Time required for indocyanine green fluorescence emission for evaluating bowel perfusion in left-sided colon and rectal cancer surgery.

BACKGROUND: Indocyanine green fluorescence imaging (ICG-FI) has been reported to be useful in reducing the incidence of anastomotic leakage (AL) in colectomy. This study aimed to investigate the correlation between the required time for ICG fluorescence emission and AL in left-sided colon and rectal cancer surgery using the double-stapling technique (DST) anastomosis. METHODS: This retrospective study included 217 patients with colorectal cancer who underwent left-sided colon and rectal surgery using ICG-FI-based perfusion assessment at our department between November 2018 and July 2022. We recorded the time required to achieve maximum fluorescence emission after ICG systemic injection and assessed its correlation with the occurrence of AL. RESULTS: Among 217 patients, AL occurred in 21 patients (9.7%). The median time from ICG administration to maximum fluorescence emission was 32 s (range 25-58 s) in the AL group and 28 s (range 10-45 s) in the non-AL group (p < 0.001). The cut-off value for the presence of AL obtained from the ROC curve was 31 s. In 58 patients with a required time for ICG fluorescence of 31 s or longer, the following risk factors for AL were identified: low preoperative albumin [3.4 mg/dl (range 2.6-4.4) vs. 3.9 mg/dl (range 2.6-4.9), p = 0.016], absence of preoperative mechanical bowel preparation (53.8% vs. 91.1%, p = 0.005), obstructive tumor (61.5% vs. 17.8%, p = 0.004), and larger tumor diameter [65 mm (range 40-90) vs. 35 mm (range 4.0-100), p < 0.001]. CONCLUSION: The time required for ICG fluorescence emission was associated with AL.

Venetoclax plus low-dose cytarabine in patients with newly diagnosed acute myeloid leukemia ineligible for intensive chemotherapy: an expanded access study in Japan.

BACKGROUND: In a Phase 3 international clinical trial (VIALE-C), venetoclax plus low-dose cytarabine improved the response rate and overall survival versus placebo plus low-dose cytarabine in patients with newly diagnosed acute myeloid leukemia who were ineligible for intensive chemotherapy. After the enrollment period of VIALE-C ended, we conducted an expanded access study to provide preapproval access to venetoclax in combination with low-dose cytarabine in Japan. METHODS: Previously, untreated patients with acute myeloid leukemia who were ineligible for intensive chemotherapy were enrolled according to the VIALE-C criteria. Patients received venetoclax (600 mg, Days 1-28, 4-day ramp-up in Cycle 1) in 28-day cycles and low-dose cytarabine (20 mg/m2, Days 1-10). All patients took tumor lysis syndrome prophylactic agents and hydration. Safety endpoints were assessed. RESULTS: Fourteen patients were enrolled in this study. The median age was 77.5 years (range = 61-84), with 78.6% over 75 years old. The most common grade ≥ 3 treatment-emergent adverse event was neutropenia (57.1%). Febrile neutropenia was the most frequent serious adverse event (21.4%). One patient developed treatment-related acute kidney injury, leading to discontinuation of treatment. Two patients died because of cardiac failure and disease progression that were judged not related to study treatment. No patients developed tumor lysis syndrome. CONCLUSIONS: The safety outcomes were similar to those in VIALE-C without new safety signals and were well managed with standard medical care. In clinical practice, more patients with severe background disease are expected, in comparison with in VIALE-C, suggesting that it is important to carefully manage and prevent adverse events.

Early laparoscopic cholecystectomy for acute cholecystitis following the Tokyo Guidelines 2018: a prospective single-center study of 201 consecutive cases.

BACKGROUND: Early laparoscopic cholecystectomy (ELC) for acute cholecystitis (AC) poses multiple challenges. The Tokyo Guidelines 2018 (TG18) eliminated the time limit (< 72 h) and expanded the surgical indication to severe AC. This study aimed to evaluate the clinical outcomes of ELC for AC following the TG18 in a single high-volume center. METHODS: From 2019 to 2021, we managed all AC patients with a TG18 flowchart and prospectively enrolled those who underwent ELC within 7 days of symptom onset. The primary outcome was overall morbidity, with a comparison between mild (Grade I) and moderate/severe (Grade II/III) AC. RESULTS: During the study period, 201 patients underwent ELC was for Grade I (56.2%), II (40.3%), and III (3.5%) ACs. Mean age was 69 ± 15.2 years and time to surgery from symptom onset was 0 (12.9%), 1-3 (66.7%), and 4-7 days (20.4%). Mean operative time and blood loss were 118.9 ± 42.7 min and 57.8 ± 99.4 mL, respectively. The critical view of safety (CVS) was achieved in 76.1% of patients, and bailout procedures were performed in 21.4%. There were no open conversions or bile duct injuries. Major morbidities (Clavien-Dindo classification ≥ IIIa) were observed in 5.5% of cases and mortality in 0.5%. Comparing Grades II/III to Grade I, operative time was longer (112.3 vs. 127.3 min, p = 0.014), blood loss was higher (40.3 vs. 80.1 mL, p = 0.005), the CVS rate was lower (83.2 vs. 67.0%, p = 0.012), and the major morbidity rate was higher (1.8 vs. 10.2%, p = 0.012). In the subgroup analysis of Grade II/III, there were no significant differences in major morbidities (p = 0.288) between the two groups (0-3 vs. 4-7 days). CONCLUSION: ELC for AC following TG18 is feasible with low morbidity rates. However, ELC for Grade II/III ACs remains challenging, and surgeons must carefully assess intraoperative difficulties and surgical risks before proceeding.

[A Case of Delayed Anastomotic Leakage after Ileocecal Resection in a Hemodialysis Patient].

A 66-year-old man was referred to our department with the diagnosis of ascending colon cancer. He was undergoing dialysis for chronic renal failure due to diabetic nephropathy. Laparoscopic ileocecal resection was planned for the ascending colon cancer, but the procedure was converted to laparotomy owing to intraoperative bleeding. The patient was discharged from the hospital after 7 days. On the 14th postoperative day, the patient presented with purulent drainage from the wound and fever and was diagnosed to have a minor anastomotic leak. The suture of the anterior sheath was exposed in part of the wound. The patient's general condition was stable, and conservative treatment was planned. However, when he coughed, the wound separated and the intestine prolapsed, and emergency surgery was performed. Intraoperative findings showed leakage of intestinal fluid from the anastomotic border, and we diagnosed delayed suture failure. We present a rare case of delayed anastomotic leakage in a hemodialysis patient.

Laparoscopic low anterior resection for rectal cancer associated with Leriche syndrome: a case report.

A 78-year-old male presented with a positive fecal occult blood test. Rectal cancer was detected during lower gastrointestinal endoscopy, and further investigations led to a diagnosis of cT1N0M0 cStage I (UICC classification, 8th edition). Preoperative contrast-enhanced computed tomography (CT) showed that the patient also had Leriche syndrome, which is associated with reduced blood flow to the rectum that may result in ischemic anastomosis during rectal cancer surgery with anastomotic reconstruction. The inferior epigastric arteries often function as collateral pathways to the lower limbs in patients with Leriche syndrome; therefore, care is needed to avoid vascular damage during trocar insertion when performing laparoscopic surgeries. We herein described a case of safe laparoscopic low anterior resection in a rectal cancer patient with Leriche syndrome using vascular architecture images obtained by preoperative CT angiography.

[A Case of Anastomotic Recurrence 10 Years after Excision of Sigmoid Colon Cancer with Submucosal Invasion].

A 72-year-old woman underwent sigmoid colon resection plus D2 lymph node dissection in 2008, with additional resection after endoscopic mucosal resection(EMR). Histopathological examination revealed only atypical ducts in the EMR scar, with no invasion below the submucosa. No lymphatic, venous, or nerve invasions were confirmed, and oral and anal stumps and lymph node metastases were negative. She was followed up for 5 years after the surgery, and no recurrence was detected. In 2018, she visited our hospital with the chief complaint of diarrhea and constipation. Colonoscopy revealed a circumferential lesion around the anastomosis. She underwent laparoscopic low anterior resection for suspected anastomotic recurrence, which was confirmed by histopathological diagnosis. The anastomotic recurrence 10 years after surgery for SM cancer of the colon with negative lymph node metastasis and vascular factor was extremely rare. We recognized the importance of surveillance 5 years after surgery.

An inguinal hernia that arose after robot-assisted radical prostatectomy and the repair of an intraoperative external iliac vein injury: A case report.

This case involved a 63-year-old man. He underwent robot-assisted radical prostatectomy (RARP) for prostate cancer. One year after the operation, he consulted our hospital about left inguinal swelling. Under a diagnosis of a left external inguinal hernia, transabdominal preperitoneal repair (TAPP) was performed under general anesthesia. The inside of the hernia orifice had been damaged by the RARP, and the resultant fibrosis was so marked that it was difficult to dissect the preperitoneal space. Furthermore, an external iliac vein injury occurred during the operation. The bleeding was controlled, and we used laparoscopic continuous non-absorbable sutures to repair the external iliac vein injury. The number of TAPP procedures performed after radical prostatectomy has been increasing in recent years, but dissecting the preperitoneal space inside a hernia orifice is difficult. Although external iliac vein injuries are rare complications of TAPP procedures, they can be laparoscopically repaired.

Laparoscopic surgery for locally advanced T4 colon cancer: the long-term outcomes and prognostic factors.

PURPOSE: For locally advanced pathological T4 (pT4) colon cancer, the safety and feasibility of laparoscopic procedures remain controversial. Therefore, this study aimed to assess short-term and long-term outcomes and to identify the prognostic factors in laparoscopic surgery for pT4 colon cancer. METHODS: The study group included 130 patients who underwent laparoscopic radical resection for pT4 colon and rectosigmoid cancer from January 2004 through December 2012. The short-term outcomes, long-term outcomes, and prognostic factors in pT4 colon cancer were analyzed. RESULTS: The median operative time was 205 min, with a median blood loss of 10 ml. The conversion rate was 3.8%, and 13 patients (10.0%) had postoperative complications. The radial resection margin was positive in 1 patient (0.8%). The median follow-up time was 73 months. The 5-year overall survival (OS) and recurrence-free survival (RFS) were 77.2 and 63.5%, respectively. On a multivariate analysis, a male sex [hazard ratio (HR) 3.09, p < 0.001], lymph node ratio ≥ 0.06 (HR 2.35, p = 0.021), tumor diameter < 38 mm (HR 2.57, p = 0.007), and right-sided colon cancer (HR 2.11, p = 0.047) were significantly related to a poor OS. CONCLUSIONS: These results suggest that laparoscopic surgery for pT4 colon cancer is safe and feasible, and the oncological outcomes are acceptable. Based on the present findings, select patients with locally advanced colon cancer should not be excluded from laparoscopic surgery.

[Treatment Strategy for Liver Metastasis of Colorectal Cancer - Including Treatment for Oligometastasis].

The mainstay of treatment for metastatic colorectal cancer is surgery. Therefore, colorectal cancer metastasis is distinctive, compared to other cancer types in which chemotherapy is the main treatment. Initially, Japan experienced medical druglag compared with western countries. However, the use of oxaliplatin for unresectable recurrent metastatic colorectal cancer became available in Japan, as well as in western countries, in 2005. We have since shifted chemotherapeutic regimens from monotherapy to combination therapy with molecular targeted agents. The combination therapy has rapidly become a standard therapy for unresectable metastatic colorectal cancer, and prognosis has dramatically increased for patients with this condition. Herein, we describe the treatment of liver metastasis of colorectal cancer, and surgery and adjuvant or neoadjuvant therapy options for resectable cancer. Furthermore, we focus on conversion therapy for unresectable cancer.

Safety and Indications of Laparoscopic Surgery for Postoperative Small-bowel Obstruction: A Single-center Study of 121 Patients.

BACKGROUND/AIMS: The purpose of this study was to evaluate the safety and effectiveness of laparoscopic surgery for the treatment of small-bowel obstruction. MATERIALS AND METHODS: The study group comprised 121 patients who underwent laparoscopic surgery for small-bowel obstruction. RESULTS: Previous operations were open surgery in 107 patients and laparoscopic surgery in 14. On univariate analysis, 4 risk factors were related to conversion to open surgery: radiotherapy (P=0.0002), previous episode of intestinal obstruction (P=0.0064), bleeding volume of ≥50 mL (P=0.0059), and the presence or absence of previous bowel resection (P=0.0269). On multivariate analysis, only radiotherapy was an independent risk factor for conversion to open surgery (odds ratio, 5.5141; P=0.0091). CONCLUSIONS: Laparoscopic surgery can be safely performed in patients with postoperative small-bowel obstruction and is considered an effective treatment with a low rate of recurrent bowel obstruction.

Risk factors for complications after diverting ileostomy closure in patients who have undergone rectal cancer surgery.

PURPOSE: To clarify the risk factors for complications after diverting ileostomy closure in patients who have undergone rectal cancer surgery. METHODS: The study group comprised 240 patients who underwent a diverting ileostomy at the time of lower anterior resection or internal anal sphincter resection, in our department, between 2004 and 2015. Univariate and multivariate analyses of 18 variables were performed to establish which of these are risk factors for postoperative complications. RESULTS: The most common complications were intestinal obstruction and wound infection. Univariate analysis showed that an age of 72 years or older (p = 0.0028), an interval between surgery and closure of 6 months or longer (p = 0.0049), and an operation time of 145 min or longer (p = 0.0293) were significant risk factors for postoperative complications. Multivariate analysis showed that age (odds ratio, 3.4236; p = 0.0025), the interval between surgery and closure (odds ratio, 3.4780; p = 0.0039), and operation time (odds 2.5179; p = 0.0260) were independent risk factors. CONCLUSIONS: Age, interval between surgery and closure, and operation time were independent risk factors for postoperative complications after diverting ileostomy closure. Thus, temporary ileostomy closure should be performed within 6 months after surgery for rectal cancer.

Pain management using acetaminophen throughout postoperative course of laparoscopic colorectal surgery: A case-matched control study.

BACKGROUD: The main advantage of laparoscopic surgery is that it is minimally invasive because of the use of small incisions. An approach using small incisions offers many benefits including attenuation of surgical wound pain. However, the presence of postoperative pain may undermine the advantages of laparoscopic surgery as a minimally invasive technique. In addition, perioperative pain management is an important factor affecting recovery after surgery. This study investigated the usefulness of a multimodal approach to postoperative pain management with acetaminophen as a baseline analgesic after minimally invasive laparoscopic colorectal surgery. MATERIALS AND METHODS: The study included 40 patients who underwent laparoscopic colorectal surgery for colorectal cancer. 20 patients received acetaminophen as a baseline analgesic for postoperative pain management and 20 received epidural anesthesia. RESULTS: The urethral catheter could be removed earlier in the acetaminophen group (2.1 ± 0.22 days postoperatively) compared with the epidural group (4.1 ± 0.45days postoperatively). The frequencies of vertigo were significantly lower in the acetaminophen than epidural group (10.0% and 45.0%, respectively). The frequencies of the use of analgesics on an as-needed basis for postoperative pain relief as well as the variabilities in these frequencies, although not significantly different between the acetaminophen and epidural groups, were lower in the acetaminophen group than the epidural group. CONCLUSION: We herein demonstrated that postoperative pain management with acetaminophen as a baseline analgesic, and without the use of epidural anesthesia, is a safe and useful analgesic modality.

Sutureless functional end-to-end anastomosis using a linear stapler with polyglycolic acid felt for intestinal anastomoses.

BACKGROUND: Gastrointestinal anastomosis remains associated with a considerable burden of morbidity and, in some cases, mortality. Functional end-to-end anastomosis, whilst extremely efficient, is vulnerable to increased intestinal pressure in the immediate postoperative period, which may predispose to development of anastomotic leakage or bleeding. Therefore, there is a requirement for new techniques that facilitate safe and efficacious anastomotic procedures. MATERIALS AND METHODS: This study examined the clinical application of functional end-to-end anastomosis with a stapler that automatically applies a bioabsorbable polyglycolic acid sheet (Endo GIA™ Reinforced Reload with Tri-Staple™ Technology). A porcine model was used to examine functional end-to-end anastomosis with and without application of a bioabsorbable polyglycolic acid sheet. As the crotch of the anastomosis is considered the weakest point, a probe was used to test the integrity of these anastomoses. Furthermore, we performed functional end-to-end anastomosis using the Endo GIA™ Reinforced stapler in a clinical series of 20 patients undergoing gastrointestinal tract resection. In all cases, functional end-to-end anastomosis was performed without suture reinforcement. RESULTS: Small intestine anastomoses in the animal study exhibited no weakness at the crotch of the anastomosis, as tested with a probe, suggesting an increased resiliency to conventional complications of functional end-to-end anastomosis. In the clinical population, no postoperative complications were noted. No adhesive intestinal obstruction was noted. CONCLUSION: Sutureless functional end-to-end anastomosis using the Endo GIA™ Reinforced appears to be safe, efficacious, and straightforward. Reinforcement of the crotch site with a bioabsorbable polyglycolic acid sheet appears to mitigate conventional problems with crotch-site vulnerability.

Risk factors for perineal wound infection after abdominoperineal resection of advanced lower rectal cancer.

PURPOSE: Abdominoperineal resection (APR) of advanced lower rectal cancer carries a high incidence of perineal wound infection. The aim of this study was to retrospectively evaluate risk factors for perineal wound infection after APR. METHODS: The study group comprised 154 patients who underwent APR for advanced lower rectal cancer in our department from January 1990 through December 2012. The following 15 variables were studied as potential risk factors for perineal wound infection: sex, age, body-mass index, American Society of Anesthesiologists score, diabetes mellitus, preoperative albumin level, preoperative hemoglobin level, neoadjuvant chemoradiotherapy(NCRT), surgical procedure (open surgery vs. laparoscopic surgery), operation time, bleeding volume, intraoperative transfusion, tumor diameter, invasion depth, and histopathological stage. RESULTS: Among the 154 patients, 30 (19%) had perineal wound infection. Univariate analysis showed that a hemoglobin level of ≤11 g/dL (p = 0.001) and NCRT (p = 0.001) were significantly related to perineal wound infection. On multivariate analysis including the preoperative albumin level (≤3.5 g/dL) in addition to the above 2 variables, neoadjuvant chemoradiotherapy (NCRT) was the only independent risk factor for perineal wound infection. Perineal wound infection developed in 31% of patients who received NCRT, as compared with 10% of patients who did not receive NCRT. The relative risk of perineal infection in the former group was 4.092 as compared with the latter group (p = 0.0002). CONCLUSIONS: NCRT is a risk factor for perineal wound infection after APR in patients with advanced lower rectal cancer.

Secure overlap stapling using a linear stapler with bioabsorbable polyglycolic acid felt.

INTRODUCTION: Despite the availability of various anastomosis techniques, postoperative anastomotic complications such as anastomosis failure and bleeding develop in some patients. Automatic suturing devices have been widely used for gastrointestinal anastomosis. However, overly thick or thin tissue, displacement of tissue, and the creation of a staple-on-staple site may lead to incomplete staple formation. These factors are considered to be related to postoperative complications such as anastomosis failure. METHODS: The iDrive™ Ultra Powered Stapling System was used to fire the automatic suturing device. Two types of automatic suturing devices were employed: (i) the Endo GIA™ Reinforced Reload with Tri-Staple™ Technology with a cartridge with the reinforcement material Neoveil™; and (ii) the Endo GIA™ with Tri-Staple™ Technology with no reinforcement material. Stapling was performed using a two-stage crossing approach to make a staple-on-staple site. RESULTS: The rates of complete formation with the Endo GIA™ with Tri-Staple™ Technology were 95.6 ± 0.6% for stomach tissue and 95.6 ± 2.3% for colon tissue, which is thinner than stomach tissue. In contrast, the rates of complete formation with the Endo GIA™ Reinforced Reload with Tri-Staple™ Technology were 99.3 ± 1.27% for stomach tissue and 100.0 ± 0.0% for colon tissue. CONCLUSION: Our results showed that the Endo GIA™ Reinforced Reload with Tri-Staple™ Technology had higher rates of complete staple formation than the Endo GIA™ with Tri-Staple™ Technology, irrespective of tissue thickness and the presence of a staple-on-staple site.

[A Patient Who Underwent Resection of Liver Metastases after Receiving Systemic Chemotherapy for Advanced Rectal Cancer and Multiple Liver Metastases].

The patient was a 52-year-old man who had a positive fecal occult-blood test on a medical check-upi n April 2015 and was referred to our hospital in June. Detailed preoperative examinations resulted in a diagnosis of cancer of the lower rectum, multiple liver metastases, and clinical Stage IV . A biopsy showed moderately differentiated tubular adenocarcinoma. All-RAS was wild type, and the patient was asymptomatic. Unresectable advanced rectal cancer was diagnosed, and the patient was scheduled to receive systemic chemotherapy. The patient received a total of 16 courses of combination chemotherapy with 5- fluorouracil, Leucovorin, and oxaliplatin(FOLFOX)plus panitumumab, starting in October 2015. In July 2016, Colonoscopy showed scar findings at the site of the primary rectal cancer lesion. A biopsy revealed no cancer cells. It was difficult to identify the primary lesion on computed tomography, and there was no evidence of clinically significant lymphadenopathy. Positronemission tomography and computed tomography showed shrinkage of the liver metastases, with no accumulation of tracer in the primary lesion or lymph nodes. The primary lesion had a clinical complete response(CR), and the metastatic lesions had a clinical partial response(PR). In October 2016, laparoscopic partial hepatectomy was performed to treat the liver metastases. Histologic examination showed that the liver metastases were from rectal cancer. It is currently under observation.

Prospective randomized controlled study on the validity and safety of an absorbable adhesion barrier (Interceed®) made of oxidized regenerated cellulose for laparoscopic colorectal surgery.

INTRODUCTION: Clinical use of an adhesion barrier made of oxidized, regenerated cellulose, Interceed®, has been reported in the field of obstetrics and gynecology to help prevent adhesions between the peritoneum and the bowel in various types of operations. In gastrointestinal surgery, sodium hyaluronate/carboxymethylcellulose has been reported as an absorbable membrane to reduce postoperative adhesions. The present study was a prospective randomized controlled study to investigate the safety and usefulness of Interceed in laparoscopic colorectal surgery. METHODS: We analyzed 99 patients who underwent laparoscopic colorectal surgery from 2013 to 2014. The patients were randomly allocated to the group that used Interceed (Interceed group) or the group that did not (Non-Interceed group). RESULTS: Fifty cases used Interceed, and 49 cases did not. The incidence of adverse events was 12.0% in the Interceed group and 16.3% in the Non-Interceed group (P = 0.58). There were no significant differences, and no adhesive bowel obstructions were observed in the Interceed group. CONCLUSION: We have shown that using Interceed in laparoscopic colorectal surgery is valid and technically safe.

Safety and efficacy of a novel linear staple device with bioabsorbable polyglicolic acid felt in laparoscopic colorectal surgery.

INTRODUCTION: Laparoscopic surgery is widely used for the treatment of colorectal cancer, but it is often associated with postoperative anastomotic complications. Generally, gastrointestinal anastomosis for colorectal surgery is performed using mechanical anastomosis with a double stapling technique. Using the automatic suture device with bioabsorbable polyglycolic acid (PGA) felt is expected to adequately reinforce staple lines on fragile tissue, helping to prevent anastomotic complications, including leakage. METHODS: This study included 17 patients who underwent laparoscopic surgery after a diagnosis of colorectal cancer. The rectosigmoidal colon was resected toward the dentate line with a novel automatic PGA-felt suture device. RESULTS: None of the patients had any postoperative bleeding, and none developed grade III or higher postoperative complications based on the Clavien-Dindo classification. When the sigmoid colon, rectosigmoid, or rectum was anastomosed, holding the excess portion of the PGA felt, stapled with the automatic PGA-felt suture device, allowed us to adequately maneuver the part of the colon or rectum to be anastomosed. With this technique, we could easily and safely insert and remove the automatic anastomotic device. When the lower rectum was resected in a planned, two-step operation, the orientation of the PGA felt helped to determine the direction in which the automatic suture device was to be inserted in the second step. Thus, the resected rectum could easily be stapled in a straight line. CONCLUSION: The automatic PGA-felt suture device is safe and effective for colorectal resections and anastomoses.

Laparoscopic Surgery is Useful for Preventing Recurrence of Small Bowel Obstruction After Surgery for Postoperative Small Bowel Obstruction.

INTRODUCTION: Risk factors for recurrence postoperative small bowel obstruction in patients who have postoperative abdominal surgery remain unclear. MATERIALS AND METHODS: The study group comprised 123 patients who underwent surgery for ileus that developed after abdominal surgery from 1999 through 2013. There were 58 men (47%) and 65 women (53%), with a mean age of 63 years (range, 17 to 92 y). The following surgical procedures were performed: lower gastrointestinal surgery in 47 patients (39%), gynecologic surgery in 39 (32%), upper gastrointestinal surgery in 15 (12%), appendectomy in 9 (7%), cholecystectomy in 5 (4%), urologic surgery in 5 (4%), and repair of injuries caused by traffic accidents in 3 (2%). Laparoscopic surgery was performed in 75 patients (61%), and open surgery was done in 48 (39%). We examined the following 11 potential risk factors for recurrence of small bowel obstruction after surgery for ileus: sex, age, body mass index, the number of episodes of ileus, the number of previously performed operations, the presence or absence of radiotherapy, the previously used surgical technique, the current surgical technique (laparoscopic surgery, open surgery), operation time, bleeding volume, and the presence or absence of enterectomy. RESULTS: The median follow-up was 57 months (range, 7 to 185 mo). Laparoscopic surgery was switched to open surgery in 11 patients (18%). The reason for surgery for postoperative small bowel obstruction was adhesion to the midline incision in 36 patients (29%), band formation in 30 (24%), intrapelvic adhesion in 23 (19%), internal hernia in 13 (11%), small bowel adhesion in 20 (16%), and others in 1 (1%). Postoperative complications developed in 35 patients (28%): wound infection in 12 (10%), recurrence of postoperative small bowel obstruction in 12 (10%), paralytic ileus in 4 (3%), intra-abdominal abscess in 3 (2%), suture failure in 1 (1%), anastomotic bleeding in 1 (1%), enteritis in 1 (1%), and dysuria in 1 (1%). Enterectomy was performed in 42 patients (38%). On univariate analysis, 2 risk factors were significantly related to the recurrence of small bowel obstruction: open surgery (P=0.017) and bleeding volume (P=0.031). On multivariate analysis, open surgery was an independent risk factor for the recurrence of small bowel obstruction (odds ratio, 5.621; P=0.015). CONCLUSIONS: Open surgery was an independent risk factor for the recurrence of small bowel obstruction after abdominal surgery. In the future, laparoscopic surgery should be performed to prevent the recurrence of small bowel obstruction.

Case report of a laparoscopically resected rectal villous tumor associated with electrolyte depletion syndrome.

A 70-year-old woman had been aware of lower extremity weakness and anal discomfort for 3 years. A soft, elastic, palm-sized mass covered by a large amount of mucus was found protruding from the anus. Biopsy revealed a villous adenoma. On the basis of these results, a villous adenoma associated with electrolyte depletion syndrome was diagnosed. After electrolyte abnormalities were improved by fluid replacement therapy, laparoscopic abdominoperineal resection was performed. The surgically resected specimen was a circumferential villous tumor measuring 210 × 140 mm. The histopathological diagnosis was an intramucosal papillary adenocarcinoma. The patient recovered uneventfully after surgery, and the electrolyte abnormalities gradually improved. She was discharged on the 28th postoperative day. The electrolyte levels normalized about 3 months after surgery.