Lower risk of postoperative delirium using laparoscopic approach for major abdominal surgery.

BACKGROUND: A laparoscopic approach is increasingly being used for major abdominal surgeries and is reportedly associated with a lower incidence of postoperative complications. However, the association of laparoscopic approach and postoperative delirium remains unclear. We aimed to retrospectively investigate risk factors for postoperative delirium after abdominal surgery particularly assessing the association between a laparoscopic approach and postoperative delirium. METHODS: We retrospectively studied 801 patients who underwent major abdominal surgery between April 2012 and December 2013. Among these, 181 (22.6%) patients underwent a laparoscopic and 620 (77.4%) patients underwent an open procedure. A Cox proportional hazard model analysis was used to identify risk factors for the development of postoperative delirium or overall survival within 180 days after surgery. Cumulative incidence of postoperative delirium was assessed using a propensity score-matching analysis. RESULTS: Postoperative delirium occurred in 56 patients (7.0%). A Multivariate Cox proportional hazard model analysis revealed that a laparoscopic approach reduced the risk of postoperative delirium [hazard ratio (HR) 0.30, 95% confidence interval (CI) 0.07-0.84, p = 0.019]. Postoperative delirium was associated with worse overall survival within 180 days (HR 4.91, 95% CI 1.96-12.22, p = 0.001) after adjusting for other confounders using the Cox proportional hazard model analysis. Patients who developed postoperative delirium showed worse outcomes including higher rate of morbidity except delirium (p < 0.001), longer hospitalization (p < 0.001), and post-discharge institutionalization (p < 0.001). After propensity score-matching, cumulative incidence rates of postoperative delirium were significantly lower in the laparoscopic group compared to the open group (30-day cumulative incidence rate, 1.7% vs. 7.8%, p = 0.006). CONCLUSIONS: The risk of postoperative delirium after major abdominal surgery is reduced using laparoscopic approach. Postoperative delirium should be prevented as it precipitates adverse postoperative events.

Development and validation of a nomogram predicting postoperative pneumonia after major abdominal surgery.

PURPOSE: Postoperative pneumonia (POP) is a common complication that can adversely affect the outcomes after surgery. This study aimed to devise and validate a model for stratifying the probability of POP in patients undergoing abdominal surgery. METHODS: We included 1050 patients who underwent major abdominal surgery between 2012 and 2013. A nomogram was devised by evaluating the predictive factors for POP. RESULTS: Of the 1050 patients, 56 (5.3%) developed POP. Multivariable logistic regression analysis revealed that the independent predictive factors for POP were age, male sex, history of cerebrovascular disease, Brinkman Index (BI) ≥ 900, and upper midline incision. A nomogram was devised by employing these five significant predictive factors. The prediction model showed a relatively good discrimination performance, with a concordance index of 0.77. CONCLUSIONS: A nomogram based on age, male sex, history of cerebrovascular disease, BI ≥ 900, and upper midline incision may be useful for identifying patients with a high probability of developing POP after major abdominal surgery.

Insufficient Lymph Node Sampling in Patients with Colorectal Cancer Perforation is Associated with an Adverse Oncological Outcome.

BACKGROUND: The impact of lymph node (LN) dissection on long-term outcomes for patients with colorectal cancer (CRC) perforation remains unclear. We aim to investigate factors associated with poor prognosis and recurrence in patients with CRC, with special reference to cancer perforation and LN dissection. METHODS: The subjects comprised 550 patients who underwent colorectal surgery for CRC at Stage II or III (TNM classification) between February 2006 and November 2013. Short- and long-term outcomes of patients with or without CRC perforation were evaluated. We also sought risk factors on poor prognosis, focusing on LN dissection in patients with CRC perforation. RESULTS: A total of 508 underwent surgery for CRC without perforation (the non-perforation group) and 39 for CRC with perforation (the perforation group). Both overall survival and recurrence-free survival rates were significantly lower in the perforation group than in the non-perforation group (overall survival, P = 0.009; recurrence-free survival, P < 0.001). The relapse rates at the peritoneum (P = 0.002), lung (P = 0.007) and LNs (P = 0.021) were significantly higher in the perforation group than in the non-perforation group. Multivariable Cox proportional hazards model revealed that CRC perforation (hazard ratio [HR] 2.55, 95 % confidential interval [CI] 1.16-4.98, P = 0.022), LN dissection <12 (HR 1.83, 95 % CI 1.07-3.13, P = 0.027), and Stage III (HR 1.79, 95 % CI 1.06-3.08, P = 0.031) were significant and independent risk factors for poor prognosis. CONCLUSIONS: Conducting <12 LN dissections independently increased the risk of reduction in overall survival for patients with CRC perforation. Thus, radical LN dissections should be performed to improve patients' survival rates, when patients' general and surgical conditions allow.

The impact and optimal indication of non-curative gastric resection for stage IV advanced gastric cancer diagnosed during surgery: 10 years of experience at a single institute.

BACKGROUND: The survival benefit of non-curative gastric resection for patients with stage IV gastric cancer is still unclear. METHODS: Of the patients who underwent open abdominal surgery that was preoperatively intended to be a radical excision procedure for gastric cancer, 72 were diagnosed with stage IV during the operation. At this institution, non-curative gastric resection is performed whenever possible. RESULTS: Non-curative gastric resection was performed in 44 of the 72 patients. According to the survival analysis, the median survival times in the gastric resection and no-resection groups were 1.9 and 0.9 years, respectively (log-rank test, p = 0.014). Based on the multivariate analysis, we selected gastric resection (hazard ratio [HR] = 0.309; 95% confidence interval [CI] = 0.152-0.615) and postoperative chemotherapy (HR = 0.136; 95% CI = 0.056-0.353) as independent factors associated with overall survival (OS). In the subgroup analyses of OS, the factors that were associated with gastric resection having no survival benefit were the existence of distant lymph node or liver metastasis (p = 0.527) and the lack of postoperative chemotherapy (p = 0.589). CONCLUSIONS: For patients who have distant lymph node or liver metastasis and those who will not undergo postoperative chemotherapy, non-curative gastric resection has no survival benefit.

Comparisons of financial and short-term outcomes between laparoscopic and open hepatectomy: benefits for patients and hospitals.

PURPOSES: This retrospective analysis compared the cost outcomes for both patients and hospitals, as well as the short-term outcomes, for laparoscopic hepatectomy (LH) and open hepatectomy (OH). METHODS: The subjects comprised 70 patients who underwent LH or OH. The total hospital charge was calculated using the Japanese lump-sum payment system according to the diagnosis procedure combination. RESULTS: Of the 70 patients, 10 in the LH group and 16 in the OH group underwent primary single limited/anatomic resection or left lateral sectoriectomy. The operation time, blood loss, and postoperative complications did not differ significantly between the two groups. The median [range] time of inflow occlusion was significantly longer [120 (50-194) vs. 57 (17-151) min, P = 0.03] and the postoperative hospital stay was significantly shorter [5 (4-6) vs. 9 (5-12) days, P < 0.01] in the LH group than in the OH group, respectively. The mean ± standard deviation surgical costs (1307 ± 596 vs. 1054 ± 365 US$, P = 0.43) and total hospital charges (12046 ± 1174 vs. 11858 ± 2096 US$, P > 0.99) were similar in the LH and OH groups, respectively, although the charges per day were significantly higher in the LH group than in the OH group (1388 ± 217 vs. 1016 ± 134 US$, P < 0.01). CONCLUSIONS: The costs to patients for LH are similar to those for OH. However, LH provides a financial advantage to hospitals due to a reduced hospital stay and comparable surgical costs.

Advances in Assessment and Planning for Surgical Treatment of Hepatocellular Carcinoma.

This chapter covers recent important topics relevant to ensuring safe liver resection. In particular, preoperative and intraoperative techniques, such as 3-dimensional CT, intraoperative ultrasonography with contrast agent and fluorescence imaging using indocyanine green are reportedly useful and have been applied to liver resection and liver transplantation. We, herein, describe the performance of liver resection under the guidance of these techniques and present tips for more accurate intraoperative tumor detection and safer surgical procedures.

False reduction of an inguinal hernia treated by Kugel patch repair via an anterior approach.

BACKGROUND: Reduction en masse of inguinal hernia is a rare condition following manual reduction of an unrecognized incarcerated inguinal hernia. The preoperative diagnosis and surgical treatment via an inguinal approach has been considered difficult. CASE PRESENTATION: A 59-year-old man with lower abdominal pain was presented to our hospital. He was diagnosed reduction en masse of an inguinal hernia based on his CT findings which showed the presence a pre-peritoneal hernia sac containing the small bowel. An emergency operation via an anterior approach was performed and we found a hernial sac containing an incarcerated small bowel at the cranial and internal sides of the internal inguinal ring. Opening of the hernial sac revealed necrosis of the incarcerated small bowel and bowel resection was performed. Kugel patch was inserted into the pre-peritoneal space and the patient made an uneventful recovery. CONCLUSION: When it is accurately diagnosed, reduction en masse of an inguinal hernia can be treated with direct Kugel repair via an anterior approach.

Outcomes of outpatient treatment for primary spontaneous pneumothorax using a small-bore portable thoracic drainage device.

BACKGROUND: There is no consensus regarding the initial intervention for primary spontaneous pneumothorax. We report the outcomes of outpatient treatment for primary spontaneous pneumothorax using a portable thoracic drainage device. PATIENTS AND METHODS: Between April 2007 and December 2011, 99 consecutive patients with a first episode of primary spontaneous pneumothorax were indicated for insertion of a portable thoracic drainage device. All patients were treated with a small-bore portable thoracic drainage device that consists of a flexible 9F silicone catheter with one-way valves and a small plastic chamber. Successful treatment was defined as when the pneumothorax was resolved after the insertion of a portable thoracic drainage device solely on an outpatient basis. Demographic data and treatment outcomes were obtained by a retrospective chart review. RESULTS: Ninety-seven patients (98%) with a first primary spontaneous pneumothorax were discharged from the emergency department after insertion of a portable thoracic drainage device. Ninety-three patients (94%) resolved with outpatient treatment. The median duration of portable thoracic drainage device insertion was 4 days (range, 0-33 days). The recurrence rate after treatment with a portable thoracic drainage device was 34% (32/93). There were two infections (2.0%), two instances of hemothoraces (2.0%), and one severe discomfort at the insertion site (1.0%). There were no cases of tension pneumothorax or reexpansion edema. CONCLUSION: Outpatient treatment for primary spontaneous pneumothorax using a portable thoracic drainage device had a high success rate with few serious complications and an acceptable recurrence rate.

The Feasibility of Central Pancreatectomy for Blunt Pancreatic Trauma: A Comparative Study of Central and Distal Pancreatectomy.

BACKGROUND/AIMS: Central pancreatectomy (CP) is an alternative technique of distal pancreatectomy (DP) for focal pancreatic tumors; however, the feasibility of CP for pancreatic trauma has not been adequately assessed. METHODOLOGY: Patients who underwent CP (n = 8) or DP (n = 8) for pancreatic duct injuries following blunt trauma were reviewed. Patient demographics, status of pancreatic duct injuries, and perioperative outcomes were compared between procedures. RESULTS: Pancreatic duct injuries occurred at the neck of the pancreas in 63% patients (10/16). Patient demographics and perioperative outcomes were comparable between the CP and DP groups. Polytrauma was found in 38% patients in both groups. No differences were found between patients treated with CP and DP in overall blood loss (median: 1025 mL vs 1800 mL, P = 0.418) and surgical duration (median: 284 min vs 188 mm, P = 0.172). The incidence of pancreas-related complications was comparable between groups (CP: 50% vs. DP: 38%, P = 0.614. CONCLUSIONS: Blunt pancreatic duct injuries tend to occur at the pancreatic neck, leaving the body and tail of the pancreas intact. CP is feasible for blunt pancreatic trauma in hemodynamically stable patients.

Sciatic hernia: is it really rare?

PURPOSE: It is generally believed that sciatic hernia is extremely rare; however, asymptomatic sciatic hernia is occasionally found in patients with an obturator hernia. We investigated the frequency, risk factors, and prognosis of asymptomatic sciatic hernia, which have never been discussed in a published report. METHODS: We retrospectively reviewed multidetector-row computed tomography (MDCT) images of 38 consecutive cases of new-onset obturator hernia. The co-existence of sciatic hernia was diagnosed from the MDCT findings of some of these patients. The clinical characteristics and clinical courses were compared between the sciatic hernia group and the non-sciatic hernia group. RESULTS: Nine patients (24 %) had concomitant asymptomatic sciatic hernias, five (13 %) of which were bilateral.The body mass index (BMI) was significantly lower in the patients with a concomitant sciatic hernia (17.2 ± 2.4 kg/m(2)) than in those without a sciatic hernia (19.6 ± 2.6 kg/m(2); P = 0.02). All patients received treatment for incarcerated obturator hernias, but none underwent repair of the concomitant sciatic hernia because all were non-incarcerated and asymptomatic. None of the patients has had trouble with their untreated sciatic hernia after the obturator hernia treatment. CONCLUSIONS: Up to 24 % of these obturator hernia patients had a concomitant sciatic hernia. A low BMI was a risk factor for concomitant sciatic hernia. Immediate surgical repair of the sciatic hernia may not be needed, unless it is symptomatic.

Obturator hernia of the fallopian tube.

Obturator hernia of the fallopian tube is extremely rare. Multidetector computed tomography of a 43-year-old nulliparous woman with sudden onset lower right abdominal pain showed a low-density mass in the right obturator canal suspected of being an obturator hernia of the uterine adnexa. She was diagnosed as having an incarcerated obturator hernia of the fallopian tube at operation and treated with prosthetic mesh. Obturator hernia of the fallopian tube is very rare, and all cases reported in the literature were localized on the right side, perhaps due to the lesser mobility of the left than the right fallopian tube.

[A case of long-term survival after undergoing S-1 treatment and splenectomy for liver, lung and splenic metastases following curative distal gastrectomy for gastric cancer].

A 7 0-year-old female underwent distal gastrectomy for gastric cancer in November 2001. She did not wish to receive postoperative adjuvant chemotherapy. In May 2002, her serum carcinoembryonic antigen(CEA)level rose. CT demonstrated liver(S5/6)and lung(S9)metastases in August 2002. We started to treat her with S-1(100mg/day day 1-14 orally), and restaging CT showed complete regression of liver and lung metastases in August 2003. In spite her complete response(CR), we continued S-1 treatment for the successive two years. No adverse reaction to chemotherapy occurred. Although CR was maintained for about 4 years, she was found to have a 9-mm solitary lesion in the upper pole of the spleen in June 2007. After 6 months, this tumor increased to 15mm in size, and we considered it as a solitary metastasis to the spleen from gastric cancer. S-1 chemotherapy was restarted, but tumor size gradually increased. Tumor size finally reached 25mm in December 2008. She underwent splenectomy in January 2009. From then until now, she has not received any chemotherapy, and has been followed well without any recurrence.

Perioperative Factors Predicting Prolonged Postoperative Ileus After Major Abdominal Surgery.

BACKGROUND: Prolonged postoperative ileus (PPOI) is among the common complications adversely affecting postoperative outcomes. Predictors of PPOI after major abdominal surgery remain unclear, although various PPOI predictors have been reported in patients undergoing colorectal surgery. This study aimed to devise a model for stratifying the probability of PPOI in patients undergoing abdominal surgery. METHODS: Between 2012 and 2013, 841 patients underwent major abdominal surgery after excluding patients who underwent less-invasive abdominal surgery, ileus-associated surgery, and emergency surgery. Postoperative managements were generally based on enhanced recovery after surgery (ERAS) program. The definition of PPOI was based on nausea, no oral diet, flatus absence, abdominal distension, and radiographic findings. A nomogram was devised by evaluating predictive factors for PPOI. RESULTS: Of the 841 patients, 73 (8.8%) developed PPOI. Multivariable logistic regression analysis revealed smoking history (P = 0.025), colorectal surgery (P = 0.004), and an open surgical approach (P = 0.002) to all be independent predictive factors for PPOI. A nomogram was devised by employing these three significant predictive factors. The prediction model showed relatively good discrimination performance, the concordance index of which was 0.71 (95%CI 0.66-0.77). The probability of PPOI in patients with a smoking history who underwent open colorectal surgery was calculated to be 19.6%. CONCLUSIONS: Colorectal surgery, open abdominal surgery, and smoking history were found to be independent predictive factors for PPOI in patients who underwent major abdominal surgery. A nomogram based on these factors was shown to be useful for identifying patients with a high probability of developing PPOI.

Laparoscopic Management of Mirizzi Syndrome Without Dissection of Calot's Triangle.

BACKGROUND: Mirizzi syndrome (MS) is a rare complication of cholecystolithiasis that causes compacted gallstones and is often accompanied by severe inflammation of Calot's triangle. This study compared the use of laparoscopic surgery for MS without dissection of Calot's triangle with routine laparoscopic cholecystectomy (LC). METHODS: A total of 411 consecutive patients underwent laparoscopic surgery for benign gallbladder (GB) disease between January 2013 and December 2014. Five patients underwent laparoscopic surgery for MS (MS group) while 406 underwent routine LC (LC group). The preoperative diagnosis was accurate in all patients in the MS group. RESULTS: The LC and MS groups did not differ significantly in the operation time, blood loss, length of hospital stay, or incidence of GB carcinoma. In addition, conversion, bile duct injury, and bile leak rate were not different between the two groups. CONCLUSIONS: This study demonstrates the safety of laparoscopic partial cholecystectomy without dissection of Calot's triangle for MS. In addition, an accurate preoperative diagnosis is critical in surgical decision making to avoid injury to the bile duct.

Three-dimensional motion and transformation of a photoelectrochemical actuator.

A new "photoelectrochemical actuator" consisting of poly(acrylic acid)/copper gel and TiO2 nanoparticles has been developed, which undergoes reversible expansion/contraction upon UV light irradiation/termination, likely due to dissociation/formation of carboxylic group/Cu2+ binding.

Spontaneous rupture of splenic hamartoma in a patient with hepatitis C virus-related cirrhosis and portal hypertension: a case report and review of the literature.

Spontaneous rupture is a rare complication of splenic hamartoma. A review of the literature revealed only four such cases. To the best of our knowledge, this is the first report of spontaneous rupture of splenic hamartoma associated with liver cirrhosis and portal hypertension. A 53-year-old woman, who was followed up for aortic dissection and hepatitis C virus (HCV)-related liver cirrhosis, was referred with sudden left chest and shoulder pain. An abdominal ultrasound showed intraabdominal bleeding, and computed tomography indicated rupture of a splenic tumor. Emergent splenectomy was carried out. The postoperative course was uneventful, and the patient was discharged on the 13th postoperative day. Pathology revealed the tumor to be a ruptured splenic hamartoma. The non-tumorous splenic parenchyma revealed congestive changes. We consider that the presence of liver cirrhosis and portal hypertension are risk factors for spontaneous rupture of the splenic hamartoma.

[Correlation between clinical pathologic factors and enzymatic activity of orotate Phosphoribosyl transferase (OPRT), Dihydropyrimidine dehydrogenase (DPD) and Thymidylate synthase (TS) in colorectal cancer].

Orotate Phosphoribosyl Transferase (OPRT), Dihydropyrimidine dehydrogenase (DPD) and Thymidylate synthase (TS) are initial key enzymes in the 5-FU metabolic pathway. In this study, we measured the activities of OPRT, DPD and TS. We also investigated the correlation between these 3 enzymatic activities and the clinical pathologic factors (Histological typing, extent of tumor invasion,extent of metastasis to the lymph nodes,stage, lymphatic invasion and venous invasion). We had surveyed 79 cases of colorectal cancers surgically removed. Poorly-differentiated adenocarcinoma showed a tendency to lower OPRT and higher DPD, as compared to moderately or well-differentiated adenocarcinomas. In case with metastasis to lymph nodes, OPRT showed a tendency to lower activities, but a significant difference was not noticed. TS showed no relation to any of these pathologic factors. In each application of 5-FU, measuring the activities of these three enzymes is important for estimation of the antitumoral effect. With poorly-differentiated adenocarcinoma, it is estimated that many cases would show high DPD and if the enzyme activities can not be measured, so administration of TS-1, which includes DPD inhibitor, may be considered.

Renal neuroendocrine tumour and synchronous pancreas metastasis: histopathological diagnosis using prostatic acid phosphatase.

A woman aged 56 years developed 2 synchronous tumours: one, 1.2 cm in diameter at the head of the pancreas; and the other, 4.0 cm in diameter, at the left side of her horseshoe kidney. Preoperative differential diagnosis of these hypovascular lesions included pancreatic ductal carcinoma (PDC) with renal metastasis, PDC with renal angiomyolipoma, renal cell carcinoma with pancreatic metastasis or PDC and renal cell carcinoma. Following pancreaticoduodenectomy and left nephrectomy, both specimens were diagnosed as grade 2 neuroendocrine tumours (NETs). Immunohistochemistry revealed that both were positive for prostatic acid phosphatase (PAP), which is specific to hindgut-derived NET, including renal NET. Accordingly, the renal tumour was diagnosed as the primary lesion, and the pancreatic tumour as a metastasis. To the best of our knowledge, this is the first report of a renal NET with a synchronous pancreas metastasis. Immunohistochemical staining for PAP was a useful diagnostic marker for synchronous NETs in the kidney and pancreas.