High Subcutaneous Fat Area Is an Independent Risk Factor for Parastomal Hernia after Transperitoneal Colostomy for Colorectal Cancer.

Objectives: Parastomal hernia (PSH) is a common complication of colostomy; however, its risk factors remain poorly investigated. In this study, we examined the associations between sarcopenia, visceral and subcutaneous fat, and PSH in patients who underwent transperitoneal colostomy for colorectal cancer. Methods: This retrospective, single-center, cohort study included 60 patients who underwent laparoscopic or robot-assisted abdominoperineal resection or Hartmann's procedure for colorectal cancer between November 2010 and February 2022. Stoma creation was uniformly performed using the transperitoneal approach, and PSH was diagnosed via abdominal computed tomography (CT) at 1 year postoperatively. Visceral fat areas (VFAs) and subcutaneous fat areas (SFAs) were measured through preoperative CT images using an image analysis system. Risk factors for PSH were retrospectively analyzed. Results: PSH was diagnosed in 13 (21.7%) patients. In the univariate analysis, PSH was significantly associated with body mass index >22.3 kg/m2 (p=0.002), operation time >319 min (p=0.027), estimated blood loss >230 mL (p=0.008), postoperative complications (p=0.028), stoma diameter >18.6 mm (p=0.015), VFA >89.2 cm2 (p=0.005), and SFA >173.2 cm2 (p=0.001). Multivariate analyses confirmed that SFA >173.2 cm2 (odds ratio: 16.7, 95% confidence interval 1.29-217.2, p=0.031) was an independent risk factor for PSH. Conclusions: Subcutaneous fat area is significantly associated with the development of PSH after transperitoneal colostomy. Applying these insights could help to prevent PSH.

Fenestrated Thoracic Endovascular Repair for Acute Type B Aortic Dissection with Isolated Left Vertebral Artery: A Case Report.

Thoracic endovascular aortic repair (TEVAR) of acute uncomplicated type B aortic dissection (uTBAD) has been discussed for its potential to prevent future aortic events. We present a fenestrated TEVAR in the case of an 86-year-old man with acute uTBAD with an isolated left vertebral artery (ILVA). The ILVA originated from the distal side of the left subclavian artery, the left subclavian artery, and the intramural hematoma with an ulcer-like projection extended close to the left subclavian artery. We selected a fenestrated stent graft to achieve a proximal healthy landing. This case demonstrates that a fenestrated stent graft for acute uTBAD is useful for preserving arch vessels.

Validation of the Diagnostic Criteria for IgG4-Related Periaortitis/Periarteritis and Retroperitoneal Fibrosis (IgG4PA/RPF) 2018, and Proposal of a Revised 2023 Version for IgG4-Related Cardiovascular/Retroperitoneal Disease.

BACKGROUND: In 2018, diagnostic criteria were introduced for IgG4-related periaortitis/periarteritis and retroperitoneal fibrosis (PA/RPF). This study assessed the existing criteria and formulated an improved version.Methods and Results: Between August 2022 and January 2023, we retrospectively analyzed 110 Japanese patients diagnosed with IgG4-related disease (IgG4-RD) involving cardiovascular and/or retroperitoneal manifestations, along with 73 non-IgG4-RD patients ("mimickers") identified by experts. Patients were stratified into derivation (n=88) and validation (n=95) groups. Classification as IgG4-RD or non-IgG4-RD was based on the 2018 diagnostic criteria and various revised versions. Sensitivity and specificity were calculated using experts' diagnosis as the gold standard for the diagnosis of true IgG4-RD and mimickers. In the derivation group, the 2018 criteria showed 58.5% sensitivity and 100% specificity. The revised version, incorporating "radiologic findings of pericarditis", "eosinophilic infiltration or lymphoid follicles", and "probable diagnosis of extra-PA/-RPF lesions", improved sensitivity to 69.8% while maintaining 100% specificity. In the validation group, the original and revised criteria had sensitivities of 68.4% and 77.2%, respectively, and specificities of 97.4% and 94.7%, respectively. CONCLUSIONS: Proposed 2023 revised IgG4-related cardiovascular/retroperitoneal disease criteria show significantly enhanced sensitivity while preserving high specificity, achieved through the inclusion of new items in radiologic, pathological, and extra-cardiovascular/retroperitoneal organ categories.

Novel tumor marker index using carcinoembryonic antigen and carbohydrate antigen 19-9 is a significant prognostic factor for resectable colorectal cancer.

We evaluated the usefulness of a newly devised tumor marker index (TMI), namely, the geometric mean of normalized carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA19-9), in determining colorectal cancer (CRC) prognosis. This retrospective cohort study included 306 patients with stages I-III CRC who underwent elective laparoscopic resection between April 2010 and March 2020. Survival rates and risk factors of relapse-free survival (RFS) and cancer-specific survival (CSS) were analyzed using Kaplan-Meier curves and Cox proportional hazards model. High-TMI group (122 patients) had significantly lower rates (95% confidence interval [95% CI]) for 5-year RFS (89.7%, 83.9-93.5 vs. 65.8%, 56.3-73.8, p < 0.001) and CSS (94.9%, 89.4-97.6 vs. 77.3%, 67.7-84.4, p < 0.001) than low-TMI group. Multivariate analysis (hazard ratio [95% CI]) indicated ≥ T3 disease (RFS: 2.69, 1.12-6.45, p = 0.026; CSS: 7.64, 1.02-57.3, p = 0.048), stage III CRC (RFS: 3.30, 1.74-6.28, p < 0.001; CSS: 6.23, 2.04-19.0, p = 0.001), and high TMI (RFS: 2.50, 1.43-4.38, p = 0.001; CSS: 3.80, 1.63-8.87, p = 0.002) as significant RFS and CSS predictors. Area under the curve (AUC) of 5-year cancer deaths (0.739, p < 0.001) was significantly higher for TMI than for CEA or CA19-9 alone. Preoperative TMI is a useful prognostic indicator for patients with resectable CRC.

Effect of low visceral fat area on long-term survival of stage I-III colorectal cancer.

OBJECTIVE: The prognostic significance of a low visceral fat area (VFA) in colorectal cancer (CRC) remains unclear. The aim of this study was to evaluate the prognostic effects of a low VFA on the long-term outcomes of patients with CRC after laparoscopic surgery. METHODS: This retrospective study included 306 patients with stages I-III CRC who underwent R0 resection. VFA was preoperatively measured via computed tomography using image processing software. Relapse-free survival (RFS) and overall survival (OS) rates were analyzed using the Cox proportional hazards model and Kaplan-Meier curves. RESULTS: Low VFA was identified in 153 patients. The low VFA group had significantly lower RFS and OS rates than did the high VFA group (5-y RFS rates: 72 versus 89%, P = 0.0002; 5-y OS rates: 72 versus 92%, P = 0.0001). The independent significant predictors of RFS were T3 or T4 disease (hazard ratio [HR], 2.75; 95% confidence interval [CI], 1.12-6.76; P = 0.027), stage III CRC (HR, 3.49; 95% CI, 1.82-6.69; P < 0.001), low psoas muscle index (PMI; HR, 2.12; 95% CI, 1.19-3.79; P = 0.011), and low VFA (HR, 2.12; 95% CI, 1.16-3.86; P = 0.014). The independent significant predictors of OS were age ≥65 y (HR, 2.59; 95% CI, 1.13-5.92, P = 0.024), carbohydrate antigen 19-9 levels ≥37 ng/mL (HR, 2.32; 95% CI, 1.18-4.58; P = 0.015), stage III CRC (HR, 2.66; 95% CI, 1.37-5.17; P = 0.004), low PMI (HR, 2.00; 95% CI, 1.06-3.77; P = 0.031), and low VFA (HR, 2.42; 95% CI, 1.24-4.70; P = 0.009). CONCLUSION: A low preoperative VFA was significantly associated with worse RFS and OS rates in patients who underwent CRC resection.

Immunoglobulin G4-related hepatic artery aneurysm.

A 49-year-old man who was a current smoker with a history of hypertension, dyslipidemia, and coronary artery disease after coronary stent placement presented because of abdominal and back pain. Contrast-enhanced computed tomography showed a 30-mm, large hepatic artery aneurysm. Resection of the aneurysm and autogenous vein bypass grafting was performed, which resulted in a successful outcome without any complications. Pathologic examination of the aneurysm confirmed that it was related to immunoglobulin G4 (IgG4). The patient's serum IgG4 level was within the normal range, and no other signs of IgG4-related organ lesions were observed.

A Case of Cholestatic Liver Involvement Secondary to Amyloid Light Chain Amyloidosis With New-Onset Hypercholesterolemia and Elevated Gamma-Glutamyltransferase Level.

Amyloid light chain (AL) amyloidosis is a rare disorder caused by the deposit of misfolded light chain proteins. AL amyloidosis causes multiple organ involvement and rarely causes fatal liver failure. We present a 68-year-old man who showed cholestatic liver injury and was diagnosed with AL amyloidosis. Due to rapidly progressing cholestatic liver involvement, the patient died five days after the renal biopsy. Preclinically, there was hypercholesterolemia, and levels of gamma-glutamyltransferase (GGT) were elevated. Previous studies have suggested hypercholesterolemia and elevated GGT levels in patients with AL amyloidosis and liver involvement; however, its clinical relevance remains unknown. Our report suggests that in addition to serum kappa/lambda, the combination of new-onset GGT level elevation and hypercholesterolemia could be preclinical characteristics of cholestatic liver involvement in AL amyloidosis.

Traditional Serrated Adenoma of the Ileum with Intussusception Successfully Treated with Laparoscopic Bowel Resection.

The most common site of traditional serrated adenomas (TSA) is the area from the left colon to the rectum; however, there are few reports on TSA in the small intestine. Herein, we report a case of TSA of the ileum with intussusception that was diagnosed and successfully treated with laparoscopic bowel resection. The patient was a 29-year-old female with the chief complaint of recurrent abdominal pain and vomiting. Contrast-enhanced computed tomography showed a mass in the ileum and intussusception with the mass as the lead point. The patient was diagnosed with intussusception secondary to a small intestinal tumor. Due to the difficulty in endoscopic treatment resulting from the localization of the lesion, elective laparoscopic surgery was planned. Intra-abdominal examination revealed intussusception of the small intestine in the pelvic ileum, and an elastic soft mass 400 cm from the ligament of Treitz was identified at the lead point of intussusception. Partial laparoscopic resection of the small intestine was performed, with an operation time of 81 min, and a small amount of bleeding. The pathological diagnosis was TSA of the ileum, and the patient's postoperative course was good, with no complications. Seven months after the surgery, no recurrence of symptoms was observed. Therefore, from our case of TSA of the ileum with intussusception that was successfully treated with laparoscopic bowel resection, we conclude that when intussusception of the small intestine occurs, TSA of the ileum with malignant potential is possible, and early diagnosis by resection should be considered.

Real-time vessel navigation using indocyanine green fluorescence during robotic-assisted gastrectomy for gastric cancer after coronary artery bypass grafting using the right gastroepiploic artery.

Injury to the right gastroepiploic artery (RGEA) graft during gastrectomy after coronary artery bypass grafting (CABG) can cause critical coronary failure. A man in his 60s with advanced gastric cancer and a history of CABG was admitted to our hospital. His cardiac blood flow was dependent on RGEA, and a gastrectomy with RGEA preservation was necessary. Robot-assisted distal gastrectomy with real-time vessel navigation using indocyanine green (ICG) fluorescence imaging and Da Vinci Firefly technology was planned. Intraperitoneal observation revealed severe adhesions around the graft. Two milliliters ICG (2.5 mg/mL) was injected intravenously, and RGEA was visualized. An RGEA-preserving robot-assisted distal gastrectomy was successfully performed. The operation time was 279 minutes, and the blood loss was 5 mL. The postoperative course was good and there were no complications.

Impact of Bifidobacterium adolescentis in patients with abdominal aortic aneurysm: a cross-sectional study.

The relationships between various diseases and the human gut microbiota (GM) have been revealed. However, the relationships between the human abdominal aortic aneurysm (AAA) and GM remains unknown. The aim of this cross-sectional study was to clarify the association between the human AAA and GM. Stool samples from 30 consecutive patients with AAA before aneurysm repair and those of 30 controls without vascular diseases were analyzed by 16S rRNA gene (V3-4) sequencing using an Illumina MiSeq system and QIIME 2. There was no significant difference in age (75 vs. 75 years) or gender (80% vs. 87% males) between the groups. No significant difference in GM composition was observed in principal coordinate analysis between the two groups, whereas the AAA group showed a significantly lower abundance of Bifidobacterium adolescentis (p<0.01) at the species level than the controls. This study demonstrated that the abundance of B. adolescentis decreased in patients with AAA. This is the first study to show the characteristics of the GM in patients with AAA. Studies are needed to reveal if causal relationships exists between the human AAA and GM.

Preemptive fenestrated endovascular repair aimed at perfusion of cervical branches in acute type B aortic dissection.

OBJECTIVE: Most of the entry tears of uncomplicated type B aortic dissection are located in the distal arch and extends in a retrograde manner to the level of the left subclavian artery. Our objective was to evaluate feasibility and effectiveness using fenestrated sent graft with complete neck vessel preservation to treat uncomplicated type B aortic dissection. SUBJECTS AND METHODS: We retrospectively reviewed the record of patients with uncomplicated type B aortic dissection who underwent fenestrated thoracic endovascular aortic repair in subacute phase (15-90 days) between August 2016 and April 2020. The Najuta fenestrated stent graft was placed proximally beyond he left subclavian artery (zone 0-2) in an attempt to seal the entry while preserving the neck vessels. RESULTS: We evaluated 9 cases (male: 7, female: 2; median age 70 years). The median distance from the LSA to the proximal entry was 37 mm. The landing zones of the proximal end of the Najuta were zone 0: 3, zone 1: 2, and zone 2: 4 cases. Technical success was 100% with no 30-day death. None of the patients had a stroke, paraplegia or retrograde dissection, and no endoleak was observed. Complete aortic remodeling with false lumen resolution was obtained in all cases while each fenestrated vessels remained patent during the follow-up period. CONCLUSION: Preemptive thoracic endovascular aortic repair aimed at perfusion of cervical branches using the Najuta fenestrated stent is safe and effective and may be considered as a reasonable treatment option for the treatment is a safe and an effective treatment.

Risk factors for refractory enterocutaneous fistula following button jejunostomy removal and its treatment using a novel extraperitoneal approach in patients with oesophageal cancer: a retrospective cohort study.

BACKGROUND: Enterocutaneous fistula after removal of the jejunostomy tube leads to multiple problems, such as cosmetic problems, decreased quality of life, electrolyte imbalances, infectious complications, and increased medical costs. However, the risk factors for refractory enterocutaneous fistula (REF) after button jejunostomy removal remain unclear. Therefore, in this study, we assessed the risk factors for REF after button jejunostomy removal in patients with oesophageal cancer and reported the surgical outcomes of the novel extraperitoneal approach (EPA) for REF closure. METHODS: This retrospective cohort study included 47 patients who underwent button jejunostomy removal after oesophagectomy for oesophageal cancer. We assessed the risk factors for REF in these patients and reported the surgical outcomes of the novel EPA for REF closure at the International University of Health and Welfare Hospital between March 2013 and October 2021. The primary endpoint was defined as the occurrence of REF after removal of the button jejunostomy, which was assessed using a maintained database. The risk factors and outcomes of the EPA for REF closure were retrospectively analysed. RESULTS: REFs occurred in 15 (31.9%) patients. In the univariate analysis, REF was significantly more common in patients with albumin level < 4.0 g/dL (p = 0.026), duration > 12 months for button jejunostomy removal (p = 0.003), and with a fistula < 15.0 mm (p = 0.002). The multivariate analysis revealed that a duration > 12 months for button jejunostomy removal (odds ratio [OR]: 7.15; 95% confidence interval [CI]: 1.38-36.8; p = 0.019) and fistula < 15.0 mm (OR: 8.08; 95% CI: 1.50-43.6; p = 0.002) were independent risk factors for REF. EPA for REF closure was performed in 15 patients. The technical success rate of EPA was 88.2%. Of the 15 EPA procedures, fistula closure was achieved in 12 (80.0%). The complications of EPA (11.7%) were major leakages (n = 3) and for two of them, EPA procedure was re-performed, and closure of the fistula was finally achieved. CONCLUSION: This study suggested that duration > 12 months for button jejunostomy removal and fistula < 15.0 mm are the independent risk factors for REF after button jejunostomy removal. EPA for REF closure is a novel, simple, and useful surgical option for patients with REF after oesophagectomy.

Extraregional lymph node recurrence of stage IA1 squamous cell carcinoma of the uterine cervix after initial surgery: two case studies.

Objective: Lymph node recurrence is extremely rare in cases of stage IA1 squamous cell carcinoma (SCC) of the uterine cervix without lymphovascular space invasion (LVSI). We present two cases of extraregional lymph node recurrence after initial surgery for stage IA1 SCC of the uterine cervix without LVSI. Patients: Both patients initially underwent hysterectomy and developed recurrent extraregional lymph nodes within a few years postoperatively. Case 1: The patient showed no symptoms of recurrence, and follow-up computed tomography (CT) for evaluation of gallstones revealed a para-aortic lymph node (9 mm). The patient subsequently underwent serum SCC antigen testing and CT and was diagnosed with recurrence. Case 2: The patient noticed a right inguinal node swelling, which was evaluated using CT. Both patients survived without relapse for 8 and 4 years, respectively. Conclusion: Although stage IA1 SCC of the uterine cervix without LVSI is associated with a low risk of lymph node recurrence, oncologists should consider the possibility of recurrence in such cases. Evaluation for recurrence is difficult in asymptomatic patients. Serum SCC antigen testing may be a useful biochemical marker before imaging for early detection of recurrence, even in asymptomatic patients.

Association between masseter muscle sarcopenia and postoperative pneumonia in patients with esophageal cancer.

Sarcopenia affects the swallowing and chewing muscles, such as the masseter muscle. However, the significance of masseter muscle loss in pneumonia remains unclear. We investigated the effects of masseter muscle sarcopenia (MMS) on postoperative pneumonia in patients with esophageal cancer. In this retrospective cohort study, we analyzed the data of 86 patients who underwent esophagectomy for stage I-III esophageal cancer at our hospital between March 2013 and October 2021. The primary endpoint was postoperative pneumonia within 3 months of surgery. MMS was defined as a (1) masseter muscle index (MMI) that was less than the sex-specific MMI cutoff values, and (2) sarcopenia diagnosed using the L3-psoas muscle index (L3-PMI). Postoperative pneumonia was noted in 27 (31.3%) patients. In multivariate analysis, FEV1.0 < 1.5 L (odds ratio, OR: 10.3; 95% confidence interval, CI 1.56-67.4; p = 0.015), RLNP (OR: 5.14; 95%CI 1.47-17.9; p = 0.010), and MMS (OR: 4.83; 95%CI 1.48-15.8; p = 0.009) were independent risk factors for postoperative pneumonia. The overall survival was significantly worse in patients with pneumonia (log-rank: p = 0.01) than in those without pneumonia. Preoperative MMS may serve as a predictor of postoperative pneumonia in patients with esophageal cancer.

The masseter muscle thickness is a predictive marker for postoperative pneumonia after endovascular aneurysm repair.

PURPOSE: Oral frailty is characterized by a decrease in the oral and swallowing function and is a risk factor for pneumonia. In the current study, we analyzed the association between the masseter muscle thickness (MMT) and postoperative pneumonia and mortality after endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm. METHODS: Overall, 247 patients were retrospectively evaluated. The primary end point was postoperative pneumonia. The MMT was measured as the maximum thickness of the masseter muscle 2 cm caudal to the zygomatic arch using computed tomography images obtained within 3 months before EVAR. Pneumonia was defined as the presence of progressive infiltrates, consolidation, or cavitation on imaging and a fever or leukocytosis. RESULTS: Twenty (8.1%) cases of postoperative pneumonia occurred within 1 year after EVAR. We found that patients with a low MMT (≤ 30th percentile: males, 10.4 mm; females: 8.8 mm) had a significantly higher risk of developing postoperative pneumonia within 1 year after elective EVAR than those with a high value. A comparison of the utility of the MMT and psoas muscle index (PMI) for predicting the 1-, 3-, and 5-year all-cause mortality revealed that the MMT had superior predictive performance. CONCLUSION: The MMT before elective EVAR predicted postoperative pneumonia and life expectancy, and its predictive performance was superior to that of the PMI.

Complete neck vessel preservation using a fenestrated stent graft for the treatment of proximal anastomotic leakage after open frozen elephant trunk graft aortic arch repair.

We have reported a case of proximal anastomotic leakage excluded with the Najuta fenestrated stent graft after a surgeon-modified frozen elephant trunk aortic arch graft. The fenestrated stent graft was deployed at the zone 0 proximal site, preserving the cervical branches. Complete neck vessel preservation during endovascular repair using a Najuta fenestrated stent graft appears to be safe and effective for anastomotic leakage after aortic arch aneurysm repair.

Preoperative Masseter Muscle Sarcopenia Predicts Mortality in Patients With Oesophageal Cancer.

BACKGROUND/AIM: The impact of masseter muscle sarcopenia on the prognosis of patients with oesophageal cancer after oesophagectomy remains unclear. PATIENTS AND METHODS: We retrospectively analysed data from 70 patients with oesophageal cancer who underwent oesophagectomy between 2013 and 2019. Overall survival and disease-free survival rates were analysed using Cox proportional hazards models and Kaplan-Meier curves with the log-rank test. RESULTS: Masseter muscle sarcopenia was diagnosed in 36 patients. Multivariate analysis identified cytokeratin 19 fragment >1.1 (p=0.04); stage II, III, and IV cancer (p=0.01); and masseter muscle sarcopenia (p<0.01) as significant independent predictors of disease-free survival. Stage II, III, and IV cancer (p<0.01); masseter muscle sarcopenia (p<0.01); and postoperative pneumonia (p<0.01) were significant independent predictors of overall survival. CONCLUSION: Preoperative masseter muscle sarcopenia could be a strong predictor of long-term outcomes in patients who undergo oesophagectomy for oesophageal cancer.

Sarcopenia Aneurysm Scoring System Predicts Early and Midterm Mortality After Endovascular Repair for Abdominal Aortic Aneurysm.

OBJECTIVE: The objective of the study was to develop a better model of prediction after EVAR using the psoas muscle index (PMI). SUMMARY BACKGROUND DATA: The Glasgow Aneurysm Score (GAS), the modified Leiden Score (mLS), the Comorbidity Severity Score (CSS), and the Euro Score (ES) are known prognostic scoring after EVAR. Similarly, sarcopenia measured by PMI has been reported to be an important predictor. This study investigated a new scoring system using PMI predicting short and midterm overall mortality after EVAR. METHODS: Three hundred ten patients were retrospectively evaluated. The primary endpoint was all-cause death. One hundred three patients were assigned to the derivation cohort and 207 patients to the validation cohort. RESULTS: The all-cause mortality rates were 8.8% at 1 year, 23.5% at 3 years, and 32.8% at 5 years. In a multivariate analysis, age, aneurysm diameter, eGFR, and PMI were associated with all-cause mortality in the derivation cohort. The SAS system was defined as the sum of the following factors: elderly (75 years), large aneurysm (65 mm), low eGFR (30 mL/min/1.73m 2 ), and low PMI (males: 48.2 cm 2 /m 2 , females: 36.8 cm 2 /m 2 ). We compared the SAS with the other prognostic scoring for 5-year mortality evaluating the area under the receiver operating characteristic curves in the validation cohort (GAS: 0.731, mLS: 0. 718, CSS: 0. 646, ES: 0.661, and SAS: 0.785, P = 0.013). CONCLUSION: We developed the SAS to predict all-cause mortality after elective EVAR and this scoring showed excellent predictive performance.