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Purpose: To clarify the influence of surgical volume on the mortality and morbidity of gastrointestinal perforation in children in Japan. Methods: We collected data on pediatric patients with gastrointestinal perforation between 2017 and 2019, from the National Clinical Database. The surgical volumes of various institutions were classified into three groups: low (average number of surgeries for gastrointestinal perforation/year < 1), medium (≥ 1, < 6), and high (≥ 6). The observed-to-expected (o/e) ratios of 30-day mortality and morbidity were calculated for each group using an existing risk model. Results: Among 1641 patients (median age, 0.0 years), the 30-day mortality and morbidity rates were 5.2% and 37.7%, respectively. The 30-day mortality rates in the low-, medium-, and high-volume institutions were 4.9%, 5.3%, and 5.1% (p = 0.94), and the 30-day morbidity rates in the three groups were 26.8%, 39.7%, and 37.7% (p < 0.01), respectively. The o/e ratios of 30-day mortality were 1.05 (95% confidence interval [CI] 0.83–1.26), 1.08 (95% CI 1.01–1.15), and 1.02 (95% CI 0.91–1.13), and those of 30-day morbidity were 1.72 (95% CI 0.93–2.51), 1.03 (95% CI 0.79–1.28), and 0.95 (95% CI 0.56–1.33), respectively. Conclusion: Surgical volume does not have significant impact on the outcomes of pediatric gastrointestinal perforation in Japan. [ABSTRACT FROM AUTHOR]

Aim: The Coronavirus Disease 2019 (COVID‐19) pandemic affected the allocation of various medical resources to several areas, including intensive care units (ICUs). However, currently, its impact on the short‐term postoperative outcomes of gastrointestinal cancer surgeries remains unclear. We aimed to evaluate the impact of the pandemic on the incidence of complications occurring after low anterior resection in patients with rectal cancer in Japan. Methods: Data from the Japanese National Clinical Database between 2018 and 2021 were retrospectively examined. The primary outcome of the study was the postoperative morbidity and mortality rates before and after COVID‐19 pandemic. Moreover, the postoperative ICU admission rate was assessed. Morbidity and mortality rates were also assessed using a standardized morbidity/mortality ratio (SMR, the ratio of the actual number of incidences to the expected number of incidences calculated by the risk calculator). Results: This study included 74 181 patients, including 43 663 (58.9%) from COVID‐19 epidemic areas. The mean actual incidences of anastomotic leakage (AL) and pneumonia during the study period were 9.2% and 0.9%, respectively. The SMRs of these complications did not increase during the pandemic but those of AL declined gradually. The mean 30‐day mortality and operative mortality rates were 0.3% and 0.5%, respectively. Moreover, SMRs did not change significantly in the pandemic or regional epidemic status. The ICU admission rate temporarily decreased, especially in the epidemic areas. Conclusion: Although the pandemic temporarily decreased the ICU admission rate, its impact on short‐term outcomes following low anterior resection in patients with rectal cancer was insignificant in Japan. [ABSTRACT FROM AUTHOR]

Purpose: Since 2002, the Japan Surgical Society has established a board certification system for surgeons to be certified for a specialty. Surgery remains a male-dominated field in Japan. This study aimed to clarify if the Japanese surgical residency training system is equally suitable for female and male residents. Methods: The Japan Surgical Society conducted the first questionnaire survey regarding the system of surgical training for the residents in 2016. The questionnaire included the degree of satisfaction with 7 aspects of the training system, including the number and variety of cases experienced and duration and quality of instruction, and the learning level for 31 procedures. The degree of satisfaction and level of learning were compared between female and male residents. Results: The degree of satisfaction was similar for all items between female and male residents. Female residents chose breast surgery as their subspecialty more frequently than male residents and were more confident in breast surgery procedures than male residents. Conversely, fewer female residents chose gastrointestinal surgery and were less confident in gastrointestinal surgery procedures than male residents. Conclusion: Female residents were as satisfied with the current surgical training system as male residents. However, there may be room for improvement in the surgical system, considering that fewer applications for gastrointestinal surgery come from female residents than from males. [ABSTRACT FROM AUTHOR]

Department of Gastrointestinal Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo, Japan Surgical site infections (SSIs) remain one of the most common serious surgical complications and are the second most frequent healthcare-associated infection. Patients with SSIs have a significantly increased postoperative length of hospital stay, hospital expenses, and mortality risk compared with patients without SSIs. The prevention of SSI requires the integration of a range of perioperative measures, and approximately 50% of SSIs are preventable through the implementation of evidence-based preventative strategies. Several international guidelines for SSI prevention are currently available worldwide. However, there is an urgent need for SSI prevention guidelines specific to Japan because of the differences in the healthcare systems of Japan versus western countries. In 2018, the Japan Society for Surgical Infection published SSI prevention guidelines for gastroenterological surgery. Although evidence-based SSI prevention guidelines are now available, it is important to consider the appropriateness of these guidelines depending on the actual conditions in each facility. A systemic inflammatory host response is a hallmark of bacterial infection, including SSI. Therefore, blood inflammatory markers are potentially useful in SSI diagnosis, outcome prediction, and termination of therapeutic intervention. In this review, we describe the current guideline-based perioperative management strategies for SSI prevention, focusing on gastroenterological surgery and the supplemental utility of blood inflammatory markers. [ABSTRACT FROM AUTHOR]

Background: The original formula name for daikenchuto (DKT) was written in 'Jin Gui Yao Lue (Kinkiyōryaku in Japanese)'. DKT as used in Japan consists of four types of crude drug. Key findings: Although there are few examples of its use in Chinese classical records, it has begun to be used extensively in modern Japan for intestinal obstruction after laparotomy. Furthermore, to prove its usefulness, many clinical trials on DKT for intestinal obstruction have been conducted since the 1990s. Although the efficacy of DKT in preventing or improving intestinal obstruction was controversial, a meta‐analysis of nine studies reported in recent years showed that DKT significantly reduced the incidence of intestinal obstruction after gastrointestinal cancer surgery, suggesting its effectiveness. Related knowledge of irritable bowel syndrome has also been accumulated through case reports. DKT has been shown to be involved in the promotion of gastrointestinal motility, inhibition of excessive gastrointestinal motility, secretion of gastrointestinal hormones, and improvement of gastrointestinal blood flow, and to have anti‐inflammatory effects. In addition to drug rash, serious adverse events include hepatic dysfunction and interstitial pneumonia, but there have been relatively few reports. Conclusion: DKT has been used in many cases in Japan, but it is often used without considering the 'pattern (shō)'. Since it was originally formulated for the treatment of chills (hie), it would be more effective if its target (pattern) were taken into consideration. Overall, DKT is a safe prescription with a wide range of applications. [ABSTRACT FROM AUTHOR]

Aim: The National Health Insurance system has reimbursed robotic gastrointestinal surgery since April 2018 in Japan. Additionally, strict facility and surgeon standards were established by the government and the academic society. This study aimed to evaluate the prevalence and safety of robotic surgery using a Japanese nationwide web‐based database. Methods: Patients who underwent the following robotic surgeries for malignant tumors in 2018 were included: esophagectomy (RE), total gastrectomy (RTG), distal gastrectomy (RDG), proximal gastrectomy (RPG), low anterior resection (RLAR), and rectal resections other than RLAR (RRR). The number of cases and surgical mortality rates each month were calculated to evaluate the prevalence and safety of robotic procedures. Results: A total of 3281 patients underwent robotic gastrointestinal surgery. The monthly number of robotic surgeries nearly doubled in April 2018 when they were initially reimbursed by the National Health Insurance system. Operative mortality rates were 0.9%, 0.4%, 0.2%, and 2.8% for RE (n = 330), RTG (n = 239), RDG (n = 1167), and RPG (n = 109), respectively. No mortality was observed in RLAR (n = 1062) or RRR (n = 374). Conclusion: Robotic surgery for gastrointestinal malignant tumors was safely introduced into daily clinical practice along with rigorous surgeon and facility standards in Japan. [ABSTRACT FROM AUTHOR]

Extensive gastrointestinal surgery surveillance data in Japan were analyzed to examine the differences in the risk factors for surgical site infection (SSI) between laparotomy and laparoscopic abdominal procedures. Surgical procedures investigated in the study were gastrectomy, cholecystectomy, colectomy, rectal resection, and appendectomy. A total of 32,629 patients were included in the study. The study participants were divided into two groups according to the year of surgery, 2003–2009 (first study period) and 2010–2015 (second study period), due to the increase in the number of laparoscopic surgeries in the second study period. The incidence of SSI was stratified by three SSI classifications (superficial incisional, deep incisional, and organ/space SSI). Multiple logistic regression analysis was performed to predict the risk factors for SSI. The percentage of laparoscopic surgeries performed has increased linearly since 2010. Patients in the second study period were significantly older and had a higher prevalence of SSI risk factors compared with those in the first study period. In addition, the predictive factors changed substantially in most surgical procedures between the two study periods. Wound class ≥ 3 was a ubiquitous risk factor for superficial incisional SSI (SI-SSI) and organ/space SSI (OS-SSI) in both open (laparotomy) and laparoscopic procedures in the first study period. Meanwhile, in the second study period, operative duration was a ubiquitous risk factor in both procedures. The risk factors for SI-SSI differed from those for OS-SSI in the five abdominal surgeries investigated in the study. Periodic examination of risk factors for SSI is recommended in an aging society. [ABSTRACT FROM AUTHOR]

Background: Elective laparoscopic surgery is now widely accepted in the treatment of abdominal diseases because of its minimal invasiveness and rapid postoperative recovery. It is also used in the emergency setting for the diagnosis and treatment of acute diffuse peritonitis regardless of the causative disease. However, the value of laparoscopy in acute diffuse peritonitis remains unclear. In this study we aimed to show trends in the use of laparoscopy over time and compare the real‐world performance of laparoscopic surgery with that of open surgery for acute diffuse peritonitis due to gastrointestinal perforation. Methods: We extracted data from the National Clinical Database, a nationwide surgery registration system in Japan, for patients with a diagnosis of acute diffuse peritonitis due to gastroduodenal or colorectal perforation between 2016 and 2019. Trends in the use of laparoscopy over time were identified. Patient characteristics, laboratory findings, surgical findings, and postoperative complications were compared between laparoscopic surgery and open surgery. Results: Patients in poor condition and those with abnormal laboratory findings tended to undergo open surgery. Anesthesia time and operating time were longer for laparoscopic surgery in patients with gastroduodenal perforation but shorter in those with colorectal perforation. Fewer complications occurred in patients who underwent laparoscopic surgery. The number of institutions where laparoscopic surgery was performed and the proportion of the use of laparoscopy at each institution increased over time. Conclusion: The use of laparoscopy is becoming common in surgery for acute diffuse peritonitis due to gastrointestinal perforation. This approach may be a useful option for acute diffuse peritonitis. [ABSTRACT FROM AUTHOR]

Background: Parkinson's disease (PD) patients with comorbid cancers are increasing in aging populations. However, little is known about the impact of PD on the outcomes of surgeries to resect these cancers. We sought to clarify the association between PD and discharge status of patients who underwent surgery for gastrointestinal cancers, as the most prevalent malignant neoplasms worldwide.Methods: We identified patients who underwent surgery for gastric and colorectal cancers between April 01, 2014 and March 31, 2018 using the Diagnosis Procedure Combination database, a nationwide administrative inpatient database in Japan. We then collected data on their sex, age, smoking status, body mass index, activities of daily living, cancer stage, and comorbidities. Multivariable Cox regression analyses were conducted to determine factors that influenced discharge to home.Results: Compared with non-PD patients (n = 272,668), PD patients (n = 1341) were significantly older and less likely to receive laparoscopic surgery, and had lower body mass index, more advanced cancer stage, and lower activities of daily living. The proportions of PD and non-PD patients discharged to home were 80.3% and 96.2%, respectively. The adjusted hazard ratio for discharge to home for PD patients was 0.68 (95% confidence interval, 0.64-0.73; P < 0.001).Conclusions: Compared with non-PD patients, PD patients were less likely to be discharged to home after surgery for gastrointestinal cancers. The present results may indicate a necessity to improve perioperative care for patients with PD. [ABSTRACT FROM AUTHOR]

Background: Surgical site infections (SSI) are the most common healthcare-associated infection, and gastrointestinal surgery is frequently followed by a high incidence of SSI. Epidemiological analysis of the temporal trends in SSI following gastrointestinal surgery has yet to be performed in Japan. Our purpose was to descriptively investigate these trends.Methods: Extracting national surveillance data from the Japan Nosocomial Infections Surveillance (JANIS) system, we analyzed the frequency of SSI events following gastrointestinal surgery, which consisted of seven surgical procedures, from 2012-2017. We calculated the standardized infection ratio to compute risk-adjusted SSI frequency, and used the trend test to detect time-dependent changes.Results: The frequency of SSI events, except for those associated with surgery of the upper gastrointestinal tract, revealed a decreasing time-dependent trend. The use of laparoscopic surgery increased dramatically over time (p < 0.01 for the six applicable surgical sites), while the frequency of SSI events during laparoscopic surgery remained unchanged.Conclusions: The increasing use of laparoscopic surgery was identified, and the observation coincided with the decreasing trend in SSI, especially in lower gastrointestinal tract surgery. If the relationship is causal, the overall SSI incidence among previously healthy individuals is expected to decrease, because the use of laparoscopic surgery has large growth potential in Japan. [ABSTRACT FROM AUTHOR]

Purpose: Olanexidine gluconate is a newly developed solution for skin disinfection that was recently approved in Japan. We aimed to compare single and double application of the solution in preventing surgical site infection (SSI) in patients undergoing general surgery. Methods: This randomized study was conducted at the Tottori University Hospital. Patients scheduled to undergo gastrointestinal or hernia surgery were randomly assigned to one of two groups using either one or two Olanedine applicators for skin disinfection. The primary endpoint was the difference in SSI incidence between the two groups. The secondary endpoint was all adverse events related to olanexidine gluconate. Results: A total of 393 patients qualified for the study protocol: 193 received a single application, and 200 received a double application of Olanedine. SSI occurred in 10 patients (2.5%) overall; nine were superficial incisional SSIs, and one patient had a deep incisional SSI. Of the 10 patients who developed SSI, six (3.1%) were in the group receiving a single application, and four (2.0%) were in the group receiving a double application; there was no statistically significant difference between the two groups (P = 0.537). Allergic reactions or skin disorders related to olanexidine gluconate were not observed. Conclusion: There was no difference in the SSI incidence between the use of one or two Olanedine applicators for skin preparation in elective general surgery. Therefore, a single application of Olanedine is sufficient and is recommended for general surgery as a standard disinfection precaution. Trial registration number: UMIN000027319; 5/12/2017. [ABSTRACT FROM AUTHOR]

Aim: Polypharmacy in elderly people is a social issue and has been reported to cause not only drug adverse events, but also falls, dysfunction and cognitive decline. Those events may trigger prolonged length of hospitalization. Therefore, the aim of this study was to investigate whether polypharmacy has a prolonging effect on hospitalization. Methods: The study subjects were 584 patients in a university hospital in Japan who had been admitted for hepatectomy, pancreaticoduodenectomy, gastrectomy or colectomy, and to whom clinical pathways had been applied. In this study, polypharmacy was defined as taking five or more regular oral medications, and prolonged hospitalization was defined as hospitalization longer than that determined by the clinical pathway. Multiple logistic regression analysis was performed to investigate whether polypharmacy affects the length of hospitalization. Results: The subjects were 348 males and 236 females, mean ± SD age of 65.8 ± 12.9 years. Among all subjects, 228 (39.0%) were receiving polypharmacy at admission, and the number of patients with prolonged hospitalization was 262 (44.9%). Multiple logistic regression analysis revealed that the following variables were significantly associated with prolonged hospitalization; polypharmacy (odds ratio = 1.532; 95% confidence interval = 1.010–2.327), age 50–59; 2.971 (1.216–7.7758), age 60–69; 2.405 (1.059–5.909), organ pancreas; 0.298 (0.122–0.708), operation time ≥386 min; 2.050 (1.233–3.432), intraoperative bleeding volume ≥401 mL; 2.440 (1.489–4.038), postoperative delirium; 2.395 (1.240–4.734), postoperative infection; 10.715 (4.270–33.059). Conclusion: The current study revealed that polypharmacy at admission was an independent factor for prolonged hospitalization. In future, measures against polypharmacy are required, collaborating with outpatient clinics, family doctors and dispensing pharmacies. Geriatr Gerontol Int 2020; 20: 1085–1090.. [ABSTRACT FROM AUTHOR]

Aim: This study evaluated the effects of a new form of mobilization care called life‐behavior‐promotion care by comparing its effectiveness with that of conventional mobilization care, which promotes only walking. Methods: This was a quasi‐experimental study that non‐randomly allocated post‐gastrointestinal surgery patients from a surgical ward into two groups: conventional care and life‐behavior‐promotion care. The participants received their respective care from ward nurses for the first 3 postoperative days and were asked to wear a pedometer and answer a self‐administered questionnaire concerning these first 3 days. In addition, time to recover gastrointestinal function, time to completion of oxygen administration, and the number of days to achieve discharge criteria were collected from medical records. Results: Overall, 23 participants in the conventional‐care group and 19 in the life‐behavior‐promotion‐care group were analyzed. The latter group performed significantly more types of out‐of‐bed life behaviors during the 3 postoperative days. Among the questionnaire items concerning awareness of recovery, an interaction between intervention and length of postoperative days was confirmed for items reading "I was interested in surrounding events" and "I could spend a day like myself." In addition, in the life‐behavior‐promotion‐care group, time to completion of oxygen administration was significantly shorter, and it took fewer days to achieve discharge criteria. Conclusions: The results of this study suggest that life‐behavior‐promotion care may promote out‐of‐bed life behaviors during the early postoperative period, and may improve mental and physical recovery in patients who have undergone gastrointestinal surgery. Clinical Trial Registration: The study was registered in the UMIN Clinical Trials Registry (trial ID: UMIN000021883). [ABSTRACT FROM AUTHOR]

Background: Most surveillance programs for postoperative infection focus on surgical site infections (SSI). However, postoperative remote infections are of emerging clinical importance. Using data from a multicenter survey administered to patients who underwent gastrointestinal surgery, we investigated the incidence of SSI and remote infection after colorectal surgery. Methods: From September 2015 through March 2016, 1,724 patients underwent colorectal surgery in 28 affiliated centers in Japan. We retrospectively recorded patient age, sex, surgical site, surgical approach, wound classification, performance status at discharge, and postoperative infection status. Results: Postoperative infection was noted in 236 (13.7%) patients; 150 and 86 patients underwent colon and rectal surgeries, respectively (incidence of postoperative infection: 13.7% and 14.8%). The incidence of postoperative infection was significantly lower after laparoscopic surgery than after open surgery, in colon and rectal surgery (p < 0.001). Among patients with postoperative infections, 211 (89.4%) had a single infection and 25 (10.6%) had multiple infections. Among patients with a single postoperative infection, SSI and remote infection occurred in 143 (60.6%) and 68 (28.8%) patients, respectively. The most common multiple postoperative infections were "incisional and organ/space SSIs" and "organ/space SSI and bacteremia of unknown origin" (n = 3 each). Conclusions: This study revealed the prevalence distributions for postoperative SSI and remote infections. Because of the substantial effect of remote infections on patient quality of life and the associated social burden, prospective periodic surveillance for SSI and remote infection is necessary for careful evaluation and prevention. [ABSTRACT FROM AUTHOR]

Purposes: To evaluate the reliability of data collected from the gastroenterological section of the National Clinical Database of Japan (NCD), which began registrations in 2011 with ten surgical subspecialty societies.Methods: During 2014 and 2015, 1,136,700 cases involving 115 procedures at 4374 hospitals were registered in the gastroenterological surgery section of the NCD. After a test audit using the 2014 data, 17 hospitals were selected for the first audit and data verification for 2015. The data accuracy of patient demographics, surgical outcomes, and processes was assessed using 45 items from the cases registered, in comparison with the medical records.Results: In the first audit of the 2015 data, case registration accuracy verification involved 338 patients (99.4% of the extracted cases). The data accuracy with the maximum postoperative variables was > 95%. Accuracy of the mortality and status 30 days after the surgery was high (> 99%) with a sensitivity of 1.00 and a specificity of 1.00. Among the six complications studied, the recorded cases had high specificity but lower sensitivity (0.70-0.89).Conclusions: We verified the data from the gastroenterological section of the NCD and found high accuracy of data entry. [ABSTRACT FROM AUTHOR]

This Editorial refers to the article by H. Inoue, p 563‐579 of the issue DEN 30:5. [ABSTRACT FROM AUTHOR]

The National Clinical Database (NCD) of Japan was established in April, 2010 with ten surgical subspecialty societies on the platform of the Japan Surgical Society. Registrations began in 2011 and over 4,000,000 cases from more than 4100 facilities were registered over a 3-year period. The gastroenterological section of the NCD collaborates with the American College of Surgeons' National Surgical Quality Improvement Program, which shares a similar goal of developing a standardized surgical database for surgical quality improvement, with similar variables for risk adjustment. Risk models of mortality for eight procedures; namely, esophagectomy, partial/total gastrectomy, right hemicolectomy, low anterior resection, hepatectomy, pancreaticoduodenectomy, and surgery for acute diffuse peritonitis, have been established, and feedback reports to participants will be implemented. The outcome measures of this study were 30-day mortality and operative mortality. In this review, we examine the eight risk models, compare the procedural outcomes, outline the feedback reporting, and discuss the future evolution of the NCD. [ABSTRACT FROM AUTHOR]

What is known and objective Endoscopic submucosal dissection of early colorectal neoplasms (ESD-ECN) is known to be an operation with risk of contamination, possibly requiring pre-operative antimicrobial prophylaxis for the prevention of post-operative infection. However, an evaluation of the need for pre-operative antimicrobial prophylaxis for ESD-ECN has yet to be reported. The objective of this study was to determine whether pre-operative antimicrobial prophylaxis is associated with a reduced incidence of post-operative infection following ESD-ECN. Methods The present retrospective case-controlled study utilized a database built from the medical records of 14 university hospitals throughout Japan. Patients who were admitted and discharged from the hospital from April 2012 to October 2013 and who had undergone ESD-ECN were included in the study. Patients who had been undergone any other operation during their course of hospitalization, and patients who were prescribed antimicrobial agents for reasons other than post-operative infection or for prophylaxis were excluded. Characteristics of the study population, pre-operative antimicrobial prophylaxis and antimicrobial therapy for post-operative infection were investigated. In addition, we compared the characteristics of patients with post-operative infection (PI) and those with no post-operative infection (NPI). Univariate analyses were used to estimate the odds ratios (OR) and 95% confidence intervals (95% CI). Results and discussion We obtained the records of 522 patients who had undergone ESD-ECN from the database. After application of exclusion criteria, 421 patients were enrolled. The post-operative infection rate was 1·2%. Peritonitis was found most to be the most common post-operative infection (44%). Pre-operative antimicrobial prophylaxis was used for 314 patients (75%), with a median duration of 3·0 (range 1-11) days. Cefotiam was most frequently prescribed for pre-operative antimicrobial prophylaxis (56%). Antimicrobial therapies were started 1-10 days after ESD-ECN for a duration of 1-14 days. Pre-operative antimicrobial prophylaxis was not associated with post-operative infection rate, with an OR (95% CI) of 0·73 (0·08-6·61). However, digestive tract perforation was shown to be associated with post-operative infection and had an OR (95% CI) of 17·1 (1·66-176·45). What is new and conclusion Post-operative infection is an exceedingly rare event following ESD-ECN. Pre-operative antimicrobial prophylaxis had no significant effect on post-operative infection following ESD-ECN and thus may be unnecessary. Instead, prevention of digestive tract perforation may be more critical for the decrease in post-operative infections. [ABSTRACT FROM AUTHOR]

Background Recent studies in the USA have shown a lower postoperative mortality rate in mildly obese patients, described as the 'obesity paradox'. The results from the relatively obese population in Western countries may not be generalizable to Asian countries, prompting the present study to investigate the relationship between body mass index ( BMI) and outcomes after gastrointestinal surgery. Methods Patients who underwent gastrectomy or colorectal resection for stage I- III cancer between July and December 2010 were identified from a nationwide inpatient database in Japan. Multivariable logistic regression models for in-hospital mortality and postoperative complications, and a linear regression model for total costs were established, with adjustment for age, sex, co-morbidities, cancer stage and BMI. Restricted cubic spline functions were used to consider potential non-linear associations between BMI and the outcomes. Results Among 30 765 eligible patients, associations between BMI and the outcomes were U-shaped, with the lowest mortality, morbidity and total costs in patients with a BMI of around 23·0 kg/m2. A BMI of 18·5 kg/m2 was associated with significantly greater mortality (odds ratio ( OR) 2·04, 95 per cent confidence interval 1·64 to 2·55), postoperative complications ( OR 1·10, 1·03 to 1·18) and total costs (difference €1389, 1139 to 1640) compared with a BMI of 23·0 kg/m2. Patients with a BMI exceeding 30·0 kg/m2 had significantly higher rates of postoperative complications and total costs than those with a BMI of 23·0 kg/m2, but no significant association was evident between a BMI of more than 23·0 kg/m2 and in-hospital death. Conclusion Unlike previous studies in the USA, in the present national Japanese cohort of patients undergoing surgery for gastrointestinal cancer, those who were either underweight or overweight had more postoperative complications and greater perioperative costs than those of normal weight. [ABSTRACT FROM AUTHOR]

Background: Endoscopic submucosal dissection (ESD) enables en bloc resection of early gastrointestinal neoplasms; however, most ESD articles report small series, with short-term outcomes performed by multiple operators on single organ. We assessed short- and long-term treatment outcomes following ESD for early neoplasms throughout the gastrointestinal tract. Methods: We performed a longitudinal cohort study in single tertiary care referral center. A total of 1,635 early gastrointestinal neoplasms (stomach 1,136; esophagus 138; colorectum 361) were treated by ESD by single operator. Outcomes were complication rates, en bloc R0 resection rates, and long-term overall and disease-specific survival rates at 3 and 5 years for both guideline and expanded criteria for ESD. Results: En bloc R0 resection rates were: stomach: 97.1 %; esophagus: 95.7 %; colorectum: 98.3 %. Postoperative bleeding and perforation rates respectively were: stomach: 3.6 and 1.8 %; esophagus: 0 and 0 %; colorectum: 1.7 and 1.9 %. Intra criteria resection rates were: stomach: 84.9 %; esophagus: 81.2 %; colorectum: 88.6 %. Three-year survival rates for lesions meeting Japanese ESD guideline/expanded criteria were for all organ-combined: 93.4/92.7 %. Five-year rates were: stomach: 88.1/84.6 %; esophagus: 81.6/57.3 %; colorectum: 94.3/100 %. Median follow-up period was 53.4 (range, 0.07-98.6) months. Follow-up rate was 94 % (1,020/1,085). There was no recurrence or disease-related death. Conclusions: In this large series by single operator, ESD was associated with high curative resection rates and low complication rates across the gastrointestinal tract. Disease-specific and overall long-term prognosis for patients with lesions within intra criteria after curative resection appeared to be excellent. [ABSTRACT FROM AUTHOR]

Abstract: Objective: We investigated an adequate vitamin C dose during peripheral parenteral nutrition therapy in patients after gastrointestinal surgery by measuring blood concentrations and urine excretions of vitamin C. We also sought to identify the effects of vitamin C on the oxidative status. Methods: In a randomized trial, 2 d after undergoing gastrointestinal surgery, 16 patients started to receive a 5-d continuous intravenous infusion of vitamin C, either 100 or 500 mg/d. Blood concentrations of vitamin C and inflammatory and immunologic parameters were measured preoperatively, the day after surgery, and 3 and 5 d after starting administration of vitamin C (day 3 and day 5). Also, excretions of vitamin C and oxidative stress markers in 24-h, cumulative urine samples, collected and stored under light protection at 0°C, were measured on day 3 and day 5. Results: Mean blood vitamin C concentration decreased markedly after surgery. The concentration returned to normal on day 3 and on day 5 in the 500-mg group and only on day 5 in the 100-mg group. Concentrations differed significantly between the groups on day 3 and on day 5 (P < 0.001 for both days). Urinary vitamin C excretion was above normal on both days in the 500-mg group, but it never reached normal in the 100-mg group (P < 0.001 for both days). Urinary excretion of 8-isoprostane, a marker of oxidative stress, was significantly lower in the 500-mg than in the 100-mg group on day 3 (P = 0.002). Conclusion: Vitamin C dose of 500 mg/d, not 100 mg/d, is adequate for patients undergoing gastrointestinal surgery and receiving peripheral parenteral nutrition therapy. Vitamin C may decrease postsurgical oxidative stress. [Copyright &y& Elsevier]

Background: Anastomotic leak (AL) is a dangerous postoperative complication in gastrointestinal surgery. The present study focuses on whether our prediction scoring system, 'Estimation of Physiologic Ability and Surgical Stress' (E-PASS), could predict occurrence of AL and its prognosis in various kinds of gastrointestinal surgical procedures. Methods: We prospectively investigated parameters of E-PASS, absence or presence of AL, and in-hospital mortality in 6,005 patients who underwent elective digestive surgery with alimentary tract reconstruction in 45 acute care hospitals in Japan between 1 April 2002 and 31 March 2007. Results: Incidences of AL were 19.6% for esophagectomy via right thoracotomy and laparotomy, 11.7% for pancreaticoduodenectomy, 7.4% for low anterior resection, 4.0% for total gastrectomy, 1.8% for open distal gastrectomy, 1.3% for open colectomy, for an overall incidence of 4.1%. The incidence in each procedure significantly correlated with median value of surgical stress score of the E-PASS ( R = 0.78, n = 11, p = 0.0048). The incidences of AL increased when Total Risk Points (TRP) of the E-PASS increased; 1.1% at the TRP range of <500, 2.8% at 500 to <1,000, 4.8% at 1,000 to <1,500, and 13.6% at ≥1,500 ( p < 0.0001). In patients who suffered from AL, an in-hospital mortality rate at TRP < 1,000 was significantly lower than that at TRP of ≥1,000 (1.1 vs. 15.9%; p = 0.00019). Conclusions: The E-PASS, requiring only nine variables, may be useful in predicting AL and its prognosis. [ABSTRACT FROM AUTHOR]

Background: The risk of patient-to-patient transmission of hepatitis C virus (HCV) during endoscopy remains controversial. Using molecular approaches, we examined the possibility of patient-to-patient transmission of HCV in three patients who developed acute hepatitis C 1–6 months after examination by upper gastrointestinal endoscopy (UGIE) in a hospital endoscopy unit in Japan. Methods: For the source of HCV infection, we used frozen sera obtained from potential candidates who underwent UGIE earlier than three index patients on the same days in the same unit. HCV genotype was determined by multiplex polymerase chain reaction (PCR) with genotype-specific primers. The 1087-nucleotide (nt) sequence of the NS5B region of the HCV genome was compared between index patients and their HCV-viremic candidates. Results: The three index patients were exclusively infected with HCV of genotype 1b. Among a total of 60 candidate patients who underwent UGIE earlier than the index patients, 14 were positive for anti-HCV, of whom 12 had detectable HCV-RNA (1b, n = 9; 2a, n = 1; 2b, n = 2) on sera collected during each UGIE. Shared identity within the 1087-nt NS5B sequence was less than 95.0% between index patients and HCV/1b-infected candidates ( n = 3, 1 and 5, respectively). None of the remaining 46 candidates who were negative for anti-HCV at UGIE examination tested positive for HCV-RNA, nor seroconverted to anti-HCV on their sera, which most likely excludes the possibility of HCV viremia despite the anti-HCV-negative serology at UGIE examination. Conclusion: The present study suggests that patient-to-patient transmission of HCV during UGIE is infrequent. [ABSTRACT FROM AUTHOR]

Background: The use of a transnasal fine gastrointestinal fiberscope (TNF-GIF) has been rapidly disseminating in Japan. However, there has been no trial of long tube insertion (LTI) using the TNF-GIF for patients with small bowel obstruction (SBO).Purpose: To examine whether TNF-GIF-guided LTI is superior to conventional LTI for patients with clinically diagnosed SBO.Methods: The time required for LTI was determined prospectively in each group of patients who underwent the conventional method (group 1, n = 10) and the TNF-GIF-guided method (group 2, n = 10) between March 2007 and November 2007. Insertion time was compared between groups 1 and 2.Results: Insertion time in group 2 was significantly shorter than that in group 1 (group 1, 22 +/- 16 min versus group 2, 9.2 +/- 5.4 min; P = 0.03).Conclusions: Novel TNF-GIF-guided LTI is useful and superior to the conventional method. [ABSTRACT FROM AUTHOR]

This retrospective cohort study aimed to determine the incidence rates of and risk factors for recurrent Clostridioides difficile infection (rCDI) in Japan using a claims database. Inpatients of any age with ≥1 record of C. difficile infection (CDI) during the study period (January 2012–September 2016) were analyzed. We estimated the incidence rate of health care onset, health care facility associated (HO-HCFA) primary CDI and HO-HCFA rCDI for each of the first to fifth recurrences. Risk factors for the first recurrence were investigated using a univariate, and subsequently, a multivariable Cox regression model. The incidence rates (95% confidence interval [CI]) of CDI and HO-HCFA CDI were 2.43 (2.40–2.46) and 1.26 (1.24–1.28) cases per 10,000 inpatient-days, respectively. Among the 11,287 inpatients with ≥1 HO-HCFA CDI, 1424 patients had ≥1 recurrent episode (12.6% [95% CI 12.0–13.2]). The rCDI incidence rates consistently increased, with the number of recurrences ranging from 29.2 to 181.8 cases per 10,000 inpatient-days. The multivariable analysis revealed five risk factors (hazard ratio [95% CI]): age ≥65 years (vs. <65 years; 65–74 years, 1.275 [1.048–1.551]; 75–79 years, 1.612 [1.315–1.975]; ≥80 years, 2.110 [1.776–2.507]); cephalosporin use both before (vs. without cephalosporin; 1.241 [1.098–1.402]) and during the primary CDI (vs. without cephalosporin; 1.137 [1.011–1.279]); higher number of comorbidities (vs. ≤10 comorbidities; 11–14 comorbidities: 1.336 [1.131–1.580]; 15–20 comorbidities: 1.433 [1.219–1.685]; ≥21 comorbidities: 1.310 [1.099–1.561]); and gastrointestinal surgery (vs. without surgery; 0.823 [0.701–0.965]). In conclusion, CDI recurred in some Japanese patients, and the incidence rates increased with the number of recurrences. Special care is needed in patients aged ≥65 years, those with a higher number (>10) of comorbidities, and those who have received cephalosporin before or during the primary CDI. • This is the first study in Japan to elucidate the epidemiology of recurrent CDI. • 12.6% of hospital-onset, health care facility-associated CDI patients had one or more recurrence. • The incidence rate of recurrent CDI progressively increased with each recurrence. • The mean age of CDI patients was higher at 75.1 in Japan. • Vancomycin usage increased, while metronidazole decreased with each recurrence. [ABSTRACT FROM AUTHOR]

Background: In 2012, the Japanese Society for Surgical Metabolism and Nutrition introduced the Essential Strategy for Early Normalization after Surgery with Patient's Excellent Satisfaction (ESSENSE) program to improve the perioperative management of gastrointestinal surgery. The ESSENSE program aimed to minimize ineffective perioperative management practices, and achieve adequate analgesia to expedite the return to work and activities of daily living., Methods: After educating relevant facilities about the ESSENSE program in 2012, we conducted questionnaire-based surveys in selected institutions in 2013 and 2016., Results: ESSENSE was implemented in 65% of the specified gastrointestinal surgical procedures in 2016. Oral fluids were discontinued >10 h before anesthesia induction by 33% and 9% of respondents in 2013 and 2016, respectively, and 2 h before anesthesia induction by 23% and 38% in 2013 and 2016, respectively. Fasting was initiated >10 h before anesthesia induction by 75% and 29% of respondents in 2013 and 2016, respectively, and 6-8 h before anesthesia induction by 20% and 60% in 2013 and 2016, respectively. Oral rehydration with a carbohydrate-containing beverage was performed 2 h preoperatively by 23% and 47% of respondents in 2013 and 2016, respectively. The median postoperative periods after which water and solids intakes were resumed were significantly shorter in 2016 than in 2013 after five surgical procedures; the exceptions were esophagectomy, laparoscopic cholecystectomy, and hepatectomy., Conclusions: There was a high level of implementation of the ESSENSE program in participating institutions in 2016, suggesting that it is possible to achieve widespread implementation of a preoperative management protocol., (Copyright © 2019. Published by Elsevier Taiwan LLC.)