Emergent cholecystectomy in patients on antithrombotic therapy

The Tokyo Guidelines 2018 (TG18) recommend emergent cholecystectomy (EC) for acute cholecystitis. However, the number of patients on antithrombotic therapy (AT) has increased significantly, and no evidence has yet suggested that EC should be performed for acute cholecystitis in such patients. The aim of this study was to evaluate whether EC is as safe for patients on AT as for patients not on AT. We retrospectively analyzed patients who underwent EC from 2007 to 2018 at a single center. First, patients were divided into two groups according to the use of antithrombotic agents: AT; and no-AT. Second, the AT group was divided into three sub-groups according to the use of single antiplatelet therapy (SAPT), double antiplatelet therapy (DAPT), or anticoagulant with or without antiplatelet therapy (AC +/- APT). We then evaluated outcomes of EC among all four groups. The primary outcome was 30- and 90- day mortality rate, and secondary outcomes were morbidity rate and surgical outcomes. A total of 478 patients were enrolled (AT, n=123, no-AT, n=355) patients. No differences in morbidity rate (6.5% vs. 3.7%, respectively; P=0.203), 30-day mortality rate (1.6% vs. 1.4%, respectively; P=1.0) or 90-day mortality rate (1.6% vs. 1.4%, respectively; P=1.0) were evident between AT and no-AT groups. Between the no-AT and AC +/- APT groups, a significant difference was seen in blood loss (10mL vs. 114mL, respectively; P=0.017). Among the three AT sub-groups and the no-AT group, no differences were evident in morbidity rate (3.7% vs. 8.9% vs. 0% vs. 6.5%, respectively; P=0.201) or 30-day mortality (1.4% vs. 0% vs. 0% vs. 4.3%, respectively; P=0.351). No hemorrhagic or thrombotic morbidities were identified after EC in any group. In conclusion, EC for acute cholecystitis is as safe for patients on AT as for patients not on AT

“Hook and Roll Technique” Using an Articulating Hook Cautery to Provide a Critical View during Single-incision Laparoscopic Cholecystectomy

We describe a new simple and easy technique called the "Hook and roll technique" (HRT) that uses an articulating hook cautery to provide a critical view during single incision laparoscopic cholecystectomy (SILC). A 2-cm incision is made at the umbilicus to insert three 5-mm trocars or a multichannel port. After dissection of the serosa of the dorsal and ventral sides of the gall bladder, including Calot's triangle, the angled tip of the hook cautery is inserted between the cystic artery and duct with its tip placed dorsally. The tip is then rotated in a clockwise manner to avoid bile duct injury, allowing the connective tissue between them to be hooked, coagulated and cut. This procedure is repeated several times, followed by dissection between the cystic artery and the liver bed to achieve a critical view. From December 2008 to May 2011, 121 patients underwent SILC using HRT in our hospital without any serious complications. This technique is suitable for SILC, as it is consists of simple procedures that can be performed safely and easily, even by left hand in a cross-over approach, and it allows complete dissection of Calot's triangle to achieve a critical view without using any dissector under dangerous in-line viewing

Modulatory effect of a serine protease inhibitor on surgical stress: its clinical implications.

The relationship between endogenous cytokine antagonists and surgical stress is poorly understood. Surgical stress induces immunosuppression, and the reversed therapy of postoperative immunosuppression has been expected. The aim of the present study was to assess the effect of a serine protease inhibitor on postoperative immune reactivity. Twenty patients with colorectal cancer were randomly separated into experimental and control groups of 10 patients each. The experimental group received perioperative administration of a serine protease inhibitor while the control group did not. Plasma levels of cytokine antagonists, which suppress cell-mediated immunity, such as cortisol, interleukin-1 receptor antagonist, soluble interleukin-2 receptor (sIL-2R) and soluble tumor necrosis factors p55, p75 (sTNF-R55, -R75) were simultaneously measured. Significant reductions of plasma concentration of sIL-2R and sTNF-R55 were observed. Perioperative administration of a serine protease inhibitor may contribute to ameliorating immunosuppression after major surgery.</p

Hydrocortisone Sodium Succinate Suppressed Production of Interleukin-10 by Human Peripheral Blood Mononuclear Cells: Clinical Significance

Corticoids are well known for their immunosuppressive properties. Interleukin-10 (IL-10) is an intrinsic antiinflammatory peptide in immune diseases, originally identified as cytokine synthesis inhibitory factor. We examined the effect of hydrocortisone sodium succinate (HSS) on the production of IL-10 by human peripheral blood mononuclear cells (PBMCs). PBMCs from healthy volunteers and cancer-burden patients were preincubated separately with or without HSS for 1 h, then stimulated with 5 microg/ml lipopolysaccharide (LPS). Production of IL-10 by human PBMCs was detected with LPS stimulation and its production was higher in cancer-burden patients than in normal volunteers, although this was not statistically significant. HSS suppressed production of IL-10 by LPS-stimulated PBMCs in a dose-dependent manner both in normal volunteers and in cancer-burden patients. These results indicate that, in addition to their antiinflammatory properties, corticoids act to restore the immunosuppressive states even in cancer-burden states</p

Can POSSUM, a Scoring System for Perioperative Surgical Risk, Predict Postoperative Clinical Course ?

POSSUM, a Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity, is a scoring system which assesses perioperative surgical risks (Copeland GP et al.: Br J Surg, 1991, Vol 78, 356-360). The POSSUM scoring system consists of two categories of assessment to assess the risk of surgery. A 12-factor (age, cardiac status, pulse rate, systolic blood pressure, respiratory status, Glasgow Coma Score, serum concentration of urea, potassium and sodium, hemoglobin concentration, white cell count and findings on electrocardiography) and 4-grade physiological score (PS) were developed. This was combined with a 6-factor (type of surgical procedure, number of procedures, blood loss, peritoneal soiling, presence of malignancy and mode of surgery) and 4-grade operative severity score (OSS). The present paper attempts to validate it retrospectively. Postoperative hospitalization period and duration of antibiotics administration were both significantly correlated with OSS, but not with PS. These results suggest that the POSSUM scoring system is useful for predicting the postoperative clinical course.</p

Can POSSUM, a Scoring System for Perioperative Surgical Risk, Predict Postoperative Clinical Course ?

POSSUM, a Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity, is a scoring system which assesses perioperative surgical risks (Copeland GP et al.: Br J Surg, 1991, Vol 78, 356-360). The POSSUM scoring system consists of two categories of assessment to assess the risk of surgery. A 12-factor (age, cardiac status, pulse rate, systolic blood pressure, respiratory status, Glasgow Coma Score, serum concentration of urea, potassium and sodium, hemoglobin concentration, white cell count and findings on electrocardiography) and 4-grade physiological score (PS) were developed. This was combined with a 6-factor (type of surgical procedure, number of procedures, blood loss, peritoneal soiling, presence of malignancy and mode of surgery) and 4-grade operative severity score (OSS). The present paper attempts to validate it retrospectively. Postoperative hospitalization period and duration of antibiotics administration were both significantly correlated with OSS, but not with PS. These results suggest that the POSSUM scoring system is useful for predicting the postoperative clinical course.</p

Laparoscopic repair of an abdominal incisional hernia above the pubis

　　Laparoscopic repair of a suprapubic hernia typically carries a high risk of recurrence, because fixation of the mesh in the peripubic area is difficult. We herein report a patient undergoing laparoscopic repair of a suprapubic hernia, along with a description of the surgical techniques employed. 　A 78-year-old woman visited our hospital with a chief complaint of swelling at the median hypogastric incision site after surgery for an ovarian cyst performed at age 25 years. Laparoscopic examination revealed the hernia orifice to be 3.5×3.0 cm in size and that the distance between the caudal margin of the hernia orifice and the pubis was 2.5 cm. Parietex composite mesh was used for fixation through all layers of the abdominal wall with non-absorbable sutures and tack fixation. On the pubic side, after the pubis had been exposed by separating it from the bladder, we performed mesh fixation through all layers of the abdominal wall immediately above the pubis with the sutures placed inside the mesh, combined with tack mesh fixation directly to the pubis. This procedure enabled definite fixation of the mesh. Six days after surgery, she was discharged without complications. To date, two years and five months after surgery, no recurrence has been observed

Characterization and immunohistlogical studies of a Pancreatic Oncofetal Antigen (POA)

Pancreatic oncofetal antigen (POA) is generally accepted as a useful tumor marker for the detection of cancer of the pancreas. However, reports on the biochemical characterization of POA have been contradictory. In the present study, biochemical and immunohistological characterizations of POA were performed with anti-fetal pancreas antibody specific to POA. POA of the fetal pancreas was located in the region of α(2)~β on immunoelectrophoretograms, and the molecular weight was estimated to be about 200,000 by gel filtration. POA did not react with anti-CEA, AFP, or ferritin antibodies in the Ouchtalony test. POA was also detected in extracts of cancerous pancreas by Ouchtalony test. From immunohistological studies with anti-POA serum, it was confirmed that POA was present in the cytoplasm of fetal and cancerous pancreas. Well differentiated tumor cells stained much more than poorly differentiated tumor cells. In conclusion, cancerous pancreas shares the same antigen, POA, with fetal pancreas, and the production of POA in cancerous pancreas is related to the degree of tumor cell differentiation