[Perineal Wound Complications after Abdominoperineal Resection for Anorectal Lesions].

BACKGROUND: Perineal wound complications(PWCs)are common after abdominoperineal resection(APR). We examined the incidence of PWCs after APR for anorectal lesions and their risk factors. METHODS: Patients who underwent APR for anorectal lesions at our hospital from January 2011 to December 2021 were included. Complications of Clavien-Dindo Grade Ⅱ or higher were considered as PWCs. RESULTS: Eighty-one patients were included; PWCs were observed in 24 patients (29.6%), and associated with a history of Crohn's disease(p=0.018), longer operation time(p=0.040), higher blood loss (p=0.011), extensive perineal resection(p=0.003), and closure with a skin flap(p=0.003). Forty-one patients underwent APR for initial rectal cancer without extended perineal resection, and PWCs were observed in 9 patients(22.0%). Prognostic nutritional index(PNI)<45(p=0.049), smoking(p=0.034), and alcohol consumption(p=0.021)were associated with PWCs. CONCLUSION: We examined the incidence of PWCs after APR for anorectal lesions and their risk factors. Appropriate intervention in nutrition, smoking, and alcohol consumption may prevent PWCs.

[A Case of Improvement by SOX Therapy for DIC Caused by Gastric Cancer].

Disseminated intravascular coagulation(DIC)has a poor prognosis in gastric cancer. The patient was a 78-year-old man. He had been diagnosed with Stage Ⅳ gastric cancer. Before chemotherapy, thrombocytopenia and elevated D-dimer occurred, and we diagnosed DIC. We started SOX therapy to treat gastric cancer with DIC. DIC improved on the 10th day after the onset of DIC. But developed DIC again on the 21st day. We started SOX therapy again. However, the DIC did not improve. The patient died 32 days after the initial DIC. Oxaliplatin regimen may be a potential treatment for DIC.

Antihypertensive and Renoprotective Effects of Dietary Flaxseed and its Mechanism of Action in Deoxycorticosterone Acetate-Salt Hypertensive Rats.

BACKGROUND/AIMS: Flaxseed contains alpha-linolenic acid (ALA), lignans, and dietary fiber, and its intake lowers blood pressure in hypertensive patients. Here, we examined the effects of flaxseed powder, which includes all flaxseed components, flaxseed oil, composed mainly of ALA, flaxseed lignan, and flaxseed fiber, on hypertension and renal damage induced by deoxycorticosterone acetate (DOCA)-salt. Then, we investigated the mechanisms of action associated with the effects of flaxseed. METHODS: Flaxseed powder, oil, lignan, or fiber was administered to DOCA-salt rats. Systolic blood pressure (SBP), urinary protein excretion, renal angiotensin converting enzyme (ACE) activity, sympathetic nerve activity, and gene expression of inflammatory mediators in the kidney and hypothalamus were measured. RESULTS: Flaxseed powder and oil reduced the increases in SBP and urinary protein excretion induced by DOCA-salt treatment, whereas lignan and fiber had no effects. Flaxseed oil suppressed the increase in renal ACE activity, sympathetic nerve activity, and gene expression of renal and hypothalamic inflammatory mediators. CONCLUSION: Flaxseed has antihypertensive and renoprotective effects in DOCA-salt rats. These effects are likely principally exerted by ALA. Furthermore, the suppression of renal ACE activity, sympathetic nerve activity, and inflammation is partly involved in the effects of flaxseed.

Clinical investigation of the cystic duct variation based on the anatomy of the hepatic vasculature.

PURPOSE: Anatomical variation of the cystic duct (CD) is rare but can result in misunderstanding of the CD anatomy during laparoscopic cholecystectomy, potentially leading to bile duct injury. Therefore, the precise preoperative identification of CD variation is important. However, preoperative imaging analyses of the biliary system are not always possible or sufficient. We therefore investigated CD variations based on the anatomy of the hepatic vasculature. METHODS: This study enrolled 480 patients who underwent imaging before hepatobiliary pancreatic surgery. We assessed the variation of the CD and hepatic vasculature and evaluated the correlations among these variations. RESULTS: A variant CD anatomy was identified in 12 cases (2.5%) as CD draining into the right hepatic bile duct (BD) in 4 cases and into the right posterior BD in 8 cases. CD variation was significantly more common in cases with portal vein (PV) and BD variation than in those without the variation. We developed a scoring system based on the presence of PV and BD variations that showed good discriminatory power for identification of CD variants. CONCLUSION: Cases with a variant CD anatomy were more likely to exhibit variant PV and BD anatomies than cases with a normal CD anatomy. These findings will be useful for the preoperative identification of CD variants.

[Pulmonary Metastases of Hepatocellular Carcinoma Treated with Repeated Pulmonary Resection-A Case Report].

A 65-year-old man visited our hospital for hepatocellular carcinoma(HCC)and underwent extended posterior sectionectomy. Eight months after the hepatic resection, follow-up computed tomography(CT)revealed a solitary, recurrent tumor in S4 of the liver, and transcatheter arterial chemoembolization and radiofrequency ablation were performed for the intrahepatic recurrence. After 12 postoperative months, follow-up CT demonstrated pulmonary metastases in S5 of the right lung and S10 of the left lung. Since there were no other metastases, the 2 metastatic lesions were resected using video-assisted thoracoscopic surgery(VATS). The resected tumors were histologically diagnosed as pulmonary metastases of HCC. Three years after the pulmonary resection, 3 additional pulmonary metastases were detected on CT in S3 and S10 of the right lung and S4 of the left lung. No other metastases were found. Bilateral VATSmetastasectomy was performed for the metastases. The tumors were diagnosed as pulmonary metastases of HCC on histological examination. One year and 8 months after the surgery, he was alive in a good condition, with no recurrences. The present case suggested that some patients with pulmonary metastasis of HCC can have long-term survival with surgical resection of the metastasis. Therefore, while systemic chemotherapy is generally considered the standard treatment for extrahepatic metastasis of HCC, surgical resection might be an option.

[A Case of Resected Primary Hepatic Neuroendocrine Tumor].

A 70s man presented with a solitary liver tumor measuring 4.5 cm on CT. On contrast-enhanced CT, the tumor appeared partly well-enhanced in the late phase, and the remaining part was enhanced in the early phase and washed out in the late phase. Contrast-enhanced MRIshowed fused multiple nodules, and the enhancement/washout pattern was clearer than that of the contrast-enhanced CT. The tumor showed a defective image in the hepatobiliary phase and a high signal on diffusionweighted imaging. Then, the tumor was diagnosed as hepatocellular carcinoma, and thus, left liver lobectomy was performed. On histological examination of the resected specimen, the tumor was found to be composed of uniform and small tumor cells with solid or trabecular growth fashion. On immunohistochemical staining, synaptophysin and chromogranin A positivity was noted, and the Ki-67 index was 14%. Finally, the tumor was diagnosed as a NET G2. Postoperatively, somatostatin receptor scintigraphy was performed to identify the primary site; however, no obvious primary site could not be identified, and thus a diagnosis of primary hepatic NET was made. Eighteen months postoperatively, the patient is alive without relapse. Preoperative diagnosis of primary hepatic NETs is difficult because NETs present various imaging findings and are rare. Moreover, no accurate preoperative diagnosis was reached in our case, suggesting the difficulty in the preoperative diagnosis of NETs.

[Resection of Hepatocellular Carcinoma with Synchronous Bilateral Adrenal Metastases].

A 59-year-old man was admitted to our hospital with liver dysfunction. Examinations revealed a huge liver tumor in the right hepatic lobe and a mass in each adrenal gland. The preoperative diagnosis was hepatocellular carcinoma(HCC)with synchronous bilateral adrenal metastases. The patient underwent right hepatic lobectomy, cholecystectomy, and bilateral adrenalectomy. Histopathological examination of the specimens confirmed the diagnosis of HCC with synchronous bilateral adrenal metastases. After surgery, he received steroid replacement therapy and had a favorable clinical course without complications. Six months after surgery, the patient has experienced no recurrence and is being followed up on an outpatient basis. Although further postoperative follow-up is necessary, the findings of this case suggested a positive oncological impact of surgical resection for HCC and synchronous bilateral adrenal metastases.

Avoiding stoma creation due to super-morbid obesity: A report of two surgical cases of colorectal cancer.

INTRODUCTION: A stoma is commonly created in patients with a high risk of anastomotic leakage. However, patients with obesity have a higher incidence of stoma-related complications, and the decision to create a stoma should be carefully considered. We report two cases of patients with colorectal cancer and super-morbid obesity wherein stoma creation was avoided. PRESENTATION OF CASES: Case 1 involved a 52-year-old male patient with a body mass index (BMI) of 41.8 kg/m2 who underwent a robotic-assisted laparoscopic low anterior resection after neoadjuvant chemotherapy for lower rectal cancer. Although temporary diverting ileostomy was initially considered, stoma creation was skipped intraoperatively, considering the complication risk-benefit ratio. Case 2 involved a 42-year-old female patient with a BMI of 64 kg/m2 who underwent open partial non-curative colon resection for descending colon cancer complicated by colonic perforation and abscess formation. The patient was considered to be at high risk of stoma-related complications due to high mobility of the subcutaneous fat of abdominal wall; therefore, we decided not to create a stoma preoperatively. DISCUSSION: Considering the high risk of stoma-associated complications, avoiding stoma creation and implementing preventive measures against potential complications are alternative options for patients with super-morbid obesity. CONCLUSION: We present our experience two cases in which stoma creation was avoided for super-morbid obese patients with BMI over 40.