PURPOSE: To evaluate the risk of vertebral compression fracture (VCF) after conventional radiotherapy (RT) for colorectal cancer (CRC) with spine metastasis and to identify risk factors for VCF in metastatic and non-metastatic irradiated spines. MATERIALS AND METHODS: We retrospectively reviewed 68 spinal segments in 16 patients who received conventional RT between 2009 and 2012. Fracture was defined as a newly developed VCF or progression of an existing fracture. The target volume included all metastatic spinal segments and one additional non-metastatic vertebra adjacent to the tumor-involved spines. RESULTS: The median follow-up was 7.8 months. Among all 68 spinal segments, there were six fracture events (8.8%) including three new VCFs and three fracture progressions. Observed VCF rates in vertebral segments with prior irradiation or pre-existing compression fracture were 30.0% and 75.0% respectively, compared with 5.2% and 4.7% for segments without prior irradiation or pre-existing compression fracture, respectively (both p < 0.05). The 1-year fracture-free probability was 87.8% (95% CI, 78.2-97.4). On multivariate analysis, prior irradiation (HR, 7.30; 95% CI, 1.31-40.86) and pre-existing compression fracture (HR, 18.45; 95% CI, 3.42-99.52) were independent risk factors for VCF. CONCLUSION: The incidence of VCF following conventional RT to the spine is not particularly high, regardless of metastatic tumor involvement. Spines that received irradiation and/or have pre-existing compression fracture before RT have an increased risk of VCF and require close observation.
Colorectal Neoplasms* ; Follow-Up Studies ; Fractures, Compression* ; Humans ; Incidence ; Multivariate Analysis ; Neoplasm Metastasis ; Radiotherapy ; Retrospective Studies ; Risk Factors ; Spinal Fractures ; Spinal Neoplasms ; Spine*

Chronic pancreatitis (CP) is an inflammatory disease and causes chronic pain, exocrine and endocrine function failure. Pain is major indication for surgical procedure indication in CP. Advances in noninvasive treatment now allow for better therapeutic options at an early stage of CP. However, many data show that surgical procedure may produce superior results to endoscopic treatment in CP management. Considerable controversy remains with respect to the surgical management of chronic pancreatitis. There are many surgical options to control chronic pain in CP, therefore preoperative assessment is important to choose optimal surgical management. Effective surgical procedures and timing of surgery for chronic pancreatitis remain unclear. This review comprehensively assesses the evidence for these different approaches to surgical intervention in chronic pancreatitis.
Chronic Pain ; Pancreatitis ; Pancreatitis, Chronic* ; Surgeons*

PURPOSE: The tumor microenvironment is known to be associated with the metabolic activity of cancer cells and local immune reactions. We hypothesized that glucose metabolism measured by 2-deoxy-2-(¹⁸F)fluoro-D-glucose (¹⁸F-FDG) positron emission tomography (PET)-computed tomography (CT) (¹⁸F-FDG PET-CT) would be associated with local immune responses evaluated according to the presence of tumor infiltrating lymphocytes (TILs). MATERIALS AND METHODS: We retrospectively reviewed 56 patients who underwent ¹⁸F-FDG PET-CT prior to gastrectomy. In resected tumor specimens, TIL subsets, including cluster of differentiation (CD) 3, CD4, CD8, Forkhead box P3 (Foxp3), and granzyme B, were subjected to immunohistochemical analysis. The prognostic nutritional index (PNI) was calculated as: (10×serum albumin value)+(0.005×peripheral lymphocyte counts). Additionally, the maximum standard uptake value (SUVmax) was calculated to evaluate the metabolic activity of cancer cells. RESULTS: The SUVmax was positively correlated with larger tumor size (R=0.293; P=0.029) and negatively correlated with PNI (R=−0.407; P=0.002). A higher SUVmax showed a marginal association with higher CD3 (+) T lymphocyte counts (R=0.227; P=0.092) and a significant association with higher Foxp3 (+) T lymphocyte counts (R=0.431; P=0.009). No other clinicopathological characteristics were associated with SUVmax or TILs. Survival analysis, however, indicated that neither SUVmax nor Foxp3 held prognostic significance. CONCLUSIONS: FDG uptake on PET-CT could be associated with TILs, especially regulatory T cells, in gastric cancer. This finding may suggest that PET-CT could be of use as a non-invasive tool for monitoring the tumor microenvironment in patients with gastric cancer.
Fluorodeoxyglucose F18 ; Gastrectomy ; Glucose ; Granzymes ; Humans ; Lymphocyte Count ; Lymphocytes ; Lymphocytes, Tumor-Infiltrating ; Metabolism ; Nutrition Assessment ; Positron-Emission Tomography ; Retrospective Studies ; Stomach Neoplasms ; T-Lymphocytes, Regulatory ; Tumor Microenvironment

PURPOSE: To investigate the patterns of locoregional recurrence of pathologic T3N0 (pT3N0) lower rectal cancer omitting postoperative radiotherapy (RT) and explore the potential of modification of a RT field. MATERIALS AND METHODS: From Jan 2003 to Nov 2011, 35 patients omitting preoperative or postoperative RT for pT3N0 lower rectal cancer were included. We defined the lower rectal cancer as the tumor with the inferior margin located below the virtual line-a convergent level between rectal wall and levator ani muscle. All patients had radiologic examinations for recurrence evaluation during the follow-up duration. RESULTS: The median follow-up duration was 66.4 months (range, 1.4 to 126.1 months). Eight (22.9%) of the 35 patients had recurrence. Three (8.6%) was local recurrence (LR) only, 3 (8.6%) was distant metastasis (DM) only, and 2 (5.7%) was LR with DM. All LR were located at primary tumor sites. The overall survival rate, LR-free survival rate, and DM-free survival rate at 5 years was 79.8%, 83%, and 87%, respectively. All LR developed from tumors over 5 cm. However, there was no statistical significance (p = 0.065). There was no other risk factor for LR. CONCLUSION: Even though the patients included in this study had pathologically favorable pT3N0 rectal cancer, LR developed in 14.3% of patients. Most of the LR was located at primary tumor sites prior to surgery. Based on these findings, it might seem reasonable to consider postoperative RT with a smaller radiation field to the primary tumor site rather than the conventional whole pelvic irradiation.
Follow-Up Studies ; Humans ; Muscles ; Neoplasm Metastasis ; Neoplasm Recurrence, Local ; Radiotherapy, Adjuvant ; Rectal Neoplasms ; Recurrence ; Risk Factors ; Survival Rate

Purpose: Intracorporeal esophagojejunostomy during reduced-port gastrectomy for proximal gastric cancer is a technically challenging technique. No study has yet reported a robotic technique for anastomosis. Therefore, to address this gap, we describe our reduced-port technique and the short-term outcomes of intracorporeal esophagojejunostomy. Materials and Methods: We conducted a retrospective review of patients who underwent a totally robotic reduced-port total or proximal gastrectomy between August 2016 and March 2020. We used an infra-umbilical Single-Site® port with two additional ports on both sides of the abdomen. To transect the esophagus, a 45-mm endolinear stapler was inserted via the right abdominal port. The common channel of the esophagojejunostomy was created between the apertures in the esophagus and proximal jejunum using a 45-mm linear stapler. The entry hole was closed with a 45-mm linear stapler or robot-sewn continuous suture. All anastomoses were performed without the aid of an assistant or placement of stay sutures. Results: Among the 40 patients, there were no conversions to open, laparoscopic, or conventional 5-port robotic surgery. The median operation time and blood loss were 254 min and 50 mL, respectively. The median number of retrieved lymph nodes was 40.5. The median time to first flatus, soft diet intake, and length of hospital stay were 3, 5, and 7 days, respectively. Three (7.5%) major complications, including two anastomosis-related complications and a case of small bowel obstruction, were treated with an endoscopic procedure and re-operation, respectively. No mortality occurred during the study period. Conclusions Intracorporeal esophagojejunostomy during reduced-port gastrectomy can be safely performed and is feasible with acceptable surgical outcomes.

Purpose: No consensus exists on whether to preserve or ligate an aberrant left hepatic artery (ALHA), which is the most commonly encountered hepatic arterial variation during gastric surgery. Therefore, we aimed to evaluate the clinical effects of ALHA ligation by analyzing the perioperative outcomes. Materials and Methods: We retrospectively reviewed the data of 5,310 patients who underwent subtotal/total gastrectomy for gastric cancer. Patients in whom the ALHA was ligated (n=486) were categorized into 2 groups according to peak aspartate aminotransferase (AST) or alanine aminotransferase (ALT) levels: moderate-to-severe (MS) elevation (≥5 times the upper limit of normal [ULN]; MS group, n=42) and no-to-mild (NM) elevation (<5 times the ULN; NM group, n=444). The groups were matched 1:3 using propensity score-matching analysis to minimize confounding factors that can affect the perioperative outcomes. Results: The mean operation time (P=0.646) and blood loss amount (P=0.937) were similar between the 2 groups. The length of hospital stay was longer in the MS group (13.0 vs.7.8 days, P=0.022). No postoperative mortality occurred. The incidence of grade ≥ IIIa postoperative complications (19.0% vs. 5.1%, P=0.001), especially pulmonary complications (11.9% vs. 2.5%, P=0.003), was significantly higher in the MS group. This group also showed a higher Comprehensive Complication Index (29.0 vs. 13.9, P<0.001). Conclusions Among patients with a ligated ALHA, those with peak AST/ALT ≥5 times the ULN showed worse perioperative outcomes in terms of hospital stay and severity of complications. More precise perioperative decision-making tools are needed to better determine whether to preserve or ligate an ALHA.

Purpose: Various studies have indicated that reduced-port robotic gastrectomies are safe and feasible for treating patients with early gastric cancer. However, there have not been any comparative studies conducted that have evaluated patients with clinically advanced gastric cancer. Therefore, we aimed to compare the perioperative outcomes of D2 lymph node dissections during reduced-port robotic distal subtotal gastrectomies (RRDGs) and conventional 5-port laparoscopic distal subtotal gastrectomies (CLDGs). Materials and Methods: We retrospectively evaluated 118 patients with clinically advanced gastric cancer who underwent minimally invasive distal subtotal gastrectomies with D2 lymph node dissections between February 2016 and November 2019. To evaluate the patient data, we performed a 1:1 propensity score matching (PSM) according to age, sex, body mass index, American Society of Anesthesiologists physical status classification score, and clinical T status. The short-term surgical outcomes were also compared between the two groups. Results: The PSM identified 40 pairs of patients who underwent RRDG or CLDG. The RRDG group experienced a significantly longer operation time than the CLDG group (P<0.001), although the RRDG group had significantly less estimated blood loss (P=0.034). The number of retrieved extraperigastric lymph nodes in the RRDG group was significantly higher than that of the CLDG group (P=0.008). The rate of postoperative complications was not significantly different between the two groups (P=0.115). Conclusions D2 lymph node dissections can be safely performed during RRDGs and the perioperative outcomes appear to be comparable to those of conventional laparoscopic surgeries. Further studies are needed to compare long-term survival outcomes.

PURPOSE: The robotic system for surgery was introduced to gastric cancer surgery in the early 2000s to overcome the shortcomings of laparoscopic surgery. The more recently introduced da Vinci Xi® system offers benefits allowing four-quadrant access, greater range of motion, and easier docking through an overhead boom rotation with laser targeting. We aimed to identify whether the Xi® system provides actual advantages over the Si® system in gastrectomy for gastric cancer by comparing the operative outcomes. MATERIALS AND METHODS: We retrospectively reviewed all patients who underwent robotic gastrectomy as treatment for gastric cancer from March 2016 to March 2017. Patients' demographic data, perioperative information, and operative and pathological outcomes were collected and analyzed. RESULTS: A total of 109 patients were included in the Xi® group and 179 in the Si® group. Demographic characteristics were similar in both groups. The mean operative time was 229.9 minutes in the Xi® group and 223.7 minutes in the Si® group. The mean estimated blood loss was 72.7 mL in the Xi® group and 62.1 mL in the Si® group. No patient in the Xi® group was converted to open or laparoscopy, while 3 patients in the Si® group were converted, 2 to open surgery and 1 to laparoscopy, this difference was not statistically significant. Bowel function was resumed 3 days after surgery, while soft diet was initiated 4 days after surgery. CONCLUSIONS: We found no difference in surgical outcomes after robotic gastrectomy for gastric cancer between the da Vinci Xi® and da Vinci Si® procedures.
Diet ; Gastrectomy ; Humans ; Laparoscopy ; Operative Time ; Range of Motion, Articular ; Retrospective Studies ; Stomach Neoplasms

PURPOSE: Clinical implications of single patient classifier (SPC) and microsatellite instability (MSI) in stage II/III gastric cancer have been reported. We investigated SPC and the status of MSI and Epstein-Barr virus (EBV) as combinatory biomarkers to predict the prognosis and responsiveness of adjuvant chemotherapy for stage II/III gastric cancer. MATERIALS AND METHODS: Tumor specimens and clinical information were collected from patients enrolled in CLASSIC trial, a randomized controlled study of capecitabine plus oxaliplatin-based adjuvant chemotherapy. The results of nine-gene based SPC assay were classified as prognostication (SPC-prognosis) and prediction of chemotherapy benefit (SPC-prediction). Five quasimonomorphic mononucleotide markers were used to assess tumor MSI status. EBV-encoded small RNA in situ hybridization was performed to define EBV status. RESULTS: There were positive associations among SPC, MSI, and EBV statuses among 586 patients. In multivariate analysis of disease-free survival, SPC-prognosis [hazard ratio (HR): 1.879 (1.101–3.205), 2.399 (1.415–4.067), p=0.003] and MSI status (HR: 0.363, 95% confidence interval: 0.161–0.820, p=0.015) were independent prognostic factors along with age, Lauren classification, TNM stage, and chemotherapy. Patient survival of SPC-prognosis was well stratified regardless of EBV status and in microsatellite stable (MSS) group, but not in MSI-high group. Significant survival benefit from adjuvant chemotherapy was observed by SPC-Prediction in MSS and EBV-negative gastric cancer. CONCLUSION: SPC, MSI, and EBV statuses could be used in combination to predict the prognosis and responsiveness of adjuvant chemotherapy for stage II/III gastric cancer.
Biomarkers ; Capecitabine ; Chemotherapy, Adjuvant ; Classification ; Disease-Free Survival ; Drug Therapy ; Herpesvirus 4, Human ; Humans ; In Situ Hybridization ; Microsatellite Instability ; Microsatellite Repeats ; Multivariate Analysis ; Prognosis ; RNA ; Stomach Neoplasms

PURPOSE: We aimed to evaluate the clinical characteristics of microsatellite instability in early gastric cancer.MATERIALS AND METHODS: The microsatellite instability status of resected early gastric tumors was evaluated using two mononucleotide repeat markers (BAT25 and BAT26) and three dinucleotide repeat markers (D5S346, D2S123, and D17S250). Tumors with instability in two or more markers were defined as microsatellite instability-high (MSI-H) and others were classified as microsatellite stable (MSS).RESULTS: Overall, 1,156 tumors were included in the analysis, with 85 (7.4%) classified as MSI-H compared with MSS tumors. For MSI-H tumors, there was a significant correlation with the female sex, older age, tumor location in the lower gastric body, intestinal histology, lymphovascular invasion (LVI), and submucosal invasion (P<0.05). There was also a trend toward an association with lymph node (LN) metastasis (P=0.056). In mucosal gastric cancer, there was no significant difference in MSI status in tumors with LN metastasis or tumors with LVI. In submucosal gastric cancer, LVI was more frequently observed in MSI-H than in MSS tumors (38.9% vs. 25.0%, P=0.027), but there was no difference in the presence of LN metastases. The prognosis of MSI-H tumors was similar to that of MSS tumors (log-rank test, P=0.797, the hazard ratio for MSI-H was adjusted by age, sex, pT stage, and the number of metastatic LNs, 0.932; 95% confidence interval, 0.423–2.054; P=0.861).CONCLUSIONS: MSI status was not useful in predicting prognosis in early gastric cancer. However, the frequent presence of LVI in early MSI-H gastric cancer may help guide the appropriate treatment for patients, such as endoscopic treatment or limited LN surgical dissection.
Dinucleotide Repeats ; Female ; Humans ; Lymph Nodes ; Microsatellite Instability ; Microsatellite Repeats ; Neoplasm Metastasis ; Prognosis ; Stomach Neoplasms