Background
The comprehensive complication index (CCI) integrates all complications of the Clavien–Dindo classification (CDC) and offers a metric approach to measure morbidity. The aim of this study ...was to evaluate the CCI at a high-volume center for gastric cancer surgery and to compare the CCI to the conventional CDC.
Methods
Clinical factors were collected from the prospective complication data of gastric cancer patients who underwent radical gastrectomy at Seoul National University Hospital from 2013 to 2014. CDC and CCI were calculated, and risk factors were investigated. Correlations and generalized linear models of hospital stay were compared between the CCI and CDC. The complication monitoring model with cumulative sum control-CCI (CUSUM-CCI) was displayed for individual surgeons, for comparisons between surgeons, and for the institution.
Results
From 1660 patients, 583 complications in 424 patients (25.5%) were identified. The rate of CDC grade IIIa or greater was 9.7%, and the overall CCI was 5.8 ± 11.7. Age, gender, Charlson score, combined resection, open method, and total gastrectomy were associated with increased CCI (
p
< 0.05). The CCI demonstrated a stronger relationship with hospital stay (
ρ
= 0.721,
p
< 0.001) than did the CDC (
ρ
= 0.634,
p
< 0.001). For prolonged hospital stays (≥30 days), only the CCI showed a moderate correlation (
ρ
= 0.544,
p
= 0.024), although the CDC did not. The CUSUM-CCI model displayed dynamic time–event differences in individual and comparison monitoring models. In the institution monitoring model, a gradual decrease in the CCI was observed.
Conclusions
The CCI is more strongly correlated with postoperative hospital stay than is the conventional CDC. The CUSUM-CCI model can be used for the continuous monitoring of surgical quality.
It is unclear whether laparoscopic distal gastrectomy for locally advanced gastric cancer is oncologically equivalent to open distal gastrectomy. The noninferiority of laparoscopic subtotal ...gastrectomy with D2 lymphadenectomy for locally advanced gastric cancer compared with open surgery in terms of 3-year relapse-free survival rate was evaluated.
A phase III, open-label, randomized controlled trial was conducted for patients with histologically proven locally advanced gastric adenocarcinoma suitable for distal subtotal gastrectomy. The primary end point was the 3-year relapse-free survival rate; the upper limit of the hazard ratio (HR) for noninferiority was 1.43 between the laparoscopic and open distal gastrectomy groups.
From November 2011 to April 2015, 1,050 patients were randomly assigned to laparoscopy (n = 524) or open surgery (n = 526). After exclusions, 492 patients underwent laparoscopic surgery and 482 underwent open surgery and were included in the analysis. The laparoscopy group, compared with the open surgery group, suffered fewer early complications (15.7%
23.4%, respectively;
= .0027) and late complications (4.7%
9.5%, respectively;
= .0038), particularly intestinal obstruction (2.0%
4.4%, respectively;
= .0447). The 3-year relapse-free survival rate was 80.3% (95% CI, 76.0% to 85.0%) for the laparoscopy group and 81.3% (95% CI, 77.0% to 85.0%; log-rank
= .726) for the open group. Cox regression analysis after stratification by the surgeon revealed an HR of 1.035 (95% CI, 0.762 to 1.406; log-rank
= .827;
for noninferiority = .039). When stratified by pathologic stage, the HR was 1.020 (95% CI, 0.751 to 1.385; log-rank
= .900;
for noninferiority = .030).
Laparoscopic distal gastrectomy with D2 lymphadenectomy was comparable to open surgery in terms of relapse-free survival for patients with locally advanced gastric cancer. Laparoscopic distal gastrectomy with D2 lymphadenectomy could be a potential standard treatment option for locally advanced gastric cancer.
Background
Spasmolytic polypeptide-expressing metaplasia (SPEM) is considered a precursor lesion of intestinal metaplasia and intestinal-type gastric cancer (GC), but little is known about microRNA ...alterations during metaplasia and GC developments. Here, we investigate miR-30a expression in gastric lesions and identify its novel target gene which is associated with the intestinal-type GC.
Methods
We conducted in situ hybridization and qRT-PCR to determine miR-30a expression in gastric tissues. miR-30a functions were determined through induction or inhibition of miR-30a in GC cell lines. A gene microarray was utilized to confirm miR-30a target genes in GC, and siRNA-mediated target gene suppression and immunostaining were performed. The Cancer Genome Atlas data were utilized to validate gene expressions.
Results
We found down-regulation of miR-30a during chief cell transdifferentiation into SPEM. MiR-30a level was also reduced in the early stage of GC, and its level was maintained in advanced GC. We identified a novel target gene of miR-30a and
ITGA2,
and our results showed that either ectopic expression of miR-30a or
ITGA2
knockdown suppressed GC cell proliferation, migration, and tumorigenesis. Levels of
ITGA2
inversely correlated with levels of miR-30a in human intestinal-type GC.
Conclusion
We found down-regulation of miR-30a in preneoplastic lesions and its tumor-suppressive functions by targeting
ITGA2
in GC. The level of
ITGA2
, which functions as an oncogene, was up-regulated in human GC. The results of this study suggest that coordination of the miR-30a-
ITGA2
axis may serve as an important mechanism in the development of gastric precancerous lesions and intestinal-type GC.
Background
With improved short-term surgical outcomes, laparoscopic distal gastrectomy has rapidly gained popularity. However, the safety and feasibility of laparoscopic total gastrectomy (LTG) has ...not yet been proven due to the difficulty of the technique. This single-arm prospective multi-center study was conducted to evaluate the use of LTG for clinical stage I gastric cancer.
Methods
Between October 2012 and January 2014, 170 patients with pathologically proven, clinical stage I gastric adenocarcinoma located at the proximal stomach were enrolled. Twenty-two experienced surgeons from 19 institutions participated in this clinical trial. The primary end point was the incidence of postoperative morbidity and mortality at postoperative 30 days. The severity of postoperative complications was categorized according to Clavien–Dindo classification, and the incidence of postoperative morbidity and mortality was compared with that in a historical control.
Results
Of the enrolled patients, 160 met criteria for inclusion in the full analysis set. Postoperative morbidity and mortality rates reached 20.6% (33/160) and 0.6% (1/160), respectively. Fifteen patients (9.4%) had grade III or higher complications, and three reoperations (1.9%) were performed. The incidence of morbidity after LTG in this trial did not significantly differ from that reported in a previous study for open total gastrectomy (18%).
Conclusions
LTG performed by experienced surgeons showed acceptable postoperative morbidity and mortality for patients with clinical stage I gastric cancer.
Background
The purpose of this study was to evaluate the nationwide benefit and cost of the national cancer screening program (NCSP) for gastric cancer treatment.
Methods
For this nationwide, ...population‐based study, the Korean National Health Insurance Big Data Base, which included gastric cancer–related treatment information and the costs for all patients with gastric cancer who were 40 years old or older between 2004 and 2013, was restructured. Patients with gastric cancer who participated in the NCSP at least once (the screening group) were compared with those who did not participate in the NCSP (the nonscreening group).
Results
The screening group (n = 116,775) spent significantly less on medical care expenses than the nonscreening group (n = 74,927) during the 5 years since the initial treatment (P < .0001). The screening group presented a significantly better prognosis for 5 and 9 years than the nonscreening group (P < .0001). The screening group revealed a 41% decreased hazard ratio (P < .0001) for death in comparison with the nonscreening group; the prognostic benefit became more obvious when treatment was started within the first 4 months after screening. The age‐standardized mortality rate ratio of the screening group versus the nonscreening group was 0.62 (P < .0001). The NCSP for gastric cancer required an average of 22,169,769 Korean Republic won (US $20,309) for 1 life‐year saved, which was less than the average gross domestic product (GDP) per capita in Korea.
Conclusions
The screening group had significantly lower medical care expenses and showed a significantly better prognosis than the nonscreening group. On the basis of the GDP per capita, the NCSP for gastric cancer was cost‐effective for treatment prognosis.
The nationwide, population‐based health insurance big database in Korea, where a national cancer screening program for gastric cancer was introduced in 2002, reveals that a screening group has lower medical care expenses and presents with a better prognosis than a nonscreening group even after stratification of the treatment group. On the basis of medical care expenses and screening costs, the national cancer screening program for gastric cancer is cost‐effective.
This paper studies the potentials of green hydrogen production from hydropower energy and its application in electricity regeneration and replacement of petroleum products from the transportation ...sector in Nepal. The potential surplus hydroelectric energy, and hydrogen production potential from the surplus energy considering different scenarios, is forecasted for the study period (2022–2030). The results showed that hydrogen production potential ranges from 63,072 tons to 3,153,360 tons with the utilization of surplus energy at 20% and 100% respectively, in 2030. The economic analysis of hydrogen from hydropower projects that electricity is valued based on per kg of hydrogen when the surplus electricity is provided at feasible lower price values compared to the US $1.17. This study concludes that hydrogen production from spilled hydro energy and its use in the transportation sector and independent electricity generation is a niche opportunity to lead the country towards sustainable energy solutions and an economy running on hydrogen.
•Methodological study for quantification of excess hydropower and hydrogen production.•Cost projections scenarios from green hydrogen from surplus hydropower electricity.•Identification of role of green hydrogen in multiple end-use areas of developing nation.•Potential replacement of conventional fuel with hydrogen in transportation sector.
The aim of this study was to combine clinicopathologic variables associated with overall survival after gastric resection with D2 lymphadenectomy (D2 gastrectomy) for gastric cancer into a prediction ...nomogram.
We retrospectively analyzed 7,954 patients who underwent D2 gastrectomy for gastric cancer at Seoul National University Hospital (SNUH) in Seoul, Korea. Two thirds of the patients were randomly assigned to the training set (n = 5,300), and one third were assigned to the validation set (n = 2,654). Multivariate analysis by Cox proportional hazards regression was performed using the training set, and the nomogram was constructed. Discrimination and calibration were performed using the SNUH validation set. Additional external validation was performed using the data set (n = 2,500) from Cancer Institute Ariake Hospital (CIAH) in Tokyo, Japan.
The multivariate Cox model identified age at diagnosis, sex, location, depth of invasion, number of metastatic lymph nodes, and number of examined lymph nodes as covariates associated with survival. In the SNUH validation set, the nomogram exhibited superior discrimination power compared with the seventh American Joint Committee on Cancer TNM classification (Harrell's C-index, 0.78 v 0.69, respectively; P < .001). Calibration of the nomogram predicted survival corresponding closely with the actual survival. In the CIAH validation set, discrimination was good (C-index, 0.79), and the predicted survival was within a 10% margin of ideal nomogram.
We developed a nomogram predicting 5- and 10-year overall survival after D2 gastrectomy for gastric cancer. Validation using the SNUH and CIAH data sets revealed good discrimination and calibration, suggesting good clinical utility. The nomogram improved individualized predictions of survival.
OBJECTIVE:The aim of the study was to evaluate the short-term outcomes of KLASS-02-RCT, a multicenter randomized controlled trial comparing laparoscopic distal gastrectomy (LDG) with D2 ...lymphadenectomy with open distal gastrectomy (ODG).
SUMMARY BACKGROUND DATA:Although several benefits of laparoscopic gastric cancer surgery have been reported, strong evidence is still limited, especially in locally advanced gastric cancer which requires extensive lymph node dissection.
METHODS:Enrollment criteria included histologically confirmed cT2-4a and N0-1 gastric adenocarcinoma. Thirty-day morbidity, 90-day mortality, postoperative pain, and recovery were compared between LDG and ODG groups.
RESULTS:A total of 1050 patients were randomly assigned to LDG (n = 526) or ODG group (n = 524) between November 2011 and April 2015. After excluding patients who received bypass or no surgery, 1011 patients were analyzed as actual treatment group. Mean number of totally retrieved lymph nodes was similar in both groups (LDG = 46.6 vs ODG = 47.4, P = 0.451). Early morbidity rate was significantly lower after LDG (16.6%) than after ODG (24.1%; P = 0.003). Postoperative analgesics use and patients’ reported pain score were significantly lower after LDG. First day of flatus was earlier after LDG (3.5 vs 3.7 d, P = 0.025) and postoperative hospital stay was shorter in LDG group (8.1 vs 9.3 d, P = 0.005). Ninety days’ mortality rate was similar in both groups (LDG = 0.4% vs ODG = 0.6%, P = 0.682).
CONCLUSIONS:Laparoscopic distal gastrectomy with D2 lymphadenectomy for locally advanced gastric cancer shows benefits in terms of lower complication rate, faster recovery, and less pain compared with open surgery.
Considering stability and fabrication cost, 3–4 columns are usually adopted for semi-submersible platform designs. Although increasing the number of columns provides more stability for both floating ...platform and system as a whole, it is generally not economically viable. In this respect, the present work provides a high-fidelity analysis of semi-submersible platform stability and hydrodynamic response for different design concepts. The number of columns was considered as the main design parameter and was varied from 3–6 columns. The semi-submersible weight was kept constant during the simulation period by changing the column diameter and amount of ballast water. The investigation was carried out using the potential code Orcawave, the results of which were input directly to the engineering tool OrcaFlex. Four different types of semi-submersible platforms with a varying number of columns were tested and compared under extreme environmental conditions in order to ensure their stability and hydrodynamic response. The simulation findings revealed that platform stability was more affected by the geometrical features of the floater than by the number of columns. Furthermore, the number of columns did not have a significant impact on hydrodynamic behavior for the same platform geometry.
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