Objective: This cohort study investigated short- and long-term postoperative outcomes of laparoscopic procedures for rectal cancer performed with versus without certified surgeons. Background: In Japan, the Endoscopic Surgical Skill Qualification System (ESSQS) evaluates surgical skills deemed essential for laparoscopic surgery; however, it is unknown whether this certification contributes to procedural safety. Methods: Outcomes of laparoscopic rectal resections for cStage II and III rectal cancer performed from 2014 to 2016 at 56 Japanese hospitals were retrospectively reviewed. The impact of having versus not having certified surgeons on postoperative complications and other short- and long-term outcomes were assessed. In cases with ESSQS-certified surgeons, surgeons attended surgery in the capacity of an operator, assistant, scope operator, or advisor. Results: Overall, 3188 procedures were analyzed, with 2644 procedures performed with and 544 without ESSQS-certified surgeons. A multivariate logistic regression model showed that the adjusted odds ratio of postoperative complications after procedures performed with ESSQS-certified surgeons was 0.68 (95% confidence interval, 0.51–0.91; P = 0.009). The adjusted odds ratios for conversion and pathological R0 resection rates with ESSQS-certified surgeons were 0.20 (P < 0.001) and 2.10 (P = 0.04), respectively. Multiple linear regression analyses showed significantly shorter surgical duration and more harvested lymph nodes for operations performed with ESSQS-certified surgeons. Multivariate Cox regression showed that the adjusted hazard ratios for poor overall and recurrence-free survival after operations performed with ESSQS-certified surgeons were 0.88 (P = 0.35) and 1.04 (P = 0.71), respectively. Conclusions: This study showed the superiority of the short-term postoperative results for laparoscopic rectal procedures performed with ESSQS-certified surgeons.
BACKGROUNDPostoperative pancreatic leakage readily results in intractable pancreatic fistula and subsequent intraperitoneal abscess. This refractory complication can be fatal; therefore, intensive treatment is important. Continuous local lavage (CLL) has recently been reevaluated as effective treatment for severe infected pancreatitis, and we report three patients with postoperative intractable pancreatic fistula successfully treated by CLL. We also discuss our institutional protocol for CLL for postoperative pancreatic fistula.CASE SUMMARYThe first patient underwent subtotal stomach-preserving pancreaticoduodenectomy, and pancreatic leakage was observed postoperatively. Intractable pancreatic fistula led to intraperitoneal abscess, and CLL near the pancreaticojejunostomy site was instituted from postoperative day (POD) 8. The abscess resolved after 7 d of CLL. The second patient underwent distal pancreatectomy. Pancreatic leakage was observed, and intractable pancreatic fistula led to intraperitoneal abscess near the pancreatic stump. CLL was instituted from POD 9, and the abscess resolved after 4 d of CLL. The third patient underwent aneurysmectomy and splenectomy with wide exposure of the pancreatic parenchyma. Endoscopic retrograde pancreatic drainage was performed on POD 15 to treat pancreatic fistula; however, intraperitoneal abscess was detected on POD 59. We performed CLL endoscopically via the transgastric route because the percutaneous approach was difficult. CLL was instituted from POD 63, and the abscess resolved after 1 wk of CLL.CONCLUSIONCLL has therapeutic potential for postoperative pancreatic fistula.
Highlights Multicystic Peritoneal mesothelioma is a distinct type of peritoneal mesothelioma with borderline malignant potential and tendency to recur after tumor debulking. Morphologically MCPM has grapelike cysts filled with clear fluid and microscopically it has cystic spaces lined by cuboidal epithelium. There are areas of increased proliferative activity in the background of benign cyst representing potential for aggressiveness. Peritoneal free floating cysts can be formed from disintegration of main mass and deposit in other areas to form metastatic deposits. Comprehensive treatment – Complete cytoreduction, involved peritonectomy and HIPEC is required for treatment of macroscopic tumor and microscopic residue.
Patient: Male, 58 Final Diagnosis: Inferior pancreaticoduodenal artery aneurysm Symptoms: Bleding Medication: — Clinical Procedure: Pancreaticoduodenectomy Specialty: Surgery Objective: Rare disease Background: Aneurysm of the inferior pancreaticoduodenal artery (IPDA) is rare among visceral artery aneurysms. Aneurysm and/or pancreatitis may have a causal relation with hemosuccus pancreaticus (HP). HP causes an obscure bleeding in the digestive tract, and this rare disease may lead to life-threatening condition. Although interventional radiology is generally employed as the initial treatment for visceral aneurysms, aneurysmic recanalization is a critical problem. Case Reports: A 58-year-old male was incidentally diagnosed as groove pancreatitis, and his pancreatitis was successfully treated by conservative management. One year later, an IPDA aneurysm was detected in image studies. Gastrointestinal bleeding was objectively observed, and a diagnosis of asymptomatic HP was made. Arteriopancreatic duct fistula was suspected, but was not identified. Coil embolization was successfully completed. Six months later, he suffered a relapse of HP, and visited our emergency unit. Pseudocystic lesion around metallic coils were confirmed. Subtotal stomach-preserving pancreaticoduodenectomy without any extended resections was performed. Intentional dissections of nerve plexuses and lymph nodes were all waived. Even a pancreatography of the resected specimen did not clarify his arterio-pancreatic duct fistula. He was discharged at postoperative day 10, and smoothly returned to his work. Conclusions: Pancreatic juice-related complications after advanced pancreaticoduodenectomy for malignancies are often intractable. However, simple pancreaticoduodenectomy which omits extended resections and intentional dissections is safe and feasible for benign diseases. After the initial interventional radiology for pancreatic aneurysms, an elective pancreatic surgery should be considered to avoid unwanted recanalization and refractory HP.
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