Predictive factors of perforated appendicitis: Impact of the C-reactive protein level.

BACKGROUND: Perforated appendicitis without an associated abscess necessitates emergency surgery. However, it is difficult to predict the presence of perforation before surgery, and the predictive factors are still unclarified. Our purposes were to characterize a patient population with perforated appendicitis without an associated abscess to identify the preoperative predictive factors of appendiceal perforation. METHODS: We retrospectively identified 150 patients who underwent appendectomy for acute appendicitis at our institution from June 2018 to November 2020. Logistic regression analysis was performed to analyze the concurrent effects of various factors on the prevalence of perforated appendicitis. RESULTS: Forty (29%) of 150 patients had appendiceal perforation detected intraoperatively. Of these 40 patients, only 19 had appendiceal perforation detected on preoperative computed tomography. Multivariable analysis found that a higher C-reactive protein level, higher total bilirubin level, and the presence of an appendiceal fecalith were independent predictive factors for appendicitis with perforation. CONCLUSION: Our analysis suggests that the presence of an appendiceal fecalith, a total bilirubin level of more than 21.38 µmol/L, and a C-reactive protein level of more than 3.0 × 104 µg/L are predictive factors of perforated appendicitis.

Successful Treatment of Protein-Losing Enteropathy After Superior Mesenteric Artery Occlusion without Surgery.

BACKGROUND Protein-losing enteropathy as a complication of superior mesenteric artery occlusion is extremely rare and severe, and sometimes requires intestinal resection. However, the ideal treatment strategy has not yet been determined. CASE REPORT A 77-year-old man with underlying hypertension and diabetes was admitted to the Emergency Department with acute abdominal pain after eating. Contrast-enhanced computed tomography revealed complete occlusion of the superior mesenteric artery with thrombosis, and superior mesenteric artery occlusion was diagnosed. It was successfully treated with interventional therapy, followed by continuous intra-arterial prostaglandin E1 infusion and continuous intravenous heparin infusion. However, the patient developed hypoproteinemia and diarrhea about 10 days after the interventional therapy. Colonoscopy and X-ray studies did not reveal any abnormal findings; however, technetium-99m-labeled human serum albumin scintigraphy indicated protein-losing enteropathy. With total parenteral nutrition and protein-rich oral nutrition, with protein intake at twice the amount in a standard diet, serum albumin improved from 15 g/L to 32 g/L after treatment. Additionally, we administered diuretics to avoiding edema related to the hypoproteinemia. The patient recovered from the hypoproteinemia and diarrhea without complications. CONCLUSIONS Protein-losing enteropathy is an extremely rare but critical complication of superior mesenteric artery occlusion. Treating the underlying pathology is the mainstay of protein-losing enteropathy and dietary modifications also play a critical role. Our patient was successfully treated with strict nutritional therapy, combined oral protein-rich nutrition and total parenteral nutrition, which avoided surgery.

[OPERATIONAL EXPERIENCE OF AUTOMATIC POSTING SYSTEM TO THE NATIONAL CLINICAL DATABASE USING FILEMAKER PRO].

We would like to introduce a semi-automated registration system for the National Clinical Database. Japan Surgery Society runs the National Clinical Database since January 2011. And automated registration system is long-awaited due to the number of cases and diverse items to register. Well-known database management system, FileMakerPro enabled collecting and registering the items to the web-site automatically. Still some items need to copy one by one, but after filling the data, all data would be input to the web page for registration. Merit for this automated system is increasing not only the efficiency of administration work but the quality and the usefulness of this database. This paper is to report the outline of the registration system to the NCD database.

Long-term survival outcomes of advanced gastric cancer patients who achieved a pathological complete response with neoadjuvant chemotherapy: a systematic review of the literature.

BACKGROUND: A pathologic complete response (pCR) can sometimes be induced by intensive or long-term neoadjuvant chemotherapy (NAC). This prognostic research study based on a systematic review of the literature evaluated the impact of a pCR on the long-term survival of gastric cancer (GC) patients. METHODS: Articles were extracted from PubMed and the Japanese medical search engine "Ichu-shi," using the terms "GC," "NAC," and "pCR." Articles were selected based on the following criteria: (1) full-text case report, (2) R0 resection following NAC for locally advanced GC, and (3) pathological complete response in both the primary stomach and in the lymph nodes. A questionnaire regarding the patients' prognoses was sent to the corresponding authors of the articles selected in July 2013. RESULTS: Twenty-four articles met the criteria. Twenty authors responded to the questionnaire. Finally, 22 patients from 20 articles were entered into the present study. The median follow-up time (range) of the survivors was 76 (range 13-161) months. Tumors that were stage III/IV (86%: 19/22) and of an undifferentiated histology (61.9%: 13/21) were dominant. An S1-based regimen was frequently selected for the NAC. All patients underwent R0 resection and D2/D3 lymphadenectomy. The overall survival and recurrence-free survival rates at 3 and 5 years were 96% and 85% and 91% and 75%, respectively. CONCLUSIONS: Although a pCR was a relatively rare event, a high pCR rate would be helpful to select the regimen and courses of NAC, especially when the pathological response rates are similar.

Hepatocellular carcinoma associated with sarcoidosis.

INTRODUCTION: The association of hepatic sarcoidosis with hepatocellular carcinoma (HCC) is considerably rare. Here we report a rare case of HCC associated with sarcoidosis. PRESENTATION OF CASE: A 75-year-old male with no history of alcohol addiction or viral hepatitis was referred to our hospital because of an abnormal liver mass. Subsegmentectomy of the liver was performed for the diagnosis of HCC. A histopathological examination revealed small non-necrotizing granulomas with a tendency to coalesce that were scattered in and around the carcinoma. No features of cirrhosis, steatohepatitis, and any other liver diseases were observed. Furthermore, swelling of the bilateral lung hilar lymph nodes with uptake of 18F-fluorodeoxyglucose was found on positron emission tomography/computed tomography and the tuberculin reaction test results were negative. On the basis of these findings, the final diagnosis of HCC associated with sarcoidosis was confirmed. DISCUSSION: By reviewing previous cases, we found only five cases that described patients diagnosed with HCC associated with sarcoidosis. Of these, four patients died within two years after diagnosis because of ruptures or inoperable huge tumors. In contrast, radical hepatectomy was performed at an earlier stage of disease in two patients, including ours, and both these patients have remained healthy with no recurrences or metastases at the latest follow-up visit. CONCLUSION: Periodic checkups of the liver should be conducted for patients with systemic sarcoidosis, regardless of the presence of liver cirrhosis.

Efficacy of self-expanding metallic stent for right-sided colonic obstruction due to carcinoma before 1-stage laparoscopic surgery.

PURPOSE: The aim of this small study was to assess the clinical outcomes of self-expanding metallic stent (SEMS) placement followed by 1-stage laparoscopic resection for treatment of acute right-sided colonic obstruction due to carcinoma. METHOD: From January 2012 to December 2012, we performed 1-stage laparoscopic colectomy after placement of SEMS for right-sided obstructive colon carcinoma in 4 patients. RESULTS: SEMS placement was technically successful in all cases and symptoms were immediately relieved. The presence of the endoluminal stent did not prevent a laparoscopic approach; moreover, decompression of the bowel obstruction provided a wide field of view and working space for the laparoscopic procedure. There were no cases of conversion to laparotomy and no intraoperative complications. CONCLUSION: One-stage laparoscopic surgery, as a minimally invasive therapy, can be safely performed by SEMS placement in patients with acute right-sided colonic obstruction due to carcinoma. A large sample study is required to confirm the efficacy of this procedure.

Retroperitoneal dedifferentiated liposarcoma with osteosarcomatous components: a case report.

We report a rare case of recurrent retroperitoneal dedifferentiated liposarcoma with osteosarcomatous components. An 82-year-old male diagnosed with recurrent retroperitoneal liposarcoma underwent a tumor resection. Histologically, osseous matrix with osteoid and mature hyaline cartilaginous tissues with high cellularity were observed in a fibrous background through most of the tumor, and scattered MDM2- and CDK4-positive atypical hyperchromatic stromal cells were detected surrounding the dedifferentiated areas. Dedifferentiation occurs in up to 10% of well-differentiated liposarcomas, frequently resembling a malignant fibrous histiocytoma-like pleomorphic sarcoma. In contrast, divergent differentiation with osteosarcomatous components is considered to be extremely rare.

A novel combined laparoscopic-endoscopic cooperative approach for duodenal lesions.

PURPOSE: A surgical approach with minimal invasion and excellent outcome for removal of duodenal lesions, using laparoscopic-endoscopic cooperative surgery (LECS), was established. PATIENTS AND METHODS: Two patients underwent the resection of duodenal lesions with our novel LECS approach. Case 1 (age: 49 years; male) had a 20-mm 0-IIa-like lesion (group IV tumor on biopsy) in the duodenal bulb. LECS interventions, performed under general anesthesia, employed a total of four trocars. The extent of lesions was determined with the endoscopic submucosal dissection (ESD) technique. The affected duodenal wall was then perforated before a one fifth turn resection was performed to expose lesions of the whole layer. A tumor, confirmed under laparoscopy, was turned over toward the abdominal cavity to facilitate resection. Case 2 (age: 49 years; female) had 20-mm 0-IIc lesions (group III adenoma) located at the second portion of the duodenum. LECS procedures for duodenal resection were performed in a manner similar to case 1 . A total of five trocars were used. RESULTS: Histologic diagnosis of the tumor in case 1 was tubular adenoma with moderate atypia (size: 20 x 12 mm). As for case 2, histopathologic findings confirmed a tubular adenoma with moderate atypia (size: 18 x 18 mm) and an adenoma-negative surgical margin. The postoperative courses, in both cases, were uneventful. CONCLUSIONS: Although only 2 cases were surgically intervened with limited experience, the present novel LECS approach allowed a reliable, adequate resection of tumors located in the duodenum, with abbreviated operation times (156-179 versus 202-229 minutes), minimal bleeding, less postoperative stress imposed on the surgeons, and an uneventful postoperative course, compared to conventional surgical methods.

[A case of complete response (CR) persisting for 3 years and 3 months from combination therapy of S-1 and CDDP in a patient with advanced gastric cancer with multiple liver metastases].

The case was a 70-year-old man with type-2 gastric cancer in the lesser curvature accompanied by multiple liver metastases. He received combination chemotherapy of S-1 and CDDP. S-1 was administered at 100 mg/body/day for 21 days followed by withdrawal for 14 days, and CDDP was prescribed at 80 mg/body/day div on day 8. After 3 courses of treatment, the multiple liver metastases disappeared. The primary gastric lesion had changed to a scar and endoscopic biopsy revealed no cancer cell. After the 4th course, we changed the therapy to S-1 alone and after that to UFT alone. Now, 3 years and 3 months after inducing CR, the patient continues to receive UFT with no regrowth of the tumor.

[A case of advanced gastric cancer responding to paclitaxel/CDDP neoadjuvant chemotherapy leading to pathologically complete response].

A 74-year-old male with advanced gastric cancer(cT3N1M0H0P0CY0, cStage III A)was treated with paclitaxel/ CDDP as neoadjuvant chemotherapy. Paclitaxel (80 mg/m(2)) and CDDP (25 mg/m(2)) were administered on days 1, 8 and 15 as one cycle. After the second course, a significant tumor reduction was obtained. Total gastrectomy, splenectomy, and D2 type nodal dissection were performed. The histological diagnosis revealed complete disappearance of cancer cells in the stomach and all of the lymph nodes, a so-called pathologically complete response. The patient has now been in good health without any recurrence for 9 months after surgery. This case suggests that neoadjuvant chemotherapy with paclitaxel/CDDP is a potential regimen for advanced gastric cancer.

[Beating heart coronary artery bypass grafting for acute myocardial infarction].

We consider that off-pump coronary artery bypass grafting (CABG) [OPCAB], which results in local myocardial ischemia, is more effective for patients with acute myocardial infarction (AMI) than conventional CABG under cardiac arrest with global myocardial ischemia. Twenty-one patients (15 males, 6 females) received OPCAB for AMI, among whom surgery was performed following percutaneous coronary intervention (PCI) failure in 4 and PCI was performed prior to OPCAB in 2, while PCI was not performed in the remaining 15. Preoperatively, 16 patients had intraaortic balloon pumping (IABP), and 4 had IABP and percutaneous cardiopulmonary support (PCPS). The mean interval from onset to surgery was 11.7 (range 3 to 40) hours. In 20 cases, a complete revascularization was performed. The mean number of bypasses was 2.3 and OPCAB was carried out in 14 patients. In 2 cases, OPCAB was converted to on-pump beating CABG for complete revascularization. Fourteen patients (67%), each maintained with preoperative left ventricular ejection fraction (EF), were discharged with an elective bypass. Four patients died after on-pump beating CABG, in whom EF was lower than 10%. In addition, 3 died of low cardiac output syndrome (LOS) under PCPS and 1 of ventricular fibrillation. Based on our results, we considered that complete revascularization using OPCAB was effective for cases of AMI with PCI difficulty. However, in shock cases requiring PCPS, cardiac function was not improved even after revascularization. Therefore, it is necessary to study new procedures for shock cases during the period from onset to surgery.