Sonographically-guided Parasacrum Infrapiriformis Drainage of Deep Pelvic Abscesses: An Anatomical Safety Study Using SYNAPSE VINCENT.

Objectives: Deep pelvic abscesses are surrounded by the pelvic bones, bladder, gynecological organs, intestinal tract, and nerve and vascular systems, and are approached by various routes for drainage. The transgluteal approach is often performed under computed tomography guidance; however, if ultrasonography can be used to confirm the approach, it is considered more effective because it reduces radiation exposure and allows for real-time puncture under sonographic and fluoroscopic guidance. Methods: This retrospective study was conducted at Tobata Kyoritsu Hospital (Fukuoka, Japan) between April 1, 2021, and December 31, 2022. Sonographically guided transgluteal drainage with fluoroscopy was performed in five consecutive cases of deep pelvic abscesses using a 3D image analysis system (SYNAPSE VINCENT) to study the anatomy for safe puncture. Results: Three patients had postoperative abscesses from colorectal cancer, one caused by perforation of the appendicitis, and one caused by sigmoid diverticulitis. The average drainage duration was 11 days (SD = 6.7). No complications, such as bleeding or nerve damage, were observed. Conclusions: We constructed a 3D image of the puncture route of the trans greater sciatic foramen using SYNAPSE VINCENT to objectively comprehend the anatomy and puncture route. The ideal transgluteal approach is to insert the catheter as close to the sacrum as possible at the level of the infrapiriformis. The parasacrum infrapiriformis approach can be performed safely and easily using ultrasound guidance and fluoroscopy.

Mechanical and oral antibiotics bowel preparation for elective rectal cancer surgery: A propensity score matching analysis using a nationwide inpatient database in Japan.

Aim: The best bowel preparation method for rectal surgery remains controversial. In this study we compared the efficacy and safety of mechanical bowel preparation (MBP) alone and MOABP (MBP combined with oral antibiotic bowel preparation [OABP]) for rectal cancer surgery. Methods: In this retrospective study we analyzed data from the Japanese Diagnosis Procedure Combination (DPC) database on 37 291 patients who had undergone low anterior resection for rectal cancer from 2014 to 2017. Propensity score matching analysis was used to compare postoperative outcomes between MBP alone and MOABP. Results: A total of 37 291 patients were divided into four groups: MBP alone: 77.7%, no bowel preparation (NBP): 16.9%, MOABP: 4.7%, and OABP alone: 0.7%. In propensity score matching analysis with 1756 pairs, anastomotic leakage (4.84% vs 7.86%, P < 0.001), small bowel obstruction (1.54% vs 3.08%, P = 0.002) and reoperation (3.76% vs 5.98%, P = 0.002) were less in the MOABP group than in the MBP group. The mean duration of postoperative antibiotics medication was shorter in the MOABP group (5.2 d vs 7.5 d, P < 0.001) than in the MBP group. There was no significant difference between the two groups in the incidence of Clostridium difficile (CD) colitis (0.40% vs 0.68%, P = 0.250) and methicillin-resistant Staphylococcus aureus (MRSA) colitis (0.11% vs 0.17%, P = 0.654). There was no significant difference in in-hospital mortality between the two groups (0.00% vs 0.11% respectively, P = 0.157). Conclusion: MOABP for rectal surgery is associated with a decreased incidence of postoperative complications without increasing the incidence of CD colitis and MRSA colitis.

The Effects of Hospital Volume on Short-Term Outcomes of Laparoscopic Surgery for Rectal Cancer: A Large-Scale Analysis of 37,821 Cases on a Nationwide Administrative Database.

INTRODUCTION: Laparoscopic low anterior resection (L-LAR) has become widely accepted for the treatment of rectal cancer. However, little is known about the superiority of L-LAR in a real-world setting (including low-volume hospitals) and the association between the short-term outcomes and hospital volume focusing on L-LAR. METHODS: This is a retrospective cohort study. A total of 37,821 patients who underwent LAR for rectal cancer were analyzed using the Diagnosis Procedure Combination (DPC) database from January 2014 to December 2017. The short-term surgical outcomes were analyzed using a multilevel analysis. Hospital volumes were divided into quartiles, including low (1-31), middle (32-55), high (56-91), and very-high volume (92-444 resections per 4 years). The effects of hospital volume on the outcomes were investigated. RESULTS: The study population included 8,335 patients (22%) who underwent open low anterior resection (O-LAR) and 29,486 patients (78%) who underwent L-LAR. The in-hospital mortality and morbidity were consistent with previous reports. In patients who underwent L-LAR, the in-hospital mortality (0.12% vs. 0.41%; OR: 0.33; p = 0.005), the rate of reoperation (3.76% vs. 6.48%; OR: 0.67; p < 0.001), and the perioperative transfusion rate (3.81% vs. 5.90%; OR: 0.66; p < 0.001) were significantly lower in very-high-volume hospitals than in low-volume hospitals. These effects of hospital volume were not observed in O-LAR. CONCLUSIONS: Our present study demonstrates that high volume improves outcomes in patients who underwent L-LAR in a real-world setting.

[Synchronous Lung Metastasis and Hilar Lymph Node Metastasis from Rectal Cancer-A Case Report].

A 64-year-old male was referred to our hospital with both advanced rectal cancer and lung tumor with swollen lymph nodes in the lung hilum. The patient underwent laparoscopic low anterior resection followed by systematic lobectomy of the lung 2 months later. Postoperative pathological examination revealed a diagnosis of metastatic lung tumor and metastasis in the lung hilum. However, hilar lymph node metastasis is considered a poor prognostic factor for lung metastasis. Herein, we report a case of synchronous lung metastasis and hilar lymph node metastasis from colorectal cancer that achieved 20 months of recurrence free survival with surgical therapy alone.

[A Case Report of Lateral Paracecal Hernia Treated with Single Port Surgery].

An 86-year-old female hospitalized for right femoral fracture complained of a sudden abdominal pain and vomited. Contrast-enhanced computed tomography (CECT) of the abdomen showed an ileal closed loop with dilatation of the oral side intestine. She was diagnosed with a bowel obstruction due to a paracecal hernia with incarceration and underwent an emergency operation. Under laparoscopy, the responsible ileum was incarcerated into the paracolic sulcus and strangulated. After releasing the strangulation by cutting the hernia hilum, the incarcerated ileum did not show any necrotic change. In this case, the CECT suggested paracecal hernia, showing the characteristic position between the cecum and the intestinal loop, which we successfully treated with a single incisional laparoscopic surgery.

Open colectomy vs. laparoscopic colectomy in Japan: a retrospective study using real-world data from the diagnosis procedure combination database.

PURPOSE: To compare the short-term outcomes of conventional open colectomy with those of laparoscopic colectomy for colon cancer. METHODS: We retrieved data between January 2014 and March 2016 from the Diagnosis Procedure Combination database. A total of 69,418 patients who underwent colectomy for colon cancer were analyzed from among 15,901,766 cases of colorectal cancer. We applied a multilevel logistic regression model using a 2-level structure of individuals nested from 1065 hospitals. RESULTS: A total of 22,440 open colectomy and 46,978 laparoscopic colectomy procedures were performed. The in-hospital mortality rate was significantly lower in the laparoscopic group than in the open group (0.28% vs. 0.06%, odds ratio [OR] 0.40, p < 0.001). Similarly, the 30-day postoperative mortality rate (0.14% vs. 0.03%, OR 0.47, p = 0.019) and surgical morbidity rate (43.0% vs. 25.3%, OR 0.47, p < 0.001) were significantly lower in the laparoscopic group than in the open group. The postoperative length of stay was significantly longer in the open group (mean difference - 5.6 days, p < 0.001) than in the open group. The admission cost was significantly greater in the open group than in the laparoscopic group (mean difference - 95,080 yen, p < 0.001). CONCLUSIONS: Laparoscopic colectomy is safe and effective in the short term.

[A Case Report of Multiple Intussusceptions by Intestinal Metastases of Pleomorphic Carcinoma of the Lung].

A 68-year-old male with abdominal pain and vomiting was brought to our hospital by ambulance. Computed tomography showed multiple intussusceptions with pseudokidney signs in the jejunum and ileocecum, and a tumor of 5 cm in diameter in the left lower lobe of the lung. We performed an emergent operation, as a release of multiple intussusceptions was difficult by conservative treatment. There were two intussusceptions, in the jejunum and the ileocecum. We performed a partial resection of the jejunum and a resection of the ileocecum. Histopathological examination of the resected specimens and a biopsy specimen collected by bronchoscopy allowed us to diagnose multiple intussusceptions due to small intestine metastases from a pleomorphic carcinoma of the lung. This case is presented here, with a review of the literature.

Robotic-Assisted Distal Gastrectomy for Gastric Cancer Using an Oval-Shaped Port Device.

INTRODUCTION: This report describes the techniques and outcomes of robot-assisted distal gastrectomy (RDG) for gastric carcinoma using an oval-shaped port device. MATERIALS AND METHODS: A total of 15 patients underwent RDG with lymphadenectomy using the E‧Z Access/LAP-PROTECTOR oval-type device (Hakko Co., Ltd., Tokyo, Japan) performed by a single surgeon between 2018 and 2019. This device was introduced to the umbilicus under two settings, depending on the patient's figure. A horizontal setting (n=7) was used to reduce the number of trocar skin incisions in thin patients by placing a scope trocar and assist port within the E-Z Access. The vertical setting (n=8) was used for large and obese patients, enabling the endoscope position to move 50mm toward the cephalad side by rotating the device 180° to improve the surgical view of the suprapancreatic area ("dual port position" using the E‧Z Access oval-type device). The intracorporeal Billroth-I anastomosis or Roux-en-Y method was used for reconstruction. The short-term patient outcomes were determined to assess the safety and feasibility of our procedures. RESULTS: The E-Z Access oval-type device was useful for maintaining an optimal surgical field and reducing the number of skin incisions and the level of surgeon stress. Furthermore, its removal cap and wound protector allowed for an airtight seal, umbilical wound protection, and smooth specimen removal and re-pneumoperitoneum. R0 resection was accomplished in all cases without the need for conversion to open or conventional laparoscopic surgery. The median operating time was 323 (range, 245-590) minutes, and the median blood loss was 5ml. The median number of retrieved lymph nodes was 30. Neither major postoperative complication, including umbilical skin damage, nor postoperative mortality, was observed. The mean length of the hospitalization was 12.5 days. CONCLUSIONS: Our robotic approach using an oval-shaped port device for gastric cancer patients is feasible in terms of patient safety and curability.

The prognostic significance of the expression of monocarboxylate transporter 4 in patients with right- or left-sided colorectal cancer.

AIM: Monocarboxylate transporter 4 (MCT4) is a proton pump that exchanges lactate through the plasma membrane. The present study investigated the clinical significance of the expression of MCT4 in patients with right- or left-sided colorectal cancer (CRC). METHODS: Surgical specimens from 237 CRC patients were immunohistochemically stained with polyclonal anti-MCT4 antibodies. The relationships among the MCT4 expression, the clinicopathological factors, and the prognosis were evaluated. RESULTS: Thirty-six (62.1%) of 58 patients with right-sided CRC and 95 (53.1%) of 179 patients with left-sided CRC showed the high expression of MCT4. The MCT4 expression was significantly correlated with gender and lymph node metastasis in patients with right-sided CRC, and size, depth of invasion, distant metastasis, and tumor-node-metastasis stage in patients with left-sided CRC. A univariate analysis demonstrated that the expression of MCT4 was a significant prognostic factor in both right- and left-sided CRC patients. A multivariate analysis demonstrated the expression of MCT4 was a significantly independent prognostic factor in patients with left-sided CRC, but not in those with right-sided CRC. CONCLUSIONS: Our results suggest that the high expression of MCT4 is a useful marker for tumor progression and a poor prognosis in CRC patients, especially those with left-sided CRC.

Prognostic Significance of Mitochondrial Transcription Factor A Expression in Patients with Right- or Left-sided Colorectal Cancer.

BACKGROUND/AIM: Mitochondrial transcription factor A (mtTFA) is necessary for both the transcription and maintenance of mitochondrial DNA (mtDNA). The present study investigated the clinical significance of mtTFA in patients with right- and left-sided colorectal cancer (CRC). PATIENTS AND METHODS: Surgical specimens from 237 CRC patients were immunohistochemically stained with polyclonal anti-mtTFA antibody. The relationships among the mtTFA expression, clinicopathological factors and prognosis were evaluated. RESULTS: Thirty-five (60.3%) of 58 right-sided CRC patients and 82 (45.8%) of 179 left-sided CRC patients showed high mtTFA expression. The mtTFA expression significantly correlated with lymph node metastasis, distant metastasis, the TNM stage and lymphatic invasion in left-sided CRC patients and did not correlate with any factors in right-sided CRC patients. Univariate and multivariate analyses revealed the mtTFA expression to be a significant prognostic factor in left-sided CRC patients but not in right-sided CRC patients. CONCLUSION: These results suggest that a high mtTFA expression is a useful marker for tumor progression and a poor prognosis in left-sided CRC patients.

A novel transperitoneal abdominal wall nerve block for postoperative pain in laparoscopic colorectal surgery.

BACKGROUND: Although the laparoscopic approach reduces pain associated with abdominal surgery, postoperative pain remains a problem. Ultrasound-guided rectus sheath block and transversus abdominis plane block have become increasingly popular means of providing analgesia for laparoscopic surgery. METHODS: Ninety patients were enrolled in this study. A laparoscopic puncture needle was inserted via the port, and levobupivacaine was injected into the correct plane through the peritoneum. The patients' postoperative pain intensity was assessed using a numeric rating scale. The effects of laparoscopic nerve block versus percutaneous anesthesia were compared. RESULTS: This novel form of transperitoneal anesthesia did not jeopardize completion of the operative procedures. The percutaneous approach required more time for performance of the procedure than the transperitoneal technique. CONCLUSION: This new analgesia technique can become an optional postoperative treatment regimen for various laparoscopic abdominal surgeries. What we mainly want to suggest is that the transperitoneal approach has the advantage of a higher completion rate. A percutaneous technique is sometimes difficult with patients who have severe obesity and/or coagulation disorders. Additional studies are required to evaluate its benefits.

Novel technique of abdominal wall nerve block for laparoscopic colostomy: Rectus sheath block with transperitoneal approach.

A 62-year-old man who had acute rectal obstruction due to a large rectal cancer is presented. He underwent emergency laparoscopic colostomy. We used the laparoscopic puncture needle to inject analgesia with the novel transperitoneal approach. In this procedure, both ultrasound and laparoscopic images assisted with the accurate injection of analgesic to the correct layer. The combination of laparoscopic visualization and ultrasound imaging ensured infiltration of analgesic into the correct layer without causing damage to the bowel. Twenty-four hours postoperatively, the patient's pain intensity as assessed by the numeric rating scale was 0-1 during coughing, and a continuous intravenous analgesic was not needed. Colostomy is often necessary in colon obstruction. Epidural anesthesia for postoperative pain cannot be used in patients with a coagulation disorder. We report the use of a novel laparoscopic rectus sheath block for colostomy. There has been no literature described about the nerve block with transperitoneal approach. The laparoscopic rectus sheath block was performed safely and had enough analgesic efficacy for postoperative pain. This technique could be considered as an optional anesthetic regimen in acute situations.

Transperitoneal rectus sheath block and transversus abdominis plane block for laparoscopic inguinal hernia repair: A novel approach.

INTRODUCTION: A laparoscopic approach for inguinal hernia repair is now considered the gold standard. Laparoscopic surgery is associated with a significant reduction in postoperative pain. Epidural analgesia cannot be used in patients with perioperative anticoagulant therapy because of complications such as epidural hematoma. As such, regional anesthetic techniques, such as ultrasound-guided rectus sheath block and transversus abdominis plane block, have become increasingly popular. However, even these anesthetic techniques have potential complications, such as rectus sheath hematoma, if vessels are damaged. We report the use of a transperitoneal laparoscopic approach for rectus sheath block and transversus abdominis plane block as a novel anesthetic procedure. MATERIAL AND SURGICAL TECHNIQUE: An 81-year-old woman with direct inguinal hernia underwent laparoscopic transabdominal preperitoneal inguinal repair. Epidural anesthesia was not performed because anticoagulant therapy was administered. A Peti-needle™ was delivered through the port, and levobupivacaine was injected though the peritoneum. Surgery was performed successfully, and the anesthetic technique did not affect completion of the operative procedure. The patient was discharged without any complications. DISCUSSION: This technique was feasible, and the procedure was performed safely. Our novel analgesia technique has potential use as a standard postoperative regimen in various laparoscopic surgeries. Additional prospective studies to compare it with other techniques are required.

A Case of Advanced Descending Colon Cancer in an Adult Patient with Intestinal Malrotation.

This report presents an operative case of advanced descending colon cancer in an adult patient with intestinal malrotation. A 63-year-old Japanese male was suffering from left side abdominal pain, abdominal distension, and constipation. An endoscopic examination revealed an advanced tumor in the descending colon. Computed tomography (CT) of the abdomen revealed the thickening of the descending colon wall and superior mesenteric vein rotation. An opaque enema detected severe stenosis of the descending colon. An abdominal X-ray examination revealed the dilation of the colon and small intestine with niveau. At the insertion of an ileus tube, the C-loop of the duodenum was observed to be absent and the small intestine was located on the right side of the abdomen. After the decompression of the bowel contents, laparotomy was performed. Descending colon cancer was observed to have directly invaded the left side of the transverse colon. Left hemicolectomy, lymph node dissection, and appendectomy were performed. The patient had an uneventful recovery and was discharged from the hospital on the 16th day after surgery. This report presents a rare operative case of descending colon cancer in an adult patient with intestinal malrotation.

Postoperative megarectum in an adult patient with imperforate anus and rectourethral fistula.

This report presents a surgical case of postoperative megarectum in an adult patient with imperforate anus/anorectal malformations. A 71-year-old Japanese male presented with a mass in the lower abdomen which was 15 × 12 × 8 cm in diameter, edema in the right lower extremity, and frequent urination. He had undergone sigmoid loop colostomy for an imperforate anus as a newborn infant. At 28 years of age, the sigmoid loop colostomy was changed to sigmoid divided colostomy in the left lower abdomen. Computed tomography revealed a large cystic mass in the lower abdomen. Retrograde urethrography indicated a rectourethral fistula and megarectum with stones. A small laparotomy incision was created in the right lower abdomen, and the wall of the megarectum was identified. Approximately 2,300 mL of gray muddy fluid was identified and drained. A mucous fistula of the upper rectum was created in the right lower abdomen. This is an extremely rare case of postoperative megarectum in an adult patient with an imperforate anus and rectourethral fistula.

Mitochondrial transcription factor a worsens the clinical course of patients with pancreatic cancer through inhibition of apoptosis of cancer cells.

OBJECTIVE: Mitochondrial transcription factor A (mtTFA) is mandatory for both the transcription and maintenance of mitochondrial DNA. This study aimed to investigate the significance of mtTFA expression in pancreatic ductal adenocarcinoma (PDAC). METHODS: Surgical specimens from 93 patients with PDAC who all underwent pancreatectomy were immunohistochemically stained using a polyclonal anti-mtTFA antibody. The relationship between the expression of mtTFA, clinicopathologic factors, and prognosis of these patients were evaluated. RESULTS: Positive mtTFA expression was significantly associated with lymphovascular invasion and metastatic recurrence in the liver and correlated with an advanced surgical stage. A univariate analysis showed that the patients with positive mtTFA expression had a significantly shorter survival time than those patients with negative mtTFA expression, and a multivariate analysis revealed that mtTFA expression was one of the independent prognostic factors in patients with PDAC. Positive mtTFA expression was significantly correlated with a low apoptotic index but not significantly correlated with the mind bomb homolog-1 (MIB-1) index. CONCLUSIONS: The expression mtTFA worsens the clinical course of patients with PDAC through the inhibition of apoptosis of PDAC cells and is an independent marker for the poor prognosis of the patients with PDAC after pancreatectomy. Mitochondrial transcription factor A may be a novel target for the treatment of PDAC.

[A review of 13 cases of obturator hernia].

We reviewed clinical features of patients who we treated for obturator hernia. The subjects were 13 patients who underwent an operation for obturator hernia in our hospital between April 2002 and December 2012. The mean age was 78.5 years, and all patients were female. The mean body mass index was 16.8 kg/m(2). The Howship-Romberg sign was present in only 3 patients. All patients were correctly diagnosed by preoperative pelvic computed tomography. All patients underwent operation. Operative procedures included the laparoscopic approach in 8 patients, the open approach in 3 patients and the inguinal approach in 2 patients. The hernia hilus was repaired with a simple closure in 5 patients, and with a mesh in 8 patients. The hernia contents were small intestine in all the patients. Three patients underwent partial resection of the small intestine because of necrosis of the intestine wall. Three patients had a recurrence of the obturator hernia. In our present series, the patients with obturator hernia were slender females at an advanced age. Plevic CT was useful for the diagnosis of obturator hernia.

Laparoscopic colectomy for transverse colon cancer in an automated peritoneal dialysis patient: A case report.

INTRODUCTION: To date, intra-abdominal surgery in patients undergoing peritoneal dialysis (PD) has been considered to be associated with increased risk even when it is performed laparoscopically. To our knowledge, this is the first case of laparoscopic colectomy for transverse colon cancer in a patient undergoing automated PD (APD). PRESENTATION OF CASE: A 67-year-old man undergoing APD for end-stage chronic renal failure secondary to diabetic nephropathy was diagnosed with transverse colon cancer. Laparoscopic tumor resection without removal of the PD catheter was performed uneventfully. After surgery, PD was interrupted for 4 weeks and then safely resumed after confirming no severe complications of anastomotic leakage or intra-abdominal abscess. DISCUSSION: In patients undergoing PD, the safety of laparoscopic surgery without removal of the catheter and the optimal timing of resuming postoperative PD with or without temporary hemodialysis remain controversial. CONCLUSION: We believe that laparoscopic colectomy can be safely performed in patients undergoing PD. Further case reports and investigations on this procedure with special reference to safety are warranted in future.

Synchronous occurrence of advanced neuroendocrine carcinoma and tubular adenocarcinoma of the rectum.

This report presents a rare case with the synchronous occurrence of advanced neuroendocrine carcinoma (NEC) and tubular adenocarcinoma of the rectum. A 52-year-old Japanese male presented with general fatigue and bloody stool. Endoscopic examination showed an ulcerated lesion of the lower rectum. The pathological diagnosis of biopsy specimens from this lesion indicated moderately differentiated adenocarcinoma. He was referred to the surgical outpatient clinic with advanced rectal cancer. Barium enema indicated two lesions in the upper and lower rectum. Computed tomography revealed multiple hepatic metastases. A low anterior resection was performed with lymph node dissection. The resected specimen indicated an elevated lesion with ulceration in the upper rectum and an ulcerated lesion in the lower rectum. Histopathological and immunohistochemical analyses revealed NEC from the upper rectum and moderately differentiated tubular adenocarcinoma from the lower rectum. These two lesions were completely separated from each other. Therefore, this case demonstrates the synchronous occurrence of advanced NEC and tubular adenocarcinoma in the rectum.

Laparoscopic cecal cancer resection in a patient with a ventriculoperitoneal shunt: A case report.

INTRODUCTION: The presence of a ventriculoperitoneal shunt has been considered to be a contraindication for laparoscopic surgery till date; however, laparoscopic cholecystectomy was recently reported as safe for patients with this shunt. PRESENTATION OF CASE: We present the first case, to the best of our knowledge, of laparoscopic colectomy for cecal cancer in a patient with a ventriculoperitoneal shunt. A 59-year-old woman with a ventriculoperitoneal shunt for hydrocephalus was referred to our hospital with cecal cancer. Laparoscopic cecal cancer resection was performed successfully and uneventfully by manipulating the shunt. DISCUSSION: Clamping of the shunt catheter at the subcutaneous region was performed before insufflation of carbon dioxide to prevent adverse effects from the pneumoperitoneum. CONCLUSION: We believe that laparoscopic colectomy for colon cancer can be performed safely in patients with a ventriculoperitoneal shunt by optimal manipulation of the shunt.