Laparoscopic Management of Perforated Peptic Ulcer: Simple Closure or Something More?

Purpose: During the last decade laparoscopic approach to perforated peptic ulcer has gained wide acceptance over the traditional open repair on the basis of being an equally efficient and less invasive technique. Methods: 198 patients with perforated duodenal or prepyloric ulcer that were surgically treated from 2003 to 2014 were included in this study. 140 were operated within 2 - 6 hours from the onset of symptoms, 55 within 6 - 24 hours, and 3 patients after 24 hours. Results: Laparoscopic simple closure with Graham patch was performed in 179 patients. In 19 patients with known chronic ulcer resistant to pharmacologic therapy, who were operated within 6 hours from the onset of symptoms, laparoscopic Taylor procedure was undertaken. Conversion to open repair was necessitated in four patients. The operating time was 40 - 100 min for the Graham patch repair and 120 - 155 min for the Taylor procedure. During follow-up, 48% of patients from the “Graham patch” group and no one from the “definitive procedure” group had recurrent ulcer. Conclusions: Laparoscopic treatment of perforated peptic ulcer is technically feasible and safe when performed by experienced surgeons. In certain cases more definitive procedures may achieve better long-term results.

Efficacy and Safety of 30% Supramolecular Salicylic Acid Peeling Combined with Isotretinoin Erythromycin Gel in the Treatment of Moderate-to-Severe Acne Vulgaris: A Comparative Study

Background: Both 30% supramolecular salicylic acid (SA) and isotretinoin erythromycin gel (IEG) have proven efficacy with good safety profiles in the treatment of acne vulgaris. Objectives: This study compared the clinical efficacy and safety of 30% SA peeling and IEG in the treatment of moderate-to-severe acne vulgaris. Methods: Patients with moderate-to-severe acne vulgaris were randomized into 3 groups of 30 persons each, and treated with SA peel, or IEG, or SA combine with IEG (SA + IEG group). Evaluation of acne was done by effective rate and individual lesion counts. And the adverse effects and recurrence were recorded. Results: The SA + IEG group was better in clinical efficacy and treating noninflammatory and inflammatory lesions than that of single treatment group (P 0.05). Conclusion: 30% SA combined with IEG had a significant effect in the treatment of moderate-to-severe acne lesions.

A Comparative Study of the Recurrence Rate in Hypofractionated versus Conventional Postmastectomy Radiation in Breast Cancer

Background: Treatment options available for breast cancer are Surgery [Breast conservation surgery (BCS) or Modified radical mastectomy (MRM)];Radiation treatment [Conventional radiation treatment or CRT and Hypofractionated radiation treatment or HRT] and Chemotherapy. In the postmastectomy or post lumpectomy setting, radiotherapy (RT) improves loco-regional control. CRT for breast includes 50 Gy in 25 fractions (2 Gy per fraction) and HRT includes 42.5 Gy in 16 fractions (2.7 Gy per fraction) or extreme hypofractionation like 26 Gy in 5 fractions. Alpha/beta value for breast is less, so HRT is ideal for breast. So, there will be good loco-regional control, without increased normal tissue damage. This study aims to identify recurrence rate and toxicity in breast cancer patients treated using conventional and hypofractionated postmastectomy radiotherapy among Indian population. Primary objective: To assess recurrence rate of disease in breast cancer patients treated using hypofractionated postmastectomy radiation and to compare it with breast cancer patients treated using conventional postmastectomy radiation. Secondary objective: To assess the toxicity in hypofractionation and conventional fractionation arm. Methods: This is a prospective observational study conducted in Department of Radiation Oncology from December 2017 to June 2019. Radically treated breast cancer patients who received radiation treatment either conventional or hypofractionated as one of the treatment modalities were included in the study. Data were collected using a structured proforma, history and physical examination, master file of the patients, lab results and the imaging reports, written informed consent form, ECOG performance status scale (Eastern Cooperative Oncology Group), RTOG (Radiation Therapy Oncology Group) Acute Radiation Morbidity Scoring Schema. Patients were monitored for 18 months to identify recurrence rate and toxicity in each arm. Results and discussion: A total of 241 patients were enrolled into this study, among them 175 patients (73%) were given hypofractionation radiotherapy and 66 patients (27%) were given conventional radiotherapy. In hypofractionation arm, recurrence was found in 14 patients (8%), of which, 3 were local recurrences [chest wall] and 11 were systemic recurrences, while in conventional arm, recurrence was found in 4 patients (6%) and all of them were systemic recurrences. Recurrence rate in hypofractionation arm was 8% and in conventional arm was 6.10%. The Kaplan Meier curve shows no significant difference between the two arms with p value = 0.76. Acute toxicities assessed were dermatitis, esophagitis and pneumonitis. Among acute dermatitis, 4 patients had grade 3 and 2 patients had grade 4 in hypofractionation arm, while in conventional arm, 7 patients had grade 3 and 1 patient had grade 4. Grade 1 and 2 together versus grade 3 and 4 acute dermatitis showed a statistically significant difference between the two arms, with more acute toxicity in the conventional arm. Among acute esophagitis, 1 patient had grade 3 and no patients had grade 4 in hypofractionation arm;while in conventional arm, no grade 3 and grade 4 acute esophagitis were found. Among acute pneumonitis, 2 patients had grade 3 and 1 patient had grade 4 in hypofractionation arm, while in conventional arm, 1 patient had grade 3 and no patients with grade 4 were found. Grade 2 and grade 3 acute lung toxicities were found in patients with central lung distance more than 1.5 cm. Conclusion: It was found that the recurrence rate of hypofractionation radiotherapy was comparable to conventional fractionation radiotherapy. With respect to acute dermatitis, grade 1 and grade 2 were significantly more in conventional than hypofractionation arm. Hypofractionated radiotherapy is an equally effective option to conventional radiotherapy and should be encouraged, especially for developing countries like India where the resource is limited, and the incidence of tumour is high.

Mitomycin C in pterygium treatment

Pterygium is a benign lesion usually growing from the nasal side of the conjunctiva onto the cornea.Most cases of pterygium does not cause problem or requires specific treatment.The exact cause of pterygium is not clear yet,but some factors are pointed as causes,being the most important the long-term ultraviolet ray exposure.Pterygium surgery is usually considered when there are symptoms that do not respond to conservative treatment.Recurrence is the main complication of the surgery,and much has been done to avoid it.Mitomycin C（MMC） has been used as a fibroblast proliferation inhibitor during the surgery to reduce the chance of recurrence of the pterygium.This review describes the use of MMC as an adjunctive,the optimal dosage,the duration of administration of MMC and possible complications,when used during,after and before the surgery.Most studies suggest that increased exposure（dose or duration） of MMC is associated with a lower recurrence,but with higher risks of complications.

Surgical outcomes in inferior recurrences of rhegmatogenous retinal detachment

AIM:To analyze the anatomical and functional outcomes in the inferior recurrences of rhegmatogenous retinal detachment(RRD)depending on the surgical approach.METHODS:Eighty-one eyes of 81 patients(47 males and 34 females with a mean age of 54.8±14.1y)who demonstrated at least one inferior recurrence of RRD were included in this retrospective study.All patients were categorized as having received either circular scleral buckling(SB),pars plana vitrectomy(PPV),a combination of SB and PPV(SB+PPV),PPV with retinotomy(PPV+RT),or PPV+RT and short-term postoperative perfluorocarbon liquid tamponade(PPV+RT+pPFCL).All cases were followed up until successful retinal reattachment or third recurrence.The primary outcome measures were the achievement of the surgical goal without recurrence of RRD and bestcorrected visual acuity(BCVA).RESULTS:After the treatment of the first recurrence,the recurrence rate in the PPV+SB group was statistically significantly lower than that of the PPV(P=0.0012),PPV+RT(P=0.028),or PPV+RT+pPFCL(P=0.047)group.There was no statistically significant difference between PPV+SB,PPV+RT,and PPV+RT+pPFCL groups in the recurrence rate after treatment of the second recurrence(42 eyes).However,there was a statistically significant(P=0.016)trend towards a decrease of recurrence rate after PPV+RT+pPFCL.There was no statistically significant improvement of BCVA in either study group(P>0.05)after both first and second recurrence surgery.The mean time follow-up was 109.0±91.0d before the first recurrence and 210.0±186.6d between previous surgery at second recurrence.CONCLUSION:Patients with first inferior recurrence of RRD may benefit from SB as an adjunct to PPV.RT and short-term pPFCL tamponade in the second recurrence may allow better anatomical outcomes,however,without functional improvement.

Critical review of topical management of oral hairy leukoplakia

Oral hairy leukoplakia(OHL) is a disease associated with Epstein-Barr virus and human immunodeficiency virus infections. OHL is usually an asymptomatic lesion, but in some cases treatment is recommended to reestablish the normal characteristics of the tongue, to eliminate pathogenic microorganisms, to improve patient comfort and for cosmetic reasons. Proposed treatments for this condition include surgery, systemic antiviral treatment and topical management. Topical treatment is an inexpensive and safe therapy that is easy to apply, noninvasive, free of systemic adverse effects and effective over a long period of time. The aim of this study was to present a review of the literature for topical therapy for OHL. Gentian violet, retinoids, podophyllin, acyclovir and podophyllin associated with topical antiviral drugs were used to treat OHL. Reports with this focus are limited, and since 2010, no new studies have been published that discuss the efficacy of topical treatments for OHL. Podophyllin with acyclovircream was found to be effective, causing regression of lesions with no recurrences. Additional searches are necessary to provide clinical evidence of topical man agement effectiveness.

Colonic stent for bridge to surgery for acute left-sided malignant colonic obstruction:A review of the literature after 2020

It has been found that 8%-29%of colorectal cancers are obstructive.The use of“stent as bridge to surgery”is one of the most debated topics in obstructive leftsided colorectal cancer management.The endoscopic placement of a selfexpanding metallic stent as bridge to surgery(BTS)could turn an emergency surgery to an elective one,increasing the number of primary anastomoses instead of stoma and facilitating the laparoscopic approach instead of an open one.However,in recent years the possible risk of perforations and microperforations facilitating cancer spread related to the use of self-expanding metallic stent for BTS has been highlighted.Therefore,despite the useful short-term outcomes related to BTS,the recent literature has focused on long-term outcomes investigating the disease-free survival,the recurrence rate and the overall survival.Due to discordant data,international guidelines are still conflicting,and the debate is still open.There is not agreement about using self-expanding metallic stent for BTS as the gold standard.

Liver transplantation for hepatocellular carcinoma： is zero recurrence theoretically possible？

BACKGROUND： Hepatocellular carcinoma（HCC） recurrence remains a key issue after liver transplantation. This study aimed to determine a subgroup of HCC patients within the Milan criteria who could achieve a theoretical goal of zero recurrence rates after liver transplantation.METHODS： Between 1999 and 2009, 179 patients who received liver transplantation for HCC within the Milan criteria were retrospectively included. Analysis of the factors associated with HCC recurrence was performed to determine the subgroup of patients at the lowest risk of recurrence.RESULTS： Seventy-two percent of the patients received a bridging therapy, including 54 liver resections. Eleven（6.1%） patients recurred within a delay of 19±22 months and ultimately died. Factors associated with recurrence were serum alpha-fetoprotein level 〉400 ng/m L, satellite nodules, poor differentiation, microvascular invasion and cholangiocarcinoma component. Recurrence rates decreased from 6.1% to 3.1% in patients without any of these factors.CONCLUSIONS： Among HCC patients within the Milan criteria, selecting patients with factors based on histology would allow tending towards zero recurrence, and prior histological assessment by liver biopsy or resection may be essential to rule out poorly differentiated tumors, microvascular invasion,and cholangiocarcinoma component.

Surgical Outcomes and Local Recurrence Following Total or Subtotal Gastrectomy for Early Adenocarcinoma of Antrum

Objective： The choice between total gastrectomy （TG） and subtotal gastrectomy （STG） for early adenocarcinoma of the lower third of the stomach is still a matter of debate and controversy amongst surgeons. The aim of this study was to compare the surgical outcomes, quality of life （QoL）, and local recurrence rates as well as other results of curative resection of early distal adenocarcinoma of the stomach using TG or STG performed in Iran. Methods： Hospital records of 66 patients with early distal adenocarcinoma of stomach that underwent even total or subtotal gastrectomy with perigastric （D2） lymphadenectomy between October 2001 and February 2006 in Taleghani Hospital, Iran were reviewed retrospectively. Demographic data as well as clinicopathological factors including number of involved lymph nodes, tumor grading, depth of invation, tumor size, and tumor type were recorded. Post-operative outcomes including mortality and morbidity, tumor recurrence and quality of life were assessed. Univariate analyses using Fisher＇s exact test, the Student t-test, and the Pearson χ^2 test were used. Results： Local recurrence of tumor was found in 8 （23%） TG group patients and in 19 （61%） patients of STG group, the Pearson χ^2 test showed a significant higher recurrence rate in STG （P value=0.002, Relative Risk=2.68, Confidence Interval： 1.37-5.24）.The mean time interval between gastrectomy and tumor recurrence was not different between TG and STG. （19.75±5.1 vs. 18.0±7.8 respectively; P value=0.507） Tumor size 〉5 cm （P value=0.004）, diffuse type （P value=0.034）, poor differentiation （P value=0.000） and serosal invasion （P value=0.012） were found to be significantly related to tumor recurrence in patients undergone gastrectomy. In none of the QoL measures a significant difference was found between TG and STG Conclusion： Our results show that subtotal and total gastrectomy methods with perigastric lymphadenectomy have a similar postoperative complication rate and surgical outcomes as well as patient＇s QoL but STG was associated to a more than twofold increase in local recurrence risk.

Meta-analysis of clinical efficacy of combined traditional Chinese and western medicine in the treatment of granulomatous mastitis

Objective:To systematically evaluate the clinical effect (including effective rate and recurrence rate) of the combination of traditional Chinese and Western medicine in the treatment of granulomatous mastitis (GM).Methods: Computer searches CNKI, Wanfang database, VIP, PubMed, web of science and EMBASE, Chinese biomedical database, and selects randomized controlled trial (RCT) of treating granulomatous mastitis with the combination of traditional Chinese and Western medicine. The retrieval time is from July 2019 to July 2019. Then, we used Revman 5.3 software to meta analyze the data.Results: Nine RCTs were included, six of which were effective observation, two of which were recurrence rate observation, one of which was effective observation and reexamination rate observation. A total of 664 patients were included, including 456 in the experimental group and 208 in the control group. After analysis, it was found that the effective rate of GM in the experimental group was 92.3%, which was significantly higher than that in the control group (Western medicine alone) by 75.5% (or = 4.09, 95% CI (2.28, 7.36), P < 00001), the recurrence rate of GM in the experimental group (treated with integrated traditional Chinese and Western Medicine) was 21.6%, which was significantly lower than that in the control group (treated with western medicine alone) by 55.7% (or = 0.19, 95% CI (0.10, 0.37), P < 0.0001).Conclusion: The combination of traditional Chinese and Western medicine in the treatment of granulomatous mastitis can not only improve the effective rate of clinical treatment, but also reduce the recurrence rate of granulomatous mastitis.

Dynamic characteristics of bubbling fluidization through recurrence rate analysis of pressure fluctuations

Pressure fluctuations signals of a lab-scale fiuidized bed （15 cm inner diameter and 2 m height） at different superficial gas velocities were measured. Recurrence plot （RP） and recurrence rate （RR）, and the simplest variable of recurrence quantification analysis （RQA） were used to analyze the pressure signals. Different patterns observed in RP reflect different dynamic behavior of the system under study. It was also found that the variance of RR （a2R） Could reveal the peak dominant frequencies （PDF） of different dynamic systems： completely periodic, completely stochastic, Lorenz system, and fluidized bed. The results were compared with power spectral density. Additionally, the diagram of σ^2RR provides a new technique for prediction of transition velocity from bubbling to turbulent fluidization regime.

Controlling the Recurrence of Pelvic Endometriosis after A Conservative Operation:Comparison between Chinese Herbal Medicine and Western Medicine

Objective： To compare the clinical effect of Chinese medicine （CM） and Western medicine （WM） for controlling the recurrence of pelvic endometriosis after a conservative operation. Methods： The study was a multi-center, randomized, parallel controlled and prospective clinical trial. Patients were randomly divided into two groups： CM group （106 cases） and WM group （102 cases）. Drugs were given to patients during 1--5 days of the first menstruation after a conservative operation in both groups. Patients with stages I and I1 （revised American Fertility Society） were treated for 3 months, while the patients with stages Ill and IV were treated for 6 months. The patients in the CM group were treated using three types of Chinese herbal medicine based on syndrome differentiation. Patients in the WM group were treated using gonadotropin releasing hormone agonist （GnRH-a） or gestrinone. Patients treated with GnRH-a received add-back therapy of Tibolone Tablets once a day after 4 months of treatment. Any cases of dysmenorrheal chronic pelvic pain, menstruation and any adverse reactions of patients were recorded once a month during the preoperative and postoperative periods and once every 3 months during the follow-up period. During the preoperative, postoperative and the follow-up periods, patients underwent type B ultrasonography of the pelvis and measurements of serum CA125 levels, gynecologic examination, routine evaluations of blood, urine, hepatic function （glutamate pyruvate transaminase）, renal function （blood urea nitrogen） and electrocardiograms. Dudng the follow-up period they underwent type B pelvic ultrasonography, measurement of serum CA125 levels and further gynecologic examinations. The two treatments were compared for clinical recurrence rates, pregnancy rates and the incidence of adverse reactions. Results： The incidence and timing of recurrence of endometriosis were not significantly different between the two groups. The first pregnancy achieved by the patient in the CM .qroup was si.clnificantly earlier than that in the WM group （P〈0.05）. Moreover, the incidence of adverse reactions in the WM group was significantly higher than in the CM group （P〈O.01）. Conclusions： Treatment with Chinese herbal medicines prevented the recurrence of endometriosis after a conservative operation, improved the conception rate and showed fewer and lighter adverse reactions than did treatment with WM therapy. Treatment with Chinese herbal medicine meets the need of patients wishing to have a child following endometriosis and is an appropriate form of clinical treatment.