Large gastric hamartomatous inverted polyp accompanied by advanced gastric cancer:A case report

BACKGROUND Gastric hamartomatous inverted polyps(GHIPs)are benign polyps of the gastric submucosal layer.Currently there are 52 reported cases in the English literature.According to a literature review,approximately 27%of GHIPs show a coexisting carcinoma.CASE SUMMARY A 66-year-old man was referred to our institution with ulcerative lesions detected on esophagogastroduodenoscopy(EGD)during a regular check-up.Other medical findings were nonspecific.The lesions had borderline histologic features that could not exclude malignancy and were followed up with three EGDs and biopsies at intervals of 3 mo.The latest biopsy was revealed as an adenocarcinoma.A total gastrectomy was performed to remove the tumor.The surgical specimen revealed a 6.9 cm×4.5 cm sized GHIP with a coexisting 1.6 cm sized well-differentiated adenocarcinoma which extended to the muscularis propria.The malignancy did not originate from the GHIP but showed an overlap.CONCLUSION A large GHIP,which was unusually presented as an ulcerative lesion,was surgically removed,and was accompanied by advanced gastric cancer.Regular follow-up and thorough examinations of ulcerative lesions with equivocal biopsy have resulted in appropriate diagnosis and treatment.Therefore,aggressive intervention may be beneficial if GHIP is suspected.

Differences in Pandemic-Related Factors Associated with Alcohol and Substance Use among Korean Adolescents:Nationwide Representative Study

The coronavirus disease 2019(COVID-19)pandemic has raised concerns about the mental health and social well-being of youth,including its potential to increase or exacerbate substance use behaviors[1].Among adolescents,the COVID-19pandemic has resulted in limited face-to-face school contact and thus missed milestones in preventing alcohol and substance use.

Priapism secondary to penile metastasis of rectal cancer

Metastatic penile carcinoma is rare and usually originates from genitourinary tumors. The presenting symptoms or signs have been described as nonspecific except for priapism. Rectal adenocarcinoma is a very unusual source of metastatic penile carcinoma. We report a case of metastatic penile carcinoma that originated from the rectum. Symptomatic improvement occurred with palliative radiotherapy.

Endoscopic band ligation: Beyond prevention and management of gastroesophageal varices

Endoscopic band ligation (EBL) is the preferred endoscopic technique for the endoscopic treatment of acute esophageal variceal bleeding. EBL has also been used to treat nonvariceal bleeding. Recently, Han et al demonstrated that EBL can be a feasible and safe alternate technique for the management of iatrogenic gastric perforation especially in cases in which closure with endoclips is difficult. EBL is technically simpler to perform than other methods and provides a good view of the lesions under direct pressure and suction from the transparent ligation cap. EBL can be used even if the diameter of the perforation is greater than 10 mm or if there is a severe tangential angle. In this commentary, we discuss the efficacy and safety of EBL for the closure of iatrogenic gastrointestinal perforation. We also discuss the advantages and disadvantages of EBL for the treatment of nonvariceal bleeding.

Which endoscopic treatment is the best for small rectal carcinoid tumors?

The incidence of rectal carcinoids is rising because of the widespread use of screening colonoscopy. Rectal carcinoids detected incidentally are usually in earlier stages at diagnosis. Rectal carcinoids estimated endoscopically as < 10 mm in diameter without atypical features and confined to the submucosal layer can be removed endoscopically. Here, we review the efficacy and safety of various endoscopic treatments for small rectal carcinoid tumors, including conventional polypectomy, endoscopic mucosal resection(EMR),cap-assisted EMR(or aspiration lumpectomy),endoscopic submucosal resection with ligating device,endoscopic submucosal dissection, and transanal endoscopic microsurgery. It is necessary to carefully choose an effective and safe primary resection method for complete histological resection.

Should anticoagulants be administered for portal vein thrombosis associated with acute pancreatitis?

Venous complications in patients with acute pancreatitis typically occur as a form of splenic,portal,or superior mesenteric vein thrombosis and have been detected more frequently in recent reports.Although a well-organized protocol for the treatment of venous thrombosis has not been established,anticoagulation therapy is commonly recommended.A 73-year-old man was diagnosed with acute progressive portal vein thrombosis associated with acute pancreatitis.After one month of anticoagulation therapy,the patient developed severe hematemesis.With endoscopy and an abdominal computed tomography scan,hemorrhages in the pancreatic pseudocyst,which was ruptured into the duodenal bulb,were confirmed.After conservative treatment,the patient was stabilized.While the rupture of a pseudocyst into the surrounding viscera is a well-known phenomenon,spontaneous rupture into the duodenum is rare.Moreover,no reports of upper gastrointestinal bleeding caused by pseudocyst rupture in patients under anticoagulation therapy for venous thrombosis associated with acute pancreatitis have been published.Herein,we report a unique case of massive upper gastrointestinal bleeding due to pancreatic pseudocyst rupture into the duodenum,which developed during anticoagulation therapy for portal vein thrombosis associated with acute pancreatitis.

Minimally invasive surgery for gastric cancer: A comparison between robotic, laparoscopic and open surgery

AIM To investigate the role of minimally invasive surgery for gastric cancer and determine surgical, clinical, and oncological outcomes.METHODS This is a propensity score-matched case-control study, comparing three treatment arms: robotic gastrectomy(RG), laparoscopic gastrectomy(LG), open gastrectomy(OG). Data collection started after sharing a specific study protocol. Data were recorded through a tailored and protected web-based system. Primary outcomes: harvested lymph nodes, estimated blood loss, hospital stay, complications rate. Among the secondary outcomes, there are: operative time, R0 resections, POD of mobilization, POD of starting liquid diet and soft solid diet. The analysis includes the evaluation of type and grade of postoperative complications. Detailed information of anastomotic leakages is also provided.RESULTS The present analysis was carried out of 1026 gastrectomies. To guarantee homogenous distribution of cases, patients in the RG, LG and OG groups were 1:1:2 matched using a propensity score analysis with a caliper = 0.2. The successful matching resulted in a total sample of 604 patients(RG = 151; LG = 151; OG = 302). The three groups showed no differences in all baseline patients characteristics, type of surgery(P = 0.42) and stage of the disease(P = 0.16). Intraoperative blood loss was significantly lower in the LG(95.93 ± 119.22) and RG(117.91 ± 68.11) groups compared to the OG(127.26 ± 79.50, P = 0.002). The mean number of retrieved lymph nodes was similar between the RG(27.78 ± 11.45), LG(24.58 ± 13.56) and OG(25.82 ± 12.07) approach. A benefit in favor of the minimally invasive approaches was found in the length of hospital stay(P < 0.0001). A similar complications rate was found(P = 0.13). The leakage rate was not different(P = 0.78) between groups.CONCLUSION Laparoscopic and robotic surgery can be safely performed and proposed as possible alternative to open surgery. The main highlighted benefit is a faster postoperative functional recovery.

New totally intracorporeal reconstructive approach after robotic total gastrectomy: Technical details and short-term outcomes

To show outcomes of our series of patients that underwent a total gastrectomy with a robotic approach and highlight the technical details of a proposed solution for the reconstruction phase.METHODSData of gastrectomies performed from May 2014 to October 2016, were extracted and analyzed. Basic characteristics of patients, surgical and clinical outcomes were reported. The technique for reconstruction (Parisi Technique) consists on a loop of bowel shifted up antecolic to directly perform the esophago-enteric anastomosis followed by a second loop, measured up to 40 cm starting from the esojejunostomy, fixed to the biliary limb to create an enteroenteric anastomosis. The continuity between the two anastomoses is interrupted just firing a linear stapler, so obtaining the Roux-en-Y by avoiding to interrupt the mesentery.RESULTSFifty-five patients were considered in the present analysis. Estimated blood loss was 126.55 ± 73 mL, no conversions to open surgery occurred, R0 resections were obtained in all cases. Hospital stay was 5 (3-17) d, no anastomotic leakage occurred. Overall, a fast functional recovery was shown with a median of 3 (3-6) d in starting a solid diet.CONCLUSIONRobotic surgery and the adoption of a tailored reconstruction technique have increased the feasibility and safety of a minimally invasive approach for total gastrectomy. The present series of patients shows its implementation in a western center with satisfying short-term outcomes.

Treatment of biliary tract cancer with NVP-AEW541:Mechanisms of action and resistance

AIM:To investigate in vitro treatment with NVPAEW541,a small molecule inhibitor of insulin-like growth factor-1 receptor(IGF-1R),in biliary tract cancer (BTC),since this disease is associated with a poor prognosis due to wide resistance to chemotherapeutic agents and radiotherapy.METHODS:Cell growth inhibition by NVP-AEW541 was studied in vitro in 7 human BTC cell lines by automated cell counting.In addition,the anti-tumoral mechanism of NVP-AEW541 was studied by Western blotting,cell cycle analysis and reverse transcription-polymerase chain reaction(RT-PCR).Anti-tumoral drug effect in combination with gemcitabine,5-fluorouracil(5-FU)and Polo-like kinase 1 inhibitor BI2536 was also studied. RESULTS:In vitro treatment with NVP-AEW541 suppressed growth in all human BTC cell lines,however response was lower in gallbladder cancer.Treatment withNVP-AEW541 was associated with dephosphorylation of IGF-1R and AKT.In contrast,phosphorylation of p42/p44 and Stat3 and expression of Bcl-xL were inconsistently downregulated.In addition,treated cells showed cell cycle arrest at the G1/S-checkpoint and an increase in sub-G1 peak.Moreover,IGF-1R and its ligands IGF-1 and IGF-2 were co-expressed in RT-PCR,suggesting an autocrine loop of tumor cell activation.Combined with gemcitabine,NVP-AEW541 exerted synergistic effects, particularly at low concentrations,while effects of combination with 5-FU or BI 2536 were only additive. CONCLUSION:Our findings suggest that NVP-AEW541 is active against BTC in vitro and potentiates the efficacy of gemcitabine.

Negative impact of bone-marrow-derived mesenchymal stem cells on dextran sulfate sodium-induced colitis

AIM:To investigate the effects of mesenchymal stem cells(MSCs)on dextran sulfate sodium-induced inflammatory bowel disease(IBD).METHODS:C57BL/6 mice were fed 3.5%(g/L)dextran sulfate sodium.On day seven,the mice received intraperitoneal injections of 1×106 MSCs.The survival rate,disease activity index values,and body weight,were monitored daily.On day ten,colon lengths and histopathologic changes were assessed.In addition,immunoregulatory changes following MSC administration were evaluated by determining the levels of effector T cell responses in the spleen and mesenteric lymph nodes,and the expression levels of inflammatory cytokines in homogenized colons.RESULTS:Intraperitoneal administration of MSCs did not prevent development of colitis and did not reduce the clinicopathologic severity of IBD.No significant difference was evident in either survival rate or disease activity index score between the control and MSCtreated group.Day ten-sacrificed mice exhibited no significant difference in either colon length or histopathologic findings.Indeed,the MSC-treated group exhibited elevated levels of interleukin(IL)-6 and transforming growth factor-β,and a reduced level of IL-10,in spleens,mesenteric lymph nodes,and homogenized colons.The IL-17 level was lower in the mesenteric lymph nodes of the MSC-treated group(P=0.0126).In homogenized colons,the IL-17 and tumor necrosis factor-α(P=0.0092)expression levels were also lower in the treated group.CONCLUSION:MSC infusion provided no significanthistopathologic or clinical improvement,thus representing a limited therapeutic approach for IBD.Functional enhancement of MSCs is needed in further study.

Non-surgical treatment of post-surgical bile duct injury: Clinical implications and outcomes

AIM: To investigate the prognostic factors determining the success rate of non-surgical treatment in the management of post-operative bile duct injuries (BDIs).

Clinical implication of FDG uptake of bone marrow on PET/CT in gastric cancer patients with surgical resection

AIM To determine the relationship between F-18 fluorodeoxyglucose(FDG) uptake of bone marrow(BM) on positron emission tomography/computed tomography(PET/CT) and clinical factors and to assess the prognostic value of FDG uptake of BM in gastric carcinoma.METHODS We retrospectively enrolled 309 gastric cancer patients who underwent staging FDG PET/CT and curative surgical resection. FDG uptake of primary tumor was visually classified as positive or negative FDG uptake. Mean FDG uptake of BM(BM SUV) and BM-to-liver uptake ratio(BLR) were measured. The relationships of BM SUV or BLR with clinical factors were evaluated. The prognostic values of BM SUV, BLR, and other clinical factors for predicting recurrence-free survival(RFS) and overall survival(OS) were assessed.RESULTS Of 309 patients, 38 patients(12.3%) experienced cancer recurrence and 18 patients(5.8%) died. Patients with advanced gastric cancer, positive FDG uptake, and recurrence had higher values of BM SUV and BLR than those with early gastric cancer, negative FDG uptake, and no recurrence(P < 0.05). BM SUV and BLR were significantly correlated with hemoglobin level, neutrophil-to-lymphocyte ratio, and platelet-tolymphocyte ratio(P < 0.05). On multivariate analysis, multiple tumors, T stage, lymph node metastasis, tumor involvement of resection margin, and BLR were significantly associated with RFS(P < 0.05). T stage, lymph node metastasis, hemoglobin level, and BLR were significantly associated with OS(P < 0.05). CONCLUSION BLR on PET/CT was an independent prognostic factor for RFS and OS in gastric cancer patients with curative surgical resection.

Perforation of the colon by invading recurrent gastrointestinal stromal tumors during sunitinib treatment

The molecular targets of sunitinib are receptor tyrosine kinases (RTKs),and this drug has also been known to exert blocking effects on the activation of KIT,which is similar to the mechanism of action of imatinib. Moreover,sunitinib has an additional anti-angiogenic effect through its inhibition of the vascular endothelial growth factor receptor activation. We report here a 70-year-old patient diagnosed with a recurrent gastrointestinal stromal tumor (GIST),which invaded the transverse colon and led to a perforation during sunitinib treatment. A computed tomography scan and 3-dimensional reconstruction showed necrosis of the recurrent hepatic mass and perforation of the invaded transverse colon. After percutaneous drainage of the intraperitoneal abscess,antibiotic treatment and restricted diet,the condition of the patient improved. The present case is the first to report that sunitinib,which is administered to treat GIST resistant to imatinib,can cause unexpected colon perforation and subsequent peritonitis.

Prognostic value of 18-fluorodeoxyglucose positron emission tomography-computed tomography in resectable colorectal cancer

AIM:To assess the prognostic value of preoperative 18 fluorodeoxyglucose positron emission tomography(FDG-PET)/computed tomography(CT) in patients with resectable colorectal cancer.METHODS:One hundred sixty-three patients with resectable colorectal cancer who underwent FDG-PET/CT before surgery were included.Patient data including pathologic stage at presentation,histology,treatment,disease-free survival and the maximum standardized uptake value(SUVmax) of the primary tumor on FDG-PET/CT were retrospectively analyzed.Median follow up duration was 756(range,419-1355).The primary end point was disease-free survival.RESULTS:Twenty-five of 163 patients(15.3%) had recurrences.The median SUVmax values of the recurrence and no-recurrence groups were 8.9(range,5-24) and 8.2(range,0-23,P = 0.998).Receiver operating characteristic(ROC) curve analysis showed no significant association between SUVmax and recurrence(area under the curve = 0.5,P = 0.998,95% CI:0.389-0.611).Because a statistically significant value was not found,SUVmax was dichotomized at its median of 8.6.The disease-free survival curve was analyzed using the median SUVmax(8.6) as the cut off.Univariate and multivariate analysis did not provide evidence that disease-free survival rates for the subgroups defined by the median SUVmax were significantly different(P = 0.52,P = 0.25).CONCLUSION:Our study suggests that the high FDG uptake of primary mass in resectable colorectal cancer doesn't have a significant relationship with tumor recurrence and disease-free survival.

Short-term overlap lamivudine treatment with adefovir dipivoxil in patients with lamivudine-resistant chronic hepatitis B

AIM： To evaluate the efficacy of short-term overlap lamivudine therapy with adefovir in patients with lamivudine-resistant and naive chronic hepatitis B, we compared patients receiving overlap therapy with those receiving adefovir alone. METHODS： Eighty patients who had received lamivudine treatment for various periods and had a lamivudineo resistant liver function abnormality were enrolled. Forty of these patients received adefovir treatment combined with lamivudine treatment for ≥ 2 mo, while the other 40 received adefovir alone. We assessed the levels of hepatitis B virus （HBV） DNA at 0, 12 and 48 wk and serum alanine aminotransferase （ALT） levels after 0, 12, 24 and 48 wk of adefovir treatment in each group. RESULTS： We found serum ALT became normalized in 72 （87.5%） of the 80 patients, and HBV DNA decreased by ≥ 2 Ioglo copies/mL in 60 （75%） of the 80 patients at the end of a 48-wk treatment. HBV DNA levels were not significantly different between the groups. The improvements in serum ALT were also not significantly different between the two groups. CONCLUSION： These findings suggest short-term overlap lamivudine treatment results in no better virological and biological outcomes than non-overlap adefovir monotherapy.

Is percutaneous endoscopic gastrostomy tube placement safe in patients with ventriculoperitoneal shunts?

AIM:To investigate whether percutaneous endoscopic gastrostomy (PEG) tube placement is safe in patients with ventriculoperitoneal (VP) shunts.METHODS: This was a retrospective study of all patients undergoing PEG insertion at our institution between June 1999 and June 2006. Post-PEG complications were compared between two groups according to the presence or absence of VP shunts. VP shunt infection rates, the interval between PEG placement and VP shunt catheter insertion, and long-term follow-up were also investigated.RESULTS: Fifty-five patients qualified for the study. Seven patients (12.7%) had pre-existing VP shunts. All patients received prophylactic antibiotics. The complication rate did not differ between VP shunt patients undergoing PEG (PEG/VP group) and non-VP shunt patients undergoing PEG (control group) [1 (14.3%) vs 6 (12.5%), P=1.000]. All patients in the PEG/VP group had undergone VP shunt insertion prior to PEG placement. The mean interval between VP shunt insertion and PEG placement was 308.7 d (range, 65-831 d). The mean follow-up duration in the PEG/VP group was 6.4 mo (range, 1-15 mo). There were no VP shunt infections, although one patient in the PEG/VP group developed a minor peristomal infection during follow-up.CONCLUSION: Complications following PEG placement in patients with VP shunts were infrequent in this study.

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.

Preoperative serum carbohydrate antigen 19-9 levels predict early recurrence after the resection of early-stage pancreatic ductal adenocarcinoma

BACKGROUND Pancreatic ductal adenocarcinoma(PDAC)is a serious disease with a poor prognosis.Only a minority of patients undergo surgery due to the advanced stage of the disease,and patients with early-stage disease,who are expected to have a better prognosis,often experience recurrence.Thus,it is important to identify the risk factors for early recurrence and to develop an adequate treatment plan.AIM To evaluate the predictive factors associated with the early recurrence of earlystage PDAC.METHODS This study enrolled 407 patients with stage I PDAC undergoing upfront surgical resection between January 2000 and April 2016.Early recurrence was defined as a diagnosis of recurrence within 6 mo of surgery.The optimal cutoff values were determined by receiver operating characteristic(ROC)analyses.Univariate and multivariate analyses were performed to identify the risk factors for early recurrence.RESULTS Of the 407 patients,98 patients(24.1%)experienced early disease recurrence:26(26.5%)local and 72(73.5%)distant sites.In total,253(62.2%)patients received adjuvant chemotherapy.On ROC curve analysis,the optimal cutoff values for early recurrence were 70 U/mL and 2.85 cm for carbohydrate antigen 19-9(CA 19-9)levels and tumor size,respectively.Of the 181 patients with CA 19-9 level>70 U/mL,59(32.6%)had early recurrence,compared to 39(17.4%)of 226 patients with CA 19-9 level≤70 U/mL(P<0.001).Multivariate analysis revealed that CA 19-9 level>70 U/mL(P=0.006),tumor size>2.85 cm(P=0.004),poor differentiation(P=0.008),and non-adjuvant chemotherapy(P=0.025)were significant risk factors for early recurrence in early-stage PDAC.CONCLUSION Elevated CA 19-9 level(cutoff value>70 U/mL)can be a reliable predictive factor for early recurrence in early-stage PDAC.As adjuvant chemotherapy can prevent early recurrence,it should be recommended for patients susceptible to early recurrence.

Fluorescence image-guided lymphadenectomy using indocyanine green and near infrared technology in robotic gastrectomy

In recent years, some researchers have tried to find a way to improve the surgical identification of the lymphatic drainage routes and lymph node stations during radical gastrectomy, thus starting a new research frontier in this field called ＂navigation surgery＂. Among the different reported solutions, the introduction of the indocyanine green （ICG） has drawn attention for its characteristics, a fluorescence dye that can be detected in the near infrared spectral band （NIR）. A fluorescence imaging technology has been integrated in the latest version of the Da Vinci robotic system and surgeons have extensively reported their experiences in colorectal and hepato-biliary surgery for tumors, vascular and lymphatic structures visualization. However, up to date, the combined use of fluorescence imaging and robotic technology has not been adequately investigated during lymphadenectomy in gastric cancer.

Incremental age-related one-year MACCE after acute myocardial infarction in the drug-eluting stent era （from KAMIR-NIH registry）

Objectives To evaluate the age-related one-year major adverse cardiocerebrovascular events （MACCE） after percutaneous coronary intervention （PCI） in acute myocardial infarction （AMI）. We analyzed the association between age and one-year MACCE after AMI. Methods A total of 13,104 AMI patients from Korea Acute Myocardial Infarction Registry-National Institue of Health （KAMIR-NIH） between November 2011 and December 2015 were classified into four groups according to age （Group I, 〈 60 years, n = 4199; Group II, 60-70 years, n = 2577; Group III; 70-80 years, n = 2774; Group IV, ≥ 80 years, n = 1018）. Patients were analyzed for one-year composite of MACCE （cardiac death, myocardial infarction, target vessel revascularization, cerebrovascular events） after AMI. Results The one-year MACCE in AMI were 3.5% （Group I）, 6.3% （Group II）, 9.6% （Group III） and 17.6% （Group IV）. After adjustment for confounding para- meters, the analysis results showed that patients with AMI had incremental risk of one-year MACCE [Group II, adjusted hazard ratios （aHR） = 1.224, 95% CI： 0.965-1.525, P = 0.096; Group III, aHR = 1.316, 95% CI： 1.037-1.671, P= 0.024; Group IV, aHR = 1.975, 95% CI： 1.500-62.601, P〈 0.001） compared to Group I. Especially, cardiac death in the composite of primary end point played a major role in this effect （Group II, aHR = 1.335, 95% CI： 0.941-1.895, P= 0.106; Group III, aHR = 1.575, 95% CI： 1.122-2.210, P= 0.009; Group IV, aHR = 2.803, 95% CI： 1.937-4.054, P 〈 0.001）. Conclusions Despite advanced techniques and medications for PCI in AMI, age still exerts a powerful influence in clinical outcomes. Careful approaches, even in the modem era of developed cardiology are needed for aged-population in AMI intervention.