Age is the Most Significantly Associated Risk Factor With the Development of Delirium in Patients Hospitalized for More Than Five Days in Surgical Wards: Retrospective Cohort Study.

OBJECTIVE: The primary purpose of this study was to assess risk factors for delirium in patients staying in a surgical ward for more than 5 days. The secondary purpose was to assess outcomes in patients with delirium. BACKGROUND: Delirium is a syndrome characterized by acute fluctuations in mental status. Patients with delirium are at increased risk of adverse inpatient events, higher mortality and morbidity rates, prolonged hospital stays, and increased health care costs. METHODS: Participants in this study were 2168 patients who had been admitted to the surgical ward of St. Luke's International Hospital for 5 days or more between January 2011 and December 2014. Data on these patients were collected retrospectively from hospital medical records. Firstly, univariate and multivariate analyses were conducted to identify risk factors for delirium. Secondly, morbidity and mortality associated with delirium were analyzed. RESULTS: Delirium occurred in 205 of 2168 patients (9.5%). Age, physical restraint, past history of a cerebrovascular disorder, malignancy, intensive care unit stay, pain, and high blood urea nitrogen value were significant risk factors for delirium in the multivariate analysis. Among these, age was the strongest factor, with an odds ratio for delirium of 12.953 in patients 75 years of age or older. The length of hospital stays and the mortality rates were higher in patients with delirium. CONCLUSIONS: Results showed that age, and also physical restraint, past history of cerebrovascular disorder, malignancy, intensive care unit stay, pain, and high serum blood urea nitrogen were important factors associated with delirium in patients hospitalized for more than 5 days in a surgical ward.

[Long-term survival of a patient with giant liver metastatic breast cancer treated with trastuzumab].

We report the long-term survival of a patient with metastatic breast cancer treated with trastuzumab and chemoendocrine therapy. The patient was a 60-year-old female. She underwent right mastectomy with axillary lymphadenectomy I c for advanced right breast cancer in 1999. In 2007, she consulted our hospital for treatment of recurrent giant liver metastasis. A giant liver metastasis up to 15 cm in diameter was detected by CT upon arrival. After 4 years of trastuzumab and chemoendocrine therapy, she was diagnosed as in progressive remission with good quality of life. Breast cancer with liver metastasis often can be life-threatening. Therefore, an optimal chemotherapy should be applied as soon as possible. Trastuzumab and chemoendocrine therapy showed efficacy for the treatment of a HER2-positive breast cancer with recurrent giant liver metastasis.

Indocyanine green fluorescence-guided laparoscopic removal of infected mesh with chronic sinus formation after inguinal mesh plug repair.

Chronic mesh infection with sinus formation is usually amenable to open method with dye. Recently, intraoperative real-time fluorescent imaging has been applied to various organs but not to mesh infection. A 72-year-old man with the history of two times removal of infected mesh was referred for groin bulge with purulent discharge. Laparoscopy assisted infected mesh removal was undertaken using intraoperative real-time fluorescent imaging with indocyanine green injection via the sinus orifice. We experienced the first case of the infected mesh with chronic sinus formation treated by the help of intraoperative indocyanine green fluorescent. This method is simple and easy to apply for laparoscopic assisted removal of chronic mesh infection with sinus.

A rare complication of the duodenal diverticulum.

Introduction: An 80-year-old woman presented to the emergency department with severe right-sided abdominal pain that had started after her last meal. Physical examination revealed fever (38.6°C) and rebound tenderness in the right upper quadrant of the abdomen. The laboratory studies showed a leucocyte count of 11.3×109/L (normal, 3.7-8.0×109/L) and a C-reactive protein level of 2.34 mg/dL (normal, <0.03 mg/dL). There were no other significant findings. A CT scan of the abdomen with contrast revealed retroperitoneal air around a duodenal diverticulum (figures 1 and 2).Figure 1Computed tomography scan of the abdomen with contrast (coronal section). A diverticulum in the second portion of the duodenum (arrow) and retroperitoneal air (asterisk) are shown.Figure 2Computed tomography scan of the abdomen with contrast (axial section). The area with retroperitoneal air (asterisk) is marked. QUESTION: What is the most likely diagnosis and the cause underlying the condition?

Fruitful first experience with an 8K ultra-high-definition endoscope for laparoscopic colorectal surgery.

We performed laparoscopic surgery for three cases of colorectal cancer using an 8K ultra-high-definition endoscopic system, which offers 16-fold higher resolution than the current 2K high-definition endoscope. The weight of the camera has been successfully reduced to 370 g. To maximize the advantages of the 8K ultra-high-definition endoscope, surgery was performed by darkening the room and placing a large 85-in. display as close to the surgeon as possible. As a result, the autonomic nerve was preserved, and the membrane structure could be clearly observed. Moreover, we were able to feel the stereoscopic effect near the 3-D image. This suggests the possibility of improved curability and function preservation with the 8K endoscope. Although there are some disadvantages that need to be overcome, the 8K ultra-high-definition endoscope will surely contribute to further progress in laparoscopic surgery.

Accuracy of Multidetector-Row Computed Tomography in the Preoperative Diagnosis of Lymph Node Metastasis in Patients with Gastric Cancer.

BACKGROUND/AIMS: Preoperative lymph node staging in gastric cancer patients is important. The aim of this study was to assess the diagnostic accuracy of computed tomography (CT) in assessing lymph nodes in patients with gastric cancer. METHODS: A total of 56 patients had undergone standardized gastric resection with lymphadenectomy between October 2013 and June 2015 were reviewed retrospectively. The short axis diameter of the largest lymph node per station was recorded when reviewing the preoperative CT images. Diagnostic accuracy was calculated by comparing CT with histopathological findings. RESULTS: In 518 stations dissected at surgery, 56 included lymph nodes with metastasis. Among them, lymph nodes were visualized on preoperative CT in 26 stations. No lymph node was detected in 382 stations among 462 infiltration-negative stations. The cutoff of 12 mm had the highest accuracy rate of 0.896. CONCLUSION: The accuracy of CT in the preoperative diagnosis of lymph node metastasis in patients with gastric cancer remains poor. Therefore, surgeons should pay attention to the visibility of lymph nodes on CT. Detection of lymph nodes on CT can be utilized for a more accurate diagnosis such as fine-needle aspiration biopsy.

Modified esophagogastrostomy in laparoscopy-assisted proximal gastrectomy: A reverse-Tornado anastomosis.

INTRODUCTION: The aim of this study was to introduce and examine a modified mechanical end-to-side esophagogastrostomy method ("reverse-Tornado" anastomosis) in laparoscopy-assisted proximal gastrectomy. METHODS: Five patients with gastric cancer who underwent laparoscopy-assisted proximal gastrectomy were analyzed retrospectively. Esophagogastrostomy in the anterior wall was performed in three patients, and esophagogastrostomy in the posterior wall was performed in two patients. Clinicopathological features, operative outcomes (operative time, operative blood loss), and postoperative outcomes (complications, postoperative hospital stay, reflux esophagitis) were evaluated. RESULTS: Operative time was normal (278 min). There was no marked operative blood loss, postoperative complications, prolonged hospital stay, or reflux esophagitis. CONCLUSION: Esophagogastrostomy was completed in a normal time with reverse-Tornado anastomosis. This method can be safe and can enable good postoperative quality of life.

Laparoscopic reduction and repair of a strangulated interparietal inguinal hernia.

An interparietal hernia is defined as a hernia in which the hernial sac lies between the tissue layers comprising the abdominal wall. A strangulated interparietal inguinal hernia without an external bulge is a rare cause of an acute abdomen and difficult to diagnose preoperatively. We report a patient with a history of a right inguinal hernia who presented with abdominal pain without inguinal bulging. An interparietal (preperitoneal) inguinal hernia was diagnosed and treated by laparoscopic reduction and a transabdominal preperitoneal hernia repair. This is the first case report of an interparietal inguinal hernia managed entirely laparoscopically. Although the laparoscopic approach is not considered standard treatment for strangulated intestinal obstruction, it may be worth considering, especially for patients with uncertain etiology, because of its decreased invasiveness compared to open exploration.

Case of intra-abdominal spindle cell tumor after laparoscopic resection of sigmoid colon cancer.

We herein report a rare case of a patient who developed a spindle cell tumor at the inferior mesenteric artery clipping site. A 58-year-old man underwent laparoscopy-assisted sigmoid colectomy for sigmoid colon cancer. As follow-up, CT scans were performed every 6 months after the primary surgery. At the 1-year CT, an nodular soft tissue density mass measuring 54 mm in diameter was found in the mesentery. Although we initially suspected locoregional recurrence of the colon cancer resected 1 year earlier, PET-CT showed that the tumor was unrelated to the previous cancer. During the subsequent laparotomy, the mass appeared to originate from the inferior mesenteric artery clipping site, and it adhered to the jejunum and the left ureter. We completely resected the tumor and part of the jejunum, which we separated from the abdominal aorta and left ureter. The tumor was histologically diagnosed of a spindle cell tumor. The patient has been free from recurrence since the surgery more than 4.5 years ago. Preoperative PET-CT was helpful in ruling out local recurrence of colon cancer, which might have made palliative care a better option than surgical resection.

Early removal of drains and the incidence of seroma after breast surgery.

BACKGROUND: Women undergoing surgery for primary breast cancer routinely have suction drains inserted deep to the wounds. A lack of data exists in relating how long suction drains should stay in situ after major breast surgery. PURPOSE: This study evaluates the appropriate timing of drain removal by comparing the 5-day-long postoperative drainage or drain removal when less than 50 mL/24 h to conventional drain removal. METHODS: This controlled clinical trial was undertaken between February 1997 and May 2012 with a total of 214 consecutive patients who underwent elective total or partial mastectomy with level II axillary lymph node dissection. The main outcome measures included the length of hospital stay, and surgical morbidity, especially seroma formation. RESULTS: In the study group, the age and operation time were significantly increased compared to the conventional group whereas the median hospital stay was significantly shorter in the study group than the control group (7 days vs. 9 days; p < 0.05). The incidence of seroma was 42.8 % in the study group and 31.6 % in the control group (p = 0.14). The mean number of outpatient visits for seroma was 3.6 in the study group and 1.5 in the control group (p < 0.05). Drainage volume of more than 150 mL/24 h all resulted in seroma formation. CONCLUSIONS: The new criteria for early drain removal are safe and acceptable despite the slightly increased chance of seroma formation.

Reduction of the Incidence of Delayed Gastric Emptying in Side-to-Side Gastrojejunostomy in Subtotal Stomach-Preserving Pancreaticoduodenectomy.

BACKGROUND: One of the most common morbidities of pancreaticoduodenectomies is delayed gastric emptying (DGE). The recent advent of subtotal stomach-preserving pancreaticoduodenectomy (SSPPD) attempts to lessen this troublesome complication; however, the incidence of DGE still remains to be 4.5-20%. This study aims to evaluate whether the incidence of DGE can be reduced by the side-to-side gastric greater curvature-to-jejunal anastomosis in comparison with the gastric stump-to-jejunal end-to-side anastomosis in SSPPD. METHODS: Between October 2007 and September 2012, a total of 160 consecutive patients who had undergone SSPPD were analyzed retrospectively. In the first period (October 2007-March 2010), gastrojejunostomy was performed with end-to-side anastomosis in 80 patients (SSPPD-ETS group). In the second period (April 2010-September 2012), gastrojejunostomy was performed with the greater curvature side-to-jejunal side anastomosis in 80 patients (SSPPD-STS group). The postoperative data were collected prospectively in a database and reviewed retrospectively. RESULTS: The incidence of DGE was 21.3% in the SSPPD-ETS group and 2.5% in the SSPPD-STS group (P = 0.0002). According to the classification of the International Study Group of Pancreatic Surgery (ISGPS), the incidence of DGE of grades A, B, and C were 5, 5, and 7 in the SSPPD-ETS group and 0, 2, and 0 in the SSPPD-STS group, respectively. The overall morbidity and postoperative hospital stay of the two groups were not significantly different. CONCLUSIONS: The greater curvature side-to-side anastomosis of gastrojejunostomy is associated with a reduced incidence of DGE after SSPPD.

Triclosan-coated abdominal closure sutures reduce the incidence of surgical site infections after pancreaticoduodenectomy.

BACKGROUND: Surgical site infection (SSI) is a serious complication after pancreaticoduodenectomy (PD). To prevent microbial colonization of suture material in operative wounds, triclosan-coated polyglactin sutures with antibacterial activity have been developed recently. Several clinical studies have shown that the use of such suture reduces SSIs in various operations, but its efficacy in PD has not been studied. We evaluated whether the incidence of SSI can be reduced when triclosan-coated sutures are used for abdominal incision closure after PD. METHODS: This controlled clinical trial took place between December 2005 and February 2012 with a total of 198 consecutive patients who had undergone PD. The study group received triclosan-coated polyglactin 910 antimicrobial sutures between March 2009 and February 2012, and the control group received conventional wound closure between January 2005 and February 2009. We compared the rate and types of infections in the two groups. RESULTS: In the study group, age, the incidence of diabetes mellitus, smoking history, and operating time were significantly greater than in the control group. The rates of SSI were 4.5% in the study group and 14.5% in the control group (p=0.037). CONCLUSIONS: The use of triclosan-coated sutures may help reduce the incidence of SSI after PD compared with conventional non-antibiotic sutures.

Triclosan-coated sutures reduce the incidence of wound infections and the costs after colorectal surgery: a randomized controlled trial.

BACKGROUND: In colorectal surgeries, surgical site infections (SSIs) frequently cause morbidity; an incidence of up to 20% has been shown in previous studies. Recently, to prevent microbial colonization of suture material in operative wounds, triclosan-coated polyglactin suture materials with antimicrobial activity have been developed; however, their significance in colorectal surgery remains unclear. This randomized controlled trial was conducted to assess the value of triclosan-coated polyglactin sutures in colorectal surgery. METHODS: A total of 410 consecutive patients who had undergone elective colorectal operations were enrolled in this trial. Of those patients, the 206 in the study group underwent wound closure with triclosan-coated polyglactin 910 antimicrobial sutures, and the 204 patients in the control group received conventional wound closures with polyglactin 910 sutures. RESULTS: The study group and the control group were comparable regarding risk factors for SSIs. The incidence of wound infection in the study group was 9 of 206 patients (4.3%), and that in the control group was 19 of 204 patients (9.3%). The difference is statistically significant in the 2 groups (P = .047). The median additional cost of wound infection management was $2,310. The actual entire additional cost, therefore, of 9 patients in the study group was $18,370, and that of 19 patients in the control group was $60,814. CONCLUSION: Triclosan-coated sutures can reduce the incidence of wound infections and the costs in colorectal surgery.

Lesser curvature approach in laparoscopic distal pancreatectomy.

Laparoscopic distal pancreatectomy (LDP) has entailed ventrally retracting the stomach to afford adequate visualization. The retracted stomach commonly droops over the pancreas and obstructs the surgical field, thus forcing the assistant surgeon to repeatedly lift the stomach out of the way ventrally and cranially. We herein reported LDP using the "lesser curvature approach" in which the pancreas was approached cephalad to the lesser curvature of the stomach in underweight patients with a coincidental low hanging stomach. An excellent view of both the distal pancreas and the spleen could be afforded, enabling complete mobilization of these organs from the retroperitoneum and easy ligation of the splenic vessels, without needing to retract the stomach ventrally and cranially. The lesser curvature approach in LDP could be performed safely and efficiently as an alternative to the conventional greater curvature approach in underweight patients with a low hanging stomach.

Clinically relevant pancreas-related infectious complication after pancreaticoenteral anastomosis could be predicted by the parameters obtained on postoperative day 3.

OBJECTIVES: Pancreatic fistula or pancreas-related infectious complications are one of the most common surgical complications after pancreatic surgery. The aims of this study were, first, to reveal the risk factors for clinically relevant pancreas-related infectious complications and, second, to identify those risk factors that are obtainable within the first 3 postoperative days. METHODS: One hundred seven consecutive patients who underwent pancreaticoenteral anastomosis between October 2007 and November 2010 were enrolled. RESULTS: There were 36 patients with clinical pancreas-related infectious complications among 107 in this series of patients. Univariate and multivariate analyses revealed that a narrow main pancreatic duct diameter (<3 mm) was an independent risk factor for clinically relevant pancreas-related infectious complication. Univariate and multivariate analyses also revealed that a body temperature of 38°C or higher on postoperative day 3 (POD3), a leukocyte count of 9.8 × 10(9)/L or greater on POD3, and a drain fluid amylase level of 3000 IU/L or higher on POD3 were significant predictive factors for clinically relevant pancreas-related infectious complication for 58 patients with a narrow main pancreatic duct. CONCLUSIONS: In view of the clinical variables obtained on POD3, such as amylase levels in drain effluent, body temperature, and leukocyte count, clinically relevant pancreas-related infections could be predicted well.

ENBD tube placement prior to laparoscopic cholecystectomy may reduce the rate of complications in cases with predictably complicating biliary anomalies.

BACKGROUND: The risk factors predisposing to bile duct injury or postoperative bile leakage associated with laparoscopic cholecystectomy (LC) include the presence of an accessory hepatic duct, the anomalous cystic duct confluence, and duct of Luschka. One method to prevent bile duct injury is preoperative placement of an endoscopic nasobiliary drainage tube (ENBD assisted LC). The aims of this investigation are first, to report the incidence of bile duct anomalies according to the classification system proposed by Wakayama Medical University and second, to evaluate the efficacy of ENBD assisted LC with regard to prevention of intraoperative bile duct injury and postoperative bile duct injury or leakage. METHODS: A total of 1,835 consecutive LCs performed at our institution during a recent 10-year period were reviewed. RESULTS: Anomalous cystic duct confluence was detected in 11 cases and an accessory hepatic duct was detected in 37 cases. These anomalies were risk factors for bile duct injury in our series. However, there was no significant difference in the length of surgery, conversion rate to laparotomy, or frequency of bile duct injury or leakage between the standard LC group and ENBD assisted LC group. CONCLUSION: A bile duct anomaly was seen in 2.6% of LC cases. Placement of an ENBD tube prior to LC in predictably complicating bile duct anomalies may have successfully decreased the incidence of complications.