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.

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.

Preoperative Masseter Muscle Sarcopenia Predicts Mortality in Patients With Oesophageal Cancer.

BACKGROUND/AIM: The impact of masseter muscle sarcopenia on the prognosis of patients with oesophageal cancer after oesophagectomy remains unclear. PATIENTS AND METHODS: We retrospectively analysed data from 70 patients with oesophageal cancer who underwent oesophagectomy between 2013 and 2019. Overall survival and disease-free survival rates were analysed using Cox proportional hazards models and Kaplan-Meier curves with the log-rank test. RESULTS: Masseter muscle sarcopenia was diagnosed in 36 patients. Multivariate analysis identified cytokeratin 19 fragment >1.1 (p=0.04); stage II, III, and IV cancer (p=0.01); and masseter muscle sarcopenia (p<0.01) as significant independent predictors of disease-free survival. Stage II, III, and IV cancer (p<0.01); masseter muscle sarcopenia (p<0.01); and postoperative pneumonia (p<0.01) were significant independent predictors of overall survival. CONCLUSION: Preoperative masseter muscle sarcopenia could be a strong predictor of long-term outcomes in patients who undergo oesophagectomy for oesophageal cancer.

Nivolumab in combination with radiotherapy for metastatic esophageal neuroendocrine carcinoma after esophagectomy: a case report.

BACKGROUND: Metastatic neuroendocrine carcinoma has an extremely poor prognosis, and no effective second-line treatment is available. Herein, we describe a case of multiple metastases after primary resection of esophageal neuroendocrine carcinoma successfully treated with nivolumab plus radiotherapy in a short time. CASE PRESENTATION: A man in his 70s presented to our hospital after an abnormality was detected on an upper gastrointestinal series. Upper gastrointestinal endoscopy revealed a type 2 tumor spanning the endothelial cell junction to the abdominal esophagus. Histopathological examination of the biopsy confirmed a diagnosis of esophageal neuroendocrine carcinoma. The patient had no distant metastases. Thoracoscopic esophagectomy with three-field lymph node dissection was performed. Histopathological examination confirmed a diagnosis of esophageal neuroendocrine carcinoma with features of adenoid cystic-like carcinoma and squamoid pattern (pT2 [MP], INF a, ly1, v1 [EVG], pIM0, pDM0, pRM0, pN1 [1/28], M0; Stage II), which was positive for synaptophysin. The postoperative course was good, with no complications. The patient was treated with 100 mg of irinotecan and 100 mg of cisplatin, administered every 4 weeks, as postoperative adjuvant chemotherapy. Grade 3 loss of appetite was observed, and adjuvant chemotherapy was discontinued after four cycles of first-line treatment. A positron emission tomography-computed tomography scan 3 years after surgery showed abnormal uptake in the subaortic, left hilar, and left axillary lymph nodes, and in a mass in the right lung apex. The patient was diagnosed with metastatic esophageal neuroendocrine carcinoma postoperatively. First-line treatment could not be repeated due to toxicity from the initial treatment. Nivolumab (240 mg every 2 weeks) was administered as second-line treatment, and radiotherapy was started (56 Gy delivered in 28 fractions to the local [subaortic and hilar] lymph nodes). After 10 cycles of nivolumab in combination with radiotherapy (56 Gy), a positron emission tomography-computed tomography scan showed disappearance of all lesions. A complete response was achieved. Maintenance therapy (240 mg of nivolumab) was continued. No recurrence has been observed for 42 months. CONCLUSIONS: We experienced a case in which nivolumab in combination with radiotherapy was effective for metastatic esophageal neuroendocrine carcinoma after primary resection.

A successful case of complete surgical resection via left upper and right lower lobectomy for bilateral lung metastases of a perivascular epithelioid cell tumor in the colon: a case report.

BACKGROUND: Perivascular epithelioid cell tumors (PEComas) are rare mesenchymal neoplasms with malignant potential. No effective treatment other than surgical resection has been established for lung metastases of PEComas. We describe a patient who underwent complete surgical resection via bilateral lobectomy involving a two-step procedure for lung metastases 8 years after undergoing radical surgery for a colonic PEComa. CASE PRESENTATION: A 53-year-old woman underwent partial colectomy for a PEComa in the transverse colon 8 years ago. She presented with an abnormal chest shadow during a health examination. Chest computed tomography (CT) revealed a solid nodule 2 cm in diameter located centrally in the right lower lobe and a solid nodule 3 cm in diameter located centrally in the left upper lobe. Positron emission tomography revealed 18F-fluorodeoxyglucose uptake in these nodules. These nodules were suspected to be metastatic tumors of the colonic PEComa and were considered for complete surgical resection. Segmentectomy could not be performed because of the anatomical location of the tumors straddling the segments; therefore, bilateral lobectomy was required for complete surgical resection. Therefore, we performed two-step lobectomy safely with the expectation of pulmonary function recovery. Microscopically, the tumors were diagnosed as lung metastases of the PEComa. One year after the last surgery, no recurrence was detected, and the patient's pulmonary function improved. CONCLUSIONS: This case indicates that even if multiple lung metastases of a PEComa require bilateral lobectomy, complete resection with a two-step surgery may be considered.

Perineal stapled prolapse resection in combination with Thiersch operation for relapsed rectal prolapse: a case report.

BACKGROUND: Treatment options for complete rectal prolapse include over 100 procedures. In previous reports, operative rectal prolapse repair, regardless of the technique by perineal approach, was associated with high recurrence rates. However, there is no consensus on the optimal surgical procedure for relapsed rectal prolapse. CASE PRESENTATION: A 97-year-old woman was admitted to our hospital with a chief complaint of complete rectal prolapse measuring > 5 cm. The patient had a history of laparoscopic anterior suture rectopexy without sigmoid resection under general anesthesia for complete rectal prolapse one year prior. The patient's postoperative course was uneventful. However, her dementia worsened (Hasegawa's dementia scale: 5/30 points) after the first operation. Further, moderate-to-severe aortic valve stenosis was first diagnosed with heart failure 6 months after the operation. Nine months after the initial surgery, she experienced a recurrence of complete rectal prolapse measuring approximately 5 cm. Considering the coexistence of advanced age, severe dementia, and aortic valve stenosis, surgery under general anesthesia was not indicated. Perineal stapled prolapse resection in combination with the t operation was planned because of its minimal invasiveness and shortened hospital stay. The procedure was performed by a team of two surgeons in the jack knife position, under spinal anesthesia. The prolapse was cut along the long-axis direction with three linear staplers and resected along the short-axis direction with four linear staplers. The cross-section of the linear stapler was reinforced with 3-0 Vicryl sutures. After rectal resection, the Thiersch operation using 1-0 nylon thread 1 cm away from the anal verge was additionally performed. The operative time was 24 min, and intraoperative blood loss was 1 mL. The postoperative course was uneventful. Three months after the operation, no recurrence was observed, and defecation function was good with improvements of Wexner score. CONCLUSIONS: Perineal stapled prolapse resection in combination with the Thiersch operation could be a useful option for patients with relapsed rectal prolapse and with poor general condition, who are not indicated for other surgical procedures.