Hye Youn Kwon

Outcomes of Laparoscopic Gastrectomy after Endoscopic Treatment for Gastric Cancer: A Comparison with Open Gastrectomy

Purpose Additional gastrectomy is needed after endoscopic resection for early gastric cancer when pathology confirms any possibility of lymph node metastasis or margin involvement. No studies depicted the optimal type of surgery to apply in these patients. We compared the short-term and long-term outcomes of laparoscopic gastrectomy with those of open gastrectomy after endoscopic resection to identify the optimal type of surgery. Materials and Methods From 2003 to 2010, 110 consecutive patients who underwent gastrectomy with lymphadenectomy either by laparoscopic (n=74) or by open (n=36) for gastric cancer after endoscopic resection were retrospectively analyzed. Postoperative and oncological outcomes were compared according to types of surgical approach. Results Clinicopathological characteristics were comparable between the two groups. Laparoscopic group showed significantly shorter time to gas passing and soft diet and hospital day than open group while operation time and rate of postoperative complications were comparable between the two groups. All specimens had negative margins regardless of types of approach. Mean number of retrieved lymph nodes did not differ significantly between the two groups. During the median follow-up of 47 months, there were no statistical differences in recurrence rate (1.4% for laparoscopic and 5.6% for open, P=0.25) and in overall (P=0.22) and disease-free survival (P=0.19) between the two groups. Type of approach was not an independent risk factor for recurrence and survival. Conclusions Laparoscopic gastrectomy after endoscopic resection showed comparable oncologic outcomes to open approach while maintaining benefits of minimally invasive surgery. Thus, laparoscopic gastrectomy can be a treatment of choice for patients previously treated by endoscopic resection.

Contributing factors on lymph node yield after surgery for mid-low rectal cancer.

Purpose The purpose of the present study was to evaluate the contributing factors to the lymph node status as well as to define the impact of preoperative concurrent chemoradiotherapy (CCRT) on the number of lymph nodes retrieved in mid-low rectal cancer. Materials and Methods We retrospectively analyzed 277 patients who underwent curative surgical resection for mid-low rectal cancer between 1998 and 2007. Eighty-two patients received long course preoperative CCRT followed by surgery. Results A mean of 13.12±9.28 lymph nodes was retrieved. In a univariate analysis, distance from the anal verge, pT stage, pN stage, lymphovascular invasion, preoperative CCRT had significant influence on the number of lymph nodes retrieved. In a multivariate model, patients in the CCRT group had fewer retrieved lymph nodes than the non-CCRT group (p<0.001). Both univariate and multivariate analyses showed that the ypN0 group had fewer retrieved lymph nodes than the ypN1-2 group (p=0.027) in the CCRT group. Conclusion Preoperative CCRT was an independent risk factor for failure to harvest an appropriate number of lymph nodes, and node-negative patients who received CCRT had fewer lymph nodes harvested.

Efficacy and toxicity of high-dose nebulized colistin for critically ill surgical patients with ventilator-associated pneumonia caused by multidrug-resistant Acinetobacter baumannii☆

Purpose Few studies have compared nebulized and intravenous (IV) colistin for multidrug‐resistant Acinetobacter baumannii and Pseudomonas aeruginosa pneumonia. This study compared the nephrotoxicity and clinical outcomes for these two delivery routes. Methods This study retrospectively compared 95 critically ill surgical patients who were diagnosed with Acinetobacter baumannii ventilator associated pneumonia and received colistin between March 2013 and January 2016. Results The most common diagnoses were brain hemorrhage (27.4%), traumatic brain injury (20%), traumatic thoracic injury (15.8%), and secondary peritonitis (11.6%). Compared to the IV group, the nebulizer group was significantly older (60.0 vs. 67.5 years, p = 0.010), had higher APACHE II scores (16.3 vs. 19.9, p = 0.001), and more frequently had diabetes mellitus (6.8% vs. 21.6%, p = 0.043). Nephrotoxicity was more common in the IV group (60.5% vs. 15.7%, p < 0.0001). Both groups had similar microbiological and clinical outcomes (p = 0.921 and p = 0.719, respectively). Patients with nephrotoxicity exhibited prolonged IV or nebulized colistin treatment and more frequent combination with vancomycin. Nephrotoxicity was independently associated with IV delivery (odds ratio: 8.48, 95% confidence interval: 2.95–24.39, p < 0.0001). Conclusions Nebulized colistin may have less nephrotoxicity and provide similar clinical results, compared to IV colistin. HighlightsColistin can be used intravenously or as a nebulized mist for treating VAP.This study compared the toxicity and clinical outcomes of these two routes.IV colistin was an independent and significant risk factor for nephrotoxicity.Nebulized and IV colistin provided similar clinical and microbiological outcomes.Nebulized colistin may be useful for treating critically ill surgical patients.

Response to letter to the editor: Nebulized colistin in ventilator-associated pneumonia: Should we trust it?

We thank Gutiérrez-Pizarraya and colleagues for their insightful remarks on our article, Efficacy and toxicity of high-dose nebulized colistin for critically ill surgical patients with ventilator-associated pneumonia caused by multidrug-resistant Acinetobacter baumannii [1]. Their letter indicated that our study had three weaknesses. First, ventilator-associated pneumonia (VAP) is a serious infectious disease, and bacteremia is found in approximately 20% of these patients. We fully agree with this opinion, and found many difficulties in treating VAP. However, VAP caused by multidrug-resistant Acinetobacter baumannii (MDR-AB) ismainly diagnosed in patients with long-term antibiotic treatment, who have a critical systemic condition. As the use of IV colistin, which has a high risk of nephrotoxicity in this condition, may exacerbate the general condition of the patient, using a nebulized colistinmonotherapywas considered in select patients. Patients treatedwith nebulized colistin were monitored by a multidisciplinary team consisting of a pulmonologist and surgical intensivist, who immediately give IV colistin if bacteremia is suspected. Second, Gutiérrez-Pizarraya and colleagues suggested that this study should includemanyVATpatients. The patientswho had VAT and VAP can be simultaneously enrolled. However, all 140 patients included in the study had, for the first time, lung infiltration confirmed using the chest X-ray after 48 h of ventilator care. They had two or more clinical features of pneumonia, and MDR-AB was detected in their endotracheal aspirates or bronchoalveolar lavage fluid [2]. Finally, the third issue was the concomitant use of vancomycin, which might have affected the renal toxicity. The multivariate analysis of 79 patients, excluding those who concomitantly use vancomycin, showed that nebulized colistin induced significantly lower nephrotoxicity than that of the IV colistin (8.46-fold). This result can be observed after adjusting the effect of vancomycin on nephrotoxicity to some extent. Recently published studies on the efficacy and safety of nebulized colistin monotherapy have also reported that nebulized colistin has lower nephrotoxicity with similar microbiologic and clinical outcomes when compared to that of the IV colistin [3,4]. The primary end-point of our study was to investigate the difference in the incidence of

In Vitro Adenosine Triphosphate-Based Chemotherapy Response Assay as a Predictor of Clinical Response to Fluorouracil-Based Adjuvant Chemotherapy in Stage II Colorectal Cancer

Purpose We evaluated the usefulness of the in vitro adenosine triphosphate-based chemotherapy response assay (ATP-CRA) for prediction of clinical response to fluorouracil-based adjuvant chemotherapy in stage II colorectal cancer. Materials and Methods Tumor specimens of 86 patients with pathologically confirmed stage II colorectal adenocarcinoma were tested for chemosensitivity to fluorouracil. Chemosensitivity was determined by cell death rate (CDR) of drug-exposed cells, calculated by comparing the intracellular ATP level with that of untreated controls. Results Among the 86 enrolled patients who underwent radical surgery followed by fluorouracil-based adjuvant chemotherapy, recurrence was found in 11 patients (12.7%). The CDR ≥ 20% group was associated with better disease-free survival than the CDR < 20% group (89.4% vs. 70.1%, p=0.027). Multivariate analysis showed that CDR < 20% and T4 stage were poor prognostic factors for disease-free survival after fluorouracil-based adjuvant chemotherapy. Conclusion In stage II colorectal cancer, the in vitro ATP-CRA may be useful in identifying patients likely to benefit from fluorouracil-based adjuvant chemotherapy.