Preoperative prognostic predictors and treatment strategies for surgical procedure focused on the sequential organ failure assessment score in nonocclusive mesenteric ischemia: a multicenter retrospective cohort study.

BACKGROUND: Several large-scale studies have assessed endovascular and surgical treatment methods for nonocclusive mesenteric ischemia (NOMI); however, the prognostic factors for NOMI remain unclear. Therefore, this study aimed to evaluate risk factors for in-hospital mortality among patients with NOMI who underwent laparotomy and to examine therapeutic strategies that may improve the prognosis. MATERIALS AND METHODS: In this multicenter retrospective study, the authors reviewed the electronic medical records retrieved from the inpatient database of patients with NOMI at eight district general hospitals between January 2011 and January 2021. A total of 88 patients who underwent laparotomies were divided into survivor and nonsurvivor groups, and statistical analysis was performed to determine clinical and physiological factors. RESULTS: Exploratory laparotomy based on second-look surgery was the first treatment choice. The overall mortality rate was 48.8%, with a male-to-female ratio of 1.1:1. The median Sequential Organ Failure Assessment (SOFA) score was 8 [interquartile range: 3.75-14.2], and the median SOFA scores were 5 [3-7] in the survivor group and 13 [9-17.5] in the nonsurvivor group. Univariate analysis revealed a significant difference in BMI ( P <0.001), hypoglycemia ( P =0.0012), previous cardiovascular surgery ( P =0.0019), catecholamine use ( P <0.001), SOFA score ( P <0.001), platelet count ( P =0.0023), and lactate level ( P <0.001). Logistic regression analysis using the factors with significant differences revealed that SOFA score ≥10 (odds ratio 23.3; 95% CI: 1.94-280.00; P =0.013) was an independent prognostic factor. In addition, catecholamine use was suggested as a factor with a SOFA score greater than or equal to 10. CONCLUSION: This study confirmed that a SOFA score of greater than or equal to 10 may be associated with increased mortality. While closely monitoring low blood pressure and renal dysfunction, survival rates may be improved if surgical intervention is performed before the SOFA score reaches greater than or equal to 10.

Missed Diagnosis of Subarachnoid Haemorrhage.

A 79-year-old woman presented with left retro-orbital pain, headache and blurred vision. Based on negative radiological tests, life-threatening conditions like subarachnoid haemorrhage (SAH) were ruled out and outpatient follow-up was planned. However, the patient returned to the hospital that night because of progressively declining consciousness and was diagnosed with SAH by head computed tomography. The diagnosis of SAH is often challenging, especially in cases with negative radiological results. We describe some strategies, other than radiological examination, for ruling out SAH, such as performing a lumbar puncture and repeating tests to take account of disease progression, and describe biases which can affect clinical decision-making. LEARNING POINTS: A high diagnostic error rate highlights the difficulty in diagnosing subarachnoid haemorrhage (SAH).Headache together with oculomotor nerve palsy is an important symptom of SAH.If SAH is suspected, further diagnostic measures including lumber puncture are warranted.A strategy of repeating tests to take account of disease progression would also be effective.

Isolated Superior Mesenteric Artery Dissection Mimicking Impending Rupture of Abdominal Aortic Aneurysm.

BACKGROUND Isolated superior mesenteric artery dissection (SMAD) is a rare vascular disease that is difficult to diagnose. We report a case of SMAD in a patient with an abdominal aortic aneurysm (AAA) that mimicked an impending rupture of the AAA. In addition, we describe several clinical biases that contributed to the delayed diagnosis. CASE REPORT A 66-year-old man presented with a 3-day history of abdominal pain, without a history of trauma, that worsened gradually and caused him to visit our hospital. The patient's medical history included an AAA under observation. The patient was well oriented and initially remained hemodynamically stable, and the abdomen was soft and non-tender on palpation. An emergency contrast-enhanced computed tomography (CT) scan confirmed a 44-mm AAA without any leakage, but with an isolated SMAD. His previous physician confirmed there was no change in the AAA size since 3 months prior to hospital admission. Thus, the symptoms were caused by the isolated SMAD. The patient showed improvement with pain-relieving and antihypertensive management, without anticoagulation therapy or revascularization, and was discharged on day 25 of admission without any complications. CONCLUSIONS The misdiagnosis in this case was attributable to several clinical biases, including search satisfaction, Sutton's slip, and anchoring bias. Physicians should guard against presumptive diagnoses based on patient symptoms or initial plausible findings and instead pursue a thorough workup to reach a definitive diagnosis.

A unique strategy for large-bowel perforation with ventriculoperitoneal shunt: Conversion to ventriculoatrial shunt: A case report.

INTRODUCTION: Large-bowel perforation can lead to critical sepsis, and urgent intervention including surgery is indispensable to control systemic infection. Here, we describe a strategy for large-bowel perforation using a ventriculoperitoneal shunt. CASE PRESENTATION: A 74-year-old Japanese female with a history of cerebral aneurysm clipping and ventriculoperitoneal shunting due to aneurysmal subarachnoid hemorrhage presented with lower abdominal pain, fever, and disturbed consciousness. Clinical findings indicated a diagnosis of large-bowel perforation and ventriculoperitoneal shunt-transmitted bacterial meningitis. Thus, sigmoidectomy and shunt externalization were performed, and the ventriculoperitoneal shunt was converted to a ventriculoatrial one. CONCLUSION: Based on our experience and the literature, we successfully discuss bowel perforation management with respect to the ventriculoperitoneal shunt, including the utility of the ventriculoatrial shunt as an alternative.

Metastatic spinal cord compression by gastric cancer: a case report.

Metastatic spinal cord compression (MSCC) is one of the serious complications of malignancy. Most cases of MSCC occur from breast or prostate cancer primaries; MSCC secondary to gastric cancer is rare. We herein report a case of a patient with gastric cancer with weakness of the lower limbs and urinary retention on initial presentation. This case demonstrates that although rare, bone metastases and MSCC may occur from gastric primaries. It also highlights the importance of prompt diagnosis and early treatment of MSCC.

Challenging management of familial adenomatous polyposis with advanced colorectal cancer: laparoscopic partial resection and cold snare polypectomy.

Background and study aims Prophylactic extended colectomy may be indicated because most surgically untreated patients with familial adenomatous polyposis (FAP) develop colorectal cancer (CRC) in their lifetime. However, some patients refuse to undergo surgery to avoid degradation of their quality of life. We report that FAP is controllable with laparoscopic partial resection and postoperative polypectomy even when complicated by advanced CRC. We also discuss the utility of cold snare polypectomy for resection of polyps.

Stomach resection with intraoperative fluoroscopy in laparoscopic distal gastrectomy for early gastric cancer.

BACKGROUND: In Japan, laparoscopic distal gastrectomy (LDG) is common for early gastric cancer. Formerly, we used to verify the location of the marking clip to decide the proximal incisional line with our hand, through a small epigastric incision. In 2015, we introduced intracorporeal reconstruction and started to decide the incisional line using intraoperative fluoroscopy. Herein, we aimed to evaluate the efficacy and safety of intraoperative fluoroscopy in LDG. PATIENTS AND METHODS:: A total of 19 patients were included in this retrospective observational study. On the day before operation, we endoscopically clipped several points located 2 cm proximal to the tumour edge to cover about half of the tumour. After lymph node dissection, we incised the stomach with an endoscopic linear stapling device, including the previously placed clips, guided by intraoperative fluoroscopy. Reconstruction was performed in all patients who underwent Billroth I and Roux-en-Y procedures. RESULTS: No complications were observed during pre-operative endoscopic clipping or intraoperatively. On pathological examination, all resected specimens had negative margins, and the mean distance from the tumour edge was 28.5 ± 16.5 (13-60) mm. CONCLUSION: Stomach resection with intraoperative fluoroscopic guidance was safe and effective.

A rare case of an infected tracheal diverticulum requiring emergency intervention: A case report.

INTRODUCTION: Recent advancement in radiological imaging has revealed an increasing amount of asymptomatic abnormalities. Tracheal diverticula are relatively rare entities and are incidentally found on radiological imaging such as computed tomography. Here, we present a case of an infected tracheal diverticulum presenting as a paratracheal mass, which required emergency intervention. CASE PRESENTATION: A 65-year-old Japanese nonsmoker man presented with a fever, lower neck pain, and the aggravation of dyspnea for a week. An enhanced computed tomography scan demonstrated that the trachea was displaced by a paratracheal mass with a well-defined thin wall. His respiratory status was so urgent that emergency intubation and surgical drainage of the abscess were performed. A computed tomography scan performed 4days after admission demonstrated shrinking of the abscess, and he was extubated and discharged 7days after admission without any complications. CONCLUSION: To the best of our knowledge, this is the first report to confirm an infected tracheal diverticulum presenting as a paratracheal abscess, which required emergency intervention. Moreover, computed tomography plays an important role in the differentiation of paratracheal masses.

[Successful Treatment of Empyema with Bronchial Fistulas by Filling under Thoracoscopic Observation; Report of a Case].

Empyema with fistula usually resists conservative treatment such as thoracic cavity drainage and administration of antibacterial agents, thus it often requires surgeries such as fenestration, omental/muscle filling, and thoracoplasty. However, due to advanced age and poor condition, conducting invasive surgeries is often difficult in elderly patients. We report a case with the improvement of empyema by bronchial filling with endobronchial Watanabe spigot (EWS) under thoracoscopic observation for an 89-year-old patient who had developed chronic empyema with a bronchial fistulas. After filling EWS, air-leakage from bronchial fistula disappeared and the patient could discharged from the hospital successfully.

[Early diagnosis of capecitabine-induced acute leukoencephalopathy by using diffusion-weighted MRI].

A 63-year-old woman with colon cancer who was treated with capecitabine as adjuvant chemotherapy presented with vertigo on day 5, and dysarthria and dysphagia on day 7 of the treatment. Diffusion-weighted magnetic resonance imaging of the brain revealed high signal intensity in the corpus callosum and corona radiata. The patient was diagnosed with acute leukoencephalopathy, and the capecitabine treatment was discontinued. Her symptoms recovered immediately. On the basis of these findings, it can be concluded that diffusion-weighted imaging is useful for the early detection and diagnosis of acute leukoencephalopathy.

Protocol-based strategy for endovascular repair of ruptured abdominal aortic aneurysms.

OBJECTIVE: Compared with conventional open surgery (COS), endovascular aneurysm repair (EVAR) has been reported to decrease the 30-day mortality rate in patients with ruptured abdominal aortic aneurysms (rAAAs). We developed an EVAR-first strategy for rAAAs that incorporates the Shonan ruptured abdominal aortic aneurysm protocol (SRAP). We describe short-term results with this protocol at our institution and compare them with outcomes in patients who underwent COS. METHODS: The records of all 57 patients in whom a rAAA was repaired during a 7-year period were reviewed retrospectively. Patients in the COS group (n = 30) were treated between January 2005 and December 2009; those in the SRAP group (n = 27) were treated between January 2010 and March 2012. The two groups were compared with respect to patient characteristics at admission, including severity of condition; operative and in-hospital variables; and 30-day mortality. RESULTS: The baseline patient characteristics in the COS and SRAP groups were similar except that the SRAP group had a significantly higher rate of cerebrovascular disease. The 30-day mortality rate was significantly higher in the COS group (43% vs. 19%), as were the intraoperative mortality rate (27% vs. 5%) and the in-hospital mortality rate (57% vs. 26%; P < 0.05 for all comparisons). The technical success rate for EVAR was 96%; no conversions to open surgery were required. CONCLUSIONS: Use of the SRAP is a promising strategy for improving initial outcomes in patients with rAAAs.