Early Removal of the Prophylactic Drain After Distal Gastrectomy : Results of a Randomized Controlled Study.

Background: The optimal timing of the drain removal after gastrectomy has been unclear. The aim of this prospective randomized controlled study was to assess the optimal timing of removal of prophylactic drains after distal gastrectomy (DG) or pylorus-preserving gastrectomy (PPG). Methods: All patients undergoing DG or PPG for gastric cancer were eligible for this study. The exclusion criteria were combined organ resection, the use of postoperative anticoagulant therapy, intraoperative injury of other organs and anastomotic problems. Just after the operation, the eligible patients were randomly assigned to either the early removal group (n=50), where the drain was removed in the morning of the postoperative day (POD) 1, or the control group (n=50), where the drain was removed on POD 3 or later. We compared the surgical outcomes between the groups. Results: The rate of overall postoperative complications was 18% in the early removal group and 18% in the control group, with no significant difference between the groups. The severity of complications was also similar between the groups. There were no significant differences between the groups with regard to the postoperative recovery, pain or the length of the postoperative hospital stay. Conclusions: The present study demonstrated the safety and feasibility of the early removal of prophylactic drains in selected patients undergoing DG or PPG for gastric cancer

The Diagnosis of Hypovascular Hepatic Lesions Showing Hypo-intensity in the Hepatobiliary Phase of Gd-EOB- DTPA-enhanced MR Imaging in High-risk Patients for Hepatocellular Carcinoma

The aim of this study was to evaluate the histologic diagnosis of hypovascular hepatic lesions showing hypointensity on hepatobiliary phase images of gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid (Gd-EOB-DTPA)-enhanced MRI (EOB-MRI). In 38 patients with hepatocellular carcinoma (HCC) after curative treatments and 18 patients with liver cirrhosis, 105 hypovascular nodules that were hypointense at the hepatobiliary phase of EOB-MRI were biopsied and the clinical usefulness of these EOB-MRI findings for the diagnosis of HCC was examined. Of the 105 nodules (median diameter＝12mm), 78 (74.3%), 11 (10.5%), and 16 (15.2%) were diagnosed as HCC, dysplastic, and non-neoplastic, respectively. The positive predictive value (PPV) of hypointensity at the hepatobiliary phase of EOB-MRI for the diagnosis of HCC increased to 77-90% when combined with the following factors: washout appearance on the delayed phase of triple-phase CT, hyperintensity in diffusion-weighted image of MRI, or the appearance of a hypoechoic part in ultrasonography. PPV increased to 100% when all 3 factors were positive. A relatively large proportion of hypovascular lesions that showed hypo-intensity in the hepatobiliary phase were confirmed to be HCC, and the accuracy of HCC increased when combined with other imaging findings

Effect of Vonoprazan on Delayed Bleeding after Endoscopic Submucosal Dissection for Gastric Neoplasia among Antithrombotic Drug Users: A Single-Center, Single-Arm Prospective Observational Case Control Study

Antithrombotic therapy is a major risk factor for delayed bleeding after endoscopic submucosal dissection (ESD) for gastric neoplasia. A potassium-competitive acid blocker, vonoprazan, is expected to prevent delayed bleeding better than conventional proton pomp inhibitors (PPIs), but the evidence is controversial. We sought to clarify the efficacy of vonoprazan for prevention of delayed bleeding after gastric ESD in patients under antithrombotic therapy. We prospectively registered 50 patients who underwent gastric ESD while receiving antithrombotic therapy and vonoprazan in our institution between October 2017 and September 2018. The incidence of delayed bleeding was compared with that in a historical control group of 116 patients treated with conventional PPI. We also evaluated risk factors associated with delayed bleeding. Delayed bleeding was observed in 8 of 50 patients (16.0%), which was not dissimilar from the incidence in the historical control group (12.1%) (p=0.49). In the univariate analysis, age (> 70 years) (p=0.034), multiple antithrombotic drug use (p 200 min) (p=0.038) and tumor size (> 40 mm) (p<0.01) were associated with delayed bleeding after gastric ESD, but vonoprazan was not (p=0.49). Vonoprazan may not be more effective than conventional PPIs in preventing delayed bleeding after gastric ESD in patients receiving antithrombotic therapy

Optimization of scan timing for aortic computed tomographic angiography using the test bolus injection technique

Background: With fast computed tomography (CT), it is possible for the scanning to outpace the contrast medium bolus during aortic CT angiography (CTA). Purpose: To evaluate the effectiveness of a new method for reducing the risk of outpacing in which the scan start timing (ST) and speed can be estimated from the peak enhancement time measured at the femoral artery using a single testbolus injection (femoral artery test injection method [FTI method]). Material and Methods: In 30 cases of aortic CTA, we measured the time to peak enhancement at the femoral artery (TPF) and the ascending aorta (TPA) with test-bolus injection performed twice in each examination. From the resultant linear relationship between TPF and transit time (TTTPF=TPA), we developed a method for determining the ST and TT from TPF. One hundred patients were assigned to two groups: FTI and bolus tracking (BT), each with 50 patients. CT values were measured in main vessels (ascending aorta, descending aorta, femoral artery). The CT values of the vessels and the rate of cases with more than 300 HU (good cases) were compared between the two groups. Results: The enhancement in the FTI method was significantly higher than that of the BT method (average CT values: FTI, 388.352.4; BT, 281.259.1; P<0.001). The rates of good cases for FTI and BT were 86.0% and 46.0%, respectively. Conclusion: The FTI method was very effective in reducing the risk of outpacing of the contrast medium transit in aortic CTA without the need for an additional contrast medium dose. © The Foundation Acta Radiologica 2015.Embargo Period 12 month

Surrogate marker of schistocytes

Objectives : Hematopoietic stem cell transplantation (HSCT)-associated thrombotic microangiopathy (TA-TMA) is an important early post-treatment condition. This study evaluated the Revised %MICRO, a parameter obtained from the ADVIA 2120i automated blood cell counter, as a surrogate marker of the schistocyte ratio. We hypothesized that individual differences between the %MICRO value and schistocyte ratio would remain constant. Design and Methods: EDTA-2K-treated peripheral blood samples were collected from 19 patients who underwent allogeneic HSCT from April 2014 to September 2018. First, the baseline difference, X, was calculated using a sample from the first day after HSCT as X = %MICRO (first day) – schistocyte ratio (first day). Next, the Revised %MICRO for each subsequent day was calculated as Revised %MICRO = %MICRO – X. We evaluated correlations of the schistocyte ratio with the calculated %MICRO and Revised %MICRO and the RBC fragment, RBC distribution width, %MICRO and Revised %MICRO data obtained from the ADVIA 2120i. Results : The mean schistocyte percentage and Revised %MICRO were both 0.4% ± 0.6. RBC fragments correlated weakly with the %MICRO and schistocyte ratio, respectively (r = 0.162 and r = 0.771, respectively), whereas the Revised %MICRO correlated strongly with the schistocyte ratio (r = 0.893). Conclusion : The Revised %MICRO appears to be a good surrogate of the schistocyte ratio in a clinical setting

Unusual endoscopic findings of gastric neuroendocrine tumor

Gastric neuroendocrine tumor (NET) is sometimes found as a submucosal tumor on upper gastrointestinal endoscopy. Gastric NET with malignant profile and neuroendocrine carcinoma (NEC) show various forms which are difficult to distinguish from gastric cancer and other disease. We report a case of a cauliflower-shaped NET of the stomach. A 61-year-old man was referred to our hospital with a complaint of abdominal fullness. Upper gastrointestinal endoscopic examination revealed an unusual, whitish cauliflower-shaped tumor that belongs to Borrmann type I on the lesser curvature of the gastric antrum. Histological examination of the biopsy specimen revealed NET G2, because the tumor cells were CD56- and synaptophysin-positive by immunohistochemical analysis. A distal gastrectomy with D2 lymphadenectomy was performed. A recurrence in the liver was revealed by follow up computed tomography after 11 months from operation. Combined chemotherapy with irinotecan (CPT-11) plus cisplatin (CDDP) was treated. The patient achieved a partial response, but he died after 31 months from gastrectomy. There is no independent, large-scaled prospective study and no standard treatment for gastric NETs with distant metastases. Our case is reported with a literature review of the treatment of metastatic gastric NET G2

Analysis of DOC and Ram for NSCLC

Background: Current clinical trials demonstrated that combination regimens comprising chemotherapy and immunotherapy lead to better patient outcomes compared to chemotherapy alone as the first line of treatment for non-small cell lung cancer (NSCLC). In addition, the combination therapy of docetaxel (Doc) and ramucirumab (Ram) was considered one of the standard treatments for advanced or relapsed NSCLC patients. However, little is known about the therapeutic responders of this combination therapy among previously treated NSCLC patients. In the present study, we aimed to identify predictive factors for therapeutic response, including programmed death-ligand 1 (PD-L1) expression in tumors, for Doc treatment in combination with Ram. Methods: We retrospectively analyzed a total of 135 advanced or relapsed NSCLC patients who were refractory to platinum-based chemotherapy at eleven institutions in Japan between July 2016 and November 2018. Results: Our observations showed that PD-L1 expression in tumors is not associated with the efficacy of combined therapy of Doc and Ram in previously treated NSCLC patients. Analysis of the patient clinical profiles indicated that prior treatment with immune checkpoint inhibitors (ICIs) is a reliable predictor for the good progression-free survival (PFS) to this combination therapy (P=0.041). Conclusions: Our retrospective study indicated that combination regimens comprising chemotherapy and ICIs followed by Doc and Ram could be an optimal therapeutic option for NSCLC patients regardless of the PD-L1 status of tumors. Further investigations are required to strengthen clinical evidence demonstrating the effectiveness of the combination therapy of Doc plus Ram in previously treated NSCLC patients

胃癌における免疫チェックポイント阻害薬の副作用と効果の関連性

Recently, immune checkpoint inhibitors（ICI）have been approved for use in advanced gastric cancer（AGC）based on the positive results of ATTRACTION‐２ trial in Japan. There has been accumulating evidence that the development of immune-related adverse events（irAE）may be associated with a response to ICI therapy, particularly in lung cancer, although little is known about these correlations in gastrointestinal cancer. To investigate the efficacy and irAE of ICI treatment and their correlation in AGC, we retrospectively examined ２９ patients with AGC who received nivolumab therapy in our departments. Among them, １５ patients（５２％）developed irAEs including ４ patients（１４％）for grade ３ irAEs ; liver dysfunction（n＝２）, type １ diabetes mellitus（n＝２） and adrenal insufficiency（n＝１）. The median overall survival was１２．０months in the irAE group and ３．２５ months in the non-irAE group（p＝０．１６４）, which suggested the relationship between the effects and irAEs in ICI treatment of AGC. Further research is required to understand the implications of irAE characteristics on ICI response in GCA patients