Masaru Koizumi

INTRODUCTION: Hernias occurring adjacent to a urinary diversion are extremely rare, and their classification and optimal surgical management have not yet been established.CASE PRESENTATION: A 76-year-old man presented with a hernia adjacent to a vesicocutaneous urinary diversion after undergoing laparoscopic abdominoperineal resection for rectal cancer combined with robot-assisted radical prostatectomy, resulting in sigmoid colostomy and vesicocutaneous fistula formation. Laparoscopic repair was performed using the intraperitoneal onlay mesh (IPOM) plus technique. After primary fascial closure, a trimmed composite mesh was placed with adequate overlap and fixed using a modified fixation strategy combining non-absorbable tacks and absorbable sutures. Tacking was deliberately avoided in the anatomically hazardous region adjacent to the external iliac vessels, and fixation in this area was achieved using superficial sutures only. The postoperative course was uneventful, with no recurrence or mesh-related complications during the 18-month follow-up.CONCLUSION: Laparoscopic IPOM plus repair may be a feasible option for hernias adjacent to a vesicocutaneous urinary diversion when primary fascial closure and safe mesh fixation can be achieved with careful consideration of pelvic anatomy and adjacent neurovascular structures. However, further accumulation of cases and long-term follow-up are required to establish its safety.

INTRODUCTION: Chylous ascites is an uncommon condition resulting from triglyceride-rich lymphatic fluid leakage into the peritoneal cavity and is typically diagnosed when the ascitic triglyceride level is ≥200 mg/dL. Small bowel volvulus is an uncommon surgical emergency, and its coexistence with chylous ascites is particularly rare. Postoperative adhesions are a common cause of small bowel volvulus; however, small bowel volvulus caused by adhesions presumed to be congenital in a virgin abdomen is infrequently reported. Herein, we report a case of small bowel volvulus associated with chylous ascites in which the adhesions were most consistent with congenital origin, although definitive differentiation was not possible.CASE PRESENTATION: A 61-year-old male with no history of abdominal surgery presented with sudden-onset abdominal pain. Contrast-enhanced CT revealed a whirl sign in the mesentery with mild ascites. Emergency exploratory laparotomy revealed milky-white ascites and 360° volvulus at the root of the small bowel mesentery. Multiple adhesions, presumed to be congenital based on the absence of prior surgery or documented inflammation, were identified as the underlying cause of the volvulus. All adhesions were carefully divided; de-torsion alone was sufficient, and bowel resection was unnecessary. Biochemical analysis of the ascitic fluid revealed a triglyceride level of 200 mg/dL, which confirmed the diagnosis of chylous ascites. The patient recovered uneventfully and remained recurrence-free for 6 months.CONCLUSIONS: This report describes a rare case of small bowel volvulus accompanied by chylous ascites presumed to be caused by multiple congenital adhesions in a virgin abdomen. Although causal relationships cannot be definitively established, this case highlights important considerations regarding intraoperative assessment of bowel viability and adhesions. The presence of chylous ascites alone should not be regarded as a reliable indicator of bowel ischemia; careful surgical evaluation remains essential.

Purpose: Non-invasive reduction in patients with incarcerated obturator hernias is an emergency surgery alternative. There are two non-invasive reduction types: manual and ultrasonographic (ultrasound-guided and ultrasound-assisted reduction). However, the impact of ultrasound guidance on manual reduction has not been adequately evaluated. We aimed to compare non-invasive ultrasound reduction with manual reduction in patients with incarcerated obturator hernias. Methods: We searched MEDLINE, Cochrane Central Library, Embase, Ichushi Web, ClinicalTrial.gov, and ICTRP for relevant studies. The primary outcomes were success and bowel resection rates. We performed a subgroup analysis between ultrasound-guided and ultrasound-assisted reductions. This study was registered in PROSPERO (CRD 42,024,498,295). Results: We included six studies (112 patients, including 12 from our cohort). The success rate was 78% (69 of 88 cases) with ultrasonographic reduction and 33% (8 of 24 cases) with manual reduction. The success rate was higher with ultrasonographic than with manual reduction. Subgroup analysis revealed no significant difference between ultrasonography-assisted (76%) and ultrasonography-guided (80%) reductions (p = 0.60). Non-invasive reductions were predominantly successful within 72 h of onset, although durations extended up to 216 h in one case. Among the successful reduction cases, emergency surgery and bowel resection were necessary in two cases after 72 h from onset. Bowel resection was required in 48% (12 of 25), where the non-invasive reduction was unsuccessful within 72 h of confirmed onset. Conclusions: Ultrasonographic reduction can be a primary treatment option for patients with obturator hernias within 72 h of onset by emergency physicians and surgeons on call. Future prospective studies are needed to evaluate ultrasonographic reduction’s impact.

膵全摘では周術期血糖・栄養管理が重要である．12年間の膵全摘32例の周術期血糖・栄養状態を検討した．一期的・二期的膵全摘は各々16例で計48病変の約80％を膵管内乳頭粘液性腫瘍と浸潤性膵管癌が占めた．5年生存率は60.2％，一期的・二期的膵全摘で差はなかった．HbA1cは術前6.7％，術後1年は7.7％と上昇，prognostic nutritional index（PNI）は術前47.8，術後1年は43.0と低下した．予後因子を単変量解析すると術後1年neutrophil-lymphocyte ratio，術前platelet-lymphocyte ratio，術後1年PNIが抽出され，多変量解析では術後1年PNIが有意な因子であった．術後1年PNI 40.5未満は予後不良で，高力価パンクレアチン製剤投与群は予後良好であった．膵全摘後は正しい病態把握のもとに内外分泌治療を行うことが重要である．

Background: Previous systematic reviews have not clarified the effect of postoperative coffee consumption on the incidence of postoperative ileus (POI) and the length of hospital stay (LOS). We aimed to assess its effect on these postoperative outcomes. Methods: Studies evaluating postoperative coffee consumption were searched using electronic databases until September 2021 to perform random-effect meta-analysis. The quality of evidence was assessed using the Cochrane risk-of-bias tool. Caffeinated and decaffeinated coffee were also compared. Results: Thirteen trials (1246 patients) and nine ongoing trials were included. Of the 13 trials, 6 were on colorectal surgery, 5 on caesarean section, and 2 on gynecological surgery. Coffee reduced the time to first defecation (mean difference (MD) −10.1 min; 95% confidence interval (CI) = −14.5 to −5.6), POI (risk ratio 0.42; 95% CI = 0.26 to 0.69); and LOS (MD −1.5; 95% CI = −2.7 to −0.3). This trend was similar in colorectal and gynecological surgeries. Coffee had no adverse effects. There was no difference in POI or LOS between caffeinated and decaffeinated coffee (p > 0.05). The certainty of evidence was low to moderate. Conclusion: This review showed that postoperative coffee consumption, regardless of caffeine content, likely reduces POI and LOS after colorectal and gynecological surgery.

症例は53歳，女性．急激な腹痛と嘔吐で救急外来を受診した．開腹歴はなかった．腹部造影CTで著明な腹水と左卵管の背側に回り込むように頭側から腹側に入り込んだ骨盤内の造影不良な腸管を認め，子宮広間膜裂孔ヘルニア嵌頓による絞扼性腸閉塞と診断された．腸管壊死を疑い，発症18時間後に緊急開腹手術を施行した．開腹時に多量の漿液性腹水を認めた．左子宮広間膜内に入り込んだ回腸を認め，容易に引き抜き可能であった．腸管は15分ほどの観察で色調は改善したが，嵌入腸管壁に脂肪腫のような黄色の腫瘤を認め，これにより嵌入した回腸が抜けなくなったものと推測された．同部を含めて色調変化のあった小腸20cmを部分切除し，ヘルニア門は縫合閉鎖した．術後はClostridium difficile腸炎になったが保存的に軽快し，第10病日で退院した．病理診断は回腸異所性膵であった．回腸異所性膵が原因で子宮広間膜裂孔ヘルニア嵌頓を起こした報告例は本邦初である．