Clinical indicators for the incidence of postoperative ileus after elective surgery for colorectal cancer.

BACKGROUND: The occurrence of postoperative ileus leads to increased patient morbidity, longer hospitalization, and higher healthcare costs. No clear policy on postoperative ileus prevention exists. Therefore, we aim to evaluate the clinical factors involved in the development of postoperative ileus after elective surgery for colorectal cancer. METHODS: We retrospectively analyzed patients who underwent elective surgery involving bowel resection with or without re-anastomosis for colon cancer between April 2015 and March 2020. The primary readout was the presence or absence of postoperative ileus. Univariate and multivariate analyses were used to identify pre- and intraoperative risk factors, and the incidence of postoperative ileus was assessed using independent factors. RESULTS: Postoperative ileus occurred in 48 out of 356 patients (13.5%). In multivariate analysis, male sex poor performance status, and intraoperative in-out balance per body weight were independently associated with postoperative ileus development. The incidence of postoperative ileus was 2.5% in the cases with no independent factors; however, it increased to 36.1% when two factors were observed and 75.0% when three factors were matched. CONCLUSIONS: We discovered that male gender, poor performance status, and intraoperative in-out balance per body weight were associated with the development of postoperative ileus. Of these, intraoperative in-out balance per body weight is a controllable factor. Hence it is important to control the intraoperative in-out balance to lower the risk for postoperative ileus.

[A Case of Long-Term Survival in a Patient with Small Intestinal Adenocarcinoma with Peritoneal Dissemination].

Primary small intestinal adenocarcinoma is rare and its outcome is poor. A 46-year-old man admitted for vomiting was found in enhanced abdominal CT to have local jejunum stenosis and dilation at its oral site. A partial jejunectomy was performed and a jejunal tumor with multiple disseminated nodules in the peritoneum was revealed. Histologically, the adenocarcinoma of the jejunum appeared to be a papillary adenocarcinoma, and also, in part, a moderately differentiated tubular adenocarcinoma. After the jejunectomy, the patient was treated with S-1 chemotherapy, but 22 months after the initial diagnosis, a recurrence was detected. The patient underwent a second partial jejunectomy, and a weekly dose of paclitaxel (PTX) plus doxifluridine (5'-DFUR) was selected as the second-line treatment. The patient is still responding to the treatment 55 months after the last operation. Combination chemotherapy with weekly PTX/5'-DFUR may improve the prognosis for S-1-resistant small intestinal adenocarcinoma.

A case report on metastatic pancreatic tumor from pulmonary adenocarcinoma that difficult to differentiate from primary pancreatic ductal carcinoma.

A woman was admitted to our department for lung adenocarcinoma and she was treated with left upper lobectomy. The carcinoembryonic antigen level had increased. Enhanced computed tomography showed a hypovascular tumor in the pancreatic tail and in the extension of the distal main pancreatic duct. Endoscopic ultrasonography (EUS) clearly showed a low echoic lesion, and histological examination revealed adenocarcinoma. On immunostaining, the lesion was diagnosed as metastatic adenocarcinoma of the lungs. The patient was treated with chemotherapy for lung cancer and survived for 4 years after diagnosis. Differentiating a metastatic lesion to the pancreas from pancreatic ductal adenocarcinoma is very important. Accurate diagnosis enables administration of appropriate treatment. In this case, EUS was especially useful for assessing the tumor in the pancreas. When patients with a history of extra-pancreatic cancer present with a pancreatic lesion, pancreatic metastases should be considered, regardless of the time elapsed since occurrence of the primary cancer. EUS-fine needle aspiration (FNA) with histological examination is the best method for definitive diagnosis of pancreatic disease in this group of patients. This approach has very high sensitivity and accuracy for the diagnosis of pancreatic metastases.

[Localized Malignant Mesothelioma of the Pleura].

A 65-year-old man presented with the chief complaint of cough. Chest computed tomography showed the mediastinal tumor. The tumor was resected under the 4th intercostal thoracotomy and the mediastinal approach. The biphasic type of localized malignant mesothelioma was diagnosed by the pathological findings. The postoperative course was uneventful. After postoperative adjuvant radiotherapy and chemotherapy (cisplatin and pemetrexed sodium hydrate), he is well without relapse 7 months after surgery.

[Pulmonary dirofilariasis].

A 70-year-old man was admitted to our department for pulmonary nodule of 15 mm in diameter in the left lower lobe detected by chest computed tomography (CT). A possibility of malignant tumor could not be ruled out, and lung partial resection was performed. Pathological examination during operation revealed a coagulation necrosis and the lesion was finally diagnosed as pulmonary dirofilariasis.

Bowel pseudo-obstruction caused by goblet cell adenocarcinoma of the appendix: A case report.

INTRODUCTION: Goblet cell adenocarcinoma of the appendix is a rare diagnosis with features of both adenocarcinomas and carcinoid tumors. Commonly presenting with chronic abdominal pain, appendicitis, or abdominal distention, it can also be incidentally discovered during appendectomies. CASE PRESENTATION: A 50-year-old man with right lower abdominal pain was admitted to our hospital, which is a critical care center. A computed tomography(CT) scan showed ileal narrowing, but endoscopy found no strictures. He was admitted with suspected bowel obstruction and improved with an ileal tube. Laparoscopic surgery revealed a tumor of the appendix. Histologically, he was diagnosed goblet cell adenocarcinoma, suggesting tumor infiltration of nerve fibers impairing peristalsis. DISCUSSION: Goblet cell adenocarcinoma of the appendix has unique histology and a poor prognosis. Treatment typically involves surgery and chemotherapy. This case highlights challenges in preoperative diagnosis, with the tumor causing bowel pseudo-obstruction by invading the intestinal wall and nerve plexus. Extensive infiltration of Auerbach's plexus was observed, consistent with the length of intestinal stenosis. CONCLUSION: This case describes goblet cell adenocarcinoma of the appendix leading to bowel pseudo-obstruction due to ileal end stenosis. It emphasizes the importance of considering this diagnosis in cases of bowel obstruction without an obvious mass.

Prolapse of duodenal bulb from esophageal hiatal hernia: A case report.

INTRODUCTION: The number of patients with hiatal hernia has increased. Paraesophageal and mixed hiatal hernias are absolute indications for surgical treatment due to the possibility of blood flow disturbances to the stomach and other organs. CASE PRESENTATION: A 77-year-old woman with a history of type IV esophageal hiatal hernia (under observation), multiple operations presented with a chief complaint of vomiting. She was diagnosed with a type IV esophageal hiatal hernia with incarceration of the duodenal bulb into the mediastinum. Although the incarceration was relieved with conservative treatment, the patient was at a high risk for recurrence; therefore, surgical hernia repair was performed. Intraoperatively, the hernia portal was severely dilated and the duodenal bulb was easily accessible to the mediastinum due to its high mobility. Fundoplication was performed using the Toupet procedure. No stenosis at the fundoplication site was observed on intraoperative upper gastrointestinal endoscopy. DISCUSSION: The causes of prolapse and incarceration of the duodenal bulb into the mediastinum were speculated to be weakening of the tissue due to aging, adhesion of the omentum to the hernia portal due to chronic prolapse of the stomach toward the mediastinum, increased intra-abdominal pressure due to a rounded back, and anatomical shortening of the distance between the esophageal hiatus and the duodenal bulb. The Toupet method was used as it is associated with a lower incidence of dysphagia. CONCLUSION: Further investigation is needed to determine the best surgical technique.

Validation of appendiceal stump invagination in laparoscopic appendectomy.

INTRODUCTION: There are various methods for appendiceal stump dissection, but the necessity for stump invagination remains unclear. This study aimed to assess the efficacy of appendiceal stump invagination in patients with acute appendicitis after laparoscopic appendectomy (LA). METHODS: We enrolled 327 patients with acute appendicitis who underwent LA between 2012 and 2020. Perioperative variables and surgical outcomes were analyzed between the invagination of the appendiceal stump and noninvagination groups. Propensity score-matched analysis (PSM) was performed. RESULTS: More patients experienced severe inflammation and severe intra-abdominal contamination in the noninvagination group than in the invagination group. Patients in the noninvagination group had an older age, higher body mass index, and poorer American Society of Anesthesiologists physical status than the invagination group. Severe inflammation in the noninvagination group was associated with longer hospital stays and poorer postoperative complications than in the invagination group. PSM analysis was performed to minimize bias in the two groups. After PSM analysis, there were no significant differences in surgical site infection, postoperative intra-abdominal abscess, Clavien-Dindo class ≥IIIa, or postoperative stay between the two groups. During the follow-up period, the postoperative adhesive ileus was not significantly different between the invagination and noninvagination groups. CONCLUSION: Invagination of the appendiceal stump during LA is not necessary to prevent short- and long-term complications. Even in cases dissected using a laparoscopic endostapler, the appendiceal stump per se is not related to postoperative adhesive ileus.

High-Output Stoma Leading to the Diagnosis of Antiphospholipid Syndrome.

Diverting stoma (DS) is widely created in colorectal surgery. High-output stoma (HOS) is a major complication of DS, which can lead to dehydration and thrombosis. Additionally, antiphospholipid syndrome (APS) is a risk factor for thrombosis, and it rarely occurs in men. Herein, we describe a case of multiple thromboses caused by chronic dehydration after HOS. A 48-year-old man visited our hospital with fever and lower abdominal pain; he was diagnosed with sigmoid diverticulitis. He underwent laparoscopic high anterior resection for relapsing diverticulitis and diverting ileostomy during the same operation. On postoperative day 1, an output of 3,000 mL/day was observed from the ileostomy. The stoma output exceeded 2,000 mL/day, which was diagnosed as HOS, and chronic dehydration persisted despite supplementation and restriction of oral water intake. Three months postoperatively, a computed tomography scan before ileostomy closure showed multiple thrombi in the inferior vena cava, right common iliac vein, and pulmonary artery. After antithrombotic therapy, ileostomy closure was performed. As lupus anticoagulant was positive twice and APS was diagnosed, antithrombotic therapy was changed from warfarin to direct oral anticoagulants. Thrombosis did not recur 6 months postoperatively. This is the first report of a case wherein APS was present in the background of thrombosis caused by HOS or chronic dehydration. It is important to be cautious about APS when there is thrombosis after HOS to select appropriate therapeutic agents.

Distal Gastrectomy for Symptomatic Stage IV Gastric Cancer Contributes to Prognosis with Acceptable Safety Compared to Gastrojejunostomy.

BACKGROUND: The prognostic prolongation effect of reduction surgery for asymptomatic stage IV gastric cancer (GC) is unfavorable; however, its prognostic effect for symptomatic stage IV GC remains unclear. We aimed to compare the prognosis of gastrectomy and gastrojejunostomy for symptomatic stage IV GC. METHODS: This multicenter retrospective study analyzed record-based data of patients undergoing palliative surgery for symptomatic stage IV GC in the middle or lower-third regions between January 2015 and December 2019. Patients were divided into distal gastrectomy and gastrojejunostomy groups. We compared clinicopathological features and outcomes after propensity score matching (PSM). RESULTS: Among the 126 patients studied, 46 and 80 underwent distal gastrectomy and gastrojejunostomy, respectively. There was no difference in postoperative complications between the groups. Regarding prognostic factors, surgical procedures and postoperative chemotherapy were significantly different in multivariate analysis. Each group was further subdivided into groups with and without postoperative chemotherapy. After PSM, the data of 21 well-matched patients with postoperative chemotherapy and 8 without postoperative chemotherapy were evaluated. Overall survival was significantly longer in the distal gastrectomy group (p = 0.007 [group with postoperative chemotherapy], p = 0.02 [group without postoperative chemotherapy]). CONCLUSIONS: Distal gastrectomy for symptomatic stage IV GC contributes to prognosis with acceptable safety compared to gastrojejunostomy.

Duodenal diverticula perforation caused by an impacted bezoar successfully treated by endoscopic drainage and lithotripsy: A case report and literature review.

Duodenal diverticula perforation due to an impacted bezoar is a rare disease. Surgical treatment is associated with high rates of complications and mortality; therefore, treatment strategies must be carefully decided. Endoscopic treatment offers significant benefits to patients over surgery.

Branching form of celiac artery to be aware of in laparoscopic surgery: A case report using MDCT angiography.

The anomalies of the celiac artery have been reported and reviewed in literature. Hence, it is not uncommon to clinically encounter its various types. This report presents the case of a 76-year-old male who underwent laparoscopic distal gastrectomy. Preoperative abdominal contrast-enhanced computed tomography showed an anomaly of the celiac artery, which was extremely rare, with various other anomalies of the artery.

Imaging diagnosis of aberrant proper hepatic and gastroduodenal arteries prior to pancreaticoduodenectomy: A case report.

In hepatobiliary and pancreatic surgery, an understanding of hepatic artery anomalies is of great importance to surgeons. Cases of the proper hepatic artery originating from the superior mesenteric artery and the gastroduodenal artery originating from the celiac trunk are extremely rare. To our knowledge, there are no reports of these arterial variants being diagnosed before hepatobiliary and pancreatic surgery. A 73-year-old woman underwent subtotal stomach-preserving pancreaticoduodenectomy and lymphadenectomy for duodenal carcinoma. Preoperative vascular construction with 3-dimensional computed tomography showed variants of the proper hepatic artery and gastroduodenal artery. The proper hepatic artery originated from the superior mesenteric artery, and the gastroduodenal artery originated from the celiac trunk. Intraoperative findings and preoperative vascular construction from 3-dimensional computed tomography were found to be matched exactly; both the proper hepatic artery and gastroduodenal artery were preserved. By diagnosing a rare arterial variant preoperatively, we were able to perform the surgery safely. In hepatobiliary and pancreatic surgery, understanding any potential variation of the hepatic artery before surgery is crucial to ensure the best patient outcomes.

Laparoscopic resection of schwannoma in the hepatoduodenal ligament: a case report.

BACKGROUND: The occurrence of schwannomas in the hepatoduodenal ligament is rare, and its preoperative accurate diagnosis is difficult. Only few cases have been treated with laparoscopic surgery. CASE PRESENTATION: A 54-year-old man visited our hospital following abnormal abdominal computed tomography findings. He had no complaints, and his laboratory investigations were normal. Abdominal contrast-enhanced computed tomography revealed a tumor with enhancement at the margin of the hepatoduodenal ligament. The abdominal magnetic resonance imaging findings of the tumor showed hypointensity on the T1-weighted images and mixed hypointensity and hyperintensity on the T2-weighted fat-suppression images. Positron emission tomography showed localized accumulation of fludeoxyglucose only in the hepatoduodenal ligament tumor. The patient underwent laparoscopic tumor resection for accurate diagnosis. Histopathologically, the tumor was mainly composed of spindle cells, which were strongly positive for S-100 protein on immunohistochemical staining. The patient was discharged without any postoperative complications on day 5. CONCLUSIONS: Complete tumor resection is essential for schwannomas to avoid recurrence. Laparoscopic surgery is useful for schwannomas occurring in the hepatoduodenal ligament and can be performed safely by devising an appropriate surgical method.

Anomalous origin of the middle colic artery from the ileocecal artery affecting laparoscopic ascending colon cancer resection.

The anomalies of the middle colic artery have rarely been reported and reviewed in literature. However, in case such anomalies are observed in clinical practice, surgery must still be performed safely. This report presents the case of a 78-years-old female who underwent ileocecal resection and hepatectomy due to ascending colon cancer with liver metastasis. Preoperative abdominal contrast-enhanced computed tomography showed an anomaly of the middle colic artery. Since such anomaly is extremely rare, preoperative evaluation of vascular structure is important for safely performing the surgery.

Appendicitis with submucosal fecalith mimicking a submucosal tumor: a case report.

BACKGROUND: Submucosal fecalith(s) mimicking submucosal tumors of the gastrointestinal lumen are rare. Moreover, accurate preoperative diagnosis of these entities is exceedingly difficult, and the mechanism(s) of their formation remains unclear. CASE PRESENTATION: A 40-year-old woman visited the authors' hospital due to lower abdominal pain and diarrhea. She had previously been treated for endometriosis. Laboratory investigation revealed increased C-reactive protein levels. Abdominal contrast-enhanced computed tomography revealed thickening of the appendix wall and dilation of the small intestine. The patient was diagnosed with paralytic ileus caused by appendicitis, and interval appendectomy was scheduled. She underwent laparoscopic-assisted appendectomy after conservative treatment. Partial cecal resection was selected due to the presence of an elastic mass in the cecum. The final pathological diagnosis was submucosal fecalith, not submucosal tumor. On day 5, the patient was discharged without any postoperative complications. CONCLUSIONS: In cases of appendicitis with fecalith(s) that appear as submucosal tumor(s) on colonoscopy, submucosal fecalith mimicking submucosal tumor should be considered in the differential diagnosis.

Risk Factors for Anastomotic Leakage after Colorectal Surgery with Double-staple Technique Anastomosis: Impact of the Agatston Score.

OBJECTIVES: Anastomotic leakage is associated with severe morbidity, mortality, and functional defects. Its risk factors remain unclear. However, blood perfusion may be a potential major risk factor. It has been reported that the Agatston score is an index for blood flow perfusion evaluation. Therefore, we evaluated the clinical indicators associated with anastomotic leakage, including the Agatston score, in patients who underwent colorectal surgery. METHODS: We retrospectively analyzed 147 patients who underwent elective colorectal surgery with the double-staple technique anastomosis for colorectal cancer between April 2015 and March 2020. The primary outcome was the presence or absence of anastomotic leakage. Univariate and multivariate analyses were employed to identify pre- and intraoperative risk factors. RESULTS: Of the 147 patients analyzed, anastomotic leakage occurred in 12 (8.16%). Male gender, history of angina and myocardial infarction, preoperative white blood cell count, the Agatston score, extent of bleeding, operation time, and intraoperative fluid volume were significantly related to a higher incidence of anastomotic leakage in univariate analysis. Multivariate analysis demonstrated that the incidence of anastomotic leakage was high in patients with a high Agatston score. CONCLUSIONS: The Agatston score can predict the incidence of anastomotic leakage in patients following colorectal surgery. Thus, perioperative measures to prevent anastomotic leakage are recommended when a high Agatston score is observed. A prospective trial is required to demonstrate, with a high level of evidence, that the Agatston score can be useful as a risk score for anastomotic leakage following colorectal surgery.

Kocuria kristinae infection associated with short bowel syndrome: A case report.

INTRODUCTION: Only a few cases of K. kristinae infection have been reported in the literature. Patients with short bowel syndrome have an increased risk of opportunistic infections due to decreased bowel immunity and the long-term central venous catheter placement. We report a rare case of K. kristinae infection associated with SBS requiring long-term central venous access port placement. PRESENTATION OF CASE: A 70-year-old woman presented with fever of approximately 39 °C to our hospital for examination. She has undergone total hysterectomy and radiation therapy for cervical cancer 36 years ago. Five years ago, she developed multiple small bowel perforations, and a jejunostomy was constructed at the oral end of the perforation and approximately 110 cm from the ligament of Treitz because of the difficulty in dissecting the adhesion. She developed short bowel syndrome, and the central venous port was constructed four years ago due to poor enteral nutrition. K. kristinae was detected in the central venous catheter tip and in two blood cultures. We administered intravenous vancomycin. After seven days of antibiotic treatment, both fever and inflammatory reaction improved, and the blood culture was negative. After 16 days of antibiotic treatment, we performed central venous port construction on the side opposite to the previous site. CONCLUSION: Patients with short bowel syndrome have an increased risk of K. kristinae infections due to decreased bowel immunity and the long-term central venous port, and therefore, these patients should be followed up carefully.

Single-incision laparoscopic surgery using the glove technique with improved maneuverability achieved through fulcrum creation via a simple ring technique.

INTRODUCTION: Single-incision laparoscopic surgery (SILS) is widely used in many surgical procedures in various specialties. Among the access methods used in SILS, the glove technique, which is typically similar to the multi-trocar approach, is simple, convenient, and inexpensive. However, given the absence of a fulcrum supporting the endoscopic surgical forceps, the technique is less advantageous than methods using commercially available access devices because of the poor maneuverability of the forceps. MATERIALS AND SURGICAL TECHNIQUE: By creating a fulcrum as a support to use with existing surgical forceps in the glove technique, we designed and used a novel method known as the "ring technique." This technique aimed to improve the maneuverability of endoscopic surgical forceps. DISCUSSION: Placing a fulcrum resulted in the improvement of the forceps' maneuverability, which helped to ameliorate a weakness of the glove technique. The ring technique could be a useful option as a method of access in SILS.

Large hydrocele of the canal of Nuck diagnosed and treated using conventional and laparoscopic methods.

A 49-year-old woman presented to the hospital with a right inguinal swelling. On examination, we suspected hydrocele of the canal of Nuck (HCN) or an appendiceal or retroperitoneal tumor. Surgery for diagnosis and removal of the mass revealed that it was large and located in the preperitoneal cavity, extending into the inguinal ring; so, it was difficult to observe the entire outline of the mass solely using the laparoscopic approach. Therefore, we added the conventional approach with an inguinal incision. This combination of conventional and laparoscopic approaches helped in safe removal of the tumor. The HCN is an unusual developmental condition in women among whom it might cause an inguinal swelling infrequently. In a case with a large HCN, a combined approach using conventional and laparoscopic methods is suggested for better observation of the abdomen and successful resection without perforation of the mass than when using a single approach.