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.

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.

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.

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, FEV_1.0 < 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.

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.

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.

Vertical distance from navel as a risk factor for bowel obstruction associated with feeding jejunostomy after esophagectomy: a retrospective cohort study

Background

Placement of feeding jejunostomy (PFJ) during esophagectomy is an effective method to maintain adequate nutrition, but is associated with serious complications such as bowel obstruction and jejunal torsion. The purpose of the current study was to analyze the incidence, clinical features, and risk factors of bowel obstruction associated with feeding jejunostomy (BOFJ) after PFJ.

Methods

This was a retrospective cohort study of 70 patients who underwent esophagectomy with three-field lymph node dissection for esophageal cancer and treated with PFJ between March 2013 and December 2019 in our hospital. Abdominal dissection was performed under hand-assisted laparoscopic surgery (HALS) from March 2013 to March 2015, and was changed to complete laparoscopic surgery in April 2015. We compared patients with and without BOFJ, and the incidence of BOFJ was evaluated. The primary endpoint was incidence of BOFJ after PFJ.

Results

Six patients (8.5%) were diagnosed with BOFJ, all of whom were symptomatic and in the HALS group. In addition, 3 cases displayed histories of recurrent BOFJ (3, 3, and 5 times). Laparotomy was performed in all cases. Subgroup analysis of the HALS group showed a significant difference only in straight-line distance between the jejunostomy and navel as a significant pre- and perioperative factor (117 mm [101–130 mm] vs. 89 mm [51–150 mm], p < 0.001). Furthermore, dividing straight-line distance between the jejunostomy and navel into VD and HD, only VD differed significantly (107 mm [93–120 mm] vs. 79 mm [28–135 mm], p = 0.010), not HD (48 mm [40–59 mm] vs. 46 mm [22–60 mm], p = 0.199).

Conclusions

VD between the jejunostomy and navel was associated with BOFJ after PFJ with HALS esophagectomy. PFJ < 9 cm above the navel during HALS esophagectomy might effectively prevent BOFJ.

New Technique for Magnetic Compression Anastomosis Without Incision for Gastrointestinal Obstruction

BACKGROUND

Magnetic compression anastomosis (MCA) is a novel technique of anastomosis similar to that with surgery, but in a minimally invasive manner. Few reports are available on the utility and feasibility of MCA for gastrointestinal anastomosis without requiring general anesthesia in humans, owing to the difficulty of delivering magnets. We evaluated the safety, efficacy, and feasibility of MCA in gastrointestinal obstruction without requiring general anesthesia.

STUDY DESIGN

In this retrospective single-center study, patients who underwent MCA from January 2013 to October 2019 were included. Adult patients with gastrointestinal obstruction or stenosis, irrespective of the underlying disease, with severe comorbidities, complicated abdominal surgical history, or postoperative complications, and who were unable to tolerate surgery, were eligible for inclusion. Two magnets were delivered by a combination of endoscopic and fluoroscopic procedures and placed in the lumen of the organ to be anastomosed. The main outcome was the technical success of MCA.

RESULTS

Fourteen patients underwent MCA, and the technical success of MCA was achieved in 100% of the cases. The mean procedural time, duration for anastomosis formation, and postoperative hospital stay were 44 minutes, 13 days, and 36 days, respectively. Two patients underwent anastomotic restenosis, and 1 patient had an anastomotic perforation due to balloon dilatation to prevent restenosis. The mean follow-up period was 34 months.

CONCLUSIONS

MCA without general anesthesia for gastrointestinal anastomosis is safe, useful, and feasible. MCA can be a valuable alternative to surgery in gastrointestinal obstruction.

Aortic Wall Enhancement Detected by Contrast Computed Tomography Scan Predicts Aortic Remodeling after Conservative Therapy for Acute Uncomplicated Type B Dissection

BACKGROUND

The Investigation of Stent Grafts in Aortic Dissection with extended length of follow-up trial showed that pre-emptive thoracic endovascular aneurysm repair (TEVAR) for the uncomplicated type B dissection (TBAD) in the subacute phase promotes aortic remodeling and avoids aortic-related death 5 years after onset. However, there are some patients with complete aortic remodeling (CAR) with optimal medical treatment (OMT) and severe complications after TEVAR such as retrograde type A dissection. Therefore, which patients should undergo pre-emptive TEVAR and optimal surgical timing are still under debate. We reported that aortic wall enhancement (AWE) after endovascular aneurysm repair for abdominal aortic aneurysm was associated with sac shrinkage. However, there is no report about the relationship between AWE and aortic dissection. Herein, we evaluated the relationship between AWE and acute TBAD.

METHODS

From March 2012 to May 2018, consecutive patients with acute TBAD were retrospectively collected. We retrospectively analyzed 35 patients with acute TBAD who were treated with OMT and without pre-emptive TEVAR in the subacute phase. AWE was defined as an increase of more than 20 Hounsfield units in mean computed tomography (CT) values, comparing images in delayed contrast-enhanced scans with those in plain scans evaluated within 3 months from onset. The measurement points were all slices including the wall of the false lumen. The patients with traumatic dissection, type A dissection, acute complicated type B dissection, chronic (>12 weeks) dissection, and those lost to follow-up within 3 months from onset were excluded. The primary end point was spontaneous CAR under OMT, as determined by the latest contrast-enhanced CT scan.

RESULTS

The median follow-up period from onset was 86 weeks and there were 25 cases (71.4%) with AWE. Under OMT, CAR was observed in 20 patients (57.1%); this was significantly associated with abdominal branch dissection (6/15 [40%] vs. 2/20 [10%], P = 0.050), number of tears more than 2 at onset (11/15 [73%] vs. 4/20 [20%], P = 0.003), multiple tears at 1 month after onset (9/15 [60%] vs. 4/20 [20%], P = 0.020), maximal false lumen diameter at 1 month after onset (14 vs. 8 mm, P = 0.025), and AWE within 3 months of onset (7/15 [47%] vs. 18/20 [90%], P = 0.010). Multivariate analysis demonstrated a significant difference with multiple tears at onset (P = 0.014) and AWE within 3 months of onset (P = 0.047).

CONCLUSIONS

AWE was associated with CAR under OMT for acute TBAD which is out of indication of pre-emptive TEVAR. Presence of AWE may be useful in predicting prognosis of TBAD.

Two cases of asymptomatic axillary artery occlusion difficult to diagnose preoperatively: pitfalls and its solution in endovascular therapy when approaching from the upper extremity

BACKGROUND

Approaching from the left brachial artery is an important access route in endovascular therapy for complicated aortic and peripheral artery cases. Here, we report two cases of a poor access route from the left brachial artery because of asymptomatic axillary artery occlusion (AAO), despite no preoperative upper arm blood pressure laterality, a normal ankle brachial pressure index, and absence of occlusion of the subclavian artery on CT scan. CASE 1: Seventy-six-year-old female. We planned endovascular aneurysm repair (EVAR) for para-renal abdominal aortic aneurysm using the snorkel technique in the renal artery, but we failed to pass through the left subclavian artery when approaching from the left brachial artery because of AAO. CASE 2: Seventy-three-year-old female. We planned zone 2 thoracic endovascular aneurysm repair (TEVAR) for thoracic aortic aneurysm and embolization of the left subclavian artery via the left brachial artery, but we failed to pass through the left subclavian artery because of AAO, and therefore, we simply covered the orifice of the left subclavian artery using a stent graft without embolization.

CONCLUSIONS

The presence of an asymptomatic AAO may alter the treatment plan but may be difficult to diagnose preoperatively. In those cases in which a brachial or radial artery access is planned, contrast medium should be injected from the contralateral upper extremity during preoperative enhanced CT since the absence of halation of the ipsilateral subclavian/axillary vein provides improved visualization of the AAO which may lead to a better preoperative strategy including the choice of the side of upper extremity access.

Case series of in situ pelvic floor reconstruction combining levator ani suture and negative pressure wound therapy for abdominoperineal resection

Background

Abdominoperineal resection (APR) is a standard surgical technique for low rectum cancer with a low recurrence rate. There are some problems associated with APR such as perineal hernia and perineal surgical site infection. Recently, the prophylactic efficacy of negative pressure wound therapy (NPWT) for surgical site infection has been reported. Herein, we analyzed the efficacy of in situ pelvic floor reconstruction combining levator ani suture and NPWT after APR for perineal hernia and perineal surgical site infection.

Methods

We analyzed six patients treated by laparoscopic APR with NPWT combined with levator ani suture retrospectively. The primary endpoints were surgical site infection within 30 days and perineal hernia within 1 year after surgery. The day following surgery, we performed NPWT for the perineal wound using the VAC^® abdominal wound management system (KCI, San Antonio, TX, USA).

Results

There were four male and two female patients ranging in age from 69 to 86 years (mean: 76 years). The mean NPTW duration was 17 days (13–20 days). The length of the postoperative hospital stay was 14–22 days (median: 18 days). There was no patient with surgical site infection within 30 days or with perineal hernia within 1 year after surgery.

Conclusion

We experienced the in situ pelvic floor reconstruction combining levator ani suture and NPWT after laparoscopic APR for perineal hernia and perineal surgical site infection. This combination treatment was safe and may be effective for preventing surgical site infection and perineal hernia.

•

Although APR has some unresolved problems such as perineal hernia and perineal surgical site infection.

•

NPWT decreased perineal wound infection after APR but not reduced deep wound infection rates.

•

Our procedure was able to reconstruct without foreign materials and provided sufficient separation from internal organs to perform safe NPWT.

•

The in situ pelvic floor reconstruction combining levator ani suture and NPWT after laparoscopic APR was safe and may be effective for preventing surgical site infection and perineal hernia.

Initial results of thoracic endovascular repair for uncomplicated type B aortic dissection involving the arch vessels using a semicustom-made thoracic fenestrated stent graft

OBJECTIVE

Thoracic endovascular aortic repair (TEVAR) for selected type B aortic dissection (TBAD) is a standard treatment; however, TBAD involving the aortic arch is difficult to treat because of the need for arch vessel reconstruction. We report our initial results of TEVAR for uncomplicated TBAD involving the arch vessels using a semicustom-made fenestrated stent graft.

METHODS

This is a retrospective study of 24 patients treated by fenestrated (F group) or debranching (D group) TEVAR from August 2011 to July 2017. The patients in the F group received the Najuta semicustom-made fenestrated stent graft (Kawasumi Laboratories, Tokyo, Japan). The fenestrated graft ensures sufficient sealing at the proximal healthy aorta without the need for arch vessel reconstruction. The primary end point was aorta-related mortality; the secondary end points were technical success and major adverse events (stroke, type IA endoleak, retrograde type A aortic dissection, and secondary intervention).

RESULTS

During the study period, we treated 65 TBAD cases by TEVAR, including 17 complicated cases. Of the 48 uncomplicated cases, 24 underwent TEVAR with arch vessel involvement (13 in the F group and 11 in the D group). The technical success rates in the F and D groups were 92.3% and 100.0%, respectively (P > .99, NS). The mean operation time was significantly shorter in the F group (158 minutes) than in the D group (202 minutes; P = .0426), and the mean postoperative hospital stay was also significantly shorter in the F group (7 days) than in the D group (22 days; P = .0168). The primary patency rate of the reconstructed branch vessel was 100%, and there were no aorta-related deaths or retrograde type A aortic dissection in either group. One patient had a type IA endoleak in the F group. In the D group, one patient had a postoperative stroke and two patients required secondary interventions for stent graft-induced new entry at the descending aorta. The median follow-up period was 14.1 months (range, 1-37 months). The rate of freedom from aorta-related death was 100% in both groups (P > .99, NS); the rate of freedom from major adverse events at 24 months was 92.3% in the F group and 72.7% in the D group (P = .749, NS).

CONCLUSIONS

The initial results of TEVAR with aortic arch vessel reconstruction for uncomplicated TBAD were acceptable. The fenestrated graft may be a less invasive option for the treatment of TBAD involving the aortic arch.

Polyester Grafts Are a Risk Factor for Postimplantation Syndrome after Abdominal Endovascular Aneurysm Repair: Retrospective Analysis for Polyester Graft, Excluder®, and Endologix Powerlink®/AFX®

Objective: Postimplantation syndrome (PIS) is a postoperative syndrome that occurs after endovascular aneurysm repair (EVAR), accompanied by high fever, leukocytosis, and high serum C-reactive protein (CRP). Its pathogenesis and clinical meaning are still under discussion. Here, we evaluate the relationship between postoperative fever after EVAR and graft fabric focusing on Endologix Powerlink® and AFX® (EPL/AFX).

Materials and Methods: From January 2015 to July 2017, data on elective EVAR for abdominal aortic aneurysm (AAA) using mainbody were retrospectively collected. The primary endpoint was maximal postoperative fever.

Results: We identified 128 patients who underwent elective EVAR for AAA (105 males, 82%; aged 57–90, median: 74 years). The median maximal postoperative fever was 37.8°C (36.6–39.7°C): polyester graft, 38.2°C (37.1–39.7°C); Excluder®, 37.8°C (36.6–39.2°C); and EPL/AFX, 37.7°C (37–38.7°C). The maximal postoperative fever with a polyester graft was significantly higher than that with an expanded polytetrafluoroethylene (ePTFE) graft (p<0.001). However, there was no difference between Excluder® and EPL/AFX (p=0.214).

Conclusion: In this study, it was found that polyester grafts are significantly associated with PIS after elective EVAR for AAA. If patient anatomy is permitted, it may be better to choose the ePTFE graft, especially for patients with a poor general condition.

Progressive Encephalomyelitis with Rigidity and Myoclonus Resolving after Thymectomy with Subsequent Anasarca: An Autopsy Case

Progressive encephalomyelitis with rigidity and myoclonus (PERM) is an autoimmune disorder involving the brainstem and spinal cord and is sometimes associated with thymoma. We encountered a 75-year-old woman with typical PERM features, glycine receptor antibody, and thymoma. Her neurologic symptoms improved after thymectomy, but she unexpectedly developed anasarca with massive pleural effusions and hypoalbuminemia and finally succumbed to death. The autopsy showed edema and mononuclear infiltration in the pleura but no neuropathological findings typical of PERM. Effective treatment of PERM can reverse the neuropathological signs of encephalomyelitis. The autoimmune nature of anasarca is possible but not proven.

Risk Factor Analyses of Abdominal Aortic Aneurysms Growth in Japanese Patients

BACKGROUND

This study aimed to retrospectively demonstrate the growth rate (mm/year) of abdominal aortic aneurysm (AAA) diameters (ADs) and to analyze risk factors for AAA expansion.

METHODS

We retrospectively investigated the clinical data of 319 patients with AAAs who were followed up as outpatients for >2 years after their initial visit and who underwent computed tomography >4 times.

RESULTS

The mean follow-up period was 3.7 ± 1.5 years. The annual average growth rates according to varying ADs were as follows: 1.9 ± 0.8 (AD 30-34 mm), 2.6 ± 1.2 (AD 35-39 mm), 2.8 ± 1.1 (AD 40-44 mm), 3.1 ± 1.3 (AD 45-49 mm), 3.4 ± 1.6 (AD 50-54 mm), and 3.5 ± 1.4 mm (AD ≥55 mm). Factors associated with AAA expansion were smoking (P = 0.017), hypertension (P < 0.001), and ADs (P < 0.001). In the subgroup analysis, data regarding growth rates of ≥3 mm were extracted, and a statistically significant difference between smoking status and ADs of ≥40 mm was observed.

CONCLUSIONS

Factors associated with AAA expansion in Japanese patients included smoking, hypertension, and ADs, and a statistically significant difference was observed between smoking status and ADs of ≥40 mm.

Optimal timing of preoperative indocyanine green administration for fluorescent cholangiography during laparoscopic cholecystectomy using the PINPOINT® Endoscopic Fluorescence Imaging System

INTRODUCTION

The PINPOINT® Endoscopic Fluorescence Imaging System (Novadaq, Mississauga, Canada) allows surgeons to visualize the bile ducts during laparoscopic cholecystectomy. Surgeons can continue operation while confirming the bile ducts' fluorescence with a bright-field/color image. However, strong fluorescence of the liver can interfere with the surgery. Here, we investigated the optimal timing of indocyanine green administration to allow fluorescent cholangiography to be performed without interference from the liver fluorescence.

METHODS

A total of 72 patients who underwent laparoscopic cholecystectomy were included in this study. The timing of indocyanine green administration was set immediately before surgery and at 3, 6, 9, 12, 15, 18, and 24 h before surgery. The luminance intensity ratios of gallbladder/liver, cystic duct/liver, and common bile duct/liver were measured using the ImageJ software (National Institutes of Health, Bethesda, USA). Visibility of the gallbladder and bile ducts was classified into three categories (grades A, B, and C) based on the degree of visibility in contrast to the liver.

RESULTS

The luminance intensity ratio for the gallbladder/liver, cystic duct/liver, and common bile duct/liver was ≥1 in the 15-, 18-, and 24-h groups. The proportion of cases in which evaluators classified the visibility of the gallbladder and bile ducts as grade A (best visibility) reached a peak in the 15-h group and decreased thereafter.

CONCLUSIONS

In the present study, the optimal timing of indocyanine green administration for fluorescent cholangiography during laparoscopic cholecystectomy using the PINPOINT Endoscopic Fluorescence Imaging System was 15 h before surgery.

Aneurysm sac enlargement 16 years after endovascular aortic aneurysm repair due to late type IIIb endoleak: A case report

INTRODUCTION

We report a case with delayed aneurysm sac enlargement 16 years after EVAR due to late type IIIb endoleak.

PRESENTATION OF CASE

An 84-year-old man was referred to our hospital with an aneurysm sac enlargement after endovascular aortic aneurysm repair (EVAR), which had been performed at another hospital 18 years earlier using the Zenith endograft. Computed tomography (CT), after EVAR had shown significant sac shrinkage. However, the patient presented with delayed aortic aneurysm enlargement due to an assumed endoleak. Duplex ultrasound showed a type IIIb and a type Ib endoleak. We performed a re-intervention with an AFX endograft, for relining due to persistent type IIIb endoleak.

DISCUSSION

Compared with the type IIIB endoleaks discussed in past reports, this case occurred with a much longer delay. Although CT could not identify the type of endoleak, duplex ultrasound led us to diagnose the type IIIb endoleak.

CONCLUSION

Relining using an ePTFE endograft may be considered an effective procedure for type IIIb endoleaks. Duplex ultrasound is useful for determining endoleak types.

Fenestrated endovascular repair of aortic arch aneurysm in patients with bovine arch using the Najuta stent graft

We describe the case of a 74-year-old man with a thoracic aortic aneurysm with a bovine arch who underwent fenestrated endovascular repair of aortic arch aneurysm using the Najuta stent graft (Kawasumi Laboratories, Inc, Tokyo, Japan). He has had a previous endovascular aneurysm repair and femoropopliteal bypass for abdominal aortic aneurysm combined with peripheral arterial disease. The Najuta stent graft was inserted and deployed at zone 0 with delicate positional adjustment of the fenestration of the stent graft to the brachiocephalic trunk. There was no endoleak or complication. His postoperative course was uneventful. At 7-month follow-up, complete exclusion of the aneurysm was noted. The Najuta stent graft repair of aortic arch aneurysms is a safe and effective treatment option for patients with a bovine arch.

[Acquisition of IgH/CCND1 translocation during the natural disease course in a patient with chronic lymphocytic leukemia]

A 69-year-old man visited a doctor because of systemic lymphadenopathy. Peripheral blood examination revealed leukocytosis, anemia, and decreased platelet count (WBC, 103,060/µl; lymph, 92.2%; Hb, 8.9 g/dl; and Plt, 4.1×10⁴/µl). Bone marrow biopsy revealed that approximately 70% of nucleated cells were small, mature lymphoid cells with positive immunostaining for CD5, CD20, and CD23. He was diagnosed with chronic lymphocytic leukemia (CLL). The IgH/CCND1 translocation and ATM locus loss in 20% and 95% peripheral cells, respectively, were detected by fluorescence in situ hybridization. Immunostaining revealed that cyclin D1 was positive in approximately 30% bone marrow cells. As the positive rate of CCND1 fusion signal was low, the diagnosis of mantle cell lymphoma was excluded. In contrast, signals of ATM locus deletion were detected in most tumor cells. Therefore, we assessed that IgH/CCND1 translocations occurred during the natural clinical course of CLL with ATM locus deletion from the onset of disease. The secondary IgH/CCND1 translocation in CLL is rare, and all reported cases with such translocations received treatments with alkylating agents. This is the first report regarding secondary IgH/CCND1 translocation during the natural clinical course of CLL and may provide insights into CLL pathogenesis.

Prophylactic retention suture for surgical site infection: a retrospective cohort study

BACKGROUND

Surgical site infection (SSI) is a common complication of gastrointestinal surgery. Because retention suture is known to prevent abdominal wound dehiscence, it is only considered indicated in high-risk patients. At present, there are no clear indications for retention suture. The purpose of this study was to analyze the effect of prophylactic retention suture and to determine what situations indicate prophylactic retention suture against SSI.

MATERIAL AND METHODS

Between January 2014 and January 2016, 135 patients who underwent midline laparotomy in our hospital were analyzed. Inclusion criteria for this study were patients with American Society Anesthesiologists' physical status classification system (ASA-PS score) ≥ 3 or emergent surgery.

RESULTS

Of the 135 patients, 30 (22.2%) received prophylactic retention suture. Diabetes mellitus, surgical wound classification, large incision, and retention suture were associated with SSI in multivariate analysis. In subgroup analysis, SSI risk factors were analyzed in each surgical wound classification. Only in surgical wound classification class II and III did retention suture significantly reduce the risk of SSI (odds ratio = 0.100 [0.012-0.837], P = 0.034). In class IV, however, half the patients developed SSI, regardless of retention suture. Table 3 summarizes the results of the subgroup analysis.

CONCLUSIONS

The present data suggest that prophylactic retention suture reduces SSI for surgical wound classification class II or III. For class IV operations, however, other methods to prevent SSI are necessary.

Disentangling the prognostic heterogeneity of stage III colorectal cancer through histologic stromal categorization

BACKGROUND

Growing evidence suggests the importance of stroma in determining cancer biology and recent studies have identified that genes closely associated with poor prognosis subtypes of colorectal cancer are expressed by the stroma rather than epithelial cancer cells. We aimed to clarify the prognostic value of the novel histologic classification of desmoplastic reaction in stage III colorectal cancer.

METHODS

A pathologic review was conducted for 466 stage III colorectal cancer patients in a single Japanese institution (1999-2006). Desmoplastic reaction was classified as mature, intermediate, or immature according to existence of hyalinized collagen bundles and myxoid stroma, both appear exclusively at the desmoplastic front. An additional 432 patients treated at four independent institutions (2007-2008) were examined as a second cohort to validate the results.

RESULTS

According to desmoplastic reaction, 164, 133, and 169 patients were classified as mature, intermediate, and immature, respectively. Five-year relapse-free survival rates were highest in the mature group (86.0%), followed by the intermediate (73.7%) and immature (50.9%) groups. An adverse prognostic impact of desmoplastic reaction was invariably observed in stage IIIB, which contained 71% of stage III cases. Harrell's concordance index for relapse-free survival was greater in desmoplastic reaction (0.66) than any conventional tumor-associated prognostic factors including tumor node metastasis substage (0.62) and tumor grade (0.53). Similar results were observed in the second cohort, wherein desmoplastic reaction categorization was the most influential prognostic factor.

CONCLUSION

Histologic desmoplastic reaction categorization could be a key to solve the issue of prognostic heterogeneity in stage III colorectal cancer, thereby enhancing the value of tumor node metastasis stage.

Prophylactic accessory renal artery coil embolization for prevention of type II endoleak following endovascular aneurysm repair: a case report

BACKGROUND

Prior reports indicate that intentional coverage of the accessory renal arteries (ARAs) with a diameter larger than 3 mm during endovascular aneurysm repair (EVAR) increases risk of additional treatment for type II endoleak. Here, we report a case of prophylactic coil embolization for a 4 mm ARA originating from an abdominal aortic aneurysm.

CASE PRESENTATION

A 76-year-old woman was admitted to our hospital after noticing an abdominal pulsatile mass. Computed tomography (CT) imaging revealed an abdominal aortic aneurysm (AAA) with a maximum diameter of 53 mm. Preoperative CT scan showed a right ARA, 4 mm in diameter, which was considered likely to lead to type II endoleak following EVAR. ARA coil embolization was performed at the time of EVAR. We observed no endoleaks and no infarct of the inferior pole of the right kidney on completion angiography. The postoperative course was uneventful, and the patient was discharged 7 days later. Postoperative eGFR (58.4 ml/min) was not significantly different from preoperative level (56.7 ml/min). After EVAR, blood pressure was under control, and no additional anti-hypertensive medicines were required. Postoperative enhanced CT image showed that the distal portion of the ARA was well perfused without type II endoleak from ARA.

CONCLUSIONS

Prophylactic coil embolization for a large ARA originating from an abdominal aortic aneurysm appears to be safe and effective in preventing type II endoleak following EVAR.

Blood flow evaluation using PINPOINT® in a case of incarcerated inguinal hernia: A case report

Indocyanine green (ICG) fluorescence for intestinal blood flow has been reported, but application during laparoscopic surgery for incarcerated inguinal hernia has not been reported. Here, we report the case of a patient with an incarcerated inguinal hernia in whom the bowel was preserved after evaluation of intestinal blood flow with ICG fluorescence using PINPOINT®, a brightfield full-color, near-infrared fluorescence camera. A man in his 80s was diagnosed with incarcerated inguinal hernia and underwent laparoscopic surgery. The ascending colon and mesentery showed deep red discoloration on gross evaluation. However, intravenous injection of ICG revealed uniform fluorescence of the mesentery and bowel wall, indicating the absence of irreversible ischemic changes of the bowel. As such, no resection was performed, and transabdominal preperitoneal patch plasty was completed. The patient had a good postoperative course. In this case, ICG fluorescence with the PINPOINT was useful to avoid bowel resection during laparoscopic surgery.