Nan-Hua Chou

Risk factors of mortality in perforated peptic ulcer

OBJECTIVE To assess the risk factors that influence mortality from perforated peptic ulcer. DESIGN Retrospective study. SETTING General hospital, Taiwan. SUBJECTS 179 patients who had their perforated peptic ulcers operated on and who had minimum follow-up of one year. MAIN OUTCOME MEASURES Mortality. RESULTS The overall mortality was 15% (26/179). Of the 26 patients who died, the cause of death was uncontrolled systemic infection in 21 (81%), hypovolaemic shock in 2, and fatal arrhythmia and heart failure in 1 each. 15 of the patients who died of sepsis did not have fulminant abdominal sepsis. Most deaths occurred early after operation, (range 1-96 days). Old age, preoperative shock, and type of operation seemed to be related to these deaths on univariate analysis, but multivariate analysis showed that coexisting medical illness, delayed treatment, and low albumin concentration were independent risk factors for mortality. CONCLUSIONS To improve the result of treatment of perforated peptic ulcer, the diagnosis and treatment should not be delayed, the associated medical illnesses should be treated, and nutritional support should be given.

Hepatitis B Genotype C Correlated with Poor Surgical Outcomes for Hepatocellular Carcinoma

BACKGROUND Genotype B and C are the predominant hepatitis B virus (HBV) strains in Taiwan. We aimed to investigate the role of genotype in HBV-related hepatocellular carcinoma (HCC) after resection. STUDY DESIGN From October 2005 to November 2008, 64 patients who underwent liver resection for HBV-related HCC were enrolled. HBV genotypes were determined by molecular method. Patient characteristics, biochemical, tumor, and viral factors were evaluated for their prognostic significance. RESULTS During a mean follow-up of 26.6 ± 13.2 months, patients infected with genotype C had higher HBV viral load (p = 0.007) and worse disease-free survival rate (p = 0.028) than patients with genotype B. By univariate analysis, genotype C, alanine transaminase >50 U/L, tumor size ≥5 cm, and microvascular invasion were associated with tumor recurrence. Further multivariate analysis demonstrated genotype C remained a significant risk factor (p = 0.034). CONCLUSIONS Genotype C is a strong risk factor for HCC recurrence after resection. More intensive monitoring for recurrence should be considered in patients with genotype C.

Intraoperative hyperthermic intraperitoneal chemotherapy as adjuvant chemotherapy for advanced gastric cancer patients with serosal invasion

Background: To evaluate hyperthermic intraperitoneal chemotherapy (HIPEC) as an adjuvant chemotherapy in advanced gastric cancer (AGC) patients with serosal invasion. Methods: Patients who received radical surgery and palliative surgery between January 2002 and December 2010 were retrospectively examined. Patients were divided into two groups, namely, one group that underwent surgery and another group that underwent surgery with HIPEC. All patients who received HIPEC had suspected serosal invasion on an abdominal computed tomography or by the surgeons assessment during the operation. Results: The prophylactic groups included 83 patients who underwent gastrectomy alone. A total of 29 patients underwent gastrectomy with HIPEC. The 5‐year survival rates were 10.7% and 43.9%, respectively. The 5‐year mean survival times were 22.66 (17.55–25.78) and 34.81 (24.97–44.66) months (p = 0.029), respectively. There were 52 patients who had a recurrence of carcinomatosis among 133 patients who had resections (52/133, 39.1%). The 3‐year disease‐free survival rate for carcinomatosis was 28.87% in the group that received surgery alone, whereas it was 66.03% in the group that received HIPEC. There was no significant difference in the rate of complication between the two groups in the prophylactic group (p = 0.542). Thus, curative surgery with HIPEC had a better prognosis for AGC with serosal invasion. The carcinomatosis recurrence time was longer in patients who underwent gastrectomy with HIPEC and received R0 resection. Conclusion: The survival benefit of HIPEC as an adjuvant therapy for gastric cancer patients with serosal invasion should be validated in a large cohort.

Number of involved lymph nodes is important in the prediction of prognosis for primary duodenal adenocarcinoma

Background: The significance of lymph node involvement regarding the prognosis of primary duodenal adenocarcinoma remains controversial. This study aims to evaluate the prognostic accuracy of nodal metastasis using the seventh edition American Joint Committee on Cancer staging system in patients with primary duodenal adenocarcinoma. Methods: Between 1993 and 2010, 36 patients who had undergone surgical resection for primary duodenal adenocarcinoma at the Kaohsiung Veterans General Hospital were retrospectively reviewed. Results: The median disease‐free survival for all patients was 19 months and the median overall survival was 21 months. Lymph node metastases were found in 26 (72%) of the patients, and 14 patients (39%) patients had in excess of three positive lymph nodes (N2). Patients with N2 disease had significantly reduced overall survival, as compared to patients with three or fewer positive lymph nodes (N1; p = 0.036). In univariate analysis, factors including age >75 years, body weight loss, tumor size ≤4 cm, N2 disease and lymph node ratio >0.4 predicted shorter overall survival. Multivariate analysis demonstrated that N2 and lymph node ratio >0.4 are significant risk factors associated with overall survival (p = 0.026 and p = 0.042 respectively). N2 is also the only independent predictive factor for disease‐free survival (p = 0.023). Conclusion: Subdivision of metastatic lymph nodes into N1 and N2 improves predictive ability. The seventh edition American Joint Committee on Cancer staging system is applicable in the present study with regard to the prediction of the prognosis for primary duodenal adenocarcinoma.

Intestinal Obstruction in Patients with Previous Laparotomy for Non-Malignancy

Background: Intestinal obstruction is one of the most common surgical emergencies. The aim of this study was to identify important management information from the evaluation of patients with intestinal obstruction who had undergone previous laparotomy for non‐malignancy. Methods: Data from 176 patients with previous laparotomy for non‐malignancy, and who were operated on for intestinal obstruction, were collected and analyzed retrospectively. Results: Gastroduodenal operations, appendectomy, and obstetric/gynecologic procedures were the 3 most common previous abdominal surgeries. More than half of all bowel obstructions developed within 10 years after previous laparotomy, and particularly within the first 5 years. Most obstructions were related to adhesion, although their etiologies were diverse. The rate of bowel strangulation was much higher in patients with internal herniation, volvulus, intussusception, closed loop, and diaphragmatic hernia than in patients with simple adhesion, bezoar, tumor, and inflammation (48.3% vs 12.2%). The surgical mortality rate correlated significantly with bowel strangulation: the overall rate was 6.8%, that in patients with strangulation was 18.8%, and that in patients without strangulation was 4.2%. Conclusion: The etiologies of intestinal obstruction were not only significantly related to bowel strangulation, but were also an important determinant of therapeutic strategy.

MiR-193a-5p and -3p Play a Distinct Role in Gastric Cancer: miR-193a-3p Suppresses Gastric Cancer Cell Growth by Targeting ETS1 and CCND1

Background/Aim: MicroRNAs (miRNAs) are small non-protein-coding RNAs, that can be generated from the 5p or 3p arm of precursor miRNA (pre-miRNA). Differential miRNA arm selection has been reported between tumor and normal tissue in many cancer types; however, the biological function and mechanism of miRNA arm switching in gastric cancer remain unclear. Materials and Methods: Profiles of miRNA expression in gastric cancer were obtained from The Cancer Genome Atlas (TCGA). The biological role of miR-193a-5p/-3p in tumor growth and invasive abilities was assessed through a gain-of-function approach. Target genes of miR-193a-3p were identified using bioinformatics and an experimental approach. Results: The expression levels of miR-193a-5p, and not of miR-193a-3p, were significantly decreased in gastric cancer compared to adjacent normal tissues. Ectopic expressions of miR-193a-5p and miR-193a-3p revealed that they both inhibited gastric cancer cell growth, but only miR-193a-3p significantly suppressed cell invasion ability. Using a bioinformatics approach, we identified 18 putative target genes of miR-193a-3p. Both mRNA and protein levels of cyclin D1 (CCND1) and ETS proto-oncogene 1 (ETS1) were significantly decreased in AGS cells transfected with miR-193a-3p mimics. ETS1 or CCND1 knockdown significantly suppressed gastric cancer cell growth, similar to miR-193a-3p overexpression. Conclusion: Our results indicated that miR-193a-3p suppressed gastric growth and motility, at least partly, by directly targeting CCND1 and ETS1 expression.

Management of Difficult Duodenal Stump: VGH-Kaohsiung Experience

Purpose: Although most peptic ulcers are currently treated successfully with medical treatment, some still need surgical intervention because of the complications caused by peptic ulcer disease, such as bleeding, perforation and obstruction. Partial gastrectomy with Billroth Ⅱ reconstruction is one of the commonly performed procedures. However, in those patients with a difficult duodenal stump, which is usually caused by chronic ulcer in the posterior wall of the duodenal bulb, the duodenal stump leakage rate is high if it is closed by a traditional method. Hence, alternative methods to the conventional duodenal closure have been reported for the management of the so-called ”difficult duodenal stump”, including Nissens closure, Bancrofts closure and tube duodenostomy, etc. We report our experience in the management of the difficult duodenal stump and present our modified method of Nissens closure. Methods: A retrospective study was performed in reviewing patients with duodenal ulcers who underwent partial gastrectomy with Billroth Ⅱ reconstruction. Patient profile, incidence of difficult stumps, method for duodenal stump closure, post-operative morbidity and mortality were collected and analyzed. We modified Nissens closure with an interrupted far-near whole layer suture for duodenal stump closure as an easier method. Results: From November 1990 to July 2002, 242 patients underwent partial gastrectomy with Billroth Ⅱ reconstruction due to complications of duodenal ulcer. The overall duodenal stump leakage rate was 13.6% (n=33). Eighty-five patients were considered to have a difficult duodenal stump and had significantly higher leakage, complication and mortality rates. No stump leakage was noted in either Nissens or our modified Nissens closure. Conclusions: Gastric resection is usually unavoidable at the management of complications of duodenal ulcer. Facing the difficult duodenal stump after gastric resection, especially in chronic and large-sized duodenal ulcers at the posterior wall of the duodenal bulb, our modified Nissens closure is a good and safe alternative method for easy duodenal stump closure.

Appendectomy during Pregnancy: Comparison of Laparoscopic and Open Appendectomy

Objectives: Acute appendicitis is the most common non-obstetric surgical emergency during pregnancy, although the incidence of acute appendicitis during pregnancy is low. There are still no accepted guidelines concerning the safety of laparoscopic appendectomy during pregnancy. In this retrospective study, we evaluated the safety and outcome of laparoscopic appendectomy compared with open appendectomy in pregnant women during the same period. The results revealed that laparoscopic appendectomy in pregnant women is as safe as open appendectomy and requires less narcotic consumption. Methods: Records of 12 pregnant patients who underwent surgery with clinical diagnosis of acute appendicitis from 1990 to 2003 were reviewed retrospectively. Results: During this period, there were 9888 deliveries and the incidence of acute appendicitis during pregnancy was 0.12%. A total of twelve patients had pathologically proven acute appendicitis. Three patients were in the first trimester, three in the second trimester, and six in the third trimester. Laparoscopic appendectomy was performed in 5 patients. There was no uterine injury or spontaneous abortion in either the open appendectomy or the laparoscopic appendectomy group. The laparoscopic appendectomy group had lower narcotic agent consumption. There was no significant difference concerning time of procedure, hospital days, rate of preterm labor, or Apgar score at the 1st and 5th minutes Conclusions: Laparoscopic appendectomy in pregnant women is as safe as open appendectomy and has lower narcotic agent consumption. Patients undergoing laparoscopic appendectomy have the same benefits that are noted in non-pregnant patients undergoing the same procedure.