Does the presence of an appendicolith or abscess predict failure of nonoperative management of patients with acute appendicitis?

PURPOSE: Nonoperative management (NOM) has been widely accepted as one of the standard treatments for patients with acute appendicitis. However, predictive factors for the failure of NOM have not been thoroughly investigated. METHODS: A total of 196 patients with acute appendicitis underwent NOM between April 2014 and December 2020. Of these 196 patients, 24 patients failed NOM and required emergency surgery (failure group: n = 24), while the other 172 patients were successfully treated with NOM (success group: n = 172). These two groups were compared, and the predictive factors for the failure of NOM were investigated. RESULTS: The number of patients who had a previous history of stroke was significantly increased in the failure group (12.5% vs. 2.9%, p = 0.026). Incarceration of an appendicolith on CT images was significantly associated with the failure group (20.8% vs. 1.7%, p < 0.001), while neither the presence of an appendicolith nor abscess was associated. The presence of periappendiceal fluid was significantly associated with the failure group (50.0% vs. 26.7%, p = 0.019). The incarceration of an appendicolith (p < 0.001, odds ratio = 19.85) and periappendiceal fluid (p = 0.009, odds ratio = 3.62) were found to be independent risk factors for failure of NOM. Neither the presence of an appendicolith nor abscess was associated with the recurrence of appendicitis. CONCLUSIONS: The presence of an appendicolith or abscess was not a crucial factor for surgery. Incarceration of an appendicolith and periappendiceal fluid on CT images was predictive factors for the failure of NOM.

A Case of Isolated Cecal Necrosis Preoperatively Diagnosed with Perforation of Cecum.

Isolated cecal necrosis (ICN) is a rare condition which is developed under decreased mesenteric perfusion. Only a few dozen cases of ICN have been reported previously. The patient was a 59-year-old male with a previous history of atrial fibrillation. He presented to our emergency room with the chief complaint of lower abdominal pain. Computed tomography imaging revealed a dilated cecum and presence of free air. With a preoperative diagnosis of perforation of the cecum; an urgent surgery was conducted. Intraoperative findings revealed an ischemic change of the cecum and a laparoscopic-assisted ileocecal resection was performed. The pathological findings showed transmural ischemic change on the anti-mesenteric side of the cecum, and the diagnosis of ICN was achieved. Preoperative diagnosis of ICN is difficult because of its non-specific radiological features. In patients with right lower abdominal pain, ICN should be considered as a differential diagnosis especially if the patient has a comorbidity causing hypotension attack.

Are Preoperative CT Findings Useful for Predicting Postoperative Intraabdominal Abscess in the Patients with Acute Appendicitis?

Background and objective: In patients with acute appendicitis (AA), preoperative computed tomography (CT) findings suggesting development of intraabdominal abscess (IAA) had not been widely used. The aim of this study was to investigate the preoperative clinical and radiological factors that predict the development of a postoperative IAA in patients with AA who were treated by laparoscopic appendectomy (LA). Methods: Two hundred and sixteen patients with pathologically proven AA underwent LA between January 2013 and March 2018 in our department. Medical records and preoperative CT images of these 216 patients were retrospectively reviewed and the predictive factors of postoperative IAA were investigated. In addition, patients were divided into complicated appendicitis (CA) and simple appendicitis (SA) and perioperative factors of two groups were compared. Results: One hundred and forty-seven patients were diagnosed with CA, while the other 69 patients were diagnosed with SA. Sixteen patients developed postoperative IAA in the CA group, while no patients in the SA group did. The univariate analysis revealed that time from onset to surgery more than 3 days (p = 0.011), the preoperative CT finding of periappendiceal fluid (p = 0.003), abscess (p < 0.001), and free air (p < 0.001), operation time more than 120 min (p = 0.023) and placement of a drainage tube (p < 0.001) were significantly associated with the development of IAA. Multivariate analysis revealed that the preoperative CT finding of free air was independently associated with the development of IAA (p = 0.007, odds ratio = 5.427, 95% CI: 1.586⁻18.57). Conclusions: IAA developed predominantly in patients with CA. Preoperative CT findings of free air was found to be an independent predictor for the development of IAA. Surgeons should be meticulous in managing the postoperative course of patients with this finding.

[A Patient with Lung Cancer Experiencing Abdominal Aortic Aneurysm Rupture during Bevacizumab Treatment-Case Report].

CASE: Right pleural effusion was detected on chest X-ray performed prior to surgery for a right inguinal hernia in a 63-yearold man. Adenocarcinoma was diagnosed based on pleural effusion cytology results. A CT scan revealed mediastinal lymphadenopathy and pleural dissemination, but no obvious lung tumor; other examinations also did not reveal a primary tumor. We, therefore, diagnosed primary lung cancer(c-TxN2M1a, Stage ⅣA, according to the General Rules for Clinical and Pathological Record of Lung Cancer, 8th edition). An abdominal aortic aneurysm was also observed on CT. Since he was diagnosed with EGFR-negative lung cancer with malignant pleural effusion, we selected chemotherapy with cisplatin, pemetrexed, and bevacizumab(CDDP/PEM/Bev)and administered 2 courses without problems. He experienced no adverse events during the 3rd course and was discharged on day 8. However, he was transported to our emergency room at 20: 45 on treatment day 10 when he developed abdominal pain and nearly fainted. An abdominal aortic rupture was diagnosed by CT, and he was transported to another hospital because he could not be treated at our hospital. Information that this patient had been treated with Bev was not provided to the doctor on duty, and abdominal aortic graft replacement was immediately performed. The patient had a good postoperative course without anastomotic leakage and was discharged on day 7 after surgery. Bev is a monoclonal antibody for vascular endothelial growth factor. CONCLUSION: We report that this drug, bevacizumab, may be associated with abdominal aortic rupture.

[A Case of Advanced Squamous Cell Lung Cancer with Hemodialysis Treated with Carboplatin and Paclitaxel].

We herein describe a patient on hemodialysis with advanced squamous cell lung cancer who was treated with chemotherapy that consisted of carboplatin(CBDCA)and paclitaxel(PTX). A 54-year-old man who was undergoing a routine hemodialysis for chronic renal failure presented with cold symptoms and was prescribed antibiotics.As no symptomatic improvement was achieved, he was referred to the Department of Internal Medicine in our hospital, where computed tomographic scan findings raised the suspicion of lung cancer.He was then referred to the Department of Surgery.A bronchoscopy detected a tumor, which obstructed the right upper lobe bronchus, and the patient was diagnosed with squamous cell carcinoma.Based on the mediastinal lymph node enlargement that extended into the contralateral hilar region, the stage was determined to be III B(c-T3N3M0), and we initiated chemotherapy.The regimen was CBDCA plus PTX.The carboplatin dose area under the curve(AUC)was 4(100 mg at a glomerular filtration rate of 0)for the first course, AUC 5 for the second course, and AUC 6 for the third to sixth courses, and the PTX dose was 200mg/m2.Only mild adverse events were noted, and the patient achieved a partial response after 6 treatment courses.Only a few reports have described chemotherapies administered to patients with lung cancer on hemodialysis, and as such, evidence of useful drugs is not yet available.This makes it difficult to select the most appropriate treatment for such patients.We report our experience with this patient, with a relevant literature review.

Extensive goblet cell metaplasia of the peripheral lung may harbor precancerous molecular changes: comparison of two cases.

We present two cases of extensive goblet cell metaplasia in the peripheral lung. The first case was a 72-year-old male with a nodule (12 × 10 mm) detected by CT. Macroscopically, it contained abundant mucin; histopathologically, goblet cells were predominant, whereas ciliated and basal cells were sparse. A KRAS G12V mutation was detected. In the pulmonary background of this case, scattered tiny foci of goblet cell metaplasia were present. The second case was a 71-year-old female with a nodule (7 × 5 mm) detected by CT. It contained abundant mucin, and microscopically, various cell types were intermingled. Although the nodule mainly comprised goblet cells, ciliated and basal cells were also easily identified. No KRAS mutation was found in this patient. Dispersed minute foci of goblet cell metaplasia were identified in the pulmonary background. Therefore, we suspect that airway irritants may have contributed to the changes that occurred in the pulmonary background of both cases. We propose that the tendency of goblet cells to overwhelm other cell types in the metaplastic epithelium may be an indicator of precancerous molecular changes.

[Study of aspiration therapy for primary spontaneous pneumothorax].

The 2003 British Thoracic Society guidelines recommend aspiration for treating primary spontaneous pneumothorax. This procedure allows the patient management on an outpatient basis, and is highly significant in terms of medical cost and quality of life (QOL). The safety and success rate of aspiration was studied in 23 patients who received this treatment. The success rate was at 69.6%, and the patients were safely managed without emergency drainage due to dyspnea. Aspiration is a possible choice for the 1st-line treatment for primary spontaneous pneumothorax.

[Descending necrotizing mediastinitis resulting from acute epiglottitis; report of a case].

Descending necrotizing mediastinitis (DNM) is a serious condition due to abscess spreading from neck into mediastinum. We report a case of DNM following acute epiglottitis and abscess. A 59-year old male visited our hospital for parotid swelling, pyrexia, and dyspnea, and was diagnosed as having acute epiglottitis at otology and hospitalized. Despite right tonsillectomy, drainage and tracheostomy on day 6 after hospitalization, he developed DNM and was referred to our department. Drainage of mediastinal regions( anterior to the trachea and tracheal bifurcation, inferoposterior mediastinum and posterior to the left main bronchus) was performed on day 14 after hospitalization. Postoperative course was uneventful.

Safety and Feasibility of Laparoscopic Transabdominal Preperitoneal Hernia Repair for Octo- and Nonagenarians.

Background: The feasibility of laparoscopic hernia repair in octo- and nonagenarians has not been investigated in detail. The aim of this retrospective study was to evaluate the safety and feasibility of laparoscopic hernia repair in octo- and nonagenarians. Methods: This study included 607 patients who underwent transabdominal preperitoneal laparoscopic hernia repair at our hospital between April 2014 and October 2020. Patients were divided into an over 80 group (112 patients aged 80 years and older) and a control group (495 patients younger than 80 years). The clinical outcomes were compared between the groups. In addition, among patients aged 80 years and older, those who underwent elective laparoscopic hernia repair (laparoscopic group: 111 patients) were compared with patients who underwent elective open hernia repair during the same study period (open group: 79 patients). Results: The number of patients who underwent bilateral hernia repair was significantly larger in the over 80 group (26.7% versus 11.7%, P < .001). The incidence of postoperative complications was not significantly different between the over 80 group and the control group. Compared with open group, the number of patients who underwent bilateral hernia repair was significantly larger in the laparoscopic group (27.0% versus 2.5%, P < .001). The incidence of postoperative complications (2.7% versus 10.1%) and the incidence of readmission (0.9% versus 6.3%) were significantly greater in the open group. Conclusions: Laparoscopic hernia repair in octo- and nonagenarian patients yields safe and noninferior outcomes. Laparoscopic hernia repair in octo- and nonagenarian patients is considered more suitable for detecting and repairing contralateral hernias simultaneously.

Emergency surgery versus elective surgery after reduction for patients with incarcerated groin hernias.

BACKGROUND: The feasibility and potential advantages of elective surgery after manual reduction of incarcerated hernia (IH) have not been investigated in detail. Therefore, the aim of this retrospective study was to compare perioperative outcomes of emergency surgery to those of elective surgery after reduction of IH. METHODS: A total of 112 patients were preoperatively diagnosed with IH between January 2010 and April 2019. Patients were divided into an emergency group (76 patients underwent emergency surgery: 21 patients received intestinal resection and 55 patients did not) and a reduction group (36 patients underwent elective surgery after reduction and none required intestinal resection). The outcomes between the groups were compared. A subgroup analysis was also performed on the patients who did not require intestinal resection. RESULTS: In patients who did not undergo intestinal resection, the post-operative length of stay was significantly shorter in the reduction group than in the emergency group (8.0 versus 4.3 days, P < 0.001). The percentage of mesh prosthesis cases was significantly higher in the reduction group (74.4% versus 100%, P = 0.001). The incidence of post-operative complications was significantly lower in the reduction group (45.4% versus 13.8%, P < 0.001). In all 112 patients, femoral hernia (P = 0.013, odds ratio = 4.76) and emergency surgery (P = 0.008, odds ratio = 4.49) were found to be independent risk factors for developing post-operative complications. CONCLUSIONS: Elective surgery after reduction showed more favourable outcomes in selected patients. Moreover, emergency surgery was an independent predictor for post-operative complications.

Laparoscopic vs open surgery for patients with strangulated small bowel obstruction.

BACKGROUND: Recent reports revealed that laparoscopic adhesiolysis is a feasible procedure for patients with adhesive small bowel obstruction (SBO). However, the feasibility of laparoscopic surgery for strangulated SBO has not been investigated in detail. METHODS: Ninety-six patients who underwent surgery for strangulated SBO between April 2008 and September 2019 were included. Of these, 49 patients were intended to undergo laparoscopic surgery, while the other 47 underwent open surgery from the first. Comparisons were made between the patients who underwent laparoscopic and open surgery in the patients with intestinal resection and without resection, respectively. RESULTS: In the resection group, eight patients (50.0%) who underwent laparoscopic surgery required conversion to open surgery. Perioperative outcomes were not statistically different between laparoscopic and open surgery except for postoperative use of continuous infusion of an analgesic agent or epidural anesthesia (P = .008). In the non-resection group, five patients (15.1%) who underwent laparoscopic surgery required conversion. Time from surgery to ingestion (P = .025) and postoperative use of continuous infusion of an analgesic agent or epidural anesthesia (P < .001) were significantly favorable in the laparoscopic group. In the patients who underwent laparoscopic surgery, white blood cell count was >12 000/µL (P = .024, odds ratio = 7.569) and intestinal resection (P = .026, odds ratio = 5.19) were found by logistic regression analysis to be independent risk factors for conversion to open. CONCLUSIONS: Laparoscopic surgery yields superior outcomes in patients without a requirement of intestinal resection. Laparoscopic surgery was considered as a first-choice strategy in selected patients with strangulated SBO.

Two Cases of Subvesical Bile Duct Injury Detected and Repaired Simultaneously during Laparoscopic Cholecystectomy.

INTRODUCTION: Subvesical bile duct (SVBD) injury is a secondary major cause of minor bile duct injury after laparoscopic cholecystectomy (LC). However, this injury is usually not recognized intraoperatively, but postoperatively. CASE REPORT: Case 1: the patient was an 84-year-old female, preoperatively diagnosed with acute cholecystitis. During LC, a tiny hole in the gallbladder fossa from which bile juice oozing was confirmed. Suturing was performed laparoscopically. Case 2: the patient was an 81-year-old male, preoperatively diagnosed with cholelithiasis. Because of a previous history of gastrectomy, laparoscopic adhesiolysis around the gallbladder was performed. During dissection, a small amount of bile was oozing from the surface of the liver adjacent to the gallbladder fossa. Suturing was performed laparoscopically. CONCLUSION: If a small amount of bile juice was detected, meticulous observation not only around the cystic duct stump but also the gallbladder fossa should be performed. Simultaneous laparoscopic suturing was feasible, and an ideal procedure against SVBD injury developed during LC.

Case of reduction en masse who presented with no symptoms.

The early and accurate diagnosis of reduction en masse followed by proper treatment is important but has been difficult. Here, we report the case of a 58-year-old Japanese man who presented with abdominal pain and vomiting at a nearby clinic. He was referred to our hospital on suspicion of small bowel obstruction. Despite the total disappearance of his symptoms, the abdominal X-ray examination showed distended loops of small bowel. The preoperative diagnosis of small bowel strangulation due to an internal hernia was made by CT, and we therefore performed emergency exploratory laparoscopy. We intraoperatively diagnosed the patient with the reduction en masse of a right inguinal hernia, and we conducted a transabdominal preperitoneal hernioplasty. This patient's case demonstrates that even when a patient is asymptomatic after the reduction of an inguinal hernia, the possibility of a reduction en masse remains.

Is postponed laparoscopic appendectomy justified for patients with acute appendicitis?

INTRODUCTION: Recent meta-analyses revealed that laparoscopic appendectomy (LA) is a feasible procedure even for patients with complicated appendicitis. More than a few patients with acute appendicitis arrive at the hospital during night shifts and have their operation postponed for various reasons. However, the feasibility and disadvantages of this so-called "postponed laparoscopic appendectomy" (PLA) remain controversial. METHODS: We included 149 patients who underwent LA for acute appendicitis within 48 h of diagnosis between January 2013 and May 2018. Patients were divided into an immediate LA group (patients who underwent LA within 4 h of diagnosis, n = 84) and a PLA group (patients who underwent LA 4-48 h after diagnosis, n = 65). Comparisons were made between these groups. RESULTS: The preoperative characteristics of the patients in the immediate LA and PLA groups were not significantly different. Operative time was significantly longer in the PLA group than in the LA group (92.5 ± 40.8 vs 78.1 ± 29.7 min, P = 0.012). The incidence of postoperative complications (grade II or higher) was significantly greater in the PLA group than in the LA group (32.3% vs 17.8%, P = 0.041). Multivariate analysis revealed that a preoperative CT finding of periappendiceal fluid (P = 0.005, odds ratio = 4.71) and surgery 4-48 h after diagnosis (P = 0.005, odds ratio = 4.425) were independent risk factors of postoperative complications (grade II or higher). CONCLUSIONS: For patients with acute appendicitis, surgeons should perform immediate LA, if that is the patient's preferred surgical treatment, as long as there is no special reason to postpone surgery.

Torsion of Atypical Meckel's Diverticulum Treated by Laparoscopic-Assisted Surgery.

INTRODUCTION: Meckel's diverticulum (MD) is the most common congenital anomaly of the intestine, with an incidence of 2~4%. Of those, only 2% of patients with MD are symptomatic. Torsion of MD is extremely rare, and only a dozen cases have been previously reported. CASE REPORT: The patient was a 49-year-old male who presented to our emergency room with a chief complaint of lower abdominal pain. Computed tomography imaging revealed an irregular polycystic mass connected to the small intestine that measured 7.5 cm in a diameter. A laparoscopic-assisted partial resection of the jejunum was performed. The lesion was found to have caused torsion and was located 130 cm from the ileocecal valve. The specimen was polycystic in appearance and showed communicating links with the submucosal layer of jejunum but not with the lumen. The pathological diagnosis was a torsion of an atypical presentation of MD. CONCLUSION: This case was different from typical cases of MD in that it was located on significantly oral side and had the appearance of polycystic morphology.

Elective laparoscopic repair after reduction might be useful strategy for incarcerated obturator hernia: a case report.

Obturator hernia is a rare clinical condition that causes intestinal obstruction. Recent reports have suggested that laparoscopic repair may be useful for incarcerated obturator hernia in select patients. The patient was a 64-year-old female who presented to our emergency department with a chief complaint of abdominal pain. Computed tomography (CT) imaging revealed an incarcerated obturator hernia on her right side, without apparent findings of irreversible ischaemic change or perforation. She had a previous history of cardiovascular surgery and was taking an anticoagulant medication. We performed a reduction of the incarcerated intestine. After heparin displacement, laparoscopic repair was electively performed. During laparoscopy, an occult obturator hernia was found on the left side. We repaired the bilateral obturator hernia using a mesh prosthesis. Elective laparoscopic repair after reduction might be a useful procedure for incarcerated obturator hernias in those patients without findings of irreversible ischaemic change or perforation.

CT value of the intestine is useful predictor for differentiate irreversible ischaemic changes in strangulated ileus.

PURPOSE: To determine the differential points of strangulated ileus with and without irreversible ischaemic changes, especially on preoperative computed tomography (CT) images. METHODS: Seventy patients with strangulated ileus underwent emergency operations between January 2009 and July 2016 in our department. Of these patients, 57 met the study requirements, including 30 patients who had irreversible ischaemic changes (ischaemic group; n = 30) and 27 patients who had reversible ischaemic changes during laparotomy (non-ischaemic group; n = 27). We compared the preoperative clinical and radiographic factors between the ischaemic and non-ischaemic groups. RESULTS: Univariate analysis revealed that a mean CT value of the intestine in an unenhanced image ≥16.5 HU (p < 0.001), a mean CT value ratio of the intestine (enhanced/unenhanced image) <1.5 (p < 0.001), presence of mesenteric fluid (p = 0.002) and presence of free peritoneal fluid (p = 0.009) were associated with the ischaemic group. CONCLUSIONS: Calculation of the mean CT value of a strangulated intestine may be a useful method for predicting irreversible ischaemic changes in addition to the presence of mesenteric fluid or free peritoneal fluid.

Strangulated gallbladder caused by a tip of the omentum attached to the abdominal wall: a case report.

Strangulation of the gallbladder associated with the omentum is extremely rare and, to our knowledge, only two cases have been previously reported. The patient was a 91-year-old female who presented to our emergency room with a chief complaint of upper abdominal pain. Computed tomography imaging revealed a gourd-shaped gallbladder with biphasic appearance divided clearly at the body. In the fundus side, the wall of the gallbladder was oedematous and thickened, while the neck side was intact. On the second day after onset, a laparoscopic cholecystectomy was performed. A tip of the omentum encircling the gallbladder was adhered to the abdominal wall and was strangling the gallbladder. By cutting the omentum at the attachment site, the strangulation was released. Laparoscopic cholecystectomy was performed, and the patient was discharged with an uneventful course. We experienced an extremely rare case of strangulated gallbladder caused by a tip of the omentum attached to the abdominal wall.

Ileo-ileal intussusception caused by lymphangioma of the small bowel treated by single-incision laparoscopic-assisted ileal resection.

Intraabdominal lymphangiomas are uncommon; additionally, those affecting the gastrointestinal tract are rare and account for less than 1% of cases. Intussusception caused by a cystic lymphangioma of the small bowel is extremely rare. The patient was a 20-year-old woman who visited our emergency room with a complaint of abdominal pain. A computed tomography image revealed ileo-ileal intussusception with a leading hypovascular mass measuring 1 cm in a diameter. Single-incision laparoscopic-assisted ileal resection was performed. The surgical specimen consisted of a soft polycystic mass. Macroscopically, a pedunculated polyp with a convolutional pattern was found. Microscopically, the inner surfaces of the cysts were covered with a single layer of endothelial cells. On immunohistochemical examination, the endothelial cells were partially positive for D2-40 and CD34. Smooth muscle cells were also found around the cysts. The lesion was diagnosed as a cystic lymphangioma. Dozens of cases of small bowel lymphangiomas have previously been reported. Of these, cases with intussusception were very rare. This is the first case of small bowel intussusception due to lymphangioma treated by single-incision laparoscopic-assisted surgery.

Multiple Gastric Gastrointestinal Stromal Tumors in a Patient with Neurofibromatosis Type 1.

Gastrointestinal stromal tumors (GISTs) are relatively common in neurofibromatosis type 1 (NF 1) patients. Approximately 90% of GISTs associated with NF 1 are located in the small intestine, while sporadic GISTs are most commonly located in the stomach. Here we report an extremely rare case of an NF 1 patient with multiple gastric GITs (90 or more) but without multiple small intestinal tumors. A 63-year-old female patient who had a history of NF 1 underwent surgery for a gastric neuroendocrine tumor and gastric submucosal tumor (SMT). During the operation, multiple small nodules were identified on the serosal surface of the upper stomach. SMT and multiple nodules on the serosal surface were diagnosed as GISTs consisting of spindle cells positive for KIT, CD34, and DOG-1. Both GIST and the normal gastric mucosa showed no mutations not only in the c-kit gene (exons 8, 9, 11, 13, and 17) but also in the PDGFRA gene (exons 12, 14, and 18). This patient is being followed up without the administration of a tyrosine kinase inhibitor.