Safety of early pelvic drain removal in colorectal surgery based on drainage quantity.

BACKGROUND: This study aimed to investigate the association between the drainage quantity of pelvic drains and postoperative complications in colorectal surgery. MATERIALS AND METHODS: This retrospective single-center study enrolled 122 colorectal surgery patients between January 2017 and December 2020. After restorative proctectomy or proctocolectomy with gastrointestinal anastomosis, a continuous, low-pressure suction pelvic drain was placed and its contents measured. Removal ensued following the absence of turbidity and a drainage quantity of ≤ 150 mL/day. RESULTS: Seventy-five patients (61.5%) and 47 patients (38.5%) underwent restorative proctectomy and proctocolectomy, respectively. Drainage quantity changes were observed on postoperative day (POD) 3, regardless of the surgical procedure or postoperative complications. The median (interquartile range) number of PODs before drain removal and organ-space surgical site infection (SSI) diagnosis were 3 (3‒5) and 7 (5‒8), respectively. Twenty-one patients developed organ-space SSIs. Drains were left in place in two patients after POD 3 owing to large drainage quantities. Drainage quality changes enabled diagnosis in two patients (1.6%). Four patients responded to therapeutic drains (3.3%). CONCLUSIONS: The drainage quantity of negative-pressure closed suction drains diminishes shortly after surgery, regardless of the postoperative course. It is not an effective diagnostic or therapeutic drain for organ-space SSI. This supports early drain removal based on drainage quantity changes in actual clinical practice. TRIAL REGISTRATION: The study protocol was retrospectively registered and carried out per the Declaration of Helsinki and approved by the Hiroshima University Institutional Review Board (approval number: E-2559).

Median arcuate ligament resection for a patient with ruptured pancreaticoduodenal artery aneurysm: A case report.

INTRODUCTION AND IMPORTANCE: Median arcuate ligament syndrome (MALS) is a rare disease characterized by compression of the celiac artery (CA) by the median arcuate ligament (MAL). A small proportion of pancreaticoduodenal artery (PDA) aneurysms are caused by compression of the CA by the MAL. Here, we report a case of rupture of a PDA aneurysm associated with MALS that was treated with coil embolization followed by MAL resection. CASE PRESENTATION: A 49-year-old man lost consciousness due to hypovolemic shock in the hospital two days after appendectomy. Contrast-enhanced multi-detector row computed tomography (MD-CT) showed a retroperitoneal hematoma and extravasation from the pancreaticoduodenal arcade vessels, therefore emergency angiography was performed. An aneurysm was detected in the anterior inferior PDA and coil embolization was performed for the inferior PDA. Three months after embolization, MAL resection was performed to prevent rebleeding from the PDA. Six months have passed after the surgery, the patient had no CA restenosis or PDA aneurysms. CLINICAL DISCUSSION: MALS is a rare disease that results from the compression of the CA by the MAL. PDA aneurysms are associated with CA stenosis, and compression of the CA by the MAL is the most frequently reported cause of CA stenosis. There is no established treatment for CA stenosis after a PDA aneurysm rupture due to MALS. CONCLUSION: It is suggested that MAL resection may be effective in reducing shear stress in the pancreaticoduodenal arcade. Improving blood flow through the CA by MAL resection might reduce risk of PDA aneurysm recurrence.

Laparoscopic repair of Morgagni hernia with extra-abdominal sutures and ileocecal resection for colon cancer: a case report.

Morgagni hernia is a rare form of diaphragmatic hernia. It is located at the anterior edge of the diaphragm and does not have an anterior rim. It is difficult to achieve a secure closure and maintain the tension of closure with laparoscopic surgery. We have performed laparoscopic resection of colorectal cancer and hernia repair simultaneously. An 89-year-old woman underwent laparoscopic hernia repair and ileocecal resection simultaneously. Regarding hernia repair, we considered that it would be difficult to use a mesh from the viewpoint of infection due to the colectomy. Therefore, we have done the extra-abdominal suture method. After laparoscopic ileocecal resection, a small incision was made in the epigastric region, and Morgagni hernia repair was performed with extra-abdominal sutures. She had no recurrence of either colon cancer or hernia for 22 months post-operatively. The extra-abdominal suture method can provide secure closure of the hernia orifice for Morgagni hernia.

Ischemic Necrosis of the Gastric Remnant Treated Successfully Using Total Remnant Gastrectomy.

Distal gastrectomy (DG) with lymph node dissection is considered as the standard treatment for gastric cancer. Ischemic necrosis of the gastric remnant is a rare but serious complication of DG that requires careful consideration for early diagnosis and treatment to lower the associated mortality rate. A 71-year-old male presented to our hospital with hyperglycemia and was evaluated for suspected diabetes. The patient's medical history was otherwise unremarkable. Computed tomography (CT) revealed a thickening of the stomach wall, with follow-up esophagogastroduodenoscopy revealing type 3 gastric cancer in the greater curvature of the antrum. Biopsy specimen confirmed a pathological diagnosis of mucinous adenocarcinoma, with a clinical diagnosis of cT3N0M0, cStageIIB. An open DG with Billroth I reconstruction was performed, without incident. On postoperative day 1, the patient developed a high fever, abdominal pain, and elevated white blood cell count (12,200/µL). On postoperative day 2, his C-reactive protein level increased to >30 mg/dL. CT revealed an edematous thickening of the stomach wall, with poor mucosal enhancement of the remnant stomach and thinning of the anastomosis wall, with air nearby. Emergency surgery was performed for suspected leakage. Intraoperative findings showed no evidence of leakage. Intraoperative endoscopy revealed a necrotic gastric remnant, and we performed a total remnant gastrectomy with Roux-en Y reconstruction. The patient was discharged in a stable condition, 25 days after the first surgery. Although ischemic necrosis of the gastric remnant is a rare complication, its possibility should be carefully considered after DG, for early diagnosis and treatment.

Association between skeletal muscle loss and the response to nivolumab immunotherapy in advanced gastric cancer patients.

BACKGROUND: Skeletal muscle loss is a hallmark of malignancies, including advanced gastric cancer (GC). Although programmed death (PD)-1 inhibitors, including nivolumab, have promising anti-cancer effects, there is limited information regarding markers that can predict these therapeutic effects, which include PD-ligand 1 (PD-L1) expression and the tumor mutation burden. Therefore, we evaluated whether the baseline psoas muscle mass index (PMI, a surrogate for skeletal muscle mass) could predict the response of GC to nivolumab treatment, based on progression-free survival (PFS), the objective response rate, and the disease control rate. METHODS: This retrospective study evaluated 31 Japanese patients who received nivolumab for advanced GC and underwent imaging analysis between November 2017 and November 2019. The computed tomography results were used to estimate the psoas major muscle mass. Sex-specific cut-off values were used for the PMI, with low PMI values defined as < 3.6 cm2/m2 for male patients and < 2.9 cm2/m2 for female patients. RESULTS: The median PFS interval was 2.3 months for the patients with stage IV GC. Nine patients (29%) had a low baseline PMI, and these patients had significantly shorter median PFS than the group with a non-low baseline PMI (0.5 months vs. 2.4 months, P = 0.004). CONCLUSIONS: As a surrogate marker for skeletal muscle loss, the PMI may be useful for predicting the response to nivolumab among patients with advanced GC.

Solitary peritoneal metastasis of gastrointestinal stromal tumor: A case report.

BACKGROUND: A gastrointestinal stromal tumor (GIST) is a mesenchymal tumor of the gastrointestinal tract that is most commonly found in the stomach. Recurrence of GISTs mostly occurs in the liver or peritoneum, and in most cases, multiple metastases occur. As a solitary peritoneal metastasis is rare, an appropriate treatment strategy has not been established. Here, we report a case of solitary peritoneal metastasis after complete resection of gastric GIST. CASE SUMMARY: A 76-year-old woman was diagnosed with stomach GIST and underwent laparoscopic local resection using the CLEAN-NET method. As the recurrence risk was intermediate, adjuvant imatinib therapy was not administered. Two years after surgery, routine computed tomography revealed an abdominal mass between the dorsal side of the right hepatic lobe and right kidney. Other imaging tests did not reveal any abnormalities. Laparoscopic observation showed that the tumor was located at the retroperitoneum, and intraperitoneal dissemination was not found. Therefore, we performed laparoscopic tumor resection. Immunohistochemically, the tumor was positive for c-kit and CD34 and had a relatively high mitotic index and MIB-1 Labeling index. We administered adjuvant imatinib therapy. There was no evidence of recurrence 3 years after the operation. CONCLUSION: This is the first reported case of a solitary recurrence of GIST in the peritoneum treated with complete laparoscopic resection.