Characteristics of early gastric tumors with different differentiation and predictors of long-term outcomes after endoscopic submucosal dissection

BACKGROUND Gastric cancer is a common malignant tumor of the digestive tract,and endosco-pic submucosal dissection(ESD)is the preferred treatment for early-stage gastric cancer.The analysis of the epidemiological characteristics of gastric mucosal tumors with different differentiation degrees and the influencing factors of long-term ESD efficacy may have certain significance for revealing the development of gastric cancer and ESD.AIM To analyze the features of gastric mucosal tumors at different differentiation levels,and to explore the prognostic factors of ESD.METHODS We retrospectively studied 301 lesions in 285 patients at The Second Affiliated Hospital of Xi'an Jiaotong University from 2014 to 2021,according to the latest Japanese guidelines(sixth edition),and divided them into low-grade intrae-pithelial neoplasia(LGIN),high-grade intraepithelial neoplasia(HGIN),and computed tomography at 3,6 and 12 months after ESD.We compared clinicopathologic characteristics,ESD efficacy,and complications with different degrees of differentiation,and analyzed the related factors associated with ESD.RESULTS HGIN and differentiated carcinoma patients were significantly older compared with LGIN patients(P<0.001)and accounted for more 0-IIc(P<0.001),atrophic gastritis was common(P<0.001),and irregular microvascular patterns(IMVPs)and demarcation lines(DLs)were more obvious(P<0.001).There was more infiltration in the undifferentiated carcinoma tissue(P<0.001),more abnormal folds and poorer mucosal peristalsis(P<0.001),and more obvious IMVPs,irregular microsurface patterns and DLs(P<0.05)than in the LGIN and HGIN tissues.The disease-free survival rates at 2,5,and 8 years after ESD were 95.0%,90.1%,and 86.9%,respectively.Undifferen-tiated lesions(HR 5.066),white moss(HR 7.187),incomplete resection(HR 3.658),and multiple primary cancers(HR 2.462)were significantly associated with poor prognosis.CONCLUSION Differentiations of gastric mucosal tumors have different epidemiological and endoscopic characteristics,which are closely related to the safety and efficacy of ESD.

Long-term outcomes after endoscopic removal of malignant colorectal polyps:Results from a 10-year cohort

BACKGROUND Choosing an optimal post-polypectomy management strategy of malignant colorectal polyps is challenging,and evidence regarding a surveillance-only strategy is limited.AIM To evaluate long-term outcomes after endoscopic removal of malignant colorectal polyps.METHODS A single-center retrospective cohort study was conducted to evaluate outcomes after endoscopic removal of malignant colorectal polyps between 2010 and 2020.Residual disease rate and nodal metastases after secondary surgery and local and distant recurrence rate for those with at least 1 year of follow-up were invest-igated.Event rates for categorical variables and means for continuous variables with 95%confidence intervals were calculated,and Fisher’s exact test and Mann-Whitney test were performed.Potential risk factors of adverse outcomes were RESULTS In total,135 lesions(mean size:22.1 mm;location:42%rectal)from 129 patients(mean age:67.7 years;56%male)were enrolled.The proportion of pedunculated and non-pedunculated lesions was similar,with en bloc resection in 82%and 47%of lesions,respectively.Tumor differentiation,distance from resection margins,depth of submucosal invasion,lymphovascular invasion,and budding were reported at 89.6%,45.2%,58.5%,31.9%,and 25.2%,respectively.Residual tumor was found in 10 patients,and nodal metastasis was found in 4 of 41 patients who underwent secondary surgical resection.Univariate analysis identified piecemeal resection as a risk factor for residual malignancy(odds ratio:1.74;P=0.042).At least 1 year of follow-up was available for 117 lesions from 111 patients(mean follow-up period:5.59 years).Overall,54%,30%,30%,11%,and 16%of patients presented at the 1-year,3-year,5-year,7-year,and 9-10-year surveillance examinations.Adverse outcomes occurred in 9.0%(local recurrence and dissemination in 4 patients and 9 patients,respectively),with no difference between patients undergoing secondary surgery and surveillance only.CONCLUSION Reporting of histological features and adherence to surveillance colonoscopy needs improvement.Long-term adverse outcome rates might be higher than previously reported,irrespective of whether secondary surgery was performed.

Long-term outcomes of endoscopic submucosal dissection for undifferentiated type early gastric cancer over 2 cm with R0 resection

BACKGROUND Endoscopic submucosal dissection(ESD)for over 2 cm in size undifferentiated type(UD type)early gastric cancer(EGC)confined to the mucosa is not only challenging,but also long-term outcomes are not well known.AIM To evaluate the long-term outcomes of ESD done for UD type EGCs confined to the mucosa over 2 cm in size and compare the results with those where the lesions were less than 2 cm.METHODS 143 patients with UD type EGC confirmed on histology after ESD at a tertiary hospital were reviewed.Cases with synchronous and metachronous lesions and a case with emergency surgery after ESD were excluded.A total of 137 cases were enrolled.79 cases who underwent R0 resection were divided into 2 cm or less(group A)and over 2 cm(group B)in size.RESULTS Among 79 patients who underwent R0 resection,the number in group A and B were 51 and 28,respectively.The mean follow-up period(SD)was 79.71±45.42 months.There was a local recurrence in group A(1/51,2%)and group B(1/28,3.6%)respectively.This patient in group A underwent surgery while the patient in group B underwent repeated ESD with no further recurrences in both patients.There was no regional lymph node metastasis,distant metastasis,and deaths in both groups.With R0 resection strategy for ESD on lesions over 2 cm,20.4%(28/137)of patients were able to avoid surgery compared with expanded indication.CONCLUSION If R0 resection is achieved by ESD,UD type EGCs over 2 cm also showed good and similar clinical outcomes as compared to lesions less than 2 cm when followed for over 5 years.With R0 resection strategy,several patients can avoid surgery.

Long-Term Outcomes after Coronary Artery Bypass Grafting with Risk Stratification

Background: Risk stratification of long-term outcomes for patients undergoing Coronary artery bypass grafting has enormous potential clinical importance. Aim: To develop risk stratification models for predicting long-term outcomes following coronary artery bypass graft (CABG) surgery. Methods: We retrospectively revised the electronic medical records of 2330 patients who underwent adult Cardiac surgery between August 2016 and December 2022 at Madinah Cardiac Center, Saudi Arabia. Three hundred patients fulfilled the eligibility criteria of CABG operations with a complete follow-up period of at least 24 months, and data reporting. The collected data included patient demographics, comorbidities, laboratory data, pharmacotherapy, echocardiographic parameters, procedural details, postoperative data, in-hospital outcomes, and follow-up data. Our follow-up was depending on the clinical status (NYHA class), chest pain recurrence, medication dependence and echo follow-up. A univariate analysis was performed between each patient risk factor and the long-term outcome to determine the preoperative, operative, and postoperative factors significantly associated with each long-term outcome. Then a multivariable logistic regression analysis was performed with a stepwise, forward selection procedure. Significant (p < 0.05) risk factors were identified and were used as candidate variables in the development of a multivariable risk prediction model. Results: The incidence of all-cause mortality during hospital admission or follow-up period was 2.3%. Other long-term outcomes included all-cause recurrent hospitalization (9.8%), recurrent chest pain (2.4%), and the need for revascularization by using a stent in 5 (3.0%) patients. Thirteen (4.4%) patients suffered heart failure and they were on the maximum anti-failure medications. The model for predicting all-cause mortality included the preoperative EF ≤ 35% (AOR: 30.757, p = 0.061), the bypass time (AOR: 1.029, p = 0.003), and the duration of ventilation following the operation (AOR: 1.237, p = 0.021). The model for risk stratification of recurrent hospitalization comprised the preoperative EF ≤ 35% (AOR: 6.198, p p = 0.023), low postoperative cardiac output (AOR: 3.622, p = 0.007), and the development of postoperative atrial fibrillation (AOR: 2.787, p = 0.038). Low postoperative cardiac output was the only predictor that significantly contributed to recurrent chest pain (AOR: 11.66, p = 0.004). Finally, the model consisted of low postoperative cardiac output (AOR: 5.976, p < 0.001) and postoperative ventricular fibrillation (AOR: 4.216, p = 0.019) was significantly associated with an increased likelihood of the future need for revascularization using a stent. Conclusions: A risk prediction model was developed in a Saudi cohort for predicting all-cause mortality risk during both hospital admission and the follow-up period of at least 24 months after isolated CABG surgery. A set of models were also developed for predicting long-term risks of all-cause recurrent hospitalization, recurrent chest pain, heart failure, and the need for revascularization by using stents.

Lower extremity amputations and long-term outcomes in diabetic foot ulcers:A systematic review

BACKGROUNDDiabetes mellitus causes a large majority of non-traumatic major and minoramputations globally. Patients with diabetes are clinically complex with amultifactorial association between diabetic foot ulcers (DFU) and subsequentlower extremity amputations (LEA). Few studies show the long-term outcomeswithin the cohort of DFU-associated LEA.AIMTo highlight the long-term outcomes of LEA as a result of DFU.METHODSPubMed/MEDLINE and Google Scholar were searched for key terms, “diabetes”,“foot ulcers”, “amputations” and “outcomes”. Outcomes such as mortality, reamputation,re-ulceration and functional impact were recorded. Peer-reviewedstudies with adult patients who had DFU, subsequent amputation and follow upof at least 1 year were included. Non-English language articles or studiesinvolving children were excluded.RESULTSA total of 22 publications with a total of 2334 patients were selected against theinclusion criteria for review. The weighted mean of re-amputation was 20.14%,29.63% and 45.72% at 1, 3 and 5 years respectively. The weighted mean of mortality at 1, 3 and 5 years were 13.62%, 30.25% and 50.55% respectively withsignificantly higher rates associated with major amputation, re-amputation andischemic cardiomyopathy.CONCLUSIONPrevious LEA, level of the LEA and patient comorbidities were significant riskfactors contributing to re-ulceration, re-amputation, mortality and depreciatedfunctional status.

Propensity score analyses of long-term outcomes of perivascular hepatocellular carcinoma: Radiofrequency ablation vs. surgery

To the Editor:WereadwithgreatinterestthearticlebyDr.Leeetal.[1],which compared the long-term outcomes of patients with perivascular hepatocellular carcinoma (HCC) after radiofrequency ablation(RFA) and surgical resection (SR) as first-line treatment. By using propensity score matching (PSM) analyses, the authors concluded that SR provided better long-term tumor control and overall survival than RFA for patients with small periportal tumors. Herein,

Long-term outcomes of staged recanalization for concurrent chronic total occlusion in patients with ST-segment elevation myocardial infarction after primary percutaneous coronary intervention

Background In patients with acute ST-segment elevation myocardial infarction(STEMI)who undergo primary percutaneous coronary intervention(PCI),approximately 10%are concomitant with a chronic total occlusion(CTO)in a non-culprit vessel.However,the impact of staged CTO recanalization on prognosis in this cohort remains disputable.This study aimed to compare the long-term outcomes of staged CTO recanalization versus medical therapy in patients with STEMI after primary PCI.Methods Between January 2005 and December 2016,a total of 287 patients were treated with staged CTO-PCI(n=91)or medical therapy(n=196)after primary PCI in our center.The primary endpoint was major adverse cardiovascular and cerebrovascular event(MACCE),defined as a composite of all-cause death,nonfatal myocardial infarction(MI),stroke or unplanned revascularization.After propensity-score matching,77 pairs of well-balanced patients were identified.Results The mean follow-up period was 6.06 years.Overall,the incidence of the primary endpoint of MACCE was significantly lower in staged CTO-PCI group than that in medical therapy group in both overall population(22.0%vs.46.9%;hazard ratio(HR)=0.48,95%CI:0.29-0.77)and propensity-matched cohorts(22.1%vs.42.9%;HR:0.48,95%CI:0.27-0.86).In addition,staged CTO-PCI was also associated with reduced risk of the composite of cardiac death,nonfatal MI or stroke compared with medical therapy in both overall population(9.9%vs.26.5%;hazard ratio(HR)=0.39,95%CI:0.19-0.79)and propensity-matched cohorts(9.1%vs.22.1%;HR:0.40,95%CI:0.16-0.96).After correction of the possible confounders,staged CTO-PCI was independently associated with reduced risks of MACCE(adjusted HR:0.46,95%CI:0.28-0.75),the composite of cardiac death,nonfatal MI or stroke(adjusted HR:0.45,95%CI:0.22-0.94)and all-cause mortality(adjusted HR:0.32,95%CI:0.13-0.83).Moreover,the results of sensitivity analysis were almost concordant with the overall analysis.Conclusions In patients with STEMI and a concurrent CTO who undergo primary PCI,successful staged recanalization of CTO in the non-culprit vessels is associated with better clinical outcomes during long-term follow-up.

Short-and long-term outcomes of endoscopically treated superficial non-ampullary duodenal epithelial tumors

BACKGROUND It is widely recognized that endoscopic resection(ER) of superficial nonampullary duodenal epithelial tumors(SNADETs) is technically challenging and may carry high risks of intraoperative and delayed bleeding and perforation.These adverse events could be more critical than those occurring in other levels of the gastrointestinal tract. Because of the low prevalence of the disease and the high risks of severe adverse events, the curability including short-and long-term outcomes have not been standardized yet.AIM To investigate the curability including short-and long-term outcomes of ER for SNADETs in a large case series.METHODS This retrospective study included cases that underwent ER for SNADETs at our university hospital between March 2004 and July 2017. Short-term outcomes of ER were measured based on en bloc and R0 resection rates as well as adverse events. Long-term outcomes included local recurrence detected on endoscopic surveillance and disease-specific mortality in patients followed up for ≥ 12 mo after ER.RESULTS In the study, 131 patients with 147 SNADETs were analyzed. The 147 ERs consisted of 136 endoscopic mucosal resections(EMRs)(93%) and 11 endoscopic submucosal dissections(ESDs)(7%). The median tumor diameter was 10 mm.The pathology diagnosis was adenocarcinoma(56/147, 38%), high-grade intraepithelial neoplasia(44/147, 30%), or low-grade intraepithelial neoplasia(47/147, 32%). The R0 resection rate was 68%(93/136) in the EMR group and73%(8/11) in the ESD group, respectively. Cap-assisted EMR(known as EMR-C)showed a higher rate of R0 resection compared to the conventional method of EMR using a snare(78% vs 62%, P = 0.06). No adverse event was observed in the EMR group, whereas delayed bleeding, intraoperative perforation, and delayed perforation in 3, 3, and 5 patients occurred in the ESD group, respectively. One patient with perforation required emergency surgery. In the 43 mo median follow-up period, local recurrence was found in four EMR cases and all cases were treated endoscopically. No patient died due to tumor recurrence.CONCLUSION Our findings suggest that ER provides good long-term outcomes in the patients with SNADETs. EMR is likely to become the safe and reliable treatment for small SNADETs.

Long-term outcomes after laparoscopic colectomy

AIM:To evaluate long-term outcomes in a large series of patients who randomly received laparoscopic or open colorectal resection.METHODS:From February 2000 to December 2004,six hundred sixty-two patients with colorectal disease were randomly assigned to laparoscopic(LPS,n = 330) or open(n = 332) colorectal resection.All patients were analyzed on an intention-to-treat basis.Long-term follow-up was carried out every 6 mo by office visits.In 526 cancer patients five-year overall and disease-free survival were evaluated.Median oncologic follow-up was 96 mo.RESULTS:Eight(4.2%) LPS group patients needed conversion to open surgery.Overall long-term morbidity rate was 7.6%(25/330) in the LPS vs 11.1%(37/332) in the open group(P = 0.17).In cancer patients,fiveyear overall survival was 68.6% in the LPS group and 64.0% in the Open group(P = 0.27).Excluding stage Ⅳ patients,five-year local and distant recurrence rates were 32.5% in the LPS group and 36.8% in the Open group(P = 0.36).Further,no difference in recurrence rate was found when patients were stratified according to cancer stage.CONCLUSION:LPS colorectal resection was associated with a slightly lower incidence of long-term complications than open surgery.No difference between groups was found in overall and disease-free survival rates.

Long-term outcomes of endoscopic resection for small(≤4.0cm) gastric gastrointestinal stromal tumors originating from the muscularis propria layer

AIM To evaluate the long-term efficacy of endoscopic resection(ER) for small(≤ 4.0 cm) gastric gastrointestinal stromal tumors(GISTs) originating from the muscularis propria layer.METHODS Between June 2005 and February 2015, we retrospectively analyzed 229 consecutive patients with gastric MP-GISTs who underwent ER with a follow-up at least 36 mo. The main outcome measurements included complete resection rate, complications, and long-term follow-up outcomes.RESULTS ER included endoscopic muscularis excavation in 179 cases, endoscopic full-thickness resection in 32 cases, and submucosal tunneling endoscopic resection in 18 cases. The median size of GISTs was 1.90 cm. Of the 229 GISTs, 147 were very low risk, 72 were low risk, 8 were intermediate risk, and 2 were high risk. Shortterm outcomes showed the complete resection rate was 96.5%, and 8 patients(3.5%) had complications. Of the 8 patients with complications, only one patient required surgical intervention. Long-term outcomes showed 225 patients were actively followed-up until composition of this manuscript. The remaining 4 patients were lost because of unrelated death. During the follow-up period(median, 57 mo), no residual, recurrent lesions, or distant metastasis were detected in any patients. Binary logistic regression analysis showed tumor size was a risk factor associated with a high mitotic index(≥ 5/50 HPF) of GISTs(P = 0.002).CONCLUSION ER seems to be an effective and safe method for gastric MP-GISTs ≤ 4.0 cm, and, for some intermediate or high risk GISTs, adjuvant therapy and/or additional surgery might be required to reduce the risk of recurrence or metastasis.

Quality of life following laparoscopic Nissen fundoplication: Assessing short-term and long-term outcomes

AIM: To investigate the quality of life following lapa-roscopic Nissen fundoplication by assessing short-term and long-term outcomes. METHODS: From 1992 to 2005, 249 patients under-went laparoscopic Nissen fundoplication. Short-term outcome data including symptom response, side effects of surgery, endoscopy, and patient's perception of over-all success were collected prospectively. Long-term out-comes were investigated retrospectively in patients witha median follow-up of 10 years by assessment of reflux symptoms, side effects of surgery, durability of antire-flux surgery, need for additional treatment, patient's perception of success, and quality of life. Antireflux sur-gery was considered a failure based on the following criteria: moderate to severe heartburn or regurgitation; moderate to severe dysphagia reported in combination with heartburn or regurgitation; regular proton pump inhibitor medication use; endoscopic evidence of erosive esophagitis Savary-Miller grade 1-4; pathological 24-h pH monitoring; or necessity to undergo an additional surgery. The main outcome measures were short-and long-term cure rates and quality of life, with patient sat-isfaction as a secondary outcome measure. RESULTS: Conversion from laparoscopy to open sur-gery was necessary in 2.4% of patients. Mortality was zero and the 30-d morbidity was 7.6% (95%CI: 4.7%-11.7%). The median postoperative hospital stay was 2 d [interquartile range (IQR) 2-3 d]. Two hundred and forty-seven patients were interviewed for short-term analysis following endoscopy. Gastro-esophageal reflux disease was cured in 98.4% (95%CI: 95.9%-99.6%) of patients three months after surgery. New-onset dysphagia was encountered postoperatively in 13 patients (6.7%); 95% reported that the outcome was better after antireflux surgery than with preopera-tive medical treatment. One hundred and thirty-nine patients with a median follow-up of 10.2 years (IQR 7.2-11.6 years) were available for a long-term evalu-ation. Cumulative long-term cure rates were 87.7% (81.0%-92.2%) at 5 years and 72.9% (64.0%-79.9%) at 10 years. Gastrointestinal symptom rating scores and RAND-36 quality of life scores of patients with treatment success were similar to those of the general population but significantly lower in those with failed antireflux surgery. Of the patients available for long-term follow-up, 83% rated their operation a success. CONCLUSION: For the long-term, our results indicate decreasing effectiveness of laparoscopic antirefluxsurgery, although most of the patients seem to have an overall quality of life similar to that of the general population.

Prognostic factors and long-term outcomes of hilar cholangiocarcinoma:A single-institution experience in China

AIM: To evaluate the prognostic factors of hilar cholangiocarcinoma in a large series of patients in a single institution.METHODS: Eight hundred and fourteen patients with a diagnosis of hilar cholangiocarcinoma that were evaluated and treated between 1990 and 2014, of which 381 patients underwent curative surgery, were included in this study. Potential factors associated with overall survival(OS) and disease-free survival(DFS) were evaluated by univariate and multivariate analyses.RESULTS: Curative surgery provided the best long-term survival with a median OS of 26.3 mo. The median DFS was 18.1 mo. Multivariate analysis showed that patients with tumor size > 3 cm [hazard ratio(HR) = 1.482, 95%CI: 1.127-1.949; P = 0.005], positive nodal disease(HR = 1.701, 95%CI: 1.346-2.149; P < 0.001), poor differentiation(HR = 2.535, 95%CI: 1.839-3.493; P < 0.001), vascular invasion(HR = 1.542, 95%CI: 1.082-2.197; P = 0.017), and positive margins(HR = 1.798, 95%CI: 1.314-2.461; P < 0.001) had poor OS outcome. The independent factors for DFS were positive nodal disease(HR = 3.383, 95%CI: 2.633-4.348; P < 0.001), poor differentiation(HR = 2.774, 95%CI: 2.012-3.823; P < 0.001), vascular invasion(HR = 2.136, 95%CI: 1.658-3.236; P < 0.001), and positive margins(HR = 1.835, 95%CI: 1.256-2.679; P < 0.001). Multiple logistic regression analysis showed that caudate lobectomy [odds ratio(OR) = 9.771, 95%CI: 4.672-20.433; P < 0.001], tumor diameter(OR = 3.772, 95%CI: 1.914-7.434; P < 0.001), surgical procedures(OR = 10.236, 95%CI: 4.738-22.116; P < 0.001), American Joint Committee On Cancer T stage(OR = 2.010, 95%CI: 1.043-3.870; P = 0.037), and vascular invasion(OR = 2.278, 95%CI: 0.997-5.207; P = 0.051) were independently associated with tumorfree margin, and surgical procedures could indirectly affect survival outcome by influencing the tumor resection margin. CONCLUSION: Tumor margin, tumor differentiation, vascular invasion, and lymph node status were independent factors for OS and DFS. Surgical procedures can indirectly affect survival outcome by influencing the tumor resection margin.

Long-term outcomes of chronic hepatitis C patients with sustained virological response at 6 months after the end of treatment

AIM: To assess the clinical, biochemical, and virological outcome during long-term follow-up of chronic hepatitis C patients with sustained virological response following effective antiviral therapy.METHODS: This study was a retrospective cohort study including 171 sustained responders defi ned as HCV RNA PCR negative at 6 mo after the end of effective antiviral treatment (SVR-6). Clinical signs and symptoms, bio- chemical hepatic parameters, ultrasonography and HCV RNA PCR were followed.RESULTS: Mean follow-up period was 35.38 ± 22.2 mo after the end of treatment. Twenty-seven (15.8%) responders had evidence of cirrhosis before treatment. Forty-eight (28.1%), 107 (62.6%) and 6 (3.5%) patients were genotype 1, 3, and 6 respectively, while 10 patients (5.8%) were unclassifi ed. There were no virological and biochemical relapses during the period of follow-up. None of the patients showed evidence of hepatic decom- pensation. However, there were 3 patients (1.8%) de- veloping hepatocellular carcinoma at 14, 18, 29 mo after treatment discontinuation, two of whom had evidence of cirrhosis prior to therapy.CONCLUSION: The study shows that during a follow- up interval for about 3 years in 171 chronic hepatitis C patients with sustained viral response after effective antiviral treatment there were no evident signs of either biochemical or clinical relapse of liver disease in all but three patients who developed hepatocellular carcinoma.

Long-term outcomes of autoimmune pancreatitis

Autoimmune pancreatitis(AIP) has been considered a favorable-prognosis disease; however,currently,there is limited information on natural course of AIP during long-term follow-up. Recently published studies regarding the long-term outcomes of AIP has demonstrated the developments of pancreatic stone formation,exocrine insufficiency,and endocrine insufficiency are observed in 5%-41%,34%-82%,and 38%-57% of patients having the disease. Furthermore,the incidence rate of developing pancreatic cancer ranges from 0% to 4.8% during the long-term followup. The event of death from AIP-related complications other than accompanying cancer is likely to be rare. During follow-up of AIP patients,careful surveillance for not only relapse of the disease but also development of complications at regular intervals is needed.

Comparison of short-and long-term outcomes of laparoscopic vs open resection for gastric gastrointestinal stromal tumors

AIM To compare the short-and long-term outcomes of laparoscopic(LR) vs open resection(OR) for gastric gastrointestinal stromal tumors(g GISTs).METHODS In total, 301 consecutive patients undergoing LR or OR for pathologically confirmed g GISTs from 2005 to 2014 were enrolled in this retrospective study. After exclusion of 77 patients, 224 eligible patients were enrolled(122 undergoing LR and 102 undergoing OR). The demographic, clinicopathologic, and survival data of all patients were collected. The intraoperative, postoperative, and long-term oncologic outcomes were compared between the LR and OR groups following the propensity score matching to balance the measured covariates between the two groups.RESULTS After 1:1 propensity score matching for the set of covariates including age, sex, body mass index, American Society of Anesthesiology score, tumor location, tumor size, surgical procedures, mitotic count, and risk stratification, 80 patients in each group were included in the final analysis. The baseline parameters of the two groups were comparable after matching. TheLR group was significantly superior to the OR group with respect to the operative time, intraoperative blood loss, postoperative first flatus, time to oral intake, and postoperative hospital stay(P < 0.05). No differences in perioperative blood transfusion or the incidence of postoperative complications were observed between the two groups(P > 0.05). No significant difference was found in postoperative adjuvant therapy(P = 0.587). The mean follow-up time was 35.30 ± 26.02(range, 4-102) mo in the LR group and 40.99 ± 25.07(range, 4-122) mo in the OR group with no significant difference(P = 0.161). Survival analysis showed no significant difference in the disease-free survival time or overall survival time between the two groups(P > 0.05).CONCLUSION Laparoscopic surgery for g GISTs is superior to open surgery with respect to intraoperative parameters and postoperative outcomes without compromising longterm oncological outcomes.

Children with Steroid-resistant Nephrotic Syndrome:Long-term Outcomes of Sequential Steroid Therapy

Objective This study aimed to investigate the long-term outcomes in children with steroid-resistant nephrotic syndrome （SRNS）, who received methylprednisolone pulse therapy （MPT）-based sequential steroid therapy. In particular, we aimed to observe whether these patients had a high risk of adverse events. Methods We conducted a retrospective study over a 5-year period. The long-term outcomes for children with SRNS receiving sequential therapy were observed. Results Sixty-three children were diagnosed with SRNS and underwent MPT-based sequential steroid therapy. Thirty-five （55.6%） achieved complete or partial remission, 19 （30.2%） of whom were in remission even after treatment cessation at last review. The mean time to initial remission after MPT was 24.3±13.1 days. Forty-nine children （77.8%） experienced relapses, of whom 31 （49.2%） demonstrated a frequent relapsing course. Adverse effects relevant to MPT were generally mild and infrequent. Five patients （7.9%） complained of vomiting or nausea during MPT infusion; 25 （39.7%） experienced excessive weight gain and developed an obvious Cushingoid appearance; and 26 （41.3%） had poor growth associated with long-term steroid use. Twenty-eight patients （44.4%） failed to respond to MPT, of whom 21 （33.3%） achieved complete or partial remission with immunosuppressive agents. Conclusion MPT-based sequential steroid therapy appears to be a safe and effective method for inducing rapid remission in childhood SRNS. Further clinical studies are needed to comprehensively evaluate this therapy.

Effect of liver cirrhosis on long-term outcomes after acute respiratory failure: A population-based study

AIM To assessed the effect of liver cirrhosis(LC) on the poorly understood long-term mortality risk after firstever mechanical ventilation(1-MV) for acute respiratory failure.METHODS All patients in Taiwan given a 1-MV between 1997 and 2013 were identified in Taiwan's Longitudinal Health Insurance Database 2000. Each patient with LC was individually matched, using a propensity-score method, to two patients without LC. The primary outcome was death after a 1-MV.RESULTS A total of 16653 patients were enrolled: 5551 LC-positive (LC^([Pos])) patients, including 1732 with cryptogenic LCs and 11102 LC-negative(LC^([Pos])) controls. LC^([Pos]) patients had more organ failures and were more likely to be admitted to medical department than were LC^([Pos]) controls. LC^([Pos]) patients had a significantly lower survival rate(AHR = 1.38, 95%CI: 1.32-1.44). Moreover, the mortality risk was significantly higher for patients with non-cryptogenic LC than for patients with cryptogenic LC(AHR = 1.43, 95%CI: 1.32-1.54) and patients without LC(AHR = 1.56, 95%CI: 1.32-1.54). However, there was no significant difference between patients with cryptogenic and without LC(HR = 1.05, 95%CI: 0.98-1.12).CONCLUSION LC, especially non-cryptogenic LC, significantly increases the risk of death after a 1-MV.

Long-term outcomes of penetrating keratoplasty in keratoconus: analysis of the factors associated with final visual acuities

AIM:To investigate the long-term results of penetrating keratoplasty(PK)in patients with keratoconus(KC)and to evaluate factors that might influence the final visual outcome.METHODS:We retrospectively reviewed the data of all patients with clinical KC who had undergone PK by a single corneal surgeon in a single center from May 1980to December 2005.The age of the patients,preoperative best-corrected visual acuity(BCVA),corneal thickness,death to preservation time,and preservation to transplantation time were recorded.Additionally,postoperative complications such as graft rejection,development of glaucoma and specular microscopy were checked during the follow-up.RESULTS:Sixty-nineeyesfrom69patientswerefinally included.The follow-up period was 8.64±6.13y.Graft rejection occurred in 4 eyes of 69 cases(5.8%),and the time to graft rejection was 2.1±1.3y.A Kaplan-Meier survival analysis showed that the estimated cumulative probability of graft rejection at 6,13,and 17y after PK were 95.6%,90.0%,and 78.8%,respectively.When we evaluated factors that might influence final BCVA in eyes,no disparity donor-host trephine size(same graft size)as well as higher spherical equivalent,and average Kvalue were associated with higher final BCVA.(P=0.006,0.051,0.092,and 0.021 in eyes with follow-up【8y;P=0.068,0.065,and 0.030 in eyes with follow-up≥8y,respectively).CONCLUSION:The long-term results of PK in patients with KC were favorable with a high percentage of good BCVA.Less myopic change and low average K-reading,as well as a surgical technique using the same size donor-recipient button may provide better visual outcomes particularly in patients with KC.

Short and long-term outcomes of endoscopic balloon dilatation for Crohn's disease strictures

AIM:To investigate the short and long-term outcomes of endoscopic balloon dilatation(EBD) for Crohn's disease(CD) strictures.METHODS:Between January 1995 and December 2011,47 EBD procedures were performed in 30 patients(8 females and 22 males) with CD.All patients had strictures through which an endoscope could not pass,and symptoms of these strictures included abdominal pain,abdominal fullness,nausea,and/or vomiting.The 47 strictures included 17 anastomotic and 30 de novo strictures.Endoscopy and dilatation were performed under conscious sedation with intravenous diazepam or flunitrazepam.The dilatations were all performed using through-the-scope balloons with diameters from 8 mm to 20 mm on inflation and lengths of 30-80 mm.Each dilatation session consisted of two to four,3-min multistep inflations of the balloon,repeated at intervals of 1 wk until adequate dilatation(up to 15-20 mm in diameter) was achieved.The follow-up data were collected from medical records and analyzed retrospectively.Primary success was defined as passage of the scope through the stricture after EBD.Longterm outcomes were analyzed focusing on interventionfree survival and surgery-free survival demonstrated by the Kaplan-Meier method.(Intervention-free meant cases in which neither endoscopic balloon re-dilatation nor surgery was needed after the first dilatation during the observation period).The log rank test was used to evaluate the difference in long-term outcomes between anastomotic and de novo stricture cases.RESULTS:Primary success was achieved in 44 of the 47 strictures(93.6%).Balloon dilatations failed in 3 cases(6.4%).In 1 case,EBD was a technical failure because the guide-wire could not be passed through the stricture which showed severe adhesion and was a flexural lesion of the intestine.In 2 cases,unexpected perforations occurred immediately after balloon dilatation.Of the 47 treatments,complications occurred in 5(10.6%).All 5 patients had de novo strictures.One suffered bleeding,two high fever and there were colorectal perforations.One of the patients with a colorectal perforation was treated surgically,the other was managed conservatively.These 2 cases correspond to the two aforementioned EBD failures.Long-term outcomes were evaluated for the 44 successfully-treated strictures after a median follow-up of 26 mo(range,2-172 mo).During the observation period,re-strictures after EBDs occurred in 26 cases(60.5%).Fourteen of these 26 re-stricture cases underwent EBD again,but in two EBD failed and surgery was ultimately performed in both cases.Twelve of the 26 re-stricture cases were initially treated surgically when the re-strictures occurred.Finally,30 of the 47 strictures(63.8%) were successfully managed with EBD,allowing surgery to be avoided.Intervention-free survival evaluated by the Kaplan-Meier method was 75% at 12 mo,58% at 24 mo,and 43% at 36 mo.There was no significant difference between the anastomotic strictures(n = 16) and de novo strictures(n = 28) in the intervention-free survival as evaluated by the log-rank test.Surgery-free survival evaluated by the Kaplan-Meier method was 90% at 12 mo,75% at 24 mo,and 53% at 36 mo.The 16 anastomotic strictures were associated with significantly better surgery-free survivals than the 28 de novo strictures(log-rank test:P < 0.05).CONCLUSION:Anastomotic strictures were associated with better long-term outcomes than de novo strictures,indicating that stricture type might be useful for predicting the long-term outcomes of EBD.

Long-term outcomes after fractional flow reserve-guided percutaneous coronary intervention in patients with severe coronary stenosis

Objective To explore the safety and efficacy of FFR-guided percutaneous coronary intervention (PCI) in vessels with severe diameter stenosis. Methods & Results Of 1090 patients undergoing fractional flow reserve (FFR) assessment from 2002 to 2009,we identified 167 patients in whom FFR was measured in at least one 70%–89% stenotic lesion. These patients were subdivided into an FFR-defer group (n = 49) if PCI was deferred (FFR > 0.80),and an FFR-perform group (n = 118) if PCI was performed (FFR ≤ 0.80). Comparatively,an additional 1176 patients undergoing PCI in at least one lesion with 70%–89% stenosis but without measurement of FFR served as a control (angiography- guided) group. Clinical outcomes were compared during a median follow-up of 49.0 months. The 5-year Kaplan-Meier estimated revascularization rates were 16% in the FFR-defer group and 33% in the FFR-perform group (P = 0.046). The incidence of major adverse cardiac events were comparable in these two groups (HR = 0.82,95% CI: 0.37–1.82,P = 0.63). The number of stents placed was significantly lower in the FFR-guided group (0.9 ± 0.8 vs. 1.4 ± 0.8,P < 0.001). Conclusions Functional revascularization for lesions with visually severe stenosis is clinically safe and associated with fewer stents use. This study suggests that extending the use of FFR to more severe coronary lesions may be reasonable.