Anemia after gastrectomy for early gastric cancer:Long-term follow-up observational study

AIM:To identify the incidence and etiology of anemia after gastrectomy in patients with long-term follow-up after gastrectomy for early gastric cancer.METHODS:The medical records of those patients with early gastric adenocarcinoma who underwent curative gastrectomy between January 2006 and October 2007 were reviewed.Patients with anemia in the preoperative workup,cancer recurrence,undergoing systemic chemotherapy,with other medical conditions that can cause anemia,or treated during follow up with red cell transfusions or supplements for anemia were excluded.Anemia was defined by World Health Organization criteria(Hb < 12 g/dL in women and < 13 g/dL in men).Iron deficiency was defined as serum ferritin < 20 g/dL.Vitamin B12 deficiency was defined as serum vitamin B 12 < 200 pg/mL.Iron deficiency anemia was defined as anemia with concomitant iron deficiency.Anemia from vitamin B 12 deficiency was defined as megaloblastic anemia(mean cell volume > 100 fL) with vitamin B 12 deficiency.The profile of anemia over 48 mo of follow-up was analyzed.RESULTS:One hundred sixty-one patients with gastrectomy for early gastric cancer were analyzed.The incidence of anemia was 24.5% at 3 mo after surgery and increased up to 37.1% at 48 mo after surgery.The incidence of iron deficiency anemia increased during the follow up and became the major cause of anemia at 48 mo after surgery.Anemia of chronic disease and megaloblastic anemia were uncommon.The incidence of anemia in female patients was significantly higher than in male patients at 12(40.0% vs 22.0%,P = 0.033),24(45.0% vs 25.0%,P = 0.023),36(55.0% vs 28.0%,P = 0.004),and 48 mo(52.0% vs 31.0%,P = 0.022) after surgery.Patients with total gastrectomy showed significantly higher incidence of anemia than patients with subtotal gastrectomy at 48 mo after surgery(60.7% vs 31.3%,P = 0.008).The incidence of iron deficiency was significantly higher in female patients than in male patients at 6(35.4% vs 13.3%,P = 0.002),12(45.8% vs 16.8%,P < 0.001),18(52.1% vs 22.3%,P < 0.001),24(60.4% vs 20.9%,P < 0.001),36(62.5% vs 29.2%,P < 0.001),and 48 mo(66.7% vs 34.7%,P = 0.001) after surgery.CONCLUSION:Anemia was frequent after gastrectomy for early gastric cancer,with iron deficiency being the major cause.Evaluation for anemia including iron status should be performed after gastrectomy and appropriate iron replacement should be considered.

Evaluation of esophageal function in patients with esophageal motor abnormalities using multichannel intraluminal impedance esophageal manometry

AIM: To evaluate the functional aspect of esophageal motility in healthy subjects and in patients who were referred for esophageal function testing using multichannel intraluminal impedance-esophageal manometry (MII-EM), and to assess the clinical utility of MII-EM. METHODS: From September 2003 to January 2004, we performed the MII-EM on healthy volunteers and all the patients who were referred for esophageal function testing. Each patient received 10 liquid and 10 viscous swallows. We analyzed the results, the impedance and the manometric findings. Some of the subjects had additional ambulatory 24-h pH study performed to diagnose gastroesophageal reflux disease (GERD). RESULTS: Among 89 studied subjects, the MII-EM findings showed normal esophageal motility in 50 (56.17%), ineffective esophageal motility (IEM) in 17 (19.10%), nutcracker esophagus in 7 (7.86%), achalasia in 4 (4.49%), and scleroderma esophagus in 11 (12.35%) cases. The completeness and the speed of bolus transit were in the order of nutcracker esophagus, normal manometry and IEM. Some of the swallows showing normal manometry and IEM had incomplete transit. In the achalasia and scleroderma esophagus, almost all the swallows had incomplete transit. The body amplitudes were higher for the swallows with complete transit than for the swallows with incomplete transit. There was not a significant difference in the manometric and impedance findings between the subjects with and without GERD. CONCLUSION: MII-EM is a useful tool in assessing theesophageal function in the patients having esophageal motility abnormality. The primary factors influencing the bolus transit are the amplitude of the esophageal body and normal peristalsis.

Clinical outcomes of self-expandable metal stents in palliation of malignant anastomotic strictures caused by recurrent gastric cancer

AIM:To examine the technical feasibility and clinical outcomes of the endoscopic insertion of a self-expandable metal stent(SEMS) for the palliation of a malignant anastomotic stricture caused by recurrent gastric cancer.METHODS:The medical records of patients, who had obstructive symptoms caused by a malignant anastomotic stricture after gastric surgery and underwent endoscopic insertion of a SEMS from January 2001 to December 2007 at Kangnam St Mary's Hospital, were reviewed retrospectively.RESULTS:Twenty patients(15 male, mean age 63 years) were included.The operations were a total gastrectomy with esophagojejunostomy(n = 12), subtotal gastrectomy with Billroth-—migration occurred with a covered stent in 3 patients who underwent a subtotal gastrectomy with Billroth-reconstruction.Two cases of partial stent migration were easily treated with a second stent or stent repositioning.The median stent patency was 56 d(range, 5-439 d).The median survival was 83 d(range, 12-439 d).CONCLUSION:Endoscopic insertion of a SEMS provides safe and effective palliation of a recurrent anastomotic stricture caused by gastric cancer.A meticulous evaluation of the presence of other strictures before inserting the stent is essential for symptom improvement.

Effect of DA-9701 on gastric emptying in a mouse model: Assessment by ^(13)C-octanoic acid breath test

AIM:To evaluate the effects of DA-9701 on the gastric emptying of a solid meal using the 13C-octanoic acid breath test in a mouse model. METHODS:Male C57BL/6 mice aged > 8 wk and with body weights of 20-25 g were used in this study. The solid test meal consisted of 200 mg of egg yolk labeled with 1.5 L/g 13C-octanoic acid. The mice were placed in a 130 mL chamber flushed with air at a flow speed of 200 mL/min. Breath samples were collected for 6 h. The half-emptying time and lag phase were calculated using a modified power exponential model. To assess the reproducibility of the 13C-octanoic acid breath test, the breath test was performed two times at intervals of one week in ten mice without drug treatment. To assess the gastrokinetic effects of DA-9701, the breath test was performed three times in another twelve mice, with a randomized crossover sequence of three drug treatments:DA-9701 3 mg/kg, erythromycin 6 mg/kg, or saline. Each breath test was performed at an interval of one week. RESULTS:Repeatedly measured half gastric emptying time of ten mice without drug treatment showed 0.856 of the intraclass correlation coefficient for the half gastric emptying time (P = 0.004). The mean cumulative excretion curve for the 13C-octanoic acid breath test showed accelerated gastric emptying after DA-9701 treatment compared with the saline control (P = 0.028). The median half gastric emptying time after the DA-9701 treatment was significantly shorter than after the saline treatment [122.4 min (109.0-137.9 min) vs 134.5 min (128.4-167.0 min), respectively; P = 0.028] and similar to that after the erythromycin treatment [123.3 min (112.9-138.2 min)]. The lag phase, which was defined as the period taken to empty 15% of a meal, was significantly shorter after the DA-9701 treatment than after the saline treatment [48.1 min (44.6-57.1 min) vs 52.6 min (49.45-57.4 min), respectively; P = 0.049]. CONCLUSION:The novel prokinetic agent DA-9701 accelerated gastric emptying, assessed with repeated measurements in the same mouse using the 13Coctanoic acid breath test. Our findings suggest that DA-9701 has therapeutic potential for the treatment of functional dyspepsia.

Incidental focal colorectal ^(18)F-fluorodeoxyglucose uptake on positron emission tomography/computed tomography

AIM: To assess the clinical significance of incidental focal colorectal 18 F-fluorodeoxyglucose ( 18 F-FDG) uptake on 18 F-FDG-positron emission tomography/computed tomography (PET/CT). METHODS: The records of all the cases which had undergone colonoscopy after PET/CT within a two weeks interval were reviewed. Adenomas were considered advanced when they were villous, ≥ 10 mm in size, or had high-grade dysplasia. Colorectal cancers and advanced adenomas are collectively referred to as advanced colorectal neoplasms. Receiver-operating characteristic curve analysis was used to determine thesignificant predictive maximum standardized uptake value (SUVmax) cutoff value for advanced colorectal neoplasms and cancer. RESULTS: Ninety-five colorectal lesions matched the site of incidental focal colorectal 18 F-FDG uptake on PET/CT and 146 did not. Colonoscopy showed advanced colorectal neoplasms corresponding to the site of 18 F-FDG uptake in 49 of the 95 (51.5%) lesions with incidental uptake. Of the lesions without incidental uptake, only 6 of 146 (4.1%) had advanced colorectal neoplasms on colonoscopy, indicating a statistically significant difference between the two groups (P < 0.001). The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of incidental focal 18 F-FDG uptake in identifying advanced colorectal neoplasms were 89.1%, 75.3%, 51.6%, 95.9%, and 78.4%, respectively. In detecting only CRC, these values were 89.2%, 69.6%, 34.7%, 97.3%, and 72.6%, respectively. The significant SUVmax cutoff value for advanced colorectal neoplasms (area under the curve 0.755, P < 0.001) was 4.35, with a sensitivity, specificity, PPV, NPV, and accuracy of 75.5%, 65.2%, 69.8%, 71.4% and 70.5%, respectively. For CRC, 5.05 was the significant SUVmax cutoff value (area under the curve 0.817, P < 0.001), with a sensitivity, specificity, PPV, NPV, and accuracy of 84.8%, 71.0%, 80.9%, 89.8%, and 75.8%, respectively. CONCLUSION: The presence of incidental focal colorectal 18 F-FDG uptake on PET/CT with a SUVmax ≥ 4.35 increases the likelihood of an advanced colorectal neoplasm.

Long-term pretreatment with proton pump inhibitor and Helicobacter pylori eradication rates

AIM:To investigate whether proton pump inhibitor(PPI)pretreatment influences Helicobacter pylori eradication rate.METHODS:We retrospectively reviewed H.pylori-infected patients who were treated with a standard triple regimen(PPI,amoxicillin 1 g,and clarithromycin 500mg,all twice daily for 7 d).The diagnosis of H.pylori infection and its eradication was assessed with the rapid urease test,histological examination by silver staining,or the13C-urea breath test.We divided the patients into two groups:one received the standard eradication regimen without PPI pretreatment(Group A),and the other received PPI pretreatment(Group B).The patients in Group B were reclassified into three groups based on the duration of PPI pretreatment:Group B-Ⅰ(3-14 d),Group B-Ⅱ(15-55 d),and Group B-Ⅲ(≥56 d).RESULTS:A total of 1090 patients were analyzed and the overall eradication rate was 80.9%.The cure rate in Group B(81.2%,420/517)was not significantly different from that in Group A(79.2%,454/573).The eradication rates in Group B-Ⅰ,B-Ⅱand B-Ⅲwere80.1%(117/146),81.8%(224/274)and 81.4%(79/97),respectively.CONCLUSION:PPI pretreatment did not affect H.pylori eradication rate,regardless of the medication period.

Hematologic diseases: High risk of Clostridium difficile associated diarrhea

AIM:To investigate the incidence and clinical outcome of Clostridium difficile(C.difficile)associated diarrhea(CDAD)in patients with hematologic disease.METHODS:We retrospectively reviewed the medical records of patients who underwent C.difficile testing in a tertiary hospital in 2011.The incidence and risk factors for CDAD and its clinical course including recurrence and mortality were assessed in patients with hematologic disease and compared with those in patients with nonhematologic disease.RESULTS:About 320 patients were diagnosed with CDAD(144 patients with hematologic disease;176with nonhematologic disease).The incidence of CDAD in patients with hematologic disease was estimated to be 36.7 cases/10000 patient hospital days,which was higher than the 5.4 cases/10000 patient hospital days in patients with nonhematologic disease.Recurrence of CDAD was more frequent in patients with hematologic disease compared to those with nonhematologic disease(18.8%vs 8.5%,P<0.01),which was associated with higher re-use of causative antibiotics for CDAD.Mortality due to CDAD did not differ between the two groups.Multivariate analysis showed that intravenous immunoglobulin was the only significant factor associated with a lower rate of recurrence of CDAD in patients with hematologic disease.CONCLUSION:The incidence and recurrence of CDAD was higher in patients with hematologic disease than in those with nonhematologic disease.