Compartment syndrome due to Capnocytophaga canimorsus infection: a case report.

BACKGROUND: Purpura fulminans secondary to Capnocytophaga canimorsus (C. canimorsus) infection without a wound is rare and often misdiagnosed initially. We report a patient who died due to C. canimorsus bacteremia with purpura fulminans and acute compartment syndrome of all extremities. CARE PRESENTATION: A 38-year-old Japanese man with a history of alcoholism presented with a 2-day history of gastroenteritis. The chief complaints were abdominal pain and diarrhea, and he had abdominal tenderness. Laboratory findings showed multiple organ failure. On day 2, pain in the lower extremities associated with motor and sensory dysfunction developed. On day 3, purpura on the whole body spread to all extremities. All four extremities became rigid, and acute compartment syndrome developed. The patient died due to uncontrolled hyperkalemia and lactic acidosis. CONCLUSIONS: Capnocytophaga canimorsus transmission can occur through licking or even close contact with animals when a risk factor of C. canimorsus infection, such as alcoholism, is present.

Infected Abdominal Aortic Aneurysm with Helicobacter cinaedi.

Helicobacter cinaedi is a rare human pathogen which has various clinical manifestations such as cellulitis, bacteremia, arthritis, meningitis, and infectious endocarditis. We report an abdominal aortic aneurysm infected with Helicobacter cinaedi, treated successfully with surgical repair and long-term antimicrobial therapy.

Laparoscopic gastric devascularization without splenectomy is effective for the treatment of gastric varices.

INTRODUCTION: Laparoscopic gastric devascularization of the upper stomach in patients with gastric varices has rarely been reported. Perioperative clinical data were compared with patients who underwent open surgery. PRESENTATION OF CASES: From 2009 to 2012, we performed laparoscopic gastric devascularization without splenectomy for the treatment of gastric varices in eight patients. The patients included four males and four females. Peri-gastric vessels were divided using electrical coagulating devices or other devices according to the diameter of the vessels. Two patients underwent conversion to open surgery due to intraoperative bleeding. DISCUSSION: Intraoperative blood loss in patients who accomplished laparoscopic devascularization was very small (mean 76ml). However, once bleeding occurs, there is a risk of causing massive bleeding. CONCLUSION: With further improvement of laparoscopic devices, laparoscopic gastric devascularization without splenectomy must be an effective and less-invasive surgical procedure in the treatment of gastric varices.

Predicting rectal cancer T stage using circumferential tumor extent determined by computed tomography colonography.

BACKGROUND AND AIM: Patients with stage T3 or T4 rectal cancer are candidates for neoadjuvant chemoradiation therapy. The aim of this study is to clarify the usefulness of circumferential tumor extent determined by computed tomography (CT) colonography in differentiating T3 or T4 from T1 or T2 rectal cancer. METHODS: Seventy consecutive rectal cancer patients who underwent curative-intent surgery were enrolled in this study. All patients underwent colonoscopy and CT colonography on the same day. The circumferential tumor extent was estimated in 10% increments. The pathological T stage was used as the reference. RESULTS: The median circumferential tumor extent evaluated by colonoscopy for T1 (n = 6), T2 (n = 21), and T3/T4 (n = 43) were 10%, 30%, and 80%, respectively (T1/T2 vs. T3/T4, p < 0.0001). The median circumferential tumor extent evaluated by CT colonography for T1, T2, and T3/T4 is 10%, 30%, and 70%, respectively (T1/T2 vs. T3/T4, p < 0.0001). The correlation coefficient between colonoscopy and CT colonography was very high (0.94). By defining a circumferential tumor extent ≥ 50% by CT colonography as the criterion for stage T3 or T4, the sensitivity, specificity, positive predictive value and accuracy were 72%, 88%, 91%, and 79%, respectively. CONCLUSION: Circumferential tumor extent ≥ 50% determined by CT colonography is a simple and potentially useful marker to identify candidates for neoadjuvant chemoradiation therapy.

Serum Total Cholesterol Levels Would Predict Nosocomial Infections After Gastrointestinal Surgery.

It has been suggested that total cholesterol levels and the use of statin medications are associated with the incidence of complications after gastrointestinal surgery. The aim of this study was to determine if preoperative total cholesterol levels are associated with a higher risk of postoperative infections and mortality. A total of 2211 patients undergoing general surgical procedures between December 2006 and November 2008 at Iizuka Hospital and between January 2010 and March 2012 at Jichi Medical University Hospital were reviewed. Multiple logistic regression models were used to evaluate serum total cholesterol and other variables as predictors of postoperative nosocomial infections. Serum total cholesterol concentrations lower than 160 mg/dl were associated with an increased incidence of superficial and deep incisional surgical site infections. Serum total cholesterol levels showed a reverse J-shaped relationship with the development of organ space surgical site infection and pneumonia. There was no discernible effect of serum cholesterol levels on the postoperative mortality observed in this cohort of patients. Decreased serum albumin was one of the strongest risk factors for the development of nosocomial infection after surgery. Postoperative pneumonia was not observed in patients taking statin medications whose cholesterol levels were <200 mg/dl. Serum total cholesterol may be a valid predictor of surgical outcome. Preoperative statin use may affect the development of postoperative pneumonia in patients with total cholesterol levels below 200 mg/dl.

CT prediction of the degree of ovarian torsion.

PURPOSE: Torsion angle determines the incidence of necrosis among patients with ovarian torsion. The purpose of this study was to evaluate the association between torsion angle and findings on CT scan. MATERIALS AND METHODS: We retrospectively reviewed CT scan findings obtained less than 36 h before surgery for 31 patients with ovarian torsion. Ovarian torsion angles measured intraoperatively ranged from 90° to 1260°. Ovaries with torsion angles less than 360° rarely develop necrosis. Patients were divided into two groups according to torsion angle: <360° (Group A) and ≥360° (Group B). A lesion corresponding to an enlarged fallopian tube and mesovarium containing dilated veins between the uterus and twisted ovary is referred to as a "mass-like swelling". RESULTS: A mass-like swelling occurred more often in Group B (p < 0.05) and had the highest correlation with torsion angles ≥360°. A mass-like swelling lacking enhancement or a high-density area was significantly different between the groups (p < 0.05) and was also indicative of torsion angles ≥360°. CONCLUSION: A mass-like swelling alone or with a high-density area or lack of enhancement suggests an ovarian torsion angle ≥360°. The presence of these findings predict ovarian necrosis and may allow ovary-sparing treatment.

Analysis of risk classification for massive transfusion in severe trauma using the gray zone approach.

BACKGROUND: The Traumatic Bleeding Severity Score (TBSS) was developed to predict the need for massive transfusion (MT). The aim of this study is evaluation of clinical thresholds for activation of a MT protocol using the gray zone approach based on TBSS. METHODS: This is a single-center retrospective study of trauma patients, admitted from 2010 to 2013. The TBSS on admission was calculated, and the accuracy of predicting MT was analyzed using area under the receiver operating characteristic curve. Risk classification for MT was made using sensitivity/specificity. The gray zone (indeterminate risk) was defined from a sensitivity of 95% to a specificity of 95%, patients were separated into MT and non-MT groups, and their clinical characteristics were compared. RESULTS: A total of 264 patients were enrolled, with an area under the TBSS curve of 0.967 (95% confidence interval, 0.94-0.99). A TBSS of 10 points or less resulted in a sensitivity of 96.5% with 146 patients in this group, and 3.4% (5/146) of them received MT. A TBSS of 17 points or higher had a specificity of 97.8%, which included 72 patients, and 94.4% (68/72) of them received MT. Forty-six patients had a TBSS from 11 to 16 points (gray zone), and 26.1% (12/46) of them received MT. Comparing the MT group (12/46) and non-MT group (34/46), coagulopathy and extravasation on computed tomographic scan were more prevalent in the MT group. CONCLUSION: The TBSS is highly accurate in predicting the need for MT, and a risk classification for needing MT was created based on TBSS.

Immunoglobulin G4-related sclerosing cholangitis mimicking hilar cholangiocarcinoma diagnosed with following bile duct resection: report of a case.

We report a rare case of immunoglobulin G4 (IgG4)-related sclerosing cholangitis without other organ involvement. A 69-year-old-man was referred for the evaluation of jaundice. Computed tomography revealed thickening of the bile duct wall, compressing the right portal vein. Endoscopic retrograde cholangiopancreatography showed a lesion extending from the proximal confluence of the common bile duct to the left and right hepatic ducts. Intraductal ultrasonography showed a bile duct mass invading the portal vein. Hilar bile duct cancer was initially diagnosed and percutaneous transhepatic portal vein embolization was performed, preceding a planned right hepatectomy. Strictures persisted despite steroid therapy. Therefore, partial resection of the common bile duct following choledochojejunostomy was performed. Histologic examination showed diffuse and severe lymphoplasmacytic infiltration, and abundant plasma cells, which stained positive for anti-IgG4 antibody. The final diagnosis was IgG4 sclerosing cholangitis. Types 3 and 4 IgG4 sclerosing cholangitis remains a challenge to differentiate from cholangiocarcinoma. A histopathologic diagnosis obtained with a less invasive approach avoided unnecessary hepatectomy.

The Dose-Response Relationship Between Body Mass Index and Mortality in Subjects Admitted to the ICU With and Without Mechanical Ventilation.

BACKGROUND: Obesity has been associated with increased mortality in the general population, whereas a paradoxical relationship between higher body mass index and lower mortality has been referred to as the obesity paradox in critically ill patients. However, it remains unknown whether a particular subgroup is most affected. The aim of the present study is to elucidate whether obesity is associated with lower mortality in the ICU population by comparing subjects with and without mechanical ventilation. METHODS: A total of 334,238 subjects from a nationwide database who were discharged between July 2010 and March 2012 and who were admitted to general ICUs during their hospitalization were included in this study. The primary outcome was in-hospital mortality. RESULTS: Of all subjects evaluated, 23.3% were started on mechanical ventilation within the first 2 d after ICU admission. Compared with the non-ventilated group, the ventilated group was more likely to have sepsis, pneumonia, or coma. The ventilated group underwent more procedures within the first 2 d after ICU admission compared with the non-ventilated group. A restricted cubic spline function showed lower mortality in subjects with a higher body mass index among the ventilated group, whereas mortality was increased with increasing body mass index in the non-ventilated group. CONCLUSIONS: This study shows that a high body mass index is associated with low mortality in the mechanically ventilated group, whereas the non-ventilated group showed a reverse J-shaped association. There was a higher mortality rate in underweight subjects in both groups.

Hepatic portal venous gas after endoscopy in a patient with anastomotic obstruction.

A 72-year-old male underwent a laparoscopic low anterior resection for advanced rectal cancer. A diverting loop ileostomy was constructed due to an anastomotic leak five days postoperatively. Nine months later, colonoscopy performed through the stoma showed complete anastomotic obstruction. The mucosa of the proximal sigmoid colon was atrophic and whitish. Ten days after the colonoscopy, the patient presented in shock with abdominal pain. Abdominal computed tomography scan showed hepatic portal venous gas (HPVG) and a dilated left colon. HPVG induced by obstructive colitis was diagnosed and a transverse colostomy performed emergently. His subsequent hospital course was unremarkable. Rectal anastomosis with diverting ileostomy is often performed in patients with low rectal cancers. In patients with anastomotic obstruction or severe stenosis, colonoscopy through diverting stoma should be avoided. Emergent operation to decompress the obstructed proximal colon is necessary in patients with a blind intestinal loop accompanied by HPVG.

Evaluation of dose reduction and image quality in CT colonography: comparison of low-dose CT with iterative reconstruction and routine-dose CT with filtered back projection.

OBJECTIVE: To prospectively evaluate the radiation dose and image quality comparing low-dose CT colonography (CTC) reconstructed using different levels of iterative reconstruction techniques with routine-dose CTC reconstructed with filtered back projection. METHODS: Following institutional ethics clearance and informed consent procedures, 210 patients underwent screening CTC using automatic tube current modulation for dual positions. Examinations were performed in the supine position with a routine-dose protocol and in the prone position, randomly applying four different low-dose protocols. Supine images were reconstructed with filtered back projection and prone images with iterative reconstruction. Two blinded observers assessed the image quality of endoluminal images. Image noise was quantitatively assessed by region-of-interest measurements. RESULTS: The mean effective dose in the supine series was 1.88 mSv using routine-dose CTC, compared to 0.92, 0.69, 0.57, and 0.46 mSv at four different low doses in the prone series (p < 0.01). Overall image quality and noise of low-dose CTC with iterative reconstruction were significantly improved compared to routine-dose CTC using filtered back projection. The lowest dose group had image quality comparable to routine-dose images. CONCLUSIONS: Low-dose CTC with iterative reconstruction reduces the radiation dose by 48.5 to 75.1% without image quality degradation compared to routine-dose CTC with filtered back projection. KEY POINTS: • Low-dose CTC reduces radiation dose ≥ 48.5% compared to routine-dose CTC. • Iterative reconstruction improves overall CTC image quality compared with FBP. • Iterative reconstruction reduces overall CTC image noise compared with FBP. • Automated exposure control with iterative reconstruction is useful for low-dose CTC.

Utility of a new reusable clip device for endoscopic treatment.

BACKGROUND AND AIM: Existing reusable endoscopic clip devices have some problems regarding opening the device and precise control of clip application. The aim of the present study was to evaluate reusable clip devices for endoscopic treatment. METHODS: Ability to close a large defect and grip force were evaluated using ex-vivo porcine colon. We assessed clip loading and opening in a non-clinical setting and describe the resulting learning curve. To evaluate clinical utility, data for clip application in 72 post-endoscopic mucosal resection (EMR) defects in 40 patients were retrospectively analyzed. RESULTS: There was no difference in the ability to close a 20-mm full-thickness defect and the grip force comparing the new clip device (ZEOCLIP®) and a previously used reusable clip device (EZClip®). Although the time to load the ZEOCLIP was almost same as the EZClip, the time to open the ZEOCLIP was significantly shorter than the EZClip (P < 0.001). Opening width of the ZEOCLIP was significantly wider than the EZClip (P < 0.05). We successfully accomplished closure of post-EMR defects by clip application in 72 lesions using ZEOCLIP. Reopening/repositioning and restoring it to the working channel were more frequently carried out in a non-easy location than in an easy location (11/35 [31%] vs 4/37 [11%], P = 0.030; and 21/35 [60%] vs 1/37 [3%], P < 0.001, respectively). CONCLUSIONS: ZEOCLIP is more quickly and easily opened to its maximum width compared with EZClip, and is feasible for clip application after EMR.

Reduction in the size of enlarged pelvic lymph nodes after chemoradiation therapy is associated with fewer lymph node metastases in locally advanced rectal carcinoma.

PURPOSE: We hypothesized that a reduction in the size of the lymph nodes after neoadjuvant therapy for locally advanced rectal carcinoma would be associated with decreased lymph node metastases and/or a better prognosis. METHODS: Between March 2006 and April 2012, 71 patients with primary rectal cancer received neoadjuvant chemoradiation therapy (CRT). For all lymph nodes 5 mm or larger in size, the major and minor axes were measured on CT scan images, and the product was calculated. The lymph node size was determined before and after CRT. The patients were divided into three groups based on the lymph node size before and after treatment. Group A exhibited a reduction in size of 60% or more, Group B a reduction of less than 60% and Group C had no lymph node enlargement before treatment. RESULTS: The incidence of lymph node metastases on pathological examination was 15% in Group A and 50% in Group B (p = 0.006). The five-year disease-free survival in Group A was 84% compared with 78% in Group B (log rank p = 0.34). The five-year overall survival in Group A was 92% compared with 74% in Group B (log rank p = 0.088). CONCLUSIONS: A reduction in the size of enlarged lymph nodes after neoadjuvant therapy may be a useful prognostic factor for recurrence and survival.

Lymph Node Size Alone Is Not an Accurate Predictor of Metastases in Rectal Cancer: A Node-for-Node Comparative Study of Specimens and Histology.

Although size criteria have been proposed to identify lymph node metastases in patients with rectal cancer, size may not be an accurate predictor. Specimens from consecutive rectal cancer patients who underwent curative-intent radical surgery were examined. The long and short axes of lymph nodes were measured on the glass slides using micrometer calipers. The pathologic diagnosis was used as the reference. The diagnostic accuracy of metastatic status according to lymph node size was evaluated. Overall, 1283 lymph nodes from 78 patients were reviewed. The metastatic rate correlates with the length of both the long and short axes. However, metastases were present even in 1-mm lymph nodes, and the metastatic rate exceeds 5 per cent in lymph nodes measuring 3 mm along both axes. Cutoff values of ≥4 mm and ≥3 mm for the long and short axes result in a sensitivity of 76 per cent and 79 per cent, and a specificity of 36 per cent and 33 per cent, respectively, for each axis. Size criteria alone do not accurately predict the N-stage of rectal cancer. Diminutive lymph nodes, which are not seen on imaging studies, can contain metastatic disease.

Nonoperative management of hemodynamically unstable abdominal trauma patients with angioembolization and resuscitative endovascular balloon occlusion of the aorta.

BACKGROUND: Many hemodynamically stable patients with blunt abdominal solid organ injuries are successfully managed nonoperatively, while unstable patients often require urgent laparotomy. Recently, therapeutic angioembolization has been used in the treatment of intra-abdominal hemorrhage in hemodynamically unstable patients. We undertook this study to review a series of hemodynamically unstable patients with abdominal solid organ injuries managed nonoperatively with angioembolization and resuscitative endovascular balloon occlusion of the aorta. METHODS: The institutional review board approved this study. All patients were appropriately resuscitated with transfusions, and angiography was performed after computed tomography. Resuscitative endovascular balloon occlusion of the aorta was performed before computed tomography in all patients. RESULTS: Seven patients underwent resuscitative endovascular balloon occlusion of the aorta following severe blunt abdominal trauma. The 28-day survival rate was 86% (6 of 7). There were no complications related to the procedure. CONCLUSION: We describe the first clinical series of hemodynamically unstable patients with abdominal solid organ injury treated nonoperatively with angioembolization and resuscitative endovascular balloon occlusion of the aorta. Survival rate was 86%, supporting the need for further study of this modality as an adjunct to the nonoperative management of patients with severe traumatic injuries. LEVEL OF EVIDENCE: Therapeutic study, level V.

Lower heart rate in the early postoperative period does not correlate with long-term outcomes after repair of type A acute aortic dissection.

Little evidence exists regarding the need for a reduction in postoperative heart rate after repair of type A acute aortic dissection. This single-center retrospective study was conducted to determine if lower heart rate during the early postoperative phase is associated with improved long-term outcomes after surgery for patients with type A acute aortic dissection. We reviewed 434 patients who underwent aortic repair between 1990 and 2011. Based on the average heart rate on postoperative days 1, 3, 5, and 7, 434 patients were divided into four groups, less than 70, 70-79, 80-89, and greater than 90 beats per minute. The mean age was 63.3 ± 12.1 years. During a median follow-up of 52 months (range 16-102), 10-year survival in all groups was 67%, and the 10-year aortic event-free rate was 79%. The probability of survival and being aortic event-free using Kaplan-Meier estimates reveal that there is no significant difference when stratified by heart rate. Cox proportional regression analysis for 10-year mortality shows that significant predictors of mortality are age [Hazard Ratio (HR) 1.04; 95% confidence interval (CI) 1.07-1.06; p = 0.001] and perioperative stroke (HR 2.30; 95% CI 1.18-4.50; p = 0.024). Neither stratified heart rate around the time of surgery nor beta-blocker use at the time of discharge was significant. There is no association between stratified heart rate in the perioperative period with long-term outcomes after repair of type A acute aortic dissection. These findings need clarification with further clinical trials.