Postoperative bleeding complications after endoscopic inguinal hernia repair in patients receiving anticoagulation agents, antiplatelet agents, or both.

INTRODUCTION: In patients receiving chronic anticoagulation agents, antiplatelet agents, or both, perioperative antithrombotic therapy for inguinal hernia repair requires an understanding of potential side-effects-specifically, the postoperative bleeding risks. In the present study, we evaluated postoperative bleeding complications after transabdominal preperitoneal patch plasty (TAPP) in patients undergoing antithrombotic therapy. METHODS: We retrospectively reviewed 413 patients who had undergone TAPP between February 2013 and June 2017. Individuals in the antithrombotic group received one of three regimens of perioperative antithrombotic therapy. The clinical indications for chronic anticoagulation agents (ie bridging therapy with unfractionated heparin), antiplatelet agents (ie continuation of aspirin), or both were followed. The antithrombotic group was compared to the control group in terms of surgical outcomes. We primarily focused on the incidence of postoperative bleeding complications. RESULTS: A total of 83 patients received antithrombotic therapy. We observed significant differences between the groups in terms of mean age, ASA physical status, and length of postoperative stay. In contrast, postoperative complications were not significantly different between the antithrombotic and control groups (4.8% vs 5.5%, P = 0.818). In addition, a significantly greater postoperative bleeding rate was not observed in the antithrombotic group than in the control group (1.2% vs 0.6%, P = 0.566). Likewise, other complications were similar in both groups. CONCLUSIONS: Antithrombotic therapy is not a risk factor for postoperative bleeding complications in patients who have undergone TAPP, suggesting its safety and efficacy in this patient population. Indeed, this group has the same incidence rates of morbidity and postoperative bleeding complications as patients who have not undergone antithrombotic therapy.

Prognostic Factors Affecting Survival After Multivisceral Resection in Patients with Clinical T4b Gastric Cancer.

BACKGROUND: The prognosis and survival of patients with advanced gastric cancer is poor. Although completeness of resection (R0) is one of the most important factors affecting survival, multivisceral resection (MVR) for locally advanced (clinical T4b, cT4b) gastric cancer remains controversial. The aim of this study was to evaluate the factors affecting prognosis and survival after MVR in patients with cT4b gastric cancer. METHODS: Between 2005 and 2015, we retrospectively reviewed the medical records of 103 patients who underwent MVR for cT4b gastric cancer with suspected direct invasion to adjacent organs. Patient characteristics, related complications, long-term survival, and prognostic factors of cT4b gastric cancer were analyzed. RESULTS: Postoperative mortality and morbidity rates of patients after MVR were 1.0 and 37.9%, respectively. R0 resection was achieved in 82.5% patients, all of whom had a significantly improved survival rate. Overall survival rates at 1 and 3 years were 78.3 and 47.7% for R0 resection and 46.6 and 14.3% for R1 resection, respectively (R0 vs. R1, P < 0.002). Multivariate analysis revealed that completeness of resection (R0) was an independent prognostic factor associated with longer survival. CONCLUSIONS: In patients with cT4b gastric cancer, gastrectomy with MVR to achieve an R0 resection can be performed with acceptable postoperative morbidity and mortality rates and can have a positive impact on long-term survival.

Does antithrombotic therapy improve survival with colorectal cancer?

BACKGROUND: The study aimed to evaluate the prognosis for patients with colorectal cancer who underwent surgery while receiving antithrombotic therapy (ATT) across all disease stages and for patients at disease stages 0-III. METHODS: This retrospective cohort study included 710 Japanese patients who underwent surgery for colorectal cancer between January 2009 and November 2015 at our institution. Approximately 35% of these patients received ATT. Of these, 199 (28.0%) received antiplatelet therapy, and 76 (10.7%) received anticoagulant therapy. We investigated the prognosis among patients with colorectal cancer receiving ATT, antiplatelet therapy, or anticoagulant therapy in all-stage and stage 0-III cancers. RESULTS: For all disease stages combined, no benefit was observed for ATT, antiplatelet therapy, and anticoagulant therapy groups in the overall survival rates (ATT: 87.8 vs. 78.4%, P = 0.23; antiplatelet therapy: 87.8 vs. 78.6%, P = 0.25; and anticoagulant therapy: 92.2 vs. 80.2%, P = 0.26). However, overall survival rates of patients with stage 0-III colorectal cancer undergoing ATT, antiplatelet therapy, and anticoagulant therapy significantly improved. (ATT: 98.5 vs. 92.7%, P = 0.01; antiplatelet therapy: 98.3 vs. 91.1%, P = 0.02; and anticoagulant therapy: 100 vs. 92.1%, P = 0.00). CONCLUSION: Receiving ATT significantly improves overall survival rates in patients with stage 0-III colorectal cancer.

Association between antithrombotic therapy and risk of postoperative complications among patients undergoing endovenous laser ablation.

BACKGROUND: The aim of the study was to evaluate the clinical results and postoperative complications, especially recanalization or bleeding complications, in patients with saphenous varicose veins undergoing endovenous laser ablation (EVLA) while receiving antithrombotic therapy (ATT). METHODS: This retrospective cohort study included 1136 Japanese patients undergoing EVLA with a 980-nm diode laser between January 2012 and November 2015 at our institution. The patients were divided into two groups: ATT users (ATT group) and nonusers (control group). The ATT group was further divided into two subgroups according to whether the patients received antiplatelet or anticoagulant therapy. Clinical outcomes and postoperative complications among these patients were assessed. RESULTS: Approximately 20% of the patients undergoing surgery for saphenous varicose veins at our institution received ATT. Of these, 141 (12.4%) received antiplatelet therapy and 95 (8.4%) received anticoagulant therapy. Successful occlusion of the full length of the treated vein was achieved in 99.9% of the patients; there were no severe perioperative complications. Endovenous heat-induced thrombosis occurred in 2.4% of patients, whereas postoperative complications developed in 1.2% of patients. One patient experienced recanalization (0.08%). There were no significant between-group differences in the incidence of recanalization and postoperative complications on univariate analysis. CONCLUSIONS: The clinical outcomes and postoperative complications of EVLA in the ATT group were equivalent to those in the control group, indicating that EVLA can be safely performed in patients receiving ATT.

Adjuvant Chemotherapy with S-1 plus Cisplatin for Patients with Stage III Gastric Cancer After Curative Resection.

BACKGROUND/AIM: The aim of this study was to investigate the efficacy and safety of S-1 plus low-dose cisplatin for stage IIIB and stage IIIC gastric cancer patients after D2 gastrectomy. PATIENTS AND METHODS: The study group comprised of 52 patients. In the first cycle, S-1 (80 mg/m2) was administered daily for 3 weeks, followed by 2 weeks of rest; low-dose cisplatin (10 mg) was administered on days 1-5 and 8-12. In the second and third cycles, S-1 was administered alone. RESULTS: Overall survival was 47.0 months for stage IIIB patients and 24.0 months for stage IIIC (p=0.038). Disease-free survival was 17.0 and 16.0 months respectively (p=0.739). Grade 3 or 4 adverse events occurred in 20 patients (38.5%). Multivariate analysis identified stage IIIC as independent prognostic factor for survival. CONCLUSION: Our treatment was manageable and safe for stage IIIB or stage IIIC patients. Stage IIIC gastric cancer portends an especially poor prognosis following D2 gastrectomy.

Associations between antithrombotic therapy and the risk of perioperative complications among patients undergoing laparoscopic gastrectomy.

BACKGROUND: The aim of this study was to identify factors associated with perioperative morbidity among patients who underwent laparoscopic gastrectomy while receiving antithrombotic therapy (ATT). PATIENTS AND METHOD: This retrospective cohort study included 46 patients (14 females and 32 males) who underwent laparoscopic gastrectomy, including 12 (26.1 %) who received perioperative ATT, between January 2012 and November 2015 in our institution. Among patients receiving only aspirin as antiplatelet therapy, none were on anticoagulation therapy. All patients took aspirin as antiplatelet therapy for cardiac indications. The clinical findings and surgical outcomes of patients who did (ATT group) and did not (control group) receive ATT were compared. RESULTS: The intraoperative mortality was 0 % for both groups. There was no significant difference in the incidence of postoperative morbidity by univariate analysis between the control and ATT groups (8.8 vs. 8.3 %, p = 0.39). CONCLUSION: The risk of postoperative morbidity of laparoscopic gastrectomy can be equivalent between the ATT and non-ATT (control) groups.

Treatment of Chilaiditi syndrome using laparoscopic surgery.

Chilaiditi syndrome is defined as the interposition of the bowel between the liver and right diaphragm. It is a rare disease and may be difficult to diagnose and manage. Treatment for asymptomatic patients with Chilaiditi is usually conservative and does not require surgical intervention, but surgery may be necessary if conservative treatment fails. This report describes a rare case of Chilaiditi syndrome causing small bowel obstruction and corrected using laparoscopic surgery.

Postpancreatectomy Hemorrhage After Pancreatic Surgery in Patients Receiving Anticoagulation or Antiplatelet Agents.

Background Postpancreatectomy hemorrhage (PPH) is a serious complication after pancreatic surgery. In this study, we evaluated PPH and thromboembolic complications after pancreatic surgery in patients with perioperative antithrombotic treatment. Methods Medical records of patients undergoing pancreatic surgery were reviewed retrospectively. Patients receiving thromboprophylaxis were given either bridging therapy with unfractionated heparin or continued on aspirin as perioperative antithrombotic treatment according to clinical indications and published recommendations. The International Study Group of Pancreatic Surgery definition of PPH was used. Risk factors associated with PPH were assessed by multivariate analysis. Results Thirty-four of 158 patients received perioperative antithrombotic treatment; this group had a significantly higher PPH rate (29.4% vs 6.5%, P = .001) and mortality (11.8% vs 2.4%, P = .039) than patients not receiving thromboprophylaxis. Multivariate analysis revealed that perioperative antithrombotic treatment was the only independent risk factor for PPH after pancreatic surgery (odds ratio 4.77; 95% CI 1.61-14.15; P = .005). Conclusions Perioperative antithrombotic treatment is an independent risk factor for PPH in patients undergoing pancreatic surgery, although this treatment effectively prevents postoperative thromboembolic events.

Immunoglobulin G4-related sclerosing cholecystitis presenting as gallbladder cancer: a case report.

Immunoglobulin G4 (IgG4)-related sclerosing disease is a systemic inflammatory syndrome, and an understanding of its characteristics is currently evolving. IgG4-related cholecystitis is a manifestation of IgG4-related sclerosing disease in the gallbladder. This case report describes the clinical, radiographic, and histopathological findings in a young male patient who presented with a synchronous mass in the gallbladder. Serum levels of IgG4 and the IgG4/IgG ratio were normal, and there was no associated autoimmune pancreatitis. Therefore, establishing a preoperative diagnosis of IgG4-related cholecystitis was very difficult, and a differential diagnosis of gallbladder cancer infiltrating the liver was suggested. Postoperative histopathological examination established a diagnosis of IgG4-related cholecystitis definitively. A preoperative diagnosis of IgG4-related cholecystitis, although possible, would have been highly challenging in this case. It is difficult to establish whether surgical intervention is necessary in IgG4-related cholecystitis. Because malignant tumors are frequently suspected with this clinical presentation, surgical intervention should be undertaken only after due deliberation.

[A case of small intestinal cancer in the upper intestine after pylorus-preserving pancreaticoduodenectomy].

We report a case of small intestinal cancer that arose in the upper intestine 16 years after pylorus-preserving pancreaticoduodenectomy( PPPD). An 84-year-old man, who had undergone PPPD for benign biliary tract disease 16 years previously, was found to have a primary small intestinal tumor in the upper intestine by upper gastrointestinal endoscopy, and primary intestinal cancer in the upper intestine was finally diagnosed. We performed partial resection of the upper small intestine and stomach and partial colectomy of the transverse colon to account for direct invasion. Histopathologically, the primary lesion was diagnosed as a moderately to poorly differentiated adenocarcinoma. Small intestinal cancer in the upper intestine after PPPD is extremely rare.

Postoperative complications and survival after gastric cancer surgery in patients older than 80 years of age.

BACKGROUND: This study sought to identify and evaluate the risk factors of postoperative complications, prognostic factors, and appropriate surgical strategies in elderly patients undergoing surgery for gastric cancer. METHODS: The medical records of 396 radical gastrectomies conducted from January 2006 to December 2011 were retrospectively reviewed. Surgical results and survival rates were assessed for 60 elderly patients (aged ≥ 80 years) and 336 non-elderly patients (aged < 80 years). The study groups were compared with respect to clinicopathological findings, surgical outcomes, and survival. RESULTS: Elderly patients underwent gastrectomies with shorter operation time, showed less extensive lymphadenectomy, and had a significant difference in overall survival compared with non-elderly patients, although there was no difference in cause-specific survival among patients receiving curative resection. No significant risk factors affecting postoperative complications were identified in the elderly patients. Number of comorbidities (≥2) (HR, 5.30; 95 % CI, 1.11-25.32; P = 0.037) and TNM stage (≥II) (HR, 12.97; 95 % CI, 1.60-105.38; P = 0.017) were identified as independent prognostic factors in the elderly patients receiving curative resection. CONCLUSIONS: Age is not an independent prognostic factor for patients receiving curative resection for gastric cancer. Multiple comorbidities may also influence the prognosis of elderly patients. Careful follow-up would improve overall survival for elderly patients.

Insulin treatment directly restores neutrophil phagocytosis and bactericidal activity in diabetic mice and thereby improves surgical site Staphylococcus aureus infection.

Bacterial infections, including surgical site infections (SSI), are a common and serious complication of diabetes. Staphylococcus aureus, which is eliminated mainly by neutrophils, is a major cause of SSI in diabetic patients. However, the precise mechanisms by which diabetes predisposes to staphylococcal infection are not fully elucidated. The effect of insulin on this infection is also not well understood. We therefore investigated the effect of insulin treatment on SSI and neutrophil function in diabetic mice. S. aureus was inoculated into the abdominal muscle in diabetic db/db and high-fat-diet (HFD)-fed mice with or without insulin treatment. Although the diabetic db/db mice developed SSI, insulin treatment ameliorated the infection. db/db mice had neutrophil dysfunction, such as decreased phagocytosis, superoxide production, and killing activity of S. aureus; however, insulin treatment restored these functions. Ex vivo treatment (coincubation) of neutrophils with insulin and euglycemic control by phlorizin suggest that insulin may directly activate neutrophil phagocytic and bactericidal activity independently of its euglycemic effect. However, insulin may indirectly restore superoxide production by neutrophils through its euglycemic effect. HFD-fed mice with mild hyperglycemia also developed more severe SSI by S. aureus than control mice and had impaired neutrophil phagocytic and bactericidal activity, which was improved by insulin treatment. Unlike db/db mice, in HFD mice, superoxide production was increased in neutrophils and subsequently suppressed by insulin treatment. Glycemic control by insulin also normalized the neutrophil superoxide-producing capability in HFD mice. Thus, insulin may restore neutrophil phagocytosis and bactericidal activity, thereby ameliorating SSI.

Novel technique of overlaying a poly-L: -lactic acid nanosheet for adhesion prophylaxis and fixation of intraperitoneal onlay polypropylene mesh in a rabbit model.

BACKGROUND: One problem with polypropylene mesh (PPM) used to repair abdominal wall hernias is dense adhesions to the visceral surface. The authors developed the biocompatible poly-L: -lactic acid (PLLA) nanosheet (thickness < 100 nm), which has the unique ability to adhere tightly to tissues but not to opposing tissues. This study investigated the antiadhesive and fixative characteristics of the PLLA nanosheet after placement of intraperitoneal onlay PPM (IPOM) overlaid with a PLLA nanosheet on intact peritoneum. METHODS: The PLLA nanosheet was fabricated by the spin-coating method and peeling technique with polyvinyl alcohol (PVA) as a supporting film. Two 1.5-cm-square pieces of mesh were implanted on each peritoneal side of the midline incision. The mesh was fixed to the peritoneum with a suture and then overlaid with a 4-cm-square piece of Seprafilm or nanosheet. To examine the fixative property, mesh was overlaid with Seprafilm or nanosheet without a fixed suture. After 4 weeks, mesh adhesion, inflammatory reaction, fixation, and dislocation of mesh were evaluated. RESULTS: Nanosheet-overlaid meshes were flexible and fit over the peritoneum. Adhesion was observed in 10% of the nanosheet-overlaid meshes and in 50% of the Seprafilm-overlaid meshes. The adhesion tenacity grade was significantly lower with the nanosheet-overlaid meshes (0.1 ± 0.1) than with the Seprafilm-overlaid meshes (1.0 ± 0.4) (p = 0.029), and the percentage of the adhesion area also was lower with the nanosheet-overlaid meshes (1.0 ± 1.0% vs 8.5 ± 3.2%; p = 0.037). The mean inflammatory cell counts were lower with the nanosheet-overlaid meshes (p = 0.0023). Regarding the fixative property, 37.5% of the nanosheet-overlaid meshes were fixated on the peritoneum, but no Seprafilm-overlaid mesh was fixated. CONCLUSION: Overlaying of a PLLA nanosheet was effective for adhesion prophylaxis of intraperitoneal mesh. It also may have a possible beneficial effect on fixation of mesh.

[A case of hepatocellular carcinoma with bone metastasis responding to concurrent TS-1/low-dose cisplatin (CDDP) therapy and radiotherapy].

A standard treatment for hepatocellular carcinoma with extrahepatic metastasis is not established and chemotherapy is ineffective. We experienced a case of hepatocellular carcinoma with bone metastasis that responded to concurrent TS-1/low-dose cisplatin (CDDP) therapy and radiotherapy. A 58-year-old male patient with left iliac bone metastasis after 2 hepatectomies was admitted to our hospital. The titer of serum AFP and PIVKA-II showed an extremely high levels, 12,350.5 ng/ml and 993 mAU/ml, respectively. The uptake area was found at the left iliac bone by scintigraphy with 99mTc-HMDP. Treatment with TS-1/low-dose CDDP therapy and radiotherapy (36 Gy) was started concurrently. The chemotherapy regimen comprised daily oral administration of 100 mg of TS-1 for 21 days and CDDP 10 mg/body infusion (day 1-5, 8-12). An additional 2 courses of TS-1/low-dose CDDP therapy were repeated. After that, severe pain diminished and the titer of serum showed AFP and PIVKA-II had improved to within normal ranges. The uptake at the left iliac bone was found to have decreased by scintigraphy. Adverse events were grade 1 nausea and leucopenia. TS-1/low-dose CDDP therapy seems to be applicable for the treatment of hepatocellular carcinoma with bone metastasis.

[A case of colon carcinoma with unresectable multiple liver metastases responding to various combined chemotherapies centering on hepatic arterial infusion therapy].

We have experienced a case of colon carcinoma with unresectable multiple liver metastases responding to various combined chemotherapies centering on hepatic arterial infusion therapy. A 42-year-old female with descending colon carcinoma and synchronous unresectable multiple liver metastases underwent left hemicolectomy in September 2001. She was treated with chemotherapy centering on hepatic arterial infusion (HAI) following implantation of a reservoir in the outpatient setting. Pharmacokinetic modulating therapy (PMC), and HAI with Leucovorin/CDDP/5-FU and Levoforinate/CDDP/5-FU were conducted sequentially. Alternative HAI of 5-FU with intravenous infusion of Levoforinate and systemic irinotecan/CDDP were continued biweekly after release of the hepatic artery occlusion. Liver metastases shrunk after 6 months of treatment and were remarkably decreased in size in May 2003. Although 3 metastatic lesions existed in both lungs, good quality of life has been maintained in the 2 years following surgery.