Early laparoscopic cholecystectomy for acute cholecystitis following the Tokyo Guidelines 2018: a prospective single-center study of 201 consecutive cases.

BACKGROUND: Early laparoscopic cholecystectomy (ELC) for acute cholecystitis (AC) poses multiple challenges. The Tokyo Guidelines 2018 (TG18) eliminated the time limit (< 72 h) and expanded the surgical indication to severe AC. This study aimed to evaluate the clinical outcomes of ELC for AC following the TG18 in a single high-volume center. METHODS: From 2019 to 2021, we managed all AC patients with a TG18 flowchart and prospectively enrolled those who underwent ELC within 7 days of symptom onset. The primary outcome was overall morbidity, with a comparison between mild (Grade I) and moderate/severe (Grade II/III) AC. RESULTS: During the study period, 201 patients underwent ELC was for Grade I (56.2%), II (40.3%), and III (3.5%) ACs. Mean age was 69 ± 15.2 years and time to surgery from symptom onset was 0 (12.9%), 1-3 (66.7%), and 4-7 days (20.4%). Mean operative time and blood loss were 118.9 ± 42.7 min and 57.8 ± 99.4 mL, respectively. The critical view of safety (CVS) was achieved in 76.1% of patients, and bailout procedures were performed in 21.4%. There were no open conversions or bile duct injuries. Major morbidities (Clavien-Dindo classification ≥ IIIa) were observed in 5.5% of cases and mortality in 0.5%. Comparing Grades II/III to Grade I, operative time was longer (112.3 vs. 127.3 min, p = 0.014), blood loss was higher (40.3 vs. 80.1 mL, p = 0.005), the CVS rate was lower (83.2 vs. 67.0%, p = 0.012), and the major morbidity rate was higher (1.8 vs. 10.2%, p = 0.012). In the subgroup analysis of Grade II/III, there were no significant differences in major morbidities (p = 0.288) between the two groups (0-3 vs. 4-7 days). CONCLUSION: ELC for AC following TG18 is feasible with low morbidity rates. However, ELC for Grade II/III ACs remains challenging, and surgeons must carefully assess intraoperative difficulties and surgical risks before proceeding.

Benefits of laparoscopic liver resection in elderly patients.

BACKGROUND: The indications of laparoscopic liver resection (LLR) have expanded to high-risk patients, such as elderly people. However, to date, little evidence has been established of the safety and feasibility of LLR in elderly patients. The short-term outcomes of LLR in elderly patients as compared to non-elderly patients were investigated. METHODS: Data of a total of 297 patients who underwent LLR were reviewed. Among these 297 patients, 181 patients were < 75 years age (non-elderly) and 116 patients were ≥ 75 years age (elderly), and the surgical outcomes were compared between the groups. In addition, we evaluated the risk factors for postoperative morbidity (Clavien-Dindo grade ≥ IIIa) utilizing the preoperative, operative, and postoperative variables RESULTS: The preoperative liver/renal function, frequency of anti-thrombotic drug use, number of comorbidities, and American Society of Anesthesiologists-physical status classification were more unfavorable in elderly patients than in non-elderly patients. No significant inter-group differences were observed in the operation time, blood loss, conversion rate, postoperative morbidity, or 30-day mortality. The 3-year overall survival rate was comparable between the two groups. Multivariate analysis identified anti-thrombotic drug use, operation time > 7 h, and peak serum total bilirubin > 2 mg/dl within postoperative day 3 as independent risk factors for Clavien-Dindo ≥ IIIa postoperative morbidity (P = 0.016, P < 0.001, and P = 0.001, respectively). CONCLUSIONS: LLR in elderly patients may provide comparable short-term outcomes to those in non-elderly patients.

Utility of Robot-assisted Laparoscopic Transabdominal Preperitoneal Repair of Inguinal Hernia Following Robot-assisted Laparoscopic Radical Prostatectomy.

BACKGROUND: To evaluate the utility of robot-assisted laparoscopic transabdominal preperitoneal repair (R-TAPP) of postprostatectomy inguinal hernia (PIH) in patients who underwent robot-assisted laparoscopic radical prostatectomy (RALP). PATIENTS AND METHODS: This was a prospective, single-centre retrospective cohort study. R-TAPP was conducted in 74 consecutive patients from September 2016 to March 2020. With the exception of women and patients who underwent previous abdominal surgery, 70 patients were classified into two groups based on the absence or presence of PIH. Their data were retrospectively compared to those who had not undergone RALP. RESULTS: The median operative time for the PIH group was longer compared to the non-PIH group. However, postoperative complications, including seroma formation, haematoma and surgical site infections, were not significantly different between the groups. The estimated blood loss was small, and hospitalisation duration was 1 day in all cases. Moreover, there were no hernia recurrences within the 90-day follow-up period in either group. CONCLUSION: R-TAPP is a feasible and safe approach for inguinal hernia repair, even in patients who undergo RALP for prostate cancer.

Laparoscopic low anterior resection for rectal cancer associated with Leriche syndrome: a case report.

A 78-year-old male presented with a positive fecal occult blood test. Rectal cancer was detected during lower gastrointestinal endoscopy, and further investigations led to a diagnosis of cT1N0M0 cStage I (UICC classification, 8th edition). Preoperative contrast-enhanced computed tomography (CT) showed that the patient also had Leriche syndrome, which is associated with reduced blood flow to the rectum that may result in ischemic anastomosis during rectal cancer surgery with anastomotic reconstruction. The inferior epigastric arteries often function as collateral pathways to the lower limbs in patients with Leriche syndrome; therefore, care is needed to avoid vascular damage during trocar insertion when performing laparoscopic surgeries. We herein described a case of safe laparoscopic low anterior resection in a rectal cancer patient with Leriche syndrome using vascular architecture images obtained by preoperative CT angiography.

[Jejunal stromal tumor concomitant ectopic pancreas in a young man with sarcoidosis:a case report].

During a medical health check, a 29-year-old man was presented to our hospital with iron deficiency anemia. He had no significant medical history in his family. Despite being diagnosed with ocular sarcoidosis 5 years ago, he had no vision problems. Physical examination revealed normal vital signs and a nontender abdomen;however, his eyelid conjuvitis was pale, and he became aware of fatigue when moving vigorously. He had upper gastrointestinal endoscopy and colonoscopy, but there was no evidence of bleeding detected. A contrasted mass 30mm in size was discovered on abdominal contrast-enhanced computed tomography at the dorsal wall of the proximal jejunum. Positron emission tomography showed an accumulation image in the bilateral hilar lymph and upper jejunum. A 30-mm submucosal tumor with a central depression in the upper jejunum was discovered using a double-balloon enteroscopy. We performed biopsies from the depression margin and tattoo marking on the oral side of the tumor. Even though the biopsies specimen revealed granulation tissue, the patient was referred to surgery and underwent a partial jejunum resection because the tumor was diagnosed as the cause of anemia. The operation went smoothly, and the patient was discharged on the seventh postoperative day. Histological examination showed a proliferation of densely packed spindle cells with prominent nuclear palisading. The immunohistochemical examination revealed that c-kit and CD34 were highly expressed, whereas desmin and S-100 proteins were not. Ki-67 expression demonstrated a very low proliferative index (2%). We discovered gastrointestinal stromal tumors (GIST), as well as an ectopic pancreas. GIST is extremely rare in young people, and the coexistence of ectopic pancreas and sarcoidosis has never been reported.

A goal-directed therapy protocol for preventing acute kidney injury after laparoscopic liver resection: a retrospective observational cohort study.

PURPOSE: Postoperative acute kidney injury (AKI) remains a serious complication of liver resection with restrictive fluid therapy. However, unlike open hepatectomy, laparoscopic liver resection (LLR) does not have established anesthesia management strategies. We compared our goal-directed therapy (GDT) protocol for LLR with/without carperitide and the conventional restrictive method regarding AKI prevention. METHODS: The GDT thresholds in this retrospective observational cohort study were as follows: stroke volume variation, ≤ 15%; pulse pressure variation, ≤ 13%; oxygen delivery index, ≥ 600 mL/min/m2; and mean arterial pressure (MAP), ≥ 55 mmHg. If the thresholds were not achieved, a 250 mL infusion fluid bolus was administered. The MAP target was changed to > 65 mmHg if the urine output was < 0.3 mL/kg/h. Postoperative AKI within 48 h and perioperative outcomes within 90 days were analyzed. RESULTS: Forty-seven propensity score-matched pairs from 127 patients were investigated. We adjusted for AKI risk factors and surgical difficulty; 46.8% of the GDT group received carperitide. The GDT group had a lower postoperative AKI rate (10.6% vs. 27.7%, P = 0.04) and shorter overall (P = 0.04) and postoperative (P < 0.01) hospital stays than the conventional group. Furthermore, the GDT group received more intraoperative fluid (P = 0.001) and phenylephrine (P = 0.02), without significant increases in blood loss and transfusion volume, than the conventional group. CONCLUSIONS: GDT reduced the AKI rates post-LLR.

Short-term Outcomes and Difficulty of Repeat Laparoscopic Liver Resection.

Objectives: To investigate the feasibility of repeat laparoscopic liver resection (Rep-LLR), including repeat anatomical resection (Rep-AR), as compared to initial-LLR (Ini-LLR). Background: The indications of LLR have expanded to treatment of recurrent liver tumors. However, the feasibility of Rep-LLR, including Rep-AR, has not yet been adequately assessed. Methods: Data of 297 patients who had undergone LLR were reviewed. Among the 297 patients, 235 (AR: 168) had undergone Ini-LLR and 62 (AR: 27) had undergone Rep-LLR, and the surgical outcomes were compared between the groups. In addition, multivariate analysis was performed to identify predictors of the difficulty of Rep-LLR based on the operation time and volume of blood loss. Results: Of the 62 patients who had undergone Rep-LLR, 44, 14, and 4 had undergone second, third, and fourth repeat LRs, respectively. No significant intergroup differences were observed in regard to the operation time, blood loss, conversion rate to open surgery, postoperative morbidity, or postoperative hospital stay. However, the proportion of patients in whom the Pringle maneuver was used was significantly lower in the Rep-LLR group than in the Ini-LLR group. Multivariate analysis identified surgical procedure ≥sectionectomy at the initial/previous LR and an IWATE difficulty score of ≥6 as being independent predictors of the difficulty of Rep-LLR. Use of adhesion barriers at the initial/previous LR was associated with a decreased risk of failure to perform the Pringle maneuver during Rep-LLR. Conclusions: Rep-LLR can offer outcomes comparable to those of Ini-LLR over the short term.

Severe intrauterine adhesions after life-threatening event caused by Epstein-Barr virus-associated atraumatic spleen laceration: Case report.

This is the first known case report of severe intrauterine adhesion (IUA) following a life-threatening event caused by an Epstein-Barr virus-associated atraumatic spleen laceration. A 22-year-old nulligravid female suffered from infectious mononucleosis for approximately 1 month. Sudden severe hypovolemic shock with massive hemoperitoneum appeared and hemostasis was completely achieved by a splenectomy for an atraumatic spleen laceration, although that was followed by multiorgan failure and abdominal compartment syndrome. Complete recovery without any neurological sequelae was achieved by intensive treatment. A postoperative pathological evaluation revealed Epstein-Barr virus-associated splenomegaly. The patient was referred to our department because of secondary amenorrhea for approximately 5 months since the last menstruation, which occurred just prior to the event. Laboratory blood test results demonstrated normal thyroid and ovarian functions. Hysterofiberscopy revealed complete obstruction at the end of the cervical canal, indicating secondary uterine amenorrhea caused by severe IUA. Hysteroscopic adhesiolysis with a rigid hysteroscope reached the opening of the uterine cavity and menstruation was restored.

[Lymphangiography by Inguinal Lymph Node Puncture was Effective for Chylothorax after Lobectomy].

A 74-year-old female with lung cancer underwent thoracoscopic right upper lobectomy. The patient was diagnosed chylothorax due to the milky drain effusion on postoperative day 1 (POD 1). Despite fasting management, chylothorax was not improved. Lymphangiography by inguinal lymph node puncture was performed on POD 4. The amount of drainage decreased on POD 6 and disappered by following pleurodesis. Early lymphangiography is recommended prior to surgical treatment for patients with chyle leakages who are unlikely to be cured by conservative treatment alone.

[S10 Segmentectomy by Thoracoscopic Surgery for a Bronchial Foreign Body Presenting More than One Year].

It is often difficult to remove long-standing bronchial foreign bodies by bronchoscopy. A 77-year-old male was referred to our department for removal of a foreign body. Chest computed tomography revealed a nail in the right S10b. A bronchoscopic examination could not detect the nail due to locating beyond the subsegmental tree, so thoracoscopic right S10 segmentectomy was performed. Intraoperative ultrasonography and X-ray fluoroscopy were useful in understanding the margin for resection.

[A Case of Anastomotic Recurrence 10 Years after Excision of Sigmoid Colon Cancer with Submucosal Invasion].

A 72-year-old woman underwent sigmoid colon resection plus D2 lymph node dissection in 2008, with additional resection after endoscopic mucosal resection(EMR). Histopathological examination revealed only atypical ducts in the EMR scar, with no invasion below the submucosa. No lymphatic, venous, or nerve invasions were confirmed, and oral and anal stumps and lymph node metastases were negative. She was followed up for 5 years after the surgery, and no recurrence was detected. In 2018, she visited our hospital with the chief complaint of diarrhea and constipation. Colonoscopy revealed a circumferential lesion around the anastomosis. She underwent laparoscopic low anterior resection for suspected anastomotic recurrence, which was confirmed by histopathological diagnosis. The anastomotic recurrence 10 years after surgery for SM cancer of the colon with negative lymph node metastasis and vascular factor was extremely rare. We recognized the importance of surveillance 5 years after surgery.

Evaluation of accuracy of laparoscopic liver mono-segmentectomy using the Glissonian approach with indocyanine green fluorescence negative staining by comparing estimated and actual resection volumes: A single-center retrospective cohort study.

BACKGROUND/PURPOSE: Laparoscopic liver mono-segmentectomy (LLMS) may improve patient outcomes, but it is difficult and its accuracy and safety are unknown. We evaluated the accuracy of LLMS using Glissonian approach with indocyanine green fluorescence (ICG) negative staining. METHODS: Seventy-four patients eligible for LLMS except for segment 1 were enrolled. Preoperative three-dimensional CT-based surgical simulation was used to determine estimated liver resection volume (ELRV), which was compared with modified actual liver resection volume (ALRV) obtained from actual liver resection mass. The LLMS accuracy was also evaluated based on operator's experience (attending surgeon [AS] or trainee surgeon [TS]). RESULTS: Estimated liver resection volumes significantly correlated with ALRVs (r = .82) in all cases. Moreover, TS-conducted LLMS also showed acceptable difference between ELRV and ALRV compared with AS-conducted LLMS. There were no intergroup differences in estimated blood loss, operation time, time of Pringle maneuver, postoperative complications, and length of postoperative hospitalization (P < .05). Moreover, R0 resection was comparable between the AS and TS groups. CONCLUSIONS: Laparoscopic liver mono-segmentectomy with Glissonian approach using ICG negative imaging ensured safe and accurate procedure owing to facilitated visualization of the resection line. Our approach was effective in avoiding postoperative liver dysfunction and securing radical resection. In addition, it might be helpful in TS education of LLMS.

Parenchymal Sparing Anatomical Liver Resections With Full Laparoscopic Approach: Description of Technique and Short-term Results.

OBJECTIVE: The aim of this study was to describe laparoscopic anatomical parenchymal sparing liver resections for hepatocellular carcinoma (HCC) and colorectal liver metastases (CRLM) and report the short-term outcomes. BACKGROUND: Anatomical resections (ARs) have better oncological outcomes compared to partial resections in patients with HCC, and some suggest should be performed also for CRLM as micrometastasis occurs through the intrahepatic structures. Furthermore, remnant liver ischemia after partial resections has been associated with worse oncological outcomes. Few experiences on laparoscopic anatomical resections have been reported and no data on limited AR exist. METHODS: We performed a retrospective analysis of 86 patients undergoing full laparoscopic anatomical parenchymal sparing resections with preoperative surgical simulation and standardized procedures. RESULTS: A total of 55 patients had HCC, whereas 31 had CRLM with a median of 1 lesion and a size of 30 mm. During preoperative three-dimensional (3D) simulation, a median resection volume of 120 mL was planned. Sixteen anatomical subsegmentectomies, 56 segmentectomies, and 14 sectionectomies were performed. Concordance between preoperative 3D simulation and intraoperative resection was 98.7%. Two patients were converted, and 7 patients experienced complications. Subsegmentectomies had comparable blood loss (166 mL, P = 0.59), but longer operative time (426 min, P = 0.01) than segmentectomies (blood loss 222 mL; operative time 355 min) and sectionectomies (blood loss 120 mL; operative time 295 min). R0 resection and margin width remained comparable among groups. CONCLUSIONS: A precise preoperative planning and a standardized surgical technique allow to pursue the oncological quality of AR enhancing the safety of the parenchyma sparing principle, reducing surgical stress through a laparoscopic approach.

Pure Laparoscopic Right Hepatectomy for Hepatocellular Carcinoma with Bile Duct Tumor Thrombus (with Video).

BACKGROUND: Laparoscopic liver resection has been increasingly utilized due to its less invasiveness approach compared with open surgery,1-3 but often creates challenges. Hepatocellular carcinoma (HCC) with bile duct tumor thrombus (BDTT) portends a poorer prognosis and often precludes patients from potential liver resection.4-6 We herein report a case of laparoscopic hepatectomy and thrombectomy in a patient with HCC and BDTT. METHODS: CT, ERCP, and POCS showed a 40-mm tumor located in the right lobe with BDTT. A five 12-mm trocar was inserted at the umbilicus for laparoscope, the epigastrium, both sides of the hypochondrium, and right lateral region. Moreover, a 5-mm trocar was inserted at left hypochondrium. After cholecystectomy, hepatoduodenal ligament was encircled using the tourniquet through 5-mm trocar site. The right portal vein was transected by stapler following transection of the right hepatic artery. After ICG staining (0.5 mg/body i.v.),7 hepatic parenchymal transection was performed using clamp-crashing technique. Moreover, CUSA also was used near Glissonian sheath. BDTT was removed from the right BD. Moreover, the cholangioscopy confirmed no BDTT remnants. The resection stump was then sutured. Finally, the right hepatic vein was divided with a stapler. A drainage tube was placed in the right subphrenic space. Operation time was 496 min, and blood loss was 91 ml. The patient was discharged without complications on postoperative day 11. Pathological diagnosis showed moderately differentiated HCC, tumor size 40 × 45 mm with negative surgical margins. CONCLUSIONS: Pure laparoscopic resection for HCC with BDTT is a radical, yet feasible procedure.

[Gallbladder Metastasis from Renal Cell Carcinoma Four Years after Nephrectomy-A Case Report].

An 80-year-old man who had undergone nephrectomy for renal cell carcinoma(RCC)4 years before presentation was admitted to our department for further investigation of the gallbladder tumor. The patient was diagnosed with early gallbladder carcinoma based on CT and MRI findings and treated with laparoscopic cholecystectomy. The intraoperative frozen section revealed that the identified tumor was clear cell carcinoma. Finally, morphological similarity with a previous specimen of RCC and immunostaining resulted in the diagnosis of gallbladder metastasis from RCC. Therefore, it is important to consider metastatic carcinoma of the gallbladder in the differential diagnosis of gallbladder tumors for patients with a history of renal cell carcinoma.

Geriatric Nutritional Risk Index Less Than 92 Is a Predictor for Late Postpancreatectomy Hemorrhage Following Pancreatoduodenectomy: A Retrospective Cohort Study.

Postpancreatectomy hemorrhage (PPH) is the most lethal complication of pancreatoduodenectomy (PD). The main risk factor for PPH is the development of a postoperative pancreatic fistula (POPF). Recent evidence shows that the geriatric nutritional risk index (GNRI) may be predictive indicator for POPF. In this study, we aimed to evaluate whether GNRI is a reliable predictive marker for PPH following PD. The present study retrospectively evaluated 121 patients treated with PD at Ageo Central General Hospital in Japan between January 2015 and March 2020. We investigated the potential of age, gender, body mass index, serum albumin, American Society of Anesthesiologists classification (ASA), diabetes mellitus and smoking status, time taken for the operation, estimated blood loss, and postoperative complications (POPF, bile leak, and surgical site infections) to predict the risk of PPH following PD using univariate and multivariate analyses. Ten patients had developed PPH with an incidence of 8.3%. Among them, the patients were divided into bleeding group (n = 10) and non-bleeding group (n = 111). The bleeding group had significantly lower GNRI values than those in the non-bleeding group (p = 0.001). We determined that the cut-off value of GNRI was 92 accounting for a sensitivity 80.0%, specificity 82.9%, and likelihood ratio of 4.6 using receiver operating characteristic curve analysis. A GNRI of <92 was statistically associated with PPH in both univariate (p < 0.001) and multivariate analysis (p = 0.01). Therefore, we could identify that a GNRI < 92 was an independently potential predictor of PPH risk following PD. We should alert surgeons if patients have low level GNRI before PD.

Geriatric nutritional risk index serves as risk factor of surgical site infection after pancreatoduodenectomy: a validation cohort Ageo study.

BACKGROUND: Surgical site infections (SSIs), which are associated with preoperative malnutrition, are a well-known potential complication of surgery that leads to increased medical costs and longer hospitalizations. Thus, surgeons need to accurately identify patients at high-risk for SSIs. Considering that the Geriatric Nutritional Risk Index (GNRI) was designed to assess the degree of malnutrition specifically among elderly patients, previous evidence (Kawaguchi study) proved that GNRI predicted the risk of SSIs in patients following pancreatoduodenectomy (PD). In this study, we aimed to validate whether that the same index could predict the risk of SSI among patients who underwent PD in our patient cohort (Ageo study). METHODS: The current validation cohort study was retrospectively conducted on 93 patients at the Department of Surgery, Ageo Central General Hospital, Japan, from January 2015 to October 2019. All patients were subjected to nutritional screening using the GNRI and were followed up for the occurrence of postoperative complications. Additionally, risk factors for developing SSI, as well as patient's height, body mass index, and preoperative laboratory values, were recorded. RESULTS: Patients were divided into the SSI (N=30) and non-SSI (N=63) groups with a determined SSI incidence rate of 32.3% (30/93). The SSI group had significantly lower GNRI than the non-SSI group (P<0.001). Receiver operating characteristic curve analysis determined a cutoff GNRI value of 94 (sensitivity, 83.3%; specificity, 83.6%), similar to that in the previous study. Univariate and multivariate analyses confirmed that a GNRI of <94 was significantly associated with SSI (P<0.001). CONCLUSIONS: The present Ageo study confirmed the consistency of results in Kawaguchi study. Thus, lower GNRI can be a universal marker for SSI risk following PD.

Carbohydrate binding specificity of recombinant human macrophage beta-glucan receptor dectin-1.

Human macrophage dectin-1, a type II transmembrane beta-glucan receptor, was expressed as a fusion protein with an N-terminal hexahistidine tag and glutathione S-transferase in an Escherichia coli cell-free translation system, and assayed for binding specificity. Recombinant dectin-1 specifically bound to some beta-glucans, but not to other carbohydrates. The beta-glucan binding of recombinant dectin-1 was inhibited by laminarin, a soluble beta-glucan, and by laminarioligosaccharides, but not by other carbohydrates. These results suggest that recombinant human dectin-1 can be used as a useful probe in identifying ligands in humans and tonic foods due to its strict binding specificity.