Gangnam Severance Hospital Research Articles

Borderline high serum calcium levels are associated with arterial stiffness and 10‐year cardiovascular disease risk determined by Framingham risk score

Recent epidemiological data indicate that the concentration of circulating calcium is related to cardiovascular disease (CVD) mortality. We determined whether serum calcium level is related to arterial stiffness and 10-year CVD risk calculated by Framingham risk score (FRS). We examined the association of normal-range serum calcium level with arterial stiffness and FRS in 565 Korean adults participating at the Health Promotion Center of Gangnam Severance Hospital between March 2016 and May 2017. High brachial-ankle pulse wave velocity (baPWV) was defined as >1460cm/s, and high FRS was defined as ≥10 percent for 10-year CVD risk. Odds ratios (ORs) and 95% confidence intervals (95% CIs) for high baPWV and high FRS were calculated using multiple logistic regression analysis after adjusting for confounding variables. The OR (95% CI) for high baPWV was 3.91 (1.15-7.36) per 1mg/dL increment of serum calcium after adjusting for age, sex, body mass index, smoking status, exercise regularity, alcohol consumption, mean blood pressure, fasting plasma glucose, triglyceride, HDL-cholesterol, C-reactive protein, γ-glutamyltransferase, uric acid level, phosphate level, potassium level, and presence of hypertension, diabetes and dyslipidemia medications (P=0.024). A positive association between serum calcium level and high FRS was also observed after adjusting for the same covariables (OR, 3.54 [95% CI, 1.01-12.44], P=0.048). Serum calcium level was independently and positively associated with baPWV and 10-year CVD risk estimates. Early detection of higher serum calcium level may be important for the assessment of arterial stiffness and future risk of a cardiovascular event.

Association between early nutritional risk and overall survival in patients with advanced pancreatic cancer: A single-center retrospective study

We investigated the predictors of overall survival (OS) among Korean patients with advanced pancreatic cancer (PC) according to their baseline nutritional status. We retrospectively reviewed the data of 412 inpatients with PC between January 2007 and February 2015at the Department of Oncology of the Gangnam Severance Hospital, Korea. Data on demographic and clinical parameters were collected from electronic medical records, and OS was estimated using the Kaplan-Meier method. Stepwise Cox regression analysis was used to determine the factors associated with survival. Patients with a Nutritional Risk Screening (NRS) 2002 score <3 were classified as "no-risk; " those with a score of 3 were classified as "moderate-risk; " and those with a score of ≥4 were classified as "high-risk." Following nutritional screening at baseline, 194 patients (47.1%, mean age 61.8±9.9 years) were classified as the "no risk" group; 81 patients (19.7%, mean age 65.4±10.8 years), as the "moderate risk" group; and 137 patients (33.3%, mean age 67.8±12.0 years), as the "high risk" group. Predictors of survival were NRS 2002 score (hazard ratio [HR]=1.238; 95% confidence interval [CI]=1.143-1.341), percentage of lymphocytes (HR=0.973; 95% CI=0.962-0.984), C-reactive protein level (HR=1.003; 95% CI=1.001-1.006), carcinoembryonic antigen level (HR=1.000; 95% CI=1.000-1.000), and carbohydrate antigen 19-9 level (HR=1.000; 95% CI=1.000-1.000). Kaplan-Meier survival analysis showed significant differences in the median OS among the NRS 2002 groups: "no risk" group: 12.3±0.4 months (95% CI: 11.47-13.13 months); "moderate risk" group: 6.5±0.9 months (95% CI: 4.78-8.17 months); and "high risk" group: 5.5±0.6 months (95% CI: 4.31-6.69 months). A good baseline nutritional status was associated with OS among Korean patients with advanced PC. An improvement in the nutritional status of patients with advanced PC through baseline nutritional interventions is therefore necessary to prolong OS.

True learning curve of laparoscopic spleen-preserving distal pancreatectomy with splenic vessel preservation

Laparoscopic distal pancreatectomy (LDP) is generally the treatment of choice for diseases of the pancreatic body and tail. Most surgeons prefer the spleen- and splenic vessel-preserving technique (SPVP-LDP) in benign/borderline pancreatic disease because complications of splenic infarction and gastric varices can arise after Warshaw technique. This study was aimed to determine the true learning curve of the SPVP-LDP procedure not LDP including Warshaw technique. Data were collected retrospectively from all patients who underwent a LDP between June 2007 and April 2017 at Gangnam Severance Hospital. We used cumulative sum control chart (CUSUM) analysis to assess the learning curve for the SPVP-LDP technique. Eight-three patients were performed LDP and we excluded patients who underwent robotic approach (N = 10) and open conversion DP (N = 8). Patients who underwent SPVP-LDP procedures were categorized into Group 1 (primary end-point). Those who underwent LDP procedures with splenectomy and the Warshaw technique were categorized into Group 2. We found that the 16th case was the cutoff point and the mean length of hospital stay was 13.0 days in the first period and 8.7 days in the second period (p = < 0.001). These results indicated that the frequency of SPVP-LDPs had increased and that technological progress had been made over time. The true learning curve for SPVP-LDP was indicated as 16 cases in a group of surgeons with no experience of laparoscopic pancreatic surgery.

Best methods to minimize pancreatic fistula after pancreatoduodenectomy: 15 years experience

Background: Postoperative pancreatic fistula(POPF) remains the most life-threaten major complication after pancreatoduodenectomy(PD). Despite numerous trials comparing anastomosis method and duct stent type, there are no consensus regarding the ideal surgical technique. In this study, we retrospectively analyzed the surgical outcomes after PD at single center. Methods: Between June 2001 and May 2015, 500 consecutive patients received PD at Gangnam severance hospital. All patients received same procedure. Duct to mucosa Pancreaticojejunostomy with internal stenting was performed. We analyzed operative time, estimated blood loss, length of hospital stay and complications. Results: Operation time, estimated blood loss, length of hospital stay and clinical relevant POPF rate decreased steadily and first plateau was noted after 100 cases. After 100 cases, Average clinical relevant POPF rate was 6.75%. Conclusion: Consistent practice of standardized technique may decrease the rate of clinical relevant POPF. It is important to stabilize surgical methods before comparing new anastomosis methods.

Crucial relationship of Neural Wiskott Aldrich syndrome protein(N-WASP) and Lysyl oxidase-like 2(LOXL2) in the promotion of pancreatic cancer metastasis

Introduction: Pancreatic cancer has been widely known to have aggressive malignancy and poor prognosis. N-WASP is part of the WASP family that regulate actin polymerization by activating Arp2/3 complex. FAK(Focal adhesion kinase) promotes N-WASP and epithelial mesenchymal transition(EMT) in cancer metastasis. The overexpression of LOXL2 promotes distant metastasis in pancreatic cancer. However, there is insufficient evidence of the relationship between LOXL2 and N-WASP in pancreatic cancer. In this study, we aimed to confirm the expression of N-WASP and relation between LOXL2 and N-WASP in pancreatic cancer. Method: Between June 2002 and December 2012, 81 patients underwent radical curative resection for pancreatic cancer at Gangnam Severance Hospital. Pancreatic cancer cell lines MIA PaCa-2, PANC-1 were used for in vitro study. To evaluate the endogenous expression level of N-WASP, we purified the whole RNA and protein to perform the qPCR, RT-PCR and Western blot. And we confirmed the motility and invasiveness of MIA PaCa-2 and PANC-1. Result: High expression of LOXL2 and N-WASP was observed and correlated with the expression of mesenchymal markers (Snail, L1CAM, Vimentin). We generated stably LOXL2 silenced pancreatic cancer cell which exhibited significant changes of factors related to invasiveness and N-WASP expression. Importantly, silencing of N-WASP markedly decrease in motility and invasiveness of MIA PaCa-2 and PANC-1 as determined from wound healing assay. Conclusion: Our results demonstrated that N-WASP is a regulator of EMT for migration and invasion in pancreatic cancer. LOXL2 and N-WASP have a powerful relationship for activating the promotion of EMT in pancreatic cancer metastasis. These findings suggest that N-WASP can be a target for the determining of distant metastasis in pancreatic cancer.

Best methods to minimize pancreatic fistula after pancreatoduodenectomy: 15 years experience

Background: Postoperative pancreatic fistula(POPF) remains the most life-threaten major complication after pancreatoduodenectomy(PD). Despite numerous trials comparing anastomosis method and duct stent type, there are no consensus regarding the ideal surgical technique. In this study, we retrospectively analyzed the surgical outcomes after PD at single center. Methods: Between June 2001 and May 2015, 500 consecutive patients received PD at Gangnam severance hospital. All patients received same procedure. Duct to mucosa Pancreaticojejunostomy with internal stenting was performed. We analyzed operative time, estimated blood loss, length of hospital stay and complications. Results: Operation time, estimated blood loss, length of hospital stay and clinical relevant POPF rate decreased steadily and first plateau was noted after 100 cases. After 100 cases, Average clinical relevant POPF rate was 6.75%. Conclusion: Consistent practice of standardized technique may decrease the rate of clinical relevant POPF. It is important to stabilize surgical methods before comparing new anastomosis methods.

Evaluation of postoperative adjuvant treatment for ampulla of vater carcinoma : Multicenter, Retrospective study

Introduction: Ampulla of vater carcinoma (AOV) is an infrequent tumor that account for about 0.2% of gastrointestinal malignancies. The incidence of AOV carcinoma is steadily increasing. But there are no guidelines from both the NCCN and the ESMO for the treatment of advanced AOV carcinoma. Only a few retrospective studies have focused on the adjuvant treatment in AOV carcinoma. So, we conducted multicenter retrospective review for evaluation of postadjuvant therapy for AOV carcinoma. Method: Patients who underwent curative resection for AOV carcinoma at the four hospital ( Yonsei Gangnam severance hospital, Seoul national university hospital, Seoul national university bundang hospital, National cancer center , n = 651; 2002-2015) were reviewed. Patients with metastatic disease at surgery, or insufficient pathologic data were excluded. Adjuvant treatment were chemotherapy or chemoradiotherapy. Overall survival and recurrence free survival was compared using Kaplan –Meier estimates. Result: In multivariate analysis, age, T stage, N stage, differentiation type remained as strong and independent risk factors for recurrence free survival and overall survival. No adjuvant group were 396 patients and adjuvant treatment group were 255 patients (Chemotherapy; 84 patients, Chemoradiotherapy; 171 patients). In the high risk patients, such as patients with node-positive, adjuvant treatment was significantly associated with increased recurrence free survival and overall survival. Conclusion: Adjuvant treatment did not improve survival in low risk patients. However adjuvant treatment maybe improved recurrence free and overall survival in high risk patients ( node-positive, advanced T stage) . Prospective evaluation of appropriate adjuvant treatment should be considered.

The Usefulness of Muscle Biopsy in Initial Diagnostic Evaluation of Mitochondrial Encephalomyopathy, Lactic Acidosis, and Stroke-Like Episodes.

PurposeThe disease entity mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes (MELAS) is characterized by an early onset of stroke-like episodes. MELAS is the most dominant subtype of mitochondrial disease. Molecular genetic testing is important in the diagnosis of MELAS. The mitochondrial DNA (mtDNA) 3243A>G mutation is found in 80% of MELAS patients. Nevertheless, molecular analysis alone may be insufficient to diagnose MELAS because of mtDNA heteroplasmy. This study aimed to evaluate whether muscle biopsy is useful in MELAS patients as an initial diagnostic evaluation method.Materials and MethodsThe medical records of patients who were diagnosed with MELAS at the Department of Pediatrics of Gangnam Severance Hospital between January 2006 and January 2017 were reviewed. The study population included 12 patients. They were divided into two subgroups according to whether the results of muscle pathology were in accordance with mitochondrial diseases. Clinical variables, diagnostic evaluations, and clinical outcomes were compared between the two groups.ResultsOf the 12 patients, seven were muscle pathology-positive for mitochondrial disease. No statistically significant difference in clinical data was observed between the groups that were muscle pathology-positive and muscle pathology-negative for mtDNA 3243A>G mutation. Additionally, the patients with weakness as the initial symptom were all muscle pathology-positive.ConclusionThe usefulness of muscle biopsy appears to be limited to an initial confirmative diagnostic evaluation of MELAS. Muscle biopsy can provide some information in MELAS patients with weakness not confirmed by genetic testing.

2449. Validation of In Vitro Activity of Aminoglycosides Against Recently Isolated Helicobacter pylori for Commercialization of Gentamicin-Intercalated Smectite Hybrid as a New Therapeutic Agent

BackgroundThe eradication rate of Helicobacter pylori as a standard therapy based on amoxicillin and clarithromycin, exhibits a decreasing trend. Alternative approaches have been explored, but there is still controversy in the regimen change and these do not provide a satisfactory substitute to the existing standard therapy. Thus, a novel and efficient H. pylori eradication regimen should be developed. Smectite can serve as a drug delivery system and gentamicin-intercalated smectite hybrids (S-GEN) are expected to supersede the standard therapy for H. pylori eradication. In the previous study, we synthesized S-GEN complexes as a novel therapeutic agent. In a murine model, S-GEN released gentamicin to the gastric wall stably and the therapeutic effect was not inferior to the conventional standard therapy. The aim of this study was to confirm whether the minimum inhibitory concentration (MIC) of aminoglycosides applied as smectite hybrids remained low against recently isolated H. pylori strains.MethodsThe H. pylori strains were collected via endoscopic biopsy from 1,422 patients at Gangnam Severance Hospital in Seoul, Korea, between March 2015 and February 2018. Antimicrobial susceptibility tests were performed, and the MICs of eight antibiotics (amoxicillin, clarithromycin, metronidazole, tetracycline, levofloxacin, gentamicin, netilmicin, and tobramycin) were determined by using the Epsilometer test and following the European Committee on Antimicrobial Susceptibility Testing recommendations.ResultsFinally, 140 H. pylori strains were analyzed in this study. The resistance rate to clarithromycin was 30.7%, although it is a major antimicrobial agent used in standard therapy. The MIC50 and MIC90 of gentamicin (MIC50 0.25 mg/L, MIC90 0.75 mg/L) and netilmicin (MIC50 0.19 mg/L, MIC90 0.75 mg/L) were lower than that of metronidazole, tetracycline and levofloxacin, which are alternative therapies for H. pylori eradication. In clarithromycin-resistant strains, the MIC50 was 0.25 mg/L and the MIC90 was 1 mg/L for gentamicin; for netilmicin, the values were 0.25 mg/L and 0.75 mg/L, respectively.ConclusionThrough the use of gentamicin and netilmicin, which have low MICs for H. pylori, aminoglycoside-intercalated smectite hybrids are expected to emerge as a new standard therapy for H. pylori eradication.Disclosures All authors: No reported disclosures.

2030. How Machine-Learning Technique Using Artificial Neural Network Determines Whether the Fever Is Actually Related to the Bacteremia

BackgroundBy applying machine-learning-based algorithm using artificial intelligence to massive medical data, we are trying to build a real-time monitoring system for prediction of diseases to support accurate and efficient clinical decision making in time. In the previous study, we presented a model for predicting bacteremia using Bayesian statistical approach. Now, we have developed various machine-learning technique-based prediction model to achieve better prediction performance.MethodsWe retrospectively analyzed 13,402 febrile patients who were admitted to Gangnam Severance Hospital, a tertiary center in Seoul, South Korea. The training data were 11,061 patients with admission date from July 2008 to August 2011, and validation data were 2,341 patients from September 2011 to February 2012. The primary outcome was bacteremia, and the training data were analyzed to make prediction model with conventional Bayesian approach, Support Vector Machine (SVM), Random Forest (RF) and multi-layer perceptron (MLP), a representative artificial neural network (ANN) model, respectively. The performance of prediction was assessed based on the area under the curve (AUC) and sensitivity from validation data. We used 20 clinical variables for predictors of bacteremia same as Bayesian approach. The difference from the previous model was that each variable had been stratified, but in this study, they were trained by continuous number as it is.ResultsA total of 1,538 bacteremia episodes were identified from 13,402 febrile patients. The AUC of bacteremia prediction performance in SVM model was lowest with the result of 0.699 (95%CI; 0.687–0.700), even though it was 0.7 in conventional Bayesian statistical method. The highest results were 0.732 (95% CI; 0.722–0.733) in RF model and in MLP with 128 nodes of hidden layer model, the AUC was 0.719 (95% CI; 0.712–0.728) and in MLP with 256 nodes, it was 0.727 (95% CI; 0.713–0.727). In comparison with sensitivity, MLP models (0.810, 95% CI 0.772–0.747 in 128 nodes, 0.810, 95% CI, 0.782–0.837 in 256 nodes) were the highest but in RF model, the sensitivity was the lowest.ConclusionCompared with conventional statistical model, ANN-based bacteremia prediction model-MLP showed better predictive value. In order to improve the performance of prediction, further larger amount of clinical data is needed to be analyzed.Disclosures All authors: No reported disclosures.

The Effect of Low Body Mass Index on the Development of Chronic Obstructive Pulmonary Disease and Mortality

Background: Sarcopenia may worsen disease progression and lead to poor outcomes in chronic obstructive pulmonary disease (COPD). However, its effect on the development of COPD is unclear. Methods: We enrolled 437,584 participants registered in the physical health check-up cohort database of the Korean National Health Interview Survey from 2002 to 2003, after exclusion of participants older than 65 years and those previously diagnosed with COPD confirmed by ICD-10 code and prescribed medication. We classified participants according to smoking duration and BMI at baseline. COPD development and mortality were checked for 13 years. Findings: Participants in the low BMI group (<18.5 kg/m2) had a significantly higher rate of COPD development for 13 years (7.6%) than those in other groups (3.4-4.1%; P < .0001). Among never or light smokers, COPD development in the low BMI group (5.6–6.7%) was significantly higher than those in other groups (2.8–4.7%). Similarly, among participants with a smoking history of ≥30 years, same trend was observed (20.1% versus 8.4-12.4%). On multivariable analysis, normal or higher than normal body weight was significantly protective against the development of COPD (hazard ratio [HR], 0.609–0.739; P < .0001) compared to low BMI. It also shows better COPD-free-survival (HR, 491–0.622; P < .0001) and overall survival (HR, 0.440–0.585; P < .0001) compared to low BMI. Interpretation: Low BMI is an important risk factor for COPD development and mortality. Maintaining normal or higher than normal body weight may reduce the risk for COPD development and mortality. Funding Statement: None Declaration of Interests: None Ethics Approval Statement: This study was approved by the Institutional Review Board of Gangnam Severance Hospital (number: 3-2018-0034). The requirement for informed consent was waived considering the retrospective nature of this study.

Three-dimensional analysis of the anterior loop of the inferior alveolar nerve in relation to the growth pattern of the mandibular functional subunit

BackgroundThe purpose of the present study was to investigate the differences in the position and shape of the anterior loop of the inferior alveolar nerve (ALIAN) in relation to the growth pattern of the mandibular functional subunit.MethodsThe study was conducted on 56 patients among those who had undergone orthognathic surgery at the Gangnam Severance Hospital between January 2010 and December 2015. Preoperative computerized tomography (CT) images were analyzed using the Simplant OMS software (ver.14.0 Materialise Medical, Leuven, Belgium). The anterior and inferior lengths of ALIAN (dAnt and dInf) and each length of the mandibular functional subunits were measured. The relationship between dAnt, dInf, and the growth pattern of the mandibular subunits was analyzed.ResultsThe length of the anterior portion of ALIAN (dAnt) reached 3.34 ± 1.59 mm in prognathism and 1.00 ± 0.97 mm in retrognathism. The length of the inferior portion of ALIAN (dInf) reached 6.81 ± 1.33 mm in prognathism and 5.56 ± 1.34 mm in retrognathism. The analysis of Pearson’s correlation coefficiency on all samples showed that the lengths of functional subunits were positively correlated with the loop depth. The length of the symphysis area in prognathic patients was positively correlated with the anterior loop depth (p = 0.005).ConclusionsBoth the anterior and inferior length of ALIAN are longer in prognathic patients. Especially, it seems to be associated with the growth of the symphysis area.

Can radial bone mineral density predict spinal bone mineral density in patients with advanced Duchenne muscular dystrophy?

In advanced Duchenne muscular dystrophy (DMD), patients with high bone fracture risk due to osteoporosis, it is difficult to measure spinal bone mineral density (BMD) because of maintaining proper posture. This study began with the idea that if we diagnose and manage osteoporosis by predicting spinal BMD through easily testable radial BMD, we could prevent fracture and improve quality of life in DMD patients. In 61 DMD patients aged 20 years or older who were admitted to Gangnam Severance Hospital from April 2013 to May 2015, radial BMD and spinal BMD were measured to compare their Z-scores. In 45 patients, the z-score was less than −2.0 in spinal BMD defined as osteoporosis. And the optimal range of Z-score in the radius was −5.2 to −5.0 (sensitivity 78.9%, specificity 71.4%). Only through the radius BMD, spinal BMD can be predicted and we suggest appropriate times for treatments.

Evaluation of postadjuvant therapy for ampulla of vater carcinoma: multicenter: a retrospective study

Ampulla of vater carcinoma (AOV) is an infrequent tumor that account for about 0.2% of gastrointestinal malignancies. The incidence of AOV carcinoma is steadily increasing. But there are no guidelines from both the NCCN and the ESMO for the treatment of advanced AOV carcinoma. Only a few retrospective studies have focused on the adjuvant treatment in AOV carcinoma. So, we conducted multicenter retrospective review for evaluation of postadjuvant therapy for AOV carcinoma. Patients who underwent curative resection for AOV carcinoma at the four hospital (Yonsei Gangnam severance hospital, Seoul national university hospital, Seoul national university bundang hospital, National cancer center, n =715; 2002-2015) were reviewed. Patients with metastatic disease at surgery, or insufficient pathologic data were excluded. Adjuvant treatment were chemotherapy or chemoradiotherapy. Overall survival and recurrence free survival was compared using Kaplan-Meier estimates. In univariate analysis, locally advanced T stage (T3-4) and node positive, perineural invasion, lymphovascular invasion, moderately cell differentiation were associated with adjuvant treatment. (p = < 0.001) No adjuvant group (Group 1) were 437 patient and adjuvant treatment group were 272 patients (Chemotherapy,Group 2; 94 patients, Chemoradiotherapy, Group 3; 184 patients). In the high risk patients, such as patients with node-positive, Group 3 was significantly associated with increased recurrence free survival (p = < 0.05). Adjuvant treatment did not improve survival in low risk patients. However adjuvant chemoradiation treatment maybe improved recurrence free survival in high risk patients (node-positive, advanced stage). Prospective evaluation of appropriate adjuvant treatment should be considered.

The impact of a quality improvement effort in reducing admission hypothermia in preterm infants following delivery.

Purpose Hypothermia at admission is associated with increased mortality and morbidity in preterm infants. We performed a quality improvement (QI) effort to determine the impact of a decrease in admission hypothermia in preterm infants.Methods The study enrolled very low birth weight (VLBW) infants born at Gangnam Severance Hospital between January 2013 and December 2016. This multidisciplinary QI effort included the use of occlusive wraps, warm blankets, and caps; the delivery room temperature was maintained above 23.0˚C, and a check-list was used for feedback.Results Among 259 preterm infants, the incidence of hypothermia (defined as body temperature <36.0˚C) decreased significantly from 68% to 41%, and the mean body temperature on neonatal intensive care unit admission increased significantly from 35.5˚C to 36.0˚C. In subgroup analysis of VLBW infants, admission hypothermia and neonatal outcomes were compared between the pre-QI (n=55) and post-QI groups (n=75). Body temperature on admission increased significantly from 35.4˚C to 35.9˚C and the number of infants with hypothermia decreased significantly from 71% to 45%. There were no cases of neonatal hyperthermia. The incidence of pulmonary hemorrhage was significantly decreased (P=0.017). Interaction analysis showed that birth weight and gestational age were not correlated with hypothermia following implementation of the protocol.Conclusion Our study demonstrated a significant reduction in admission hypothermia following the introduction of a standardized protocol in our QI effort. This resulted in an effective reduction in the incidence of massive pulmonary hemorrhage.

True learning curve of laparoscopic spleen-preserving distal pancreatectomy with splenic vessel preservation.

Laparoscopic distal pancreatectomy (LDP) is generally the treatment of choice for diseases of the pancreatic body and tail. Most surgeons prefer the spleen- and splenic vessel-preserving technique (SPVP-LDP) in benign/borderline pancreatic disease because complications of splenic infarction and gastric varices can arise after Warshaw technique. This study was aimed to determine the true learning curve of the SPVP-LDP procedure not LDP including Warshaw technique. Data were collected retrospectively from all patients who underwent a LDP between June 2007 and April 2017at Gangnam Severance Hospital. We used cumulative sum control chart (CUSUM) analysis to assess the learning curve for the SPVP-LDP technique. Eight-three patients were performed LDP and we excluded patients who underwent robotic approach (N = 10) and open conversion DP (N = 8). Patients who underwent SPVP-LDP procedures were categorized into Group 1 (primary end-point). Those who underwent LDP procedures with splenectomy and the Warshaw technique were categorized into Group 2. We found that the 16th case was the cutoff point and the mean length of hospital stay was 13.0 days in the first period and 8.7 days in the second period (p = < 0.001). These results indicated that the frequency of SPVP-LDPs had increased and that technological progress had been made over time. The true learning curve for SPVP-LDP was indicated as 16 cases in a group of surgeons with no experience of laparoscopic pancreatic surgery.

Efficacy of adjuvant chemotherapy for completely resected stage IB non-small cell lung cancer: a retrospective study.

Lung cancer is being increasingly detected in the early stages, highlighting the importance of lung cancer screening. However, there is no consensus on the post-operative management of stage IB non-small cell lung cancer (NSCLC). Therefore, this study aimed to identify the predictive factors for prognosis of stage IB NSCLC and determine the efficacy of adjuvant chemotherapy on recurrence and survival. We enrolled 89 patients with stage IB NSCLC who underwent complete resection surgery at Gangnam Severance Hospital from Jan 2008 to Dec 2014. As per the National Comprehensive Cancer Network guidelines, patients were considered to be at high risk when they showed poorly differentiated tumors, lymphovascular invasion, tumor size >4 cm, and visceral pleural invasion (VPI). Among the 89 patients, 27 underwent adjuvant chemotherapy. Young patients or patients with squamous cell lung cancer received adjuvant chemotherapy frequently. Adjuvant chemotherapy was not a significant factor for disease-free survival and overall survival. Adjuvant chemotherapy did not show a significant protective effect for survival, even for high-risk patients. However, VPI was a significant risk factor for disease-free survival [hazard ratio (HR): 7.051; 95% confidence interval (CI): 1.570-31.659; P=0.011] and overall survival (HR: 8.289; 95% CI: 1.036-66.307; P=0.046), even after adjustment for various factors. Adjuvant chemotherapy does not affect the prognosis of stage IB NSCLC, even in high-risk patients. Additionally, VPI is a strong prognostic factor of stage IB NSCLC.

Clinical outcomes and factors related to colonic perforations in patients receiving self-expandable metal stent insertion for malignant colorectal obstruction

Although colonic perforation is a dreadful adverse event associated with stent placement, data on this topic are sparse. We aimed to investigate the clinical outcomes of colonic perforation and factors related to its occurrence in patients who received self-expandable metal stents (SEMSs) for malignant colorectal obstruction. We retrospectively reviewed the data of 474 patients with malignant colorectal obstruction who received endoscopic SEMS insertion from April 2004 to May 2011 in Severance Hospital and Gangnam Severance Hospital. Early perforation, defined as perforation occurring within 2 weeks, was assessed in bridge-to-surgery (n= 164) and palliative stent placement patient groups (n= 310). Delayed perforation was analyzed using data from the palliative stent placement group alone. The technical and clinical success rates were 90.5% and 81.0%, respectively. Early and delayed perforations occurred in 2.7% (13/474) and 2.7% (8/301) of patients, respectively. Among 21 patients with perforation, 14 (66.7%) received emergency surgery and 5 (23.8%) died within 30 days after perforation. Regarding the perforation-related factors, age≥70 years (odds ratio, 3.276; 95% confidence interval [CI], 1.041-10.309) and sigmoid colonic location (odds ratio, 7.706; 95% CI, 1.681-35.317) were independently associated with occurrence of early perforation. Stent location in the flexure (hazard ratio, 17.573; 95% CI, 2.004-154.093) and absence of peritoneal carcinomatosis (hazard ratio, 6.139; 95% CI, 1.150-32.776) were significantly associated with delayed perforation. The perforation-related 30-day mortality rate was 23.8%. Older age and sigmoid colonic location were significantly associated with occurrence of early perforation, whereas flexure location and absence of peritoneal carcinomatosis were related to delayed perforation.

Validation of the 8th AJCC TNM staging system for gastric cancer: Survival analysis with high volume Asian centers and SEER database by comparing with 7th TNM staging system.

18 Background: Recently, the 8th AJCC TNM staging system for estimating prognosis for patients with gastric cancer was revised with new subgroups. There are little number of studies have shown its validation with other datasets. We aimed to validate the new TNM staging system by using various datasets with large number of gastrectomies. Methods: We retrospectively reviewed data of 17160, 11324 and 1500 patients treated for gastric cancer in Yonsei University Severance Hospital (SH), The Surveillance, Epidemiology, and End Results (SEER) and Gangnam Severance Hospital (GSH), respectively. Survival curves were plotted and the performance of tumor staging defined by the 7th and 8th TNM staging was compared based on the log-rank test, Concordance index (C-index) and Akaike information criterion (AIC). Results: The performance of predicting survival using the 8th TNM staging system is superior to that of the previous version in SH by evaluating log-rank, C-statistics, and AIC (8444.5 vs. 9263.8, 0.796 vs. 0.798, 104152 vs. 103909), respectively. It is also superior in a data with SEER and GSH (log-rank, C-statistics, and AIC; 3342 vs. 3527, 0.7064 vs. 0.709, 100931 vs. 100820 in SEER, 973 vs. 1031, 0.8021 vs. 0.8038, 7173 vs. 7154 in GSH), respectively. In subgroup analysis of each subclassification, IA, IB, IIA, IIB, IIIA, IIIB, IIIC, and IV in SH, the 8th TNM staging system shows similar or more homogenous survival (0.0324 vs. &lt; 0.001 in Stage IIB, 0.020 vs. &lt; 0.0001 in Stage IIIB, 0.0004 vs. &lt; 0.0001 in Stage IIIC, respectively) in each subclassification than that of the 7th TNM staging system by measuring log-rank p values. Conclusions: The 8th TNM staging system provides more accurate prediction of prognosis of gastric cancer patients than the previous one. In addition, each subgroup in the same stage is relatively homogenous with respect to survival than the previous staging system. It is also applicable to Eastern and Western patients with various backgrounds.

Perioperative inflammatory marker as a predictive factor for prolonged postoperative ileus after gastrectomy for gastric cancer.

31 Background: Inflammatory markers such as the C-reactive protein (CRP), neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) have recently been proposed as prognostic markers for post-operative complications and poor prognosis in solid tumors especially in colon cancer. However, there are few related reports in gastric cancer patients. Therefore, the aim of this study is to assess how perioperative inflammatory markers influence the prolonged postoperative ileus (PPOI) following gastric cancer surgery. Methods: Between 2013 and 2016, 435 patients were diagnosed with gastric cancer and underwent surgery in Gangnam Severance hospital. Patients were divided into prolonged postoperative ileus (PPOI) and control groups. Uncomplicated postoperative ileus (POI) is generally identified as an inevitable process after surgery, which typically resolves within 3 days. Ileus that persists for more than 3 days following surgery is termed PPOI. Results: The total PPOI rate was 33.8%. In univariate analysis, PPOI group was significantly associated with male sex, old age, open operative technique, preoperative gastric outlet obstruction and combined colon resection. PPOI group also was significantly associated with elevated perioperative inflammatory marker (pre- and post-operative CRP, NLR, and PLR). In multivariate analysis, open operative technique and elevated perioperative inflammatory markers (CRP, NLR and PLR) were identified as significant predictors of PPOI. In addition, postoperative length of hospital stay delayed in PPOI group compared with the control group (11.58 ± 9.48 vs.7.98 ± 5.44, respectively; P &lt; 0.001). Conclusions: In this study, PPOI group was significantly associated with elevated perioperative inflammatory marker. Patients with PPOI also are more likely to have an increased postoperative hospital stay. Therefore, the perioperative inflammatory markers may be used as clinically relevant predictive markers for PPOI following gastric cancer surgery