Cell-free and concentrated pleural effusion reinfusion therapy with aggressive nutritional support improved refractory pleural effusion in a patient with malnutrition after distal gastrectomy for gastric cancer

Refractory pleural effusion can be a life-threatening complication in patients receiving maintenance hemodialysis. We report successful treatment of refractory pleural effusion using a Denver® pleuroperitoneal shunt in one such patient. A 54-year-old Japanese man, who had previously undergone left nephrectomy, was admitted urgently to our department because of a high C-reactive protein (CRP) level, right pleural effusion, and right renal abscess. Because antibiotics proved ineffective and his general state was deteriorating, he underwent emergency insertion of a thoracic drainage tube and nephrectomy, and hemodialysis was started. Although his general state improved slowly thereafter, the pleural effusion, which was unilateral and transudative, remained refractory and therefore he needed to be on oxygenation. To control the massive pleural effusion, a pleuroperitoneal shunt was inserted. Thereafter, his respiratory condition became stable without oxygenation and he was discharged. His general condition has since been well. Although pleural effusion is a common complication of maintenance hemodialysis, few reports have documented the use of pleuroperitoneal shunt to control refractory pleural effusion. Pleuroperitoneal shunt has been advocated as an effective and low-morbidity treatment for refractory pleural effusion, and its use for some patients with recurrent pleural effusion has also been reported, without any severe complications. In the present case, pleuroperitoneal shunt improved the patient's quality of life sufficiently to allow him to be discharged home without oxygenation. Pleuroperitoneal shunt should be considered a useful treatment option for hemodialysis patients with refractory pleural effusion.

Laparoscopy assisted distal gastrectomy (LADG) for gastric cancer has been rapidly adopted for the treatment of both early and advanced gastric cancers which need lymph node dissection, but remains difficult procedure, especially in patients with obesity. We evaluated the impact of obesity on short- and long-term outcomes of LADG for gastric cancer. We retrospectively investigated 243 patients who underwent LADG for gastric cancer between January 2007 and December 2014. The patients were classified based on their body mass index (BMI) into the Obese (BMI≥25) and Non-Obese (BMI<25) Groups. Patient characteristics, clinicopathologic and operative findings, and short- and long-term outcomes were investigated and compared between the groups. The groups did not differ in age, sex, American Society of Anesthesiologists score, the presence of comorbidities, or pathologic stage. Operative time (265±46.6 vs. 244±55.6min; P=0.007) and estimated blood loss (113±101.4 vs. 66.5±95.2ml; P=0.007) were greater in the Obese Group. Fewer lymph nodes were retrieved in the Obese Group (38±23.7 vs. 47.5±24.3; P=0.004). No differences were evident in postoperative complication rate (20% vs. 17%; P=0.688) or the duration of postoperative hospital stay (9±8.5 vs. 9±5.1days; P=0.283) between the two groups. In the Obese Group, the 5-year overall survival rate was significantly lower than in the Non-Obese Group (67.6% vs. 90.3%; P=0.036). Furthermore, 5-year disease-specific survival was significantly lower in the Obese Group than in the Non-Obese Group (72.7% vs. 94.9%; P=0.015). LADG in patients with obesity could be performed as safe as in patients without obesity, with comparable postoperative results. But obesity may be a poor prognostic factor in gastric cancer.

Objective To investigate the value of paraffin-embedded section of cell block in the diagnosis of benign or malignant pleural and peritoneal effusion. Methods 105 patients suspected with malignant pleural and peritoneal effusion admitted into tour hospital from November, 2015 to December, 2017 were selected as the research objects. The specimens of pleural and peritoneal effusion of all the patients were collected. And these specimens were given paraffin-embedded section of cell block, cell smear, and exfoliative cell pathological examination. The results of exfoliative cell pathological examination were taken as the gold standard. The positive rates of malignant pleural and peritoneal effusion diagnosed by paraffin-embedded section of cell block and cell smear were evaluated. The diagnostic value of the two methods was compared. Results Among the 50 pleural effusion specimens, the results of exfoliative cell pathological examination showed that there were 36 cases of malignant pleural effusion. Among the 55 peritoneal effusion specimens, the results of exfoliative cell pathological examination showed that there were 42 cases of malignant peritoneal effusion. The positive detection rate of pleural effusion diagnosed by paraffin-embedded section of cell block (80.56%) was higher than that diagnosed by cell smear (58.33%), with a statistical difference (P<0.05). The positive detection rate of peritoneal effusion diagnosed by paraffin-embedded section of cell block (85.71%) was higher than that diagnosed by cell smear (64.29%), with a statistical difference (P<0.05). The sensitivity, specificity, and accuracy of paraffin-embedded section of cell block in the diagnosis of malignant pleural and peritoneal effusion were higher than those of cell smear, with statistical differences (all P<0.05). Conclusions Paraffin-embedded section of cell block in the differential diagnosis of benign or malignant pleural and peritoneal effusion has high sensitivity and specificity, and can increase the diagnostic accuracy and provide an important basis for clinical diagnosis and treatment of the disease. Key words: Pleural effusion; Paraffin-embedded section of cell block; Cell smear; Exfoliative cell pathological examination

Objective To assess the significance of COX-2 and VEGF in the differential diagnosis of benign and malignant pleural effusions by detecting their levels in pleural effusion. Methods Fifty-eight cases of pleural effusion were collected at our hospital, including 48 cases of malignant pleural effusion and 10 cases of benign pleural effusion. Expression levels of COX-2 and VEGF in pleural effusions were detected by ELISA and compared between benign and malignant pleural effusions. Results The expression levels of COX-2 and VEGF had no significant association with gender or age in both 48 cases of malignant pleural effusion and 10 cases of benign pleural effusion (P>0.05). The average COX-2 and VEGF levels were (788.04 ± 128.85) U/L and (365.27 ± 80.63) ng/L, respectively, in the malignant pleural effusion group, and the corresponding values in the benign pleural effusion group were (366.92 ± 41.08) U/L and (114.67 ± 15.69) ng/L. COX-2 and VEGF levels in malignant pleural effusion were significantly higher than those in benign pleural effusion (P<0.001). Conclusion COX-2 and VEGF expression levels are higher in malignant pleural effusion than in benign pleural effusion, and they may serve as prognostic factors to distinguish between benign and malignant pleural effusions. Key words: Cyclooxygenase-2; Vascular endothelial growth factor; Pleural effusion; Tumor

Diaphragmatic stripping or coagulation is a technique aiming to optimally cytoreduce ovarian cancer. We investigated the complications, the overall survival, and the relapse rate following this procedure. Records of 69 patients with diaphragmatic involvement who underwent debulking surgery between September 1993 and December 2001 were reviewed. A total of 69 patients underwent diaphragmatic surgery as part of cytoreductive surgery for epithelial ovarian cancer. In 17 cases, the diaphragmatic tumors were stripped from the muscle, in 22 cases coagulated, and in 30 cases stripped and coagulated. Postoperative complications were pleural effusion (41 cases, 3 needed a chest drain, 7 needed a pleural puncture, 1 needed both) and pneumothorax (4 cases, 1 needed a chest drain). In one case of bilateral pleural effusion, the patient developed pneumonia. In one case of pleural effusion on the right side, the patient needed a pleural puncture and developed a partial atelectasis of the middle lobe of the right lung. The median overall survival was 66 months in the stripping group compared with 49 months in the coagulation group. In 56 cases (81%), the patient developed a relapse, and the first site of relapse was the diaphragm in 11 cases (20%). We conclude that diaphragmatic resection is an important part of optimal debulking surgery with an acceptable morbidity.

Diaphragmatic stripping or coagulation is a technique aiming to optimally cytoreduce ovarian cancer. We investigated the complications, the overall survival, and the relapse rate following this procedure. Records of 69 patients with diaphragmatic involvement who underwent debulking surgery between September 1993 and December 2001 were reviewed. A total of 69 patients underwent diaphragmatic surgery as part of cytoreductive surgery for epithelial ovarian cancer. In 17 cases, the diaphragmatic tumors were stripped from the muscle, in 22 cases coagulated, and in 30 cases stripped and coagulated. Postoperative complications were pleural effusion (41 cases, 3 needed a chest drain, 7 needed a pleural puncture, 1 needed both) and pneumothorax (4 cases, 1 needed a chest drain). In one case of bilateral pleural effusion, the patient developed pneumonia. In one case of pleural effusion on the right side, the patient needed a pleural puncture and developed a partial atelectasis of the middle lobe of the right lung. The median overall survival was 66 months in the stripping group compared with 49 months in the coagulation group. In 56 cases (81%), the patient developed a relapse, and the first site of relapse was the diaphragm in 11 cases (20%). We conclude that diaphragmatic resection is an important part of optimal debulking surgery with an acceptable morbidity.

BackgroundDiaphragm dysfunction is frequently observed in patients with pleural effusion. The aim of the study was to determine the criteria for estimating the impact of pleural fluid on diaphragm function and detecting impairment of diaphragmatic muscle.MethodsThis was a retrospective observational study carried out in a university hospital. Cases of free pleural effusion were recruited from the ultrasound consultation of the lung function test laboratory. The quantification of pleural effusion and analysis of diaphragmatic function were performed using chest ultrasound performed while sitting. In case of abnormal diaphragmatic motion, the examination was repeated in supine position.Results109 pleural effusions (57 left, 52 right) were included in the analysis. Pleural effusions were detected after thoracic surgery in 89% of cases and in the context of medical disease in other cases. Excursion during deep inspiration was reduced by the amount of fluid (4.3 ± 2.1 cm for small effusions, 3.2 ± 1.7 cm for moderate effusions and 1.1 ± 1.8 cm for large effusions). In 23 cases of large pleural effusion, the excursions during deep inspiration were always below the lower limit of normal. In some cases, a paradoxical motion suggesting hemidiaphragm paralysis was observed. When the inspiratory thickening was normal, the paradoxical excursions disappeared in supine position. In moderate pleural effusion (53 cases), hemidiaphragm excursion was above lower limit of normal in 68% of cases. In cases of paradoxical motions, repeated ultrasound examinations were in favor of hemidiaphragm paralysis. In small pleural effusion (32 cases) the excursion was most often normal.ConclusionThe ultrasound analysis of diaphragm excursion and thickening in sitting and supine positions is useful to assess the impact of pleural effusion and detect impairment in diaphragm muscle function.

BACKGROUND AND OBJECTIVES:We investigated the efficacy of pleural drainage with the use of different chest tube methods in patients after coronary artery bypass graft (CABG) surgery.DESIGN AND SETTING:Prospective randomized study of 60 patients undergoing elective on-pump single CABG surgery.PATIENTS AND METHODS:The left internal mammary arterial grafts were harvested from all patients. The patients were separated into three groups: In one group (IC6, n=20), pleural tubes were inserted through the sixth intercostal space at the midaxillary line; in the second group (SX-r, n=20), rigid straight pleural tubes were inserted from the mediastinum through the subxiphoid area; and in the third group (SX-s, n=20), soft curved drainage tubes were inserted from the mediastinum through the subxiphoid area. The residual pleural effusion was examined by multislice CT scans within 8 hours of removal of the drainage tubes. Pain was evaluated according to standard methods.RESULTS:The groups did not differ with respect to volume of residual pleural effusion (P>.05). The IC6 group had a higher mean pain score than the other two groups (P<.05), whose mean pain scores did not differ significantly from each other (P>.05). IC6 group patients had a higher requirement for analgesics. The rate of atelectasis was higher in group IC6 (P<.05).CONCLUSION:CT scans revealed that different chest tube insertion sites have the same efficiency for draining of pleural effusion, although drainage tubes inserted through the thoracic cage may result in more severe pain.

Gastric cancer (GC) is the third leading cause of cancer deaths, with surgery as the primary treatment; however, the outcomes of different types of surgeries still need to be understood further. This study evaluated the surgical outcomes and prognosis after minimally invasive distal gastrectomy (MIDG) for GC in a multicenter retrospective cohort using propensity score matching. This study retrospectively enrolled 688 patients who underwent curative MIDG for GC at five institutions between January 2018 and December 2024. Patients were categorized into Billroth-I reconstruction (B-I) and Roux-en-Y (R-Y) reconstruction groups. Propensity score matching was performed using the following covariates: age, sex, body mass index, American Society of Anesthesiologists physical status, extent of lymph node dissection, Japanese Classification of Gastric Carcinoma stage, neoadjuvant chemotherapy, and adjuvant chemotherapy. Surgical outcomes and prognoses were compared. Three hundred propensity score-matched pairs were identified. The R-Y group had longer median operation time [309 (131 to 531)min vs. 265 (126 to 532)min; P <0.001], longer postoperative hospital stay [10 (5 to 110)d vs. 10 (5 to 43)d; P =0.042], and greater median blood loss ( P =0.047) than the B-I group. Complications of Clavien-Dindo (CD) grade II ( P <0.001) and grade III ( P =0.027) were more frequent in the R-Y group than in the B-I group. Five-year overall survival (OS) was significantly higher in the B-I group than in the R-Y group (91.1% vs. 83.4%; P =0.019), whereas 5-year relapse-free survival (RFS) showed no significant difference between these 2 groups ( P =0.056). Independent prognostic factors included reconstruction method, postoperative complications (≥CD III), and lymph node metastasis (pN) for OS and age (≥80), pT, and pN for RFS. Patients who underwent R-Y reconstruction had more frequent postoperative complications than those who underwent B-I reconstruction after MIDG. Although not significantly associated with RFS, these complications may affect OS. The findings of this study could help develop strategies for improving GC treatment.

The relationship between postoperative complications and prognosis after laparoscopic distal gastrectomy (LDG) for gastric cancer (GC) remains controversial. This study evaluated this association using propensity score-matched analysis. We analyzed data of 590 patients who underwent curative LDG for GC at five institutions between January 2018 and December 2024. Patients were categorized into non-complication and complication groups (non-CG and CG, respectively), with complications defined as Clavien-Dindo grade ≥II (CD ≥II). Minor complications were defined as CD grades I or II, and major complications were defined as CD grades ≥III. Propensity score matching (PSM) was performed using the following covariates: age, sex, body mass index, American Society of Anesthesiologists physical status, extent of lymph node dissection, reconstruction method, Japanese Classification of Gastric Carcinoma stage, neoadjuvant chemotherapy, and adjuvant chemotherapy. Survival curves were compared using the log-rank test, and multivariate analysis was performed using the Cox proportional hazard models. Overall incidence of postoperative complications (CD ≥II) was 14.9% (88/590 patients). After the PSM (85 pairs), the CG group had a significantly longer postoperative hospital stay than the non-CG group [median (range), 18 (7-110) days vs. 9 (5-18) days; p<0.001]. Five-year overall survival (OS) rate was 90.7% in the non-CG group and 70.4% in the CG group (p=0.009), and 5-year relapse-free survival rate was 87.7% in the non-CG group and 70.9% in the CG group (p=0.027). Multivariable analysis identified age ≥80 years, postoperative complications (CD ≥II), and lymph node metastasis (pN) as independent prognostic factors for OS. Reducing the incidence of postoperative complications (CD ≥II) may improve prognosis in patients with GC undergoing LDG, contributing to better treatment strategies for GC.

PurposeLaparoscopic gastrectomy is widely used to treat early gastric cancer. The advantages of totally laparoscopic distal gastrectomy (TLDG) are unproven, and some concerns remain regarding the early surgical outcomes due to its technical difficulty. We compared the early surgical outcomes and acute inflammatory response between patients undergoing TLDG and laparoscopy-assisted distal gastrectomy (LADG) for treatment of early gastric cancer.MethodsWe performed a retrospective study on 212 consecutive patients who underwent laparoscopic distal gastrectomy for gastric cancer between January 2008 and June 2014. A total of 179 LADG cases and 33 TLDG cases were included. After age, sex, body mass index, and American Society of Anesthesiologists physical status score were matched using propensity score matching (PSM), we compared the short-term surgical outcomes between the LADG and TLDG groups.ResultsThe TLDG group had a shorter hospital stay (9.5 days vs. 11.0 days, P = 0.046) and less blood loss (116.6 mL vs. 141.5 mL, P = 0.031) than those in the LADG group. There were no differences in the preoperative WBC count and CRP level and the other clinical data between the two groups after PSM. Postoperative WBC count, serum CRP level, and decrease rate of WBC count in the TLDG group were significantly lower than those in the LADG group.ConclusionThe short-term outcomes of TLDG revealed better than that of LADG in this study. Therefore, TLDG is one of the safe and feasible procedure for the treatment of early gastric cancer.

Gastrectomy for gastric cancer in overweight patients is associated with a high incidence of postoperative complications and difficulties in achieving adequate lymph node dissection. We conducted this study to compare the outcomes of laparoscopic and open distal gastrectomy (ODG) for gastric cancer in overweight Japanese patients. This retrospective study analyzed data from 180 patients with a body mass index ≥ 25 who underwent distal gastrectomy for pStage I-III gastric cancer. Postoperative complications, the number of harvested lymph nodes, and long-term survival were compared between ODG and laparoscopic distal gastrectomy (LDG). Postoperative complications of Clavien-Dindo (CD) grade ≥ 2 and ≥ 3 were significantly higher after ODG than after LDG (p < 0.001 and p = 0.004). Multivariate analysis identified age and ODG as factors related to complications of CD ≥ 2 (p = 0.014 and 0.002). The number of harvested lymph nodes at region 4sb was significantly higher in LDG for patients with pStage III disease. The 5-year lymph node recurrence-free survival tended to be better in LDG; however, no difference was found between ODG and LDG at any pathological stage. There were no significant differences in the 5-year overall and recurrence-free survival rates after ODG vs. LDG. LDG for gastric cancer appears to be associated with a lower incidence of postoperative complications than ODG, without compromising long-term survival, even for overweight patients.

Cholelithiasis occurs often after gastrectomy. However, no consensus has been established regarding the difference in the incidence of postgastrectomy cholelithiasis with different reconstruction methods. In this study, we examined the frequency of cholelithiasis after two major reconstruction methods, namely Billroth-I (B-I) and Roux-en-Y (R-Y) following laparoscopic distal gastrectomy (LDG) for gastric cancer. Among 696 gastric cancer patients who underwent LDG between April 2000 and March 2017, after applying the exclusion criteria, 284 patients who underwent B-I and 310 who underwent R-Y were examined retrospectively. The estimated incidence of cholelithiasis was compared between the methods, and factors associated with the development of cholelithiasis in the gallbladder and/or common bile duct were investigated. During the median follow-up of 61.2months, 52 patients (8.8%) developed cholelithiasis postgastrectomy; 12 patients (4.2%) after B-I and 40 (12.9%) after R-Y (p = 0.0002). Among them, choledocholithiasis was more frequent in patients who underwent R-Y (n = 11, 27.5%) vs. B-I (n = 1, 8.3%) (p = 0.0056). Univariate and multivariate analyses revealed that male sex, body mass index > 22.5kg/m2, and R-Y reconstruction were significant predictors of the development of postLDG cholelithiasis. Regarding cholelithiasis development, B-I reconstruction should be preferred whenever possible during distal gastrectomy.

Background : The percutaneous pleural needle biopsy have been regarded as cornerstone in the diagnosis of lymphocyte dominant pleural effusions of which acid fast bacilli smear and cytologic exam was negative. However, the complications of percutaneous pleural needle biopsy is not rare and its diagnostic efficacy is not always satisfactory. Recently, pleural fluid adenosine deaminase (ADA) and carcinoembryonic antigen (CEA) are widely accepted as markers of tuberculous pleurisy and malignant pleural effusion respectively. We designed this study to re-evaluate the role of percutaneous pleural needle biopsy in the diagnosis of lymphocyte dominant exudative pleural effusions whose AFB smear, cytologic exam was negative. Method : Retrospective analysis of 73 cases of percutaneous pleural needle biopsy in case of lymphocyte dominant exudative pleural effusions whose AFB smear and cytoloic exam was negative from Jan 1994 to Feb 1996 was done. Result : In 35 cases, specific diagnosis was obtained(all cases were tuberculous pleurisy), and in 30 cases specific diagnosis was not obtained in spite of getting adequate pleural tissues, and in the other 8 cases, percutaneous pleural biopsy failed to get pleural tissues. In 9 cases, complications were combined including pneuomothorax and hemothorax. All 49 cases of pleural effusions whose ADA value was higher than 40IU/L and satisfying other categories were finally diagnosed as tuberculous pleurisy, however, the pleural biopsy confirmed only 28 cases as tuberculous pleurisy. In 6 cases of pleural effusions of which CEA value is higher than 10ng/ml, the pleural biopsy made specific diagnosis in no case. Final diagnosis of above 6 cases consisted of 4 malignant effusions, 1 malignancy associated effusion and 1 tuberculous pleurisy. Conclusion : In the diagnosis of 73 cases of lymphocyte dominant pleural effusions of which acid fast bacilli smear and cytologic exam was negative, percutaneous pleural biopsy diagnosed only in 35 cases. In the diagnosis of tuberculous pleurisy, the positive predictive value of higher ADA than 40 IU/L in lymphocyte dominant pleural effusion with negative AFB smear and negative cytologic exam was 100%. And the diagnostic efficacy of pleural biopsy was 57%. In cases of effusions with high CEA than 10ng/ml 83% and 0% respectively. Finally, we concluded that percutaneous pleural needle biopsy in the diagnosis of AFB smear negative and cytologic exam negative lymphocyte dominant exudative pleural effusion was not obligatory. especially in effusions with high ADA and low CEA value.

Objective To investigate the clinical efficacy of Da Vinci robotic and laparoscopic distal gastrectomy for gastric cancer. Methods The propensity score matching and retrospective cohort study was conducted. The clinicopathological data of 171 patients with gastric cancer who were admitted to the First Affiliated Hospital of Nanchang University from January 2015 to October 2016 were collected. There were 110 males and 61 females, aged from 38 to 81 years, with a median age of 57 years. Of 171 patients, 70 undergoing Da Vinci robotic distal gastrectomy for gastric cancer and 101 undergoing laparoscopic distal gastrectomy were allocated into the robotic group and laparoscopic group, respectively. Observation indicators: (1) the propensity score matching conditions and comparison of general data between the two groups after the propensity score matching; (2) intraoperative and postoperative situations; (3) situations of pathological examination; (4) follow-up. Patients were followed up by outpatient examination and telephone interview to detect severe complications and survival after discharge up to October 2018. The overall survival time was from the operation data to end of follow-up or time of death. The propensity score matching was used to perform 1∶1 matching by Empower Stats. Measurement data with normal distribution were represented as Mean±SD, and comparison between groups was done using the t test. Measurement data with skewed distribution were represented as M (range), and comparison between groups was done using the Mann-Whitney U test. Count data were represented as absolute number, and comparison between groups was analyzed using the chi-square test and comparison of ordinal data between groups was analyzed using the Mann-Whitney U test. The survival rate and curve were respectively calculated and drawn by the Kaplan-Meier method, and Log-rank test was used for survival analysis. Results (1) The propensity score matching conditions and comparison of general data between the two groups after the propensity score matching: 124 of 171 patients had successful matching, including 62 in each group. The body mass index (BMI) and tumor diameter before matching were (24.2±2.4)kg/m2 and (50±13)mm in the robotic group, (25.1±2.1)kg/m2 and (45±14)mm in the laparoscopic group, showing statistically significant differences between the two groups (t=-2.676, 2.045, P 0.05). (2) Intraoperative and postoperative situations: the total operation time, volume of intraoperative blood loss, level of C-reactive protein at day 1 postoperatively, level of C-reactive protein at day 3 postoperatively, volume of totally abdominal drainage were (147±13)minutes, (115±12)mL, (52.2±7.2)mg/L, (33.7±11.9)mg/L, 353.5 mL (range, 267.0-1 350.0 mL) in the robotic group, and (140±12)minutes, (131±12)mL, (58.2±7.4)mg/L, (41.1±16.9)mg/L, 397.0 mL (range, 255.0-1 600.0 mL) in the laparoscopic group, respectively, showing statistically significant differences in the above indexes between the two groups (t=3.163, -7.814, -4.631, -2.840, Z=-4.351, P 0.05). Conclusions Compared with laparoscopic surgery, Da Vinci robotic distal gastrectomy for gastric cancer has advantages in postoperative recovery and minimally invasion. There are similar 2-year overall survival rates in the two groups. Key words: Gastric neoplasms; Gastric cancer; Da Vinci robotic surgery system; Laparoscopy; Propensity score matching; Clinical efficacy