Primary hepatic chronic expanding hematoma: a case report and literature review.

Chronic expanding hematoma (CEH), first reported in 1968, is a hematoma that gradually enlarges over a long course of time after an initial period of bleeding. It can occur anywhere in the body; however, there are many reports of its occurrence in the thoracic cavity. Primary hepatic CEH is extremely rare. In this current study, we report on a case of primary hepatic CEH diagnosed preoperatively, with a review of the literature. A 68-year-old man presented with liver dysfunction. Abdominal computed tomography revealed a giant cystic tumor in the left lobe of the liver, with a longer axis of approximately 12 cm. Magnetic resonance imaging revealed a mosaic pattern with a mixture of high and low signals within the tumor on T1-weighted images and a high signal at the tumor margin on T2-weighted images. Based on these findings, primary hepatic CEH was suspected. However, other malignant tumors could not be excluded owing to tumor compression resulting in bile duct dilatation. Left trisectionectomy was performed, followed by bile duct drainage and percutaneous transhepatic portal vein embolization. Intraoperative hemorrhage was controlled by the Pringle maneuver and with temporary clamping of the inferior vena cava. Pathological examination revealed a pseudocyst containing a clot, consistent with CEH. In conclusions, the case report illustrates the potential to enhance preoperative diagnosis, inform surgical approaches, and minimize associated risks. Furthermore, it highlights the importance of increasing awareness and research on this condition for improved clinical decision-making and patient care.

Early Identification of Patients with Potential Failure of Nonoperative Management for Gastroduodenal Peptic Ulcer Perforation.

INTRODUCTION: We aimed to identify objective factors associated with failure of nonoperative management (NOM) of gastroduodenal peptic ulcer perforation (GDUP) and establish a scoring model for early identification of patients in whom NOM of GDUP may fail. METHODS: A total of 71 patients with GDUP were divided into NOM (cases of NOM success) and operation groups (cases requiring emergency operation or conversion from NOM to operation). Using logistic regression analysis, a scoring model was established based on the independent factors. The patients were stratified into low-risk and high-risk groups according to the scores. RESULTS: Of the 71 patients, 18 and 53 were in the NOM and operation groups, respectively. Ascites in the pelvic cavity on computed tomography (CT) and sequential organ failure assessment (SOFA) score at admission were identified as independent factors for NOM failure. The scoring model was established based on the presence of ascites in the pelvic cavity on CT and SOFA score ≥2 at admission. The operation rates for GDUP were 28.6% and 86.0% in the low-risk (score, 0) and high-risk groups (scores, 2 and 4), respectively. CONCLUSION: Our scoring model may help determine NOM failure or success in patients with GDUP and make decisions regarding initial treatment.

Preoperative scoring system for prediction of extended resection during emergency surgery for acute appendicitis.

PURPOSE: Appendicectomy is the primary treatment for acute appendicitis. However, extended resection (ER) may be required in difficult cases. Preoperative prediction of ER may identify challenging cases but remains difficult. We aimed to establish a preoperative scoring system for ER prediction during emergency surgery for acute appendicitis. METHODS: This was a single-center retrospective study. Patients who underwent emergency surgery for acute appendicitis between January 2014 and December 2022 were included and divided into ER and appendicectomy groups. Independent variables associated with ER were identified using multivariate logistic regression analysis. A new scoring system was established based on these independent variables. The discrimination of the new scoring system was assessed using the area under the receiver operating characteristic curve (AUC). The risk categorization of the scoring system was also analyzed. RESULTS: Of the 179 patients in this study, 12 (6.7%) underwent ER. The time interval from symptom onset to surgery ≥ 4 days, a retrocecal or retrocolic appendix, and the presence of an abscess were identified as independent preoperative predictive factors for ER. The new scoring system was established based on these three variables, and the scores ranged from 0 to 6. The AUC of the scoring system was 0.877, and the rates of ER among patients in the low- (score, 0-2), medium- (score, 4), and high- (score, 6) risk groups were estimated to be 2.5%, 28.6%, and 80%, respectively. CONCLUSION: Our scoring system may help surgeons identify patients with acute appendicitis requiring ER and facilitate decision-making regarding treatment options.

Development of a scoring model based on objective factors to predict gangrenous/perforated appendicitis.

BACKGROUND: The mortality rate of gangrenous/perforated appendicitis is higher than that of uncomplicated appendicitis. However, non-operative management of such patients is ineffective. This necessitates their careful exam at presentation to identify gangrenous/perforated appendicitis and aid surgical decision-making. Therefore, this study aimed to develop a new scoring model based on objective findings to predict gangrenous/perforated appendicitis in adults. METHODS: We retrospectively analyzed 151 patients with acute appendicitis who underwent emergency surgery between January 2014 and June 2021. We performed univariate and multivariate analyses to identify independent objective predictors of gangrenous/perforated appendicitis, and a new scoring model was developed based on logistic regression coefficients for independent predictors. Receiver operating characteristic (ROC) curve analysis and the Hosmer-Lemeshow test were performed to assess the discrimination and calibration of the model. Finally, the scores were classified into three categories based on the probability of gangrenous/perforated appendicitis. RESULTS: Among the 151 patients, 85 and 66 patients were diagnosed with gangrenous/perforated appendicitis and uncomplicated appendicitis, respectively. Using the multivariate analysis, C-reactive protein level, maximal outer diameter of the appendix, and presence of appendiceal fecalith were identified as independent predictors for developing gangrenous/perforated appendicitis. Our novel scoring model was developed based on three independent predictors and ranged from 0 to 3. The area under the ROC curve was 0.792 (95% confidence interval, 0.721-0.863), and the Hosmer-Lemeshow test showed a good calibration of the novel scoring model (P = 0.716). Three risk categories were classified: low, moderate, and high risk with probabilities of 30.9%, 63.8%, and 94.4%, respectively. CONCLUSIONS: Our scoring model can objectively and reproducibly identify gangrenous/perforated appendicitis with good diagnostic accuracy and help in determining the degree of urgency and in making decisions about appendicitis management.

Risk factors for postoperative disseminated intravascular coagulation in surgical patients with non-occlusive mesenteric ischemia.

PURPOSE: The prognostic impact of disseminated intravascular coagulation (DIC) in surgical patients with non-occlusive mesenteric ischemia (NOMI) is unclear. This study aimed to confirm the association between postoperative DIC and prognosis and to identify preoperative risk factors associated with postoperative DIC. METHODS: This retrospective study included 52 patients who underwent emergency surgery for NOMI between January 2012 and March 2022. Kaplan-Meier curve analysis with the log-rank test was used to compare 30-day survival and hospital survival between patients with and without postoperative DIC. In addition, univariable and multivariable logistic regression analyses were performed to identify the preoperative risk factors for postoperative DIC. RESULTS: The 30-day and hospital mortality rates were 30.8% and 36.5%, respectively, and the incidence rate of DIC was 51.9%. Compared to patients without DIC, patients with DIC showed significantly lower rates of 30-day survival (41.5% vs 96%, log-rank P < 0.001) and hospital survival (30.2% vs 86.4%, log-rank, P < 0.001). Logistic regression analyses showed that the Japanese Association for Acute Medicine (JAAM) DIC score (OR = 2.697; 95% CI, 1.408-5.169; P = 0.003) and Sequential Organ Failure Assessment (SOFA) score (OR = 1.511; 95% CI, 1.111-2.055; P = 0.009) were independent risk factors for postoperative DIC in surgical patients with NOMI. CONCLUSION: The development of postoperative DIC is a significant prognostic factor for 30-day and hospital mortalities in surgical patients with NOMI. In addition, the JAAM DIC score and SOFA score have a high discriminative ability for predicting the development of postoperative DIC.

Efficacy of CT Value Along Portal Vein for Preoperative Prediction of Portal Vein Resection in Pancreatic Head Cancer.

BACKGROUND: It is important for surgeons to determine whether combined portal vein (PV) resection (PVR) is necessary before surgery. The present study aimed to determine the ability of computed tomography (CT) value along the PV in predicting the necessity for concomitant PVR. METHODS: A total of 107 consecutive patients who underwent pancreaticoduodenectomy (PD) for invasive ductal carcinoma of the pancreatic head at our institute between September 2007 and September 2020 were reviewed retrospectively. Univariate analysis to predict PVR was performed with preoperative radiological valuables acquired by Synapse Vincent. The resected specimen near the PV or the PV notch was analyzed by histopathological findings. RESULTS: Only the CT value of the PV was independently associated with PVR (Mann-Whitney U test; P = .045, logistic regression test; P = .039). The outer boundary of the PV was unclear in the cases without pathological PV invasion and PVR due to the development of smooth muscle in the outer membrane of the PV and the proliferation of collagen fibers. The elastic fibers were arranged regularly in the notch portion of the PV in cases wherein PVR was not performed. DISCUSSION: The CT value along the PV was independently associated with PVR and is the only predictor of PVR. These results were very useful in predicting PVR preoperatively and were histopathologically supportive.

Impact of atherosclerosis on the postoperative complications of colorectal surgery in older patients with colorectal cancer.

BACKGROUND: Atherosclerosis is associated with various comorbidities; nonetheless, its effect on the postoperative complications of colorectal surgery in older patients with colorectal cancer (CRC) remains unclear. This study aimed to evaluate the impact of atherosclerosis on the postoperative complications of colorectal surgery in older adults with CRC. METHODS: Patients aged ≥ 65 years who underwent surgery for CRC between April 2017 and October 2020 were enrolled. To evaluate atherosclerosis, we prospectively calculated the cardio-ankle vascular index (CAVI) measured by the blood pressure/pulse wave test and abdominal aortic calcification (AAC) score from computed tomography. Risk factors for Clavien-Dindo grade ≥ III postoperative complications were evaluated by univariate and logistic regression analyses. RESULTS: Overall, 124 patients were included. The mean CAVI value and AAC score were 9.5 ± 1.8 and 7.0 ± 8.0, respectively. Clavien-Dindo grade ≥ III postoperative complications were observed in 14 patients (11.3%). CAVI (odds ratio, 1.522 [95% confidence interval, 1.073-2.160], p = 0.019), AAC score (1.083 [1.009-1.163], p = 0.026); and operative time (1.007 [1.003-1.012], p = 0.001) were identified as risk factors for postoperative complications. Based on the optimal cut-off values of CAVI and AAC score, the probability of postoperative complications was 27.8% in patients with abnormal values for both parameters, which was 17.4 times higher than the 1.6% probability of postoperative complications in patients with normal values. CONCLUSIONS: Atherosclerosis, particularly that assessed using CAVI and AAC score, could be a significant predictor of postoperative complications of colorectal surgery in older adults with CRC.

Prediction model for irreversible intestinal ischemia in strangulated bowel obstruction.

BACKGROUND: Preoperatively diagnosing irreversible intestinal ischemia in patients with strangulated bowel obstruction is difficult. Therefore, this study aimed to establish a prediction model for irreversible intestinal ischemia in strangulated bowel obstruction. METHODS: We included 83 patients who underwent emergency surgery for strangulated bowel obstruction between January 2014 and March 2022. The predictors of irreversible intestinal ischemia in strangulated bowel obstruction were identified using logistic regression analysis, and a prediction model for irreversible intestinal ischemia in strangulated bowel obstruction was established using the regression coefficients. Receiver operating characteristic analysis and fivefold cross-validation was used to assess the model. RESULTS: The prediction model (range, 0-4) was established using a white blood cell count of ≥ 12,000/µL and the computed tomography value of peritoneal fluid that was ≥ 20 Hounsfield units. The areas of the receiver operating characteristic curve of the new prediction model were 0.814 and 0.807 after fivefold cross-validation. A score of ≥ 2 was strongly suggestive of irreversible intestinal ischemia in strangulated bowel obstruction and necessitated bowel resection (odds ratio = 15.938). The bowel resection rates for the prediction scores of 0, 2, and 4 were 15.2%, 66.7%, and 85.0%, respectively. CONCLUSION: Our model may help predict irreversible intestinal ischemia that necessitates bowel resection for strangulated bowel obstruction cases and thus enable surgeons to recognize the severity of the situation, prepare for deterioration of patients with progression of intestinal ischemia, and select the appropriate surgical procedure for treatment.

Prognostic Impact of N2 of the Primary Tumour in Surgical Resection for Colorectal Liver Metastases.

BACKGROUND/AIM: The status of lymph node metastasis of primary tumours remains to be completely investigated. This study investigated the prognostic impact of the degree of primary lymph node metastasis in patients with colorectal liver metastasis. PATIENTS AND METHODS: We retrospectively analysed the clinical data of 106 patients with colorectal liver metastases who underwent surgical resection. Prognostic factors, including the degree of the positive primary lymph nodes, positive lymph node ratio, and log odds of positive lymph nodes, were evaluated. RESULTS: The T factor and N2 status were independent risk factors for overall survival in patients who underwent surgical resection. Survival was significantly lower in the N2 group than in the N0-1 group. Additionally, ≥N2 status showed better prognostic performance than ≥N1 status. CONCLUSION: N2 of primary tumours is an independent useful prognostic factor in colorectal liver metastasis and can help determine the indication of surgical resection and pre/post-operative chemotherapy.

Prediction Model for Failure of Nonoperative Management of Uncomplicated Appendicitis in Adults.

BACKGROUND: Prediction of failure of nonoperative management (NOM) in uncomplicated appendicitis (UA) is difficult. This study aimed to establish a new prediction model for NOM failure in UA. METHODS: We included 141 adults with UA who received NOM as initial treatment. NOM failure was defined as conversion to operation during hospitalization. Independent predictors of NOM failure were identified using logistic regression analysis. A prediction model was established based on these independent predictors. Receiver operating characteristic (ROC) curve analysis and the Hosmer-Lemeshow test were used to assess the discrimination and calibration of the model, respectively, and risk stratification using the model was performed. RESULTS: Among 141 patients, NOM was successful in 120 and unsuccessful in 21. Male sex, maximal diameter of the appendix, and the presence of fecalith were identified as independent predictors of NOM failure for UA. A prediction model with scores ranging from 0 to 3 was established using the three variables (male sex, maximal diameter of the appendix ≥ 15 mm, and the presence of fecalith). The area under the ROC curve for the new prediction model was 0.778, and the model had good calibration (P = 0.476). A score of 2 yielded a sensitivity of 71.4% and a specificity of 90.8%. Patients were stratified into low (0-1), moderate (2), and high (3) risk categories, which had NOM rates of 5.2%, 47.1%, and 77.8%, respectively. CONCLUSIONS: Our prediction model may predict NOM failure in UA with good diagnostic accuracy and help surgeons select appropriate treatments.

New risk factors of postoperative complications in elective gastrointestinal surgery of elderly patients: a prospective cohort study.

BACKGROUND: Gastrointestinal surgery in elderly individuals presents unexpected postoperative complications. However, predicting postoperative complications in elderly patients undergoing gastrointestinal surgeries is challenging because of the lack of a reliable preoperative evaluation system. We aimed to prospectively evaluate three new preoperative assessment methods to predict the postoperative complications in elderly patients undergoing elective gastrointestinal surgery. Moreover, we aimed to identify new risk factors of postoperative complications in this patient group. METHODS: This prospective cohort study enrolled 189 patients (age ≥ 65 years) who underwent elective gastrointestinal surgery at Tokyo Medical University Hachioji Medical Center between April 2017 and March 2019. Assessments performed preoperatively included the biological impedance analysis for evaluating the skeletal muscle mass, the SF-8 questionnaire for evaluating the subjective health-related quality of life, and the blood pressure/pulse wave test for assessing arteriosclerosis. The risk factors for Clavien-Dindo Grade ≥ III postoperative complications were assessed using these new evaluation methods. RESULTS: Clavien-Dindo Grade ≥ III postoperative complications were observed in 28 patients (14.8%). Univariate and multivariate analyses identified male sex, low skeletal muscle mass, and cardio-ankle vascular index ≥ 10 (arteriosclerosis) as significant independent risk factors of developing Grade ≥ III complications. CONCLUSIONS: Male sex, low skeletal muscle mass, and arteriosclerosis were significant risk factors of postoperative complications in elderly patients undergoing elective gastrointestinal surgery. The obtained knowledge could be useful in identifying high-risk patients who require careful perioperative management.

[A Case of Left Transverse Colon Cancer Safely Resected Using Three-Dimensional CT Angiography and Indocyanine Green Fluorography].

A 77-year-old man was admitted to our hospital because of a positive occult blood test result and diagnosed as having left transverse colon cancer(cT2N0M0)on detailed examination. The patient underwent a sigmoidectomy for colon cancer 24 years previously. Three-dimensional(3D)-CT angiography was performed before the present operation. The left branch of the middle colic artery, which was independently branched, and the marginal artery of the colon were found to be supplying blood from the left side of the transverse colon to the anastomosis of the sigmoid colon. In addition, the root of the left branch of the middle colic artery arose from the caudal side of the first jejunal vein. Therefore, a left hemicolectomy was performed. In accordance with the preoperative simulation, we safely resected the left branch of the middle colic artery at the root. Intraoperative blood flow evaluation using indocyanine green(ICG)fluorography clearly displayed the demarcation of the oral blood flow and the point of anastomosis. No notable complications occurred after the surgery. The results of the pathological analyses indicated a pT1bN0M0 tumor stage. Therefore, we conclude that 3D-CT angiography and ICG fluorography are useful for performing safer operations for left transverse colon cancers.

High Serum CA19-9 Concentration Predicts Poor Prognosis in Elderly Patients with Stage IV Colorectal Cancer.

BACKGROUND/AIM: The optimal treatment strategy for elderly patients with stage IV colorectal cancer (CRC) remains controversial due to limited research data. The purpose of this study was to evaluate treatment results and to clarify the prognostic factors, especially poor prognosis factors, in elderly patients with stage IV CRC. METHODS: We retrospectively reviewed the data of 82 elderly patients (aged ≥75 years) with stage IV CRC who underwent surgical treatment at our hospital between April 2001 and March 2017. Factors that affected prognosis and the ability to undergo treatment were analyzed via multivariate analysis. RESULTS: The median overall survival (OS) in the patients with high pretreatment serum carbohydrate antigen 19-9 (CA19-9) concentration (> 370 U/mL) was significantly worse than in those with lower serum CA19-9 concentration (0-370 U/mL) (8.5 vs. 19.2 months, p = 0.0059). In univariate analysis, age (≥80 years) (p = 0.014), performance status of 1-3 (p = 0.028), and high pretreatment serum CA19-9 concentration (p = 0.014) were significant prognostic factors for poor OS. By contrast, resection of the primary tumor (p = 0.024), chemotherapy (p < 0.0001), and resection of distant metastasis (p = 0.0005) were significant prognostic factors for favorable OS. Multivariate analysis showed that a high pretreatment serum CA19-9 concentration was an independent prognostic factor for poor OS (p = 0.01). Meanwhile, resection of the primary tumor (p = 0.033), chemotherapy (p < 0.0001), and resection of distant metastasis (p = 0.0008) were prognostic factors for favorable OS. CONCLUSIONS: A high pretreatment serum CA19-9 concentration (> 370 U/mL) was a reliable predictive factor for poor prognosis, and aggressive treatments should be performed carefully in these patients. Moreover, various treatments, including surgery and chemotherapy, might improve OS in elderly patients with stage IV CRC.

The ability of positron emission tomography/computed tomography to detect synchronous colonic cancers in patients with obstructive colorectal cancer.

Positron emission tomography/computed tomography (PET/CT) is frequently used to detect colorectal cancer. The present retrospective study assessed the ability of PET/CT to identify synchronous colonic lesions in 72 patients with obstructive colorectal cancer. All patients had undergone surgical resection without undergoing preoperative total colonoscopy (TCS) at the Digestive Disease Center (April 2007 to September 2016), and subsequently underwent TCS of the proximal colon within 2 years post-surgery. A total of 11 patients exhibited 18F-fluorodeoxyglucose uptake during PET/CT of the proximal colon (4 invasive cancers, 3 advanced adenomas and 4 false-positive results), and 61 patients had no uptake in the proximal colon. Among these 61 patients, postoperative TCS revealed 2 invasive cancers and 4 advanced adenomas. The sensitivity of PET/CT for detecting synchronous invasive cancers was 66.6% (4/6), with a specificity of 89.4% (59/66), a positive predictive value of 36.4% (4/11), a negative predictive value of 96.7% (59/61), and an accuracy of 87.5% (63/72). Negative PET/CT results indicated a low probability of synchronous lesions in the proximal colon. Thus, PET/CT may be a useful tool for detecting synchronous colonic cancers in patients with obstructive colon cancer.

Safety and curability of laparoscopic gastrectomy in elderly patients with gastric cancer.

BACKGROUND: Elderly patients are often considered as a high-risk population for major abdominal surgery due to reduced functional reserve and increased comorbidities. The aim of this study was to assess the safety and curability of laparoscopic gastrectomy in elderly patients with gastric cancer compared with short- and long-term outcomes in non-elderly patients. METHODS: We retrospectively investigated 386 patients who underwent laparoscopic gastrectomy for gastric cancer between January 2007 and December 2015 at the Digestive Disease Center, Showa University, Northern Yokohama Hospital. We categorized the patients into two groups by age: the elderly patients (≥ 75 years old) and the non-elderly patients (< 74 years old). Patient characteristics, clinicopathologic and operative findings, and short- and long-term outcomes were investigated and compared between the two groups. RESULTS: The elderly group showed a significantly higher rate of comorbidities (73.1 vs. 49.2%, P < 0.001), and American Society of Anesthesiologists (ASA) scores ≥ 2 (76.3 vs. 43.7%, P < 0.001), and using anticoagulant agents (25.8 vs. 7.9%, P < 0.001) than the non-elderly group. The postoperative morbidity and mortality did not differ between the two groups (19.4 vs. 18.8%; P = 0.880, 2.2 vs. 0%; P = 0.058). In the multivariate analysis, male sex was the only risk factor for postoperative morbidity after laparoscopic gastrectomy. However, age was not found to be a risk factor. The 5-year overall survival ratio was significantly lower in the elderly group than in the non-elderly group (67.7 vs. 85.0%; P < 0.001). However, the 5-year disease-specific survival ratio was similar in the two groups (84.8 vs. 89.1%; P = 0.071). CONCLUSION: Laparoscopic gastrectomy for gastric cancer could be safely performed in elderly patients with acceptable postoperative morbidity and curability.

Artificial intelligence may help in predicting the need for additional surgery after endoscopic resection of T1 colorectal cancer.

BACKGROUND AND STUDY AIMS: Decisions concerning additional surgery after endoscopic resection of T1 colorectal cancer (CRC) are difficult because preoperative prediction of lymph node metastasis (LNM) is problematic. We investigated whether artificial intelligence can predict LNM presence, thus minimizing the need for additional surgery. PATIENTS AND METHODS: Data on 690 consecutive patients with T1 CRCs that were surgically resected in 2001 - 2016 were retrospectively analyzed. We divided patients into two groups according to date: data from 590 patients were used for machine learning for the artificial intelligence model, and the remaining 100 patients were included for model validation. The artificial intelligence model analyzed 45 clinicopathological factors and then predicted positivity or negativity for LNM. Operative specimens were used as the gold standard for the presence of LNM. The artificial intelligence model was validated by calculating the sensitivity, specificity, and accuracy for predicting LNM, and comparing these data with those of the American, European, and Japanese guidelines. RESULTS: Sensitivity was 100 % (95 % confidence interval [CI] 72 % to 100 %) in all models. Specificity of the artificial intelligence model and the American, European, and Japanese guidelines was 66 % (95 %CI 56 % to 76 %), 44 % (95 %CI 34 % to 55 %), 0 % (95 %CI 0 % to 3 %), and 0 % (95 %CI 0 % to 3 %), respectively; and accuracy was 69 % (95 %CI 59 % to 78 %), 49 % (95 %CI 39 % to 59 %), 9 % (95 %CI 4 % to 16 %), and 9 % (95 %CI 4 % - 16 %), respectively. The rates of unnecessary additional surgery attributable to misdiagnosing LNM-negative patients as having LNM were: 77 % (95 %CI 62 % to 89 %) for the artificial intelligence model, and 85 % (95 %CI 73 % to 93 %; P < 0.001), 91 % (95 %CI 84 % to 96 %; P < 0.001), and 91 % (95 %CI 84 % to 96 %; P < 0.001) for the American, European, and Japanese guidelines, respectively. CONCLUSIONS: Compared with current guidelines, artificial intelligence significantly reduced unnecessary additional surgery after endoscopic resection of T1 CRC without missing LNM positivity.

Impact of obesity on short- and long-term outcomes of laparoscopy assisted distal gastrectomy for gastric cancer.

BACKGROUND: Laparoscopy assisted distal gastrectomy (LADG) for gastric cancer has been rapidly adopted for the treatment of both early and advanced gastric cancers which need lymph node dissection, but remains difficult procedure, especially in patients with obesity. We evaluated the impact of obesity on short- and long-term outcomes of LADG for gastric cancer. METHODS: We retrospectively investigated 243 patients who underwent LADG for gastric cancer between January 2007 and December 2014. The patients were classified based on their body mass index (BMI) into the Obese (BMI ≥ 25) and Non-Obese (BMI < 25) Groups. Patient characteristics, clinicopathologic and operative findings, and short- and long-term outcomes were investigated and compared between the groups. RESULTS: The groups did not differ in age, sex, American Society of Anesthesiologists score, the presence of comorbidities, or pathologic stage. Operative time (265 ± 46.6 vs. 244 ± 55.6 min; P = 0.007) and estimated blood loss (113 ± 101.4 vs. 66.5 ± 95.2 ml; P = 0.007) were greater in the Obese Group. Fewer lymph nodes were retrieved in the Obese Group (38 ± 23.7 vs. 47.5 ± 24.3; P = 0.004). No differences were evident in postoperative complication rate (20% vs. 17%; P = 0.688) or the duration of postoperative hospital stay (9 ± 8.5 vs. 9 ± 5.1 days; P = 0.283) between the two groups. In the Obese Group, the 5-year overall survival rate was significantly lower than in the Non-Obese Group (67.6% vs. 90.3%; P = 0.036). Furthermore, 5-year disease-specific survival was significantly lower in the Obese Group than in the Non-Obese Group (72.7% vs. 94.9%; P = 0.015). CONCLUSIONS: LADG in patients with obesity could be performed as safe as in patients without obesity, with comparable postoperative results. But obesity may be a poor prognostic factor in gastric cancer.

Retrospective analysis of large bowel obstruction or perforation caused by oral preparation for colonoscopy.

BACKGROUND AND STUDY AIMS: Patients undergoing bowel preparation for colonoscopy are at risk of potentially severe adverse events such as large-bowel obstruction (LBO) and perforation. These patients usually need emergency surgery and the consequences may be fatal. Little is known about the risk factors for LBO and perforation in these circumstances. We sought to establish the natural history of LBO and perforation caused by oral preparation for colonoscopy. PATIENTS AND METHODS: We retrospectively analyzed data from 20 patients with LBO or perforation associated with oral preparation for colonoscopy. All patients were treated at the Showa University Northern Yokohama Hospital (SUNYH) between April 2001 and December 2015. Drugs used for bowel preparation, age, sex, indication for colonoscopy, pathogenesis and treatment were recorded. RESULTS: Eighteen of the patients had LBO and 2 had perforation. Fourteen events occurred at SUNYH, which accounted for 0.016 % of patients who underwent bowel preparation during this period. Seventeen patients were symptomatic when the decision to undertake colonoscopy was made (including 7 who complained of constipation and 4 who complained of abdominal pain; 3e were asymptomatic). Nineteen patients ultimately required surgery, 13 within 3 days of presentation. Eleven patients ultimately required colostomy. There was no perioperative mortality in our cases. CONCLUSION: Large bowel obstruction and perforation are rare events associated with oral preparation for colonoscopy, but frequently require surgery. Exacerbation of constipation might be a risk factor for LBO or perforation. Potentially catastrophic situations can be avoided by early detection and treatment.

Accuracy of diagnosing invasive colorectal cancer using computer-aided endocytoscopy.

Background and study aims Invasive cancer carries the risk of metastasis, and therefore, the ability to distinguish between invasive cancerous lesions and less-aggressive lesions is important. We evaluated a computer-aided diagnosis system that uses ultra-high (approximately × 400) magnification endocytoscopy (EC-CAD). Patients and methods We generated an image database from a consecutive series of 5843 endocytoscopy images of 375 lesions. For construction of a diagnostic algorithm, 5543 endocytoscopy images from 238 lesions were randomly extracted from the database for machine learning. We applied the obtained algorithm to 200 endocytoscopy images and calculated test characteristics for the diagnosis of invasive cancer. We defined a high-confidence diagnosis as having a ≥ 90 % probability of being correct. Results Of the 200 test images, 188 (94.0 %) were assessable with the EC-CAD system. Sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV) were 89.4 %, 98.9 %, 94.1 %, 98.8 %, and 90.1 %, respectively. High-confidence diagnosis had a sensitivity, specificity, accuracy, PPV, and NPV of 98.1 %, 100 %, 99.3 %, 100 %, and 98.8 %, respectively. Conclusion: EC-CAD may be a useful tool in diagnosing invasive colorectal cancer.