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Tumor necrosis factor-alpha inhibitor (TNFi) treatment is effective for ulcerative colitis (UC) and Crohn's disease (CD). Although several meta-analyses have been performed to evaluate the association between TNFi treatment and surgical morbidity, the results are controversial. We conducted a systematic review and meta-analysis of the prevention of surgical site infection (SSI) after surgery for UC and CD in patients on TNFis, based on literature published between January 2000 and May 2019 (registered on PROSPERO, No. CRD42019134156). Overall, 2175 UC patients in 13 observational studies (OBSs) and 7084 CD patients in 16 OBSs were included. The incidences of incisional (INC) SSI and organ/space (O/S) SSI after surgery for UC were 179/1985 (9.0%) and 176/2175 (8.1%), respectively. TNFi use was not associated with the incidences of INC SSI (odds ratio (OR) 1.04, 95% confidence interval (CI) (0.47-2.32) or O/S SSI (OR 1.85, 95% CI (0.82-4.20)) after surgery for UC. The INC SSI and O/S SSI incidences after surgery for CD were 289/3089 (9.4%) and 526/7,084 (7.4%), respectively. Preoperative TNFi use was not associated with INC SSI (OR 0.98, 95% CI (0.52-1.83)) or O/S SSI incidence (OR 1.09, 95% CI (0.78-1.52)) after surgery for CD. We did not find a significant association between preoperative TNFi use and SSI in surgery for UC or CD.

Background: The guidelines for the prevention, detection, and management of gastroenterological surgical site infections (SSIs) were published in Japanese by the Japan Society for Surgical Infection in 2018. This is a summary of these guidelines for medical professionals worldwide., Methods: We conducted a systematic review and comprehensive evaluation of the evidence for diagnosis and treatment of gastroenterological SSIs, based on the concepts of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. The strength of recommendations was graded and voted using the Delphi method and the nominal group technique. Modifications were made to the guidelines in response to feedback from the general public and relevant medical societies., Results: There were 44 questions prepared in seven subject areas, for which 51 recommendations were made. The seven subject areas were: definition and etiology, diagnosis, preoperative management, prophylactic antibiotics, intraoperative management, perioperative management, and wound management. According to the GRADE system, we evaluated the body of evidence for each clinical question. Based on the results of the meta-analysis, recommendations were graded using the Delphi method to generate useful information. The final version of the recommendations was published in 2018, in Japanese., Conclusions: The Japanese Guidelines for the prevention, detection, and management of gastroenterological SSI were published in 2018 to provide useful information for clinicians and improve the clinical outcome of patients.

Purpose: Restorative proctocolectomy with ileal pouch-anal anastomosis is a surgical procedure for ulcerative colitis, but pouch failure or pelvic sepsis still occurs in some patients. We conducted this study to investigate the cause of pouch failure and evaluate defecatory function after pelvic sepsis., Methods: A total of 234 patients who underwent restorative proctocolectomy were enrolled. We analyzed the cause of pouch failure, as well as defecatory function and manometric outcomes, with and without the complication of pelvic sepsis., Results: Pelvic sepsis developed in 29 (12.3%) of the 234 patients who underwent restorative proctocolectomy (pelvic sepsis group). The pelvic sepsis led to pouch failure in two of these patients (as a vaginal fistula in one and ileo-anal anastomotic leakage in one). Of the remaining majority of patients who did not suffer pelvic sepsis (control group), nine suffered pouch failure (as vaginal fistula in four, perianal abscess in two, pouch-spinal marrow fistula in one, and chronic pouchitis in two). There were no significant differences in defecatory function or manometric outcomes between the two groups. In the pelvic sepsis group, stool frequency was significantly correlated with white blood cell count (P = 0.01) and the duration until onset of pelvic sepsis (P < 0.01)., Conclusions: Pelvic sepsis after restorative proctocolectomy for ulcerative colitis does not affect defecatory and manometric function, but control of the inflammation caused by pelvic sepsis is integral for defecatory function.

Purpose: The coexistence of sarcopenia is associated with postoperative complications, including infection after abdominal surgery. We evaluated the association between sarcopenia and surgical site infection (SSI) after surgery for ulcerative colitis., Methods: The subjects of this retrospective study were 69 patients who underwent restorative proctocolectomy with perioperative abdominal computed tomography (CT). Sarcopenia was diagnosed by measuring the cross-sectional area of the right and left psoas muscles as the total psoas muscle area on CT images. We assessed whether sarcopenia was associated with SSI and clinical factors, including nutritional and inflammatory markers., Results: The lowest quartiles defined as sarcopenia in men and women were 567.4 and 355.8 mm 2 /m 2 , respectively. According to this classification, 12 men and 6 women had sarcopenia. Patients with sarcopenia had a lower body mass index (p = 0.0004) and a higher C-reactive protein concentration (p = 0.05) than those without sarcopenia. SSIs were identified in 12 patients (17.3 %) and included six pelvic abscesses and seven wound infections. According to multivariate analysis, sarcopenia was an independent risk factor for SSI (odds ratio = 4.91, 95 % confidence interval 1.09-23.5, p = 0.03)., Conclusion: Sarcopenia is predictive of SSI after pouch surgery for ulcerative colitis.

Purpose: Afferent limb syndrome (ALS) is a type of small bowel obstruction (SBO) caused by obstruction of the afferent intestinal limb after ileal pouch-anal anastomosis (IPAA). The aim of this study was to reveal the clinical features and management of ALS., Methods: Of 320 patients undergoing IPAA for ulcerative colitis, we analyzed data from patients presenting with SBO., Results: Six of 19 patients with SBO were diagnosed with ALS. All patients with ALS presented with recurrent intermittent obstructive symptoms before admission, whereas 15 % of patients without ALS presented with these symptoms (P < 0.0005). Among the six patients with ALS, four patients required surgery, although they underwent transanal decompression for each episode of obstruction. The proportion of surgery was higher in the ALS group (P < 0.01). Acute angulation of the afferent limb was recognized in four cases and followed by fixation of the afferent limb. No further surgery was required in any patient following the last fixation., Conclusions: SBO after IPAA may be caused by acute angulation of the afferent limb of the ileal J-pouch. Most patients with ALS may eventually require fixation of the afferent limb due to acute angulation of the afferent limb.

MicroRNAs (miRNAs) are a class of small, endogenous, non-coding, single-stranded RNAs that act as post-transcriptional regulators. Their discovery has provided new avenues for the diagnosis and treatment of cancer. The expression of both oncogenic and tumor suppressor miRNAs can be aberrantly either up- or down-regulated in cancer cells. These miRNAs target mRNAs of genes that either promote or inhibit tumor growth, and are one of several epigenetic factors that control the initiation and progression of colorectal cancer (CRC) and other cancers. Investigations of miRNAs as CRC biomarkers have employed the expression profiling of traditional tissue samples and, more recently, non-invasive samples, such as feces and body fluids, have been analyzed. MiRNAs may also be able to predict responses to chemo- and radiotherapy, and may be manipulated to modify CRC characteristics. We herein discuss the use of circulating miRNAs as possible non-invasive biomarkers of early CRC onset, relapse, or response to treatment. We also discuss the obstacles that currently limit the routine use of epigenetic biomarkers in clinical settings.

Purpose: The aims of this study were to reveal how using the antibiotics recommended by the 2010 Surgical Infection Society (SIS) and Infectious Disease Society of America (IDSA) guidelines can affect the therapeutic outcomes., Methods: We reviewed the cases of 53 patients with a postoperative intra-abdominal abscess without anastomotic leakage after gastrointestinal surgery who underwent image-guided percutaneous abscess drainage (PAD) and concomitant antibiotic therapy. The type of antibiotic initially administered was determined based on the surgeon's judgment. A persistent abscess was defined as one or more PAD procedures resulting in complete resolution after 21 or more days. The recommended antibiotics were defined according to 2010 SIS/IDSA guidelines., Results: All 53 patients had complete resolution without the need for surgery. The results of a multivariable analysis revealed that a C-reactive protein level ≥12 mg/dL and non-recommended antibiotics were significant risk factors for a persistent abscess (P = 0.042 and 0.013, respectively). With regard to a fever lasting more than 48 h, there was a significant difference between the recommended (45.1%) and non-recommended (72.7 %) antibiotic groups (P = 0.046)., Conclusions: Using the recommended antibiotics may shorten the time to defervescence and reduce the risk of a persistent abscess in patients undergoing PAD for a postoperative abscess after gastrointestinal surgery.

Pouch failure has been reported to occur after ileal pouch-anal anastomosis for Crohn's disease. We report two cases of patients with Crohn's disease, who underwent redo ileal pouch-anal anastomosis (redo-IPAA) combined with anti-TNF-α maintenance therapy, with good functional results. The first patient, a man with presumed ulcerative colitis, suffered pelvic fistula recurrence and anastomotic dehiscence. He underwent redo-IPAA, at which time longitudinal ulcers were found. Infliximab was started 4 days postoperatively and continued. The second patient, a woman treated for ulcerative colitis, underwent laparoscopic IPAA 8 years later. After the development of a pelvic fistula, twisted mesentery of the ileal pouch was found intraoperatively and Crohn's disease was diagnosed. Adalimumab therapy resulted in fistula closure. Redo-IPAA was performed to normalize the twisted mesentery of the ileal pouch. No complications have been observed in either patient, both of whom have experienced good functional results after closure of the covering stomas.

Purpose: A prospective, multicenter, observational study was performed to investigate the risk factors of surgical site infection (SSI) in patients with ulcerative colitis (UC)., Methods: From 2009 to 2010, perioperative clinicopathological data were collected from patients who had undergone surgery for UC within the research period, for up to 6 consecutive months in 13 hospitals in Japan. The primary outcome was the development of SSI., Results: A total of 195 patients with UC who underwent colorectal surgery were enrolled. SSI was diagnosed in 38 (19.5 %) patients, in the form of incisional infection in 23 (11.8 %), organ/space infection in 16 (8.2 %), and both in 1 (0.5 %). There were no significant risk factors associated with an increased risk of development of incisional SSI. An American Society of Anesthesiologists physical status of ≥ 3 was indicated as the only significant risk factor for organ/space SSI (P = 0.02) compared with other factors, such as a neutrophil count of >100 × 10(2)/mm(3), albumin level of <3.5 g/dl, perioperative packed red blood cell transfusion, fair or poor colonic cleanliness, and therapeutic use of antibiotics., Conclusion: Poor general physical status was the significant independent risk factor for organ/space SSI in patients with UC in Japan.

Purpose: Our aim was to examine the association between postoperative infection and preoperative systemic inflammation in patients undergoing resection of gastrointestinal cancer., Methods: We studied 862 patients who underwent elective gastrointestinal cancer surgery at six institutions. The levels of C-reactive protein and albumin were included as parameters of preoperative systemic inflammation measured using the Glasgow prognostic score. The Glasgow prognostic score was calculated based on the admission data as follows: patients with an elevated level of C-reactive protein (>1.0 mg/dl) and hypoalbuminemia (<3.5 g/dl) were allocated a score of 2, while patients showing one or none of these blood chemistry abnormalities were allocated a score of 1 or 0, respectively. The significance of the Glasgow prognostic score for predicting postoperative infection was analyzed using a multivariate analysis., Results: After surgery, 182 (21 %) patients developed postoperative infections. According to a multivariate analysis, the Glasgow prognostic score (p < 0.01) was independently associated with an increased risk of developing a postoperative infection. When the postoperative infections were divided into surgical site infections and remote site infections, the Glasgow prognostic score was significantly associated with an increased risk of developing remote site infections., Conclusions: Preoperative systemic inflammation is associated with postoperative infection in patients undergoing resection of gastrointestinal cancer.

Pyoderma gangrenosum (PG) is an idiopathic, inflammatory, ulcerative skin disorder; the etiology and pathogenesis of which are still poorly understood. It is one of the most important extraintestinal manifestations that can appear in the course of ulcerative colitis (UC). Although skin ulcers with destructive and necrotizing components are more commonly observed on the lower extremities and trunk, PG at stomal sites (peri-stomal PG) has been increasingly reported in patients with inflammatory bowel diseases (IBDs), including UC. Although PG at various surgical sites has been reported as an unusual presentation of PG, postoperative PG developing at the ileal pouch-anal anastomosis (IPAA) has not been reported previously. We herein report the first published case of a patient with UC who developed peri-anastomotic PG after IPAA during the postoperative tapering of systemic corticosteroids.

Purpose: Anastomotic leakage is the most concerning complication that can occur after colorectal surgery. The aim of this study was to determine the incidence of and risk factors for clinical anastomotic leakage following colorectal resection. In addition, we evaluated the efficacy of empirical antimicrobial therapy with respect to the clinical outcomes., Methods: Between January 2002 and December 2010, we prospectively collected surveillance data for patients, who were undergoing colorectal resection at Mie University Hospital., Results: A total of 918 patients undergoing elective colorectal surgery were included in our surveillance program, 633 of whom were eligible for the study. Clinical anastomotic leakage was identified in 40 (6.3 %) patients. The use of preoperative irradiation and an NNIS risk index ≧2 were found to be independent predictors of clinical anastomotic leakage after colorectal surgery. Empirical antibiotic treatment strayed from the 2010 IDSA/SIS guidelines, the length of hospital stay was prolonged and the rate of re-intervention was increased., Conclusions: Anastomotic leakage remains a major complication of colorectal surgery. Surgeons should be aware of such high-risk patients. In patients with anastomotic leakage after surgery, the empirical use of antimicrobial regimens with broad-spectrum activity against both aerobic and anaerobic organisms to treat postoperative intra-abdominal infections following colorectal surgery in accordance with the 2010 IDSA/SIS guidelines is associated with better outcomes.

Laparoscopic adhesiolysis has been the focus of much recent attention; however, the role of single-port laparoscopic surgery for adhesive small bowel obstruction remains unclear. We report our experience of performing single-port laparoscopic surgery for adhesive small bowel obstruction through a retrospective review of 15 consecutive patients who underwent single-port laparoscopic surgery for single adhesive small bowel obstruction between 2010 and 2012. We analyzed data on patient demographics, operating time, conversion, and surgical morbidity. Surgery was completed successfully without conversion to laparotomy or the need for additional intraoperative ports in 14 patients, but the remaining patient had peritoneal dissemination from colon cancer. The median operative time was 49 (25-148) min, and the estimated blood loss was 19 (2-182) ml. There were no major postoperative complications. We conclude that single-port laparoscopic surgery is a technically feasible approach for selected patients with adhesive small bowel obstruction when preoperative imaging identifies a single adhesive obstruction.

Purpose: Trehalose, naturally occurring disaccharide, has been reported to prevent postoperative abdominal adhesions in animal models. We investigated whether trehalose affects the function of human polymorphonuclear neutrophils (PMNs) in vitro to assess the feasibility of its clinical application as an anti-adhesive barrier., Methods: Human PMNs were obtained from 17 healthy volunteers. Escherichia coli and Staphylococcus aureus were used for the bacterial infection model, whereas lipopolysaccharide (LPS) and interleukin (IL)-1β were used for inflammation induction model. The PMN phagocytosis rates of bacteria and apoptosis/necrosis were assessed on trehalose, maltose, and control media. Cytokines; namely, tumor necrosis factor-α, IL-1α, IL-1Ra, IL-6, and IL-8; and PMN-elastase were measured on each medium in both models., Results: There were no significant differences in the phagocytosis rates, apoptosis/necrosis rates, or levels of all cytokines or PMN-elastase among the three media in the bacterial infection model. There were also no significant differences in the levels of all cytokines and PMN-elastase among the three media in the IL-1β inflammation induction model. PMN-elastase was lower in trehalose and maltose medium after LPS stimulation, at 3 and 24 h., Conclusions: Our results suggest that trehalose does not affect the cellular function, cytokine production, or release of PMN-elastase of human PMNs in an in vitro bacterial infection model.

The role of restorative proctocolectomy with ileal J-pouch anal anastomosis (IPAA) is uncertain for patients with ulcerative colitis (UC), when advanced lower rectal cancer is diagnosed. We report what to our knowledge is the first documented case of successful preoperative chemoradiotherapy followed by IPAA with partial intersphincteric resection of advanced rectal cancer associated with UC. A 59-year-old woman with a 24-year history of extensive UC was found to have advanced rectal cancer located 2 cm from the anal verge. She underwent preoperative conventional chemoradiotherapy followed by restorative proctocolectomy with total mesorectal excision. The procedure included intersphincteric resection of one quadrant and construction of an IPAA with diverting ileostomy. The postoperative course was uneventful, and the ileostomy was closed 6 months after the initial surgery. The patient was doing well with good pouch function and no evidence of recurrent disease 1 year after her initial surgery.

Purpose: Preventing a recurrence of Crohn's disease is a problem that remains to be solved. We evaluated the impact of using infliximab as a postoperative therapy on preventing the surgical recurrence of Crohn's disease., Methods: We performed a pair-matched study comparing 100 patients who had received postoperative infliximab maintenance therapy with those who had not between 1995 and 2010. The patients were matched by gender, Vienna classification and age at the time of the operation. Crohn's disease-related reoperation was evaluated as surgical recurrence., Results: In the postoperative infliximab maintenance therapy group, infliximab was administrated within 8 weeks after the operation. The median follow-up period was 36 months in the postoperative infliximab maintenance therapy group and 51 months in the control group. Surgical recurrences were recognized in 37 patients (three in the postoperative infliximab maintenance therapy group and 34 in the control group). A univariate analysis by the Kaplan-Meier method identified a body mass index >18 at the time of the operation (HR 0.19, p = 0.01) and postoperative infliximab maintenance therapy (HR 0.22, p = 0.0022) as factors related to the reduction of surgical recurrence. The multivariate analysis revealed that postoperative infliximab maintenance therapy was the only significant factor preventing surgical recurrence., Conclusion: Postoperative infliximab maintenance therapy for Crohn's disease prevents surgical recurrence, at least within 3 years after the operation.

Purpose: The aim of this study was to evaluate the sexual activity after restorative proctocolectomy with ileal J-pouch-anal anastomosis (ileoanal anastomosis) in Japanese patients with ulcerative colitis., Methods: Sixty-one patients who had undergone ileoanal anastomosis and were followed for at least 6 months after surgery were randomly selected. Their quality of life was assessed using the Japanese version of the Inflammatory Bowel Disease Questionnaire. Scores of three or less for the item "Sex life" were predetermined to represent poor sexual activity. The medical staff then asked them the reasons for this using a non-structured interview and open-ended questions., Results: Overall, 19 patients reported poor sexual activity. There was a significant difference in the scores for "Social functions" other than Sex life between individuals with poor and good sexual activities (21.6 ± 4.6 vs. 24.1 ± 4.2, P = 0.016). Ileoanal anastomosis after the age of 40 (OR 22, P = 0.02) and a total preoperative corticosteroid dose ≥15 g (OR 7.4, P = 0.04) were significant risk factors for poor sexual activity after ileoanal anastomosis., Conclusion: Our results suggest that ileoanal anastomosis results in relatively poor sexual activity, which was associated with other social functions, older age and a higher dose of corticosteroids administered to Japanese patients with ulcerative colitis.

Background: The prognostic nutritional index (PNI), which is calculated based on the serum albumin concentration and peripheral blood lymphocyte count, is a useful tool for predicting short-term and long-term postoperative outcome in patients undergoing cancer surgery. However, few studies have investigated PNI in colorectal cancer surgery. We examined the ability of PNI to predict short- and long-term outcomes in patients with colorectal cancer., Methods: This retrospective study included 365 patients who underwent resection for colorectal cancer. The prognostic nutritional status was calculated on the basis of admission data as follows: 10 × serum albumin (g/dl) + 0.005 × total lymphocyte count (per mm(3)). The primary outcomes measured were the impact of PNI on overall survival and postoperative complications., Results: Kaplan-Meier analysis and the log rank test revealed that low PNI was significantly associated with poor survival (P < 0.0001). In multivariate analysis for survival, preoperative low PNI was an independent prognostic factor for poor survival: odds ratio: 2.25, 95 % confidence interval 1.42-3.59). Moreover, low PNI significantly correlated with the incidence of postoperative complications, especially serious ones., Conclusions: Preoperative PNI is a useful predictor of postoperative complications and survival in patients with colorectal cancer.

Purpose: To improve the selection of patients for percutaneous abscess drainage (PAD) to treat postoperative intra-abdominal abscess after gastrointestinal surgery, we investigated the factors predictive of outcome., Methods: Of 143 consecutive patients with symptomatic postoperative intra-abdominal abscess after a gastrointestinal tract resection, 104 who underwent image-guided PAD as the initial treatment were reviewed. We assessed the possible associations between successful PAD and patient-, abscess-, surgical-, and drainage-related variables, and investigated the success rates of PAD for patients with vs. those without the factors related to successful outcome., Results: Based on monitoring for 1 year after PAD, the success rate of this procedure was 85.6% (89/104). Multivariate analysis revealed that the interval between surgery and the onset of abscess (p = 0.0234) and a single abscess (p = 0.0038) were independently associated with a successful outcome. Single late-onset abscess resolved completely within 10 weeks in 91.4% of these patients., Conclusions: Despite new strategies aimed at preventing surgical site infection, PAD remains an important factor in the postoperative management of gastrointestinal surgery in Japan. Initial recognition of the day of onset and the number of abscesses are important prognostic factors.

Two-photon laser scanning microscopy (TPLSM), relying on two-photon excitation restricted to the focal plane, has become the gold standard in biomedical research because of its ability to produce high-resolution, higher penetrating imaging of biological materials over an extended duration without an significant photobleaching. Intravital (in vivo) imaging using TPLSM for intra-abdominal organs has long been a technical challenge because of the difficulty of achieving high-quality and higher magnification imaging with acceptable cardiac and respiratory motion artifacts. A method of intravital TPLSM was developed using an organ-stabilizing system for imaging the intra-abdominal organs of green fluorescent protein transgenic mice. This method was further refined for the time-series imaging of intra-abdominal organs in the same mouse model using intravital TPLSM. These procedures allow the observation of not only a single cell or tissue microenvironment at a higher penetrating depth for a longer period of time but also to observe the same organ of the same mouse at multiple time points in preclinical models. This report presents the general principles and properties of TPLSM for biomedical research. In addition, the methods and the usefulness of time-series intravital TPLSM imaging for preclinical gastrointestinal diseases is discussed.

Purpose: The aim of this study was to determine if the placement of prophylactic drains influences the incidence of postoperative adverse events in neonates., Methods: Neonatal patients undergoing laparotomy between April 2000 and December 2007 were prospectively assigned to aggressive peritoneal cavity lavage, without the placement of prophylactic drains, before abdominal closure (non-drainage group, n = 111). The historical control group consisted of neonates who underwent laparotomy with routine prophylactic drain placement between January 1993 and March 2000 (drainage group, n = 87). The incidence of postoperative adverse events was compared between the two groups., Results: There were no significant differences in the incidence of overall complications (drainage, 48%; non-drainage, 36%: p = 0.08), infectious complications (drainage, 34%; non-drainage, 26%: p = 0.20) or surgical site infections (drainage, 20%; non-drainage, 14%: p = 0.25) between the two groups. In the subgroup analysis, the incidences of total postoperative complications and infectious complications were significantly higher in the drainage group compared with the non-drainage group for upper gastrointestinal tract operations (52 vs. 20%; 39 vs. 6.7%) (p = 0.04 and 0.02, respectively)., Conclusion: Prophylactic drainage did not reduce the incidence of postoperative complications, and the placement of drains may possibly increase the incidence of infectious complications.

We herein report our findings for an asymptomatic 65-year-old man presenting with multiple solitary leiomyomas in the esophagus, who was undergoing follow-up for primary aldosteronism with high levels of serum progesterone. Esophageal endoscopy and computed tomography showed multiple submucosal tumors with calcification in the thoracic esophagus. A subtotal esophagectomy was performed because the possibility of malignancy could not be ruled out based on a needle biopsy taken of the specimen. The final resected specimen showed eight solitary, encapsulated nodules between the middle and lower thoracic esophagus. Histopathological examinations showed these nodules to have the typical histological findings of leiomyomas. In addition, staining with antibodies against the progesterone receptor revealed diffuse expression in the nuclei of the leiomyoma cells. Only four cases with more than eight solitary leiomyomas have been reported, including the current case. However, this is the first reported case where primary aldosteronism with elevated serum progesterone levels has been implicated in the pathogenesis of multiple solitary leiomyomas in the esophagus.

Purpose: To evaluate the effectiveness of our surgical site infection (SSI) preventive strategies for rectal cancer patients., Methods: We compared the incidences and risk factors for SSI before (1990-1999) and after the implementation of our SSI prevention policies (2002-2006). A total of 250 patients who underwent surgery for rectal cancer were enrolled in this study. Peripheral venous blood samples were obtained perioperatively to measure the circulating pro- and anti-inflammatory cytokines., Results: The incidence of SSI was significantly lower after the introduction of SSI prevention policies [SPP(+)] than before [SPP(-)], at 13.1% vs 32.0%, respectively (P = 0.0004). Even with the infection control programs, abdominoperineal resection (APR) was an independent factor predictor of SSI after rectal cancer surgery. The consumption of postoperative interleukin (IL)-6 soluble receptor was much higher in the APR patients than in the non-APR patients. The exaggeration of postoperative IL-6 response was more pronounced in the APR patients in the SPP(+) group than in those in the SPP(-) group, although preoperative chemotherapy and/or radiotherapy might have influenced the inflammatory response., Conclusions: These findings suggest that the introduction of SPP helped reduce the incidence of SSI, especially in the non-APR patients.

Background: Various factors regarding the biological state of tumors or the nutritional status of patients have been reported individually to correlate with prognosis. Identification of defined patient groups based on a prognostic score may improve the prediction of survival and individualization of therapy. The aim of the present study was to identify clinically useful parameters obtainable before treatment that could be used for predicting clinical outcomes in patients with gastric cancer., Methods: In 357 consecutive patients who had been treated for potentially curable gastric cancer, we retrospectively analyzed the following clinicopathological factors: sex, age, body mass index, body weight changes, hemoglobin, white blood cell count, neutrophil to lymphocyte (N/L) ratio, serum C-reactive protein (CRP), serum albumin, serum cholinesterase, tumor location, tumor size, histology, and clinical tumor node metastasis (TNM) stage. Factors related to prognosis were evaluated by univariate and multivariate analysis., Results: From univariate analysis, significant differences in survival were found for age, hemoglobin, N/L ratio, serum CRP, serum albumin, serum cholinesterase, tumor size, and clinical T and N grouping. N/L ratio, tumor size, and clinical T grouping were identified as independent prognostic indicators in multivariate analysis. A prognostic score was constructed using these variables to estimate the probability of death. The model gave an area under the receiver operating characteristic curve of 0.85 for prediction of death at 5 years., Conclusions: This model based on N/L ratio, tumor size, and clinical T grouping before treatment offers a very informative scoring system for predicting prognosis of gastric cancer.

Background: Postoperative hospital-acquired pneumonia (HAP) is recognized as a major risk associated with surgery. Although upper abdominal surgery is known to have the highest incidence of postoperative HAP, little is known about the risk factors that contribute to HAP after gastric cancer surgery. The aim of this study was to determine the incidence and risk factors for HAP after elective surgery for gastric cancer., Methods: We conducted prospective surveillance of all elective gastric resections by surgeons in ten affiliated hospitals, including ours, from May 2001 to May 2005. The outcome of interest was postoperative HAP. Univariate and multivariate analyses were performed to determine the predictive significance of variables in gastric cancer surgery., Results: A total of 529 patients undergoing elective operations for gastric cancer were admitted to the program. Postoperative HAP was identified in 20 patients (3.6%). Univariate and multivariate analyses showed that male gender and intra- and/or postoperative blood transfusion were independently predictive of postoperative HAP., Conclusions: Male gender and intra- and/or postoperative blood transfusion were independent risk factors for the development of HAP after elective resection of gastric cancer. Surgeons should keep these risk factors in mind when managing postoperative patients.

Background: Surgical site infection (SSI) prolongs hospital stay, increases medical costs, and occasionally leads to mortality. Our goal was to clarify the differences in SSI incidence between our own data and the National Nosocomial Infections Surveillance (NNIS) data., Methods: From January 2003 to December 2006, we prospectively collected surveillance data from patients who were undergoing elective colorectal resection at the Mie University Graduate School of Medicine., Results: Three hundred fifty-five elective colorectal resections (144 colon surgeries, 211 rectal surgeries) were included. The median patient age was 57.4 years. SSIs were identified in 60 patients. Cumulative SSI incidence was 16.9%. The average SSI onset was 8.7 days (range = 3-20 days) after operation. Nineteen patients (19/30:31.7%) developed SSI within 6 days of the operation. The incidence of SSI occurring within 6 days after the operation was 5.4%., Conclusion: Seventeen percent of SSIs occurred despite the use of perioperative management according to the CDC guidelines. We reported a much higher SSI incidence than that in the NNIS data. However, the SSI incidence within 6 days of surgery was similar to that of the NNIS data. The difference in SSI incidence between our data and that of the NNIS range may result from the different strict surveillance periods.

The aim of the present review was to investigate whether host-tumor interactions are causal or consecutive clinical factors associated with surgical stress that influence the long-term survival after a curative resection of colorectal cancer. A Medline/PubMed search was conducted to identify the relevant articles investigating the factors related to surgical stress and their effects on the long-term survival after a curative resection of colorectal cancer. The intraoperative state is defined as a cytokine storm in which ongoing local cytokine production occurs at the site of the tumor, thus further enhancing the autocrine cytokine loop for angiogenic factor production. The postoperative state is defined as tissue regeneration in which surgery-related clinical events enhance the systemic induction of inflammatory cytokines, which in turn synergistically exaggerate the local activation of tumor growth factors. Host-tumor interactions under surgical stress may act synergistically as potent tumor growth factors, and may thus influence long-term survival. Controlling surgical insults and/or regulating perioperative inflammatory responses may therefore lead to new therapeutic approaches for controlling disease recurrence.

Although it is generally accepted that aging increases postoperative morbidity and mortality rates, the underlying mechanism remains unknown. The present review evaluates the clinical implications of remodeling the immunoinflammatory status with reference to inflammaging and tumor-specific hyperinflammation. We conducted a Medline/PubMed search for articles investigating factors related to aging and their effects on postoperative outcomes. Inflamm-aging results in both decreased immunity to exogenous antigens and increased auto-reactivity, whereby the beneficial effects of inflammation devoted to the neutralization of harmful agents early in life become detrimental late in life. Cancer also represents an immunologic challenge, which upregulates the systemic immune response. Thus, tumor-related hyperinflammation and inflamm-aging synergistically lead to the systemic priming of inflammatory mediators preoperatively; then, surgical stress acts as the second hit, increasing the risk of an exaggerated postoperative inflammatory response. Age-related molecular events may place elderly patients at greater risk of postoperative complications which could result in death. For regulating uncontrolled hyperinflammation, the clinical advantages of perioperative immunonutrition or steroids have been advocated; however, double-blind, randomized, controlled trials of pharmacologic modulation therapy are needed.

Purpose: The use of preoperative oral antibiotics during preparation for elective colorectal surgery remains controversial. This was a prospective randomized clinical trial to compare the efficacy of intravenous antimicrobial prophylaxis alone with combined oral and intravenous antimicrobial prophylaxis for surgical site infection (SSI) in patients undergoing elective colorectal surgery., Methods: Five hundred patients were enrolled in this study. Of these, 491 were randomly assigned to receive either intravenous antimicrobial prophylaxis or combined oral and intravenous antimicrobial prophylaxis. The primary outcome was the incidence of SSI within 6 weeks of elective colorectal surgery., Results: The incidence of SSI was similar in the two treatment groups: intravenous alone, 10.7%; and oral and intravenous, 7.0% (difference 3.7%; 95% confidence interval -4.8% to 5.6%). No critical adverse events were reported., Conclusion: The addition of oral antibiotics to intravenous antimicrobial prophylaxis showed no advantage in the prevention of SSI.

Introduction: We examined the clinical manifestations and computed tomography findings of patients with leakage after gastrectomy for cancer and determined the sensitivity of the contrast swallow for the leakage diagnosis., Methods: The medical records of 331 consecutive patients undergoing gastrectomy between January 1992 and December 2003 were reviewed. Routine contrast swallow was performed in all patients before oral intake. Once leakage was suspected, an emergency contrast swallow was performed and its diagnostic sensitivity determined., Results: In total, leakage was diagnosed 9 of 17 times by the contrast swallow, for a diagnostic sensitivity of 53%. The clinical signs or another imaging modality often corrected the misdiagnosis., Conclusions: The diagnostic sensitivity of contrast swallow for leakage after gastrectomy was low. Therefore, if we employ the contrast swallow technique, we should keep in mind its low sensitivity.

Purpose: High-frequency ultrasound energy was introduced in gastrointestinal surgery to improve dissection and coagulation. We assessed the safety and efficacy of ultrasonic dissection compared with standard electrosurgery in gastrectomy for large gastric cancers, which is associated with high morbidity., Methods: The subjects of this retrospective study were 52 patients who underwent gastrectomy for gastric cancers, > or =7 cm in diameter. Gastrectomy was performed with ultrasonically activated shears (UAS) between January 2005 and June 2006 (UAS group, n = 26) and with standard electrosurgery between July 2003 and December 2004 (control group, n = 26). We compared morbidity, operating time, and intraoperative blood loss between the two groups., Results: The mean operating time and intraoperative blood loss were significantly lower in the UAS group than in the control group. Morbidity in the UAS group was also lower, but the difference was not significant., Conclusion: Our findings showed that UAS gastrectomy was safe, with significantly shorter operating times and less intraoperative blood loss than standard electrosurgery.

Purpose: In Japan, sterile water is used for rinsing in surgical handwashing, whereas in Western countries tap water is generally used. We conducted this study to examine the conditions and the equipment that affect bacterial contamination in tap water and to determine whether the tap water in our institute is suitable for surgical handwashing., Methods: First, we examined the water pipes and measured the free chlorine content in the tap water in the operating room. Next, we recruited 40 volunteers and conducted preliminary tests with sterile water. Thirty of these subjects participated in a handwashing test using tap water., Results: The mean free chlorine levels in the tap water and the sterile water were 0.30 +/- 0.05 and 0.07 +/- 0.03 mg/l, respectively. The handwashing test using tap water showed immediate, persistent, and cumulative bacteria activity within the minimum limits set by the Food and Drug Administration (FDA)., Conclusion: The free chlorine levels in the tap water in our institute satisfied Japanese health regulations. Moreover, the handwashing test met the criteria of the FDA. Thus, we conclude that this tap water is safe to use for rinsing in surgical handwashing.

Sentinel node (SN) biopsies might be useful for performing minimally invasive surgery without interrupting surgical curability. This study examined the cause of false negativity during laparoscopic lymphatic mapping and SN biopsies for early-stage gastric cancer. Thirty-seven patients with gastric cancer (preoperative stage T1-2 or N0) who underwent laparoscopic lymph node mapping and SN biopsies between March 2001 and June 2004 were enrolled in this study. The tracer, patent blue and technecium-99m-labeled tin colloid, was injected endoscopically. Blue-stained or radioactive nodes were defined as SNs. Gastrectomy with lymphadenectomy was performed then the results of the SN biopsies were compared with the final diagnosis of the removed lymph nodes in permanent sections. Sentinel nodes were successfully identified in 35 patients (94.6%), and they were positive in 3 of 4 patients with metastatic lymph nodes; sensitivity was 75% and specificity was 100%. Sentinel node status could therefore be used to diagnose lymph node status with 97.1% accuracy. Of 6 SNs with metastasis, 5 showed radioactivity, and only 2 were blue stained. In the false negative case, a radioactive SN with metastasis in the right paracardial region was missed during laparoscopic mapping. An error in laparoscopic intracorporeal detection of the radioactive node with metastasis occurred because we could not eliminate the shine-through effect. We found that during laparoscopic SN mapping there is a high risk of false negativity with SNs located in the right paracardial region. To apply laparoscopic SN mapping to early-stage gastric cancer patients, the shine-through effect must be eliminated because radiotracers are essential for this method.

Purpose: To evaluate the effectiveness of Seprafilm in preventing abdominal adhesions after radical resection of rectal carcinoma, and to observe whether Seprafilm had any adverse effects in patients treated with radiotherapy and chemotherapy., Methods: A total of 62 patients participated in this prospective randomized clinical study, which was conducted to compare the outcomes of patients operated on with Seprafilm (SEPRA+) with those operated on without Seprafilm (SEPRA-). All patients received preoperative radiotherapy, followed by a two-stage operation, and 5-fluorouracil (5-FU)-based systemic chemotherapy. The primary endpoint of severity and extent of adhesions were evaluated at the time of ileostomy closure. The secondary endpoint included the recurrence of tumors, late complications, and outcome., Results: Seprafilm significantly reduced the adhesions in both the midline incision area and peristomal area. This in turn reduced the operation time, blood loss, and extent of the incision at ileostomy closure. Seprafilm was not associated with any postoperative complications or chemoradiation-related toxicity, nor did it affect recurrence or survival rates., Conclusion: Seprafilm effectively reduced abdominal adhesions in chemoradiated patients, and had no adverse effects on the oncologic results of fully introduced adjuvant therapy. Thus, Seprafilm is a safe and effective tool for use in rectal carcinoma surgery.

Purpose: To determine whether Seprafilm aggravates the systemic inflammatory response and adversely affects the outcome of postoperative intraperitoneal septic conditions., Methods: We retrospectively analyzed the relationship between the intraperitoneal placement of Seprafilm and the rate of intraperitoneal septic complications in 278 consecutive patients. Experimentally, 40 rats were subjected to laparotomy with or without the intraperitoneal placement of Seprafilm. Bacterial peritonitis was induced by cecal ligation and puncture (CLP) and the serum cytokine levels were measured., Results: Seprafilm did not increase the rate of septic complications or aggravate inflammatory responses in patients with or without postoperative intraperitoneal inflammatory complications. Experimentally, there was no significant difference between the serum inflammatory cytokine levels after CLP with or without Seprafilm., Conclusions: Seprafilm did not adversely affect postoperative inflammatory response or clinical outcomes, even in patients with intraperitoneal septic complications.

We examined the kinetics of serum monocyte chemoattractant protein-1 (MCP-1) perioperatively and clarified its significance regarding the development of infectious complications. We studied 94 patients who underwent gastrointestinal surgery for gastric or colorectal cancer at Mie University Hospital from 1996 to 2000. Serum concentrations of MCP-1 and interleukin-6 (IL-6) were measured perioperatively. The number of circulating lymphocytes and neutrophils were counted to assess the apoptotic rate of neutrophils. Patients were divided into two groups at the median preoperative MCP-1 level obtained from 40 gender- and age-matched healthy volunteers. The rate of developing infectious complications was significantly higher and tumor size was significantly larger in the low MCP-1 group than in the high MCP-1 group. The increasing IL-6 ratio (postoperative/preoperative IL-6 level) in the low MCP-1 group was about twofold greater than that in the high MCP-1 group. The neutrophil level calculated for the low MCP-1 group was significantly higher than that in the high MCP-1 group on postoperative day 3. We concluded that a decreased level of serum MCP-1 reflected tumor-related immunosuppression. Low MCP-1 levels were associated with an exaggerated postoperative IL-6 response and delayed neutrophil apoptosis, which affected the incidence of postoperative infectious complications developing in patients with gastrointestinal malignancies.

Purpose: Groin dissection remains the treatment of choice for malignant neoplasms of the skin in the lower extremities and perineum. We sought to quantify the hospital complications after groin dissection, and to identify the patient- and procedure-related factors affecting these complications., Methods: We reviewed 20 consecutive patients who underwent a collective 25 groin dissections for malignant neoplasms of the skin between 1996 and 2002 to determine the incidence and degree of morbidity, and to analyze the clinical factors associated with morbidity. An S-shaped incision was used for the first 8 procedures, whereas a straight incision was used for the next 17., Results: The overall incidences of complications were 24% for wound infection, 52% for skin flap problems, 32% for seromas, 40% for edema, and 4% for hemorrhage, whereas the incidences of moderate to severe complications were 16% for wound infection, 16% for skin flap problems, 12% for seromas, 4% for edema, and 4% for hemorrhage. The incidence of wound infection tended to be higher after S-shaped incisions than after straight incisions ( P = 0.059), and the incidence of leg edema was significantly higher after S-shaped incisions than after straight incisions ( P = 0.028)., Conclusion: S-shaped incisions more often resulted in lymphatic collection and stagnation, with a higher incidence of wound infections and leg edema than straight incisions. Therefore, we now perform straight incisions to minimize the risk of wound infections and leg edema.