Simplified risk stratification in early cholecystectomy for acute cholecystitis based on age: A report from an institution with zero mortality.

BACKGROUND/PURPOSE: The existing risk stratification for early cholecystectomy in patients with acute cholecystitis (AC) is complex. This study aims to establish a simpler risk assessment for surgical complications after cholecystectomy based on age group. METHODS: This single-center retrospective observational study enrolled 350 patients diagnosed with AC who underwent early cholecystectomy within 72 h of diagnosis from 2013 to 2021. Patients were divided into three subgroups based on age: young (<65 years), elderly (65-79 years), and very elderly (≥80 years). Since no mortality was observed, risk factors for the Clavien-Dindo (CD) grade ≥ II complications were identified within the entire cohort and in each subgroup. RESULTS: There were 120 young, 130 elderly, and 100 very elderly patients. The overall prevalence of complications with CD grade ≥ II was 11.1%. Age and Tokyo Guidelines 18 (TG18) severity were independent risk factors for surgical complications in the whole cohort. Subgroup analysis revealed that there was no independent risk factor in the young group. Meanwhile, age and poor physical status were independent risk factors in the elderly group, and TG18 severity in the very elderly group. CONCLUSION: Evaluation of only age, physical status, and TG18 severity may be sufficient for risk stratification of surgical complications of AC.

Impact of the coronavirus disease 2019 pandemic on gastric and colorectal cancer surgeries: a multicenter epidemiologic study from the Kinki region of Japan.

The coronavirus disease 2019 pandemic affected cancer surgeries and advanced cancer diagnoses; however, the trends in patient characteristics in medical institutions during this time, and the surgical approaches used are unclear. We investigated the impact of the pandemic on gastric and colorectal cancer surgeries in the Kinki region of Japan. We grouped 1688 gastric and 3493 colorectal cancer surgeries into three periods: "pre-pandemic" (April 2019-March 2020), "pandemic 1" (April 2020-March 2021), and "pandemic 2" (April 2021-September 2021), to investigate changes in the number of surgeries, patient characteristics, surgical approaches, and cancer progression after surgery. Gastric and colorectal cancer surgeries decreased from the pre-pandemic levels, by 20% and 4%, respectively, in pandemic 1, and by 31% and 19%, respectively, in pandemic 2. This decrease had not recovered to pre-pandemic levels by September, 2021. Patient characteristics, surgical approaches, and cancer progression of gastric and colorectal surgeries did not change remarkably as a result of the coronavirus disease 2019 pandemic.

Surgeons' involvement in COVID-19 treatment: a practice by a regional core hospital in Japan to avoid physician burnout.

BACKGROUND: To prevent task accumulation on certain divisions, our institution developed a unique system of allocating inpatient treatment of COVID-19 patients to doctors who were not specialized in respiratory infections. The objective of this study was to investigate whether surgeons can be involved in the COVID-19 inpatient treatment without negatively affecting patient outcome, and how such involvement can affect the wellbeing of surgeons. METHODS: There were 300 patients diagnosed with COVID-19 and hospitalized from January to June 2021, and 160 of them were treated by the redeployed doctors. They were divided into 3 groups based on the affiliation of the treating doctor. Patient characteristics and outcomes were compared between the groups. In addition, the impact of COVID-19 duty on participating surgeons was investigated from multiple perspectives, and a postduty survey was conducted. RESULTS: There were 43 patients assigned to the Department of Surgery. There were no differences in the backgrounds and outcomes of patients compared with other groups. The surgeon's overtime hours were significantly longer during the duty period, despite no change in the number of operations and the complication rate. The questionnaire revealed that there was a certain amount of mental and physical burden from the COVID-19 duty. CONCLUSION: Surgeons can take part in inpatient COVID-19 treatment without affecting patient outcome. However, as such duty could negatively affect the surgeons' physical and mental wellbeing, further effort is needed to maintain the balance of fulfilling individual and institutional needs.

Is Palliative Gastrojejunostomy for Malignant Gastric Outlet Obstruction an Optimal Choice for Very Elderly Patients? A Report from a Long-Lived Country.

BACKGROUND: Gastrojejunostomy (GJ) is a surgical option for malignant gastric outlet obstruction (mGOO). Confronting an aging society, the demand to treat elderly cancer patients with unresectable malignancies is increasing; however, the benefit of GJ to the very elderly (≥ 80 years of age) has never been investigated. METHODS: This multicenter, retrospective review included 108 patients who had undergone GJ for mGOO from two medical centers in Japan, one of the most long-lived countries. Patients were divided into two groups, with 80 years of age as the cut-off. Various factors, including surgical complications and patient survival, were compared. RESULTS: GJ in the very elderly (aged ≥ 80 years) was associated with a higher incidence of surgical complications (p = 0.049), such as delayed gastric emptying (DGE; p < 0.001), aspiration pneumonia (p = 0.029), and consequent mortality (p = 0.016). Age ≥80 years was also identified as an independent predictor of DGE (odds ratio 6.444, p = 0.005) and survival after GJ (hazard ratio 7.767, p = 0.016). In particular, the median survival time after GJ in the population aged ≥80 years with gastric cancer was only < 2 months. About the surgical procedure, antiperistaltic anastomosis with partial stomach partitioning (PSP) yielded the lowest occurrence rate of DGE (3.4%) and aspiration pneumonia (1.7%). CONCLUSIONS: GJ does not seem to be the optimal choice for very elderly patients, particularly those with gastric cancer. If performed, antiperistaltic anastomosis with PSP should be employed to reduce the surgical complications.

Laparoscopic duodenojejunostomy for malignant stenosis as a part of multimodal therapy: A case report.

BACKGROUND: Laparoscopic duodenojejunostomy (LDJ) has become the standard surgical procedure for superior mesenteric artery syndrome due to its sufficient outcome in terms of safety and symptom relief. However, there are only a few reports about LDJ for malignant stenosis and its indication remains uncertain. CASE SUMMARY: A 77-year-old woman with a history of pancreatic cancer (PC) treated with distal pancreatectomy with en bloc resection of the transverse colon 7 mo ago was admitted for recurrent vomiting. Imaging upon admission revealed marked distention of the duodenum and a tumor around the duodenojejunal flexure. She was diagnosed with malignant stenosis caused by local recurrence of PC. LDJ was performed with an uneventful postoperative course, followed by chemotherapy which gave her 10 mo overall survival. CONCLUSION: We think that LDJ is a valuable method for unresectable malignant stenosis around the duodenojejunal flexure as a part of multimodal therapy.

Enhanced-view totally extraperitoneal repair in a patient with incisional hernia after robot-assisted laparoscopic radical prostatectomy: a case report.

BACKGROUND: Although laparoscopic incisional hernia repair, especially laparoscopic intraperitoneal onlay mesh, is a widely used technique, it can cause serious complications, including mesh erosion, adhesive bowel obstruction, and chronic pain. The enhanced-view totally extraperitoneal (eTEP) technique has been reported to prevent such complications by placing the mesh in the retrorectus space. Here, we report the case of a patient with post-robot-assisted laparoscopic radical prostatectomy (RARP) incisional hernia repaired using the eTEP technique. CASE PRESENTATION: A 67-year-old man, who underwent RARP for prostate cancer 4 years ago developed an incisional hernia. Abdominal computed tomography showed the presence of an epigastric incisional hernia measuring 4 cm long and 3.7 cm wide. We performed an eTEP repair. We closed the hernia defect using a 0 barbed suture and placed a self-gripping mesh measuring 20 cm long and 15 cm wide in the developed retrorectus space with no fixation. There were no postoperative complications, and the patient was discharged on postoperative day 2. CONCLUSIONS: eTEP repair is considered an extremely effective surgical treatment option for incisional hernias because of its few resulting postoperative mesh-and-tacker-related complications.

The safety and feasibility of laparoscopic gastrectomy for gastric cancer in very elderly patients: short-and long-term outcomes.

PURPOSE: It remains unclear whether laparoscopic gastrectomy (LG) for gastric cancer is a suitable treatment for very elderly (VE) patients. We aimed to assess the safety and feasibility of LG for gastric cancer in VE patients. METHODS: We reviewed 226 consecutive patients who underwent LG between January 2010 and December 2016. We compared VE patients (age ≥ 80, n = 38) with non-elderly patients (age ≤ 79, n = 188). RESULTS: An ASA-PS score ≥ 2 was more common in VE group (86.8 vs. 48.9%; P < 0.01). There were no significant differences in the operating time, blood loss, postoperative hospital stay, or postoperative morbidity between the groups. The 3-year survival rate and 3-year disease-specific survival rate were lower in the VE group (53.7 vs. 85.6%; P < 0.0001, 78.5 vs. 92.4%; P = 0.0116). A univariate analysis showed that PS scores ≥ 2, Charlson comorbidity index ≥ 4, and pN stage were independent predictors of decreased overall survival rates in the VE group. A multivariate analysis showed total gastrectomy, a Charlson comorbidity index ≥ 4, and the pN stage to be independent predictors in the VE group. CONCLUSION: LG for gastric cancer is, thus, considered to be safe for patients aged 80 years or older. Total gastrectomy, a Charlson comorbidity index ≥ 4, and the pN stage were independent risk factors for a poor prognosis in these patients.

A novel technique of laparoscopic reduction of incarcerated internal supravesical hernia via peritoneal incision: A case report.

INTRODUCTION: Laparoscopic reduction techniques for internal supravesical hernia have not been discussed much in literature. CASE PRESENTATION: A 90-year old woman was admitted for symptoms of intestinal obstruction. She was diagnosed with small bowel strangulation by CT scan and laparoscopy was performed. Laparoscopy revealed a mass medial to the medial inguinal fold with tightly incarcerated small bowel. The bowel could not be reduced by traction or external compression, and required incision of the hernia ring. The tight incarceration posed a risk of bowel injury and so we performed peritoneal incision in a similar manner to the TAPP approach for loosening and precise incision of the hernia ring. The bowel was successfully reduced and the hernia was repaired by partial sac resection. DISCUSSION: Surgical methods as well as reduction technique were reviewed from previous literature. Procedures with open laparotomy, laparoscopy and anterior approach have been described, but details of reduction were not seen in many of these reports. Various methods have been described for bowel reduction in other hernias, but none involving peritoneal incision. This is the first report describing bowel reduction via the peritoneal incision technique. CONCLUSION: Internal supravesical hernia may pose difficulty in bowel reduction, but the peritoneal incision technique allows safe incision of the hernia ring under laparoscopic situations.

Laparoscopic duodenojejunostomy requiring a side-to-side jejunojejunostomy in malignant stenosis of the gastrojejunal anastomosis in jejunal cancer: A case report.

INTRODUCTION: Laparoscopic duodenojejunostomy is a common surgical treatment for SMA syndrome. Although there are successful cases of laparoscopic duodenojejunostomies on malignant conditions, cancer patients with opioid-induced bowel dysfunction could struggle in maintaining an oral diet despite surgical treatment of the mechanical obstruction. CASE PRESENTATION: A 66 year-old woman with a chemotherapy history of 18 months for Stage 4 jejunal cancer near the ligament of Treiz presented with vomiting and dehydration. She had a gastrojejunostomy constructed prior to the induction of chemotherapy. CT scan and endoscopic studies confirmed the stricture of this anastomosis due to tumor invasion. Laparoscopic duodenojejunostomy was performed, but tolerable food intake was not achieved, likely due to limited bowel movements caused by opioid use and tumor invasion of the celiac plexus. A side-to-side jejunojejunostomy was constructed, since accumulation of food in her jejunal loop was thought to be a significant cause of her limited food intake and vomiting. She was able to tolerate oral intake after the second intervention and was discharged home. DISCUSSION: Successful cases of laparoscopic duodenojejunostomy in malignant strictures of the duodenum have been reported. In this case, the outcome was not so well due to limited bowel movements caused by opioid use. Literature review of laparoscopic duodenojejunostomy on SMA syndrome revealed some cases to be unsuccessful in enabling oral feeding or resolving nausea, and methods to treat such cases could be discussed further. CONCLUSION: Laparoscopic duodenojejunostomy is an option for malignant strictures of the duodenum, but a favorable outcome could not be achieved in our case. A side to side anastomosis of the jejunal loop and the efferent jejunum may help in improving the outcome.

Manifestation of osteoblastic phenotypes in the sarcomatous component of epithelial carcinoma and sarcomatoid carcinoma.

Epithelial carcinomas occasionally have sarcomatous components that consist primarily of spindle and cuboidal cells, which often resemble osteoblasts. Sarcomatoid carcinomas consist of similar cells. Recent studies have characterized these phenomena as a manifestation of epithelial-mesenchymal transition in carcinoma cells, but the mesenchymal phenotypes that manifest in sarcomatous cells of epithelial carcinomas are not well understood. Here, we examined the expression profiles of four osteoblastic differentiation biomarkers in the sarcomatous components of multiple carcinoma types, including five renal clear cell, four breast invasive ductal, two esophageal, one maxillary squamous cell, three larynx, three lung, one liver, and one skin sarcomatoid carcinoma. Expression was analyzed by immunohistochemistry using antibodies against cell adhesion molecule 1, a member of the IgCAM superfamily, osterix transcription factor (Osterix), cluster of differentiation 151, a transmembrane 4 superfamily member, and alkaline phosphatase. Immunostaining intensity was rated in scale 0 (negative), 0.5 (weak), and 1 (strong) for each marker, and the four scale values were summed to calculate osteoblastic scores. In all, 10 cases had a osteoblastic score ≥3, and all of these 10 cases were cell adhesion molecule 1- and Osterix-positive. Eight and five of the nine samples with a osteoblastic score <3 were negative for cell adhesion molecule 1 ( p < 0.0001) and Osterix ( p = 0.006), respectively. The other markers showed no statistical significance. These results indicate that osteoblastic differentiation can occur in carcinoma cells and that cell adhesion molecule 1 could be a useful marker for identifying this phenomenon in carcinoma tissues.

Does laparoscopic adhesiolysis decrease the risk of recurrent symptoms in small bowel obstruction? A propensity score-matched analysis.

BACKGROUND: The outcomes of laparoscopic adhesiolysis for small bowel obstruction have generally been satisfactory over the short term. However, the long-term outcomes, including recurrence of symptoms and management of recurrence, remain controversial. This study compares the long-term outcomes of a series of laparoscopic and open surgery procedures for the treatment of small bowel obstruction. METHODS: Patients who underwent adhesiolysis for small bowel obstruction at our institution between 2008 and 2015 were retrospectively reviewed. In total, 156 patients were enrolled, 78 with laparoscopic and 78 with open surgery. Propensity score matching was used to minimize the bias in patient selection. Long-term outcomes included incidence of recurrent symptoms and reoperation. In addition to the comparison of outcomes, risk factor assessment for recurrent symptoms and analysis of detailed information in patients with reoperation were performed. Statistical methods included χ 2 test, Mann-Whitney U test, Cox proportional hazards model, and Kaplan-Meier plots with log-rank comparison. RESULTS: Laparoscopy was performed in a younger population with milder bowel dilation and less complicated etiologies. These factors were used to construct the propensity score model, which yielded a matched cohort of 52 legs in each group. Laparoscopy achieved good short-term outcomes including early recovery of gastrointestinal function, reduced incidence of complications, and shorter hospital stay. For long-term outcomes, while the overall recurrence rate did not differ between the groups (11.5 vs 7.7%), the incidence of reoperation for recurrence was significantly higher in the laparoscopically treated group (7.7 vs 0%, p = .017). The Cox proportional hazards model showed that multiple prior surgeries (≥3 times) were a risk factor for overall recurrence (hazard ratio 7.39, p = .041). CONCLUSION: Laparoscopic adhesiolysis did not decrease the incidence of recurrent symptoms; rather, it was related to higher incidence of recurrent small bowel obstruction requiring surgical treatment.

Outcomes of laparoscopic management of acute small bowel obstruction: a 7-year experience of 110 consecutive cases with various etiologies.

PURPOSE: Laparoscopic surgery is emerging as an alternative to open surgery for treating acute small bowel obstruction (SBO). While postoperative adhesion is the most frequent etiology, the optimum treatment for all types of SBO needs to be evaluated. METHODS: A retrospective review was performed of 110 consecutive patients who underwent laparoscopic surgery at our institution between 2009 and 2015. The short-term outcomes included perioperative factors, while the long-term outcome included the recurrence rate. RESULTS: Of the 110 patients, 55 were female. The median age at surgery was 69.5 years. Laparoscopic surgery was completed in 91.8 %. The median operative time was 82 min, median amount of bleeding was 0 ml, and median postoperative hospital stay was 8 days. Intraoperative major organ injury was seen in 2.7 %. The complication rate (Clavien-Dindo ≥ class II) was 8.2 %, and the mortality rate was 3.6 %. The recurrence rate was 8.2 %. Only dense and matted adhesion was a predictive factor for conversion (OR 30.244). CONCLUSION: Good short-term outcomes and feasible long-term outcomes were achieved with a laparoscopic approach to treating acute SBO. It was a safe and effective method, especially in patients with isolated bands, simple enteral angulation, and foreign body or tumor, while dense and matted adhesions were still challenging.

Primary closure of a spontaneous esophageal rupture under hand-assisted laparoscopy: a case report.

Spontaneous rupture of the esophagus, which is also known as Boerhaave's syndrome, is a rare life-threatening condition that requires urgent surgical management. The optimal treatment involves surgical repair of the esophageal defect, which is usually accomplished via laparotomy, thoracotomy, or both, and mediastinal debridement. Here, we report a case of spontaneous rupture of the esophagus that was treated with suturing repair and drain insertion using a hand-assisted laparoscopic approach.

A case of deep femoral artery aneurysm.

A 58-year-old man presented with paralysis and pain in the left leg, and a mass was found in his thigh. Because of the growth of the mass and the worsening of his symptoms, the patient visited our hospital. Multidetector computed tomography revealed a large deep femoral arterial (DFA) aneurysm. Surgical intervention was planned because of the large size of the aneurysm, the high risk of perforation and the worsening symptoms. Aneurysmectomy and revascularization of the distal DFA with an artificial blood vessel graft were performed. DFA aneurysms are extremely rare. These aneurysms have a high rate of rupture, and surgery plays an important role in their treatment. However, standard methods have not yet been established because of their rarity of DFA aneurysm. We describe a case of DFA aneurysm in a patient who was successfully treated with aneurysmectomy and revascularization with an artificial blood vessel graft.

Laparoscopic right hemicolectomy for metachronous ascending colon cancer with preservation of an ileal conduit constructed after previous radical cystectomy for bladder cancer.

A 79-year-old woman who had undergone laparoscopic radical cystectomy and ileal conduit construction for bladder cancer 4 years earlier presented to our hospital with anemia. We diagnosed advanced ascending colon cancer (cT4bN2M1) and documented tumor regression after six courses of folinic acid, 5-fluorouracil, and oxaliplatin therapy. We then performed laparoscopic right hemicolectomy. Intraoperatively, we found that the right colic artery was the feeding artery of the tumor, whereas the ileocolic artery, which was the main feeder of the conduit, was not. We performed lymph node dissection along the surgical trunk with central vascular ligation of the right colic artery and the right branch of the middle colic artery while preserving the ileal conduit and its blood supply (ileocolic artery and ileal branches). The postoperative course was uneventful, and the patient remains well and cancer-free 2 years after colonic surgery. We believe that this is the first report of laparoscopic right colectomy in a patient with an ileal conduit.

The role of CXCR3 and CXCR4 in colorectal cancer metastasis.

Chemokines and their receptors play key roles in leukocyte trafficking and are also implicated in cancer metastasis. We previously demonstrated that forced expression of CXCR3 promotes colon cancer metastasis preferentially to the draining lymph nodes (LNs), with poor prognosis. Using clinical colorectal cancer (CRC) samples, here, we show that expressions of CXCR3 and CXCR4 are significantly higher in metastatic foci within LNs and liver compared to primary tumors, whereas ligands for CXCR3 and CXCR4 are not. We also have demonstrated that some human CRC cell lines constitutively express both CXCR3 and CXCR4, and that activation of CXCR3 strengthens the CXCR4-mediated cell migration in vitro in a synergistic manner. By constructing SW620 cell lines with reduced expression of CXCR3 and/or CXCR4 using microRNA, we investigated in vivo metastatic activities in a mouse rectal transplantation model. Six weeks after inoculation, CXCR3-, CXCR4-, and CXCR3/CXCR4 double-knockdowns significantly reduced metastasis to LNs, liver and lungs, compared to the control (p < 0.05). Importantly, its suppressive effect on LN metastasis was significantly stronger in CXCR3- and CXCR3/CXCR4 double-knockdowns. In addition, CXCR3- and CXCR3/CXCR4 double-knockdowns significantly decreased the dissemination of cancer cells to liver and lungs, even after 2 weeks. These results indicate that targeting CXCR3 and CXCR4 can be a promising therapy against CRC metastasis.

Relationship between 18F-fluorodeoxyglucose accumulation and KRAS/BRAF mutations in colorectal cancer.

PURPOSE: Positron emission tomography (PET) with (18)F-fluorodeoxyglucose (FDG) has been widely used in the management of colorectal cancer (CRC). However, the relationship between FDG accumulation and KRAS/BRAF mutations has not yet been investigated. The purpose of this study was to investigate whether KRAS/BRAF mutations affect FDG accumulation in CRC. EXPERIMENTAL DESIGN: Retrospective analysis was conducted in 51 patients with CRC who underwent FDG-PET/computed tomographic (CT) scans for staging before primary tumor resection. The maximum standardized uptake value (SUV(max)) for the primary tumor and the tumor-to-liver ratio (TLR) were calculated from FDG accumulation and compared between KRAS/BRAF mutated and wild-type groups. Expression levels of glucose transporter-1 (GLUT1) and hexokinase type-II (HXK-II) were assessed by immunohistochemical analysis. RESULTS: Both SUV(max) and TLR were significantly higher in the KRAS/BRAF-mutated group compared with the wild-type group (P = 0.006 and 0.001, respectively). Multivariate analysis indicated that SUV(max) and TLR remained significantly associated with KRAS/BRAF mutations (P = 0.016 and 0.01, respectively). KRAS/BRAF status could be predicted with an accuracy of 75% when a SUV(max) cutoff value of 13 or 14 was used. GLUT1 expression in cancer cells was positively correlated with FDG accumulation and KRAS/BRAF status whereas HXK-II expression was not. CONCLUSION: FDG accumulation was higher in CRC with KRAS/BRAF mutations. FDG-PET/CT scans may be useful for predicting the KRAS/BRAF status of patients with CRC and thus aid in determination of therapeutic strategies for patients with CRC.

Molecular mechanisms of liver metastasis.

Colorectal cancer is the second most common cancer, and is the third leading cause of cancer-related death in Japan. The majority of these deaths is attributable to liver metastasis. Recent studies have provided increasing evidence that the chemokine-chemokine receptor system is a potential mechanism of tumor metastasis via multiple complementary actions: (a) by promoting cancer cell migration, invasion, survival and angiogenesis; and (b) by recruiting distal stromal cells (i.e., myeloid bone marrow-derived cells) to indirectly facilitate tumor invasion and metastasis. Here, we discuss recent preclinical and clinical data supporting the view that chemokine pathways are potential therapeutic targets for liver metastasis of colorectal cancer.