Impact of Preoperative Continued Aspirin Therapy on Perioperative Bleeding Complications in Patients Undergoing Gastrectomy for Malignancy.

Background The question of whether antiplatelet therapy (APT) should be discontinued prior to gastrectomy is controversial. In this study, we investigated the impact of continuing aspirin preoperatively on perioperative bleeding and thromboembolic complications in patients receiving gastrectomy for malignancy. Methods The study cohort comprised 1001 patients with malignant gastric tumors who had undergone gastrectomy between 2005 and 2021. This study excludes emergency surgery. The patients were allocated to the following three groups: those who continued aspirin monotherapy prior to surgery (cAPT group), those who stopped receiving it seven days prior to surgery (dAPT group), and those who did not take APT at any stage (non-APT group). The differences between the groups in intraoperative and postoperative complications, such as bleeding and thromboembolism, were examined. Results The non-APT group comprised 682 patients, the dAPT group had 164, and the cAPT group had 155. There were 22 bleeding events (2.2%) in the whole cohort, 11 (1.1%) of which occurred in the non-APT group, six (3.7%) in the dAPT group, and five (3.2%) in the cAPT group. The differences between the three groups were not significant in terms of bleeding complications. There were 10 (1.0%) thromboembolic events in the whole cohort, five (0.7%) of which occurred in the non-APT group, four (2.4%) in the dAPT group, and one (0.6%) in the cAPT group. The differences between the three groups were not significant in terms of thromboembolic complications. In a multivariate analysis of the whole cohort, intraoperative blood loss (≥1000 mL) (p < 0.001, odds ratio (OR) = 11.8) and multidrug APT (p < 0.001, OR = 7.8) were both independent predictors of bleeding complications. However, continuing to take aspirin before surgery was not a risk factor for bleeding complications. Conclusions In patients with malignant gastric tumors, preoperative continuation of aspirin monotherapy has no impact on either intraoperative or postoperative bleeding. Gastrectomy can be performed safely, even in patients who continue aspirin treatment.

Spray-Type Adhesion Barrier Enhances Safety and Feasibility of Robotic Repeat Liver Resection: Initial Experience and Outcomes.

Background Although various types of adhesion barriers are widely utilized in liver surgery, the safety and feasibility of their use during repeat robotic liver resection (R-RLR) are still unknown. Methods Among the 68 patients undergoing RLR with the application of the spray-type adhesion barrier at Kokura Memorial Hospital, Kitakyushu, Japan, between 2021 and 2023, 24 cases that underwent R-RLR were included in this study. The included patients were divided into two groups: those who underwent previous hepatectomy with the use of a spray-type adhesion barrier (R-RLR-B, n = 14) and those without its previous use (R-RLR-NB, n = 10). The perioperative outcomes were compared between the groups. Results There were no differences between the R-RLR-B and R-RLR-NB groups in background characteristics, difficulty scores, operative and console time, or surgical blood loss. Although no difference was found between the groups in the time required for adhesiolysis before the robotic operation, both the time required for robotic adhesiolysis (75 minutes vs. 58 minutes, p = 0.034) and total time for adhesiolysis (192 minutes vs. 141 minutes, p = 0.014) were significantly shorter in the R-RLR-B group than in the R-RLR-NB group. Otherwise, there was no conversion to open hepatectomy, no intraoperative transfusion of red blood cells, no cases of grade B or C post-hepatectomy liver failure, and no mortality in the whole cohort. Conclusions The spray-type adhesion barrier may not be associated with an increase in the incidence of postoperative complications, including bile leakage or intraperitoneal abscess. In addition, its application during the previous hepatectomy can facilitate a secure R-RLR with reduced time for adhesiolysis. Thus, the use of the spray-type adhesion barrier for R-RLR is safe, effective, and time efficient.

An Efficient Saline-Linked Cautery (SLiC) Method for Robotic Liver Parenchymal Transection Using Simultaneous Activation of Saline-Linked Cautery and Robotic Suctioning: Detailed Technical Aspects and Short-Term Outcomes.

Introduction While there are several advantages to utilizing robotics in liver surgery compared to traditional open and laparoscopic approaches, the most challenging part of robotic liver resection (RLR) remains the liver parenchymal transection. This is primarily due to the constraints of the existing robotic tools and the absence of a standard procedure. This study presents detailed technical aspects of our novel saline-linked cautery (SLiC) method for RLR and assesses the short-term outcomes for both non-anatomical and anatomical RLRs. Methods In this study, 82 cases that underwent RLR utilizing the SLiC method at our hospital from September 2021 to December 2023 were examined. A novel SLiC method is introduced in this study for robotically transecting the liver parenchyma utilizing bipolar cautery or monopolar scissors. The technique involves activating the SLiC and robotic suctioning simultaneously. The included patients were divided into two groups: patients undergoing robotic anatomical hepatectomy (n=39), and those receiving robotic non-anatomical hepatectomy (n=43). Short-term outcomes, including intraoperative and postoperative complications, were assessed in patients receiving both anatomical and non-anatomical hepatectomies. Results In the whole cohort, 74% of patients had performance status 1 or 2, and 24% were classified as Child-Pugh class B. RLR was performed without Pringle's maneuver in more than 80% of cases in patients receiving robotic non-anatomical hepatectomy, and more than 80% of patients undergoing robotic anatomical hepatectomy required only four or fewer 15-minute Pringle's maneuvers. There was no conversion to open hepatectomy, no cases of grade B or C post-hepatectomy liver failure, and no mortality in the entire cohort. Four postoperative complications with CDC IIIa or higher occurred (small bowel obstruction in two cases, intraabdominal hemorrhage in one, and bile leak in another), but no differences in the frequency of complications were found between those undergoing non-anatomical and anatomical hepatectomy (p=0.342). Conclusions The SLiC method, which involves simultaneously activating SLiC and robotic suctioning with either monopolar scissors or bipolar cautery, appears to be a secure and convenient technique for liver parenchymal transection in RLR. This innovative method permits precise access to the major Glissonean and venous structures within the liver, making RLR more standardized and easily applicable in routine patient care.

Damage Control Surgery for Duodenal Ulcer Bleeding With Massive Hematoma and Perforation Due to Over-the-Scope Clip (OTSC).

Due to the advances in endoscopic technology, surgery for duodenal ulcer (DU) bleeding has decreased, although surgery is still necessary for more complicated cases. The concept of damage control surgery (DCS) has been established in the field of trauma, and a simple surgical approach may be preferable in serious cases such as uncontrolled DU bleeding. We present a successful case of bleeding with massive hematoma and perforation of the duodenum due to an over-the-scope clip that was treated by a less invasive surgical approach with consideration of the DCS.

Surgical Strategy in Bouveret's Syndrome: Report of a Case With One-Stage Surgery.

Bouveret's syndrome is a rare condition caused by a gallstone that impacts the duodenum via a cholecystoduodenal fistula and obstructs the gastric outlet. Despite its high mortality rate, the treatment strategy for Bouveret's syndrome is debatable and frequently challenging. The main issue is whether cholecystectomy and fistula repair following stone extraction should be performed concurrently with one-stage surgery. We present a case of Bouveret's syndrome that was treated with one-stage surgery using a bailout procedure.

Preventing an 8-mm Port Site Hernia in Robot-Assisted Laparoscopic Surgery: Insights From Two Rare Cases and Future Preventive Measures.

Port-site incisional hernia (PIH) is an uncommon complication that can arise subsequent to a laparoscopic procedure, potentially leading to severe adverse effects such as intestinal obstruction. We currently present two cases of incarcerated hernia that occurred at an 8-mm trocar site after robot-assisted laparoscopic surgery (RALS). While occurrences of an 8-mm port-site incisional hernia are infrequent, it is imperative to note that most PIH cases are due to inadequate fascial closure of the port site. Therefore, surgeons must pay attention to closing the fascia of an 8-mm trocar site following RALS.

Successful Multimodal Treatment of Pancreatic Cancer With Extensive Superior Mesenteric Vein Thrombosis Utilizing Chemotherapy Combined With Direct Oral Anticoagulant.

It is well known that portal vein thrombosis (PVT) sometimes occurs in pancreatic cancer (PC). However, no effective treatment plan for PVT in PC patients has yet been proposed. We experienced a successfully treated case of borderline resectable pancreatic cancer (PC-BR) with extensive superior mesenteric vein thrombosis utilizing intensive chemotherapy combined with direct oral anticoagulant. The thrombus disappeared and the tumor shrank, enabling curative surgery, and long-term survival for more than five years has been achieved. We report this successful case that we experienced as an option for the treatment of PC-BR with PVT in the future era when multimodal treatment is important.

Successful Multidisciplinary Treatment, Including Atezolizumab Plus Bevacizumab Biological Therapy, for Multiple Hepatocellular Carcinomas Adjacent to Major Vessels: A Case Report.

Multiple hepatocellular carcinomas (HCCs) are currently being treated with multimodal therapy that includes liver resection and local therapy. Although the necessity of multimodal therapy for multiple HCCs is evident, treating them is extremely difficult due to the complex nature of multiple HCCs and the frequent occurrence of underlying liver damage. We encountered a case in which long-term tumor control was achieved through multidisciplinary treatment, including atezolizumab plus bevacizumab combination biological therapy. As in the current case, less-invasive surgical resection combined with radiofrequency ablation after a combination of biological therapy may be one of the preferred options for the treatment of initially unresectable multiple HCCs.

Two resected cases of benign adenomyoepithelioma.

BACKGROUND: Adenomyoepithelioma (AME) of the breast is an uncommon tumor characterized by the proliferation of ductal epithelial and myoepithelial cells with the heterogeneity. Although benign AME is relatively easy to differentiate from breast cancer by core needle biopsy (CNB) alone, a definitive diagnosis is often difficult. The imaging findings of AME are also variable, and there are particularly few reports about radiological features, including contrast-enhanced magnetic resonance imaging (MRI) and apparent diffusion coefficient (ADC) values in AME. CASE PRESENTATION: We present two cases of benign AME. Case 1 is a 30-year-old woman with a history of asthma. The cystic tumor shows smooth borders, and the intracystic solid component is irregular in shape and high vascularity. The pathological findings of the tumor were benign on CNB. The MRI scan showed a decreased ADC value. Case 2 is a 60-year-old woman with only a history of arrhythmia. The tumor shows a lobulated mass with cystic space and coarse calcifications. The pathological findings of the tumor were found to be benign by CNB. Dynamic MRI scan showed a fast washout pattern with a decreased ADC value. Both patients underwent excisional biopsy to confirm the diagnosis, and the pathological diagnosis was benign AME in both cases. CONCLUSIONS: The AME of the breast has little specific imaging information, so it can be difficult to diagnose based on pathological findings of biopsy specimen. In our case, the ADC values were exceptionally low, contrary to previous reports. It is essential to carefully diagnose AME, considering the discrepancies in imaging findings observed in this case.

Trans-anal Minimally Invasive Surgery Combined With a Robotic Anterior Approach for Sleeve Resection of a Huge Rectal Gastrointestinal Stromal Tumor.

Due to anatomical complexity, large rectal gastrointestinal stromal tumors (GISTs) in the pelvis at the anterior aspect often require extended abdominal surgery to obtain clear surgical margins. Here, we show our trans-anal minimally invasive surgery combined with a robotic anterior approach for a huge low rectal GIST that was widely in contact with the prostate and urethra. By performing lateral dissection first, we can identify the orientation of critical organs such as the prostate, urethra, and neurovascular bundles, facilitating anterior anorectal dissection without urethral injury. Although the combination with a transabdominal robotic approach was required because of firm inflammatory adhesion between the tumor and prostate, the preceding trans-anal dissection plane facilitated the robotic anterior dissection and contributed to achieving complete dissection with negative resection margins.

Conversion to Curative Resection and Pathological Complete Response Following Targeted Therapies With Atezolizumab and Bevacizumab for Initially Unresectable Hepatocellular Carcinoma: A Case Report.

Hepatocellular carcinoma is a malignancy with an increasing incidence worldwide and is one of the most serious cancers in adults. We encountered a case of initially unresectable massive hepatocellular carcinoma in which conversion to curative resection and pathological complete response were achieved after atezolizumab plus bevacizumab therapy. Atezolizumab plus bevacizumab combination chemotherapy may be one of the most promising options for unresectable hepatocellular carcinoma.

Management of Patients Receiving Antiplatelet Therapy During Gastroenterological Surgery: A Multicenter Prospective Cohort Study (GSATT).

OBJECTIVE: This study aimed to evaluate the effect of continuing preoperative aspirin monotherapy on surgical outcomes in patients receiving antiplatelet therapy (APT). SUMMARY BACKGROUND DATA: The effectiveness of continuing preoperative aspirin monotherapy in patients undergoing APT in preventing thromboembolic consequences is mostly unknown. METHODS: This prospective multicenter cohort study on the Safety and Feasibility of Gastroenterological Surgery in Patients Undergoing Antithrombotic Therapy (GSATT study) conducted at 14 clinical centers enrolled and screened patients between October 2019 and December 2021. The participants (n=1,170) were assigned to the continued APT group, discontinued APT group, or non-APT group, and the surgical outcomes of each group were compared. Propensity score matching was performed between the continued and discontinued APT groups to investigate the effect of continuing preoperative aspirin therapy on thromboembolic complications. RESULTS: The rate of thromboembolic complications in the continued APT group was substantially lower than that in the non-APT or discontinued APT groups (0.5% vs. 2.6% vs. 2.9%; P=0.027). Multivariate investigation of the entire cohort revealed that discontinuation of APT (P<0.001) and chronic anticoagulant use (P<0.001) were independent risk factors for postoperative thromboembolism. The post-matching evaluation demonstrated that the rates of thromboembolic complications were significantly different between the continued and discontinued APT groups (0.6% vs. 3.3%; P=0.012). CONCLUSIONS: APT discontinuation following elective gastroenterological surgery increases the risk of thromboembolic consequences, whereas continuing preoperative aspirin greatly reduces this risk. The continuation of preoperative aspirin therapy in APT-received patients is considered one of the best alternatives for preventing thromboembolism during elective gastroenterological surgery.

Laparoscopic Liver Resection Utilizing a Water Jet Scalpel for Patients With Liver Fibrosis.

Introduction A variety of devices are utilized in order to resect liver parenchyma in laparoscopic liver resection. However, liver fibrosis makes hepatectomy problematic because the liver is rigid and prone to bleeding. The water jet scalpel, which dissociates the liver parenchyma with a jet stream has no thermal damage and is clinically utilized in liver resection, but its safety and efficacy during laparoscopic liver resection for patients with liver fibrosis remain unknown. Methods We analyzed patients who underwent laparoscopic liver resection utilizing the water jet scalpel with liver fibrosis at our hospital. A water jet scalpel was used for liver parenchymal transection, and a saline-linked ball-tipped electrocautery was simultaneously used for hemostasis. Results Subsectionectomy was one case, left lateral sectionectomy was two cases, and non-anatomical liver resection was three cases. The median blood loss was 70 mL (24-104 mL). There was no need for the intraoperative Pringle's maneuver. No perioperative blood transfusion was performed, and there were no postoperative complications, including posthepatectomy liver failure. Conclusion It was suggested that laparoscopic liver resection in patients with liver fibrosis can be safely performed with the water jet scalpel.

Intrahepatic Glissonean Approach for Robotic Anatomical Liver Resection of Segment 7 Using the Saline-Linked Monopolar Cautery Scissors (SLiC-Scissors) Method: A Technical Case Report With Videos.

Anatomical hepatectomy of segment 7 (S7) is technically difficult due to its difficult accessibility. Here, we present our experience of robotic anatomical S7 subsectionectomy of the liver employing the saline-linked cautery scissors (SLiC-Scissors) technique. After the right lobe was fully mobilized, dissection of the Glissonean pedicle and hepatic venous branch of S7, as well as the liver parenchymal transection, were safely performed using the SLiC-Scissors method. Despite its technological complexity, the intrahepatic Glissonean approach for robotic anatomical S7 subsectionectomy of the liver employing the SLiC scissors method is safe and efficient.

Non-Stick Liver Parenchymal Transection With Saline-Linked Bipolar Clamp-Crush Technique in Robotic Liver Resection.

Background Without satisfactory instruments, liver parenchymal transection during robotic liver resection (RLR) remains challenging. We combined the commonly used bipolar clamp-crush technique with the saline drip, achieving a comfortable liver resection without coagulated liver tissues sticking to the bipolar forceps. Methods Between December 2022 and March 2023, six RLRs were performed using the saline-linked bipolar clamp-crush method for both anatomical and non-anatomical liver resections. We assessed the safety and feasibility of our robotic liver parenchymal transection technique. Results Three of six patients were diagnosed with colorectal liver metastasis, two with hepatocellular carcinoma (HCC), and the other with intrahepatic bile duct stricture. Three of the six patients received anatomical liver resection, and the other three underwent non-anatomical liver resection. There were no conversions to open surgery. The median operative time and estimated blood loss were 406.5 minutes (196-670 minutes) and 5 ml (5-465 ml), respectively. The median length of the postoperative hospital stay was nine days (7-10 days). Postoperative complications (Clavien-Dindo classification grade II or more) or mortality were not encountered in this cohort. Conclusion We presented here our saline-linked bipolar clamp-crush method for liver parenchymal transection in RLR. By simply adding the saline drip to the commonly used bipolar clamp-crush technique, non-stick and comfortable liver parenchymal transection is now possible. This technique may help overcome the limitations of currently available robotic instruments for liver parenchymal resection.

Thoracoscopic and laparoscopic approach for pleuroperitoneal communication under peritoneal dialysis: a report of four cases.

BACKGROUND: Pleuroperitoneal communication (PPC) is a rare complication of continuous ambulatory peritoneal dialysis (CAPD) and often forces patients to switch to hemodialysis. Some efficiencies of video-assisted thoracic surgery (VATS) for PPC have been reported recently; however, there is no standard approach for these complications. In this case series, we present a combined thoracoscopic and laparoscopic approach for PPC in four patients to better assess its feasibility and efficiency. CASE PRESENTATION: Clinical characteristics, perioperative findings, surgical procedures, and clinical outcomes were retrospectively analyzed. We combined VATS with a laparoscopic approach to detect and repair the diaphragmatic lesions responsible for PPC. We first performed pneumoperitoneum in all patients following thoracoscopic exploration. In two cases, we found bubbles gushing out of a small pore in the central tendon of the diaphragm. The lesions were closed with 4-0 non-absorbable monofilament sutures, covered with a sheet of absorbable polyglycolic acid (PGA) felt, and sprayed with fibrin glue. In the other two cases without bubbles, a laparoscope was inserted, and we observed the diaphragm from the abdominal side. In one of the two cases, two pores were detected on the abdominal side. The lesions were closed using sutures and reinforced using the same procedure. In one case, we failed to detect a pore using VATS combined with the laparoscopic approach. Therefore, we covered the diaphragm with only a sheet of PGA felt and fibrin glue. There was no recurrence of PPC, and CAPD was resumed at an average of 11.3 days. CONCLUSIONS: The combined thoracoscopic and laparoscopic approach is an effective treatment for detecting and repairing the lesions responsible for PPC.

Long-Term Oncological Control by Repeated Minimally Invasive Hepatectomy for Intrahepatic Cholangiocarcinoma Exhibiting Atypical Marker Expression of CK7-CK20+: A Case Report.

There are few reports of repeated liver resections being performed multiple times for intrahepatic recurrence of intrahepatic cholangiocarcinoma (ICC). We performed five minimally invasive liver resections and two minimally invasive lung resections for ICC with metachronous intrahepatic recurrence and lung metastases. Pathological examination revealed that all resected tumors were moderately differentiated mass-forming ICC with immunohistochemical marker expression of CK7 negative and CK20 positive. We present this as a rare case of ICC with atypical marker expression in which long-term tumor control was achieved with multiple minimally invasive liver resections over 47 months from the initial diagnosis.

Safety and Feasibility of Gastrectomy in Super Elderly Patients (Aged ≥ 80): A Propensity Score-Matched Analysis.

INTRODUCTION: The benefits of gastrectomy in elderly patients with gastric cancer (GC) remain unknown. This study was conducted to evaluate the short- and long-term outcomes of elderly patients with GC (≥ 80 years) who underwent gastrectomy. METHODS: We enrolled 479 patients (Stages I-IV) who underwent gastrectomy with R0-1 resection. The patients were divided into an elderly group (E group; age ≥ 80 years) (n = 115) and a non-elderly group (NE group; age < 80 years) (n = 364). After propensity score matching (PSM) was performed, the short- and long-term outcomes were compared between the groups. RESULTS: The rate of postoperative complications (Clavien-Dindo classification ≥ IIIa) in the two groups did not differ significantly (p = 0.657). Before PSM, the five-year overall survival (OS, 35.3% vs. 71.7%, p < 0.001) and disease-specific survival (DSS, 56.8% vs. 81.8%, p < 0.001) in the E group were significantly shorter than that in the NE group, respectively. On the other hand, significant differences between the E and NE groups were not shown in either the five-year OS (35.5% vs. 50.8%, p = 0.0985) or the five-year DSS (56.5% vs. 66.9%, p = 0.274) after PSM. CONCLUSION: Gastrectomy for elderly patients with GC can be considered safe based on short-term outcomes. In terms of long-term results, elderly patients are not inferior to non-elderly patients if the patients' backgrounds are the same. On the other hand, the long-term outcomes of elderly GC patients who have various comorbidities are not satisfactory, so we should carefully consider the indications for gastrectomy.

Intraoperative Indocyanine Green Imaging for the Evaluation of Blood Perfusion Area in Cancer of the Splenic Flexure With an Occluded Inferior Mesenteric Artery: A Report of Two Cases.

Radical resection for cancer of the splenic flexure requires careful consideration of the dissection line so that blood flow in the remnant bowel is maintained, particularly when the root of the inferior mesenteric artery (IMA) is already occluded. Intraoperative indocyanine green (ICG) imaging is a promising method for evaluating blood perfusion of organs and vessels. However, there are few reports on the use of ICG to determine the dissection line in patients with altered blood flow. In this article, we describe two cases of successful resection of splenic flexure cancer (SFC) in patients with an occluded IMA under ICG guidance. Case one was a 76-year-old man with a diagnosis of stage III SFC who had previously undergone endovascular aortic repair without reimplantation of the IMA. Intraoperative ICG imaging revealed that the left side of the colon was perfused mainly by the left branch of the middle colic artery (MCA). We performed a hemicolectomy with preservation of the MCA-left colic artery (LCA) arcade and resected an enlarged lymph node en bloc. Case two was a 77-year-old man with a diagnosis of stage II SFC in whom the root of the IMA appeared to be occluded by arteriosclerosis. Computed tomography showed that the LCA was anastomosed to the accessory middle colic artery (AMCA) while the left branch of the MCA was joined to the marginal artery. Intraoperative ICG imaging revealed that the left side of the colon was perfused by the AMCA and not the MCA. By preserving the AMCA-LCA arcade, we were able to safely divide the left branch of the MCA. Both patients were discharged with no symptoms of bowel ischemia or recurrence of cancer during follow-up. Interindividual variation in vessel branching patterns and dominant vessels in the descending and distal transverse colon may result from congenital factors or acquired disease. Detailed information on blood perfusion is required to avoid postoperative bowel ischemia. This report is the first to focus on patients with SFC and altered blood flow. We show that ICG imaging might be a reasonable option for determining an adequate surgical dissection area.

Novel Liver Parenchymal Transection Technique Using Saline-linked Monopolar Cautery Scissors (SLiC-Scissors) in Robotic Liver Resection.

Introduction Although there are a number of benefits to using robotics in liver surgery over conventional open and laparoscopic approaches, liver parenchymal transection is still the most difficult aspect of robotic liver resection (RLR) due to the limitations of the currently available robotic instruments and the lack of a standardized method. Methods We present a novel method for transecting the liver parenchyma during RLR employing saline-linked monopolar cautery (SLiC) scissors (SLiC-Scissors method). Between September 2021 and April 2022, 10 RLRs were performed utilizing the SLiC-Scissors method for both anatomical and non-anatomical liver resections. We assessed the short-term results, as well as the safety and practicality of our robotic liver parenchymal transection technique. Results Six of the 10 patients had malignant liver tumors, and four of them had liver metastases from colorectal cancer. Except for S1, the target lesions were present everywhere, and their median size was 25 mm (14-43 mm). The median amount of intraoperative bleeding was 5 mL (5-30 mL), and the median operative and console times were 223 and 134 min, respectively. There were no conversions to open liver resections. The median length of the postoperative stay was seven (4-13) days, and there were no serious postoperative complications or mortality. Conclusions The SLiC-Scissors method is a safe and practical procedure for liver parenchymal transection in RLR. In order to standardize and broadly implement RLR into normal patient treatment, this unique approach enables an advanced, locally controlled preparation of intrahepatic vessels and bile ducts.