Incisional Negative Pressure Wound Therapy for Wounds in Patients with Lower Intestinal Perforations.

Objectives: Laparotomy for lower intestinal perforation is associated with a high incidence of surgical site infections. This study aimed to assess whether incisional negative pressure wound therapy (iNPWT) could reduce the incidence of these infections and wound dehiscence in patients with lower intestinal perforation. Methods: This single-center prospective study was conducted between September 2019 and July 2022. In the therapy group, wounds were closed with subcuticular sutures, and iNPWT was applied at -120 mmHg for 5 days. A total of 10 days of iNPWT was employed. These patients were compared with a historical control group. The iNPWT group (Group A) comprised 22 patients.The historical control group (Group B) had 65 patients. Table outlines patient characteristics and compares the two study groups. Results: Patient characteristics were demographically similar. The incidence of surgical site infections was lower in the therapy group than in the control group (9.1% vs. 52.3%, p < 0.001). Wound dehiscence was not observed in the therapy group but was noted in three patients (4.6%) in the control group. In univariate and multivariate analysis, an application of the therapy device was associated with reduced incidence of surgical site infections (p < 0.001 and p = 0.002, respectively). Conclusions: The application of iNPWT in patients with lower intestinal perforation was associated with reduced surgical site infections.

Emergency transanal total mesorectal excision for perforated rectal cancer: a two-case series.

BACKGROUND: Surgery for perforated rectal cancer is technically difficult because of paralytic dilatation due to generalized fecal peritonitis, the presence of a bulky tumor, and fecal retention due to obstruction. Transanal total mesorectal excision (TaTME) is the latest minimally invasive transanal technique pioneered to facilitate difficult pelvic dissections. It can provide a good surgical field linearly from the perineal side and reduce manipulations from the intraabdominal side. Here, we present two cases of emergency TaTME performed for perforated rectal cancer. CASE PRESENTATION: The patients were a 38-year-old female and a 75-year-old male. They were diagnosed with perforated rectal cancer and were in a state of septic shock. Emergency Hartmann's procedure was performed in both cases. Intraoperative findings showed fecal contamination of the entire abdomen and dilated intestines and bulky tumors with perforation. The female patient had multiple uterine fibroids, and the male patient had an enlarged prostate. For both patients, dissection of the mesorectum to the anal side of the tumor and transection of the rectum on the anal side of the tumor via a linear stapler were considered difficult because of the insufficient surgical field of view into the pelvis. Therefore, a two-team approach with TaTME was adopted. En bloc resection of the rectum was completed by collaboration of the abdominal team and the transanal team, and the autonomic nerves were successfully preserved. Finally, the specimens were resected, and the anal edge of the rectum was closed with a purse-string suture by the transanal team. Although these two cases were emergency surgeries in difficult situations, the cancer lesions were successfully and safely removed without involvement of the resection margin. CONCLUSIONS: This is the first report of emergency TaTME. Although these cases were emergency operations in a situation where it was difficult to pursue radical resection-and often times in these situations, the operation may end with only stoma creation-the specimens were safely resected. Emergency TaTME is a useful procedure for treatment of perforated rectal cancer.

New Scoring System for Prediction of Surgical Difficulty During Laparoscopic Cholecystectomy After Percutaneous Transhepatic Gallbladder Drainage.

Background: The surgical difficulty of laparoscopic cholecystectomy (LC) after percutaneous transhepatic gallbladder drainage (PTGBD) remains unknown. This study aimed to establish a scoring system (SS) to predict the necessity of a bailout procedure during LC after PTGBD and to evaluate the relationship between SS and perioperative complications. Methods: We retrospectively studied 70 patients who underwent LC after PTGBD. Preoperative factors potentially predictive of the need for the bailout procedure were analyzed. The SS included significantly predictive factors, with their cutoff values determined by receiver operating characteristic curves. Patients were assigned a score of 1 when exhibiting only one of these abnormalities. We compared the perioperative factors between three groups with scores of 0, 1, or 2. The SS was applied to another series of 65 patients for validation. We compared the score-2 patient perioperative factors between LC with the bailout procedure and open cholecystectomy from the beginning (OC). Results: Independent predictors were time until PTGBD after symptom onset and the maximal wall gallbladder thickness (cutoff values: 3 days and 10 mm, respectively). The high-score group was significantly associated with bile duct injury (BDI). The sensitivity and specificity of our SS were 75.0% and 98.1% in validation, respectively. The score-2 OC and laparoscopic subtotal cholecystectomy (LSC) groups had no BDI. Conclusions: The SS using time until PTGBD after symptom onset and gallbladder wall thickness for predicting the need for the bailout procedure correctly predicted the need. The scores might be associated with the risk of BDI, and LSC or OC might be a better choice for score-2 patients.

Feasibility of using a tailored mesh in laparoscopic Sugarbaker parastomal hernia repair.

BACKGROUND: In parastomal hernia (PH) repair, laparoscopic Sugarbaker technique (LS) is considered the best practice; however, meshes specific for LS repairs ceased to be available. PURPOSE: The aim of the study was to evaluate feasibility of using a physician-modified mesh (tailored mesh: TM) in LS. METHODS: Thirty-three patients who underwent LS for PH between June 2012 and September 2021 were examined to compare surgical outcomes between LS with TM (n = 11) and with a ready-made specific mesh (SM, n = 22). All meshes were coated plastic meshes. Statistical analysis was performed with the Mann-Whitney U test and Fisher's exact test. P < .05 was considered to be statistically significant. RESULTS: We compared the outcomes of TM with SM in LS for similar hernia types during median follow-up periods of 23 (range, 2-29) and 74 (range, 36-110) months (P < .0001), respectively. The median operation times were 146 (range, 45-423) for TM and 193 (range, 65-386) minutes for SM (P = .2301). Perioperative complications were observed in one TM patient (9%) and two SM patients (9%) (P = 1.0000). The lengths of postoperative stay were similar. Recurrence was observed in two cases in the SM group (9%) within 1 year after the operation. CONCLUSION: In LS, TM seems to be a feasible mesh comparable to SM within short- and mid-term follow-up.

Risk of Outlet Obstruction Associated With Defunctioning Loop Ileostomy in Rectal Cancer Surgery.

Background: The outlet obstruction (OO) rate is 5.4-18.4% after defunctioning ileostomy (DI) following rectal cancer resection to reduce the incidence and severity of anastomotic leakage; OO affects a patient's quality of life and prolongs hospitalization. Patients and Methods: A retrospective analysis was performed of patients who underwent anterior rectal resection and DI for rectal cancer. Results: Among 100 patients undergoing anterior rectal resection with DI for rectal cancer, 28 (28%) developed OO. Anastomotic leakage and a rectus abdominis muscle thickness ≥10 mm on preoperative computed tomography were significantly associated with the risk of OO in univariate analysis. Multivariate analysis also demonstrated that anastomotic leakage (odds ratio=4.320, 95% confidence interval=1.280-14.60, p=0.019) and rectus abdominis muscle thickness ≥10 mm (odds ratio=3.710, 95% confidence intervaI=1.280-10.70, p=0.016) were significantly risk factors for OO. Conclusion: When OO is observed, an anastomotic leakage should be suspected, especially if there is a high rectus abdominis muscle thickness.