Background Various methods of reconstruction after laparoscopic distal gastrectomy (LDG) have been developed and published, whereas only a limited number of reports are available on the utility of the delta-shaped anastomosis (Delta). This study compared Delta and Roux-en-Y anastomoses (RY), with the aim to clarify the utility of Delta. MethodsStage 1 gastric cancer patients who had undergone LDG with Delta (group D, n = 68) and those who had undergone LDG with RY (group RY, n = 60) were compared in terms of operative outcomes, postoperative clinical symptoms, gastrointestinal fiberscopic findings, and changes in body weight.ResultsBoth the operative and anastomotic times were significantly shorter in group D (230 and 13 min, respectively) than in group RY (258 and 38 min, respectively) (p < 0.001). Among the complications observed at the anastomotic site, obstruction was seen in one group D patient and two group RY patients but was relieved with conservative management. Postoperative clinical symptoms were reported for 26.4 % of the group D patients but had decreased to 5.9 % 1 year later. Group RY yielded similar results. Upper gastrointestinal fiberscopy performed 1 year postoperatively showed no intergroup differences in the incidence of gastritis or residual retention and a significantly more frequent occurrence of bile reflux in group D. Postoperative weight changes did not differ between the two groups.ConclusionsDelta reconstruction after LDG is a safe and effective procedure that is totally laparoscopic, less time consuming, and associated with a favorable postoperative course and a better quality of life.

Background: Technical factors leading to hernia recurrence after transabdominal preperitoneal repair include insufficient dissection, inadequate prosthetic overlap and prosthetic size, improper fixation and folding, or crinkling of the prosthesis. However, determining intraoperatively if a case will develop recurrent hernias due to these factors remains unclear. Methods: Five surgeons blind-reviewed operation videos of primary laparoscopic hernioplasty in 13 lesions that went on to develop recurrent hernias (i.e., future recurrence), as well as 28 control lesions, to assess twelve items of surgical techniques. Since we changed a surgical policy of covering myopectineal orifice (MPO) in April 2003, we analyzed the data for the earlier and later periods. The data was analyzed with hierarchical clustering to obtain a gross grouping. The differences of the ratings between the future recurrent and control lesions were then analyzed and the association of the techniques with the hernia recurrence rate, the size of the prosthesis, and the hernia type across hernia recurrence were explored. Results: The lesions were grouped based on the time series, and its boundary was approximated when we changed our surgical policy. This policy change caused ratings to progress from 34% satisfactory, to 79% satisfactory. The recurrence rate decreased to 0.7% (5/678), compared with 6.2% (10/161) before the policy was implemented (p < 0.001). With univariate analysis, the ratings of posterior prosthesis overlap to the MPO in the recurrent lesions were significantly lower than controls in the later period (p = 0.019). Although various types of recurrences were noted in the earlier period, only primary indirect and recurrent indirect hernias were observed in the later period (p = 0.006). Conclusions: Fully covering the MPO with mesh is essential for preventing direct recurrence hernias. Additional hernia recurrence prevention can be obtained by giving appropriate attention to prosthesis overlap posterior to the MPO in a large indirect hernia.

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Aim The prophylactic effect of negative‐pressure wound therapy against incisional surgical site infection after highly contaminated laparotomies has not been sufficiently explored. This study aimed to evaluate the prophylactic effect of negative‐pressure wound therapy against incisional surgical site infection after emergency surgery for colorectal perforation. Methods This nationwide, multicenter, retrospective cohort study analyzed data from the 48 emergency hospitals certificated by the Japanese Society for Abdominal Emergency Medicine. Patients who underwent an emergency laparotomy for colorectal perforation between April 2015 and March 2020 were included in this study. Outcomes, including the incidence of incisional surgical site infection, were compared between patients who were treated with prophylactic negative‐pressure wound therapy and delayed sutures (i.e., negative‐pressure wound therapy group) and patients who were treated with regular wound management (i.e., control group) using 1:4 propensity score matching analysis. Results The negative‐pressure wound therapy group comprised 88 patients, whereas the control group consisted of 1535 patients. Of them, 82 propensity score‐matched pairs (negative‐pressure wound therapy group: 82; control group: 328) were evaluated. The negative‐pressure wound therapy group showed a lower incidence of incisional surgical site infection [18 (22.0%) in the negative‐pressure wound therapy group and 115 (35.0%) in the control group, odds ratio, 0.52; 95% confidence interval, 0.30 to 0.92; p = 0.026]. Conclusions The prophylactic use of negative‐pressure wound therapy with delayed sutures was associated with a lower incidence of incisional surgical site infection after emergency surgery for colorectal perforation.

Crowned dens syndromeDear Editor, A 90-year-old man visited our emergency department owing to neck pain and occipital headache. The pain occurred suddenly a few days previous, and had become gradually worse. He had a history of cerebral infarction, dementia, and cholelithiasis, but was not on any medication. The patient's vital signs were stable excluding a body temperature of 37.5°C. Physical examination showed the reduction of passive cervical spine movements with posterior neck pain and occipital headache. Rotation, extension, and flexion in the neck were all limited. However, there was no tenderness in the nape of the neck. In terms of neurological findings, overall cranial nerve, motor, and sensory nervous systems were intact. In laboratory data, the value of the C-responsive protein was 4.34 mg/dL (normal range, 0.0-0.1 mg/dL); all other findings were unremarkable. Computed tomography (CT) of the neck showed crown-shaped calcium deposits surrounding the odontoid process (Fig. 1A, arrows), and dotted calcifications of the transverse ligament of the atlas (Fig. 1B, arrows). There were no other lesions causative of pain in brain or spine. By integrating the results, we diagnosed crowned dens syndrome (CDS).The chief complaint of patients of CDS is neck pain, due to calcification deposition around the odontoid process. The cause of CDS is thought to be the microcrystalline deposition, most often calcium pyrophosphate dihydrate crystals and/or hydroxyapatite crystals, in the transverse ligament of the atlas around the odontoid process.1,2 However, the pathophysiologic process has not been completely proven. 3Clinicians could confuse the differential diagnosis and misdiagnose CDS as meningitis, polymyalgia rheumatica, or dissecting aneurysm of the vertebral and basilar artery. In particular, meningitis must be considered first in the differential diagnosis because the triad of fever, headache, and neck stiffness due to meningitis are very similar to the symptoms of CDS. Using CT scans, CDS is identified in up to 5% of the patients over the age of 70 years who present to hospital with the chief symptom of neck pain.4 Therefore, it is not a rare entity but becoming unclear using plain radiography for the diagnosis because of improper images. Computed tomography is the gold standard for detecting calcification in transverse, apical, and alar ligaments. However, when the CT scan is carried out a long time after the onset of symptoms, calcification around the odontoid process may not be detected as it may have been absorbed. Non-steroidal anti-inflammatory drugs (NSAIDs) have been commonly used as first-line therapy for CDS. In cases without improvement using NSAIDs alone, treatment with moderate dosage of corticosteroids is recommended. 5 In our case, NSAID therapy alleviated the patient's symptoms completely.