Management of Patients Receiving Antiplatelet Therapy During Gastroenterological Surgery: A Multicenter Prospective Cohort Study (GSATT).

OBJECTIVE: This study aimed to evaluate the effect of continuing preoperative aspirin monotherapy on surgical outcomes in patients receiving antiplatelet therapy (APT). SUMMARY BACKGROUND DATA: The effectiveness of continuing preoperative aspirin monotherapy in patients undergoing APT in preventing thromboembolic consequences is mostly unknown. METHODS: This prospective multicenter cohort study on the Safety and Feasibility of Gastroenterological Surgery in Patients Undergoing Antithrombotic Therapy (GSATT study) conducted at 14 clinical centers enrolled and screened patients between October 2019 and December 2021. The participants (n=1,170) were assigned to the continued APT group, discontinued APT group, or non-APT group, and the surgical outcomes of each group were compared. Propensity score matching was performed between the continued and discontinued APT groups to investigate the effect of continuing preoperative aspirin therapy on thromboembolic complications. RESULTS: The rate of thromboembolic complications in the continued APT group was substantially lower than that in the non-APT or discontinued APT groups (0.5% vs. 2.6% vs. 2.9%; P=0.027). Multivariate investigation of the entire cohort revealed that discontinuation of APT (P<0.001) and chronic anticoagulant use (P<0.001) were independent risk factors for postoperative thromboembolism. The post-matching evaluation demonstrated that the rates of thromboembolic complications were significantly different between the continued and discontinued APT groups (0.6% vs. 3.3%; P=0.012). CONCLUSIONS: APT discontinuation following elective gastroenterological surgery increases the risk of thromboembolic consequences, whereas continuing preoperative aspirin greatly reduces this risk. The continuation of preoperative aspirin therapy in APT-received patients is considered one of the best alternatives for preventing thromboembolism during elective gastroenterological surgery.

A Case of Retroperitoneal Paraganglioma.

We report a surgical case of retroperitoneal paraganglioma. A paraganglioma is a catecholamine-producing tumor originating in the chromaffin cells of the sympathetic ganglion. It is a kind of pheochromocytoma which occurs on the outside of the adrenal gland. The patient was a 72 year old male with a history of hypertension and a pacemaker implantation. A mass in the ventral side of the right iliopsoas muscle was detected during a routine contrasting computed tomography (CT) examination for checking his pacemaker. The mass was considered to be malignant, and a laparotomy and mass enucleation was performed. It was diagnosed as phaeochromocytoma, based on the pathology and immunestology of the excised specimen. The hypertension was cured soon after the surgery. Nine months after surgery, there is no evidence of any abnormality or recurrence. There is a previous report of a recurrence 25 years after surgery, so a careful follow-up of this patient will be necessary in the future.

A Review of 7 Cases of Laparoscopic Cholecystectomy for Pediatric Cholecystolithiasis.

Pediatric cholecystolithiasis is a relatively rare disease, but it is recently increasing in Japan. Laparoscopic cholecystectomy (LC) is a standard procedure for cholecystolithiasis not only in adults but also in children, and we are aggressively introducing single-incision laparoscopic cholecystectomy (SILC) at our hospital. We reviewed the patient characteristics, operation procedures and outcomes of 7 children (15 years old and under) with cholecystolithiasis who underwent LC in our hospital between August 1995 and December 2015. The 7 patients included 5 males and 2 females, with a mean age of 8 years 6 months. Underlying diseases were found in 5 patients (cerebral palsy in 2 patients, pancreaticobiliary maljunction with common bile duct stones in 1, acute lymphocytic leukemia in 1, hereditary stomatocytosis in 1), and none were found in the other 2. LC (3 conventional LC and 2 SILC) was performed in 5 of the patients. Laparoscopic choledocholithotomy was performed in 1 patient and laparoscopic splenectomy (LS) was performed in 1 patient at the same time. The mean operative time in all the cases of LC was 108 (70-140) minutes (conventional LC 113 (70-140) min, SILC 100 (90-100) min). Intraoperative cholangiography was performed in 4 cases and omitted in 3 cases. The only postoperative complication was a wound infection in 1 patient. The umbilical skin incision length in the SILC was 2.0 cm. We conclude that LC can be safely performed for children with cholecsytolithiasis, and that SILC is feasible and advantageous in terms of its improved cosmesis.

Rapid postoperative reduction in prognostic nutrition index is associated with the development of pancreatic fistula following distal pancreatectomy.

BACKGROUNDS: Despite recent advances in surgical techniques and devices for pancreatic remnant closure, postoperative pancreatic fistula (POPF) still remains one of the common complications after distal pancreatectomy (DP). Identification of risk factors for POPF may lead to the development of new strategies to prevent this ominous complication. METHODS: We retrospectively reviewed data on 44 patients undergoing DP with the use of a stapler to identify risk factors for POPF. Study variables included preoperative prognostic nutritional index (PNI) and reduction rate of PNI on postoperative day (POD) 7. RESULTS: POPF occurred in 23 patients (52%), of which 13 (56%) were grade B or C. Univariate analyses comparing patients with POPF and those without POPF showed significant differences in body mass index (P = 0.0102), pancreatic thickness (P = 0.0134), white blood cell count on POD7 (P = 0.0432), C-reactive protein level on POD7 (P = 0.0123), and PNI reduction rate (P = 0.0471). A multivariate analysis revealed pancreatic thickness (P = 0.0121) and PNI reduction rate (P = 0.0165) to be significant factors for POPF. Furthermore, the PNI reduction rate was significantly higher in patients with clinically relevant (grade B/C) POPF than in those with no or grade A POPF (P = 0.0257). In most patients, the massive postoperative PNI reduction preceded the diagnosis of clinically relevant POPF. CONCLUSIONS: These findings suggest that rapid postoperative reduction in PNI is associated with the development of POPF.

Pancreatic somatostatinoma diagnosed preoperatively: report of a case.

CONTEXT: Somatostatinoma is a rare neoplasm of the pancreas. Preoperative diagnosis is often difficult. CASE REPORT: We report a 72-year-old woman with a pancreatic head tumor measuring 37 mm in diameter, and enlargement of the lymph nodes on the anterior surface of the pancreatic head and the posterior surface of the horizontal part of the duodenum. Laboratory data showed an elevated plasma somatostatin concentration. Examination of a biopsy specimen of the pancreatic head mass obtained by endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) showed histopathological features of a neuroendocrine tumor. Immunohistochemical staining showed that the tumor cells were positive for somatostatin, leading to a preoperative diagnosis of pancreatic somatostatinoma. The patient underwent pylorus-preserving pancreaticoduodenectomy. The plasma somatostatin concentration decreased progressively after surgery. CONCLUSIONS: A rare case of pancreatic somatostatinoma with lymph node metastases was presented. Immunohistochemical analysis of a biopsy specimen obtained by EUS-FNA was useful for preoperative diagnosis.

Risk factors for a prolonged operative time in a single-incision laparoscopic cholecystectomy.

BACKGROUND: A prolonged operative time is associated with adverse post-operative outcomes in laparoscopic surgery. Although a single-incision laparoscopic cholecystectomy (SILC) requires a longer operative time as compared with a conventional laparoscopic cholecystectomy, risk factors for a prolonged operative time in SILC remain unknown. METHODS: A total of 20 clinical variables were retrospectively reviewed to identify factors for a prolonged operative time (longer than 3 h) in a total of 220 consecutive patients undergoing SILC. RESULTS: The median operative time was 145 min (range, 55-435) and a prolonged operative time was required in 62 patients (28%). Independent factors that predict a prolonged operative time as identified through multivariate analysis were body mass index (BMI) (P = 0.009), acute cholecystitis (P < 0.001) and operator (resident or staff surgeon) (P < 0.001). Furthermore, a prolonged operative time was significantly associated with an increased amount of intra-operative blood loss (P < 0.001) and a prolonged stay after surgery (P < 0.001). CONCLUSIONS: These findings suggest that a higher BMI, acute cholecystitis and a resident as an operator significantly increase the duration of SILC procedures.

Laparoscopic approach for port site mass diagnosed as a Schloffer tumor following surgery of ascending colon cancer.

Schloffer tumor is a foreign body granuloma that develops in the subcutaneous layer of the abdomen over several months to several years after surgery due to sutures. Here, we performed a laparoscopic resection for a benign Schloffer tumor that showed positive F-18 fluorodeoxyglucose (FDG) positron emission tomography (PET) at the port site of a laparoscopic right hemicolectomy for advanced colon cancer. We report a case in which systemic chemotherapy was avoided as a result of the histological examination following the laparoscopic approach. A 66-year-old female, who underwent laparoscopic right hemi colectomy for stage IIIA ascending colon cancer, was revealed an enhanced mass at the right side of the abdominal subcutaneous layer. PET examination showed a high accumulation of FDG. Laparoscopic tumor resection was performed. Pathological findings reported the formation identical to the Schloffer tumor. Schloffer tumor, which is rare, should be considered as one of the differential diagnoses for tumor with FDG-PET positivity at the port site during the postoperative surveillance period of colorectal cancer.

Intermittent negative pressure external drainage of the pancreatic duct reduces the incidence of postoperative pancreatic fistula after pancreaticojejunostomy.

BACKGROUND/AIMS: The formation of a pancreatic fistula remains one of the serious morbidities after pancreaticojejunostomy. This study is focused on the efficacy of negative pressure external drainage of the main pancreatic duct in pancreaticojejunostomy. METHODOLOGY: Fifty-eight consecutive patients who underwent pancreaticojejunostomy at our hospital from May 2008 to May 2012 were enrolled in this study. They were divided into a group of 25 earlier patients (Group A) with gravity drainage of the pancreatic duct (from May 2008 until May 2010) and a group of 33 later patients (Group B) with negative pressure drainage (treated from June 2010 until May 2012). These two groups were compared based on the patient characteristics, parameters related to the operation, and postoperative complications and hospital stay. Furthermore, examinations were performed for subgroups of patients with a soft pancreas (43 patients) or a hard pancreas (15 patients) based on the hardness of the remnant pancreas. RESULTS: There were no statistically significant differences between the two groups in the patient demographics, laboratory data or parameters related to the operation. Although there was no difference in the amount of drainage from the pancreaticojejunostomy, the amylase values in the drainage around the pancreaticojejunostomy of group B were significantly lower than those of group A (p = 0.026). The complication rates were also significantly lower in group B than in group A for the development of a postoperative pancreatic fistula (POPF) (p = 0.012), intraabdominal abscess (p = 0.045), or wound infection (p = 0.01). There were no statistically significant differences between the two groups in the mean hospital stay. When restricted to patients with a soft pancreas, the incidence of POPF (grade B or C) of group B was significantly lower than that of group A (p = 0.003). The P-value for the soft pancreas group was lower than that of the overall cases. In the examination restricted to patients with a hard pancreas, POPF (grade B or C) did not occur in either group. CONCLUSIONS: This retrospective study showed that the application of intermittent negative pressure external drainage of the main pancreatic duct significantly reduces the rate of pancreatic fistula and intra-abdominal abscess formation after pancreaticojejunostomy, and these effects were more remarkable in the patients with a soft pancreas.

[A review of 13 cases of obturator hernia].

We reviewed clinical features of patients who we treated for obturator hernia. The subjects were 13 patients who underwent an operation for obturator hernia in our hospital between April 2002 and December 2012. The mean age was 78.5 years, and all patients were female. The mean body mass index was 16.8 kg/m(2). The Howship-Romberg sign was present in only 3 patients. All patients were correctly diagnosed by preoperative pelvic computed tomography. All patients underwent operation. Operative procedures included the laparoscopic approach in 8 patients, the open approach in 3 patients and the inguinal approach in 2 patients. The hernia hilus was repaired with a simple closure in 5 patients, and with a mesh in 8 patients. The hernia contents were small intestine in all the patients. Three patients underwent partial resection of the small intestine because of necrosis of the intestine wall. Three patients had a recurrence of the obturator hernia. In our present series, the patients with obturator hernia were slender females at an advanced age. Plevic CT was useful for the diagnosis of obturator hernia.

Changes in operative trends and short-term outcomes of surgery for congenital biliary dilatation in adults using real-world data: A multilevel analysis based on a nationwide administrative database in Japan.

Aim: We aimed to evaluate the operative trends and compare the short-term outcomes between open and laparoscopic surgery for congenital biliary dilatation (CBD) in adults using real-world data from Japan. Methods: Data from the Japanese Diagnosis Procedure Combination database on 941 patients undergoing surgery for CBD at 357 hospitals from April 1, 2016, to March 31, 2021, were analyzed. The patients were divided into two groups: open surgery (n = 764) and laparoscopic surgery (n = 177). We performed a retrospective analysis via a multilevel analysis of the short-term surgical outcomes and costs between open and laparoscopic surgery. Results: The rate of laparoscopic surgery has been increasing annually and had almost doubled to 25% by 2021. There were no significant differences in the in-hospital mortality rate or postoperative morbidity between the two groups. The length of anesthesia was significantly longer in the laparoscopic than open surgery group (8.80 vs 6.16 hours, p < .001). The time to removal of the abdominal drain and length of hospital stay were significantly shorter in the laparoscopic than open surgery group (6.12 vs 8.35 days, p = .001 and 13.57 vs 15.79 days, p < .001, respectively). The coefficient for cost was 463 235 yen (95% confidence interval, 289 679-636 792) higher in laparoscopic than open surgery (p < .001). Conclusion: The short-term results were comparable between laparoscopic and open surgery for CBD. Further investigation is needed to validate our findings and long-term outcomes.

Short-term outcomes of pancreatoduodenectomy in older individuals over a 9-year period using real-world data: A multilevel analysis based on a nationwide administrative database in Japan.

BACKGROUND: We aimed to evaluate the short-term outcomes of pancreatoduodenectomy (PD) in older individuals. METHODS: Data from the Japanese Diagnosis Procedure Combination database on 62 275 patients who underwent PD from 1 April 2012 to 31 March 2020 were analyzed. Patients were divided into five age groups: <70, 70-74, 75-79, 80-84, and ≥85 years. The associations between postoperative outcomes and age were investigated using multilevel analysis. The mean differences in length of hospital stay and cost were also compared. RESULTS: The rate of PD in older individuals increased annually. Compared with the youngest age group (< 70 years), the incidence rate ratios for in-hospital mortality were 1.52 (95% confidence interval [CI]: 1.30-1.76), 2.07 (1.82-2.37), 2.29 (1.94-2.71), and 2.92 (2.20-3.87) in the 70-74, 75-79, 80-84, and ≥ 85-year-old age groups, respectively (all p < .001). Postoperative complications, length of postoperative hospital stay, and cost increased significantly with increasing age. CONCLUSIONS: These real-world data emphasize the higher levels of morbidity, mortality, and cost in older patients. Careful attention should be paid when considering the indication for PD in older individuals.

Efficacy of micafungin in empirical therapy of deep mycosis in surgically ill patients.

Micafungin (MCFG), an echinocandin antifungal agent, exhibits antifungal activity against Candida albicans and non-albicans Candida. The fungicidal activity of MCFG against clinical isolates of Candida species was investigated, and the clinical efficacy of MCFG in therapy of deep mycosis in surgery was studied using the AKOTT algorithm. The minimum inhibitory concentration and minimum fungicidal concentration values of fluconazole were ≤0.06-4 and >64 µg/ml, respectively, for each strain, whereas these values of MCFG were 0.008-0.5 and 0.016-1 µg/ml, suggesting that MCFG provided superior fungicidal ability against Candida albicans and non-albicans Candida. The subjects were separated into two groups: group A consisted of 20 subjects with both persisting fever refractory to broad-spectrum antibiotics and positive reaction to ß-D-glucan test, and group B consisted of 20 subjects with either of those conditions. The overall response was evaluated as "effective" in 17 patients (85%) and 20 patients (100%) in groups A and B, respectively. In total, response was evaluated as "effective" in 37 patients (92.5%) and "ineffective" in 3 patients (7.5%). These findings suggest that MCFG administration should be used as empirical therapy for deep mycosis in surgically ill patients as it was shown to be an effective antifungal drug lacking serious adverse effects.

Evaluation of cholecystectomy in older individuals using real-world data: a multilevel analysis based on a nationwide administrative database in Japan.

BACKGROUND: In the present study, we aimed to evaluate the clinical outcomes of cholecystectomy in older individuals. METHODS: In this retrospective study, data from the Japanese Diagnosis Procedure Combination database on 96,620 patients who had undergone cholecystectomy at 1060 hospitals from 2018 to 2020 were analyzed. Patients were divided into five age groups: < 75, 75-79, 80-84, 85-89, and ≥ 90 years. Associations between postoperative outcomes and age group were investigated by logistic regression analysis. Mean differences between age groups in time to postoperative recovery and cost were also compared. RESULTS: Older patients had higher rates of poor scores for activities of daily living and preoperative comorbidity. Compared with the youngest age group (< 75 years), the odds ratios for in-hospital mortality were 3.00 (95% confidence interval, 1.74-5.19), 7.54 (4.73-12.01), 13.47 (8.21-22.14), and 27.64 (15.56-49.09), in the 75-79, 80-84, 85-89, and ≥ 90-year-old age group, respectively (all p < 0.001). Furthermore, the length of postoperative hospital stay and rates of postoperative complications, postoperative reintubation, and reoperation with general anesthesia increased significantly in parallel with increasing age, the highest rates being in the ≥ 90 year-old age group. CONCLUSIONS: Our real-world data highlight the worse postoperative outcomes, including a higher mortality rate, in older patients undergoing cholecystectomy. Care should be taken when considering the indications for surgery in such patients.

A case of gallbladder adenocarcinoma arising in association with intracystic papillary neoplasm (ICPN) with abundant mucin production.

Intracystic papillary neoplasm (ICPN) of the gallbladder is a rare clinicopathological entity with a wide range of malignant potentials. Here, we report a case of mucin-producing gallbladder carcinoma possibly derived from ICPN. A 78-year-old female patient was referred to our hospital for examination of jaundice. Abdominal CT showed dilated biliary trees and a contrast-enhanced large polypoid mass in the gallbladder. Duodenoscopy showed a large amount of mucin extravasating from the ampulla of Vater. Bile cytology showed no evidence of malignancy. Under the diagnosis of mucin-producing gallbladder tumor, we performed laparoscopic cholecystectomy. Macroscopically, there was a large papillary tumor throughout the entire gallbladder mucosa. Pathological examinations showed a gallbladder adenocarcinoma localized to the mucosa in association with ICPN. Immunohistochemical analysis of the tumor revealed positive staining for MUC2 and MUC5AC but negative for MUC1 and MUC6, suggestive of the intestinal type.

[A case of sigmoid colon cancer with peritoneal dissemination responding to third-line therapy employing bevacizumab combination therapy after failure of FOLFOX and FOLFIRI].

A58 -year-old man with sigmoid colon cancer with peritoneal dissemination was treated with bevacizumab (BV) plus mFOLFOX6 therapy as third-line chemotherapy after treatment failures with FOLFOX4 and FOLFIRI regimen. BV combination therapy resulted in a decrease in ascites and disappearance of the primary lesion. His ECOG performance status (PS) recovered from level 3 to level 1, and BV combination therapy improved his quality of life. This case suggested that BV in combination with chemotherapy could be a promising systemic chemotherapy for patients with colorectal cancer with peritoneal dissemination, and this regimen may be useful for patients progressing after receiving FOLFOX, FOLFIRI regimen.

Gallbladder metastasis of renal cell carcinoma presenting as a hypervascular polypoid lesion: case report of two cases with immunohistochemical analysis.

BACKGROUND: Metastasis of renal cell carcinoma (RCC) to the gallbladder is rare, and its clinicopathological feature remains poorly understood. We here present two cases of gallbladder metastasis from RCC presenting as a hypervascular polypoid lesion. CASE PRESENTATION: The first case was a 73-year-old man who had undergone right nephrectomy for clear cell RCC. Imaging studies detected a hypervascular polypoid lesion in the gallbladder 6 years after nephrectomy. Laparoscopic cholecystectomy was done. The pathological findings of the polypoid lesion showed proliferation of clear cells in the submucosal layer. Immunohistochemically, the tumor was positive for carbonic anhydrase 9 (CA9) but negative for cytokeratin 7 (CK7), suggestive of metastatic RCC. The second case was a 43-year-old man who had undergone right nephrectomy for clear cell RCC. Imaging studies revealed a hypervascular polypoid lesion of 20 mm in diameter in the gallbladder 1 year after nephrectomy. The patient underwent expanded cholecystectomy and extra-hepatic bile duct resection with lymphadenectomy. Microscopically, the polypoid lesion of the gallbladder was composed of clear cells in the submucosal layer. Immunohistochemical analysis showed positive staining for epithelial membrane antigen (EMA) and carcinoembryonic antigen (CEA) but negative staining for CK7, leading to the diagnosis of metastatic RCC. CONCLUSIONS: Gallbladder metastasis from RCC is rare but should be considered when a hypervascular polypoid lesion in the gallbladder is detected during the follow-up period after RCC treatment.

[A case of intraoperative latex anaphylaxis during general anesthesia for rectal cancer resection].

A 72-year-old woman underwent high anterior resection for rectal cancer. Fifteen minutes after the start of the operation, the pressure on the respiratory tract rose, blood pressure and SpO2 dropped, and skin rash, wheezing and ECG disorder appeared. The anesthesiologist suspected latex anaphylaxis and interrupted the operation. The patient was treated immediately for anaphylactic shock, and recovered. Post-operation, she showed positive reaction to latex specific IgE, suggesting that the anaphylaxis was induced by latex allergy. A re-operation was performed under a latex-free environment. No allergic reaction was seen during or after the re-operation.

[A long-term survivor case with good quality of life due to biliary bypass and gemcitabine for advanced pancreatic cancer].

A 54-year-old man was admitted to the hospital because of upper abdominal pain and anorexia. Physical examination revealed jaundice, and abdominal CT demonstrated a pancreatic mass and dilatation of bile duct. The patient was operated with the diagnosis of pancreatic cancer. However, the pancreatic cancer was unresectable because of invasion of the surrounding organs and metastasis to paraaortic lymph nodes, so a biliary bypass was performed. After operation, chemotherapy using gemcitabine was performed in the outpatient clinic. He survived for more than two years and eleven months without recurrence of jaundice. Combination of biliary bypass and gemcitabine is considered helpful for good quality of life and long-term survival of a patient with advanced pancreatic cancer.

Sepsis and disseminated intravascular coagulation.

Sepsis is frequently complicated by coagulopathy and, in about 35 % of severe cases, by disseminated intravascular coagulation (DIC). In Japan, aggressive treatment of septic DIC is encouraged using antithrombin and recombinant thrombomodulin. The macrophages, monocytes, and neutrophils are a source of TF and participate in the direct activation of the coagulation cascade in the early phases of sepsis. And activated factor X (FXa), which is involved in hemostasis, thrombogenesis, inflammation, and cellular immune responses, induces TF expression in human peripheral monocytes and, conversely, that inhibition of FXa activity reduces TF expression. Both inflammation and coagulation play an important role in DIC due to sepsis. In addition to inflammatory cytokines (TNF-α, IL-1 and so on), HMGB1 has recently been shown to mediate the lethal late phase of sepsis and caused coagulopathy. TM not only binds HMGB1 but also aids the proteolytic cleavage of HMGB1 by thrombin. There have been many reports of the efficacy of recombinant TM and antithrombin for treatment of septic DIC from Japan. Further investigation of the efficacy of recombinant TM and AT in countries other than Japan, as well as the monitoring of medical costs incurred during hospitalization, will help validate the use of TM and AT for treatment of septic DIC.