Association between loss of hypercoagulable phenotype, clinical features and complement pathway consumption in COVID-19.

Background: Coronavirus disease 2019 (COVID-19) features a hypercoagulable state, but therapeutic anticoagulation effectiveness varies with disease severity. We aimed to evaluate the dynamics of the coagulation profile and its association with COVID-19 severity, outcomes, and biomarker trajectories. Methods: This multicenter, prospective, observational study included patients with COVID-19 requiring respiratory support. Rotational thromboelastometry findings were evaluated for coagulation and fibrinolysis status. Hypercoagulable status was defined as supranormal range of maximum clot elasticity in an external pathway. Longitudinal laboratory parameters were collected to characterize the coagulation phenotype. Results: Of 166 patients, 90 (54%) were severely ill at inclusion (invasive mechanical ventilation, 84; extracorporeal membrane oxygenation, 6). Higher maximum elasticity (P=0.02) and lower maximum lysis in the external pathway (P=0.03) were observed in severely ill patients compared with the corresponding values in patients on non-invasive oxygen supplementation. Hypercoagulability components correlated with platelet and fibrinogen levels. Hypercoagulable phenotype was associated with favorable outcomes in severely ill patients, while normocoagulable phenotype was not (median time to recovery, 15 days vs. 27 days, P=0.002), but no significant association was observed in moderately ill patients. In patients with severe COVID-19, lower initial C3, minimum C3, CH50, and greater changes in CH50 were associated with the normocoagulable phenotype. Changes in complement components correlated with dynamics of coagulation markers, hematocrit, and alveolar injury markers. Conclusions: While hypercoagulable states become more evident with increasing severity of respiratory disease in patients with COVID-19, normocoagulable phenotype is associated with triggered by alternative pathway activation and poor outcomes.

Effectiveness of a novel semi-closed barrier device with a personalized exhaust in cough aerosol simulation according to particle counts and visualization of particles.

Oxygen therapy is an essential treatment for patients with coronavirus disease 2019, although there is a risk of aerosolization of additional viral droplets occurring during this treatment that poses a danger to healthcare professionals. High-flow oxygen through nasal cannula (HFNC) is a vital treatment bridging low-flow oxygen therapy with tracheal intubation. Although many barrier devices (including devices without negative pressure in the barrier) have been reported in the literature, few barrier devices are suitable for HFNC and aerosol infection control procedures during HFNC have not yet been established. Hence, we built a single cough simulator model to examine the effectiveness of three protective measures (a semi-closed barrier device, a personalized exhaust, and surgical masks) administered in isolation as well as in combination using particle counter measurements and laser sheet visualization. We found that the addition of a personalized exhaust to a semi-closed barrier device reduced aerosol leakage during HFNC without negative pressure. This novel combination may thus reduce aerosol exposure during oxygen therapy, enhance the protection of healthcare workers, and likely reduce nosocomial infection risk.

Isolated internal iliac artery aneurysm causing rectal necrosis due to compression early after endovascular repair: A case report.

INTRODUCTION: Recently, endovascular repair has become the first-line treatment for internal iliac artery aneurysm (IIAA). However, rectal necrosis due to the compression of the residual IIAA early after endovascular repair is rare. PRESENTATION OF CASE: We present a rare case of a huge, isolated left IIAA that severely compressed the rectum and ureter. The patient underwent emergency endovascular repair; however, rectal necrosis occurred 10 days later because the repair failed to shrink the size of the aneurismal sac. DISCUSSION: We hypothesize that the compression of the residual IIAA caused rectal necrosis. During open surgery, endovascular repair disrupted blood flow within the IIAA, which probably allowed for aneurysm dissection and residual hematoma removal. CONCLUSION: Endovascular repair alone could not immediately release compression on the surrounding organs; however, open surgical removal of aneurysms after successful endovascular repair may be a useful option for IIAAs with compression of surrounding organs.

Surgical Resection of Anastomotic Stenosis after Rectal Cancer Surgery Using a Circular Stapler and Colostomy with Double Orifice.

The double stapling technique has greatly facilitated intestinal reconstruction, particularly for anastomosis after anterior resection. However, anastomotic stenosis may occur, which sometimes requires surgical treatment. Redo surgery with reresection and reanastomosis presents a high risk of complications. Treatment methods need to be selected depending on the degree and location of stenosis. In an effort to propose a new resolution, reporting new cases and sharing valid experiences are necessary. An 82-year-old man diagnosed with rectal cancer had undergone laparoscopic anterior resection. Endoscopic balloon dilation performed for anastomotic stenosis had failed. Therefore, colostomy with double orifice was constructed on the oral side at 10 cm from the stenosis. Approaching from the anal and stoma side, the anastomotic stenosis was resected using a circular stapler. The colostomy was closed 1 month after surgery. Stenosis resection using a circular stapler requires the following steps: (1) passing the center shaft through the stenosis, (2) inserting the anvil head into the oral side of the stenosis, and (3) attaching the anvil head to the center shaft. This method can resect the stenosis using a circular stapler without being affected by postoperative adhesion in the pelvis. Compared to endoscopic balloon dilation, resection of the stricture by the circular stapler is thought to be reliable. This technique is particularly effective for localized stenosis, including anastomotic stenosis. It is considered that this method is minimally invasive and is low risk for complications. This method can contribute to the useful surgical option for refractory anastomotic stenosis after anterior resection.

Transarterial Embolization With Complementary Surgical Ligation of Gastroduodenal Artery for Ruptured Pancreaticoduodenal Artery Aneurysm.

The association between pancreaticoduodenal artery aneurysm (PDAA) and local hemodynamic changes in pancreaticoduodenal arcades is well established. However, there are few case reports of PDAA associated with acute aortic dissection. In this article, we outline and discuss the case of a 61-year-old man diagnosed with a type A acute aortic dissection who underwent emergency surgery and developed sudden-onset severe abdominal pain and shock 10 days later. Contrast-enhanced computed tomography showed a ruptured PDAA with feeding vessels from the gastroduodenal and superior mesenteric arteries, with evidence that the celiac artery was diverged from a false lumen. Transarterial embolization via the superior mesenteric artery alone was not expected to achieve hemostasis, so we performed a hybrid procedure involving transarterial embolization cannulated from superior mesenteric artery with complementary surgical ligation of the gastroduodenal artery. The postoperative course was uneventful, and follow-up contrast-enhanced computed tomography showed no persistence of the aneurysm 8 days after the second operation. This case proposed that visceral arterial malperfusion due to acute aortic dissection can cause PDAA in the early postoperative period. Although previous reports suggest that endovascular treatment is preferable, it may not always be feasible. Since ruptured PDAAs are often not detected during surgery, surgical treatment can be overly invasive. Whereas, transarterial embolization with complementary clamping or ligation of the gastroduodenal artery for ruptured PDAA is less invasive and can control hemorrhage, especially when cannulation to the celiac artery is impossible. Notably, the technique did not cause organ ischemia, presumably because the small collateral vessels of the pancreaticoduodenal arcades permitted sufficient blood flow. If endovascular treatment is unable to achieve rapid hemostasis, this technique may be a useful option for ruptured PDAA.

Iatrogenic esophageal perforation that could be treated indirectly by cervical esophagostomy and laparoscopic surgery.

INTRODUCTION: Successful nonoperative management has been reported for esophageal perforation; however, some cases require surgery. CASE PRESENTATION: We presented the case of an 85-year-old woman with iatrogenic thoracic esophageal perforation in whom primary repair or resection of the perforated esophagus was difficult because she was elderly and had severe aortic valve stenosis. Therefore, we selected a two-stage surgery; laparoscopic gastrostomy, jejunostomy, posterior mediastinal drainage, and cervical esophagostomy were performed. We planned reconstruction after the perforation was closed, but endoscopic examination revealed spontaneous patency of each esophageal stump. Endoscopic balloon dilation was necessary because of esophageal stenosis; however, anastomotic surgery was unnecessary. CONCLUSION: This case report suggests that esophageal perforation is resolved without direct closure if appropriate drainage is performed.

A case of synchronous advanced gastric cancer and locally advanced prostate cancer with combined laparoscopic and robotic surgery: A case report.

INTRODUCTION: The optimal management strategy for synchronous gastric cancer (GC) and prostate cancer (PCa) remains unclear, particularly in cases in which two cancers are progressive. PRESENTATION OF CASE: A 68-year-old man diagnosed with synchronous advanced GC and locally advanced PCa was referred to our institution. Laparoscopic total gastrectomy (LTG) and robotic-assisted radical prostatectomy were simultaneously performed. The postoperative course was similar to the standard postoperative course of LTG alone. Pathological diagnoses were T3N3aM0 gastric adenocarcinoma and T3N0M0 prostatic adenocarcinoma. Adjuvant chemotherapy and adjuvant androgen deprivation therapy (ADT) for GC and PCa were initiated on postoperative days 15 and 27, respectively. Six months subsequent to surgery, the patient received adjuvant chemotherapy and ADT, and no evidence of cancer recurrence was observed. DISCUSSION: In terms of survival, curative resection with adjuvant therapy is advantageous for patients with advanced GC or locally advanced PCa. At present, treatment for synchronous cancer should be combined with optimal management for individual cancers. Minimally invasive surgery may play an important role in the multidisciplinary treatment of synchronous advanced cancer. CONCLUSION: Combined laparoscopic and robotic surgery for synchronous GC and PCa allows for minimally invasive radical resection and appropriate adjuvant therapy.

A rare case of for synchronous advanced cancer of ascending colon and urinary bladder with simultaneous laparoscopic resection: A case report.

INTRODUCTION: Advances in diagnostic techniques have resulted in an increase in the diagnosis of numerous patients with multiple primary cancers. However, the diagnosis of synchronous primary colorectal cancer and bladder cancer remains rare. PRESENTATION OF CASE: A 69-year-old man diagnosed with synchronous advanced cancer of the ascending colon and urinary bladder underwent simultaneous laparoscopic resection. His postoperative course was similar to that of routine colorectal cancer. The patient refused adjuvant therapy. The patient was diagnosed as having recurrence of bladder cancer 3 months after surgery; he died 9 months after surgery. DISCUSSION: For multiple primary malignant tumors, simultaneous tumor resection is preferred. Simultaneous laparoscopic resection may be proposed for postoperative multidisciplinary treatment. If an established regimen is determined in the future, neoadjuvant chemotherapy may be an option for the treatment of synchronous advanced cancer. CONCLUSION: Simultaneous laparoscopic surgery is a greatly beneficial approach for synchronous cancer requiring multidisciplinary treatment. Additionally, an appropriate support system for patients is indispensable for completing multidisciplinary treatment.

Laparoscopic Resection of Advanced Colorectal Cancer in a Patient with Lumboperitoneal Shunt.

A 78-year-old woman with lumboperitoneal (LP) shunt was diagnosed with advanced cancer of the ascending colon. Laparoscopic right hemicolectomy was performed without manipulating the catheter. The patient's postoperative course was uneventful, with no shunt-related complications or neurological deficit. The number of patients with cerebrospinal fluid (CSF) shunt who require abdominal surgery has been increasing. There are only few studies on laparoscopic surgery for patients with LP shunt, and the safety of pneumoperitoneum in the CSF shunt remains controversial. Consistent with other studies, we considered that pneumoperitoneum with a pressure of 10 mmHg has few negative effects. Our recommendations are as follows: (1) during colorectal resection, laparoscopic surgery can be performed without routine manipulation of the shunt catheter; (2) altering the location of the port is necessary to prevent both damage to the shunt tube during surgery and wound infection postoperatively; and (3) laparoscopic surgery is superior to laparotomy because it is associated with reduced surgical site infections and postoperative adhesions. However, laparoscopy should be performed at least 3 months after the construction of CSF shunt.

Combined laparoscopic and robotic surgery for synchronous colorectal and genitourinary cancer: A case series.

INTRODUCTION: Advances in diagnostic techniques and treatment have resulted in an increase in patients with synchronous cancer. Surgical reports of combined laparoscopic and robotic resection for synchronous colorectal and genitourinary cancer are rare. MATERIALS AND METHODS: Between August 2015 and November 2017, three patients underwent combined laparoscopic and robotic surgery for synchronous colorectal and genitourinary cancer in our hospital. RESULTS: Case 1 was a 59-year-old man with synchronous rectal and prostate cancer treated by combined laparoscopic anterior resection and robotic-assisted prostatectomy. Case 2 was a 77-year-old man with synchronous cancer of transverse colon and left kidney treated by combined laparoscopic transverse colectomy and robotic-assisted partial nephrectomy. Case 3 was a 74-year-old man with synchronous adenocarcinoma of descending colon and prostate treated by combined laparoscopic left hemicolectomy and robotic-assisted prostatectomy. DISCUSSION: In simultaneous endoscopic surgery, it is necessary to consider sequence of resection, intraoperative position of patient and port arrangement. Simultaneous surgery allows promptly for postoperative adjuvant chemotherapy. CONCLUSION: Combined laparoscopic and robotic surgery for synchronous colorectal and genitourinary cancer is suitable for advanced cancer cases requiring multidisciplinary treatment.

Laparoscopic Resection of Appendiceal Schwannoma.

BACKGROUND: Schwannoma arises from Schwann's cell of the neural sheath. Schwannoma of the large intestine, particularly of the appendix, is rare. We report a case of appendiceal schwannoma resected using laparoscopic surgery. CASE PRESENTATION: A 75-year-old man was referred to our hospital for abdominal fullness and nausea since 2 months. Abdominal CT revealed a well-demarcated oval mass of 25 mm at the tip of the appendix. Contrast-enhanced CT revealed a lesion with gradually enhanced contrast from the arterial phase to the equilibrium phase. Abdominal US revealed a well-demarcated hypoechoic tumor. Preoperative diagnosis indicated appendiceal mesenchymal or neuroendocrine tumor. Ileocecal resection with D3 lymph node dissection was performed. Pathological and immunohistochemical findings confirmed the diagnosis of appendiceal schwannoma. CONCLUSIONS: For determining the surgical procedure of nonepithelial tumor of the appendix, preoperative diagnosis of mesenchymal or neuroendocrine tumors is required. However, appendiceal schwannoma is extremely rare, and its characteristic findings have not yet been established. Accumulating cases of appendiceal schwannomas is necessary for improving imaging diagnosis and surgical treatment.