Challenges to the Monocentric ModelMuch received urban theory remains beset by a particular image of urbanization, the concentrated core-oriented metropolis that emerged to solve the problem of slow and expensive transportation by agglomerating industry and employment in a single center and packing the population around that center and along radiating transport networks.This urban form was at its zenith by World War 11, but since has been eroded by suburbanization, decentralization, and dispersion.Yet even today, urban economists and planners seem bemused by the reduction in commuting times that has accompanied these changes in the nation's twenty largest metropolitan areas because, simultaneously, traffic congestion is perceived to have worsened.This, say Gordon, Richardson, and Jun (1991), is "the commuting paradox," yet they also acknowledge that "rational commuters will, sooner or later, seek to escape congestion by changing the location of their homes and/or their jobs.This type of adjustment is easier to make in large, dispersed metropolitan areas with alternative employment subcenters and a wide variety of residential neighborhoods.The process is facilitated by the decentralizing location decisions of firms seeking to move closer to suburban labor pools."We already were aware two decades ago that the extent of these adjustments was far more profound then indicated in this acknowledgment (Berry 1973).The result is that, today, received theory fails to capture the essential qualities of what historian Robert Fishman calls America's "New City" that, during the 1970s, "successfully challenged the old downtowns in the last area of their supremacy, ofice employment. . . .By the 198Os, even social scientists could not ignore the fact that the whole terminology of 'suburb' and 'central city' deriving from the era of the industrial metropolis had become obsolete" (Fishman 1990, p. 37).To Fishman, the "New Cities" are the sprawling regions in which the "basic unit.. . is not the street measured in blocks but the 'growth corridor' stretching 50to 100 miles" (ibid., p. 28), regions that lack "what gave shape and meaning to
It is well known that gastrectomy with curative intent is the best way to improve outcomes of patients with remnant gastric cancer. Recently,several investigators reported their experiences with laparoscopic gastrectomy of remnant gastric cancer. We report the case of an 83-year-old female patient who was diagnosed with remnant gastric cancer with obstruction. She underwent an entirely laparoscopic distal gastrectomy with colectomy because of direct invasion of the transverse colon. The operation time was 200 minutes. There were no postoperative complications. The pathologic stage was T4b (transverse colon) N0M0. Our experience suggests that laparoscopic surgerycould be an effective method to improve the surgical outcomes of remnant gastric cancer patients.
To assess independent prognostic factors for lymph node-negative metastatic gastric cancer patients following curative resection is valuable for more effective follow-up strategies.Among 1,874 gastric cancer patients who received curative resection, 967 patients were lymph node-negative. Independent prognostic factors for overall survival in lymph node-negative gastric cancer patients grouped by tumor invasion depth (early gastric cancer versus advanced gastric cancer) were explored with univariate and multivariate analyses.There was a significant difference in the distribution of recurrence pattern between lymph node-negative and lymph node-positive group. In the lymph node-negative group, the recurrence pattern differed by the depth of tumor invasion. In univariate analysis for overall survival of the early gastric cancer group, age, macroscopic appearance, histologic type, venous invasion, lymphatic invasion, and carcinoembryonic antigen level were significant prognostic factors. Multivariate analysis for these factors showed that venous invasion (hazard ratio, 6.695), age (≥59, hazard ratio, 2.882), and carcinoembryonic antigen level (≥5 ng/dl, hazard ratio, 3.938) were significant prognostic factors. Multivariate analysis of advanced gastric cancer group showed that depth of tumor invasion (T2 versus T3, hazard ratio, 2.809), and age (hazard ratio, 2.319) were prognostic factors on overall survival.Based on our results, independent prognostic factors such as venous permeation, carcinoembryonic antigen level, and age, depth of tumor invasion on overall survival were different between early gastric cancer and advanced gastric cancer group in lymph node-negative gastric cancer patients. Therefore, we are confident that our results will contribute to planning follow-up strategies.
Purpose: The present study aims to provide an applicability of laparoscopic gastrectomy used in the treatment of giant duodenal ulcer perforation. Methods: Between July 2010 and April 2011, laparoscopic distal gastrectomy with ROUX-EN-Y gastrojejunostomy and truncal vagotomy was performed in consecutive 5 patients with giant duodenal ulcer perforation. Results: There was no conversion to open surgery. There was no severe postoperative complication. The days of normalization of leukocytosis were 3, 1, 2, 2, and 5, respectively. The times to first flatus were postoperative days 2, 3, 5, 2, and 3. The days of commencement of a soft diet were postoperative days 5, 5, 6, 5, and 5. They were discharged on postoperative days 9, 11, 20, 10, and 11. Conclusions: We suggest that laparoscopic surgery may be a good surgical method to improve surgical outcomes and is worth a try in experts.
Purpose: To evaluate the necessity for additional surgical treatment after Endoscopic Mucosal Resection (EMR) and Endoscopic Submucosal Dissection (ESD), we analyzed the pathologic results of patients who underwent surgical treatment. Methods: 140 consecutive patients underwent additional surgical treatment after EMR/ESD with en bloc resection between April 2005 and November 2009 at ASAN Medical Center. Additional surgical treatments were undergone for following conditions such as incomplete dissection (involvement of margin), undifferentiated-type histology (≥2 ㎝) and submucosal cancer. Results: One patient with deep margin involvement displayed advanced gastric cancer after gastrectomy. Three of 74 patients with clear resection margin were confirmed to have residual cancer at ESD site and 2 of 3 patients displayed advanced gastric cancer after surgery. In univariate analysis for metastasis of lymph node, deep submucosal invasion (over sm2 or 500㎛) and the presence of lymphovascular invasion showed significant differences for lymph node metastasis. Especially, lymphovascular invasion was an important predictive factor for lymph node metastasis in multivariate analysis. In analysis for residual cancer, lateral margin involvement and large tumor (＞3 ㎝) were risk factors. And, only lateral margin involvement showed significant risk in multivariate analysis. Conclusion: Although EMR/ESD were fully accomplished for resection margin, gastrectomy and lymph node dissection were positively necessary for patients with deepsubmucosal invasion (over sm2 or 500㎛) and the presence of lymphovascular invasion to eliminate the possibility of residual cancer or more advanced gastric cancer or metastatic lymph nodes.
It is well known that old age is a risk factor for postoperative complications. Therefore, this study aimed to explore the risk factors for poor postoperative surgical outcomes in elderly gastric cancer patients.Between January 2006 and December 2015, 247 elderly gastric cancer patients who underwent curative gastrectomy were reviewed. In this study, an elderly patient was defined as a patient aged ≥65 years. All possible variables were used to explore the risk factors for poor early surgical outcomes in elderly gastric cancer patients.Based on multivariate analyses of preoperative risk factors, preoperative low serum albumin level (<3.5 g/dl) and male sex showed statistical significance in predicting severe postoperative complications. Additionally, in an analysis of surgery-related risk factors, total gastrectomy was a risk factor for severe postoperative complications.Our study findings suggest that low serum albumin level, male sex, and total gastrectomy could be risk factors of severe postoperative complications in elderly gastric cancer patients. Therefore, surgeons should work carefully in cases of elderly gastric cancer patients with low preoperative serum albumin level and male sex. We believe that efforts should be made to avoid total gastrectomy in elderly gastric cancer patients.
Totally laparoscopic distal gastrectomy (TLDG) has several advantages over laparoscopic-assisted distal gastrectomy (LADG), including a shorter incision, less pain, and earlier recovery. We compared the feasibility and early surgical outcomes of TLDG and LADG in patients with gastric cancer.Between September 2008 and December 2009, 180 patients with gastric cancer underwent TLDG with intracorporeal gastroduodenostomy using linear staplers; and between January 2006 and December 2009, 268 patients with gastric cancer underwent LADG with extracorporeal gastroduodenostomy using circular staplers. Clinical features and early surgical outcomes were compared between the two groups.There were no between-group differences in postoperative clinical course and complications. Postoperative pain and the amount of pain killer administered were significantly lower (P<.05 each), and postoperative scars were smaller in the TLDG group.TLDG with intracorporeal gastroduodenostomy is as safe and feasible as LADG for patients with gastric cancer. Moreover, TLDG is less invasive and more comfortable for patients than LADG.
Abstract Background This study aimed to investigate the oncologic long-term safety of proximal gastrectomy for upper-third advanced gastric cancer (AGC) and Siewert type II esophagogastric junction (EGJ) cancer. Methods The study enrolled patients who underwent proximal gastrectomy (PG) or total gastrectomy (TG) with standard lymph node (LN) dissection for pathologically proven upper-third AGC and EGJ cancers between January 2007 and December 2018. Propensity score-matching with a 1:1 ratio was performed to reduce the influence of confounding variables such as age, sex, tumor size, T stage, N stage, and tumor-node-metastasis (TNM) stage. Kaplan-Meier survival analysis was performed to analyze oncologic outcome. The prognostic factors of recurrence-free survival (RFS) were analyzed using the Cox proportional hazard analysis. Results Of the 713 enrolled patients in this study, 60 received PG and 653 received TG. Propensity score-matching yielded 60 patients for each group. The overall survival rates were 61.7 % in the PG group and 68.3 % in the TG group ( p = 0.676). The RFS was 86.7 % in the PG group and 83.3 % in the TG group ( p = 0.634). The PG group showed eight recurrences (1 anastomosis site, 1 paraaortic LN, 1 liver, 1 spleen, 1 lung, 1 splenic hilar LN, and 2 remnant stomachs). In the multivariate analysis, the operation method was not identified as a prognostic factor of tumor recurrence. Conclusion The patients who underwent PG had a long-term oncologic outcome similar to that for the patients who underwent TG for upper-third AGC and EGJ cancer.
Despite the popularity of laparoscopic-assisted distal gastrectomy (LADG), studies have reported a high incidence of postoperative complications in patients who have had LADG. The present study explores the preoperative risk factors for complications from LADG.This study involves 1257 patients who underwent standardized LADG in a single institution between January 2006 and June 2011. The risk factors for postoperative complications of LADG were evaluated by univariate and multivariate analyses.In univariate analysis of overall postoperative complications, there were significant effects of age (above 65 years), obesity (a body mass index above 25 kg/m(2)), comorbidity, cerebrovascular disease, heart disease, hypertension, diabetes mellitus, and combined comorbidities (three or more). Multivariate analysis of these risk factors showed that old age (P=.006), obesity (P<.001), and heart disease (P=.014) were independent risk factors for postoperative complications. Univariate analysis showed that obesity also had a significant effect on severe postoperative complications.Older age, obesity, and heart disease are risk factors for postoperative complications after LADG. Greater caution or more limited surgery is required to reduce the high rate of complications in patients with these risk factors.
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