High Subcutaneous Fat Area Is an Independent Risk Factor for Parastomal Hernia after Transperitoneal Colostomy for Colorectal Cancer.

Objectives: Parastomal hernia (PSH) is a common complication of colostomy; however, its risk factors remain poorly investigated. In this study, we examined the associations between sarcopenia, visceral and subcutaneous fat, and PSH in patients who underwent transperitoneal colostomy for colorectal cancer. Methods: This retrospective, single-center, cohort study included 60 patients who underwent laparoscopic or robot-assisted abdominoperineal resection or Hartmann's procedure for colorectal cancer between November 2010 and February 2022. Stoma creation was uniformly performed using the transperitoneal approach, and PSH was diagnosed via abdominal computed tomography (CT) at 1 year postoperatively. Visceral fat areas (VFAs) and subcutaneous fat areas (SFAs) were measured through preoperative CT images using an image analysis system. Risk factors for PSH were retrospectively analyzed. Results: PSH was diagnosed in 13 (21.7%) patients. In the univariate analysis, PSH was significantly associated with body mass index >22.3 kg/m2 (p=0.002), operation time >319 min (p=0.027), estimated blood loss >230 mL (p=0.008), postoperative complications (p=0.028), stoma diameter >18.6 mm (p=0.015), VFA >89.2 cm2 (p=0.005), and SFA >173.2 cm2 (p=0.001). Multivariate analyses confirmed that SFA >173.2 cm2 (odds ratio: 16.7, 95% confidence interval 1.29-217.2, p=0.031) was an independent risk factor for PSH. Conclusions: Subcutaneous fat area is significantly associated with the development of PSH after transperitoneal colostomy. Applying these insights could help to prevent PSH.

The introduction of fluoroscopic surgery: A report of an initial trial case.

INTRODUCTION: Switching from white light to fluorescence mode is necessary to confirm the fluorescence during fluorescence-guided surgery. This case report presents the use of a syringe pump to continuously inject indocyanine green (ICG), which enabled the vessels to be visualised and the operation to be performed without switching. PRESENTATION OF CASE: An Asian male patient in his 40s underwent an interval appendectomy following conservative treatment for appendicitis. Laparoscopic surgery was performed using the VISIONSENSE® system. Diluted ICG (25 mg/15 mL) was intravenously administered at 1 mL/min. The appendiceal artery was visualised in light green, and the intensity of the visualisation was defined relative to the tissue surrounding the dissected appendiceal artery. The superior rectal artery and the vessels within the mesentery of the small intestine were confirmed to be continuously visualised throughout the surgery. Therefore, continuous ICG angiography made it possible to operate while keeping the appendiceal artery visible in this case. DISCUSSION: ICG angiography enabled the operation to be performed with the appendiceal artery continuously visualised. This method was developed for use in cancer surgery; however, since operations of longer duration are speculated to require larger doses of ICG, we opted to introduce this method in an initial trial for appendectomy. CONCLUSION: The fluoroscopic surgery using a syringe pump was feasible in this first case report without switching to white light mode.

Effect of low visceral fat area on long-term survival of stage I-III colorectal cancer.

OBJECTIVE: The prognostic significance of a low visceral fat area (VFA) in colorectal cancer (CRC) remains unclear. The aim of this study was to evaluate the prognostic effects of a low VFA on the long-term outcomes of patients with CRC after laparoscopic surgery. METHODS: This retrospective study included 306 patients with stages I-III CRC who underwent R0 resection. VFA was preoperatively measured via computed tomography using image processing software. Relapse-free survival (RFS) and overall survival (OS) rates were analyzed using the Cox proportional hazards model and Kaplan-Meier curves. RESULTS: Low VFA was identified in 153 patients. The low VFA group had significantly lower RFS and OS rates than did the high VFA group (5-y RFS rates: 72 versus 89%, P = 0.0002; 5-y OS rates: 72 versus 92%, P = 0.0001). The independent significant predictors of RFS were T3 or T4 disease (hazard ratio [HR], 2.75; 95% confidence interval [CI], 1.12-6.76; P = 0.027), stage III CRC (HR, 3.49; 95% CI, 1.82-6.69; P < 0.001), low psoas muscle index (PMI; HR, 2.12; 95% CI, 1.19-3.79; P = 0.011), and low VFA (HR, 2.12; 95% CI, 1.16-3.86; P = 0.014). The independent significant predictors of OS were age ≥65 y (HR, 2.59; 95% CI, 1.13-5.92, P = 0.024), carbohydrate antigen 19-9 levels ≥37 ng/mL (HR, 2.32; 95% CI, 1.18-4.58; P = 0.015), stage III CRC (HR, 2.66; 95% CI, 1.37-5.17; P = 0.004), low PMI (HR, 2.00; 95% CI, 1.06-3.77; P = 0.031), and low VFA (HR, 2.42; 95% CI, 1.24-4.70; P = 0.009). CONCLUSION: A low preoperative VFA was significantly associated with worse RFS and OS rates in patients who underwent CRC resection.

Indocyanine Green Fluorescent Lymphography During Open Inguinal Hernia Repair: Relationship Between Lymphatic Vessel Injury and Postoperative Hydrocele.

BACKGROUND: This prospective case series analyzed patients who underwent indocyanine green (ICG) fluorescent lymphography during open inguinal hernia repair. The aim of this study was to investigate the association between ICG leakage and postoperative hydroceles in patients who underwent inguinal hernia repair. MATERIALS AND METHODS: Data were analyzed from 40 patients who underwent primary open hernia repair between October 2020 and June 2021 (44 cases in total). Hydroceles were categorized into two types: symptomatic and "ultrasonic" (detected only by ultrasound imaging). RESULTS: In the univariate analysis, hernia type (p = 0.044) and ICG leakage (p = 0.007) were independent risk factors for postoperative ultrasonic hydroceles. Additionally, mesh type (p = 0.043) and ICG leakage (p = 0.025) were independent risk factors for postoperative symptomatic hydroceles. In the multivariate analysis, ICG leakage (p = 0.034) was an independent risk factor for postoperative ultrasonic hydroceles. CONCLUSIONS: ICG leakage after inguinal hernia repair was independently associated with postoperative ultrasonic and symptomatic hydroceles. These findings suggest a relationship between lymphatic vessel injury and the incidence of postoperative hydroceles.

Utility of Novel Clavicle-lifting Technique in Mediastinal Thyroid Surgery: A Case Series Study.

BACKGROUND/AIM: Symptomatic mediastinal goitre requires surgery and is usually resectable using the cervical approach alone; however, sternotomy is occasionally required. Sternotomy is a highly invasive procedure, and its complications, including mediastinitis and osteomyelitis, can be critical. To date, there have been no reports of non-invasive techniques to avoid sternotomy for mediastinal thyroid tumours. We investigated the safety and efficacy of thyroidectomy using the clavicle lifting technique with a paediatric Kent hook. PATIENTS AND METHODS: This was a retrospective study of 8 patients who underwent thyroidectomy with a clavicle lifting technique between November 2014 and July 2021 at the Department of Surgery, International University of Health and Welfare Hospital. The primary endpoint was sternotomy avoidance rate and R0 resection rate. An extension retractor used in paediatric surgery was used for the clavicle lifting technique. RESULTS: Sternotomy avoidance rate and R0 resection rate were 100%. The mean operative time was 161±53.5 min, and the mean blood loss was 125.6±125.8 ml. There were no intraoperative or postoperative complications related to the clavicle lifting technique. CONCLUSION: Thyroidectomy with a clavicle lifting technique for mediastinal goitre and thyroid cancer is safe and useful because it avoids sternotomy without causing massive intraoperative bleeding or damage to other organs.

Colonoscopy-assisted percutaneous sigmoidopexy (CAPS) for complete rectal prolapse treatment: Case series.

Background and study aims We have previously reported on the effectiveness of colonoscopy-assisted percutaneous sigmoidopexy (CAPS) for sigmoid volvulus treatment. This study describes the CAPS application to treat complete rectal prolapse by straightening and fixing the rectum. Complete rectal prolapse is common in older women. Due to their comorbidities, management must comprise a simple, safe, and reliable surgical method not involving general anesthesia or colon resection. Patients and methods We enrolled 13 patients in our outpatient department diagnosed with complete rectal prolapse between June 2016 and 2021. The endoscope was advanced into the anterior proximal rectal wall, straightening the intussuscepted sigmoid colon and rectum to approximate the puncture site. The fixation sites were anesthetized with 1% xylocaine, and a 2-mm skin incision was made using a scalpel. A two-shot anchor was used to fix the sigmoid colon to the abdominal wall (Olympus, Tokyo, Japan). Results The median patient age was 88 years (range: 50-94). The median CAPS procedure time was 30 minutes (range: 20-60). In one patient, the transverse colon was accidentally punctured and interposed between the abdominal wall and sigmoid colon, requiring a laparotomy to remove the causative fixation thread and provide re-fixation. Fecal incontinence was resolved in 10 of 13 cases. Conclusions CAPS is a quick and simple procedure. In addition, it is a treatment option for complete rectal prolapse that can be performed under local anesthesia.

Efficacy and Safety of Gastrointestinal Tumour Site Marking with da Vinci-Compatible Near-Infrared Fluorescent Clips: A Case Series.

BACKGROUND: The conventional near-infrared fluorescent clip (NIRFC) ZEOCLIP FS® has been used successfully in marking tumour sites during laparoscopic surgeries. However, this clip is difficult to observe with the Firefly imaging system equipped with the da Vinci® surgical system. We have been involved in the modification of ZEOCLIP FS® and development of da Vinci-compatible NIRFC. This is the first prospective single-centre case series study verifying the usefulness and safety of the da Vinci-compatible NIRFC. METHODS: Twenty-eight consecutive patients undergoing da Vinci®-assisted surgery for gastrointestinal cancer (16 gastric, 4 oesophageal, and 8 rectal cases) between May 2021 and May 2022 were enrolled. RESULTS: Tumour location was identified by the da Vinci-compatible NIRFCs in 21 of 28 (75%) patients, which involved 12 gastric (75%), 4 oesophageal (100%), and 5 rectal (62%) cancer cases. No adverse events were observed. CONCLUSION: Tumour site marking with da Vinci-compatible NIRFC was feasible in 28 patients enrolled in this study. Further studies are warranted to substantiate the safety and improve the recognition rate.

A technique for esophagojejunostomy following robot-assisted gastrectomy: a liner stapler and barbed suture device-based technique: a case series.

Intracorporeal esophagojejunostomy after total or proximal robot-assisted gastrectomy is technically more demanding than gastroduodenostomy and gastrojejunostomy for distal gastrectomy, as well as laparoscopic surgery. We have established a safe and simple esophagojejunostomy procedure using a liner stapler attached to the Da Vinci Surgical System and a barbed suture device. Patients and methods: For esophagojejunostomy after total gastrectomy or proximal gastrectomy with double-tract reconstruction, we choose the "overlap method," in which entry holes were made at the left of the esophageal stump and at 5 cm of the anal side in antimesentric area of the jejunum, followed by anastomosis on the left of the esophagus using SureForm (blue 45 mm) and hand-sewing closure of the common entry hole with V-Loc. We analyzed the short-term surgical outcomes of all patients. Results: 23 patients underwent this reconstruction technique. None of the patients required any further open surgeries. The mean time to perform anastomosis was 24.7±2.8 min. The postoperative course was uneventful in 22 patients; a single patient developed minor anastomotic leakage (Clavien-Dindo grade 3), which was treated with conservative therapy employing a drainage tube. Conclusion: Our esophagojejunostomy method following robot-assisted gastrectomy is simple and feasible, with acceptable short-term outcomes, and could represent the procedure of choice for esophagojejunostomy.

Traditional Serrated Adenoma of the Ileum with Intussusception Successfully Treated with Laparoscopic Bowel Resection.

The most common site of traditional serrated adenomas (TSA) is the area from the left colon to the rectum; however, there are few reports on TSA in the small intestine. Herein, we report a case of TSA of the ileum with intussusception that was diagnosed and successfully treated with laparoscopic bowel resection. The patient was a 29-year-old female with the chief complaint of recurrent abdominal pain and vomiting. Contrast-enhanced computed tomography showed a mass in the ileum and intussusception with the mass as the lead point. The patient was diagnosed with intussusception secondary to a small intestinal tumor. Due to the difficulty in endoscopic treatment resulting from the localization of the lesion, elective laparoscopic surgery was planned. Intra-abdominal examination revealed intussusception of the small intestine in the pelvic ileum, and an elastic soft mass 400 cm from the ligament of Treitz was identified at the lead point of intussusception. Partial laparoscopic resection of the small intestine was performed, with an operation time of 81 min, and a small amount of bleeding. The pathological diagnosis was TSA of the ileum, and the patient's postoperative course was good, with no complications. Seven months after the surgery, no recurrence of symptoms was observed. Therefore, from our case of TSA of the ileum with intussusception that was successfully treated with laparoscopic bowel resection, we conclude that when intussusception of the small intestine occurs, TSA of the ileum with malignant potential is possible, and early diagnosis by resection should be considered.

Prognostic significance of the cachexia index in patients with stage I-III colorectal cancer who underwent laparoscopic surgery.

PURPOSE: The prognostic significance of the cachexia index, a novel biomarker of cancer cachexia, remains unclear in colorectal cancer; we, therefore, evaluated this relationship. METHODS: This retrospective cohort study included 306 patients with stage I-III colorectal cancer who underwent R0 resection between April 2010 and March 2020. The cachexia index was calculated as (skeletal muscle index [cm2/m2] × serum albumin level [g/dL])/neutrophil-to-lymphocyte ratio. The overall and disease-free survival rates were analyzed using a Cox proportional hazards model. RESULTS: A low cachexia index was found in 94 patients. This group had significantly lower disease-free survival and overall survival than the high-cachexia index group (5-year survival, 86.3% vs. 63.1%, p < 0.01; 87.9% vs. 67.2%, p < 0.01). Multivariate analyses showed that T3 or T4 (hazard ratio [HR]: 2.56; 95% confidence interval CI 1.04-6.25, p = 0.039), stage III (HR: 3.77; 95% CI 1.79-7.93, p < 0.01), and a low cachexia index (HR: 2.27; 95% CI 1.31-3.90, p = 0.003) were significant independent predictors of the disease-free survival. CA19-9 ≥ 37.0 ng/mL (HR: 2.68; 95% CI: 1.37-5.24, p = 0.004), stage III (HR: 2.57; 95% CI 1.34-4.92, p = 0.004), and a low cachexia index (HR: 2.35; 95% CI 1.31-4.21, p = 0.004) were significant independent predictors of the overall survival. CONCLUSION: A low cachexia index might be a long-term prognostic factor of colorectal cancer.

Real-time vessel navigation using indocyanine green fluorescence during robotic-assisted gastrectomy for gastric cancer after coronary artery bypass grafting using the right gastroepiploic artery.

Injury to the right gastroepiploic artery (RGEA) graft during gastrectomy after coronary artery bypass grafting (CABG) can cause critical coronary failure. A man in his 60s with advanced gastric cancer and a history of CABG was admitted to our hospital. His cardiac blood flow was dependent on RGEA, and a gastrectomy with RGEA preservation was necessary. Robot-assisted distal gastrectomy with real-time vessel navigation using indocyanine green (ICG) fluorescence imaging and Da Vinci Firefly technology was planned. Intraperitoneal observation revealed severe adhesions around the graft. Two milliliters ICG (2.5 mg/mL) was injected intravenously, and RGEA was visualized. An RGEA-preserving robot-assisted distal gastrectomy was successfully performed. The operation time was 279 minutes, and the blood loss was 5 mL. The postoperative course was good and there were no complications.

Colonoscopy-assisted percutaneous sigmoidopexy for a complete rectal prolapse: A case report.

Colonoscopy-assisted percutaneous sigmoidopexy is a simple and swift procedure that does not require general anesthesia. While we first developed this procedure for treating sigmoid volvulus, we herein present the first case in which we used it to correct a complete rectal prolapse in an older patient. Existing treatment modalities for rectal prolapses are limited by high recurrence rates, greater invasiveness, and greater complications; thus, there is a need for minimally invasive techniques that are associated with lower recurrence rates and fewer complications. In this case, a woman in her 90s complained of persistent fecal incontinence, dysuria, anal pain, and difficulty in walking. She was diagnosed with a complete rectal prolapse of 15 cm and was treated with colonoscopy-assisted percutaneous sigmoidopexy. The sigmoid colon was tractioned colonoscopically and fixed to the abdominal wall to immobilize the prolapsed rectum. The patient developed no complications intraoperatively and postoperatively and experienced no recurrence during a 5-year postoperative period. This report documents the first case wherein colonoscopy-assisted percutaneous sigmoidopexy was used successfully to correct a complete rectal prolapse.

Risk factors for refractory enterocutaneous fistula following button jejunostomy removal and its treatment using a novel extraperitoneal approach in patients with oesophageal cancer: a retrospective cohort study.

BACKGROUND: Enterocutaneous fistula after removal of the jejunostomy tube leads to multiple problems, such as cosmetic problems, decreased quality of life, electrolyte imbalances, infectious complications, and increased medical costs. However, the risk factors for refractory enterocutaneous fistula (REF) after button jejunostomy removal remain unclear. Therefore, in this study, we assessed the risk factors for REF after button jejunostomy removal in patients with oesophageal cancer and reported the surgical outcomes of the novel extraperitoneal approach (EPA) for REF closure. METHODS: This retrospective cohort study included 47 patients who underwent button jejunostomy removal after oesophagectomy for oesophageal cancer. We assessed the risk factors for REF in these patients and reported the surgical outcomes of the novel EPA for REF closure at the International University of Health and Welfare Hospital between March 2013 and October 2021. The primary endpoint was defined as the occurrence of REF after removal of the button jejunostomy, which was assessed using a maintained database. The risk factors and outcomes of the EPA for REF closure were retrospectively analysed. RESULTS: REFs occurred in 15 (31.9%) patients. In the univariate analysis, REF was significantly more common in patients with albumin level < 4.0 g/dL (p = 0.026), duration > 12 months for button jejunostomy removal (p = 0.003), and with a fistula < 15.0 mm (p = 0.002). The multivariate analysis revealed that a duration > 12 months for button jejunostomy removal (odds ratio [OR]: 7.15; 95% confidence interval [CI]: 1.38-36.8; p = 0.019) and fistula < 15.0 mm (OR: 8.08; 95% CI: 1.50-43.6; p = 0.002) were independent risk factors for REF. EPA for REF closure was performed in 15 patients. The technical success rate of EPA was 88.2%. Of the 15 EPA procedures, fistula closure was achieved in 12 (80.0%). The complications of EPA (11.7%) were major leakages (n = 3) and for two of them, EPA procedure was re-performed, and closure of the fistula was finally achieved. CONCLUSION: This study suggested that duration > 12 months for button jejunostomy removal and fistula < 15.0 mm are the independent risk factors for REF after button jejunostomy removal. EPA for REF closure is a novel, simple, and useful surgical option for patients with REF after oesophagectomy.

A novel method for treating complete rectal prolapse with laparoscopic sigmoidopexy to the abdominal wall: A case report.

INTRODUCTION: The existing treatment methods for rectal prolapse still have problems in terms of their recurrence, invasiveness, and complications; hence, minimally invasive techniques with fewer recurrences and complications are necessary. We performed laparoscopic sigmoidopexy to the abdominal wall to treat complete rectal prolapse. PRESENTATION OF CASE: An Asian woman in her 80s presented with a complaint of constant faecal and urinary incontinence. She was diagnosed with a 4 cm complete rectal prolapse and underwent surgery. The sigmoid colon was tractioned laparoscopically and fixed to the abdominal wall. The patient had no intraoperative or postoperative complications, and her defaecation was well-controlled without recurrence for one year after surgery. DISCUSSION: In this study, we performed laparoscopic sigmoidopexy to the abdominal wall with good results. CONCLUSION: This simple method, which requires only five sutures, can be a candidate treatment method for complete rectal prolapse.

Association between masseter muscle sarcopenia and postoperative pneumonia in patients with esophageal cancer.

Sarcopenia affects the swallowing and chewing muscles, such as the masseter muscle. However, the significance of masseter muscle loss in pneumonia remains unclear. We investigated the effects of masseter muscle sarcopenia (MMS) on postoperative pneumonia in patients with esophageal cancer. In this retrospective cohort study, we analyzed the data of 86 patients who underwent esophagectomy for stage I-III esophageal cancer at our hospital between March 2013 and October 2021. The primary endpoint was postoperative pneumonia within 3 months of surgery. MMS was defined as a (1) masseter muscle index (MMI) that was less than the sex-specific MMI cutoff values, and (2) sarcopenia diagnosed using the L3-psoas muscle index (L3-PMI). Postoperative pneumonia was noted in 27 (31.3%) patients. In multivariate analysis, FEV1.0 < 1.5 L (odds ratio, OR: 10.3; 95% confidence interval, CI 1.56-67.4; p = 0.015), RLNP (OR: 5.14; 95%CI 1.47-17.9; p = 0.010), and MMS (OR: 4.83; 95%CI 1.48-15.8; p = 0.009) were independent risk factors for postoperative pneumonia. The overall survival was significantly worse in patients with pneumonia (log-rank: p = 0.01) than in those without pneumonia. Preoperative MMS may serve as a predictor of postoperative pneumonia in patients with esophageal cancer.

Acute respiratory distress syndrome due to sepsis caused by Bacteroides ovatus after acute appendicectomy.

BACKGROUND: Appendicectomy is generally a minimally invasive surgery, after which postoperative complications such as acute respiratory distress syndrome (ARDS) are rare. We describe a case of ARDS due to sepsis caused by Bacteroides ovatus after appendicectomy. CASE PRESENTATION: A man in his 60 s presented to our hospital with a chief complaint of right lower quadrant abdominal pain. He was diagnosed with acute appendicitis and underwent emergency laparoscopic appendicectomy. Cefmetazole was administered as a perioperative antibacterial drug. Postoperatively, the abdominal findings improved. However, on postoperative day three, bloody sputum and respiratory distress were observed. We performed thoracoabdominal computed tomography (CT) and observed bilateral pleural effusion and mottled frosted glass shadows extending to both lung fields. ARDS was diagnosed. We treated the patient with steroids and sivelestat sodium and switched the antibacterial drug to meropenem. The patient's general condition improved. After the patient was treated, Bacteroides ovatus was isolated from preoperative blood culture, which was resistant to cefmetazole. CONCLUSIONS: We encountered a case in which ARDS due to sepsis was caused by Bacteroides ovatus after acute appendicectomy. Blood culture to isolate the causative organism and determine its antimicrobial sensitivity after commencement of empiric antibiotics is important even in common diseases, such as acute appendicitis.

Usefulness of percutaneous transesophageal gastrotubing for gastric outlet obstruction secondary to duodenal ulcer, a case report.

Severe duodenal ulcer stenosis requires continuous decompression, which makes oral ingestion difficult, yet poor nutritional status before surgery increases the risk postoperative complications. Double percutaneous transesophageal gastrotubing (dPTEG) is a new treatment that provides both decompression and enteral nutrition. We report a case of duodenal ulcer scar stenosis in which dPTEG was used for preoperative management. A man in his 40s visited our hospital with vomiting as a chief complaint. CT scan showed duodenal ulcer stenosis. As the existence of malignant disease could not be ruled out, surgery was planned. Before surgery, dPTEG was inserted to achieve decompression and nutritional management. The patient's gastric distension and nutritional status improved significantly, and laparoscopic distal gastrectomy was performed 22 days after the insertion. dPTEG may be an effective management method for patients with pyloric stenosis due to duodenal ulcer.

Near-infrared fluorescence clip guided robot-assisted wedge resection of a gastric submucosal tumour: A case report.

BACKGROUND: The conventional near-infrared fluorescence clip (NIRFC): ZEOCLIP FS®, was difficult to observe using the Firefly on da Vinci. We improved the ZEOCLIP FS® and produced the da Vinci compatible NIRFC. In this report, we describe a robot-assisted wedge resection of a submucosal tumour (SMT) of the stomach using the da Vinci compatible NIRFC. PRESENTATION OF CASE: Surgery was performed for an enlarging SMT (from 18 to 22 mm with an intragastric growth type). Through endoscopy, four da Vinci-compatible NIRFCs were placed at the tumour edge two days prior to the surgery. The location of the NIRFC was confirmed when observed with the Firefly. The distal NIRFC site was incised with a monopolar shear blade to identify the NIRFCs and tumour base. The open area was sutured in two layers using a 3-0 V-Loc. The operation time was 83 min, and the amount of blood loss was 2 g. There were no complications or clip dropout. DISCUSSION: This method could be performed without intraoperative endoscopist. CONCLUSION: In this case, we were able to observe the position of the da Vinci-compatible NIRFC with Firefly on da Vinci. This technique may be an option as a simple procedure to minimize the resection area of the stomach.