Post-laparotomy heterotopic ossification of the xiphoid process: A case report

BACKGROUND Heterotopic ossification(HO)represents all types of extraskeletal ossification in the body.It occurs in various areas,including the skin,subcutaneous tissue,muscle,and joints.Surgical excision is recommended for symptomatic HO.Postoperative radiotherapy,oral nonsteroidal anti-inflammatory drugs,and topical sealants,such as bone wax,have been recommended as preventive measures.As HO is rare in occurrence,these recommendations are based on personal experiences,and there is a lack of information on individualized treatments depending on its location.CASE SUMMARY A 62-year-old male was admitted for symptomatic HO along a laparotomy scar.Surgical excision was performed for an 11 cm-sized ossification originating from the xiphoid process,and bone wax was applied to the excisional margin.However,the surgical wound failed to heal.After several weeks of saline-soaked gauze dressing,delayed wound closure was performed.The patient was finally discharged eight weeks after the excision.Because HO can occur in various areas of the body,a treatment strategy that may be effective for some may not be for others.Bone wax has been used as a topical sealant over excisional margins in the shoulder,elbow,and temporomandibular joints.However,in our case,its application on an abdominal surgical wound delayed its primary healing intention.The valuable lesson was that,when choosing a treatment method for HO based on available research data,its location must be considered.CONCLUSION Complete excision should be the priority treatment option for symptomatic HO along the laparotomy scar.Bone wax application is not recommended.Core Tip:Heterotopic ossification(HO)represents all types of extraskeletal ossification,and occurs in various areas,including the skin,muscle,and joints.There are some suggested treatment and preventive approaches for symptomatic HO,which include surgical excision and preventive measures such as postoperative radiotherapy,oral nonsteroidal anti-inflam-matory drugs,and topical sealants(bone wax).However,these recommendations are based on personal experiences limited to HO in certain locations.It is important to individualize our treatment approaches depending on its location.For symptomatic HO along the laparotomy scar,complete surgical excision should be the priority treatment option,and bone wax application is not recommended.

Radiologic evaluation of nonalcoholic fatty liver disease

Nonalcoholic fatty liver disease(NAFLD)is a frequent cause of chronic liver diseases,ranging from simple steatosis to nonalcoholic steatohepatitis(NASH)-related liver cirrhosis.Although liver biopsy is still the gold standard for the diagnosis of NAFLD,especially for the diagnosis of NASH,imaging methods have been increasingly accepted as noninvasive alternatives to liver biopsy.Ultrasonography is a well-established and costeffective imaging technique for the diagnosis of hepatic steatosis,especially for screening a large population at risk of NAFLD.Ultrasonography has a reasonable accuracy in detecting moderate-to-severe hepatic steatosis although it is less accurate for detecting mild hepatic steatosis,operator-dependent,and rather qualitative.Computed tomography is not appropriate for general population assessment of hepatic steatosis given its inaccuracy in detecting mild hepatic steatosis and potential radiation hazard.However,computed tomography may be effective in specific clinical situations,such as evaluation of donor candidates for hepatic transplantation.Magnetic resonance spectroscopy and magnetic resonance imaging are now regarded as the most accurate practical methods of measuring liver fat in clinical practice,especially for longitudinal followup of patients with NAFLD.Ultrasound elastography and magnetic resonance elastography are increasingly used to evaluate the degree of liver fibrosis in patients with NAFLD and to differentiate NASH from simple steatosis.This article will review current imaging methods used to evaluate hepatic steatosis,including the diagnostic accuracy,limitations,and practical applicability of each method.It will also briefly describe the potential role of elastography techniques in the evaluation of patients with NAFLD.

Are there any disbenefits to patients in choosing laparoscopic gastrectomy by an expert in open gastrectomy？ Aspects of surgical outcome and radicality of lymphadenectomy

Background There may be concerns over disbenefits to patients who have chosen to undergo laparoscopic gastrectomy by experts in open gastrectomy, considering the disparity between the level of proficiency in open gastrectomy, at which they are already experts, and that in laparoscopic gastrectomy, at which they are beginners. The aim of this study was to compare surgical radicality and outcomes between laparoscopic gastrectomy and open gastrectomy during the learning period of laparoscopic gastrectomy for a senior surgeon who was already an expert in open gastrectomy. Methods Data of short-term surgical outcomes were obtained from patients following laparoscopy assisted distal gastrectomy （LADG） by a surgeon. The initial and following 30 experiences were grouped into LADG-I and LADG-II, respectively. Patients who underwent open distal subtotal gastrectomy （ODSG） and yet could have been candidates for LADG were grouped into ODSG. Known indicators of proficiency levels and the postoperative hospital course were compared. The consequences of extended lymphadenectomy, and the radicality of surgery by completing D2 lymphadenectomy were analyzed. Results The LADG group revealed longer operation time and less bleeding compared to the ODSG group （P 〈0.001）. The number of retrieved lymph nodes and the rate of complications were not significantly different. In the LADG-I group, the DI＋：D2 ratio was 4：1, showing significant differences from those in the LADG-II （0.36：1） and ODSG （0.16：1） groups （P 〈0.001）. The surgeon was able to complete D2 lymphadenectomy during LADG without significant change in the amount of bleeding and the rate of complications, but with a longer operation time （P=0.009）. The number of lymph nodes from the 12a station was not significantly different between the LADG and ODSG groups with D2 lymphadenectomy. Conclusions The surgical outcomes were comparable between LADG and ODSG even during the learning period of LADG, and the equivalence of radicality in lymphadenectomy was soon achieved. As long as the surgeon can accept a long operation time, an expert in open gastrectomy should not refrain from performing laparoscopic gastrectomy in well selected patients because of concerns about disbenefits to patients from choosing laparoscopic gastrectomy over open gastrectomy.

Impact of gender and body mass index on surgical outcomes following gastrectomy： an Asia-Pacific perspective

Background Although surgeons may expect difficulties in performing gastrectomy on patients with high body mass index （BMI）,it is not always the case,especially regarding patient gender.The aim of this study was to evaluate gender as a predictive factor of surgical outcomes related to obesity,as defined by the World Health Organization for the Asia-Pacific region.Methods Data of short-term surgical outcomes were obtained from 243 patients following open curative distal subtotal gastrectomy for gastric adenocarcinoma.Patients were classified into two groups by gender,and were further classified by BMI into group A （BMI ≥25 kg/m2） and group B （BMI 〈25 kg/m2）.The operation time,extent of surgical bleeding,the number of resected lymph nodes,postoperative hospital stay,serum amylase levels,white blood cell count and postoperative complications were accessed for each group.Results Within male patients,the operation time tended to be longer in group A,albeit without statistical significance （P=0.075）.However,the extent of surgical bleeding was significantly larger in group A （P=0.002）.Within female patients,there were no such differences.When comparisons were made between male and female patients in group A,the operation time was significantly longer in male patients （P=0.019）.The extent of bleeding tended to be larger in males,albeit without statistical significance （P=0.065）.No such differences were seen when comparisons were made between male and female patients in group B.Conclusions Disparity in surgical outcomes between male and female patients does exist,particularly in patients with high BMI.Gender adjustment of BMI must be performed when predicting surgical outcomes.