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Purpose: Transversus abdominis plane (TAP) block is a safe, effective, and promising analgesic procedure, but TAP block only cannot overcome postoperative pain. We conducted a prospective randomized study to evaluate postoperative pain control using multimodal analgesia (MA) combined with a single injection TAP block compared with epidural analgesia (EA) after laparoscopic colon cancer surgery., Methods: Sixty-seven patients scheduled for elective laparoscopic colon cancer surgery were enrolled in this study and randomized into EA and MA groups. The primary endpoint was the frequency of additional analgesic use until postoperative day (POD) 2. The VAS score, blood pressure, time to bowel movement, time to mobilization, postoperative complications, and length of hospital stay were also compared between the two groups., Results: Sixty-four patients (EA group, n = 33; MA group, n = 31) were analyzed. The patient characteristics did not differ markedly between the two groups. The frequency of additional analgesic use was significantly lower in the MA group than in the EA group (P < 0.001), whereas the VAS score did not differ markedly between the two groups. The postoperative blood pressure on the day of surgery was significantly lower in the MA group than in the EA group (P = 0.016), whereas urinary retention was significantly higher in the EA group than in the MA group (P < 0.001)., Conclusion: MA combined with a single injection TAP block after laparoscopic colon cancer surgery may be comparable to EA in terms of analgesia and superior to EA in terms of urinary retention., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: Urinary retention (UR) is a frequent complication following laparoscopic colorectal surgery. The aim of the present study was to investigate the risk factors for acute UR after laparoscopic surgery for colorectal cancer in patients receiving epidural analgesia., Methods: A retrospective study was conducted of 201 patients who underwent laparoscopic surgery for colorectal cancer among those receiving epidural analgesia. Univariate and multivariate analyses were performed to determine the clinicopathological factors associated with acute UR. Acute UR was defined as Clavien-Dindo classification grade ≥ 1., Results: The overall incidence of acute UR was 17.9% (36/201). The univariate analysis showed that male gender (P = 0.043), a history of chronic heart failure (P = 0.009), an increased level of serum creatinine (P = 0.028), an increased intraoperative fluid volume (P = 0.016), and an early postoperative date of urinary catheter removal (P = 0.003) were both associated with acute UR. The multivariate logistic regression analysis revealed an increased intraoperative fluid volume (100-ml increments; odds ratio [OR]: 1.085, 95% confidence interval [CI]: 1.034-1.138, P < 0.001), history of chronic heart failure (OR: 6.843, 95% CI: 1.893-24.739, P = 0.003), and postoperative date of urinary catheter removal (OR: 0.550, 95% CI: 0.343-0.880, P = 0.013) were independent risk factors for acute UR., Conclusion: Our findings suggest that an increased intraoperative fluid volume, history of chronic heart failure, and early removal of the urinary catheter are risk factors of UR after laparoscopic surgery for colorectal cancer in patients receiving epidural analgesia. An assessment using these factors might be helpful for predicting acute UR., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: Early post-operative delirium (EPOD) is a frequent complication following colorectal surgery. The present study investigated the risk factors for EPOD after laparoscopic colorectal surgery in elderly patients., Methods: A retrospective study was conducted among 208 patients ≥70 years old who underwent laparoscopic colorectal surgery. Univariate and multivariate analyses were performed to determine the clinicopathological factors associated with the EPOD., Results: The overall incidence of EPOD was 10.1% (21/208). The univariate analysis showed that an older age (≥80 years old; P=0.002), sleeping pill medication before surgery (P=0.037), a history of dementia (P=0.030) and cerebrovascular disease (P=0.017), elevated levels of D-dimer (P=0.016), maximum intraoperative temperature ≥37 °C (P=0.036), and non-continuous usage of droperidol with analgesia (P=0.005) were associated with EPOD. The multivariate logistic regression analysis revealed an older age (≥80 years old; odds ratio [OR]: 6.26, 95% confidence interval [CI]: 1.94-20.15, P=0.002), sleeping pill medication before surgery (OR: 5.39, 95% CI: 1.36-21.28, P=0.016), history of cerebrovascular disease (OR: 3.91, 95% CI: 1.12-13.66, P=0.033), and maximum intraoperative temperature ≥37 °C (OR: 5.10, 95% CI: 1.53-16.92, P=0.008) to be independent risk factors. When the patients were divided into groups according to the number of positive risk factors, the prevalence rate was 6.5%, 16.0%, and 63.6% for patients with 1, 2, and 3 positive risk factors, respectively., Conclusion: Our findings suggest that an older age, sleeping pill medication before surgery, history of cerebrovascular disease, and maximum intraoperative temperature ≥37 °C are independent risk factors of EPOD after laparoscopic colorectal surgery in elderly patients.

Purpose: Urinary dysfunction (UD) is a frequent complication following rectal surgery. The aim of the present study was to investigate the risk factors for acute UD after laparoscopic low anterior resection (LALAR) for rectal cancer in patients receiving epidural analgesia., Methods: A retrospective study was conducted on 131 patients who underwent LALAR among those receiving epidural analgesia in a single institution between October 2008 and December 2019. Univariate and multivariate analyses were performed to determine the clinicopathological factors associated with acute UD., Results: The overall incidence of acute UD was 16.0% (21/131). Univariate analysis showed that older age (P = 0.016) and earlier urinary catheter removal (P = 0.036) were associated with acute UD. Multivariate logistic regression analysis revealed that older age (10-year increments; odds ratio (OR) 2.046, 95% confidence interval (CI) 1.171-3.543, P = 0.011), urinary catheter removal before epidural analgesia discontinuation (OR 6.393, 95% CI 1.540-26.534, P = 0.011), and a large tumor circumference rate (10% increments; OR 1.263, 95% CI 1.043-1.530, P = 0.017) were independent risk factors for acute UD., Conclusion: Our findings suggest that older age, early removal of urinal catheter before epidural analgesia discontinuation, and large tumor circumference rate are risk factors of acute UD after LALAR for rectal cancer in patients receiving epidural analgesia.

Background: Patients with strangulating small bowel obstructions (SBOs) can rapidly deteriorate, in condition; therefore, immediate and appropriate diagnosis is required. However, some cases of SBO are difficult to diagnose using axial computed tomography (CT) images alone. The impact of 3D vessel imaging for the diagnosis, surgical indication, and timing of strangulating SBOs was investigated, prospectively., Methods: Clinical data were collected for 111 strangulating SBOs and 48 simple SBOs from patients receiving surgical interventions from January 2009 to March 2018. The accuracy of preoperative diagnoses for the type of SBO was evaluated. Among 159 patients, 27 underwent contrast-enhanced CT imaging as well as prospectively reconstructed 3D vessel imaging of the superior mesenteric artery, vein, and branches. The concordance rate of operative findings and preoperative diagnoses of the type of SBO were compared between axial CT imaging alone and combination of axial and 3D vessel imaging., Results: Overall concordance rate of diagnosis for the type of SBO by axial imaging was 93.1% and that of strangulating and simple SBOs was 92.8% and 93.8%, respectively. Combined axial and 3D vessel imaging resulted in 100% accuracy of preoperative diagnoses for both types of SBO. In addition, abnormalities could be classified from 3D vessel images as central twists or peripheral twists, and deteriorated vascular flow could also be detected., Conclusions: The combination of axial imaging and 3D vessel imaging can be used to accurately diagnose SBOs, and this imaging technique may be useful for determining the surgical indication and suitable timing of strangulating SBOs.

Purpose: To examine the regeneration of mesothelium under a bioresorbable membrane., Methods: A 1 cm 2 piece of peritoneum was resected from both sides of the abdominal wall of retired female mice. A piece of hyaluronate and carboxymethyl-cellulose (Seprafilm ® ) was placed over the wound on one side and the other side was left uncovered. We evaluated the degree of adhesion and regeneration of mesothelial cells macroscopically and histologically using immunohistochemistry at different times., Results: Macroscopically, the degree of postoperative adhesion in the treated site was significantly less than that in the untreated site. The membrane was left in place for 7 postoperative days (PODs). By POD 5, the regenerated peritoneum mesothelial cells covered part of the area and by POD 7, they had regenerated over almost all of that area in the abdominal wall., Conclusion: The anti-adhesion membrane worked as a physical barrier to prevent postoperative adhesion until the mesothelial cells had regenerated completely. To our knowledge, this is the first study conducted to assess the regeneration of peritoneum mesothelial cells under a bioresorbable membrane using immunohistochemistry.

We report a patient with benign bile duct stricture causing difficulty in differential diagnosis from bile duct carcinoma. A 66-year-old woman consulted a local physician because of general fatigue. Blood biochemical tests showed increased levels of biliary tract enzymes. Abdominal ultrasonography (US) revealed tapering and blockage of the midportion of the bile duct and dilation of the intrahepatic bile ducts. Magnetic resonance cholangiopancreatography (MRCP) demonstrated obstruction of the midportion of the bile duct. Later, because a marked increase in biliary tract enzymes and jaundice appeared, percutaneous transhepatic biliary drainage (PTBD) was performed. Post-PTBD cytological examination of bile was negative for cancer. A third biopsy showed slight hyperplasia with no malignant findings. Recholangiography, performed through PTBD, suggested gradual improvement of bile duct stricture, but could not completely exclude the possibility of malignancy; thus, resection of the bile duct including the stricture site was performed, and the resected specimen was submitted for intraoperative frozen section examination. Histopathological diagnosis did not reveal malignant findings. After cholecystectomy and bile duct resection, hepaticojejunostomy (Roux-en-Y) was performed. Because only erosion and desquamation of the mucosal epithelium and mild submucosal inflammatory cell infiltration and fibrosis were observed, chronic cholangitis was diagnosed histopathologically. Surgical resection of the bile duct should be considered for potentially malignant stricture of the bile duct.

There have been no reported cases of xanthogranulomatous cholecystitis with a liver abscess and metastatic endophthalmitis in the literature. There has been only one other case of xanthogranulomatous cholecystitis associated with a liver abscess in Japan prior to the present report. A 53-year-old man was admitted to a local hospital complaining of high fever. Abdominal ultrasonography and computed tomography showed a liver abscess. After percutaneous transhepatic abscess drainage, he complained of an abnormal sensation in his left eyeball and was diagnosed to have endophthalmitis. After being treated for the endophthalmitis, he was referred to our hospital to have the liver abscess evaluated. Endoscopic retrograde cholangiopancreatography showed a normal biliary system without any communication with the liver abscess. Two weeks after endoscopic retrograde cholangiopancreatography he complained of right hypochondralgia. Ultrasonography revealed the presence of sludge in the swollen gallbladder. Under a diagnosis of cholecystitis with a liver abscess, a cholecystectomy was performed. A histological examination indicated xanthogranulomatous cholecystitis based on the findings of a granulomatous lesion consisting of foamy cells in the gallbladder wall. We herein present the first known case of xanthogranulomatous cholecystitis with a liver abscess and metastatic endophthalmitis, while also making a review of the literature.

We report two cases of a nonparasitic solitary huge liver cyst. The first case, that of a 42-year-old woman, was admitted with a chief complaint of upper abdominal pain. Computed tomography (CT) scans revealed a huge cyst, 10 cm in diameter, in segments 4 and 5 of the liver, and spontaneous rupture of the cyst with intracystic hemorrhage. Her general condition was improved by transcatheter arterial embolization (TAE). Percutaneous cystic needle aspiration cytological examination revealed no malignant cells, so she was discharged. After 3 weeks, however, the cyst had increased in size, and simple cystectomy was performed. Histological examination proved the cyst to be benign. The patient in the second case, a 70-year-old man, was admitted with epigastric discomfort and obstructive jaundice. CT scans revealed a huge liver cyst, 18 x 15 cm, in the right lobe of the liver, with dilation of the bile duct in the lateral segment. Magnetic resonance cholangiopancreatography showed compression of the left hepatic duct by the cyst and dilation of the bile duct in the lateral segment. Endoscopic retrograde cholangiopancreatography disclosed no communication between the bile duct and the cyst. Percutaneous transhepatic cyst drainage was performed, and minocycline hydrochloride was infused. The cyst was reduced in size, and the reduction has been maintained for 20 months since treatment.

A 67-year-old woman was referred with an abnormal finding on an abdominal echogram but presented with no symptoms; a pancreatic tail tumor was detected by ultrasonography. Biochemical examinations showed slight elevation of serum carcinoembryonic antigen level. The lesion was resected by tail and body pancreatectomy and her postoperative course was uneventful. Seven years and 4 months after the initial operation, however, her serum level of carbohydrate antigen 19-9 was found to be elevated, and a recurrence of pancreatic cancer was suspected. Examinations revealed a mass in the head of the remnant pancreas. The lesion was radically resected by total remnant pancreatectomy. Histological examinations showed that the initial tumor was a well differentiated tubular adenocarcinoma, while the second tumor was characterized as a moderately differentiated tubular adenocarcinoma. The surgical margins of the distal pancreatectomy specimen were free of atypical cells. Therefore, the position of the second lesion diminished the likelihood that it had developed by intrapancreatic metastasis. This suggests that the second carcinoma in the head of the pancreas may have been a second primary lesion.