Effector Function Characteristics of Exhausted CD8+ T-cell in Microsatellite Stable and Unstable Gastric Cancer

Purpose

Gastric cancer exhibits molecular heterogeneity, with the microsatellite instability high (MSI-H) subtype drawing attention for its distinct features. Despite a higher survival rate, MSI-H gastric cancer lack significant benefits from conventional chemotherapy. The immune checkpoint inhibitors (ICIs), presents a potential avenue, but a deeper understanding of the tumor immune microenvironment of MSI-H gastric cancer is essential.

Materials and Methods

We explored the molecular characteristics of CD8+ T cell subtypes in three MSI-H and three microsatellite stable (MSS) gastric cancer samples using single-cell RNA sequencing and spatial transcriptome analysis.

Results

In MSI-H gastric cancer, significantly higher proportions of effector memory T cell (Tem), exhausted T cell (Tex), proliferative exhausted T cell (pTex), and proliferative T cell were observed, while MSS gastric cancer exhibited significantly higher proportions of mucosal-associated invariant T (MAIT) cell and NKT cell. In MSI-H gastric cancer, Tex and pTex exhibited a significant upregulation of the exhaustion marker LAG3, as well as elevated expression of effector function markers such as IFNG, GZMB, GZMH, and GZMK, compared to those in MSS gastric cancer. The IFN-γ signaling pathway of Tex and pTex was retained compared to those of MSS gastric cancer. The spatial transcriptome analysis demonstrates the IFN-γ signaling pathway between neighboring Tex and malignant cell, showcasing a significantly elevated interaction in MSI-H gastric cancer.

Conclusion

Our study reveals novel finding indicating that IFN-γ signaling pathway is retained in Tex and pTex of MSI-H gastric cancer, offering a comprehensive perspective for future investigations into immunotherapy for gastric cancer.

Prognostic roles of leptin-signaling proteins, PD-L1, and tumor-infiltrating lymphocytes in surgically-resected biliary tract cancers

BACKGROUND

Biliary tract cancers are rare, with a poor patient prognosis. Leptin and programmed death-ligand 1 (PD-L1) influence CD8⁺ and forkhead box P3 (FOXP3)⁺ lymphocytes, and thus, cancer cell growth. We aimed to define the prognostic implications of these variables and the clinicopathological features of biliary tract cancers.

METHODS

Immunohistochemistry for leptin signaling-related proteins (leptin, leptin receptor, pSTAT3, extracellular-regulated kinase, mammalian target of rapamycin), PD-L1, CD8, and FOXP3 and in situ hybridization for Epstein-Barr virus-encoded small RNAs were performed in 147 cases of surgically-resected biliary tract cancers.

RESULTS

Immune cell PD-L1-positivity, tumor size < 3 cm, adjuvant chemotherapy, no recurrence, and early-stage tumors were correlated with better 5-year survival in the tumoral PD-L1^(-) and leptin^(-) subgroups, and extrahepatic cholangiocarcinoma through multivariate analysis (all p < 0.05). Immune cell PD-L1 and adjuvant chemotherapy lost its prognostic significance in the tumoral PD-L1⁺ and leptin⁺ subgroups.

CONCLUSIONS

The prognostic implication of the variables may depend upon tumoral protein expression and the anatomical site. Immune cell PD-L1-positivity and the administration of adjuvant chemotherapy may indicate the favorable survival of patients with surgically-resected biliary tract cancers, specifically, in the tumoral PD-L1^(-) or tumor leptin^(-) subgroups and extrahepatic cholangiocarcinoma. PD-L1- or leptin-targeted therapy combined with conventional chemotherapy may benefit the tumoral PD-L1⁺ or leptin⁺ subgroups.

Closure of Petersen's Space Lowers the Incidence of Gastric Food Retention after Distal Gastrectomy with Gastrojejunostomy in Gastric Cancer Patients

Purpose

Delayed gastric emptying usually manifests as gastric food retention. This study aimed to evaluate the incidence of gastric food retention after distal gastrectomy with gastrojejunostomy in gastric cancer patients and identify the risk factors for its development.

Materials and Methods

We retrospectively enrolled 245 patients who underwent distal gastrectomy with gastrojejunostomy for gastric cancer at Boramae Medical Center between March 2017 and December 2019. We analyzed the presence of gastric food residue via computed tomography (CT) scans at 3 and 12 months postoperatively and analyzed the risk factors that may influence the development of gastric food retention.

Results

CT scans were performed on 235 patients at 3 months and on 217 patients at 12 months postoperatively. In the group that received closure of Petersen's space, the incidence of gastric food retention was significantly low as per the 3- and 12-month postoperative follow-up CT scans (P=0.028 and 0.003, respectively). In addition, hypertension was related to gastric food retention as per the 12-month postoperative follow-up CT scans (P=0.011). No other factors were related to the development of gastric food retention. In the multivariate analysis, non-closure of Petersen's space (hazard ratio [HR], 2.54; 95% confidence interval [CI], 1.20–5.38; P=0.010) was the only significant risk factor for gastric food retention at 3 months postoperatively, while non-closure of Petersen's space (HR, 2.81; 95% CI, 1.40-5.64; P=0.004) and hypertension (HR, 2.30; 95% CI, 1.14–4.63; P=0.020) were both significant risk factors for gastric food retention at 12 months postoperatively.

Conclusions

Closure of Petersen's space has an effect on decrease the incidence of gastric food retention after distal gastrectomy with gastrojejunostomy in gastric cancer patients.

Are the elderly patient's changes in the health-related quality of life one year after gastrectomy for stomach cancer different from those in young patients?

Purpose

Gastrectomy for elderly patients can significantly deteriorate the health-related quality of life (HRQoL). There was no report comparing HRQoL of elderly patients with young patients after gastrectomy for gastric cancer. This study assessed the differences in the changes of HRQoL at one year after gastrectomy according to age.

Methods

From May 2014 to Feb 2016, we prospectively enrolled patients undergoing gastrectomy for gastric cancer. They completed the European Organization for Research and Treatment of Cancer and gastric questionnaires preoperatively and at postoperative 1, 3, 6, 9, and 12 months.

Results

We included 57 elderly patients (≥70 years old) and 74 younger patients. The elderly had similar demographic, surgical, and pathological characteristics with young patients except that elderly had more comorbidity, laparoscopic gastrectomies, and lesser postoperative chemotherapy. One month after gastrectomy, the score of global health status/quality of life, physical, role, and social functioning were significantly impaired in elderly patients. Among them, physical and role functioning were more impaired than those of young patients. The scores of physical functioning, role functioning, cognitive functioning, and social functioning were not fully recovered till 1 year after surgery. There was a significant age group difference in the changes in physical function over the 1-year follow-up.

Conclusion

Elderly patients' global health status/quality of life and social functioning significantly decreased at postoperative 1 month and recovered by 6 months after gastrectomy. There was a significant age-specific difference in physical functioning throughout the 1-year follow-up. Surgeons need to pay more attention to recovery of the elderly patients' HRQoL after gastrectomy.

Comparing the surgical outcomes of dual-port laparoscopic distal gastrectomy and three-port laparoscopic distal gastrectomy for gastric cancer

Purpose

Many studies have demonstrated that single-incision or reduced-port laparoscopic distal gastrectomy is a feasible method compared to conventional laparoscopic distal gastrectomy. Using rigid-type laparoscope and right-side approach, we could perform dual-port laparoscopic distal gastrectomy (DPLDG) for gastric cancer. This study aimed to compare the surgical outcomes of DPLDG to those of 3-port laparoscopic distal gastrectomy (TPLDG).

Methods

From March 2017 to December 2019, this retrospective study included 218 patients with gastric cancer who underwent DPLDG (106 patients) or TPLDG (112 patients) at SMG-SNU Boramae Medical Center. Surgical outcomes were compared between 2 operation methods.

Results

Operation time was similar between DPLDG and TPLDG (158.9 ± 33.4 minutes vs. 154.0 ± 31.1 min, P = 0.787). The number of retrieved lymph nodes was similar between the 2 groups (35.3 ± 14.6 vs. 37.0 ± 13.5, P = 0.415). The complication rate in DPLDG and TPLDG groups was 10.4% and 8.9%, respectively (P = 0.894). The time to first flatus, time to first diet, and postoperative hospital stay were similar between the 2 groups. There were no reoperation or mortality cases. The cost of trocars was 359.9 US dollars (USD) in DPLDG and 291–391.4 USD in TPLDG.

Conclusion

The surgical outcomes of DPLDG and TPLDG did not differ. Regarding fewer incisions, DPLDG can be an alternative option for TPLDG.

Risk factors of elderly patients with postoperative delirium following major abdominal surgery for cancer

Purpose

Postoperative delirium (POD) is a common complication in elderly patients after major abdominal surgery for cancer. Although POD is related with a poor outcome, there have not been many reports about POD after abdominal surgery in Korea. The aims of study were to analyze the characteristics and surgical outcomes of elderly patients with POD and to identify the risk factors of POD.

Methods

From November 2016 to January 2019, we prospectively enrolled 63 patients who were aged ≥75 years and underwent major abdominal surgery for cancer. POD was daily assessed for up to 10 days postoperatively with the Confusion Assessment Method and a validated chart review.

Results

POD occurred in eight patients (12.7%). Univariate analysis showed that the occurrence of POD was related to sodium <135 mEq/L (P=0.037), combined resection (P=0.023), longer surgery/anesthesia time (P=0.023 and P=0.037, respectively), increased blood loss (P=0.004), postoperative admission to intensive care unit (ICU) (P=0.023), and duration of Foley catheter (P=0.011), however, multivariate analysis identified no significant risk factors of POD. There was no difference in postoperative outcomes such as hospital stay, mortality, reoperation, and morbidity between patients with POD and without POD.

Conclusion

Elderly patients with hyponatremia, combined resection, longer operation/anesthesia time and admission to ICU had tendencies to develop POD after major abdominal surgery. Surgeons should pay more attention to prevent POD, and a large-scale prospective study is needed to identify the risk factors of POD.

Prognostic perspectives of PD-L1 combined with tumor-infiltrating lymphocytes, Epstein-Barr virus, and microsatellite instability in gastric carcinomas

Background

The prognostic potential of PD-L1 is currently unclear in gastric carcinomas, although the immune checkpoint PD-1/PD-L1 inhibitors have produced promising results in clinical trials.

Methods

We explored the prognostic implications of programmed death ligand 1 (PD-L1) in 514 consecutive surgically-resected gastric carcinomas. Overall survival and recurrence-free survival were evaluated. Immunohistochemistry for PD-L1, CD8, FOXP3, and PD-1, and molecular grouping by in situ hybridization for Epstein-Barr virus (EBV)-encoded small RNAs and multiplex PCR for microsatellite instability (MSI) markers were performed. Additionally, to explore the function inherent to PD-L1, PD-L1-specific siRNA transfection, cell proliferation, invasion, migration and apoptosis assays were conducted in five gastric carcinoma cell lines.

Results

PD-L1(+) tumor and immune cells were observed in 101 (20%) and 244 patients (47%), respectively. “Tumoral PD-L1(+)/immune cell PD-L1(-)/CD8^+/low tumor-infiltrating lymphocytes (TILs),” and more advanced-stage tumors were associated with unfavorable clinical outcomes in the entire cohort through multivariate analysis. Furthermore, tumoral PD-L1(+)/FOXP3^+/low TILs were associated with worse clinical outcomes in EBV-positive and MSI-high carcinomas. Tumoral PD-L1(+) alone was an adverse prognostic factor in EBV-positive carcinomas, but not in MSI-high carcinomas, whereas PD-L1(+) immune cells or FOXP3^+/high TILs alone were correlated with a favorable prognosis. PD-L1 knockdown in gastric carcinoma cells suppressed cell proliferation, invasion and migration, and increased apoptosis, which were all statistically significant in two EBV(+) cell lines, but not all in three EBV(−) cell lines.

Conclusions

The prognostic impact of PD-L1 may depend on the tumor microenvironment, and statuses of EBV and MSI, although PD-L1 innately promotes cancer cell survival in cell-based assays. The combination of “tumoral PD-L1/immune cell PD-L1/CD8⁺ TILs” may serve as an independent prognostic factor. Tumoral PD-L1(+)/immune cell PD-L1(−)/CD8^+/low TILs showing a worse prognosis may be beneficial for combinatorial therapies of anti-PD-L1/PD-1 and anti-cytotoxic T-lymphocyte associated antigen 4 (CTLA4) that would promote effector T cells, thus attack the tumor.

Correlation between internal pudendal artery stenosis and erectile dysfunction in patients with suspected coronary artery disease

Background

Stenoses of internal pudendal arteries (IPAs) appear to be related to erectile dysfunction (ED). Nevertheless, the correlation between the severity of ED and stenosis of the IPAs is not well established.

Objectives

To evaluate angiographic findings of IPAs in patients with suspected coronary artery disease (CAD) and to assess the correlation between the severity of ED and IPA stenosis.

Materials and methods

Ninety-one patients who were scheduled for cardiac angiogram (CAG) because of suspected CAD participated. ED was assessed using the International Index of Erectile Function (IIEF) questionnaire. Erectile function (EF) domain scoring was used to assess the severity of ED: severe (EF score = 1–10); moderate (11–16); mild-moderate (17–21); mild (22–25); and no ED (26–30). Angiography was performed in bilateral common, internal iliac, and IPAs and the location and extent of stenoses were measured. We divided patients according to those with maximum stenosis of less than 50% (Group I) and those with more than 50% (Group II), regardless of direction.

Results

We diagnosed 88 patients (88/91, 96.70%) with ED. There was no correlation between increasing age and severity of ED (r = - 0.063, p = 0.555). There were 72 patients in Group I and 19 in Group II. In Group I, 62 patients were diagnosed with ED even though there was no stenosis. There was no significant correlation between the severity of ED and the extent of stenosis in IPAs (r = -0.118, p = 0.265).

Conclusions

There was no significant correlation between the severity of ED and the extent of stenosis of IPAs. We believe that this is because the progression of ED is induced by endothelial cell dysfunction, not by mechanical obstruction leading to blood flow reduction.

Evidence-Based Practice Guideline for Surgical Treatment of Gastroesophageal Reflux Disease 2018

The prevalence of gastroesophageal reflux disease (GERD) is increasing in Korea, and physicians, including surgeons, have been focusing on its treatment. Indeed, in Korea, medical treatment using a proton pump inhibitor is the mainstream treatment for GERD, while awareness of surgical treatment is limited. Accordingly, to promote the understanding of surgical treatment for GERD, the Korean Anti-Reflux Surgery Study Group published the Evidence-Based Practice Guideline for the Surgical Treatment of GERD. The guideline consists of 2 sections: fundamental information such as the definition, symptoms, and diagnostic tools of GERD and a recommendation statement about its surgical treatment. The recommendations presented 5 debates regarding fundoplication: 1) comparison of the effectiveness of medical and surgical treatments, 2) effectiveness of surgical treatment in cases of refractory GERD, 3) effectiveness of surgical treatment of extraesophageal symptoms, 4) comparison of effectiveness between total and partial fundoplication, and 5) effectiveness of fundoplication in cases of hiatal hernia. The present guideline is the first to demonstrate the efficacy of the surgical treatment GERD in Korea.

Effect of perioperative oral nutritional supplementation in malnourished patients who undergo gastrectomy: A prospective randomized trial

BACKGROUND

The aim of this study was to examine the effect of a perioperative oral nutritional supplement in malnourished patients who undergo gastrectomy.

METHODS

Patients who were determined as being moderately or severely malnourished according to a patient-generated subjective global assessment or who had a body mass index <18.5, were enrolled. The oral nutritional supplement group received 500 mL/d of standard oral nutritional supplement for 2 weeks before gastrectomy and for 4 weeks postoperatively. The primary endpoint was postoperative complications (Clavien-Dindo classification ≥II). The secondary endpoints included body weight changes, biochemical parameters, and quality of life survey results.

RESULTS

A total of 127 patients (65 in the oral nutritional supplement group and 62 in the control group) were enrolled. The complication rates were not significantly different (29.2% versus 37.1%, P = .346). However, the incidences of overall complications, complications persisting until postoperative week 3 or 5, and severe complications (grade ≥IIIa) were significantly lower in the oral nutritional supplement group for patients with patient-generated subjective global assessment grade C. Total lymphocyte counts were significantly higher in the oral nutritional supplement group at postoperative weeks 3 and 5. For most patients, oral nutritional supplement was well tolerated preoperatively. However, only 26.2% and 50.8% of the patients in the oral nutritional supplement group could consume >250 mL/d of oral nutritional supplement postoperatively during the 2nd and 4th weeks, respectively.

CONCLUSIONS

The routine application of perioperative oral nutritional supplement is not recommended for malnourished patients receiving gastrectomy. However, perioperative standard oral nutritional supplement administration may reduce the incidence, severity, and duration of complications after gastrectomy in severely malnourished patients (patient-generated subjective global assessment grade C).

External Validation of a Gastric Cancer Nomogram Derived from a Large-volume Center Using Dataset from a Medium-volume Center

Purpose

Recently, a nomogram predicting overall survival after gastric resection was developed and externally validated in Korea and Japan. However, this gastric cancer nomogram is derived from large-volume centers, and the applicability of the nomogram in smaller centers must be proven. The purpose of this study is to externally validate the gastric cancer nomogram using a dataset from a medium-volume center in Korea.

Materials and Methods

We retrospectively analyzed 610 patients who underwent radical gastrectomy for gastric cancer from August 1, 2005 to December 31, 2011. Age, sex, number of metastatic lymph nodes (LNs), number of examined LNs, depth of invasion, and location of the tumor were investigated as variables for validation of the nomogram. Both discrimination and calibration of the nomogram were evaluated.

Results

The discrimination was evaluated using Harrell's C-index. The Harrell's C-index was 0.83 and the discrimination of the gastric cancer nomogram was appropriate. Regarding calibration, the 95% confidence interval of predicted survival appeared to be on the ideal reference line except in the poorest survival group. However, we observed a tendency for actual survival to be constantly higher than predicted survival in this cohort.

Conclusions

Although the discrimination power was good, actual survival was slightly higher than that predicted by the nomogram. This phenomenon might be explained by elongated life span in the recent patient cohort due to advances in adjuvant chemotherapy and improved nutritional status. Future gastric cancer nomograms should consider elongated life span with the passage of time.

Bladder stone formation on permanent suture material ten years after laparoscopic high uterosacral ligament suspension

The present authors describe an uncommon case of iatrogenic bladder stone formation in a patient who underwent surgery for pelvic organ prolapse. A female patient who underwent high uterosacral ligament suspension ten years ago presented with pyuria and irritable bladder symptoms that did not respond to treatment. She had not experienced any specific urinary symptoms during the previous ten years. Patient evaluation revealed bladder stone formation on the non-absorbable suture material used during the previous operation. Cystoscopy during the previous operation did not find the suture material, and the suture knot that was tied extravesically during the operation was found inside the bladder. These strongly suggest delayed migration and rotation of the'suture knot after surgery rather than direct penetration of the bladder during operation. Delayed suture migration is a long-term complication that clinicians should consider in a patient who suffers from recurrent urinary symptoms after pelvic surgery around the bladder.

Risk Factors for Reoperation After Photoselective Vaporization of the Prostate Using a 120 W GreenLight High Performance System Laser for the Treatment of Benign Prostatic Hyperplasia

OBJECTIVE

We investigated risk factors in a large cohort of patients who underwent reoperation after photoselective vaporization of the prostate using the 120 W GreenLight High Performance System laser for treatment of benign prostatic hyperplasia.

BACKGROUND DATA

Complications such as recurrent/residual adenoma, urethral stricture, or bladder neck might occur after photoselective vaporization of the prostate for treatment of benign prostatic hyperplasia.

MATERIALS AND METHODS

We reviewed the data of 1040 patients who underwent photoselective vaporization of the prostate between April 2009 and December 2014, and analyzed the clinical data of 630 patients who completed >12 months of follow-up. Patients were evaluated for perioperative and late complications. Reoperation was defined as the necessity for any surgical intervention to resolve recurrent/residual adenoma, urethral stricture, or bladder neck contracture. Patients with recurrent/residual adenoma, urethral stricture, or bladder neck contracture were compared with those without complications to identify the risk factors for reoperation. Logistic regression analysis was conducted to estimate the risk of reoperation.

RESULTS

Reoperation was performed in 25 of 630 patients (3.9%) at 35.5 months mean follow-up: 12 had recurrent/residual adenoma, 5 had urethral stricture, and 8 had bladder neck contracture. Multivariate analysis revealed that a higher prostate-specific antigen (PSA) (OR, 1.129; p = 0.023) and longer lasing time (OR, 0.883; p = 0.024) were predictors of recurrent/residual adenoma. Urethral stricture was associated with a history of transurethral surgery (OR, 1.321; p = 0.042). Preoperative small prostate volume was a risk factor for bladder neck contracture (OR, 0.901; p = 0.011).

CONCLUSIONS

In our study, the significant factors related to recurrent/residual adenoma were a high preoperative PSA and longer lasing time. A history of transurethral surgery was significantly associated with urethral stricture, whereas preoperative small prostate volume was significantly associated with bladder neck contracture.

Corrigendum. Early versus delayed passive range of motion exercise for arthroscopic rotator cuff repair: a meta-analysis of randomized controlled trials

Chang KV, Hung CY, Han DS, Chen WS, Wang TG, Chien KL. Early versus delayed passive range of motion exercise for arthroscopic rotator cuff repair: a meta-analysis of randomized controlled trials. Am J Sports Med. 2015;43(5):1265-1273. (Original DOI: 10.1177/0363546514544698 )

Preoperative neutrophil-to-lymphocyte ratio is a prognostic factor for overall survival in patients with gastric cancer

Purpose

Preoperative neutrophil-to-lymphocyte ratio (NLR) reflects patients' inflammation status, clinical stage, and survival in various malignancies. However, only a limited amount of information on the clinical importance and prognostic significance of NLR in gastric cancer has been reported. The objective of this study is to assess the prognostic values of preoperative NLR in patients with gastric cancer.

Methods

During the period between August 1, 2005 and December 31, 2011, we collected data from 601 patients among those who had undergone surgery for gastric cancer at the Department of Surgery, Konkuk University Medical Center. We classified the subjects into high NLR (NLR ≥ 1.7) group and low NLR (NLR < 1.7) group.

Results

The gender, age, and American Society of Anesthesiologists (ASA) score did not differ in the two NLR groups. The pathologic features (tumor size, histology, number of examined lymph node, T stage, N stage, and TNM stage) did not differ either, except for tumor location (P = 0.006). Multivariate analysis identified TNM stage, NLR, and age as significant prognostic factors. Gender, tumor size, location, and histology did not show their prognostic significance when we applied the Cox proportional hazard model.

Conclusion

Our study verified that advanced stage, high preoperative NLR (NLR ≥ 1.7), and old age (≥ 70 years) are significant, independent prognostic factor for overall survival in patients with gastric cancer.

Intra-abdominal fibromatosis after gastrectomy for gastric cancer

Intra-abdominal fibromatosis (IAF) may arise either sporadically or in association with familial adenomatous polyposis. The characteristics of fibromatosis are slow-growth, benign histological features, and aggressive local invasion. Surgery remains a reasonable first treatment option. Here, we report 2 cases of a phenomenon rarely described in published literature, IAF after gastrectomy for gastric cancer. Intra-abdominal masses were found during the routine follow-up period in a 50-year-old man who had received a radical subtotal gastrectomy for early gastric cancer. Two mesenteric masses were detected in the upper abdomen by CT and were excised completely along with segments of the jejunum. Another intra-abdominal mass was found in 60-year-old man who had received a radical total gastrectomy for advanced gastric cancer. A 4.2-cm-sized mass was detected in the periumbilical region by follow-up CT and was excised completely along with a segment of the ileum.

Comparison of Surgical Outcomes of Robot-Assisted and Laparoscopy-Assisted Pylorus-Preserving Gastrectomy for Gastric Cancer: A Propensity Score Matching Analysis

BACKGROUND

The three-dimensional view and articulating devices in robot system might have a benefit performing the delicate procedure of pylorus-preserving gastrectomy. This study was conducted to evaluate the feasibility and safety of robot-assisted pylorus-preserving gastrectomy (RAPPG) and to compare the perioperative outcomes and oncologic safety between RAPPG and laparoscopy-assisted pylorus-preserving gastrectomy (LAPPG) for middle-third early gastric cancer.

METHODS

Between June 2008 and December 2013, we retrospectively collected data of 68 patients with RAPPG and propensity score matched 68 patients with LAPPG for the treatment of early gastric cancer at Seoul National University Hospital. The covariates for propensity score matching were: age, sex, American Society of Anesthesiologists score, body mass index, and operators. Clinicopathologic characteristics and surgical outcomes were compared between the two groups.

RESULTS

All RAPPG cases were performed successfully without open or laparoscopic conversion. Patient demographics and perioperative outcomes did not differ between the two groups except in operation time (258.3 vs. 193.9 min; P < 0.001). There was no significant difference in complication rates between the two groups (19.1 vs. 22.1 %; P = 0.671). The mean number of examined lymph nodes (33.4 vs. 36.5; P = 0.153), and the mean number of lymph nodes at each station was not different between the two groups.

CONCLUSIONS

RAPPG can be a safe treatment option for middle-third early gastric cancer in terms of surgical complications and oncologic outcomes. However, RAPPG has no benefit over LAPPG in this study.

Clinical courses following acute bacterial prostatitis

Purpose:

There are few studies about clinical courses following acute bacterial prostatitis (ABP). We evaluated the progression rates of chronic bacterial prostatitis (CBP) and inflammatory chronic pelvic pain syndrome (CPPS) after ABP treatment. Also evaluated the characteristics of the patients who developed CBP and inflammatory CPPS after ABP treatment.

Methods:

Total 437 patients compatible with a confirmed diagnosis of ABP from 5 urological centers between 2001 and 2010 were enrolled to study. We defined chronic infection (CI) as a progression to CBP and inflammatory CPPS after treatment of ABP in admission periods when followed up at 3 months or more. Results were analyzed between two groups: recovered without CI (group A, n=385) and developed to CI (group B, n=52).

Results:

Of the 437 ABP patients, 1.3% (6/437) progressed to CBP and 10.5% (46/437) progressed to inflammatory CPPS. The progression rate of CI was 11.8% (52/437). The patients who developed to CI were higher in alcohol consumption rate, diabetes, voiding symptoms, prior manipulation rate, enlarged prostate volume, catheterization history rate and short duration of antibiotic treatment (P<0.05).

Conclusions:

The identification and characterization of these factors may accelerate the development of preventive, diagnostic and therapeutic strategies for the treatment of CI from ABP.

Outcomes of surgery aiming at curative resection in good responder to induction chemotherapy for gastric cancer with distant metastases

BACKGROUND

The aim of this study is to analyze the outcome of surgery with curative intent in good responder to induction chemotherapy for gastric cancer with distant metastases (M1 gastric cancer).

MATERIALS AND METHODS

We reviewed M1 gastric cancer patients in whom radiologic evaluation suggests disappearance of metastatic lesion after chemotherapy and received operation from January 2000 to December 2009. Clinicopathologic variables and oncologic outcomes were evaluated.

RESULTS

Of the 34 patients who underwent surgery with curative intent after chemotherapy, overall R0 resection rate was 76.5% (26/34). R0 resection rate was 88.0% (22/25) in initial one metastatic site and 44.4% (4/9) in two metastatic sites (P = 0.017). Postoperative morbidity and mortality rate were 14.7% and 0%. Recurrence rate was 61.5% (16/26) after R0 resection. Median survival was 22.9 and 7.8 months according to R0 versus non-R0 resection (P = 0.033). After R0 resection, 3-year overall survival was 51.7% in ypN0-2 stage group.

CONCLUSION

The present study provides evidence that in patients with M1 gastric cancer which confined to one site who respond well to induction chemotherapy, a higher rate of R0 resection and longer survival can be expected. A multicenter cohort study is needed to explore this concept further.

Nomogram predicting long-term survival after d2 gastrectomy for gastric cancer

PURPOSE

The aim of this study was to combine clinicopathologic variables associated with overall survival after gastric resection with D2 lymphadenectomy (D2 gastrectomy) for gastric cancer into a prediction nomogram.

PATIENTS AND METHODS

We retrospectively analyzed 7,954 patients who underwent D2 gastrectomy for gastric cancer at Seoul National University Hospital (SNUH) in Seoul, Korea. Two thirds of the patients were randomly assigned to the training set (n = 5,300), and one third were assigned to the validation set (n = 2,654). Multivariate analysis by Cox proportional hazards regression was performed using the training set, and the nomogram was constructed. Discrimination and calibration were performed using the SNUH validation set. Additional external validation was performed using the data set (n = 2,500) from Cancer Institute Ariake Hospital (CIAH) in Tokyo, Japan.

RESULTS

The multivariate Cox model identified age at diagnosis, sex, location, depth of invasion, number of metastatic lymph nodes, and number of examined lymph nodes as covariates associated with survival. In the SNUH validation set, the nomogram exhibited superior discrimination power compared with the seventh American Joint Committee on Cancer TNM classification (Harrell's C-index, 0.78 v 0.69, respectively; P < .001). Calibration of the nomogram predicted survival corresponding closely with the actual survival. In the CIAH validation set, discrimination was good (C-index, 0.79), and the predicted survival was within a 10% margin of ideal nomogram.

CONCLUSION

We developed a nomogram predicting 5- and 10-year overall survival after D2 gastrectomy for gastric cancer. Validation using the SNUH and CIAH data sets revealed good discrimination and calibration, suggesting good clinical utility. The nomogram improved individualized predictions of survival.

Translationally controlled tumour protein is associated with podocyte hypertrophy in a mouse model of type 1 diabetes

AIMS/HYPOTHESIS

Translationally controlled tumour protein (TCTP) is thought to be involved in cell growth by regulating mTOR complex 1 (mTORC1) signalling. As diabetes characteristically induces podocyte hypertrophy and mTORC1 has been implicated in this process, TCTP may have a role in the pathogenesis of diabetes-induced podocyte hypertrophy.

METHODS

We investigated the effects and molecular mechanisms of TCTP in diabetic mice and in high glucose-stimulated cultured podocytes. To characterise the role of TCTP, we conducted lentivirus-mediated gene silencing of TCTP both in vivo and in vitro.

RESULTS

Glomerular production of TCTP was significantly higher in streptozotocin induced-diabetic DBA/2J mice than in control animals. Double-immunofluorescence staining for TCTP and synaptopodin revealed that podocyte was the principal cell responsible for this increase. TCTP knockdown attenuated the activation of mTORC1 downstream effectors and the overproduction of cyclin-dependent kinase inhibitors (CKIs) in diabetic glomeruli, along with a reduction in proteinuria and a decrease in the sizes of podocytes as well as glomeruli. In addition, knockdown of TCTP in db/db mice prevented the development of diabetic nephropathy, as indicated by the amelioration of proteinuria, mesangial expansion, podocytopenia and glomerulosclerosis. In accordance with the in vivo data, TCTP inhibition abrogated high glucose-induced hypertrophy in cultured podocytes, which was accompanied by the downregulation of mTORC1 effectors and CKIs.

CONCLUSIONS/INTERPRETATION

These findings suggest that TCTP might play an important role in the process of podocyte hypertrophy under diabetic conditions via the regulation of mTORC1 activity and the induction of cell-cycle arrest.

Stomach hanging technique using gauze during laparoscopic gastrectomy

INTRODUCTION

Lifting the stomach using laparoscopic instruments during laparoscopic gastrectomy is difficult and increases the risk of crushing the tumor. In this study, we present a stomach hanging technique using gauze pieces that reduces the risk to the tumor.

MATERIALS AND SURGICAL TECHNIQUE

After a partial omentectomy and the opening of the lesser sac, the antrum was wrapped with a 15-20-cm gauze piece. Next, a straight needle with 2-0 monofilament suture material pierced the abdominal cavity through the right subcostal area on the mid-clavicular line, and the gauze was then sutured twice in a figure of eight manner. The needle was removed percutaneously through the right middle quadrant of the abdomen. Another suture was applied to wrap the left side of the stomach. The stomach was easily lifted and positioned by pulling the four suture strings in different directions. After the suture materials were fastened to the abdominal wall using hemostat forceps, the surgical field was sufficiently exposed, facilitating lymph node dissection on the superior surface of the pancreas. This method freed the assistant from holding the stomach and enabled this individual to assist the operation in other ways.

DISCUSSION

This stomach lifting technique using gauze is a good option for exposing the surgical field, enables the assistant to perform other tasks, and reduces the risk of crushing the tumor during laparoscopic gastrectomy.

Prealbumin levels as a useful marker for predicting infectious complications after gastric surgery

BACKGROUND/OBJECTIVES

Preoperative nutritional status is associated with postoperative complications. Prealbumin, a visceral protein, is sensitive to protein malnutrition. The objective of this study is to evaluate the role of preoperative prealbumin levels as a marker for predicting complications after gastric surgery.

METHODS

An observational study was performed on 183 patients who underwent gastric surgery due to benign or malignant gastric disease at Seoul National University Hospital (SNUH) between August 2009 and October 2010. Preoperative prealbumin levels were also measured. Nutritional variables such as prealbumin (cutoff value, 18 mg/dL), albumin, body mass index (BMI), and clinicopathologic data were collected. Postoperative hospital stay, 30-day complications and mortality rate were obtained to investigate outcomes.

RESULTS

The complication rate was 52% in the abnormal prealbumin group (n = 23) and 24% in the normal prealbumin group (n = 160; p = 0.005). The complication rate was higher in patients with low preoperative albumin levels (<3.5 g/dL) and abnormal BMI (<18.5 kg/m(2)), but the differences were not statistically significant. Comorbidity of diabetes mellitus (DM), resection extent, combined resection, TNM stage and prealbumin levels were associated with complications. In multivariate analysis, DM and combined resection were significantly correlated with complications (p = 0.001 for each). In subgroup analysis, resection extent, approach, combined resection, TNM stage, and prealbumin levels were significantly associated with infectious complications. Multivariate analysis identified combined resection (p = 0.001) and prealbumin levels (p = 0.032) as independent variables.

CONCLUSIONS

Preoperative prealbumin levels could be a useful marker for predicting complications, especially infectious complications, after gastric surgery.

Criteria for decision making after endoscopic resection of well-differentiated rectal carcinoids with regard to potential lymphatic spread

BACKGROUND AND STUDY AIM

Rectal carcinoids are low-grade malignancies that are usually treated by endoscopic resection. However, on pathologic examination, resection margins that are positive for carcinoid cells are frequently found. Patient outcomes were reviewed after endoscopic resection of rectal carcinoids and the clinical significance of possible residual disease, as defined by pathologic and endoscopic examination, was evaluated.

PATIENTS AND METHODS

The medical records and endoscopic findings of 347 patients presenting with rectal carcinoids to 14 university hospitals in Korea between January 1999 and June 2007 were retrospectively analyzed.

RESULTS

A total of 304 patients were treated with endoscopic resection, and 43 patents were treated with surgery. In the endoscopic resection group, the complete resection rate was 88.2% based on endoscopic appearance (CR-E) and 60.2% based on pathologic evaluation (CR-P). The agreement between CR-E and CR-P was low (κ=0.192). No residual tumors were found in 77 of 85 patients (90.6%) who were CR-E but not CR-P and who had endoscopic biopsy taken at 24-month follow-up. The receiver-operating characteristic curve identified an optimal cut-off value of 10.5 mm, at which the sensitivity and the specificity for metastasis were 100% and 89%, respectively. The risk factors for metastasis by multivariate analysis were tumor size, increased mitotic rate, and lymphovascular invasion.

CONCLUSIONS

Endoscopic resection is a safe and effective modality for treating well-differentiated rectal carcinoids smaller than 10 mm in diameter. Discrepancies were observed between CR-E and CR-P. The risk factors for metastasis were tumor size, increased mitotic rate, and lymphovascular invasion.

Laparoscopy-assisted distal gastrectomy compared to open distal gastrectomy in early gastric cancer

BACKGROUND

This study aimed to evaluate the feasibility of laparoscopy-assisted distal gastrectomy (LADG) in early gastric cancer (EGC) with special interest in a learning curve effect.

METHODS

The clinical outcomes of EGC patients who underwent LADG (n = 100) and sex-, age- and body mass index- (BMI) matched EGC patients who underwent open distal gastrectomy (ODG; n = 100) were compared retrospectively. In addition, the outcomes between the early (n = 50) and late LADG group (n = 50) were compared.

RESULTS

The mean number of retrieved lymph nodes was significantly smaller in the LADG group than in the ODG group (29.3 vs. 36.4, p < 0.001). The operative time of the LADG group was significantly longer than in the ODG group (249.1 vs. 152.9 min, p < 0.001). The complication rates were comparable between both groups (14 vs. 13%, p = 0.84). No cancer-related death was observed in either group. Between early and late LADG groups, the operative time was shorter (p < 0.001) and the number of retrieved lymph nodes was higher (p = 0.016) in the late group.

CONCLUSIONS

LADG seems to be a safe and feasible procedure in treating EGC, as it shows comparable outcomes with ODG. The potential disadvantages of LADG, such as longer operation time and smaller number of retrieved lymph nodes, diminished after overcoming the learning curve.

Anthocyanin extracted from black soybean reduces prostate weight and promotes apoptosis in the prostatic hyperplasia-induced rat model

Anthocyanin is a natural plant pigment and potent antioxidant. This study was designed to investigate the effects of anthocyanin extracted from black soybeans on a rat model of benign prostatic hyperplasia (BPH), a disease associated with the geriatric population. Thirty male rats were divided into five experimental groups: a control group, a BPH-induced group, and three BPH-induced groups that received oral doses of anthocyanin (40, 80, and 160 mg/kg). Prostate hyperplasia was induced by the administration of testosterone propionate for 4 weeks. Following BPH induction, the anthocyanin-treated groups received the compound for 4 weeks. After anthocyanin treatment, the prostates from the rats in all groups were removed, weighed, and subjected to histological examination. Apoptosis in the prostates was measured by the TUNEL assay. The mean prostate weight for the control animals was 674.17 ± 28.24 mg, whereas the BPH-induced rats had a mean prostate weight of 1098.33 ± 131.31 mg. The mean prostate weights for the rats receiving 40, 80, and 160 mg/kg anthocyanin were 323.00 ± 22.41, 324.00 ± 26.80, and 617.50 ± 31.08 mg, respectively. The average prostate weight in the BPH-induced group was significantly higher than in the control group (p < 0.05), whereas the prostate weights in the anthocyanin-administered groups were significantly lower than in the BPH-induced group (p < 0.05). Injected testosterone led to prostatic hyperplasia as observed histologically, but anthocyanin administration helped to prevent this change. Apoptotic body counts were significantly higher in groups receiving anthocyanin than in the BPH-induced group (p < 0.05). These results suggest that anthocyanin may be effective in decreasing the volume and suppressing the proliferation of the prostate. Further studies are needed to better understand the mechanisms and actions of anthocyanin, and these studies may lead to the clinical application of anthocyanin in treating BPH.

Lactobacillus casei prevents the development of dextran sulphate sodium-induced colitis in Toll-like receptor 4 mutant mice

Probiotics, defined as live or attenuated bacteria or bacterial products, confer a significant health benefit to the host. Recently, they have been shown to be useful in the treatment of chronic inflammatory bowel disease and infectious colitis. In this study, we investigated the effect of probiotics on the development of experimental colitis using Toll-like receptor 4 (TLR-4) mutant (lps-/lps-) mice. TLR-4(lps-/lps-) and wild-type (WT) mice were given 2.5% dextran sulphate sodium (DSS) in drinking water to induce colitis with or without Lactobacillus casei pretreatment. Clinical and histological activity of DSS-colitis was attenuated markedly both in TLR-4(lps-/lps-) and WT mice pretreated with L. casei. Interestingly, histological activity was less severe in TLR-4(lps-/lps-) mice than in WT mice. The levels of myeloperoxidase activity and interleukin (IL)-12p40 were attenuated in pretreated TLR-4(lps-/lps-) mice after DSS administration. By contrast, transforming growth factor (TGF)-beta and IL-10 mRNA and protein expressions were increased markedly in pretreated TLR-4(lps-/lps-) mice. The current results suggest that L. casei has a preventive effect in the development of acute DSS-induced colitis and its action depends largely upon TLR-4 status. L. casei modulates the expression of inflammatory cytokines and down-regulates neutrophilic infiltration in the case of incomplete TLR-4 complex signalling.

Patient factors predictive of pain and difficulty during sedation-free colonoscopy: a prospective study in Korea

BACKGROUND

Successful colonoscopy depends on insertion of the instrument to the cecum, precise observation, and minimal patient discomfort during the procedure. This prospective study was designed to identify factors, apart from the endoscopist's skill, that predict patient pain and technical difficulty during sedation-free colonoscopy.

METHODS

A total of 426 sedation-free colonoscopies performed by one experienced endoscopist were evaluated in a prospective manner. Factors were recorded, including patient pain level, intubation time, demographic data, history of abdominal surgery, bowel preparation status, diverticular disease, bowel habits, anxiety level, and number of previous colonoscopies. These factors were analysed to determine their association with difficulty and pain during the procedure.

RESULTS

Four hundred six colonoscopies were completed to the cecum (95.3%). Mean insertion time for complete colonoscopy was 6.5+/-3.5 min. Multivariate logistic regression analyses revealed that older age, lower body mass index, previous hysterectomy, diarrhoea, 1st time colonoscopy and anxiety were predictors of patient pain. Older age, lower body mass index and previous hysterectomy were predictors of difficulty of intubation.

CONCLUSIONS

This prospective study identified several factors that may predict patient pain and technical difficulty associated with the procedure. These findings have implications for the practice and teaching of colonoscopy.

Podocyte biology in diabetic nephropathy

Glomerular visceral epithelial cells, namely podocytes, are highly specialized cells and give rise to primary processes, secondary processes, and finally foot processes. The foot processes of neighboring podocytes interdigitate, leaving between them filtration slits. These are bridged by an extracellular substance, known as the slit diaphragm, which plays a major role in establishing size-selective barrier to protein loss. Furthermore, podocytes are known to synthesize matrix molecules to the glomerular basement membrane (GBM), including type IV collagen, laminin, entactin, and agrin. Because diabetic nephropathy is clinically characterized by proteinuria and pathologically by glomerular hypertrophy and GBM thickening with foot process effacement, podocytes have been the focus in the field of research on diabetic nephropathy. As a result, many investigations have demonstrated that the diabetic milieu per se, hemodynamic changes, and local growth factors such as transforming growth factor-beta and angiotensin II, which are considered mediators in the pathogenesis of diabetic nephropathy, induce directly and/or indirectly hypertrophy, apoptosis, and structural changes, and increase type IV collagen synthesis in podocytes. This review explores some of the structural and functional changes of podocytes under diabetic conditions and their role in the development and progression of diabetic nephropathy.

Activation of the renin-angiotensin system within podocytes in diabetes

The autocrine and paracrine activation of the renin-angiotensin system (RAS) within cells of the kidney plays a role in the overall pathophysiology of the renal disease due to diabetes. In this study, we focus on components of the RAS in the podocyte as these cells are important in the pathogenesis of glomerulosclerosis and proteinuria. Immortalized mouse podocytes were exposed to media containing normal glucose (NG) or high glucose (HG) for in vitro studies. In vivo studies utilized kidney tissue obtained from rats treated for 3 months with streptozotocin to induce diabetes. Angiotensinogen (AGT) and the angiotensin II (AII) type 1 receptor mRNA and protein were significantly increased in the podocytes cultured under the high glucose conditions. Both angiotensins I and II levels were significantly higher in cell lysates and the conditioned media of cells grown in high glucose. There were no differences in renin activity, angiotensin-converting enzyme level, or AII type 2 receptor level. Glomerular AGT and AII type 1 receptor assessed by means of immunohistochemistry were increased in diabetic rats compared with the control rats. Other measured components of the RAS within the glomeruli were not different. We suggest that increased AGT, an attendant increase in AII and increased AII type 1 receptor in podocytes experiencing diabetic conditions play an important role in the pathogenesis of diabetic nephropathy.

New insight of amino acid-based dialysis solutions

Malnutrition is a major complication of peritoneal dialysis (PD) and is associated with increased morbidity and mortality. Daily losses of proteins and amino acids (AAs) into dialysate contribute to this problem. Previous metabolic balance study demonstrated that treatment with 1.1% AA-based dialysis solution is safe and may improve protein malnutrition in continuous ambulatory peritoneal dialysis (CAPD) patients ingesting low protein intake. Other prospective studies also showed that AA solution can provide nutritional benefit for malnourished PD patients resulting in a significant improvement in some biochemical and/or anthropometric nutritional parameters. However, there are other studies showing no particular improvement in nutritional parameters after long-term use of AA solution. This may be related to the differences in the study design, sample size, methods used to assess nutritional status, and other factors such as dietary intake and comorbidities of study subjects. Published data will be reviewed to further emphasize the nutritional benefit of long-term use of AA solution in malnourished PD patients along with a brief discussion on the various reasons that may partly explain the different study results. We will also present the results of a longitudinal observational study evaluating changes in nutritional parameters following use of one exchange of 1.1% AA solution in malnourished Korean PD patients. A significant improvement of somatic protein status such as lean body mass (LBM) and hand grip strength was observed. No significant change in serum albumin level was noted. Patients with a positive estimated coefficient for LBM in the fitted regression model to the repeated observations over 1 year were classified as responders and patients with neutral or negative coefficient were considered as non-responders. Thirty-one out of 43 malnourished patients (72%) showed nutritional benefit based on the change of LBM. Hand grip strength and back lift strength were significantly higher in responders at baseline. Other baseline parameters did not differ between the two groups.

Association of obesity, serum glucose and lipids with the risk of advanced colorectal adenoma and cancer: a case-control study in Korea

BACKGROUND

Previous studies on colorectal cancer risk suggest that obesity, serum lipids and glucose might be related to colorectal carcinogenesis. This case-control study was conducted to investigate the association between obesity, serum lipids and glucose, and the risk of advanced colorectal adenoma and cancer.

METHODS

Patients with histologically confirmed colorectal cancers (n=105), same number of patients with advanced colorectal adenomas matched by age and sex, and the same number of controls matched by age and sex were selected in Hanyang University Guri Hospital between January 2002 and June 2004.

RESULTS

Adenoma and cancer group showed significantly higher levels of mean body mass index and serum glucose. Cancer group also showed significantly lower mean serum lipids levels than controls. We used an unordered polytomous logistic model to calculate multivariate odds ratios for advanced adenoma and cancer relative to controls. Higher serum glucose level was more strongly associated with increased risk of cancer relative to controls (odds ratio, 3.0; 95% confidence interval, 0.9-9.8) than with increased risk of advanced adenoma (odds ratio, 2.1; 95% confidence interval, 0.9-5.4). Higher body mass index was strongly associated with increased risk of advanced adenoma (odds ratio, 10.8; 95% confidence interval, 4.6-25.3), but associated with attenuated risk of cancer (odds ratio, 2.3; 95% confidence interval, 0.9-5.8). Serum triglycerides and cholesterol levels were strongly associated with reduced risk of cancer (odds ratio, 0.3; 95% confidence interval, 0.1-0.8 and odds ratio, 0.2; 95% confidence interval, 0.1-0.6, respectively).

CONCLUSIONS

Obesity and hyperglycaemia are positively related to advanced colorectal adenoma formation. Furthermore, hyperglycaemia plays an important role in progression to cancer. Findings on an inverse relationship between serum triglyceride and cholesterol levels and the risk of colorectal cancer may be the secondary results from metabolic or nutritional changes in advanced colorectal cancer patients and should be clarified in further studies.

Huge gastric diospyrobezoars successfully treated by oral intake and endoscopic injection of Coca-Cola

A diospyrobezoar is a type of phytobezoar that is considered to be harder than any other types of phytobezoars. Here, we describe a new treatment modality, which effectively and easily disrupted huge gastric diospyrobezoars. A 41-year-old man with a history of diabetes mellitus was admitted with lower abdominal pain and vomiting. Upper gastrointestinal endoscopy revealed three huge, round diospyrobezoars in the stomach. He was made to drink two cans of Coca-Cola every 6 h. At endoscopy the next day, the bezoars were partially dissolved and turned to be softened. We performed direct endoscopic injection of Coca-Cola into each bezoar. At repeated endoscopy the next day, the bezoars were completely dissolved.

Diagnostic yield of advanced colorectal neoplasia at colonoscopy, according to indications: an investigation from the Korean Association for the Study of Intestinal Diseases (KASID)

BACKGROUND AND STUDY AIMS

The factors that more accurately predict the detection of colorectal cancers and adenomas at colonoscopy are different. We conducted a prospective multicenter study to evaluate which indications were most closely associated with advanced colorectal neoplasm (CRN), including colorectal cancer, in a group of patients undergoing colonoscopy.

PATIENTS AND METHODS

The 17 468 patients were enrolled in this study between July 2003 and March 2004, from 11 tertiary medical centers in Korea. They were recruited according to 11 itemized colonoscopic indications. The term "advanced adenoma" refers here to tubular adenomas of diameter of 11 mm or more, or to tubulovillous, villous, or severely dysplastic adenomas, irrespective of their size. Cancer was defined as the invasion of malignant cells beyond the muscularis mucosa. Advanced CRN was defined as advanced adenoma or invasive cancer.

RESULTS

Advanced CRN was found in 1227/17 307 patients (1176 advanced adenomas plus 51 carcinomas, 7.1 %). According to univariate and multivariate analysis, the factors associated with advanced CRN included age >60 years (odds ratio (OR) 2.1, 95 % confidence interval (CI) 1.8 - 2.4, P < 0.0001), male gender (OR 2.1, 95 %CI 1.7 - 2.7, P < 0.0001), referral for colonoscopy from primary care physician (OR 3.1, 95 %CI 2.5 - 3.7, P < 0.0001), and several other indications (OR 1.8, 95 %CI 1.5 - 2.3, P < 0.001). The yield of colonoscopy for advanced CRN was lower (2.2 %) than expected in patients with iron-deficiency anemia (OR 0.5, 95 %CI 0.2 - 0.9, P = 0.03).

CONCLUSIONS

Age, gender, and referral for colonoscopy from primary care physician constituted important independent predictors of advanced CRN in patients undergoing colonoscopy.

Omental torsion: CT features

A 33-year-old male presented to the emergency department complaining of right upper quadrant pain and was initially diagnosed with acute cholecystitis. Abdominal computed tomography showed a whirling pattern of fatty streaks and vessels within the greater omentum, and surgery confirmed infarction of the omentum secondary to torsion. We report a case of surgically and pathologically proven omental torsion that demonstrated the typical whirling appearance on computed tomography.

Clinical outcome in continuous ambulatory peritoneal dialysis patients is not influenced by high peritoneal transport status

OBJECTIVES

We undertook this study to examine the influence of demographics, peritoneal membrane transport characteristics, nutrition indices, dialysis adequacy, and comorbid diseases on patient survival on continuous ambulatory peritoneal dialysis (CAPD), and to identify whether high peritoneal membrane transport is an independent risk factor for mortality on CAPD.

DESIGN

Our retrospective study was carried out in CAPD patients in a large tertiary care teaching hospital.

METHODS

Until December 2000, we followed 212 patients who started CAPD between 1994 and 1997 and who underwent a peritoneal equilibration test (PET) within 3 months of CAPD initiation.

RESULTS

By univariate analysis, comorbid diseases, old age, high peritoneal transport, and serum albumin predicted patient mortality. Independent predictors of mortality as determined by the Cox proportional hazard model included diabetes mellitus, cardiovascular disease, serum albumin, and old age. High peritoneal transport failed to independently influence mortality in our CAPD patients.

Novel findings in inhibition of mast cell-dependent immediate-type cutaneous reactions by Gahmi-Shini-San

This report describes an inhibitory effect of Gahmi-Shini-San (GSS) on mast cell-mediated immediate-type allergic reactions. GSS is an Oriental herbal medication, which has been successfully used in Korea for the treatment of allergic disorders, mainly skin anaphylactic diseases. GSS inhibited the ear swelling response induced by intradermal injection of compound 48/80 in a mouse model on a concentration-dependent basis. The mast cells in mouse ear tissue were stained by alcian blue/nuclear fast red. GSS significantly inhibited the compound 48/80-induced degranulation from mast cells in ear tissue. GSS dose-dependently inhibited the histamine release from the rat peritoneal mast cells by compound 48/80. We also studied the effect of GSS on mast cell-dependent passive cutaneous anaphylaxis activated by dinitrophenyl IgE antibody. GSS showed inhibition of passive cutaneous anaphylaxis following oral administration. These results indicated that GSS has inhibitory effect on mast cell-dependent immediate type cutaneous reactions.

Long-term outcome of kidney transplantation in adult recipients with focal segmental glomerulosclerosis

Focal segmental glomerulosclerosis (FSGS) is an important cause of nephrotic syndrome and end-stage renal disease. FSGS recurrence after renal transplantation has a potentially detrimental course leading to the loss of renal function. In order to establish FSGS recurrence rates and evaluate the course of the disease on living-related-donor renal transplantation in ethnic Korean adults (> or = 18 years), we reviewed our experiences of 27 kidney transplantations with FSGS over the last 15 years. Of the 27 renal allografts, 13 were found to have recurrent FSGS by graft biopsy. In comparison with background data upon patients with and without recurrence of FSGS, the donor age of patients with recurrent FSGS was significantly higher than that of those without recurrence (median, 39 years vs 26, p < 0.05). In terms of, age at transplantation, length of dialysis period, and mode of dialysis no differences were found between recurrent and nonrecurrent cases. The graft survival rate of recipients from a kidney donor of age less than 40 years was significantly higher than that of recipients from a kidney donor of age more than 40 years, at 5 and 10 years, respectively (87% vs 33%, 41% vs 0%, p < 0.05). The association between clinical variables and recurrence was assessed by multiple logistic regression analysis, and donor age was found to be a risk factor of FSGS recurrence (p<0.05). Variables such as HLA-mismatch numbers and immunosuppression were not found to be associated. In conclusion, the recurrence rate of FSGS in adult recipients with FSGS was 48% and patients that received kidney from an older donor appear to be at higher risk of developing recurrence. The use of a renal graft from a younger donor is considered advisable for adult recipients with FSGS.

An analysis of 4,514 cases of renal biopsy in Korea

To evaluate the distribution and changing patterns of renal diseases in Korea, a total of 4,514 cases of renal biopsy collected over a 23-year period between 1973 and 1995 were reviewed. Of 4,200 cases excluding 314 unsatisfactory biopsies, adult cases comprised 59.5% and pediatric cases, 40.5%. The male to female ratio was 1.5:1 in adults and 2.2:1 in children. Glomerulonephritis (GN) comprised 80.0% of the total. The most common primary GN in adults was minimal change disease (MCD) (26.6%), followed by IgA nephropathy (IgAN) (22.1%), membranous GN (MGN) (11.8%), and membranoproliferative GN (MPGN) (5.9%). In children, the primary GN incidence rates were MCD (24.8%), IgAN (10.3%), poststreptococcal (including postinfectious) GN (PSGN) (8.6%), and focal segmental glomerulosclerosis (FSGS) (4.0%). The most common secondary GN in adults was lupus nephritis and in children Henoch-Schonlein purpura nephritis. The most common cause of nephrotic syndrome was MCD in both adults and children, followed by MGN and FSGS. The elderly, aged sixty years and older, comprised 2.7% of cases and recorded equal numbers of MCD and MGN. The proportion of the biopsies found to be seropositive for HBs antigen was 27.9%, and these showed either MGN or MPGN pattern. Repeat biopsy was performed in 168 patients, due to previous biopsy failure in 15.5%. When the primary GN cases were analyzed at 5-year intervals, the prevalence of PSGN, which was greater than 25% during the 1973-1982 period, decreased abruptly in children thereafter, whereas the prevalence of FSGS increased slowly since the 1988-1992 period in both adults and children. The decrease of PSGN and the increase of FSGS suggest a role for socioeconomic and environmental factors in Korea.