Esophagogastrostomy Versus Double Tract Reconstruction for Laparoscopic Proximal Gastrectomy: Short-term Outcomes Based on Nutritional Parameters and Skeletal Muscle Index

BACKGROUND/AIM

The optimal reconstruction method for laparoscopic proximal gastrectomy (LPG) remains controversial. The present study aimed to compare short-term outcomes, including assessment of nutritional parameters and skeletal muscle, between two different methods, double-tract reconstruction (DTR) versus esophagogastrostomy (EG).

PATIENTS AND METHODS

Data from patients who underwent LPG for gastric tumor(s) between 2018 and 2021, were retrospectively analyzed. Patients were divided into two group: DTR (n=11) and EG (n=17). Since 2020, the authors have applied the modified side overlap with fundoplication by Yamashita (mSOFY) method as the EG technique.

RESULTS

Compared with DTR, EG was associated with a shorter reconstruction time (p=0.003). Complications of grade ≥3 occurred only in the EG group [n=4 (23.5%)] and the incidence of abnormal endoscopic findings after surgery was numerically higher in the EG group (n=2 vs. n=9; p=0.047). Across virtually all data points on the line graph, the EG group exhibited greater changes in post-discharge nutritional parameters, with Skeletal Muscle Index also demonstrating significant superiority (0.83 vs. 0.89; p=0.045).

CONCLUSION

Among reconstruction methods for LPG, EG demonstrated superiority over DTR in preserving nutritional parameters and skeletal muscle mass. However, further research, including larger cohorts and longer-term follow-up, is necessary to validate this finding.

Survival impact of post-operative immunotherapy in resected stage III cutaneous melanomas in the checkpoint era

BACKGROUND

Checkpoint inhibitors have shown improvement in recurrence-free survival in the post-operative setting for node-positive melanoma and were first approved in late 2015. However, single-agent checkpoint therapies have yet to show benefit to overall survival (OS) for lower-risk stage III cancers. We evaluated the OS benefit of post-operative immunotherapy in the National Cancer Database (NCDB).

PATIENTS AND METHODS

Patient cases were selected from the NCDB 2020 Participant Use File. Patients diagnosed with stage III cutaneous melanoma between 2016 and 2019 who underwent definitive resection for their melanoma were included. OS between those who received post-operative immunotherapy within 84 days of surgery and those who did not was analyzed by the Kaplan-Meier method. Demographic and clinical characteristics between the two groups were compared via Cox proportional hazard models.

RESULTS

14 978 patients with stage III melanoma were included. Of those, 34.9% (n = 5234) received post-operative immunotherapy and 65.1% (n = 9744) did not. Using the American Joint Committee on Cancer version 8 (AJCCv8) staging, 36-month survival was significantly higher in patients who received post-operative immunotherapy compared to no post-operative systemic therapy in those diagnosed with stage IIIB (88.0% versus 84.7%, P = 0.011), IIIC (75.6% versus 68.1%, P < 0.001), or IIID (59.2% versus 48.4%, P = 0.002). No significant improvement in 36-month survival was seen in patients who received post-operative immunotherapy in patients with stage IIIA disease (93.0% versus 92.2%, P = 0.218).

CONCLUSIONS

Post-operative immunotherapy had an OS benefit in patients with AJCCv8 stage IIIB, IIIC, and IIID disease, but had no significant survival benefit for patients with stage IIIA melanomas.

Clinical Impact of Laparoscopic Surgery on the Long-term Survival of Advanced Gastric Cancer Patients With Regard to Facilitating Doublet Adjuvant Chemotherapy

BACKGROUND/AIM

The impact of laparoscopic gastrectomy (LG), a standard gastric cancer (GC) management strategy, in advanced GC cases involving doublet adjuvant chemotherapy remains unclear. This study was aimed at comparing short- and long-term LG and open gastrectomy (OG) results.

PATIENTS AND METHODS

Patients who underwent gastrectomy with D2 lymph node dissection for stage II/III GC between 2013 and 2020 were retrospectively analyzed. Patients were divided into two groups: patients undergoing LG (n=96, LG-group) and OG (n=148, OG-group). The primary outcome was relapse-free survival (RFS).

RESULTS

Compared with the OG group, the LG group was associated with a longer operation time (373 vs. 314 min, p<0.001), less blood loss (50 vs. 448 ml, p<0.001), fewer grade 3-4 complications (5.2 vs. 17.1%, p=0.005), and a shorter hospital stay (12 vs. 15 days, p<0.001). More lymph nodes were dissected in the LG group (49 vs. 40, p<0.001). The intergroup difference in prognosis was insignificant [5-year RFS: 60.4% (LG) vs. 63.1% (OG), p=0.825]. The LG group more frequently received doublet adjuvant chemotherapy (46.8 vs. 12.7%, p<0.001) and started treatments within 6 weeks after surgery (71.1% vs. 38.9%, p=0.017), and the completion rate of doublet AC was significantly higher in the LG group (85.4% vs. 58.8%, p=0.027). Compared to OG, LG for stage III GC tended to be associated with improved prognosis (HR=0.61, 95%CI=0.33-1.09, p=0.096).

CONCLUSION

LG for advanced GC may facilitate doublet regimens due to favorable postoperative outcomes and its intervention may contribute to survival benefits.

Comparison of Minimally Invasive Surgery with Open Surgery for Remnant Gastric Cancer: A Multi-institutional Cohort Study

BACKGROUND

Despite growing evidence of the effectiveness of minimally invasive surgery (MIS) for primary gastric cancer, MIS for remnant gastric cancer (RGC) remains controversial due to the rarity of the disease. This study aimed to evaluate the surgical and oncological outcomes of MIS for radical resection of RGC.

PATIENTS AND METHODS

Patients with RGC who underwent surgery between 2005 and 2020 at 17 institutions were included, and a propensity score matching analysis was performed to compare the short- and long-term outcomes of MIS with open surgery.

RESULTS

A total of 327 patients were included in this study and 186 patients were analyzed after matching. The risk ratios for overall and severe complications were 0.76 [95% confidence interval (CI): 0.45, 1.27] and 0.65 (95% CI: 0.32, 1.29), respectively. The MIS group had significantly less blood loss [mean difference (MD), -409 mL; 95% CI: -538, -281] and a shorter hospital stay (MD, -6.5 days; 95% CI: -13.1, 0.1) than the open surgery group. The median follow-up duration of this cohort was 4.6 years, and the 3-year overall survival were 77.9% and 76.2% in the MIS and open surgery groups, respectively [hazard ratio (HR), 0.78; 95% CI: 0.45, 1.36]. The 3-year relapse-free survival were 71.9% and 62.2% in the MIS and open surgery groups, respectively (HR, 0.71; 95% CI: 0.44, 1.16).

CONCLUSIONS

MIS for RGC showed favorable short- and long-term outcomes compared to open surgery. MIS is a promising option for radical surgery for RGC.

Advantages of minimally invasive surgery for remnant gastric cancer: A multi-institutional cohort study

357

Background: Remnant gastric cancer (RGC) is defined as a cancer arising in the remnant stomach after initial gastrectomy, regardless of the previous disease or surgical procedure. Despite growing evidence of the effectiveness of minimally invasive surgery (MIS) for primary gastric cancer, MIS for RGC remains controversial due to the rarity of the disease. This study aimed to evaluate the surgical and oncological outcomes of MIS for radical resection of RGC. Methods: We collected the data of patients with RGC who underwent surgery with curative intent between 2005 and 2020 from 17 institutions in Japan, and performed a propensity score (PS) matching analysis to compare the short- and long-term outcomes of MIS with open surgery. Results: A total of 327 patients were included in this study and 186 patients were analyzed after matching. The risk ratios for overall and severe complications were 0.76 (95% confidence interval [CI]: 0.45–1.27) and 0.65 (95% CI: 0.32–1.29), respectively. The MIS group had significantly less blood loss (50 ml vs. 361 ml, P<0.001) and a shorter hospital stay (13 days vs. 16 days, P=0.009) than the open surgery group, while the operative time was longer in the MIS group (344 min vs. 273 min, P<0.001). The median follow-up duration of this cohort was 4.6 years, and the 3-year overall survival rates were 77.9% in the MIS group and 76.2% in the open surgery group (hazard ratio [HR], 0.78; 95% CI: 0.45–1.36). The 3-year relapse-free survival rates were 71.9% in the MIS group and 62.2% in the open surgery group (HR, 0.71; 95% CI: 0.44–1.16). Locoregional recurrence occurred in three patients (3.2%) in the MIS group and four patients (4.3%) in the open surgery group. There were also no differences in the other patterns of recurrence between the groups. Conclusions: MIS for RGC showed favorable short- and long-term outcomes compared to open surgery. MIS is a promising option for radical surgery for RGC.

Derivation and validation of a machine learning-based risk prediction model for in-hospital mortality in patients with acute heart failure

Background

Although risk stratification is important in patients with acute heart failure (AHF) to predict patient prognosis, pre-existing risk models have not often been used due to its complexity. Recently, machine learning methods have been presented as an alternative approach to analyzing the predictive probability of large clinical datasets.

Purpose

The aim of this study is to develop a user-friendly risk score developed by one of machine learning methods and compare the performance of the new risk score to the existing conventional risk models.

Methods

A machine-learning-based risk model was developed using least absolute shrinkage and selection operator (LASSO) regression by identifying predictors of in-hospital mortality in the derivation cohort (REALITY-AHF) and externally validating and comparing its performance with two pre-existing risk models: the Get With The Guidelines risk score incorporating brain natriuretic peptide and hypochloremia (GWTG-BNP-Cl-RS) and the acute decompensated heart failure national registry (ADHERE) risk model.

Results

In-hospital deaths in the derivation and validation (NARA-HF) cohorts were 76 (5.1%) and 61 (4.9%), respectively. The risk score comprised four variables (systolic blood pressure, blood urea nitrogen, serum chloride, and C-reactive protein) and was developed according to the results of the LASSO regression weighting the coefficient for selected variables using a logistic regression model (4V-RS). Even though 4V-RS comprised fewer variables, In the validation cohort, it showed a higher area under the receiver operating characteristic curve (AUC) than the ADHERE risk model (AUC, 0.783 vs. 0.740; P=0.059) and a significant improvement in net reclassification (0.359; 95% CI, 0.10–0.67; p=0.006). 4V-RS performed similarly to GWTG-BNP-Cl-RS in terms of discrimination (AUC, 0.783 vs. 0.759; p=0.426) and net reclassification (0.176; 95% CI, −0.08–0.43; p=0.178).

Conclusions

The 4V-RS model comprising only four readily available data points at the time of admission performed similarly to the more complex pre-existing risk model in patients with AHF.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Cardiovascular Research Fund

Redo pancreaticojejunal anastomosis for late-onset complete pancreaticocutaneous fistula after pancreaticojejunostomy

BACKGROUND

Pancreaticojejunal (PJ) anastomosis occasionally fails several months after pancreaticoduodenectomy (PD) with Child reconstruction and can ultimately result in a late-onset complete pancreaticocutaneous fistula (Lc-PF). Since the remnant pancreas is an isolated segment, surgical intervention is necessary to create internal drainage for the pancreatic juice; however, surgery at the previous PJ anastomosis site is technically challenging even for experienced surgeons. Here we describe a simple surgical procedure for Lc-PF, termed redo PJ anastomosis, which was developed at our facility.  METHODS: Between January 2008 and December 2020, six consecutive patients with Lc-PF after PD underwent a redo PJ anastomosis, and the short- and long-term clinical outcomes have been evaluated. The abdominal cavity is carefully dissected through a 10-cm midline skin incision, and the PJ anastomosis site is identified using a percutaneous drain through the fistula tract as a guide, along with the main pancreatic duct (MPD) stump on the pancreatic stump. Next, the pancreatic stump is deliberately immobilized from the dorsal plane to prevent injury to the underlying major vessels. After fixing a stent tube to both the MPD and the Roux-limb using two-sided purse-string sutures, the redo PJ anastomosis is completed using single-layer interrupted sutures. Full-thickness pancreatic sutures are deliberately avoided by passing the needle through only two-thirds of the anterior side of the pancreatic stump.

RESULTS

The redo PJ anastomosis was performed without any intraoperative complications in all cases. The median intraoperative bleeding and operative time were 71 (range 10-137) mL and 123 (range 56-175) min, respectively. Even though a new mild pancreatic fistula developed postoperatively in all cases, it could be conservatively treated within 3 weeks, and no other postoperative complications were recorded. During the median follow-up period of 92 (range 12-112) months, no complications at the redo PJ anastomosis site were observed.

CONCLUSIONS

This research shows that the redo PJ anastomosis for Lc-PF we developed is a safe, feasible, and technically no demanding procedure with acceptable short- and long-term clinical outcomes. This procedure has the potential to become the preferred treatment strategy for Lc-PF after PD.

O-183 Frequent spontaneous abortion in pregnancies followed by ICSI using frozen sperm from patients with testicular germ cell tumor (TGCT)

Study question

Despite the high rate of sperm chromosome abnormalities in testicular germ cell tumor (TGCT), why is newborn aneuploidy rate in pregnancies with TGCT patient normal?

Summary answer

Miscarriage rate is higher in the pregnancy of TGCT patients than of non-TGCT cancer patients, although the pregnancy rate in ICSI was not significantly different.

What is known already

Previous reports showed higher sperm aneuploidy in TGCT patients than control males. The sperm aneuploidy rate is high before treatment, and after radical treatments peaked at 6 months after treatment and remained high until 24 months after treatment. However, in the Swedish government base study, the rate of newborn malformations including aneuploidy in all pregnancy with TGCT patients was higher than without TGCT, but not statistically significant. In only natural pregnancies, the rate was not significantly different between the two groups. The cause for discrepancy within sperm aneuploidy and newborn aneuploidy was not well clarified.

Study design, size, duration

To clarify the mechanism for the purifying selection of aneuploid sperm in conception, we examined ICSI cases with TGCT patients that did not include natural sperm competition and compared to controls with non-TGCT cancer patient, who have normal rate of aneuploid sperm. By investigating ICSI outcomes, we aimed to determine which stage of embryonic development are affected by the sperm of TGCT patients.

Participants/materials, setting, methods

Under ethical review of Yokohama city university, the 10 TGCT patients (123 oocytes) and 16 non-TGCT cancer patients (251 oocytes) who underwent ICSI with their frozen sperm from 2012 to 2021 were enrolled. Fertilization, embryo viability and embryo transfer outcomes (pregnancy and miscarriage rate) were examined between two groups underwent ICSI with cryopreserved sperm for fertility preservation. Clinical information was retrospectively collected from medical records.

Main results and the role of chance

The patients' age of sperm cryopreservation was 21-56 years old. 10 cases of TGCT were diagnosed as seminoma (3), non seminoma (6), and unknown (2). 15 cases of non-TGCT were diagnosed as malignant blood diseases (9), prostate cancer (2), bladder cancer (1), and others (3). In both groups, all patients were treated by ICSI with cryopreserved sperm obtained prior to chemotherapy. The mean age of female partners in TGCT was 33.2±3.5 years and not different with 35.8±3.4 years in non-TGCT meaning no different age factor. The fertilization rate, viable embryo rate, pregnancy rate and chemical abortion rate of TGCT vs non-TGCT group were 76.4% vs 67.7%, 64.3% vs 61.7%, 37.1% vs 21.7%, 7.1% vs 23.1%, respectively. Those developmental evaluations were not significantly different between two groups. However, spontaneous abortion rate was significantly higher 46.2% in TGCT group than 10% in non-TGCT group (p &lt; 0.05). Further, in our follow-up, no congenital malformations in the babies born in either group (5 babies in TGCT vs 7 babies in non-TGCT group). The outcome of ICSI using sperm in TGCT patients show normal pregnancy rate but include higher spontaneous abortions rate, suggesting aneuploid embryo were negatively purifying selected under post-implantation stage.

Limitations, reasons for caution

Because ICSI with fertility-preserving frozen sperm in TGCT patient is rare even in reproduction center in general university hospital, single center analysis is still small and limited. More case reports and studies for TGCT fertility preservation are needed for more accurate evaluation.

Wider implications of the findings

In TGCT patients, chromosome aberrations and DNA fragmentation of sperm may not be apparent in natural pregnancies with normal sperm competition, but may become apparent as spontaneous abortions when ICSI were performed, suggesting PGT-A can predict and avoid the hidden risk of repeated pregnancy loss in ICSI to TGCT patients.

Trial registration number

not applicable

OP0112 THE EVER-LARGEST ASIAN GWAS FOR SYSTEMIC SCLEROSIS AND TRANS-POPULATION META-ANALYSIS IDENTIFIED SEVEN NOVEL LOCI AND A CANDIDATE CAUSAL SNP IN A CIS-REGULATORY ELEMENT OF THE FCGR REGION

Background

Genome-wide association studies (GWASs) have identified 29 disease-associated single nucleotide polymorphisms (SNPs) for systemic sclerosis (SSc) in non-human leukocyte antigen (HLA) regions (1-7). While these GWASs have clarified genetic architectures of SSc, study subjects were mainly Caucasians limiting application of the findings to Asians.

Objectives

The study was conducted to identify novel causal variants for SSc specific to Japanese subjects as well as those shared with European population. We also aimed to clarify mechanistic effects of the variants on pathogenesis of SSc.

Methods

A total of 114,108 subjects comprising 1,499 cases and 112,609 controls were enrolled in the two-staged study leading to the ever-largest Asian GWAS for SSc. After applying a strict quality control both for genotype and samples, imputation was conducted using the reference panel of the phase 3v5 1,000 genome project data combined with a high-depth whole-genome sequence data of 3,256 Japanese subjects. We conducted logistic regression analyses and also combined the Japanese GWAS results with those of Europeans (6) by an inverse-variance fixed-effect model. Polygenicity and enrichment of functional annotations were evaluated by linkage disequilibrium score regression (LDSC), Haploreg and IMPACT programs. We also constructed polygenic risk score (PRS) to predict SSc development.

Results

We identified three (FCRLA-FCGR, TNFAIP3, PLD4) and four (EOMES, ESR1, SLC12A5, TPI1P2) novel loci in Japanese GWAS and a trans-population meta-analysis, respectively. One of Japanese novel risk SNPs, rs6697139, located within FCGR gene clusters had a strong effect size (OR 2.05, P=4.9×10-11). We also found the complete LD variant, rs10917688, was positioned in cis-regulatory element and binding motif for an immunomodulatory transcription factor IRF8 in B cells, another genome-wide significant locus in our trans-ethnic meta-analysis and the previous European GWAS. Notably, the association of risk allele of rs10917688 was significant only in the presence of the risk allele of the IRF8. Intriguingly, rs10917688 was annotated as one enhancer-related histone marks, H3K4me1, in B cells, implying that FCGR gene(s) in B cells may play an important role in the pathogenesis of SSc. Furhtermore, significant heritability enrichment of active histone marks and a transcription factor C-Myc were found in B cells both in European and Japanese populations by LDSC and IMPACT, highlighting a possibility of a shared disease mechanism where abnormal B-cell activation may be one of the key drivers for the disease development. Finally, PRS using effects sizes of European GWAS moderately fit in the development of Japanese SSc (AUC 0.593), paving a path to personalized medicine for SSc.

Conclusion

Our study identified seven novel susceptibility loci in SSc. Downstream analyses highlighted a novel disease mechanism of SSc where an interactive role of FCGR gene(s) and IRF8 may accelerate the disease development and B cells may play a key role on the pathogenesis of SSc.

References

[1]F. C. Arnett et al. Ann Rheum Dis, 2010.

[2]T. R. Radstake et al. Nat Genet, 2010.

[3]Y. Allanore et al. PLoS Genet, 2011.

[4]O. Gorlova et al. PLoS Genet, 2011.

[5]C. Terao et al. Ann Rheum Dis, 2017.

[6]E. López-Isac et al. Nat Commun, 2019.

[7]W. Pu et al. J Invest Dermatol, 2021.

Disclosure of Interests

None declared

Mesenteric closure after laparoscopic total gastrectomy with Roux-en-Y reconstruction is effective for prevention of internal hernia: a multicenter retrospective study

BACKGROUND

Internal hernia (IH) is one of the critical complications after gastrectomy with Roux-en-Y reconstruction, which can be prevented by closing mesenteric defects. However, only few studies have investigated the incidence of IH after laparoscopic total gastrectomy (LTG) with Roux-en-Y reconstruction for gastric cancer till date. This study aimed to assess the efficacy of defect closure for the prevention of IH after LTG.

METHODS

This multicenter, retrospective cohort study collected data from 714 gastric cancer patients who underwent LTG with Rou-en-Y reconstruction between 2010 and 2016 in 13 hospitals. We evaluated the incidence of postoperative IH by comparing closure and non-closure groups of Petersen's defect, jejunojejunostomy mesenteric defect, and transverse mesenteric defect.

RESULTS

The closure group for Petersen's defect included 609 cases, while the non-closure group included 105 cases. The incidence of postoperative IH in the closure group for Petersen's defect was significantly lower than it was in the non-closure group (0.5% vs. 4.8%, p < 0.001). The closure group for jejunojejunostomy mesenteric defect included 641 cases, while the non-closure group included 73 cases. The incidence of postoperative IH in the closure group of jejunojejunostomy mesenteric defect was significantly lower than that in the non-closure group (0.8% vs. 4.1%, p = 0.004). Out of 714 patients, 41 underwent retro-colic reconstruction. No patients in the transverse mesenteric defect group developed IH.

CONCLUSION

Mesenteric defect closure after LTG with Roux-en-Y reconstruction may reduce postoperative IH incidence. Endoscopic surgeons should take great care to prevent IH by closing mesenteric defects.

Association between Malnutrition Severity and Swallowing Function in Convalescent Rehabilitation Wards: A Multi-Center Cohort Study in Malnourished Patients with Sarcopenic Dysphagia

OBJECTIVES

To evaluate the characteristics of sarcopenic dysphagia (SD) and the prognosis of swallowing function in convalescent rehabilitation hospital patients; and to investigate the association between malnutrition severity and SD.

DESIGN

A prospective, multi-center, cohort study.

SETTING

We extracted registry data from the Japanese Sarcopenic Dysphagia Database, focusing on patients admitted to convalescent rehabilitation hospitals.

PARTICIPANTS

A total of 207 participants were recruited and stratified according to the presence or absence of SD. Next, the participants were divided into groups based on nutrition status using the Global Leadership Initiative on Malnutrition criteria: normal nutrition, moderate malnutrition, and severe malnutrition. We also compared the outcomes between patients with SD (SD group) and those without SD (no-SD group) according to malnutrition status.

MEASUREMENTS

The Food Intake LEVEL Scale (FILS) score was the outcome measure. Higher scores on the FILS indicate better swallowing function. We compared the patient characteristics between the SD and non-SD groups among all patients and then according to the severity of malnutrition.

RESULTS

A total of 207 patients were recruited. 11 were diagnosed with normal nutrition, 72 with moderate malnutrition, and 124 with severe malnutrition. There were 128 participants with SD and 79 participants without SD; the prevalence of SD was 61.8%. Hip fracture was the most common disease among the SD patients (34.4%). The median time to the end of follow-up was 73.5 days for the SD group and 84.0 days for the no-SD group. There was no significant difference in the FILS score between the SD and no-SD groups, but the increase in the FILS score was significantly lower in the SD group than the no-SD group among patients with severe malnutrition after adjusting for confounding factors (age, sex, FILS at admission, BMI, cognitive functional independence measure, and care level before onset) (β = -0.206, p = 0.011, 95% confidence interval = -0.723, -0.098).

CONCLUSION

Orthopedic diseases are the most common type of disease among SD patients in convalescent rehabilitation hospitals. Swallowing dysfunction was particularly severe in malnourished patients with SD. This result suggests the importance of the definition of SD for malnourished patients. We should practice nutritional management as soon as possible in severely malnourished patients diagnosed with SD.

The feasibility of combined resection and subsequent reconstruction of the right hepatic artery in left hepatectomy for cholangiocarcinoma

BACKGROUND

Combined resection of the right hepatic artery (RHA) is sometimes required to achieve complete resection of hilar cholangiocarcinoma. The present study aimed to evaluate the feasibility of combined resection and subsequent reconstruction by continuous suture of the RHA during left hepatectomy for cholangiocarcinoma.

MATERIALS AND METHODS

We retrospectively compared the outcomes after left hepatectomy with biliary reconstruction for cholangiocarcinoma between patients with and without RHA resection and reconstruction.

RESULTS

Of the 25 patients who underwent left hepatectomy combined with biliary reconstruction, eight patients (32%) underwent combined resection and reconstruction of the RHA (AR group). The demographic characteristics were not different between the AR and non-AR groups. The amount of intraoperative bleeding was significantly greater in patients with AR (2350 mL vs. 900 mL, p = 0.017). The prevalence of early complications above grade III in Clavien-Dindo classification and late complications were not significantly different between the AR and non-AR groups. In the AR group, complications directly associated with AR, such as thrombosis or reanastomosis, were not observed. On Kaplan-Meier analysis, recurrence-free survival (p = 0.618) and overall survival (p = 0.803) were comparable between the two groups despite the advanced T stages in the AR group.

CONCLUSIONS

Combined resection and subsequent reconstruction of the RHA during left-sided hepatectomy is a feasible treatment alternative for cholangiocarcinoma.

Role of right ventricular free wall longitudinal strain in prediction outcome in patients with cardiac sarcoidosis

Introduction

Right ventricular free wall longitudinal strain (RVFWLS) is a sensitive tool for right ventricular (RV) function assessment. Furthermore, it shows incremental prognostic role in various cardiac diseases. RV involvement is frequently observed along with left ventricular (LV) involvement in cardiac sarcoidosis (CS) patients, while its impact on outcome is unclear.

Purpose

The aim of this study is to investigate the association between RV dysfunction detected by RVFWLS and cardiovascular event in patients with CS.

Methods

We retrospectively evaluated 51 patients with CS who were treated with prednisone from 2012 through 2020. Diagnosis of CS was made according to the Japanese Circulation Society diagnostic criteria. We evaluated RVFWLS at baseline using vender-independent software. We considered major adverse cardiovascular event (MACE: ventricular arrhythmia, heart failure hospitalization) to be the primary outcome.

Results

Mean age of the study population was 63±11 years, and 61% were female. At baseline, 25 patients (49%) had reduced left ventricular (LV) ejection fraction (EF) (&lt;50%) and 18 patients (35%) had impaired RVFWLS (&lt;17%). Patients with impaired RVFWLS showed lower LVEF% (42±12% vs. 53±13%, P=0.005) and larger LV end-systolic volume index (54±33 vs. 37±23ml/m2, P=0.04) compared with those with preserved RVFWLS. Impaired RVFWLS patients also showed trend towards higher prevalence of basal interventricular thinning (50 vs. 28%, P=0.12). During a median follow-up of 548 days, eleven patients had MACE. In multivariable Cox-proportional hazards model analysis, RVFWLS was independently associated with MACE (HR 1.28, 95% CI: 1.07–1.10, P=0.009). Kaplan-Meier survival curves showed worse event-free survival in patients with impaired RVFWLS (log-rank test, P=0.001).

Conclusions

In patients with CS, RVFWLS is an independent predictor for MACE. RVFWLS may be valuable in improving risk stratification in CS.

Funding Acknowledgement

Type of funding sources: None. Kaplan-Meier survival curves

Percutaneous fetoscopic spina bifida repair: effect on ambulation and need for postnatal cerebrospinal fluid diversion and bladder catheterization

OBJECTIVE

A trial comparing prenatal with postnatal open spina bifida (OSB) repair established that prenatal surgery was associated with better postnatal outcome. However, in the trial, fetal surgery was carried out through hysterotomy. Minimally invasive approaches are being developed to mitigate the risks of open maternal-fetal surgery. The objective of this study was to investigate the impact of a novel neurosurgical technique for percutaneous fetoscopic repair of fetal OSB, the skin-over-biocellulose for antenatal fetoscopic repair (SAFER) technique, on long-term postnatal outcome.

METHODS

This study examined descriptive data for all patients undergoing fetoscopic OSB repair who had available 12- and 30-month follow-up data for assessment of need for cerebrospinal fluid (CSF) diversion and need for bladder catheterization and ambulation, respectively, from eight centers that perform prenatal OSB repair via percutaneous fetoscopy using a biocellulose patch between the neural placode and skin/myofascial flap, without suture of the dura mater (SAFER technique). Univariate and multivariate logistic regression analyses were used to examine the effect of different factors on need for CSF diversion at 12 months and ambulation and need for bladder catheterization at 30 months. Potential cofactors included gestational age at fetal surgery and delivery, preoperative ultrasound findings of anatomical level of the lesion, cerebral lateral ventricular diameter, lesion type and presence of bilateral talipes, as well as postnatal findings of CSF leakage at birth, motor level, presence of bilateral talipes and reversal of hindbrain herniation.

RESULTS

A total of 170 consecutive patients with fetal OSB were treated prenatally using the SAFER technique. Among these, 103 babies had follow-up at 12 months of age and 59 had follow-up at 30 months of age. At 12 months of age, 53.4% (55/103) of babies did not require ventriculoperitoneal shunt or third ventriculostomy. At 30 months of age, 54.2% (32/59) of children were ambulating independently and 61.0% (36/59) did not require chronic intermittent catheterization of the bladder. Multivariate logistic regression analysis demonstrated that significant prediction of need for CSF diversion was provided by lateral ventricular size and type of lesion (myeloschisis). Significant predictors of ambulatory status were prenatal bilateral talipes and anatomical and functional motor levels of the lesion. There were no significant predictors of need for bladder catheterization.

CONCLUSION

Children who underwent prenatal OSB repair via the percutaneous fetoscopic SAFER technique achieved long-term neurological outcomes similar to those reported in the literature after hysterotomy-assisted OSB repair. © 2021 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Multiple Gastric Carcinomas Associated with Epstein-Barr Virus and Helicobacter pylori: A Thought-Provoking Case

BACKGROUND Epstein-Barr virus (EBV) and Helicobacter pylori (HP) infections are associated with gastric carcinoma (GC). We present a thought-provoking case of multiple GCs associated with EBV and HP infections. CASE REPORT HP infection was incidentally detected in an asymptomatic 60-year-old man. Upper endoscopy revealed gastric "kissing" ulcers. The lesions were located in the body of the stomach and measured 25 and 27 mm, respectively. They were diagnosed on pathology as moderately differentiated tubular adenocarcinoma. Imaging revealed no enlarged lymph nodes or distant metastatic lesions. Distal gastrectomy with lymphadenectomy was performed and surgical cure was obtained. The multiple GCs were categorized on pathology as infß ly0 v0 pT1b(SM)UL1N0M0H0P0CY0 pStage IA according to the Japanese classification and as T1bN0M0 Stage IA according to the tumor, node, metastasis classification. Pathological examination revealed remarkable lymphocytic infiltration into the stroma, as shown by in situ hybridization of EBV. These lymphocytic infiltrations were observed only at the sites of GC. In the immunohistochemical examination, in situ hybridization of EBV was positive for EBV-encoded small ribonucleic acid. The patient's postoperative course was uneventful. Hence, an unexpected relationship between EBV infection and multiple GCs was suggested by pathology. Quantitative determination of EBV DNA in peripheral blood was normal postoperatively. Adjuvant chemotherapy was not recommended. HP eradication therapy was successful. The patient remained asymptomatic and developed no recurrence or metastasis for 3 years after surgery. CONCLUSIONS This thought-provoking case suggests that coinfection with EBV and HP increases GC occurrence.

Hemispheric Asymmetries in a Tactile Thought Task for Normal Subjects

14 normal subjects were given two tactile-recognition tasks. Subjects were asked to match the factually presented nonsense figures to the visual-recognition display on a Non-rotation task. On the Mental-rotation task subjects matched the tactile figures which were presented in various directions by means of mental rotation to the visual display. A greater superiority of the left hand on the Mental-rotation task was noted while on the Non-rotation task no differences between hands were shown. The right hemisphere may contribute more strongly to higher thought processes especially those which do not need verbal mediation.

Comparative Outcomes of Laparoscopic Gastrectomy and Open Gastrectomy for Scirrhous Gastric Cancer: A Multicenter Retrospective Cohort Study

Objective

A multicenter retrospective cohort study was performed to compare the outcomes of laparoscopic gastrectomy (LG) versus open gastrectomy (OG) for scirrhous gastric cancer (GC) as a unique subtype also known as type 4 gastric cancer or linitis plastica.

Background

Although data on the efficacy and safety of LG as an alternative to OG are emerging, the applicability of LG to scirrhous GC remains unclear.

Methods

Patients with clinical type 4 GC undergoing gastrectomy at 13 hospitals from 2005 to 2015 were retrospectively reviewed. As the primary endpoint, we compared overall survival (OS) between the LG and OG groups. To adjust for confounding factors, we used multivariate Cox regression analysis for the main analyses and propensity-score matching for sensitivity analysis. Short-term outcomes and recurrence-free survival were also compared.

Results

A total of 288 patients (LG, 62; OG, 226) were included in the main analysis. Postoperative complications occurred in 25.8% and 30.1%, respectively (P = 0.44). No significant difference in recurrence-free survival was observed (P = 0.72). The 5-year OS rates were 32.4% and 31.6% in the LG and OG groups, respectively (P = 0.60). The hazard ratio (LG/OG) for OS was 0.98 (95% confidence interval [CI], 0.65-1.43) in the multivariate regression analysis. In the sensitivity analyses after propensity-score matching, the hazard ratio for OS was 0.92 (95% CI, 0.58-1.45).

Conclusions

Considering the hazard ratios and 95% CIs for OS, LG for scirrhous GC was not associated with worse survival than that for OG.

Aggressive Resection of Malignant Paraaortic and Pelvic Tumors Accompanied by Arterial Reconstruction with Synthetic Arterial Graft

BACKGROUND Advanced malignancies in the lower abdomen easily invade the retroperitoneal and pelvic space and often metastasize to the paraaortic and pelvic lymph nodes (LNs), resulting in paraaortic and/or pelvic tumor (PPT). CASE REPORT A total of 7 cases of aggressive malignant PPT resection and orthotopic replacement of the abdominal aorta and/or iliac arteries with synthetic arterial graft (SAG) were experienced during 16 years. We present our experience with aggressive resection of malignant PPTs accompanied by arterial reconstruction with SAG in detail. The primary diseases included 2 cases endometrial cancer and 2 cases of rectal cancer, and 1 case each of ovarian carcinosarcoma, vaginal malignant melanoma, and sigmoid cancer. Surgical procedures are described in detail. Briefly, the abdominal aorta and iliac arteries were anastomosed to the SAG by continuous running suture using unabsorbent polypropylene. Five Y-shaped and 2 I-shaped SAGs were used. This en bloc resection actually provided safe surgical margins, and tumor exposures were not pathologically observed in the cut surfaces. Graphical and surgical curability were obtained in all cases in which aggressive malignant PPT resections were performed. The short-term postoperative course of our patients was uneventful. From a vascular perspective, the SAGs remained patent over the long term after surgery, and long-term oncologic outcomes were satisfactory. CONCLUSIONS To our knowledge, this case series is the first report of aggressive malignant PPT resection accompanied by arterial reconstruction with SAG. This procedure is safe and feasible, shows curative potential, and may play a role in multidisciplinary management of malignant PPTs.

Diffuse large B-cell lymphoma in the liver accompanied by primary biliary cholangitis: A rare and difficult-to-diagnose tumor with portal venous thrombosis

INTRODUCTION AND IMPORTANCE

The most common liver malignancies are hepatocellular carcinoma, intrahepatic cholangiocarcinoma, and metastatic tumors. Hepatocellular carcinoma and intrahepatic cholangiocarcinoma may invade the portal vein (PV). An association between diffuse large B-cell lymphoma (DLBCL) and primary biliary cholangitis (PBC) remains unclear. We herein report a thought-provoking case of a difficult-to-diagnose liver tumor with PV thrombosis in a PBC patient.

PRESENTATION OF CASE

A 66-year-old woman had PBC, systemic sclerosis, diabetes, and osteoporosis. A solitary liver tumor accompanied by macrovascular thrombosis in the PV was detected incidentally. Based on dynamic imaging findings, we considered the tumor to be intrahepatic cholangiocarcinoma, and right lobectomy with lymphadenectomy was performed. Unexpectedly, pathological assessment made a definitive diagnosis of DLBCL that did not invade the vessels and bile duct. In fluorine-18-fluorodeoxyglucose positron emission tomography, abnormal accumulations were clearly observed in the breast tissue and peritracheal, parasternal, mediastinal, and pericardial lymph nodes. The patient achieved complete remission after systemic chemotherapy, and there has been no recurrence 3 years after surgery.

CLINICAL DISCUSSION

Primary lymphoma in the liver is rare, and we did not consider our patient's tumor as primary liver lymphoma. Our case actually showed no tumor thrombosis in the PV. Although autoimmune disorders may increase the risk of non-Hodgkin's lymphoma, an association between DLBCL and PBC is still unclear, and we must remember that DLBCL may develop rarely in a PBC patient.

CONCLUSION

Our case report provides a timely reminder for clinicians and surgeons in the fields of hepatology and hematology.

Fatal arterial hemorrhage after pancreaticoduodenectomy: How do we simultaneously accomplish complete hemostasis and hepatic arterial flow?

BACKGROUND

Although arterial hemorrhage after pancreaticoduodenectomy (PD) is not frequent, it is fatal. Arterial hemorrhage is caused by pseudoaneurysm rupture, and the gastroduodenal artery stump and hepatic artery (HA) are frequent culprit vessels. Diagnostic procedures and imaging modalities are associated with certain difficulties. Simultaneous accomplishment of complete hemostasis and HA flow preservation is difficult after PD. Although complete hemostasis may be obtained by endovascular treatment (EVT) or surgery, liver infarction caused by hepatic ischemia and/or liver abscesses caused by biliary ischemia may occur. We herein discuss therapeutic options for fatal arterial hemorrhage after PD.

AIM

To present our data here along with a discussion of therapeutic strategies for fatal arterial hemorrhage after PD.

METHODS

We retrospectively investigated 16 patients who developed arterial hemorrhage after PD. The patients’ clinical characteristics, diagnostic procedures, actual treatments [transcatheter arterial embolization (TAE), stent-graft placement, or surgery], clinical courses, and outcomes were evaluated.

RESULTS

The frequency of arterial hemorrhage after PD was 5.5%. Pancreatic leakage was observed in 12 patients. The onset of hemorrhage occurred at a median of 18 d after PD. Sentinel bleeding was observed in five patients. The initial EVT procedures were stent-graft placement in seven patients, TAE in six patients, and combined therapy in two patients. The rate of technical success of the initial EVT was 75.0%, and additional EVTs were performed in four patients. Surgical approaches including arterioportal shunting were performed in eight patients. Liver infarction was observed in two patients after TAE. Two patients showed a poor outcome even after successful EVT. These four patients with poor clinical courses and outcomes had a poor clinical condition before EVT. Fourteen patients were successfully treated.

CONCLUSION

Transcatheter placement of a covered stent may be useful for simultaneous accomplishment of complete hemostasis and HA flow preservation.

Mucinous Cystic Adenoma of the Liver: A Thought-Provoking Case of an Uncommon Hepatic Neoplasm

Patient: Male, 70-year-old

Final Diagnosis: Liver disease

Symptoms: Asymptomatic

Medication:—

Clinical Procedure: Hepatectomy

Specialty: Gastroenterology and Hepatology

Reduction of Pneumocystis jirovecii pneumonia and bloodstream infections by trimethoprim-sulfamethoxazole prophylaxis in patients with rheumatic diseases

Objective: Trimethoprim-sulfamethoxazole (TMP/SMX) prophylaxis against Pneumocystis jirovecii pneumonia (PJP) is routinely administered to patients with rheumatic diseases in Japan. The present study aimed to evaluate the effect of TMP/SMX prophylaxis on PJP and non-central line-associated bloodstream infections (BSIs) in patients receiving high-dose glucocorticoids for the treatment of rheumatic diseases.Method: This study enrolled patients who were admitted between 1 October 2003 and 31 March 2018 and began high-dose glucocorticoid therapy for rheumatic diseases during hospitalization. The observation period was 4 months from the commencement of high-dose glucocorticoid therapy. The effect of TMP/SMX prophylaxis on PJP and non-central line-associated BSI was analysed.Results: Of the 437 patients included in the study, 376 received TMP/SMX prophylaxis and 61 patients did not. During the observation period, TMP/SMX prophylaxis was discontinued in 76 patients (20.2%). Three PJP cases (0.7%) occurred. Among the 399 patients included in our analysis of non-central line-associated BSI, eight experienced non-central line-associated BSI (2.0%). Among the covariates, TMP/SMX prophylaxis was associated with reduced PJP and non-central line-associated BSI incidence [odds ratio (OR) 0, 95% confidence interval (CI) 0.00-0.38, and OR 0.08, 95% CI 0.01-0.42, respectively].Conclusion: Routine TMP/SMX prophylaxis reduced the incidence of both PJP and BSI in patients with rheumatic diseases undergoing high-dose glucocorticoid therapy.

Laparoscopic and open liver resection for hepatocellular carcinoma with Child-Pugh B cirrhosis: multicentre propensity score-matched study

BACKGROUND

Laparoscopic liver resection for hepatocellular carcinoma (HCC) in Child-Pugh A cirrhosis has been demonstrated as beneficial. However, the role of laparoscopy in Child-Pugh B cirrhosis is undetermined. The aim of this retrospective cohort study was to compare open and laparoscopic resection for HCC with Child-Pugh B cirrhosis.

METHODS

Data on liver resections were gathered from 17 centres. A 1 : 1 propensity score matching was performed according to 17 predefined variables.

RESULTS

Of 382 available liver resections, 100 laparoscopic and 100 open resections were matched and analysed. The 90-day postoperative mortality rate was similar in open and laparoscopic groups (4.0 versus 2.0 per cent respectively; P = 0.687). Laparoscopy was associated with lower blood loss (median 110 ml versus 400 ml in the open group; P = 0.004), less morbidity (38.0 versus 51.0 per cent respectively; P = 0.041) and fewer major complications (7.0 versus 21.0 per cent; P = 0.010), and ascites was lower on postoperative days 1, 3 and 5. For laparoscopic resections, patients with portal hypertension developed more complications than those without (26 versus 12 per cent respectively; P = 0.002), and patients with a Child-Pugh B9 score had higher morbidity rates than those with B8 and B7 (7 of 8, 10 of 16 and 21 of 76 respectively; P < 0.001). Median hospital stay was 7.5 (range 2-243) days for laparoscopic liver resection and 18 (3-104) days for the open approach (P = 0.058). The 5-year overall survival rate was 47 per cent for open and 65 per cent for laparoscopic resection (P = 0.142). The 5-year disease-free survival rate was 32 and 37 per cent respectively (P = 0.742).

CONCLUSION

Patients without preoperative portal hypertension and Child-Pugh B7 cirrhosis may benefit most from laparoscopic liver surgery.

Safety and feasibility of minimally invasive esophagectomy for elderly esophageal cancer patients

The number of elderly patients with esophageal cancer has increased in recent years. The use of thoracoscopic esophagectomy has also increased, and its minimal invasiveness is believed to contribute to postoperative outcomes. However, the short- and long-term outcomes in elderly patients remain unclear. This study aimed to elucidate the safety and feasibility of minimally invasive esophagectomy in elderly patients. This retrospective study included 207 patients who underwent radical thoracoscopic esophagectomy for thoracic esophageal squamous cell carcinoma at Kobe University Hospital between 2005 and 2014. Patients were divided into non-elderly (<75 years) and elderly (≥75 years) groups. A propensity score matching analysis was performed for sex and clinical T and N stage, with a total of 29 matched pairs. General preoperative data, surgical procedures, intraoperative data, postoperative complications, in-hospital death, cancer-specific survival, and overall survival were compared between groups. The elderly group was characterized by lower preoperative serum albumin levels and higher American Society of Anesthesiologists grade. Intraoperative data and postoperative complications did not differ between the groups. The in-hospital death rate was 4% in the elderly group, which did not significantly differ from the non-elderly group. Cancer-specific survival was similar between the two groups. Although overall survival tended to be poor in the elderly group, it was not significantly worse than that of the non-elderly group. In conclusion, the short- and long-term outcomes of minimally invasive esophagectomy in elderly versus non-elderly patients were acceptable. Minimally invasive esophagectomy is a safe and feasible modality for elderly patients with appropriate indications.

Adrenocorticotropic hormone-dependent hypercortisolism caused by pancreatic neuroendocrine carcinoma: A thought-provoking but remorseful case of delayed diagnosis

•

Diagnosis of functioning neuroendocrine neoplasms (NENs) in the pancreas is challenging.

•

Adrenocorticotropic hormone (ACTH) regulates adrenal cortisol production.

•

Functioning NENs may cause hypercortisolism as a result of ectopic ACTH secretion.

•

Systematic endocrine examination and functional imaging studies are vital.

•

Making a precise diagnosis enables appropriate treatment of NENs.

Introduction and importance

Definitive diagnosis of functioning neuroendocrine neoplasms (NENs) in the pancreas is challenging. Adrenocorticotropic hormone (ACTH) regulates adrenal cortisol production. Ectopic ACTH secretion by functioning NENs may cause hypercortisolism.

Presentation of case

A 62-year-old woman who was receiving medications for hypertension and hyperlipidemia was referred to our hospital because of abnormal blood tests. Diabetes mellitus was initially diagnosed. Dynamic computed tomography and endoscopic ultrasound revealed a 35-mm diameter hypovascular tumor in the distal pancreas and multiple liver metastases. Endoscopic ultrasound-guided fine-needle aspiration resulted in a diagnosis of neuroendocrine carcinoma. The patient developed pancreatic leakage progressing to peritonitis, abscess formation, pleural effusion, and ascites after the fine-needle aspiration biopsy. Her clinical condition deteriorated to a septic state, necessitating emergency surgery comprising distal pancreatectomy, intraperitoneal lavage, and drainage. Wound healing was protracted and accompanied by ongoing high white blood cell counts and neutrophilia. She also developed a gastric ulcer postoperatively. Systematic endocrine investigations were performed because hypercortisolism caused by a functioning NEN was suspected. Eventually, a definitive diagnosis of an ACTH-producing NEN in the pancreas was made. Systemic chemotherapy was proposed; however, the patient and her family opted for palliative treatment only. She died 42 days after the initial diagnosis.

Clinical discussion

We here present a patient with ACTH-dependent hypercortisolism attributable to a pancreatic NEN who died of progressive cancer after a delay in definitive diagnosis.

Conclusion

Detailed investigation, including systematic endocrine examination and functional imaging studies, are important for precise diagnosis of, and appropriate treatment for, NENs.

Loss of Ftsj1 perturbs codon-specific translation efficiency in the brain and is associated with X-linked intellectual disability

FtsJ RNA 2'-O-methyltransferase 1 (FTSJ1) gene has been implicated in X-linked intellectual disability (XLID), but the molecular pathogenesis is unknown. We show that Ftsj1 is responsible for 2'-O-methylation of 11 species of cytosolic transfer RNAs (tRNAs) at the anticodon region, and these modifications are abolished in Ftsj1 knockout (KO) mice and XLID patient-derived cells. Loss of 2'-O-methylation in Ftsj1 KO mouse selectively reduced the steady-state level of tRNA^Phe in the brain, resulting in a slow decoding at Phe codons. Ribosome profiling showed that translation efficiency is significantly reduced in a subset of genes that need to be efficiently translated to support synaptic organization and functions. Ftsj1 KO mice display immature synaptic morphology and aberrant synaptic plasticity, which are associated with anxiety-like and memory deficits. The data illuminate a fundamental role of tRNA modification in the brain through regulation of translation efficiency and provide mechanistic insights into FTSJ1-related XLID.

Coherent Beam Splitting of Flying Electrons Driven by a Surface Acoustic Wave

We develop a coherent beam splitter for single electrons driven through two tunnel-coupled quantum wires by surface acoustic waves (SAWs). The output current through each wire oscillates with gate voltages to tune the tunnel coupling and potential difference between the wires. This oscillation is assigned to coherent electron tunneling motion that can be used to encode a flying qubit and is well reproduced by numerical calculations of time evolution of the SAW-driven single electrons. The oscillation visibility is currently limited to about 3%, but robust against decoherence, indicating that the SAW electron can serve as a novel platform for a solid-state flying qubit.

Left atrial strain and outcome in heart failure with preserved ejection fraction

Funding Acknowledgements

Type of funding sources: None.

Background

Left atrial (LA) function is impaired in heart failure with preserved ejection fraction (HFpEF). However, the association between LA longitudinal strain and heart failure (HF) events in patients with HFpEF is still unknown. We evaluated whether LA strain measurements would be useful to predict hospitalizations for worsening HF in this study.

Methods

This study included 121 patients (Male 73, Female 48) with HFpEF who had echocardiogram at our institute (Age = 76 ± 14y, Left ventricular ejection fraction; LVEF = 63 ± 8%). Patients with atrial fibrillation were excluded. LA longitudinal strain was measured by speckle-tracking echocardiography, using TOMTEC imaging system. The endpoints were hospitalizations for worsening HF.

Results

During follow-up period of 319 ± 269 days, 33 patients (27%) experienced hospitalizations for worsening HF. LA strain was markedly lower in patients with HF events at 11.3 ± 5.6, whereas LA strain was higher at 20.3 ± 10.1 in patients without HF events. Kaplan-Meier analysis demonstrated a significant separation of survival curves stratified by median value of LA strain (Figure).

Conclusions

LA dysfunction in HFpEF is associated with a higher risk of HF hospitalization, and LA strain measurements would be useful to predict HF events.

Abstract Figure

Paratenon of the cruciate ligaments of the knee: a macroscopic and histological study of human fetuses

BACKGROUND

The paratenon is a sheath-like connective tissue that allows the tendon to move with minimal friction. The careful removal of the paratenon along the cruciate ligaments is a critical step of knee surgery. Thus, orthopedic surgeons and interventional radiologists consider the paratenon as a basic anatomical tissue along a ligament, not along a tendon.

MATERIALS AND METHODS

We performed macroscopic and histological observations of cruciate ligament-associated paratenons in 43 human fetuses.

RESULTS

This tissue usually had a thick armor-like appearance that was distant from the infrapatellar fat pad. The anterior cruciate ligament, rather than the posterior ligament, was deeply embedded in the paratenon. The paratenon contained abundant arteries and veins and, at and near the crossing between the cruciate ligaments, had a well-developed venous plexus. Notably, there were abundant fused veins in the paratenon venous plexus, and prenatal knee movements (especially rotation) seemed to restrict its blood supply, leading to the development of a large cavity by way of advancing fusion of veins in the degenerating plexus. This unique manner of cavitation likely expanded the joint cavity.

CONCLUSIONS

Differences in knee movements in utero seemed to cause differences in the thickness of the paratenon among fetuses. New-borns might have limited knee flexion due to a mass-effect of the thick paratenon around the cruciate ligaments. A slight twisting or rotation at the knee may help to release the knee, because it can break the fetal paratenon and accelerate cavitation.

Do liver metastases from gastric cancer contraindicate aggressive surgical resection? A 14-year single-center experience

BACKGROUND

Advanced gastric cancer (GC) with liver metastasis is often characterized by multiple and bilobular metastases and may also be associated with extrahepatic metastatic lesions. Hence, many physicians consider that radical surgeries are contraindicated for liver metastases from GC (LMGC). According to the 2017 Japanese treatment guideline for GC, a smaller number of liver metastases without unresectable factors may be an indication for liver resection (LR) with curability. The actual 5-year overall survival (OS) rate ranges from 0 to 0.37.

AIM

To present the institutional indications for LR for LMGC and identify important factors for prognostic outcomes.

METHODS

In total, 30 patients underwent LR for LMGC during a 14-year period, and we evaluated the clinical, surgical, and oncological findings. In all patients, radical surgery with intentional lymphadenectomy was performed for the primary GC. The median follow-up duration after the initial LR was 33.7 mo, and three patients with no recurrence died of causes unrelated to the LMGC. The OS and recurrence-free survival rates after the initial LR were assessed.

RESULTS

Seventeen patients had metachronous LMGC. The initial LR achieved curability in 29 patients. Perioperative chemotherapy was introduced in 23 patients. The median greatest LMGC dimension was 30 mm, and the median number of LMGC was two. Twenty-two patients had unilobular LMGC. The 5-year OS and recurrence-free survival rates were 0.48 and 0.28, respectively. The median survival duration and recurrence-free duration after the initial LR were 16.8 and 8.6 mo, respectively. Twenty-one patients developed recurrence after the initial LR. Additional surgeries for recurrence were performed in nine patients, and these surgeries clearly prolonged the patients' survival. Pathological serosal invasion was an independent predictor of a poor prognostic outcome after the initial LR. Aggressive LR may be indicated for carefully selected patients with LMGC.

CONCLUSION

Our results of LR for LMGC seem acceptable. Additional surgeries for recurrence after the initial LR might prolong OS. Pathological serosal invasion is important for poor prognostic outcomes.

Smooth muscle cell-specific SOCS3 deficiency promote pericardial fibrosis and diastolic dysfunction in aging mice

Background

Suppressor of cytokine signaling-3 (SOCS3) is a cytokine-inducible negative regulator of signal transducer and activator of transcription-3 (STAT3) signaling pathway. We have previously shown that cardiac-specific SOCS3 deficiency spontaneously develop cardiac dysfunction with advanced age. However, the role of SOCS3 in smooth muscle cells in cardiovascular pathophysiology remains elusive. In this study, we determined whether STAT3 and SOCS3 in smooth muscle cells would play a role in cardiovascular pathophysiology.

Methods and results

To target inactivation of the SOCS3 gene to smooth muscle cells, SOCS3-flox mice were bred with transgenic mice expressing Cre recombinase under control of the mouse SM22-α promoter (sm-SOCS3-KO mice). Left ventricular weight to body weight ratio was significantly increased in sm-SOCS3-KO mice compared with wild-type mice at 12 months of age (p&lt;0.05). Echocardiographic analyses of smSOCS3-KO mice showed significantly increased left ventricular diastolic dysfunction compared with wild-type from 12 months of age (p&lt;0.05). Sirius-red staining revealed that thickness of pericardium and cardiac interstitial fibrosis in sm-SOCS3-KO mice were markedly greater compared with wild-type mice at 12 months of age (p&lt;0.05). Western blot analyses showed that phosphorylated STAT3 was significantly increased in sm-SOCS3-KO hearts compared with wild-type mice at 12 months of age (p&lt;0.05), whereas no significant differences were observed at 2 months of age. To investigate the mechanism that gave rise to promoted cardiac fibrosis and diastolic dysfunction during aging in sm-SOCS3-KO, we conducted a real-time PCR array analysis for fibrosis. The expression of pro-fibrotic CTGF (connective tissue growth factor), PDGFb (platelet growth factor-b), and TGF (transforming growth factor) family genes including TGFb1, TGFb2, and TGFb3, were significantly higher in sm-SOCS3-KO hearts than those in wild-type at 6 months of age.

Conclusion

Thus, smooth muscle cell-specific SOCS3 deletion induces increased pericardial fibrosis, cardiac interstitial fibrosis, and increased diastolic dysfunction in aging mice, possibly through the augmentation of pro-fibrotic growth factors.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Grant JSPS KAKENHI

Short-term effects of low-dose tolvaptan in acute decompensated heart failure patients with severe aortic stenosis: the LOHAS registry

Background

Tolvaptan exerts potent diuretic effects in heart failure patients without hemodynamic instability. Nonetheless, its clinical efficacy for acute decompensated heart failure (ADHF) due to severe aortic stenosis (AS) remains unclear. This study aimed to evaluate the short-term effects of tolvaptan in ADHF patients with severe AS.

Methods

The LOw-Dose Tolvaptan (7.5 mg) in Decompensated Heart Failure Patients with Severe Aortic Stenosis (LOHAS) registry is a multicenter (7 centers) prospective registry that assessed the short-term effects of tolvaptan in subjects hospitalized for ADHF with severe AS. A total of 59 subjects were enrolled between September 2014 and December 2017. The primary endpoints were changes in body weight and fluid balance measured daily from baseline up to 4 days.

Results

The median [interquartile range] patient age and aortic valve area were 85.0 [81.0–89.0] years and 0.58 [0.42–0.74] cm2, respectively. Body weight continuously decreased, and fluid balance was maintained from baseline to day 4 (p&lt;0.001, p=0.194, respectively). Median serum B-type natriuretic peptide concentration significantly decreased from 910.5 to 740.0 pg/mL by day 4 (p=0.002). However, systolic blood pressure and heart rate were non-significantly changed (p=0.250, p=0.656, respectively). Hypernatremia (&gt;150 mEq/L) and worsening renal function occurred in 2 (3.4%) and 4 (6.8%) patients, respectively.

Conclusions

Short-term treatment with low-dose tolvaptan is safe and effective, providing stable hemodynamic parameters in patients with ADHF and severe AS.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): This research was supported by Otsuka Pharmaceutical Co., Ltd.