Perineoplasty for anal incontinence after obstetric anal sphincter injury repair: a case report.

BACKGROUND: The rectal and vaginal walls are typically sutured if severe perineal lacerations with rectal mucosal damage occur during vaginal delivery. In case of anal incontinence after the repair, re-suturing of the anal sphincter muscle is standard procedure. However, this procedure may not result in sufficient improvement of function. CASE PRESENTATION: A 41-year-old woman underwent suture repair of the vaginal and rectal walls for fourth-degree perineal laceration at delivery. She was referred to our department after complaining of flatus and fecal incontinence. Her Wexner score was 15 points. Examination revealed decreased anal tonus and weak contractions on the ventral side. We diagnosed anal incontinence due to sphincter dysfunction after repair of a perineal laceration at delivery. We subsequently performed sphincter re-suturing with perineoplasty to restructure the perineal body by suturing the fascia located lateral to the perineal body and running in a ventral-dorsal direction, which filled the space between the anus and vagina and increased anal tonus. One month after surgery, the symptoms of anal incontinence disappeared (the Wexner score lowered to 0 points), and the anorectal manometry values increased compared to the preoperative values. According to recent reports on the anatomy of the female perineal region, bulbospongiosus muscle in women does not move toward the midline to attach to the perineal body, as has been previously believed. Instead, it attaches to the ipsilateral surface of the external anal sphincter. We consider the fascia lateral to the perineal body to be the fascia of the bulbospongiosus muscle. CONCLUSIONS: In a case of postpartum anal incontinence due to sphincter dysfunction after repair of severe perineal laceration, perineoplasty with re-suturing an anal sphincter muscle resulted in improvement in anal sphincter function. Compared to conventional simple suture repair of the rectal wall only, this surgical technique may improve sphincter function to a greater degree.

CD44-positive Cancer Stem-like Cells as a Potential Source of Peritoneal Metastasis After Surgery.

BACKGROUND/AIM: The role of CD44 in gastric cancer-derived peritoneal metastasis is currently unknown. It was previously shown that viable, tumorigenic cancer cells are spilled into the peritoneal cavity during surgery, providing a potential cause of peritoneal recurrence after surgery. The purpose of this study was to elucidate the mechanism of peritoneal metastasis of gastric cancer through the expression of CD44 and to propose a method for preventing peritoneal recurrence. MATERIALS AND METHODS: Gastric cancer cell line MKN-45 was sorted into CD44+ and CD44- cells and then injected intraperitoneally into NOD/ShiJic-scidJcl mice. Differences in tumor-initiating capacity between the two groups were assessed using in vivo limiting dilution assays. Tumors harvested from both groups were examined for CD44 and ALDH1A1 expression using immunohistochemistry. The effects of CD44 blockade with anti-CD44 antibody on cell invasion and peritoneal metastasis formation in vivo were assessed. RESULTS: CD44+ cells showed significantly higher efficiency in initiating peritoneal tumor than CD44- cells. Blockade of CD44 significantly reduced peritoneal dissemination of CD44+ cells in vivo, indicating that the CD44 function of intraperitoneally disseminated cancer cells helped promote the formation of peritoneal metastasis. The margin of established tumors showed clusters of cells co-expressing CD44 and ALDH1A1. Peritoneally administered CD44- cells resulted in peritoneal metastases consisting of CD44+ and CD44- cancer cells. CONCLUSION: CD44 expressing cells are a potential source of peritoneal metastasis after surgery and could be a promising target for preventing peritoneal recurrence.

Clinical impact of postoperative malnutrition after pancreaticoduodenectomy: prediction based on estimated functional remnant pancreatic volume, prognostic nutritional index, and body mass index.

BACKGROUND: The present study aimed to evaluate the association between estimated functional remnant pancreatic volume (eFRPV) and postoperative malnutrition after pancreaticoduodenectomy (PD). METHODS: The medical records of 131 patients who underwent PD and preoperative computed tomography were retrospectively reviewed. Onodera's prognostic nutritional index (PNI) was assessed 6-months after PD. Patients with PNI values of at least 45 were included in the non-malnutrition group, while those with values <45 and <40 were included in the mild and severe malnutrition groups, respectively. Associations between eFRPV and postoperative nutritional status were evaluated to identify factors predictive of severe malnutrition after PD. RESULTS: Fifty-three patients (40%) were included in the non-malnutrition group, while 38 (29%) and 40 (31%) were included in the mild and severe malnutrition groups, respectively. Overall survival was significantly shorter in the severe malnutrition group (p < 0.001). The eFRPV was significantly lower in the severe malnutrition group (p = 0.003; Jonckheere-Terpstra trend test, p < 0.001). In the multivariate analysis, eFRPV ≤55.2 mL·HU (odds ratio [OR] = 5.20; p = 0.004), preoperative PNI ≤41.9 (OR = 6.37; p = 0.010), and body mass index ≤19.1 kg/m2 (OR = 3.43; p = 0.031) were independent predictors of severe malnutrition after PD. CONCLUSION: The current results indicate that eFRPV may predict low PNI values after PD.

[A Case of Laparoscopic Abdominoperineal Resection with TpTME for Adenocarcinoma of Anal Canal with Pagetoid Spread].

A man in his 80s was referred to our hospital with the chief complaint of perianal erosion. Colonoscopy revealed a peripheral flat lesion in the anal canal. Since immunohistological examination showed positive for CK20 and negative for GCDFP15, we made a preoperative diagnosis of anal canal cancer with Pagetoid spread. It was diagnosed as cT1bN0M0, cStage Ⅰ by TNM classification, and laparoscopic abdominoperineal resection with TpTME was performed. Negative biopsy of the perianal skin was confirmed both preoperation and during the operation. The postoperative course was uneventful, and no urinary dysfunction was observed. The patient was discharged 15 days after the operation. The histopathological diagnosis was negative margin. The patient is alive without recurrence 1 year after the operation. Adenocarcinoma of anal canal with Pagetoid spread is rare, and differentiation from Paget's disease is important for determining treatment policy. By conducting a detailed examination of the extent of tumor progression and using TpTME together, it was possible to perform surgery that both secured the CRM and preserved urinary function.

Preoperative Physical Activity Level Measurement by Accelerometer for Predicting Post-Hepatectomy Complications: A Prospective Observational Study.

INTRODUCTION: Recently, accelerometers have received much attention around the world. This study examined whether the preoperative physical activity level measured by an accelerometer could be a useful predictor of post-hepatectomy complications. METHODS: Between December 2016 and December 2020, the physical activity levels of 185 patients were measured using an accelerometer 3 days before hepatectomy and from postoperative day 1 to 7. The patients without postoperative complications (n = 153) and those with postoperative complications (n = 32) were compared using either the χ2 test or Fisher's exact test for nominal variables; continuous variables were analyzed using either Student's t test or Mann-Whitney U test. Differences were considered statistically significant when the p value was <0.05. Risk factors for postoperative complications following hepatectomy were also investigated. RESULTS: The number of patients with an anatomical resection was significantly higher in patients with postoperative complications (p = 0.001). Furthermore, laparoscopic hepatectomy was performed in 65.4% of patients without postoperative complications and in 25.0% of those with postoperative complications; the difference was statistically significant (p < 0.001). The average preoperative physical activity level was 150.6 kcal/day in patients without postoperative complications and 84.5 kcal/day in those with postoperative complications (p = 0.001). Multivariate analysis identified blood loss, operative time, and preoperative physical activity level as independent risk factors for postoperative complications. DISCUSSION/CONCLUSION: Patients with lower preoperative physical activity levels are at a high risk of developing postoperative complications after hepatectomy. Hence, preoperative physical activity level measurement may be useful in predicting post-hepatectomy complications.

Clinical effect of home enteral tube feeding supplementation on nutritional status after esophagectomy with retrosternal gastric tube reconstruction.

Body weight loss and poor nutritional status are frequently observed after esophageal cancer surgery. The aim of this study was to pilot an investigation on the impact of home enteral tube feeding supplementation (HES) for up to 3 months after esophageal cancer surgery. We retrospectively reviewed consecutive 67 esophageal cancer patients who underwent esophagectomy with gastric tube reconstruction. We started HES from April 2017. The patients were divided into 2 groups. Among 67 patients, 40 patients underwent HES between April 2017 and November 2020 (HES group). Other 27 patients who underwent esophagectomy between January 2012 and March 2017 were not administered HES (C group). Thereafter, multiple factors concerning patient nutritional status at long-term follow-up were evaluated. The baseline characteristics were balanced between the two groups. There were no significant differences in nutritional status scores before esophagectomy. The percentage weight loss was less in the HES group compared with the C group both at 3 months and 1 year after surgery: 7.3% (-7.6 to 15.2), 7.7% (-4 to 13.9) in the HES group and 10.6% (-3.6 to 29.1), 10.8% (-5.8 to 20.0) in C group (P < 0.05, P < 0.05). In the patients with anastomotic stenosis, the percentage weight loss was less in the HES group compared with the C group: 7.2% (2.0-14.9) and 14.6% (6.2-29.1), P < 0.05. HES may improve early weight loss in postesophagectomy patients.

[A Case of Postoperative Anastomotic Leakage with Septic Shock after Esophageal Cancer Surgery Treated by Two Stage Operation Using Ileocolic Reconstruction].

The patient was a 60s male. He underwent esophagectomy and gastric tube reconstruction for Barrett's esophageal cancer( pT3N1M0, pStage Ⅲ). Postoperatively, anastomotic leakage and mediastinitis resulted in septic shock. On the 8th day after first surgery, he transferred to our hospital. At the time of admission, qSOFA was 3 points. We judged to be difficult to treat with conservative treatment. Emergency right thoracotomy drainage underwent with resection of the esophagogastric anastomosis and cervical esophagostomy construction. He was discharged on the 55th postoperative day with home enteral nutrition. He underwent presternal ileocolic reconstruction on the 97th day after right thoracotomy drainage. On the 19th day after reconstruction, oral intake was started. The general condition is good without recurrence, and oral intake is sufficient at 1 year after reconstruction. We report a case of anastomotic leakage with septic shock after esophageal cancer surgery successfully treated by 2 stage ileocolic reconstruction.

[Clinical Outcomes of Treatment for Esophageal Cancer Recurrence after Surgery].

Many cases with esophageal cancer recurrence have worse clinical survival. Treatment with immune checkpoint inhibitor (ICI)has been reported to result in significantly longer overall survival. We investigated the clinical outcomes in 30 patients with esophageal cancer recurrence who underwent neoadjuvant chemotherapy followed by surgery, chemotherapy, and chemoradiotherapy. Results: Of the 30 patients investigated, 25 were men. Median patient age was 70(range 52-84)years. The recurrence sites are as follows: 17 in locoregional, 5 in lung, 2 in bone, 3 in liver, and 5 in others. The overall survival in early recurrence(within 6 months after surgery)cases and multiple recurrence cases were significantly shorter than that in later recurrence(>6 months after surgery)and single recurrence(p=0.031, p<0.01). Of 30 recurrence cases, 9 cases (30%)achieved complete response(CR). Five of CR cases were treated by chemotherapy with ICI. In esophageal cancer recurrence, treatment with ICI showed good response and survival benefit. In future, the indication of ICI is evaluated for adjuvant therapy after surgery.

Adverse impact of postoperative intra-abdominal infectious complications on cancer recurrence-related survival after curative gastric cancer surgery.

BACKGROUND: This study aimed to evaluate the impact of postoperative intra-abdominal infectious complications (PICs) on survival after surgery for gastric cancer. METHODS: A total of 152 patients who underwent curative gastrectomy for gastric cancer were included. The effect of clinicopathological features and PICs on recurrence-free survival (RFS) and overall survival (OS) were investigated. RESULTS: The median age was 67 years. The pathological stage was stage I (61), II (40), and III (51). Thirty-two patients (21.1%) had PICs: 9, pancreatic fistula; 14, anastomotic leakage; and 17, intra-abdominal abscess. The five-year RFS and OS rates were significantly lower in patients with PICs than in those without PICs (63.4 vs. 85.6%; p < 0.01 and 56.4 vs. 80.3%; p < 0.01, respectively). In multivariate analysis, intraoperative blood loss was an independent prognostic factor for PICs. CONCLUSIONS: Patients with PICs had worse clinical outcomes. Reducing intraoperative bleeding may improve the prognosis of gastric cancer.

Predictors and clinical impact of postoperative diarrhea after colorectal cancer surgery: a prospective, multicenter, observational study (SHISA-1602).

PURPOSE: Postoperative diarrhea, including high-output stoma (HOS), frequently occurs after colorectal surgery; its risk factors and clinical implications on subsequent complications remain unknown. This study aimed to evaluate the risk factors and clinical implications of postoperative diarrhea after primary colorectal cancer (CRC) surgery. METHODS: This prospective observational study included patients with CRC who underwent radical surgery at six hospitals between June 2016 and December 2017. The patients were categorized into three groups (non-stoma, colostoma, and ileostoma groups). RESULTS: A total of 178 patients participated in the study. In the non-stoma group, the incidence of postoperative diarrhea was 18.4% (27/147). The incidence of HOS was 28.6% (4/14) in the ileostoma group, and 0% in the colostoma group. Multivariable analyses of the incidence of diarrhea in the non-stoma group indicated that habitual smoking and hypertension were significantly associated with postoperative diarrhea (P = 0.012 and P = 0.0274, respectively). Postoperative diarrhea was more likely to occur in patients with rectal cancer than in those with colon cancer (P = 0.0501). In the non-stoma and ileostoma groups, the probability of the occurrence of other complications with Clavien-Dindo (C-D) grades II or higher was significantly higher in patients with C-D grade I diarrhea, including HOS, than in patients without diarrhea (39.3% vs. 14.6%, P = 0.0061). CONCLUSIONS: Smoking and hypertension are the independent predictors of postoperative diarrhea after an elective CRC surgery. Rectal cancer surgery seems to be associated with postoperative diarrhea more than colon cancer surgery does. Mild postoperative diarrhea may lead to more severe complications.

Incidence of surgical site infections with triclosan-coated monofilament versus multifilament sutures in elective colorectal surgery.

PURPOSE: Surgical site infections (SSIs) are the most frequent complication of abdominal surgery. Using triclosan-coated sutures for abdominal wall closure reportedly reduces the incidence of SSIs. However, the SSI incidence has not been compared between the use of triclosan-coated multifilament and triclosan-coated monofilament sutures. We, therefore, compared the incidence of incisional SSIs between the use of triclosan-coated polyglactin 910 sutures (Vicryl Plus) and triclosan-coated polydioxanone sutures (PDS Plus). METHODS: This observational cohort study was conducted on 318 consecutive patients who underwent elective colorectal cancer surgery at the Shiga University of Medical Science Hospital from January 2015 to December 2018. Based on the suture type for abdominal wall closure, 151 patients were enrolled in the PDS Plus group, and 167 were enrolled in the Vicryl Plus group. RESULTS: The two suture groups were not significantly different in terms of risk factors for SSIs. Other postoperative complications also did not differ markedly between the two groups. In the multivariate logistic regression analysis, the presence of stoma was the only independent risk factor for incisional SSIs. CONCLUSION: The incidence of incisional SSIs was unaffected by the type of triclosan-coated sutures. The presence of stoma was an independent risk factor for incisional SSIs.

Usefulness of measuring temporal changes in physical activity levels using an accelerometer for prediction and early detection of postoperative complications after hepatectomy.

BACKGROUND: This research aimed to determine whether patterns of temporal changes in activity levels can indicate postoperative complications following hepatectomy. METHODS: Between December 2016 and December 2019, 147 patients wore an accelerometer to measure their physical activity levels after hepatectomy until postoperative day 7. Patterns of changes in activity levels were categorized as follows: upward slope type (n = 88), wherein activity levels gradually increased; bell curve type (n = 13), wherein activity levels initially increased but subsequently decreased; and flat type (n = 46), wherein there was no apparent increase in activity levels. Patient characteristics and postoperative complications were compared for each group. RESULTS: Postoperative complications occurred in 4.5% of patients in the upward slope group, in 76.9% in the bell curve group, and in 65.2% in the flat group (p < 0.001). Surgical site infections (SSI), refractory pleural effusion, and ascites were more common in the bell curve group, while pneumonia was only observed in the flat group. CONCLUSION: SSI, pleural effusion, and ascites should be considered when previously increasing activity levels decline during the postoperative period. In addition, there is a high risk of SSI and pneumonia when activity levels do not increase at all after surgery.

Long-term prognosis of patients with cancer-related genes detected in postoperative peritoneal washings obtained during curative gastrectomy.

BACKGROUND: Cancer cells in intraoperative peritoneal washings (PW) indicate increased peritoneal recurrence. Detection of CEA or CK20 genes indicates poor prognosis. We assessed long-term prognosis of patients with amplification of cancer-related genes in PW obtained intraoperatively during curative gastric cancer surgery. METHODS: PW was collected before and immediately after curative gastrectomy. CEA, CK20, TFF1, MUC2, and FABP1-mRNA were selected as marker genes for reverse transcription polymerase chain reaction. Peritoneal recurrence-free survival (PRFS) and overall survival (OS) after >7-year follow-up were examined using the Kaplan-Meier method. RESULTS: Of 138 patients who underwent gastrectomy with negative cytological findings at laparotomy, 80 patients showed negative cancer-related gene amplification in preoperative PW. Fifty-eight patients were excluded due to positive gene amplification, which suggested presence of preoperative peritoneal cancer cells. The 80 patients had mRNA amplification in PW after surgery. Amplification of multiple and single cancer-related marker genes was observed in 38 and 21 patients; 21 cases had marker-negative results. Five-year PRFS was 69.1%, 95.2%, and 100% in multi-marker-positive, single marker-positive, and marker-negative cases, respectively. Multi-marker-positive patients had significantly worse PRFS than the other groups (p < 0.05). Multivariate analysis in the Cox proportional hazards model identified multi-marker-positivity as an independent prognostic factor for PRFS (hazard ratio, 7.6; 95% confidence interval, 1.07-62.63; p = 0.046), and multi-marker-positive patients had significantly worse OS than other groups (p < 0.01). CONCLUSION: Multi-marker cancer-related gene amplification in PW is associated with worse prognosis in PRFS and OS even after a long follow-up; PRFS can be stratified by the number of genes amplified.

[Short- and Long-Term Effects of Palliative Stoma Creation on Quality of Life].

Palliative stoma creation for malignant gastrointestinal obstruction improves quality of life, and advances in chemotherapy have resulted in long-term survival after stoma creation. We reviewed early and late complications in 24 patients treated with palliative stoma creation. Results: 14 men(58%)and 10 women(42%)had a median age of 60 years. Twenty-three patients(96%)were able to eat more than a porridge diet postoperatively, and the median The ColoRectal Obstruction Scoring System(CROSS)improved from 1(0-3)to 4(2-4)(p<0.001). Postoperative complications(all Clavien-Dindo grades)were observed in 10 patients(42%), with a longer postoperative hospital stay in the complication group than in the group without complication(median 34 days: 17 days, p=0.026). When divided into long-term survivors and short- term survivors based on a median overall survival of 101 days, more stoma prolapse occurred in the long-term survivors(4 cases 33% vs 0 cases 0%, p=0.028), one of which required repair surgery. Conclusion: Long-term survivors after exploratory stoma creation are more likely to develop a stoma prolapse. Careful surgical manipulation and postoperative support system including stoma care are important.

The Comparison of Fecal Microbiota in Left-Side and Right-Side Human Colorectal Cancer.

INTRODUCTION: Microbiomes play a vital role in the development and progression of cancer. The clinical status, including prognosis, genetic mutations, and sensitivity to chemotherapy, differs depending on the location of colorectal cancer (CRC); however, the association between gut microbiota and the location of CRC is not entirely understood. This study was conducted to evaluate the differences in the gut microbiota in patients with CRC according to the location of the tumor. METHODS: Fifty-six patients who underwent surgery for CRC between August 2018 and November 2019 were included in the study. Three patients who had received neoadjuvant therapy or antibiotic treatment within 1 month before surgery were excluded. The metagenomes of microbiota in preoperative feces were assessed using the V3-V4 region of 16s rRNA amplicon sequences. RESULTS: The beta diversity of the Bray-Curtis distance was significantly higher in left-sided than in right-sided CRC. Fusobacterium predominated in left-sided CRC according to the linear discriminant analysis effect size method. Blautia, Eryspelotrichales, Holdemanella, Faecalibacterium, Subdoligranulum, and Dorea constituted the dominant intestinal flora in right-sided CRC. Pathway analysis revealed that L-lysine fermentation and cob(II)yrinate a,c-diamide biosynthesis I were predominant in left-sided CRC. DISCUSSION: This study demonstrated that fecal microbiota in left-sided CRC constitutionally and functionally differ from those in right-side CRC. These results will help to elucidate the biological differences according to tumor location and develop treatments for human CRC.

Comparison of self-expandable metallic stent placement followed by laparoscopic resection and elective laparoscopic surgery without stent placement for left-sided colon cancer.

AIM: Self-expandable metallic stent (SEMS) placement for obstructive colon cancer is widely performed as a bridge to surgery (BTS) procedure before resection. This study aimed to investigate the surgical and oncological results of laparoscopic elective surgery with or without SEMS placement to assess the efficacy of SEMS placement as a BTS. METHODS: We retrospectively analyzed consecutive patients with stage II, III, and IV left-sided colon cancer who underwent elective laparoscopic resection between 2013 and 2019. All patients were divided into two groups: with and without SEMS placement. RESULTS: The SEMS group included 24 patients, whereas the non-SEMS group included 86 patients. The serum hemoglobin and albumin levels were lower (P = .049, P = .03), and the serum leukocyte and C-reactive protein levels were higher (P < .0001, P = .022) in the SEMS group. The tumor diameter and tumor circumferential rate were higher in the SEMS group (both P < .0001). No significant differences were observed in operation time, blood loss, postoperative complications, or postoperative hospital stay. After 1:1 propensity score matching, 15 patients in the SEMS group were compared with 15 patients in the non-SEMS group. The 3-year overall survival rates of the SEMS and non-SEMS groups were 87.5% and 88.9%, respectively (P = .97). The 3-year recurrence-free survival rates of the SEMS and non-SEMS groups were 58.2% and 81.7%, respectively (P = .233). No significant difference was found in the sites of recurrence. CONCLUSION: The perioperative and long-term outcomes of SEMS placement as a BTS before laparoscopic resection could be acceptable compared with other elective laparoscopic operations without SEMS placement.

INI1-negative colorectal undifferentiated carcinoma with rhabdoid features and postoperative rapidly growing liver metastases: a case report and review of the literature.

BACKGROUND: Malignant tumors with rhabdoid features are extremely rare. They can occur in various organs, including the gastrointestinal tract, with common clinical features of high malignancy and poor prognosis. CASE PRESENTATION: A 41-year-old man visited our hospital complaining of lower abdominal pain and fever. Computed tomography (CT) revealed two wall-thickening lesions in the rectum and sigmoid colon, with the latter invading the small intestine and abdominal wall. Lymph nodes were swollen in the sigmoid mesocolon and at the roots of the inferior mesenteric artery. Colonoscopy revealed a circular type 3 lesion in the sigmoid colon and a semicircular type 2 lesion in the rectum. Biopsies of the sigmoid colon and rectum lesions revealed poorly and moderately differentiated adenocarcinoma cells, respectively. The sigmoid colon, rectum, invaded small intestine, and abdominal wall were resected; lymph node dissection was also performed. Histopathological finding of the sigmoid colon lesion revealed that the tumor cells had poor connectivity with each other, and each cell had eosinophilic cytoplasm and a polymorphic nucleus. These characteristics are termed rhabdoid features, because the morphology of these cells is similar to that of rhabdomyosarcoma tumor cells. Immunohistochemical examination showed that the tumor cells were positive for both epithelial (cytokeratin AE1/AE3) and mesenchymal cell markers (vimentin); however, they were negative for integrase interactor 1 (INI1). Therefore, the sigmoid colorectal cancer was diagnosed as an INI1-negative undifferentiated carcinoma with rhabdoid features. The patient continued to experience high fever after surgery; thus, we performed an abdominal CT scan that revealed cystic lesions in the liver 4 days after surgery. These were absent in the positron emission tomography (PET)-CT scan performed 14 days before surgery. These tumors grew rapidly, and fine needle aspiration cytology revealed that they were undifferentiated carcinomas compatible with metastatic lesions from the undifferentiated carcinoma with rhabdoid features from the sigmoid colon. Chemotherapy was administered but was not effective. The patient died 60 days after surgery. CONCLUSIONS: INI1-negative colorectal undifferentiated carcinomas with rhabdoid features are extremely rare, have high histological malignancy, and a poor prognosis. Chemotherapy is not effective. Effective systemic therapy is desired.

Attenuation around the gallbladder on plain abdominal computed tomography as a predictor of surgical difficulty in laparoscopic cholecystectomy.

PURPOSE: This study examined whether abdominal plain computed tomography (CT) can predict surgical difficulty in acute cholecystitis. METHODS: We retrospectively analyzed 84 consecutive patients who underwent laparoscopic cholecystectomy for acute cholecystitis between January 2015 and December 2018. We distinguished three degrees of surgical difficulty based on the operative time and blood loss: difficult, both ≥120 minutes and ≥ 100 mL, respectively (n = 27); moderate, either ≥120 minutes or ≥ 100 mL, respectively (n = 30); and easy, both <120 minutes and < 100 mL, respectively (n = 27). We calculated the attenuation around the gallbladder on CT before surgery and compared the values among the three groups. RESULTS: Mean age, albumin levels, C-reactive protein levels, and the CT attenuation around the gallbladder (P < .001) were significantly different between groups. The surgical difficulty was unrelated to the timing of surgery. The postoperative complications were more frequent in operations more than 72 hours after disease onset (P = .04) and with CT attenuation around the gallbladder of ≥1.4 (P = .036). CONCLUSION: High attenuation around the gallbladder on plain CT predicted a high surgical difficulty of laparoscopic cholecystectomy. We recommend measuring the CT attenuation around the gallbladder in patients with acute cholecystitis.

[A Case of Intussusception Due to Juvenile Colorectal Cancer with Suspected Lynch Syndrome].

A 20-year-old man presenting with abdominal pain and distension from 3 months ago was admitted to our hospital. Colonoscopy showed a type 1 tumor in the transverse colon. The biopsy was moderately differentiated adenocarcinoma. Abdominal enhanced CT revealed intussusception associated with the tumor. After non-invasive reduction of intussusception was performed, a full-body examination revealed no findings suggestive of distant metastases or other Lynch syndrome- related tumors. We performed laparoscopic right hemicolectomy. Lynch syndrome was suspected based on his family history, MMR protein immunohistochemistry and MSI-High, but genetic testing was rejected due to cost reasons. If young people have chronic abdominal symptoms and a family history of suspected hereditary colorectal cancer, a close examination of colon cancer should be performed.

The Elevation in Preoperative Procalcitonin Is Associated with a Poor Prognosis for Patients Undergoing Resection for Colorectal Cancer.

BACKGROUND: Procalcitonin (PCT) is a well-known marker for bacterial infection; however, the clinical significance of PCT in the long-term prognosis after colorectal cancer (CRC) surgery remains unclear. METHODS: This is a retrospective review of 277 patients that underwent CRC surgery to investigate the relationship between preoperative PCT, clinicopathological condition, cancer-specific overall survival (OS), and relapse-free survival (RFS). RESULTS: Median follow-up interval was 5.0 years in all patients. Thirty-six patients developed recurrence, and 46 patients died due to recurrences or metastases of CRC. Preoperative PCT levels were highest in Stage IV patients. The cancer-specific OS in patients with Stage IV/PCT ≤0.05 ng/mL was significantly higher than those with Stage IV/PCT >0.05 ng/mL (3 years survival; 42.3 vs. 14.3%, p = 0.0413). On multivariate analysis, gender, TNM classification, and PCT were identified as significant risk factors for cancer-specific OS in patients with Stage I-III CRC. The cancer-specific OS rate of these patients with PCT ≥0.08 ng/mL, compared with PCT <0.08 ng/mL, was significantly decreased (5 years survival; 59.1 vs. 92.7%, p < 0.0001). TNM classification was finally identified as an independent risk factor for cancer-specific RFS in these patients by multivariate analysis. CONCLUSION: High preoperative PCT values in CRC patients appeared to be associated with poor OS but not RFS following surgical treatments.