[Three Cases Who Underwent Laparoscopic Radical Resection after Preoperative Therapy for Massive Rectal GIST].

The gastrointestinal stromal tumor(GIST)guidelines state that the use of neoadjuvant chemotherapy(NAC)for curable GIST is not apparent. However, NAC is performed for massive rectal GIST at our hospital to reduce surgical invasion and improve surgical results. The cases were a 39-year-old man, a 48-year-old man, and a 78-year-old man. The site was Rb in all cases, and the maximum diameters at the rectal GIST diagnosis were respectively 70 mm, 75 mm, and 60 mm, which were massive tumors. Imatinib mesylate(imatinib)was started as NAC. The duration of NAC was respectively 6, 11, and 12 months. The maximum tumor diameter on preoperative CT was smaller than before NAC, and the average reduction rate was 23%. Two cases underwent laparoscopic abdominal perineal resection, and 1 underwent laparoscopic ultra-low anterior resection and ileostomy. No perioperative complications of Clavien-Dindo classification Grade Ⅱ or higher were unsettled. All patients were in the high risk group and received imatinib as postoperative adjuvant chemotherapy. Currently, respectively 2 years and 3 months, 1 year and 2 months, and 1 year after surgery, all are alive without recurrence. NAC with imatinib has contributed to minimally invasive and radical surgery for giant rectal GIST.

Clinical usefulness of a perioperative bacteriological culture to treat patients with postoperative pneumonia after esophagectomy.

AIM: The aim of the present study was to examine the usefulness of a perioperative bacteriological culture in predicting the pathogenic bacteria responsible for postoperative pneumonia after esophagectomy. METHODS: This study included 293 consecutive esophageal cancer patients who underwent esophagectomy with gastric conduit reconstruction. We compared the pathological bacteria that were detected in bacteriological cultures of sputum, mouthwash and gastric fluid on the second postoperative day with the pathogenic bacteria responsible for postoperative pneumonia. RESULTS: Postoperative pneumonia occurred in 26 (8.8%) of the 293 patients. Enterobacter cloacae was detected most frequently in the perioperative bacteriological culture, followed by Enterococcus faecalis and Pseudomonas aeruginosa. Detection of each pathogenic bacterium in the perioperative bacteriological culture was not associated with the occurrence of pneumonia, excluding Pseudomonas aeruginosa. As the pathogens responsible for postoperative pneumonia, 32 bacteria were detected in 26 patients with postoperative pneumonia. Detection rate of the pathogenic bacteria responsible for postoperative pneumonia in a perioperative bacteriological culture was 43.8% in a sputum culture, 40.6% in a mouthwash culture and 65.6% in a gastric fluid culture. The detection rate of the pathogenic bacteria responsible for pneumonia was up to 78.1% in the combination of sputum and gastric fluid culture. CONCLUSIONS: Although the perioperative bacteriological culture does not seem to be useful for predicting the occurrence of postoperative pneumonia, it is useful for predicting the pathogenic bacteria responsible for pneumonia in cases of postoperative pneumonia. The perioperative bacteriological culture helps us to select appropriate antibiotics to treat pneumonia after esophagectomy.

Prognostic Significance of Sarcopenia and Systemic Inflammatory Response in Patients With Esophageal Cancer.

BACKGROUND/AIM: The association between the presence of sarcopenia and systemic inflammatory response is unclear in patients with esophageal cancer. This study was performed to investigate the relationship between sarcopenia and systemic inflammatory response and clarify the effect of these factors on the prognosis in patients with esophageal cancer. PATIENTS AND METHODS: This study included 163 patients with esophageal cancer. The patients' body composition was assessed before esophagectomy using multifrequency bioelectrical impedance. The relationship between sarcopenia and inflammatory factors were investigated before surgery. RESULTS: Sarcopenia was significantly associated with a high C-reactive protein-to-albumin (CRP/Alb) ratio (p=0.046). Patients with sarcopenia significantly associated with worse overall survival (OS) (p=0.025) and tended to show a worse recurrence-free survival (RFS) (p=0.065). A high CRP/Alb ratio was significantly associated with worse OS and RFS. Multivariate analysis revealed that among all inflammatory factors, only a high CRP/Alb ratio was an independent prognostic factor for RFS (p=0.022). CONCLUSION: Sarcopenia is associated with systemic inflammatory response such as high CRP/Alb ratio, while the latter is an independent prognostic marker in patients with esophageal cancer.

Closure method for thick pancreas stump after distal pancreatectomy: soft coagulation and polyglycolic acid felt with fibrin glue.

PURPOSE: Pancreatic fistula (PF) remains an obstacle to safe distal pancreatectomy (DP). A thick pancreatic parenchyma is a major risk factor for PF. In this paper, we elucidate the feasibility of the new closure method using soft coagulation and polyglycolic acid felt with fibrin glue. METHODS: In 2009-2013, 96 patients underwent DP with a novel closure method for pancreatic stump that utilized soft coagulation and polyglycolic acid felt with fibrin glue. We evaluated amylase levels in drainage fluid on postoperative days (POD) 1 and 3 and the incidence of postoperative PF according to International Study Group of Pancreatic Fistula (ISGPF) definitions. RESULTS: Drain amylase levels on POD1 and POD3 were 275 and 241 U/L, respectively, and ISGPF-defined Grade B/C PF rates were 16.7%. No clinical factors were significantly associated with PF. Average pancreatic parenchymal thicknesses were similar in PF-positive and PF-negative patients (10.4 ± 2.6 mm vs. 10.1 ± 2.2 mm, P = 0.639). There was no significant difference in the postoperative PF rate between patients with thick (≥12 mm) and thin (<12 mm) pancreas (11.1 vs. 18.8%, P = 0.544). CONCLUSION: Our novel pancreatic stump closure method appears to be simple and effective, particularly in patients with thick pancreas.

A simple and safe anastomosis in pancreaticogastrostomy using mattress sutures.

When a suture does not trap a sufficient volume of pancreatic parenchyma in the conventional pancreatic anastomosis, laceration may be caused by even modest tension. Therefore, we used mattress sutures with gastric wall, which works protectively. An opening was made on the posterior wall of the stomach. By using a 3-0 polypropylene monofilament thread with a straightened needle at each end, the proximal gastric wall, the pancreas, and the distal gastric wall were sutured sequentially to accomplish anastomosis in a U-like fashion. After 2 to 4 additional sutures were completed, the pancreatic stump was invaginated into the stomach and all sutures are tied. Mattress sutures were made on the pancreas, which was held between the superior and inferior walls of the stomach. Postoperative amylase levels in the drainage fluid decreased significantly and none of the 17 patients developed pancreatic fistula formation. The technique is simple and shortens the time required for anastomosis.

[A case of heparin-induced thrombocytopenia associated with unexpected excessive argatroban anticoagulation after abdominal aortic aneurysm resection].

We experienced excessive anticoagulation induced by argatroban for the treatment of heparin-induced thrombocytopenia (HIT). A 74-year-old man was scheduled for elective abdominal aortic aneurysm resection. During the surgery, both femoral arteries were found non-pulsatile requiring thrombectomy. The next day, second laparotomy was needed because of superior mesenteric artery occlusion. After the surgery, acute renal failure and hypoxemia continued with progressive thrombocytopenia necessitating frequent administration of platelet concentrates. Considering possibility of HIT, we stopped heparin and began argatroban. Due to his mild liver dysfunction, we initiated argatroban at 0.5 microg x kg(-1) x min(-1) one-fourth of standard initial dose, according to its drug information approved by FDA. Although expected APTT level was from 50 to 60 sec, it increased immediately up to 93 sec. Excessive anticoagulation continued more than 24 hours after cessation of argatroban and bleeding occurred from the tracheostomy site. When APTT decreased to the target range, we restarted argatroban and found the adequate dosage at 0.08 microg x kg(-1) x min(-1). After argatroban treatment, platelet count recovered immediately and no thromboembolism was observed. We recommend that argatroban should be initiated at a lower dosage than the dose shown in its drug information for HIT patients after cardiovascular surgery with frequent monitoring of APTT.