Distance of Peritoneum to Inferior Mesenteric Artery Predicts the Operation Time During Laparoscopic Colectomy for Sigmoid or Rectosigmoid Colon Cancer.

Background/Aim: Obesity is a major technical limiting factor for laparoscopic surgery because abundant visceral fat is known to extend the operation time. However, special hardware is needed to assess it. We hypothesized that the depth from the peritoneum to the bifurcation of the inferior mesenteric artery (IMA) defined as 'peritoneum to IMA distance (PID)' might be a simple predictive factor for extended operation time during laparoscopic colectomy. Patients and Methods: One hundred twenty-four patients who were diagnosed with sigmoid or rectosigmoid colon cancer and underwent laparoscopic colectomy were included. The patients were divided into two groups based on the operation time (210 min). The vertical distance from the peritoneum to the bifurcation of the inferior mesenteric artery was defined as PID. The factors eliciting an operation time longer than 210 min were investigated. Results: There was significant difference in sex, BMI, cT, cN, and PID between the Early group (<210 min) and Late group (≥210 min). Less blood loss was observed in the Early group than in the Late group. Multivariate analysis showed that PID was the only independent factor that affected operation time (p<0.001). Conclusion: PID predicts the operation time during laparoscopic colectomy for sigmoid or rectosigmoid colon cancer.

Taking antithrombic therapy during emergency laparoscopic cholecystectomy for acute cholecystitis does not affect the postoperative outcomes: a propensity score matched study.

BACKGROUND: Continuing antithrombic therapy (ATT) during surgery increases the risk of bleeding. However, it is difficult to discontinue the ATT in emergency surgery. Therefore, safety of emergency laparoscopic cholecystectomy (LC) for acute cholecystitis (AC) is still unclear. We aimed to clarify the affect of ATT during emergency LC for AC. METHODS: Patients with AC were classified into ATT group (n = 30) and non-ATT group (n = 120). Postoperative outcomes were compared after propensity score matching (n = 22). RESULTS: Higher level of c-reactive protein level and shorter activated partial thromboplastin time (APTT) was observed in ATT group than in non-ATT group after matching. No significant difference was found between other patient characteristics and perioperative results. Blood loss over 100 mL was observed in 8 patients. Multivariate analyze showed that APTT was an independent risk factor for bleeding over 100 mL (P = 0.039), while ACT and APT was not. CONCLUSIONS: Taking ATT does not affect the blood loss or complications during emergency LC for AC. Controlling intraoperative bleeding is essential for a safe postoperative outcome.

Purse-string suture after ligating by endoloop for closing of the appendiceal stump is an alternative for endostapler in selected cases: A propensity score-matched study.

INTRODUCTION: The closure of the appendiceal stump is a crucial part of a laparoscopic appendectomy, and an endoloop or endostapler is generally used. The endoloop can be more cost effective than the endostapler. However, reports have shown that the endoloop has a higher postoperative abdominal abscess rate than the endostapler in complicated appendicitis. At our institution, we perform a purse-string suture after ligating by endoloop to reduce postoperative abdominal abscess risk. This study aimed to clarify whether this method could reduce the incidence of postoperative abdominal abscess compared with the endostapler. METHODS: Patients with acute appendicitis were classified into the purse-string suture group (n = 149) and the endostapler group (n = 82). Postoperative outcomes were compared after propensity score matching (n = 47). RESULTS: No significant difference was found between the two groups in terms of the patient characteristics and postoperative complications, including abdominal abscess. However, the purse-string suture group had more drain placement and a shorter hospital stay than the endostapler group (P = .04 and P = .02, respectively). In patients with complicated appendicitis, there was less drain placement and a shorter hospital stay in the purse-string suture group than in the endostapler group (P < .01 and P < .01, respectively). This might have reflected the difficulty of the operation. All postoperative abdominal abscesses occurred in complicated appendicitis cases. CONCLUSIONS: Endoloop with additional purse-string suture had a lower incidence of abscess than previous reports of using endoloop alone. Moreover, the postoperative abdominal abscess rate is similar between the two closure methods.

Laparoscopic anatomical liver resection using indocyanine green fluorescence imaging.

BACKGROUND: Anatomical liver resections guided by a demarcation line after portal staining or inflow clamping of the target area have been established as essential methods for curative treatment of hepatocellular carcinoma (HCC) and have subsequently been applied to other malignancies. However, laparoscopic anatomical liver resection (LALR) procedures are very difficult to reproduce, and the confirmation of demarcation of the hepatic segment on a monitor is also challenging. Recently, indocyanine green (ICG) fluorescence imaging has been used to identify hepatic tumors and segmental boundaries during hepatectomy. Herein, we describe LALR using ICG fluorescence imaging. METHODS: Three patients underwent pure LALR using ICG fluorescence imaging at our institute. One patient underwent anatomical partial liver resection for HCC, another underwent segmentectomy 3 for metastatic liver cancer, and the third underwent right anterior sectionectomy for HCC. To visualize hepatic perfusion and the demarcation line by negative staining using an optical imaging system, 2.5 mg ICG was injected intravenously during surgery following clamping or closure of the proximal Glissonean pedicles. RESULTS: For all three cases, ICG fluorescent imaging clearly delineated the demarcation lines and allowed identification of intersegmental planes to some extent because the tumor-bearing hepatic region became non-fluorescing parenchyma during parenchymal transection. This allowed surgeons to recognize the direction and guide the transection of the liver parenchyma when performing LALR. CONCLUSION: LALR using ICG fluorescence imaging is a feasible procedure for resection of the tumor-bearing hepatic region and facilitates visualization of the demarcation line and identification of the boundaries of the hepatic sections.

[Adjuvant Chemotherapy for High-Risk Stage â ¡ Colon Cancer].

BACKGROUND: This study was designed to clarify effects of postoperative adjuvant chemotherapy for high-risk Stage Ⅱ colorectal cancer. METHOD: The subjects were 99 patients with high-risk Stage Ⅱcolorectal cancer who underwent surgery at our department from October 2013 to March 2018. Patients were classified into adjuvant chemotherapy group and nonadjuvant chemotherapy group. Overall survival(OS)and recurrence-free survival(RFS)were analyzed between the 2 groups. RESULTS: Thirty six patients(36.4%)underwent adjuvant chemotherapy. Adjuvant chemotherapy group were younger(p<0.010), had a better ASA-PS(p<0.010), good preoperative Hb(p<0.010), and preoperative Alb(p<0.010)compared to non-adjuvant chemotherapy group. There was no difference between the 2 groups in the high-risk factors for recurrence. Most patient had an oral medication as for adjuvant chemotherapy. There was no difference in OS and RFS between the 2 groups. CONCLUSION: Postoperative adjuvant chemotherapy for high-risk Stage Ⅱ colorectal cancer did not significantly improve the OS and RFS. Further study is necessary to asses the suitable regimen and patients eligible for chemotherapy.

[Preoperative Chemotherapy with DCF for Advanced Esophageal Cancer].

We conducted a retrospective study to evaluate the efficacy and the problem of the neoadjuvant chemotherapy using DCF for cStage Ⅲ/Ⅳ(squamous cell)esophageal cancer. Eleven patients from January 2017 to December 2018 were enrolled into this study. The median age was 67 years old, male/female ratio was 9:2, performance status was 0 in all patients, and UICC cStage Ⅲ/Ⅳa was 7:4. Cycles of chemotherapy was 2 in 1 patients, 3 in 5 patients and additional 2 courses in 1 patient. Four patients switched to FP therapy after a course of DCF. The efficacy of chemotherapy was evaluated by the clinical response rate, average tumor reduction rate, and histological therapeutic effect rate over Grade 2 which was 63.6%, 48.3%, and 40%, respectively. Neutropenia over Grade 3 was observed in all patients and Grade 4 was observed in 6 patients. In conclusion, preoperative chemotherapy with DCF therapy is useful for the treatment of cStage Ⅲ/Ⅳ(squamous cell) esophageal cancer as long as bone marrow suppression is managed.

Feasibility and Effectiveness of Gastrectomy for Elderly Gastric Cancer Patients.

BACKGROUND/AIM: The benefits of gastrectomy for elderly gastric cancer (GC) patients remain unknown. The aim of this study was to evaluate the validity of gastrectomy. PATIENTS AND METHODS: Patients who had R0 or R1 resection and diagnosed as pathological Stage I-III GC were enrolled in this study. Patients were classified according to age: Elderly group (≥80 years old), non-Elderly group (70-79 years old), Standard group (≤69 years old). RESULTS: As the age raised, the number of comorbidities increased and patients had a worse physical status. Operative procedure and postoperative complications of the Elderly group were similar to that of the non-Elderly group. The overall survival was similar in pathological Stages I and III between the Elderly and non-Elderly groups, while the Stage II Elderly group had shorter overall survival. Also, the Elderly group did not undergo adjuvant chemotherapy compared to other groups. CONCLUSION: Gastrectomy can be performed safely in elderly patients following gastrectomy, survival of elderly patients was similar to non-elderly patients. Therefore, gastrectomy is an acceptable treatment for elderly patients in good condition.

Laparoscopic transabdominal preperitoneal approach for giant inguinal hernias.

BACKGROUND: Many surgical techniques have been developed to treat inguinal hernia. In recent years, the laparoscopic transabdominal preperitoneal (TAPP) approach has been widely performed to repair inguinal hernia. Giant inguinal hernia (GIH) is an extremely rare disease that is a challenge for general surgeons. GIH appears when patients neglect the treatment for many years and it is defined as an inguinal hernia that extends below the midpoint of inner thigh in standing position. According to previous publications, the Lichtenstein tension-free hernioplasty is recommended to repair GIH. In this article, we describe consecutive four cases of GIH repaired via the TAPP approach. METHODS: From April 2015 to March 2017, 200 patients underwent hernioplasty against inguinal hernia at our hospital. Inguinal hernias were treated via the TAPP approach in principle. We performed hernioplasty via the TAPP approach in all 4 patients (2%) who met the definition of Type 1 GIH. Demographic information, maximum diameter of hernia sac, hernia orifice size, and surgical data were obtained. RESULTS: The mean operative time was 135 min. No intraoperative complications were encountered. All patients could walk from postoperative day 1 and were discharged home early, but they all had scrotal seromas. Three patients did not need puncture or drainage, but one of them required puncture. All seromas disappeared within 6 months. There was no recurrence in the 8- to 24-month follow-up. CONCLUSION: The TAPP approach is a feasible, safe therapeutic option that may reduce wound size and pain following surgical treatment of Type 1 GIH.

Omental abscess due to a spilled gallstone after laparoscopic cholecystectomy.

Omental abscess due to a spilled gallstone is extremely rare after laparoscopic cholecystectomy. Herein, we report a 68-year-old man who presented with left upper abdominal pain after laparoscopic cholecystectomy for gangrenous cholecystitis. Seven months prior to admission, gallbladder perforation with spillage of pigment gallstones and bile occurred during laparoscopic cholecystectomy. The spilled gallstones were retrieved through vigorous peritoneal lavage. Abdominal computed tomography showed a 3 × 2.5 cm intra-abdominal heterogeneous mass, suspected to be an omental abscess, and ascites around the spleen. Exploratory laparoscopy revealed an inflammatory mass within the greater omentum. Laparoscopic partial omentectomy and abscess drainage were performed, and a small black pigment gallstone was unexpectedly found in the whitish abscess fluid. Abscess fluid culture results were positive for extended-spectrum ß-lactamase-producing Escherichia coli and Streptococcus salivarius, which were previously detected in the gangrenous gallbladder abscess. The histopathological diagnosis was abscess in the greater omentum. Postoperative course was uneventful, and the patient was discharged 13 days later. In conclusion, we report a successful case of laparoscopic management of an omental abscess due to a spilled gallstone after LC. It is important to attempt to retrieve spilled gallstones during LC because they may occasionally result in serious complications.

[A case of erythema multiforme induced by regorafenib therapy for metastatic colon cancer].

A 47-year-old woman underwent colectomy for advanced colon cancer and thereafter received regorafenib therapy as fourth-line chemotherapy. On treatment day 12, the patient developed erythema multiforme (EM) induced by the regorafenib therapy. Immediately after regorafenib was withdrawn, the patient was treated with oral bepotastine and steroid ointment, which relieved the EM without progressing to Stevens-Johnson syndrome (SJS). Regorafenib is used for third- or fourth-line chemotherapy. Progression of regorafenib-induced EM to SJS may cause critical dysfunction among patients. Before administering regorafenib therapy, the patient should be made aware of this potential adverse effect and be advised to withdraw the treatment and visit the hospital immediately if symptoms of EM are observed.

[Pathological complete response in a large gastric GIST that became resectable after neoadjuvant chemotherapy with imatinib mesylate].

We report a case of a large gastric gastrointestinal stromal tumor (GIST), which became resectable and achieved pathological complete response after neoadjuvant chemotherapy with imatinib mesylate. A 59-year-old man presented with left hypochondrial pain. Abdominal computed tomography (CT) revealed gastric GIST invading the spleen and the diaphragm. Administration of imatinib mesylate was initiated as neoadjuvant chemotherapy. Six months after neoadjuvant chemotherapy with imatinib mesylate, abdominal CT revealed a reduction in tumor size. We judged the tumor resectable and performed partial gastrectomy and splenectomy. Histologically, number of myofibroblasts increased, but no viable tumor cells were observed. Pathological complete response was obtained.