Rare symptom of left inguinal abscess secondary to a retroperitoneal perforation of diverticulitis of the sigmoid colon: A case report

RATIONALE

Complicated colorectal diverticulitis could be fatal, and an abscess caused by this complication is usually formed at the pericolic, mesenteric, or pelvic abscess. Therefore, we report a rare case of sigmoid colon diverticulitis that developed a large inguinal abscess.

PATIENT CONCERNS

A woman in her 70s was admitted to our hospital with a chief complaint of left inguinal swelling and tenderness 1 week before admission. Physical examination showed swelling, induration, and tenderness in the left inguinal region. Blood tests revealed elevated inflammatory reaction with C-reactive protein of 11.85 mg/dL and white blood cells of 10,300/μL. Contrast-enhanced computed tomography showed multiple colorectal diverticula in the sigmoid colon, edematous wall thickening with surrounding fatty tissue opacity, and abscess formation with gas in the left inguinal region extending from the left retroperitoneum.

DIAGNOSES

The diagnosis was sigmoid colon diverticulitis with large abscess formation in the left inguinal region.

INTERVENTIONS

Immediate percutaneous drainage of the left inguinal region was performed, as no sign of panperitonitis was observed. Intravenous piperacillin-tazobactam of 4.5 g was administered every 6 hours for 14 days.

OUTCOMES

The inflammatory response improved, with C-reactive protein of 1.11 mg/dL and white blood cell of 5600/μL. Computed tomography of the abdomen confirmed the disappearance of the abscess in the left inguinal region, and complete epithelialization of the wound was achieved 60 days after the drainage. The patient is under observation without recurrence of diverticulitis.

LESSONS

We report a rare case of sigmoid colon diverticulitis that developed a large inguinal abscess, which was immediately improved by percutaneous drainage and appropriate antibiotics administration.

Validation of the Diagnostic Criteria for IgG4-Related Periaortitis/Periarteritis and Retroperitoneal Fibrosis (IgG4PA/RPF) 2018, and Proposal of a Revised 2023 Version for IgG4-Related Cardiovascular/Retroperitoneal Disease

BACKGROUND

In 2018, diagnostic criteria were introduced for IgG4-related periaortitis/periarteritis and retroperitoneal fibrosis (PA/RPF). This study assessed the existing criteria and formulated an improved version.

METHODS AND RESULTS

Between August 2022 and January 2023, we retrospectively analyzed 110 Japanese patients diagnosed with IgG4-related disease (IgG4-RD) involving cardiovascular and/or retroperitoneal manifestations, along with 73 non-IgG4-RD patients ("mimickers") identified by experts. Patients were stratified into derivation (n=88) and validation (n=95) groups. Classification as IgG4-RD or non-IgG4-RD was based on the 2018 diagnostic criteria and various revised versions. Sensitivity and specificity were calculated using experts' diagnosis as the gold standard for the diagnosis of true IgG4-RD and mimickers. In the derivation group, the 2018 criteria showed 58.5% sensitivity and 100% specificity. The revised version, incorporating "radiologic findings of pericarditis", "eosinophilic infiltration or lymphoid follicles", and "probable diagnosis of extra-PA/-RPF lesions", improved sensitivity to 69.8% while maintaining 100% specificity. In the validation group, the original and revised criteria had sensitivities of 68.4% and 77.2%, respectively, and specificities of 97.4% and 94.7%, respectively.

CONCLUSIONS

Proposed 2023 revised IgG4-related cardiovascular/retroperitoneal disease criteria show significantly enhanced sensitivity while preserving high specificity, achieved through the inclusion of new items in radiologic, pathological, and extra-cardiovascular/retroperitoneal organ categories.

Impact of Cilostazol Administration on Prevention of Aspiration Pneumonia in Patients With Chronic Limb-Threatening Ischemia

Background

Cilostazol has reported effectiveness for preventing aspiration pneumonia in patients with ischemic stroke, but whether it is similarly beneficial for patients with chronic limb-threatening ischemia (CLTI) is unclear.

Methods and Results

This retrospective single-center study enrolled 1,368 CLTI patients treated with endovascular therapy (EVT). In the multivariate analysis, predictors for aspiration pneumonia were age (hazard ratio [HR] 1.06 [95% confidence interval (CI) 1.03-1.10]), non-ambulatory status (HR 2.54 [95% CI 1.38-4.65]), the Geriatric Nutritional Risk Index (HR 0.97 [95% CI 0.95-0.99]), and cilostazol (HR 0.37 [95% CI 0.16-0.87]).

Conclusions

Cilostazol administration reduced the risk of aspiration pneumonia in patients with CLTI undergoing EVT.

Preoperative Vertebral Fracture: A Prognostic Factor in Stage I-III Colorectal Cancer

BACKGROUND/AIM

This study evaluated the prognostic impact of vertebral fractures (VFs) on the survival of patients with colorectal cancer (CRC).

PATIENTS AND METHODS

We included 299 patients with stage I-III CRC who had undergone elective surgery. The patients were divided into the VF group (n=94) and non-VF group (n=205). VFs were assessed using sagittal computed tomography image reconstruction (Th11-L5) performed preoperatively. Disease-free survival (DFS) and overall survival (OS) rates were analyzed.

RESULTS

The VF group had lower 5-year DFS and OS rates compared to the non-VF group (both, p<0.001). The independent predictors of DFS were carbohydrate antigen 19-9 (CA19-9) ≥37.0 ng/ml, T3/T4 disease, stage III CRC, osteopenia, and VF; for OS, CA19-9 ≥37.0 ng/ml, stage III, osteopenia, and VF. VF, compared with osteopenia, was a more significant prognostic factor for DFS and OS in patients with stage I+ II CRC (both, p<0.001).

CONCLUSION

Preoperative VF was associated with worse DFS and OS following CRC resection.

High Subcutaneous Fat Area Is an Independent Risk Factor for Parastomal Hernia after Transperitoneal Colostomy for Colorectal Cancer

Objectives

Parastomal hernia (PSH) is a common complication of colostomy; however, its risk factors remain poorly investigated. In this study, we examined the associations between sarcopenia, visceral and subcutaneous fat, and PSH in patients who underwent transperitoneal colostomy for colorectal cancer.

Methods

This retrospective, single-center, cohort study included 60 patients who underwent laparoscopic or robot-assisted abdominoperineal resection or Hartmann's procedure for colorectal cancer between November 2010 and February 2022. Stoma creation was uniformly performed using the transperitoneal approach, and PSH was diagnosed via abdominal computed tomography (CT) at 1 year postoperatively. Visceral fat areas (VFAs) and subcutaneous fat areas (SFAs) were measured through preoperative CT images using an image analysis system. Risk factors for PSH were retrospectively analyzed.

Results

PSH was diagnosed in 13 (21.7%) patients. In the univariate analysis, PSH was significantly associated with body mass index >22.3 kg/m2 (p=0.002), operation time >319 min (p=0.027), estimated blood loss >230 mL (p=0.008), postoperative complications (p=0.028), stoma diameter >18.6 mm (p=0.015), VFA >89.2 cm2 (p=0.005), and SFA >173.2 cm2 (p=0.001). Multivariate analyses confirmed that SFA >173.2 cm2 (odds ratio: 16.7, 95% confidence interval 1.29-217.2, p=0.031) was an independent risk factor for PSH.

Conclusions

Subcutaneous fat area is significantly associated with the development of PSH after transperitoneal colostomy. Applying these insights could help to prevent PSH.

Fenestrated Thoracic Endovascular Repair for Acute Type B Aortic Dissection with Isolated Left Vertebral Artery: A Case Report

Thoracic endovascular aortic repair (TEVAR) of acute uncomplicated type B aortic dissection (uTBAD) has been discussed for its potential to prevent future aortic events. We present a fenestrated TEVAR in the case of an 86-year-old man with acute uTBAD with an isolated left vertebral artery (ILVA). The ILVA originated from the distal side of the left subclavian artery, the left subclavian artery, and the intramural hematoma with an ulcer-like projection extended close to the left subclavian artery. We selected a fenestrated stent graft to achieve a proximal healthy landing. This case demonstrates that a fenestrated stent graft for acute uTBAD is useful for preserving arch vessels.

Novel tumor marker index using carcinoembryonic antigen and carbohydrate antigen 19-9 is a significant prognostic factor for resectable colorectal cancer

We evaluated the usefulness of a newly devised tumor marker index (TMI), namely, the geometric mean of normalized carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA19-9), in determining colorectal cancer (CRC) prognosis. This retrospective cohort study included 306 patients with stages I-III CRC who underwent elective laparoscopic resection between April 2010 and March 2020. Survival rates and risk factors of relapse-free survival (RFS) and cancer-specific survival (CSS) were analyzed using Kaplan-Meier curves and Cox proportional hazards model. High-TMI group (122 patients) had significantly lower rates (95% confidence interval [95% CI]) for 5-year RFS (89.7%, 83.9-93.5 vs. 65.8%, 56.3-73.8, p < 0.001) and CSS (94.9%, 89.4-97.6 vs. 77.3%, 67.7-84.4, p < 0.001) than low-TMI group. Multivariate analysis (hazard ratio [95% CI]) indicated ≥ T3 disease (RFS: 2.69, 1.12-6.45, p = 0.026; CSS: 7.64, 1.02-57.3, p = 0.048), stage III CRC (RFS: 3.30, 1.74-6.28, p < 0.001; CSS: 6.23, 2.04-19.0, p = 0.001), and high TMI (RFS: 2.50, 1.43-4.38, p = 0.001; CSS: 3.80, 1.63-8.87, p = 0.002) as significant RFS and CSS predictors. Area under the curve (AUC) of 5-year cancer deaths (0.739, p < 0.001) was significantly higher for TMI than for CEA or CA19-9 alone. Preoperative TMI is a useful prognostic indicator for patients with resectable CRC.

Effect of low visceral fat area on long-term survival of stage I-III colorectal cancer

OBJECTIVE

The prognostic significance of a low visceral fat area (VFA) in colorectal cancer (CRC) remains unclear. The aim of this study was to evaluate the prognostic effects of a low VFA on the long-term outcomes of patients with CRC after laparoscopic surgery.

METHODS

This retrospective study included 306 patients with stages I-III CRC who underwent R0 resection. VFA was preoperatively measured via computed tomography using image processing software. Relapse-free survival (RFS) and overall survival (OS) rates were analyzed using the Cox proportional hazards model and Kaplan-Meier curves.

RESULTS

Low VFA was identified in 153 patients. The low VFA group had significantly lower RFS and OS rates than did the high VFA group (5-y RFS rates: 72 versus 89%, P = 0.0002; 5-y OS rates: 72 versus 92%, P = 0.0001). The independent significant predictors of RFS were T3 or T4 disease (hazard ratio [HR], 2.75; 95% confidence interval [CI], 1.12-6.76; P = 0.027), stage III CRC (HR, 3.49; 95% CI, 1.82-6.69; P < 0.001), low psoas muscle index (PMI; HR, 2.12; 95% CI, 1.19-3.79; P = 0.011), and low VFA (HR, 2.12; 95% CI, 1.16-3.86; P = 0.014). The independent significant predictors of OS were age ≥65 y (HR, 2.59; 95% CI, 1.13-5.92, P = 0.024), carbohydrate antigen 19-9 levels ≥37 ng/mL (HR, 2.32; 95% CI, 1.18-4.58; P = 0.015), stage III CRC (HR, 2.66; 95% CI, 1.37-5.17; P = 0.004), low PMI (HR, 2.00; 95% CI, 1.06-3.77; P = 0.031), and low VFA (HR, 2.42; 95% CI, 1.24-4.70; P = 0.009).

CONCLUSION

A low preoperative VFA was significantly associated with worse RFS and OS rates in patients who underwent CRC resection.

Immunoglobulin G4-related hepatic artery aneurysm

A 49-year-old man who was a current smoker with a history of hypertension, dyslipidemia, and coronary artery disease after coronary stent placement presented because of abdominal and back pain. Contrast-enhanced computed tomography showed a 30-mm, large hepatic artery aneurysm. Resection of the aneurysm and autogenous vein bypass grafting was performed, which resulted in a successful outcome without any complications. Pathologic examination of the aneurysm confirmed that it was related to immunoglobulin G4 (IgG4). The patient's serum IgG4 level was within the normal range, and no other signs of IgG4-related organ lesions were observed.

Socio-Economic Status in Risk of Acute Adverse Events Following Radiotherapy

PURPOSE/OBJECTIVE(S)

Socio-economic status (SES) are known to influence cancer patient outcomes. The purpose of this study is to evaluate whether SES affected the short-term clinical experience of patients treated with radiotherapy (RT) during the pandemic.

MATERIALS/METHODS

This was a single institution, retrospective cohort quality improvement study. The primary endpoint consisted of adverse events (AEs) defined as an unplanned admission to a drop-in radiation-nursing clinic (RNC) or the institution's emergency department (ED) within 90 days of a radiation course. Adult cancer patients who received external beam RT from April 1, 2019, to March 31, 2022 were included. Patients were classified into two periods: treated prior to the pandemic (pre-COVID), and during the pandemic (COVID era), with a cutoff date of March 31, 2020. SES, age, RT intent (curative, palliative, SBRT), regimen (conventional fractionation and hypofractionation), disease site, and sex were included as co-variables. SES was obtained by matching a patient's postal code with a provincial data tool with four distinct dimensions: 1) residential instability, 2) material deprivation, 3) ethnic concentration, and 4) dependency. For each SES dimension, a score of 1-5 (best-worst) is assigned to individuals. A backward stepwise multivariable logistic regression analysis was performed to analyze the variables and identify the factors that were significantly associated (p<0.05) with increased risk of AEs. Institutional ethics review board exemption was obtained.

RESULTS

Across the 3-year period, 15715 patients (5499 pre-COVID and 10216 COVID era patients) were identified and included in the analyses, and 5756 AEs were observed. The analyses revealed that patient age (p<0.001), disease site (p<0.001), treatment intent (p<0.001) and treatment regimen (p = 0.005) were associated with the risk of developing AEs. AEs risk was correlated with the treatment period (pre-COVID vs. COVID era) (p<0.001) and material deprivation (p = 0.027). Adjusting for the other variables, patients who were least materially deprived were at lower risk (Odds Ratio (OR) = 0.88, 95% CI [0.78-0.98]) of developing AEs than patients who were most materially deprived. Patient sex (p>0.1), residential instability (p = 0.069), ethnic concentration (p>0.5) and dependency (p>0.5) were not associated with AEs risk. Patients with more (SES score 1-4 vs 5) residential instability (p<0.001; OR = 0.82, 95% CI [0.74-0.90]) and less (SES score 1 vs 2-5) material deprivations (p = 0.006; OR = 0.76, 95% CI [0.66-0.88]) were at reduced the risk of ED visits. SES was not associated with RNC visits.

CONCLUSION

In a universal health care system, SES (residential instability and material deprivation) were associated with the increased risk of ED within 90 days of RT. Proactive care and virtual monitoring during the 90-day period after RT in high-risk patients may reduce ED visits. ED visits beyond our tertiary institution are being gathered to address this study limitation.

A Case of Cholestatic Liver Involvement Secondary to Amyloid Light Chain Amyloidosis With New-Onset Hypercholesterolemia and Elevated Gamma-Glutamyltransferase Level

Amyloid light chain (AL) amyloidosis is a rare disorder caused by the deposit of misfolded light chain proteins. AL amyloidosis causes multiple organ involvement and rarely causes fatal liver failure. We present a 68-year-old man who showed cholestatic liver injury and was diagnosed with AL amyloidosis. Due to rapidly progressing cholestatic liver involvement, the patient died five days after the renal biopsy. Preclinically, there was hypercholesterolemia, and levels of gamma-glutamyltransferase (GGT) were elevated. Previous studies have suggested hypercholesterolemia and elevated GGT levels in patients with AL amyloidosis and liver involvement; however, its clinical relevance remains unknown. Our report suggests that in addition to serum kappa/lambda, the combination of new-onset GGT level elevation and hypercholesterolemia could be preclinical characteristics of cholestatic liver involvement in AL amyloidosis.

Traditional Serrated Adenoma of the Ileum with Intussusception Successfully Treated with Laparoscopic Bowel Resection

The most common site of traditional serrated adenomas (TSA) is the area from the left colon to the rectum; however, there are few reports on TSA in the small intestine. Herein, we report a case of TSA of the ileum with intussusception that was diagnosed and successfully treated with laparoscopic bowel resection. The patient was a 29-year-old female with the chief complaint of recurrent abdominal pain and vomiting. Contrast-enhanced computed tomography showed a mass in the ileum and intussusception with the mass as the lead point. The patient was diagnosed with intussusception secondary to a small intestinal tumor. Due to the difficulty in endoscopic treatment resulting from the localization of the lesion, elective laparoscopic surgery was planned. Intra-abdominal examination revealed intussusception of the small intestine in the pelvic ileum, and an elastic soft mass 400 cm from the ligament of Treitz was identified at the lead point of intussusception. Partial laparoscopic resection of the small intestine was performed, with an operation time of 81 min, and a small amount of bleeding. The pathological diagnosis was TSA of the ileum, and the patient's postoperative course was good, with no complications. Seven months after the surgery, no recurrence of symptoms was observed. Therefore, from our case of TSA of the ileum with intussusception that was successfully treated with laparoscopic bowel resection, we conclude that when intussusception of the small intestine occurs, TSA of the ileum with malignant potential is possible, and early diagnosis by resection should be considered.

Real-time vessel navigation using indocyanine green fluorescence during robotic-assisted gastrectomy for gastric cancer after coronary artery bypass grafting using the right gastroepiploic artery

Injury to the right gastroepiploic artery (RGEA) graft during gastrectomy after coronary artery bypass grafting (CABG) can cause critical coronary failure. A man in his 60s with advanced gastric cancer and a history of CABG was admitted to our hospital. His cardiac blood flow was dependent on RGEA, and a gastrectomy with RGEA preservation was necessary. Robot-assisted distal gastrectomy with real-time vessel navigation using indocyanine green (ICG) fluorescence imaging and Da Vinci Firefly technology was planned. Intraperitoneal observation revealed severe adhesions around the graft. Two milliliters ICG (2.5 mg/mL) was injected intravenously, and RGEA was visualized. An RGEA-preserving robot-assisted distal gastrectomy was successfully performed. The operation time was 279 minutes, and the blood loss was 5 mL. The postoperative course was good and there were no complications.

Evaluating the Short-Term Environmental and Clinical Effects of a Radiation Oncology Department's Response to the COVID-19 Pandemic (STEER COVID-19)

Purpose/Objective(s)

During the COVID-19 pandemic, hypofractionated regimens and virtual care was adopted by our institution to preserve hospital capacity and reduce foot traffic. This study's primary objective was to assess the collective environmental impact of these strategic changes by identifying sources of carbon dioxide equivalents (CO₂e). As sustainable healthcare is only justifiable if the quality of the care is maintained, we also evaluated the rate of radiation-related acute adverse event.

Materials/Methods

All patients treated with external beam radiation therapy from April 1, 2019 to March 31, 2021 at our single institution were identified (n=10,175) along with their radiotherapy visits (176,423 fractions), and visits to the radiation nursing clinic (RNC) or emergency (ER) department. A treatment regimen was considered hypofractionated if the dose per fraction was ≥ 240 cGy. If the dose per fraction was ≥ 600 cGy and the total dose of the treatment regimen was > 2000 cGy, then the treatment regimen was classified as SBRT. Out-patient hospital and virtual visits (n=75,853) during this same period were also analyzed. Environmental impact measures, including linear accelerator power usage, patient travel distances, and personal protection equipment (PPE) consumption were all converted into CO₂e. A waiver of individual patient consent was granted for this study by our institution's Research Ethics Board (REB).

Results

The use of curative hypofractionated regimens increased from 17% to 27% during the pandemic year. Twelve out of 15 cancer sites increased their use of hypofractionated regimens. Carbon footprint was reduced by 39% during the pandemic year (1,332,388 kg CO₂e) as compared to the pre-pandemic year (2,024,823 kg CO₂e). For comparison, the 744 tonnes of CO₂e saved during the pandemic year equates to the CO₂e produced by the annual energy consumption of 182 Canadian households or the CO₂e sequestered by 12,000 seedling trees planted and grown for 10 years. On average 121 kg CO₂e and 100 kg CO₂e were emitted per radiation regimen delivered during the pre-pandemic and pandemic year, respectively. Comparing patients in the pre-pandemic vs. pandemic year, there was a significant reduction in the proportion of hypofractionated patients who needed a visit to either the RNC (39% vs. 25%; p<0.001) or ER (6% vs. 2%; p<0.001) during and within 90 days of radiotherapy.

Conclusion

This study demonstrated the environmental benefits of increased use of hypofractionated regimens and virtual care, while assuring that there was no added acute radiation-related adverse event. Our findings support their continued use as one of many long-term strategies to reduce the environmental footprint of healthcare delivery. Treatment efficacy and side-effects will need to be assessed in subsequent years to further support the sustainability of these strategies.

Extraregional lymph node recurrence of stage IA1 squamous cell carcinoma of the uterine cervix after initial surgery: two case studies

Objective: Lymph node recurrence is extremely rare in cases of stage IA1 squamous cell carcinoma (SCC) of the uterine cervix without lymphovascular space invasion (LVSI). We present two cases of extraregional lymph node recurrence after initial surgery for stage IA1 SCC of the uterine cervix without LVSI. Patients: Both patients initially underwent hysterectomy and developed recurrent extraregional lymph nodes within a few years postoperatively. Case 1: The patient showed no symptoms of recurrence, and follow-up computed tomography (CT) for evaluation of gallstones revealed a para-aortic lymph node (9 mm). The patient subsequently underwent serum SCC antigen testing and CT and was diagnosed with recurrence. Case 2: The patient noticed a right inguinal node swelling, which was evaluated using CT. Both patients survived without relapse for 8 and 4 years, respectively. Conclusion: Although stage IA1 SCC of the uterine cervix without LVSI is associated with a low risk of lymph node recurrence, oncologists should consider the possibility of recurrence in such cases. Evaluation for recurrence is difficult in asymptomatic patients. Serum SCC antigen testing may be a useful biochemical marker before imaging for early detection of recurrence, even in asymptomatic patients.

Association between masseter muscle sarcopenia and postoperative pneumonia in patients with esophageal cancer

Sarcopenia affects the swallowing and chewing muscles, such as the masseter muscle. However, the significance of masseter muscle loss in pneumonia remains unclear. We investigated the effects of masseter muscle sarcopenia (MMS) on postoperative pneumonia in patients with esophageal cancer. In this retrospective cohort study, we analyzed the data of 86 patients who underwent esophagectomy for stage I-III esophageal cancer at our hospital between March 2013 and October 2021. The primary endpoint was postoperative pneumonia within 3 months of surgery. MMS was defined as a (1) masseter muscle index (MMI) that was less than the sex-specific MMI cutoff values, and (2) sarcopenia diagnosed using the L3-psoas muscle index (L3-PMI). Postoperative pneumonia was noted in 27 (31.3%) patients. In multivariate analysis, FEV1.0 < 1.5 L (odds ratio, OR: 10.3; 95% confidence interval, CI 1.56-67.4; p = 0.015), RLNP (OR: 5.14; 95%CI 1.47-17.9; p = 0.010), and MMS (OR: 4.83; 95%CI 1.48-15.8; p = 0.009) were independent risk factors for postoperative pneumonia. The overall survival was significantly worse in patients with pneumonia (log-rank: p = 0.01) than in those without pneumonia. Preoperative MMS may serve as a predictor of postoperative pneumonia in patients with esophageal cancer.

The masseter muscle thickness is a predictive marker for postoperative pneumonia after endovascular aneurysm repair

PURPOSE

Oral frailty is characterized by a decrease in the oral and swallowing function and is a risk factor for pneumonia. In the current study, we analyzed the association between the masseter muscle thickness (MMT) and postoperative pneumonia and mortality after endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm.

METHODS

Overall, 247 patients were retrospectively evaluated. The primary end point was postoperative pneumonia. The MMT was measured as the maximum thickness of the masseter muscle 2 cm caudal to the zygomatic arch using computed tomography images obtained within 3 months before EVAR. Pneumonia was defined as the presence of progressive infiltrates, consolidation, or cavitation on imaging and a fever or leukocytosis.

RESULTS

Twenty (8.1%) cases of postoperative pneumonia occurred within 1 year after EVAR. We found that patients with a low MMT (≤ 30th percentile: males, 10.4 mm; females: 8.8 mm) had a significantly higher risk of developing postoperative pneumonia within 1 year after elective EVAR than those with a high value. A comparison of the utility of the MMT and psoas muscle index (PMI) for predicting the 1-, 3-, and 5-year all-cause mortality revealed that the MMT had superior predictive performance.

CONCLUSION

The MMT before elective EVAR predicted postoperative pneumonia and life expectancy, and its predictive performance was superior to that of the PMI.

Complete neck vessel preservation using a fenestrated stent graft for the treatment of proximal anastomotic leakage after open frozen elephant trunk graft aortic arch repair

We have reported a case of proximal anastomotic leakage excluded with the Najuta fenestrated stent graft after a surgeon-modified frozen elephant trunk aortic arch graft. The fenestrated stent graft was deployed at the zone 0 proximal site, preserving the cervical branches. Complete neck vessel preservation during endovascular repair using a Najuta fenestrated stent graft appears to be safe and effective for anastomotic leakage after aortic arch aneurysm repair.

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.

A case report of gallbladder cancer and pancreas cystic neoplasm associated with pancreaticobiliary maljunction

INTRODUCTION AND IMPORTANCE

Pancreaticobiliary maljunction (PBM) is a rare congenital anomaly that is frequently associated with carcinoma of the biliary tract. However, there is still no clear evidence that PBM is associated with pancreatic tumors. Here we describe a case of gallbladder cancer and intraductal papillary mucinous neoplasm (IPMN) that is associated with PBM.

CASE PRESENTATION

A 72-year-old man underwent a cholecystectomy with hepatectomy (S4a + S5) and regional lymph node dissection for gallbladder adenocarcinoma invading the front lobe branch of the hepatic artery. A pylorus-preserving pancreaticodudenectomy was also performed for pancreatic IPMN.

CLINICAL DISCUSSION

Presence of mucin type 6 (MUC6) -positive pyloric gland metaplasia in both the dilated pancreatic duct and the gallbladder background mucosa suggests that pancreatic IPMN and gallbladder cancer may have a common phenotypic origin. Additionally, analysis of 41 reported cases of pancreatic cancer associated with PBM revealed that in all metachronous multiple cancer cases, biliary tract cancer preceded the pancreatic cancer with congenital biliary dilatation accompanied by PBM. The analysis also revealed an increased proportion of pancreatic cancer cases with PBM in patients who had not undergone a flow diversion procedure located in pancreatic head.

CONCLUSION

We show an interesting relationship between pancreatic/gallbladder cancer and PBM. More comprehensive evaluations of the whole pancreaticobiliary system in follow-up of patients with PBM is required to understand the full extent of this relationship.

New Scoring System for Predicting the Risk of Surgical Site Infections Following Stoma Reversal

BACKGROUND

Surgical site infections (SSI) are one of the most frequent complications following stoma reversal (SR-SSI) and lead to multiple problems such as decreased mobility of the patients or increased hospital costs. Several risk factors for SR-SSI have been reported, but there are no risk scoring systems for predicting SR-SSI. The current study aimed to analyze the risk factors for SR-SSI and develop a scoring system.

MATERIALS AND METHODS

Multivariate analysis of risk factors for SR-SSI was performed in patients who underwent elective SR and were followed-up during the first month after surgery. A logistic regression model was used to identify risk factors and construct a predictive score.

RESULTS

Of the 182 patients, 53 (29.1%) developed SSI. In multivariate analysis, three variables as preoperative risk factors were associated with increased SR-SSI incidence: subcutaneous fat thickness (≥ 20 mm) (odds ratio [OR]: 8.46 [95% confidence interval (CI): 3.45-20.7], P <0.001), period from stoma creation (≤ 20 weeks) (OR: 2.88 [95% CI: 1.14-7.28], P = 0.025), and SSI after the primary operation (OR: 3.06 [95% CI: 1.19-7.90], P = 0.021). Each of these variables contributed 2,1, and 1 points to the risk score, respectively. The SR-SSI rate was 2.9%, 20.3%, 34.2%, 54.5%, and 81.8% for the scores of 0,1,2,3, and 4 points, respectively. The area under the receiver operating characteristic curve was 0.773 (95% CI: 0.703-0.844).

CONCLUSIONS

A simple clinical scoring system based on three preoperative variables may be useful in predicting the risk of SR-SSI.

One-stage fluoroscopy-guided laparoscopic transcystic papillary balloon dilation and laparoscopic cholecystectomy in patients with cholecystocholedocholithiasis who previously had undergone gastrectomy for gastric cancer

BACKGROUND

Patients with a history of gastrectomy have a higher incidence of cholecystocholedocholithiasis (CCL) and related morbidities than the general population. However, the management of common bile duct (CBD) stones with endoscopic retrograde cholangiopancreatography is challenging in patients after Roux-en-Y or Billroth II reconstruction because of the altered gastrointestinal anatomy. The aim of the current study was to evaluate the safety and efficacy of one-stage laparoscopic transcystic papillary balloon dilation and laparoscopic cholecystectomy (LTPBD+LC) in patients with previous gastrectomy for gastric cancer.

METHODS

This retrospective cohort study included five patients with CCL who had previously undergone gastrectomy. All five underwent LTPBD+LC between May 2015 and February 2020 at our institution. The primary end-point was complete clearance of the CBD stones.

RESULTS

Of the 311 patients who had undergone gastrectomy for gastric cancer from December 2009 to December 2018 at our institution, six (1.9%) were later diagnosed with CCL. Five of the six patients did not need emergency biliary drainage and underwent conservative therapy and subsequent elective LTPBD+LC. LTPBD+LC was successfully performed in all cases. None of the patients required conversion to open surgery. The rate of complete clearance of the CBD stones was 100%. The mean operative time of the entire procedure was 126 minutes (range, 102-144 minutes), and the mean blood loss was 12.4 mL (range, 1-50 mL). There were no major perioperative complications, and the mean length of postoperative hospital stay was 4.2 days (range, 3-7 days).

CONCLUSION

One-stage LTPBD+LC may be a feasible procedure for patients with CCL who have previously undergone gastrectomy for gastric cancer.

Evaluation of heparin-bonded ePTFE grafts for forearm loop vascular access: Comparison between Gore® PROPATEN vascular graft and ACUSEAL vascular graft

BACKGROUND

This retrospective study evaluates the clinical outcomes of two heparin-bonded expanded polytetrafluoroethylene grafts, PROPATEN and ACUSEAL (W. L. Gore & Associates, Flagstaff, AZ, USA), for forearm loop vascular access.

METHODS

We prospectively collected data on 60 patients who had undergone arteriovenous graft of the forearm loop type between January 2015 and December 2019. The primary endpoints were graft primary, assisted primary, and secondary patency rates. Secondary endpoints were time to first cannulation and postoperative complications.

RESULTS

We enrolled 36 patients in the PROPATEN group (Group P) and 24 in the ACUSEAL group (Group A). All procedures were successful without any 30-day mortality. The median times to first cannulation were 16.5 days and 3 days in Groups P and A, respectively (p < 0.001). Mean follow-up periods were 13.4 ± 14.5 and 17.3 ± 9.3 months, respectively. Primary patency rates were 81% and 64%, respectively, at 6 months, and 60% and 40%, respectively, at 12 months (p = 0.008). Assisted primary patency rates were 96% and 83% at 6 months, 91% and 73% at 12 months, and 81% and 35% at 24 months (p = 0.044). Secondary patency rates were 96% and 81% at 12 months, and 87% and 62% at 24 months (p = 0.207). As a remote-period complication, disruption of the luminal layer of the graft was observed in two patients (4.2%) in Group A due to puncture and thrombectomy.

CONCLUSIONS

Although the ACUSEAL graft offers the advantage of early cannulation, its primary and assisted primary patency outcomes were inferior to those of the PROPATEN graft. It is important for physicians to be aware of the different characteristics of each graft to select the best option for each patient.

Dermatomyositis associated with prostate adenocarcinoma with neuroendocrine differentiation

Background

Although it is known that malignancies can be associated with dermatomyositis, there are few reports on dermatomyositis associated with prostate cancer with neuroendocrine differentiation.

Case presentation

A 63-year-old man visited our hospital due to pollakiuria. High levels of PSA and NSE were observed, and prostate biopsy revealed an adenocarcinoma with neuroendocrine differentiation. Multiple metastases to the lymph nodes, bones, and liver were identified, and androgen deprivation therapy (ADT) was started immediately. Following 2 weeks of treatment, erythema on the skin, and muscle weakness with severe dysphagia appeared. The patient was diagnosed with dermatomyositis, and high-dose glucocorticoid therapy was initiated. ADT and subsequent chemotherapy with etoposide and cisplatin (EP) were performed for prostate cancer, which resulted in decreased PSA and NSE and reduction of all metastases. After the initiation of EP therapy, dermatomyositis improved, and the patient regained oral intake function. Although EP therapy was replaced by docetaxel, abiraterone, and enzalutamide because of adverse events, no cancer progression was consistently observed. Dermatomyositis worsened temporarily during the administration of abiraterone, but it improved upon switching from abiraterone to enzalutamide and dose escalation of glucocorticoid.

Conclusions

We successfully treated a rare case of dermatomyositis associated with prostate adenocarcinoma with neuroendocrine differentiation.