recurrence in multivariable analysis (HR 3.945, 95% CI 1.196-13.016, P = 0.024). (18)F-FDG-PET/CT is an independent and significant predictor of early tumor recurrence in LDLT for HCC.

Surgical outcome of pancreatic cancer using radical antegrade modular pancreatosplenectomy procedure

AIM: To evaluate the surgical outcomes following radical antegrade modular pancreatosplenectomy (RAMPS) for pancreatic cancer.

METHODS: Twenty-four patients underwent RAMPS with curative intent between January 2005 and June 2009 at the National Cancer Center, South Korea. Clinicopathologic data, including age, sex, operative findings, pathologic results, adjuvant therapy, postoperative clinical course and follow-up data were retrospectively collected and analyzed for this study.

RESULTS: Twenty-one patients (87.5%) underwent distal pancreatectomy and 3 patients (12.5%) underwent total pancreatectomy using RAMPS. Nine patients (37.5%) underwent combined vessel resection, including 8 superior mesenteric-portal vein resections and 1 celiac axis resection. Two patients (8.3%) underwent combined resection of other organs, including the colon, stomach or duodenum. Negative tangential margins were achieved in 22 patients (91.7%). The mean tumor diameter for all patients was 4.09 ± 2.15 cm. The 2 patients with positive margins had a mean diameter of 7.25 cm. The mean number of retrieved lymph nodes was 20.92 ± 11.24 and the node positivity rate was 70.8%. The median survival of the 24 patients was 18.23 ± 6.02 mo. Patients with negative margins had a median survival of 21.80 ± 5.30 mo and those with positive margins had a median survival of 6.47 mo (P = 0.021). Nine patients (37.5%) had postoperative complications, but there were no postoperative mortalities. Pancreatic fistula occurred in 4 patients (16.7%): 2 patients had a grade A fistula and 2 had a grade B fistula. On univariate analysis, histologic grade, positive tangential margin, pancreatic fistula and adjuvant therapy were significant prognostic factors for survival.

CONCLUSION: RAMPS is a feasible procedure for achieving negative tangential margins in patients with carcinoma of the body and tail of the pancreas.

Safety and efficacy of laparoscopic radiofrequency ablation for hepatic malignancies

Purpose

Radiofrequency ablation (RFA) is an accepted treatment option for primary and metastatic liver tumors. As percutaneous RFA has some limitations, laparoscopic RFA (LRFA) has been used as a therapeutic alternative for the treatment of hepatic malignancies.

Methods

Between March 2006 and September 2009, thirty patients with hepatic malignancies that were contraindicated for resection or percutaneous RFA underwent LRFA. Indications for this procedure were hepatocellular carcinoma (HCC, 21 patients), metastatic liver tumor (8 patients) and intrahepatic cholangiocarcinoma (1 patient).

Results

Among the 30 patients who underwent LRFA, 5 patients underwent concomitant laparoscopic liver resection. Intraoperative laparoscopic ultrasound detected new malignant lesions in 4 patients (13.3%). A total of 46 lesions were ablated by LRFA. There was no postoperative mortality. The three-year overall survival rate was 83.7% for the HCC group and 64.3% for the metastatic group.

Conclusion

LRFA for hepatic malignancies proved to be a safe and effective treatment. Also, this procedure is indicated for lesions that are not amenable to percutaneous RFA or liver resection.

Bouveret's syndrome: a case report and a review of the literature

Bouveret's syndrome is a gastric outlet obstruction caused by an impacted gallstone that passes through a cholecysto-gastric or cholecysto-duodenal fistula. An elderly woman visited a local clinic with nausea and abdominal pain. Abdominal computed tomography revealed a stone that was impacted in the duodenal lumen and a fistula between the gallbladder and duodenum. Malignancy could not be excluded due to the mass in the cystic duct showing enhancement and the presence of enlarged lymph nodes on computed tomography, and increased fludeoxyglucose uptake in the cystic duct on positron emission tomography. The patient underwent simultaneous cholecystectomy, segmental duodenectomy and gastro-jejunostomy. Pathological examination exhibited chronic inflammation and no primary cancer of the gallbladder and fistula.

Lymph node ratio is an independent prognostic factor in patients with rectal cancer treated with preoperative chemoradiotherapy and curative resection

PURPOSE

To evaluate the prognostic effect of lymph node ratio (LNR) in patients with locally advanced rectal cancer who were treated with curative resection after preoperative chemoradiotherapy (CRT).

METHODS

Between October 2001 and December 2007, 519 patients who had undergone curative resection of primary rectal cancer after preoperative CRT were enrolled. Of these, 154 patients were positive for lymph node (LN) metastasis and were divided into three groups according to the LNR (≤ 0.15 [n=80], 0.16-0.3 [n=44], >0.3 [n=30]) to evaluate the prognostic effect on overall survival (OS) and disease-free survival (DFS).

RESULTS

LNR (≤ 0.15, 0.16-0.3, and >0.3) was significantly associated with 5-year OS (90.3%, 75.1%, and 45.1%; p<0.001) and DFS (66.7%, 55.8%, and 21.9%; p<0.001) rates. In a multivariate analysis, LNR (≤ 0.15, 0.16-0.3, and >0.3) was a significant independent prognostic factor for OS (hazard ratios [HRs], 1, 3.609, and 8.197; p<0.001) and DFS (HRs, 1, 1.699, and 3.960; p<0.001). LNR had a prognostic impact on OS and DFS in patients with <12 harvested LNs, as well as in those with ≥ 12 harvested LNs (p<0.05).

CONCLUSION

LNR was a significant independent prognostic predictor for OS and DFS in patients with locally advanced rectal cancer who were treated with curative resection after preoperative CRT.

Increased striatal dopamine transporter density in moderately severe old restless legs syndrome patients

BACKGROUND AND PURPOSE

Dopamine dysregulation in restless legs syndrome (RLS) may be varied by the severity of RLS, which could contribute to the conflicting results from previous functional neuroimaging studies on the central dopaminergic neurotransmission of RLS. The aim of this study was to observe whether reduced striatal dopaminergic neurotransmission is associated with moderate to moderately severe RLS.

METHODS

Thirteen elderly patients with RLS and 12 normal elderly controls were enrolled in the study. All the subjects were dopaminergic-drug naïve and twelve patients with RLS had the severity of moderate to moderately severe degree based on the International Restless Legs Syndrome Study Group (IRLSSG) Severity Scale. We compared dopamine transporter density (DAT) availability and D2 receptor density in the striatum between patients with RLS and controls using [(123)I]2β-carbomethoxy-3β-(4-iodophenyl)tropane single-photon emission computed tomography (SPECT) and [(123)I]iodobenzamide SPECT.

RESULTS

Dopamine transporter density of patients with RLS was increased in the caudate (P = 0.037), posterior putamen (P = 0.041), and entire striatum (P = 0.046) compared with that of normal controls. DAT density was higher in the anterior putamen of patients with RLS than controls, although statistically not significant (P = 0.079). There was no difference in the D2 receptor density between patients with RLS and normal controls in the whole striatum or any of subregions.

CONCLUSIONS

Dysregulation rather than simple upregulation or downregulation of central dopaminergic neurotransmission may underlie the pathogenesis of RLS, and decreased dopaminergic neurotransmission may cause moderate to moderately severe RLS in the elderly.

Chronic obstructive lung disease-related health care utilisation in Korean adults with obstructive lung disease

OBJECTIVES

The numbers of nationwide epidemiological surveys about chronic obstructive pulmonary disease (COPD) prevalence and prospective cohort studies for health care utilisation are limited. We investigated COPD-related health care utilisation in adults with obstructive lung disease in the second Korean National Health and Nutritional Survey (KNHANES II) in 2001 using Korean national medical insurance claim data.

METHODS

Among people aged >40 years, obstructive lung disease (OLD) is defined according to Global Initiative for Chronic Obstructive Lung Disease criteria. Data from a total of 1942 subjects were linked with Korean national medical insurance claims data, and we investigated their COPD-related out-patient visits from 2002 to 2005.

RESULTS

Among the 1942 subjects, 256 (13.2%) had airflow obstruction. COPD-related out-patient visits were reported for 8.2% of patients without airway obstruction, 18.1% of those with mild airway obstruction, and 33.9% of those with moderate to very severe airway obstruction. Multivariate analysis revealed that previous COPD diagnosis by a physician (OR 2.54; P = 0.02) and lower socio-economic status (OR 0.45; P = 0.02) were independent predictors of COPD-related out-patient visits in subjects with OLD.

CONCLUSIONS

Of the subjects with airway obstruction, those with poor financial status utilised COPD-related health care services less frequently, and those previously diagnosed as having COPD by a physician utilised the services more frequently.

Jejunal varix bleeding with extrahepatic portal vein obstruction after pylorus-preserving pancreatoduodenectomy: report of two cases

We present 2 patients showing afferent jejunal varix bleeding around hepaticojejunostomy caused by extrahepatic portal vein obstruction after pylorus-preserving pancreatoduodenectomy (PPPD). The case 1 was a 58-year-old woman who had recurrent anemia and hematochezia 3 years after undergoing PPPD. On the portography, the main portal vein was obliterated and collaterals around hepaticojejunostomy were developed. After percutaneous transhepatic balloon dilatation and stent placement through the obliterated portal vein, jejunal varices had disappeared and thereafter no bleeding occurred for 32 months. The case 2 was a 71-year-old man who had frequent melena 7 years after PPPD. Portal stent insertion was first tried, but failed due to severe stenosis of the main portal vein. Therefore, meso-caval shunt operation was attempted in order to reduce the variceal flow. Although an episode of a small amount of melena occurred one month after the shunt operation, there was no occurrence of bleeding for the next 8 months. For the treatment of jejunal varices, a less invasive approach, such as the angiographic intervention of stent insertion, balloon dilatation, or embolization is recommended first. Surgical operations, such as a shunt or resection of the jejunal rim, could be considered when noninvasive approaches have failed.

Relative bioavailability of two 5-mg montelukast sodium chewable tablets: a single dose, randomized, open-label, 2-period crossover comparison in healthy korean adult male volunteers

Montelukast sodium, cysteinyl leukotriene receptor 1 specific antagonist, has been marketed in Korea for the treatment of bronchial asthma and allergic rhinitis. The aim of this study was to compare the pharmacokinetics and relative bioavailability of a test and reference formulation of montelukast 5-mg chewable tablets in healthy Korean male volunteers to meet KFDA regulatory criteria for marketing of the new generic formulation. This study was designed as a single-dose, 2-treatment, and 2-period crossover trial with 32 healthy volunteers. Each subject was randomly assigned to receive the test (Dong-Kook Montelukast Sodium Chewable Tablet 5 mg®) or reference (Singulair Chewable Tablet 5 mg®) formulation. The tablet was chewed 20 times, and then swallowed with 240 mL of water. Plasma concentrations of montelukast up to 24 h after the dose were determined using a validated UPLC-MS/MS method, and the bioequivalence between the 2 formulations was assessed by statistical analysis of mean ratios of log-transformed AUC0-24 h and Cmax. No period or sequence effects were detected. The AUC0-24 h was 1 835 ng·h/mL for the test formulation, and 1 930 ng·h/mL for the reference formulation. The respective values of AUC0-∞ were 1 917 and 2 015 ng·h/mL. The Cmax of the test and reference products (247 and 283 ng/mL, respectively) reached at 2.25 and 2.72 h, respectively. Then, they gradually decreased with the mean terminal t1/2 of 5.25 and 5.30 h for the test and reference products, respectively. The 90% CIs for the ratio of log-transformed AUC0-24 h and Cmax for the test and reference formulations were 0.92-0.99 and 0.83-0.91, respectively. No adverse events were reported in this study. This single dose study found that the test and reference products met the regulatory criteria for bioequivalence in these fasting healthy Korean male volunteers.

Co-morbid diabetes in patients with Crohn's disease predicts a greater need for surgical intervention

BACKGROUND

The prevalence of diabetes is increasing rapidly. Given its pro-inflammatory nature, comorbid diabetes may affect the course of Crohn's disease (CD).

AIM

To determine whether comorbid diabetes influences the natural history of CD.

METHODS

We compared a cohort with CD and comorbid diabetes to a nondiabetic control population and calculated the period prevalence of surgical intervention over a 5-year period. Unadjusted and adjusted odds-ratios were calculated regarding the need for surgical intervention using univariate and multivariate logistic regression.

RESULTS

A total of 240 patients were identified, 16 of whom were diabetics (6.7%). The period prevalence of CD-specific surgery in the diabetic cases was 75.0% and in the nondiabetic controls, 31.7%. The diabetic patients were more obese than the controls (44% vs. 10%; P < 0.0001) and older than the controls (47.4 years vs. 38.6; P < 0.01). There was no difference in the frequency of biologic therapy use, immunomodulator use, smoking, perianal disease, ileal involvement or corticosteroid use between the diabetics and controls. Univariate analysis revealed that diabetes (OR 6.46 [95% CI 2.01-20.8]), smoking (OR 2.46 [95% CI 1.24-4.90]), ileal disease (OR 2.21 [95% CI 1.15-4.24]) and obesity (OR 2.22 [95% CI 1.04-4.77]) were risk factors for needing surgery. After adjustment for covariates, the OR for surgical intervention in diabetics was 5.4 (95% CI 1.65-17.64).

CONCLUSION

Co-morbid diabetes in patients with Crohn's disease predicts a greater need for surgical intervention.