Effect of Preoperative Oral Antibiotics and Mechanical Bowel Preparations on the Intestinal Flora of Patients Undergoing Laparoscopic Colorectal Cancer Surgery: A Single-Center Prospective Pilot Study.

INTRODUCTION:  In the last few decades, considerable progress has been made in controlling surgical site infections (SSIs) using a combination of mechanical and oral antibiotic bowel preparation. However, the number of bacteria present after bowel preparation has not been clarified. In this study, we investigated the bacterial cultures of intestinal fluid samples from patients undergoing laparoscopic surgery for colorectal cancer after preoperative bowel preparation. METHODS: This prospective observational study was designed as a pilot study at a single center. We enrolled 25 consecutive patients who underwent laparoscopic surgery for colorectal cancer between March 2021 and February 2022 at our institution. RESULTS: The rate of bacterial culture positivity was 56.0%. The most abundant bacterium was Escherichia coli (44.0%). The positivity rates for E. coli on the right and left sides were 54.5% and 35.7%, respectively (P = 0.60). Moreover, there was a significant relationship between a low American Society of Anesthesiologists Physical Status score and E. coli positivity on the right side (P = 0.031). In the left-sided group, female sex and large tumor size were significantly associated with E. coli positivity (P = 0.036 and 0.049, respectively). Superficial SSI occurred in the patient in the left-sided group, but E. coli was negative. CONCLUSION: This study emphasizes the importance of understanding intestinal fluid contamination and its relationship to infection risk. Future prospective multicenter studies should be conducted to determine the association between intestinal bacteria and different types of preoperative preparation.

Laparoscopic subtotal cholecystectomy for difficult cases of acute cholecystitis: a simple technique using barbed sutures.

BACKGROUND: Laparoscopic cholecystectomy (LC) for difficult acute cholecystitis (AC) cases bears a high risk of vasculobiliary injuries (VBI). The Tokyo Guidelines 2018 (TG18) recommend the use of bailout procedures and subtotal cholecystectomy to prevent VBI. Performing a safe LC is challenging, even when followed by an accurate pre-surgical assessment. Laparoscopic cholecystectomy (LSC) requires advanced skills, and there is a risk of recurrence of cancer and/or gallbladder stones (GBS) in the remnant gallbladder (GB). Moreover, it is sometimes impossible to safely close the cystic duct with either a loop tie or linear staples because of anatomical and fragility problems. Here, we report a novel technique employing barbed sutures for LSC in difficult AC cases. CASE PRESENTATION: We performed urgent LSC using barbed sutures for the stump of the cystic duct in two patients. In preoperative assessments, we found that these cases were qualified for operations rather than GB drainages, but the cystic ducts appeared difficult to close due to their severe inflammation and fragility during the operations. We applied barbed suture as a surrogate technique to close the stump of cystic duct. In patient 1, a 67-year-old woman with severe heart failure and type 2 diabetes mellitus was diagnosed with grade III AC. Pathological diagnosis was gangrenous cholecystitis. In patient 2, a 68-year-old woman who was referred to our hospital after 15 days of treatment for AC with antibiotics without drainage. The severity of AC was grade II according to TG18. Pathological diagnosis was acute-on-chronic cholecystitis. Both patients were discharged without complication. CONCLUSIONS: The utilization of barbed sutures in LSC stems as a feasible and safe surrogate technique. Furthermore, this approach could decrease the risks associated with the remnant GB.

Surgical Resection with Neoadjuvant Chemotherapy for Locoregionally Recurrent Appendiceal Cancer Invading the External Iliac Vessels.

Recent advancements in multimodal therapy can provide oncologic benefits for patients with recurrent colorectal cancer. This report presents a case of locoregionally recurrent appendiceal cancer treated with neoadjuvant chemotherapy followed by surgical resection with vascular reconstruction. A 68-year-old Japanese woman was diagnosed with appendiceal cancer and underwent ileocecal resection. The pathological evaluation revealed KRAS-mutant adenocarcinoma with the final stage of T4bN1M0. She received oral fluorouracil-based adjuvant chemotherapy. One year later, she was found to have peritoneal dissemination in the pelvic cavity and vaginal metastasis. She received an oxaliplatin-based chemotherapy followed by surgical resection. One year after the second surgery, she developed a locoregional recurrence involving the right external iliac vessels and small intestine. She received an irinotecan-based regimen with bevacizumab as neoadjuvant chemotherapy, followed by surgical resection. At first, a femoro-femoral bypass was made to secure the blood supply to the right lower extremities. Subsequently, an en bloc resection including the recurrent tumor and the external iliac vessels was completed. Surgical resection for recurrent colorectal cancer is often technically challenging because of the tumor location and invasion to adjacent organs. In this case, a surgical approach with persistent chemotherapy achieved oncologic resection of locoregionally recurrent appendiceal cancer.