Comparison of Three Clinical Trials of Preoperative Predictors for Complicated Appendicitis.

BACKGROUND/AIM: We previously reported three items that preoperatively predicted complicated appendicitis (body temperature, C-reactive protein, and fluid retention around the appendix). In this study, we aimed to compare other predictors to confirm the usefulness of our predictors with those of previous reports on the items as predictors of complicated appendicitis preoperatively (criteria A which consist of 8 items, criteria B which consist of 7 items). PATIENTS AND METHODS: We retrospectively evaluated 417 adult patients who underwent surgery for acute appendicitis between January 2013 and December 2019 and compared our items with criteria A and criteria B according to the results of the area under the receiver operating characteristic curve (AUC), homogeneity, discriminatory ability, and Akaike information criterion (AIC). RESULTS: The AUC for the sensitivity to diagnose complicated appendicitis according to according to our criteria, as well as criteria A, and criteria B was 0.823, 0.839, and 0.856, respectively. The discriminatory ability linear trend χ2 of our criteria and those of criteria A and B were 128.9, 121.1, and 142.5, respectively. The homogeneity likelihood ratios χ2 calculated using the Cox regression model, which indicate homogeneity, were 146.4, 143.6, and 172.8, respectively. The AIC of each criterion was 397.0, 345.8, and 369.0, respectively. CONCLUSION: Although the criteria B were the best, it was possible to predict complicated appendicitis preoperatively by all criteria. Above all, our criteria have only three items, therefore they have the advantage of making it possible to make decisions quickly with a certain degree of accuracy, regardless of the degree of experience.

Spontaneous rupture of hemorrhagic hepatic cyst: two case reports.

BACKGROUND: Spontaneous rupture of a hemorrhagic hepatic cyst is extremely rare. There is no standard treatment recommended for this condition. We report two cases of hemorrhagic hepatic cysts that spontaneously ruptured and were successfully treated with laparoscopic deroofing. We review the literature and discuss the characteristic features of spontaneous rupture of hemorrhagic hepatic cysts and their treatment. CASE PRESENTATION: The first patient was an 85-year-old man admitted for sudden-onset right hypochondralgia and fever. Computed tomography revealed a 13-cm hepatic cyst occupying the right lobe of the liver and spontaneous rupture of the cyst. Laparoscopic deroofing was performed and continuous oozing from the cystic wall was found. Histological examination revealed a simple hepatic cyst. The patient was discharged on postoperative day 6. In the second case, a 77-year-old woman who had been followed up for a simple hepatic cyst (13 cm) was admitted for sudden onset of right hypochondralgia. Computed tomography demonstrated a 9.9-cm hepatic cyst occupying segment 4 of the liver. Laparoscopic deroofing was performed and continuous oozing from the cystic wall was observed. Histological examination revealed a simple hepatic cyst. The patient was discharged on postoperative day 6. CONCLUSION: Laparoscopic deroofing was performed in patients with spontaneous rupture of hemorrhagic nonparasitic hepatic cysts.

Laparoscopic repair of sciatic hernia recognizing the ureterohypogastric nerve fascia and vesicohypogastric fascia: a case report.

BACKGROUND: Sciatic hernias are rare pelvic floor hernias that occur through the sciatic foramen and often present as abdominal or pelvic pain, particularly in women. Historically, they were repaired using an open approach, with limited reports on their laparoscopic treatment. CASE PRESENTATION: Here we present the case of an 85-year-old woman who had repeated abdominal pain and was referred to our hospital for sciatic hernia surgery after conservative treatment. We laparoscopically observed the deep pelvis and identified the right sciatic hernia. When an extraperitoneal space was dissected, an ureterohypogastric nerve fascia (UNF) and a vesicohypogastric fascia (VF) were identified. Moreover, the maneuver to mobilize the fasciae inside from the pelvic wall made it possible to separate the ureter and urinary bladder, which might have otherwise incarcerated in the hernia. We repaired the defect of the sciatic foramen with a mesh plug and patch. The patient had an uneventful recovery, and the absence of sciatic herniation recurrence was confirmed 1 year after surgery. CONCLUSION: A laparoscopic repair of a sciatic hernia could permit detailed non-invasive observations of the deep pelvis and be performed effectively by recognizing an UNF and a VF located near the sciatic foramen.

Postoperative oral energy and protein intakes for an enhanced recovery after surgery program incorporating early enteral nutrition for pancreaticoduodenectomy: A retrospective study.

BACKGROUND: Although postoperative early oral feeding in the enhanced recovery after surgery (ERAS) program for pancreaticoduodenectomy (PD) is deemed safe, the assessment of oral intakes has been insufficient. This study aimed to investigate postoperative oral intakes and the effectiveness of an ERAS program incorporating early enteral nutrition (EN). METHODS: In total, 203 patients with PD were enrolled retrospectively. The first group (group E1; n = 61) comprised 11 ERAS care elements, whereas the second group (group E2; n = 106) comprised 19 elements. The control group (group C; n = 36) was managed using traditional care before ERAS was implemented. Postoperative energy and protein requirements were estimated at 25-30 kcal per kilogram of ideal body weight and 1.2-1.5 g per kilogram of ideal body weight, respectively, and were investigated along with the length of hospital stay (LOS). RESULTS: The oral energy and protein intakes from the diets in the ERAS groups at postoperative day 7 significantly increased compared with those in group C. Intakes in groups E1 and E2 were not significantly different and provided <30% of the requirements. However, the total intakes, which were compensated by EN, were maintained at >80% of the requirements. LOS was significantly shorter in groups E1 (31 days) and E2 (19 days) than in group C (52 days). CONCLUSIONS: Postoperative early oral energy and protein intakes of this modified ERAS program failed to meet the dietary requirements. However, early EN compensated for the shortages and contributed to the reduction of LOS.

Retroperitoneal Bronchogenic Cyst Resected by Single-Incision Laparoscopic Surgery in an Adolescent Female: A Case Report.

A 16-y-old Japanese female was referred to our hospital with a suspicion of infected retroperitoneal cyst. Abdominal CT MRI revealed a 38-mm diameter retroperitoneal cyst under the left diaphragm. Because a retroperitoneal bronchogenic cyst was suspected, total resection was planned. In addition, preoperative 3D reconstruction using multidetector CT provided a detailed location of the lesion. Based on the anatomical position, we decided that single-incision laparoscopic surgery with an anterior approach through the umbilicus would be the optimal choice. The lesion was completely resected without intraoperative complications. Histopathological examination confirmed the diagnosis of bronchogenic cyst. Postoperatively, the surgical wound became completely unnoticeable, and there was no incisional hernia or cyst recurrence at the 2-y follow-up.

Mixed neuroendocrine non-neuroendocrine neoplasm: a case report and review.

Mixed neuroendocrine non-neuroendocrine neoplasm (MiNEN) of the pancreas is a rare entity, and obtaining a preoperative diagnosis is difficult. We present a 70-year-old man in whom the possibility of MiNEN was successfully discovered preoperatively by endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA). Immunostaining revealed positive results for the neuroendocrine markers chromogranin A and synaptophysin. We considered the possibility for MiNEN before surgery. He underwent distal pancreatectomy with splenectomy. Immunohistochemical examination of the tumor cells showed a wide range of positivity for trypsin as well as for chromogranin A and synaptophysin. Considering that ≥ 30% tumors ware positive for both acinar and neuroendocrine markers, the patient was diagnosed with MiNEN. MiNEN is a malignant tumor that requires early detection and treatment but is a rare disease for which no method has been established. We found that EUS-FNA and immunostaining are effective diagnostic methods for MiNEN.

A lymphoepithelial cyst in the pancreatic accessory spleen: A case report.

We present the first report of a lymphoepithelial cyst. As additional cases will likely be encountered in the future, our study sets the precedent for future research.

Intussusception caused by small intestine metastasis of malignant pleural mesothelioma: a case report.

Malignant pleural mesothelioma (MPM) is an aggressive form of malignant tumor that originates in the pleural mesothelioma and presents as a local disease in the affected hemithorax. Small intestine metastasis is a rare complication. Herein, the case of a patient with jejunal intussusception caused by small intestine metastasis of MPM has been reported. A 72-year-old man with MPM was admitted to our hospital for abdominal pain. Computed tomography revealed small intestine intussusception. An emergency surgery was performed, and the tumor and intussusception were located in the upper jejunum. Histopathological examination of the resected jejunum revealed that the tumor was a small intestinal metastasis of the MPM from the chest wall. This case showed that MPM may metastasize to the small intestine, and metastatic tumors may cause intussusception.

Perforation of the descending colon diverticulum in a patient following recovery from severe COVID-19 pneumonia: a case report.

The outcome of surgery in patients who have recovered from severe coronavirus disease 2019 (COVID-19) is unknown. Herein, we present a case of an emergency operation for acute pan-peritonitis due to perforation of the descending colon diverticulum in a patient who recovered from severe COVID-19 pneumonia. A 59-year-old man, who had recovered from severe COVID-19 pneumonia ~6 months previously, developed acute pan-peritonitis due to perforation of a diverticulum in the descending colon. Emergency surgery was performed, and the perforation was sutured and closed. He was discharged from the hospital 13 days postoperatively. There was no relapse of COVID-19 during the perioperative period of peritonitis surgery. General perioperative management may, therefore, be sufficient in patients who have recovered from COVID-19.

Management of acute cholecystitis in patient with cyclic neutropenia: a case report.

BACKGROUND: Cyclic neutropenia is a disease that causes a neutropenic decrease in peripheral blood in a cycle of about 21 days. It is a rare hereditary disorder with an estimated incidence of 0.5-1 cases per million population. The absolute neutrophil count can drop to zero, and neutropenic nadir may last for 3-5 days. This is a rare disease, and there are few reports of abdominal surgery in cyclic neutropenia patients; thus, we report this case of neutrophil count fluctuation and perioperative management. CASE PRESENTATION: A 31-year-old man with cyclic neutropenia was transferred to our hospital complaining of right season rib pain, but no rebound tenderness. His C-reactive protein was elevated (4.37 mg/L) and computed tomography revealed a large number of small stones in the gallbladder body and an incarceration in the gallbladder neck. He was diagnosed with acute cholecystitis. Ideally, surgical intervention should have been performed immediately, but because his neutrophil count was 300/µL, endoscopic naso-gallbladder drainage was performed and he was provided antibiotics until his neutrophil count increased to acceptable levels. Three days after admission, his neutrophil count had increased and laparoscopic cholecystectomy was performed. For one week after the operation, antibiotics were administered; he had an uneventful postoperative recovery. He was discharged on the seventh postoperative day and provided an oral antibiotic. CONCLUSIONS: Infection can be serious in patients with cyclic neutropenia, and it is therefore, important to determine the timing of surgery and to apply appropriate perioperative management with drainage and antibiotic administration.

[A Case of Extranodal NK/T-Cell Lymphoma with Perforation of the Small Intestine].

A rare case of extranodal NK/T-cell lymphoma(ENKL)with small intestinal perforation is reported. A 92-year-old man was admitted for a loss of consciousness. Computed tomography(CT)scan revealed the presence of an intraperitoneal abscess that was drained. Two days later, the drained fluid changed to intestinal juice, and intestinal perforation was suspected. The patient underwent surgery which revealed a 1 cm perforation site in the ileum. A high fever continued after surgery, and malignant lymphoma was diagnosed from pathological findings; however, further treatment could not be performed. He died 24 days after the operation. Pathological dissection revealed metastasis of ENKL at the systemic lymph nodes.

Laparoscopic repair of traumatic diaphragmatic hernia with colon incarceration: A case report.

Traumatic diaphragmatic hernia is a serious complication of blunt trauma to the abdomen or thorax. Although traumatic diaphragmatic hernia is treated with surgical repair, a laparoscopic approach is infrequently employed. Here we present the case of a 66-year-old man with a bruise on the left side of his back. CT revealed a left pneumothorax and left rib fractures. He was urgently hospitalized and relieved with conservative treatment. However, on day 4 of hospitalization, an incarcerated diaphragmatic hernia containing the transverse colon was observed on CT. The herniated viscera of the abdominal cavity were reduced laparoscopically, and the hernial orifice was repaired with direct closure. One-lung ventilation was used to limit the movement of the affected diaphragm, enabling effective laparoscopic suturing. The patient had an uneventful recovery period and was discharged 8 days postoperatively. The absence of diaphragmatic herniation recurrence was confirmed 6 months after surgery.

Capecitabine Plus Bevacizumab for Cardiac Metastasis of Sigmoid Colon Cancer: Case Report and Literature Review.

BACKGROUND/AIM: Right ventricular cardiac metastasis from colorectal cancer (CRC) is rare and clinically silent. There is no standardised treatment. To date, only twelve cases have been reported in the literature. This is a case report and literature review of right ventricular cardiac metastasis from CRC. CASE REPORT: A 75-year-old woman with a history of CRC treated with sigmoidectomy followed by liver and lung metastasectomy presented with a right ventricle tumour. Biopsy showed metastatic adenocarcinoma not suitable for resection because multiple lung metastases coexisted. The metastases were controlled for a prolonged duration by chemotherapy with capecitabine plus bevacizumab. According to the review of 13 cases, the median age of metastatic CRC that involves the right ventricle is 71 years and the primary site is half the colon and rectum. Half of cases have non-cardiac metastases at cardiac metastasis diagnosis. Chemotherapy is more suitable than resection in cases with metastases other than heart because resection of the right ventricle has a high risk. CONCLUSION: Cardiac right ventricular metastasis from CRC can be controlled by capecitabine plus bevacizumab.

Step-up approach combined with negative pressure wound therapy for the treatment of severe necrotizing pancreatitis: a case report.

A step-up approach and continuous drainage using NPWT was an effective strategy for the treatment of severe necrotizing pancreatitis. A 62-year-old woman developed severe necrotizing pancreatitis after endoscopic retrograde cholangiopancreatography, extending from the left anterior pararenal space to the interior renal pole. Endoscopic transluminal drainage and percutaneous catheter drainage were unsuccessful in controlling the disease. We proceeded with video-assisted retroperitoneal necrosectomy, at the pancreas and splenic hilum, and drainage, with two additional surgical drains located at the left inferior renal pole and, subcutaneously, at the incision wound. NPWT enhanced fluid drainage and facilitated surgical wound closure, which was infected and opened. Four subsequent endoscopic necrosectomy procedures were required, at the site of the draining fistula, to achieve complete resolution of fluid collection and wound closure.

A case of a diverticulum-like giant jejunal gastrointestinal stromal tumour presenting with intraperitoneal peritonitis due to rupture.

INTRODUCTION: Early diagnosis of small intestinal gastrointestinal stromal tumours (GISTs) is difficult. These tumours often present with peritonitis and intraperitoneal bleeding due to rupture. We experienced a case of a tumor that grows to 12 cm asymptomatic. PRESENTATION OF CASE: A 46-year-old man presented with sudden abdominal pain. Computed tomography revealed free air in the abdominal cavity, a 12-cm sized dilatation in the small intestine, and pooled residues. He was diagnosed with perforation of the gastrointestinal tract, and emergency surgery was performed. Inside the abdominal cavity, approximately 500 mL of bloody ascites was observed. A diverticulum-like mass measuring approximately 12-cm long was observed on the jejunum approximately 30 cm from the Treitz ligament. There was a large hematoma inside the mass, and perforation was recognised at the neck of the diverticulum. Partial resection of the jejunum and intraperitoneal drainage were performed. Immunohistochemistry revealed that the tumour was positive for KIT and CD34, and GIST was diagnosed. The patient was discharged on postoperative day 10 without significant complications. The patient did not relapse while taking imatinib as an adjuvant chemotherapy. DISCUSSION: Gastrointestinal stromal tumours are the most common mesenchymal tumours of the gastrointestinal tract and may undergo increased diverticulum-like growth, as seen in this case. Local resection and proper chemotherapy increase long-term survival, suppress tumour growth, and reduce the risk of relapse. CONCLUSION: Diagnosing GIST can be difficult due to the absence of clinical symptoms. It is necessary to ensure local resection and careful long-term follow-up.

A single institution experience of the treatment of pancreatic ductal carcinoma: The demand and the role of radiation therapy.

We aimed to demonstrate a single institution experience of treatment of pancreatic ductal carcinoma and to identify the role of radiation therapy. We assessed all patients who were diagnosed with pancreatic ductal carcinoma from January 2011 to December 2017. A total of 342 patients were enrolled. Thirteen, 131, 36, and 162 patients had stage I, II, III, and IV disease, respectively (UICC TNM, 7th edition). Among the patients with stages I-III disease, 94 underwent surgery, and the median overall survival (OS) was 33 months. Of patients with stages I-III disease who were not suitable for surgery, 58 patients received chemotherapy, and the median OS was 12 months. Among them, 17 patients received chemoradiotherapy added on chemotherapy and their OS was significantly better than that of patients who received chemotherapy alone. Of patients with stage IV disease, 111 received chemotherapy, and the median OS was 6 months. This study evaluated the demand, role, and outcome of each treatment modality and demonstrated a single institution experience of treatment of pancreatic ductal carcinoma. The demand and role of radiation therapy remained small; however, radiation therapy might have some importance as a local treatment.

Single-incision totally extraperitoneal hernia repair with intraperitoneal inspection of strangulated femoral hernia at risk for intestinal ischemia after repositioning: a case report.

BACKGROUND: Totally extraperitoneal hernia repair and the transabdominal preperitoneal approach have advantages and disadvantages. We used the advantages of totally extraperitoneal hernia repair and the transabdominal preperitoneal approach and performed single-incision totally extraperitoneal hernia repair with intraperitoneal inspection for the treatment of strangulated femoral hernia in a patient at risk for intestinal ischemia. CASE PRESENTATION: We report a case of a 75-year-old Japanese woman who presented with black vomiting of 5 days' duration. Physical examination revealed a right inguinal bulge and sharp pain. Computed tomography revealed a right strangulated femoral hernia with no intestinal ischemia. We were able to reposition the hernia; however, we performed the operation with consideration of the possibility of intestinal ischemia by incarceration of the intestine because the onset was 5 days previously. Intraperitoneal observation revealed a right femoral hernia and confirmed that the intestinal tract was not ischemic. However, the intestinal tract was expanded because of ileus, and securing a clear field of vision was difficult. Hence, we switched to totally extraperitoneal hernia repair at the same incision and performed single-incision totally extraperitoneal hernia repair with intraperitoneal inspection. The hernia sac was observed at the femoral rings and obturator foramen. The mesh was inserted through the incision, and after it was positioned to cover the Hesselbach triangle, femoral rings, inguinal ring, and obturator foramen, it was fixed with SECURESTRAP®. Observation of the abdominal cavity confirmed complete repair. After the operation, there was no recurrence or other complications. CONCLUSION: We report a case of successful single-incision totally extraperitoneal hernia repair with intraperitoneal inspection for the treatment of strangulated femoral hernia in a patient at risk for intestinal ischemia after repositioning.

Antimicrobial prophylaxis for 1 day versus 3 days in liver cancer surgery: a randomized controlled non-inferiority trial.

PURPOSES: This study compared the effectiveness of 1-day vs 3-days antibiotic regimen to prevent surgical site infection (SSI) in open liver resection. METHOD: We performed a randomized controlled non-inferiority trial in 480 patients at 39 hospitals across Japan (registered as UMIN000002852). Patients with hepatocellular carcinoma scheduled to undergo resection were randomly assigned to receive either a 1-day regimen for antimicrobial prophylaxis, or a 3-day regimen. The primary endpoint was the incidence of SSI. RESULTS: Among 480 randomized patients, 232 assigned to the 1-day regimen and 235 to the 3-day regimen were included in the full analysis set. Baseline characteristics of the two groups were well balanced. SSI was diagnosed in 22 patients (9.5%) in the 1-day group vs 23 patients (9.8%) in the 3-day group (difference, - 0.30; 90% CI - 4.80 to 4.19% [95% CI - 5.66% to 5.05%]; one-sided P = 0.001 for non-inferiority), meeting the non-inferiority hypothesis. In both groups, remote site infection (16 [6.9%] vs 22 [9.4%], P ˂ 0.001 for non-inferiority) and drain-related infection (5 [2.2%] vs 4 [1.7%], P ˂ 0.001 for non-inferiority) were comparable. CONCLUSION: To prevent SSI in liver cancer surgery, a 1-day regimen of flomoxef sodium is recommended for antimicrobial prophylaxis because of confirming the non-inferiority to longer usage.