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Aim Clinical staging is vital for selecting appropriate candidates and designing neoadjuvant treatment strategies for advanced tumors. The aim of this review was to evaluate diagnostic abilities of clinical TNM staging for gastrointestinal, gastrointestinal cancers. Methods We conducted a systematic review of recent publications to evaluate the accuracy of diagnostic modalities on gastrointestinal cancers. A systematic literature search was performed in PubMed/MEDLINE using the keywords “TNM staging,” “T4 staging,” “distant metastases,” “esophageal cancer,” “gastric cancer,” and “colorectal cancer,” and the search terms used in Cochrane Reviews between January 2005 to July 2020. Articles focusing on preoperative diagnosis of: (a) depth of invasion; (b) lymph node metastases; and (c) distant metastases were selected. Results After a full‐text search, a final set of 55 studies (17 esophageal cancer studies, 26 gastric cancer studies, and 12 colorectal cancer studies) were used to evaluate the accuracy of clinical TNM staging. Positron emission tomography–computed tomography (PET‐CT) and/or magnetic resonance imaging (MRI) were the best modalities to assess distant metastases. Fat and fiber mode of CT may be useful for T4 staging of esophageal cancer, CT was a partially reliable modality for lymph node staging in gastric cancer, and CT combined with MRI was the most reliable modality for liver metastases from colorectal cancer. Conclusion The most reliable diagnostic modality differed among gastrointestinal cancers depending on the type of cancer. Therefore, we propose diagnostic algorithms for clinical staging for each type of cancer., We conducted a systematic review of recent publications to evaluate the accuracy of diagnostic modalities on gastrointestinal cancers. Such systematic review on all three cancer types—esophageal cancer, gastric cancer, colorectal cancer—cannot be found in recent publications on PubMed. We believe that this review may be fundamental information to design clinical studies related to neoadjuvant therapy for gastrointestinal cancers.

Aim Gastric cancer is the second leading cause of cancer death worldwide. Surgery is the mainstay treatment for gastric cancer. There are no prediction models that examine the severity of postoperative morbidity. Herein, we constructed prediction models that analyze the risk for postoperative morbidity based on severity. Methods Perioperative data were retrieved from the National Clinical Database in patients who underwent elective gastric cancer resection between 2011 and 2012 in Japan. Severity of postoperative complications was determined by Clavien‐Dindo classification. Patients were randomly divided into two groups, the development set and the validation set. Logistic regression analysis was used to build prediction models. Calibration powers of the models were assessed by a calibration plot in which linearity between the observed and predicted event rates in 10 risk bands was assessed by the Pearson R 2 statistic. Results We obtained 154 278 patients for the analysis. Prediction models were constructed for grade ≥2, grade ≥3, grade ≥4, and grade 5 in the development set (n = 77 423). Calibration plots of these models showed significant linearity in the validation set (n = 76 855): R 2 = 0.995 for grade ≥2, R 2 = 0.997 for grade ≥3, R 2 = 0.998 for grade ≥4, and R 2 = 0.997 for grade 5 (all: P

Aim The quick sequential organ failure assessment (qSOFA) score, shock index (SI), and systemic inflammatory response syndrome (SIRS) criteria are simple indicators for the mortality of patients in the emergency department (ED). These simple indicators using only vital signs might be more useful in prehospital care than in the ED due to their quick calculation. However, these indicators have not been compared in prehospital settings. The aim of the present study is to compare these indicators measured in prehospital care and verify whether the qSOFA score is useful for prehospital triage. Methods We undertook a single-site retrospective study on patients transferred by ambulance to the Kumamoto Medical Center ED (Kumamoto, Japan) between January 2015 and December 2016. We compared areas under the receiver operating characteristic (AUROC) curves of the qSOFA score, SI, and SIRS criteria measured in prehospital care. We also carried out sensitivity and specificity analyses using the Youden index. Results A total of 4,827 patients were included in the present study. The AUROC (95% confidence interval) of the qSOFA score for in-hospital mortality was 0.64 (0.61-0.67), which was significantly higher than those of the SIRS criteria (0.59 [0.56-0.62]) and SI (0.58 [0.54-0.62]). According to the optimal cut-off values (qSOFA ≥ 2) decided on as the Youden index, the sensitivity of the qSOFA score was 52.3% and its specificity was 69.9%. Conclusions The qSOFA score had the highest AUROC among three indicators. However, it might not be practical in actual prehospital triage due to its low sensitivity.

Background Benchmarking of long-term surgical outcomes has rarely been attempted. We previously devised a prediction model for assessing the outcome of late survival after surgery, termed the Estimation of Postoperative Overall Survival for Gastric Cancer (EPOS-GC). This study was undertaken to validate EPOS-GC in an external data set. Methods A retrospective cohort study was conducted in 11 cancer care hospitals in Japan, analyzing a consecutive series of patients who underwent elective gastric cancer resection between April 2007 and March 2009. EPOS-GC consists of three tumor-related variables and three physiological variables. The primary endpoint was postoperative overall survival. The observed-to-expected (O/E) ratio of 5-year survival rates was defined as a metric of quality of care. The sample size for O/E was determined as 42. Results We included 2045 patients for analysis. The median (95% confidence interval) follow-up time was 5.1 (1.2–6.8) years for censored patients. Although EPOS-GC demonstrated a good discriminative power (Harrell's C-index, 95% confidence interval: 0.80, 0.79–0.83), the calibration plot revealed that EPOS-GC underestimated 5-year survival rates in the high-risk group. Therefore, we recalibrated the model with Cox's regression analysis. The recalibrated EPOS-GC showed a good calibration, preserving the high discriminative power (C-index, 95% confidence interval: 0.80, 0.78–0.82). The O/E among hospitals according to the recalibrated EPOS-GC ranged between 0.87 and 1.27. The O/E correlated with hospital volumes (Spearman's correlation = 0.76, n = 11, p = .006). Conclusion EPOS-GC with recalibration can convey risk-adjusted quality assurance regarding late survival following gastric cancer resection.

Purpose The impact of postoperative complications on survival after radical surgery for esophageal, gastric, and colorectal cancers remains controversial. We conducted a systematic review of recent publications to examine the effect of postoperative complications on oncological outcome. Methods A literature search of PubMed/MEDLINE was performed using the keywords “esophageal cancer,” “gastric cancer,” and “colorectal cancer,” obtaining 27 reports published online up until the end of April 2016. Articles focusing on (i) postoperative morbidity and oncological outcome; and (ii) body mass index (BMI), postoperative morbidity, and oncological outcome, were selected. Univariate and multivariate analyses (Cox proportional hazards model) were performed. Results Patients with postoperative complications had significantly poorer long-term survival than those without complications. Complications were associated with impaired oncological outcomes. The hazard ratios for overall survival were 1.67 (95% confidence interval [CI], 1.31-2.12), 1.59 (95% CI, 1.13-2.24), and 1.55 (95% CI, 1.28-1.87) in esophageal, gastric, and colorectal cancers, respectively. High BMI was associated with postoperative morbidity rate but not with poor oncological outcome. Low BMI was significantly associated with inferior oncological outcome. Conclusions Complications after radical surgery for esophageal, gastric, and colorectal cancers are associated with patient prognosis. Avoiding such complications might improve the outcomes.

Aim The American Society of Anesthesiologists Physical Status (ASA-PS) classification system is used worldwide and has also been incorporated into various prediction rules. However, concerns have been raised regarding inter-rater agreement in various surgical fields. Although emergency gastrointestinal surgery is relatively common and associated with high postoperative mortality, a reliability study has not yet been undertaken in this field. The aim of the present study was to investigate the inter-rater reliability of ASA-PS for emergency gastrointestinal surgery. Methods Three sets of scenarios were generated for each ASA-PS class (2E, 3E, and 4E) in emergency gastrointestinal surgery, resulting in nine scenarios. These scenarios described the preoperative profiles of patients in one hospital. Two or three anesthesiologists from 18 other hospitals provided scores for ASA-PS for each scenario. Results Fifty anesthesiologists scored the ASA-PS class. Between 66% and 90% of these anesthesiologists assigned the same ratings as the reference ratings for the individual scenarios. Inter-rater reliability was assessed using Fleiss’ kappa (95% confidence interval) of 0.55 (0.54–0.56, P < 0.001) and an intraclass correlation coefficient (95% confidence interval) of 0.79 (0.63–0.93, P < 0.001). Conclusion The results of the present study revealed the consistency of ASA-PS ratings between anesthesiologists for emergency gastrointestinal surgery. The ASA-PS may serve as a reliable variable in the prediction rules for this field.

Endoscopic extraction is the first choice for removing esophageal foreign bodies, but dentures with complicated sharp clasps that invaginate the esophageal mucosa are difficult to remove endoscopically; surgical management is required for patients who have ingested dentures. Seven patients who underwent emergency surgery for dentures with complicated sharp clasps lodged in the cervicothoracic esophagus were enrolled. We describe the surgical management and postoperative courses of these patients. There were four male and three female patients with an average age of 78.4 years (range 71–84). All cases were difficult to diagnosis by interview because the patients had dementia or schizophrenia. Emergency surgery was performed for seven patients. A skin incision was made along the anterior border of the left sternocleidomastoid muscle. The esophageal wall was opened and the denture was extracted. The esophageal wall was repaired with interrupted sutures. A tracheostomy was constructed in three cases, and bilateral drainage was performed in two cases. However, tracheostomy and bilateral drainage were not necessary, and the subsequent four patients received only left-sided drainage tubes without tracheostomy. All seven patients progressed favorably postoperatively. No ruptured sutures or esophageal stenosis occurred. The outcomes of all seven patients who underwent surgical denture removal were satisfactory. Tracheostomy and bilateral drainage may not be essential.

It has previously been reported that a general risk model, Estimation of Physiologic Ability and Surgical Stress (E-PASS), and its modified version, mE-PASS, had a high predictive power for postoperative mortality and morbidity in a variety of gastrointestinal surgeries. This study evaluated their utilities in proximal biliary carcinoma resection.E-PASS variables were collected in patients undergoing resection of perihilar cholangiocarcinoma and gallbladder carcinoma in Japanese referral hospitals.Analysis of 125 patients with gallbladder cancer and 97 patients with perihilar cholangiocarcinoma (n = 222). Fifty-six patients (25%) underwent liver resection with either hemihepatectomy or extended hemihepatectomy. The E-PASS models showed a high discrimination power to predict in-hospital mortality; areas under the receiver operating characteristic curve (95% confidence intervals) were 0.85 (0.76-0.94) for E-PASS and 0.82 (0.73-0.91) for mE-PASS. The predicted mortality rates correlated with the severity of postoperative complications (Spearman's rank correlation coefficient: ρ = 0.51, P 0.001 for E-PASS; ρ = 0.47, P 0.001 for mE-PASS).The E-PASS models examined herein may accurately predict postoperative morbidity and mortality in proximal biliary carcinoma resection. These models will be useful for surgical decision-making, informed consent, and risk adjustments in surgical audits.

Remnant gastric cancer, most frequently defined as cancer detected in the remnant stomach after distal gastrectomy for benign disease and those cases after surgery of gastric cancer at least 5 years after the primary surgery, is often reported as a tumor with poor prognosis. The Task Force of Japanese Gastric Cancer Association for Research Promotion evaluated the clinical impact of remnant gastric cancer by systematically reviewing publications focusing on molecular carcinogenesis, lymph node status, patient survival, and surgical complications. A systematic literature search was performed using PubMed/MEDLINE with the keywords "remnant," "stomach," and "cancer," revealing 1154 relevant reports published up to the end of December 2014. The mean interval between the initial surgery and the diagnosis of remnant gastric cancer ranged from 10 to 30 years. The incidence of lymph node metastases at the splenic hilum for remnant gastric cancer is not significantly higher than that for primary proximal gastric cancer. Lymph node involvement in the jejunal mesentery is a phenomenon peculiar to remnant gastric cancer after Billroth II reconstruction. Prognosis and postoperative morbidity and mortality rates seem to be comparable to those for primary proximal gastric cancer. The crude 5-year mortality for remnant gastric cancer was 1.08 times higher than that for primary proximal gastric cancer, but this difference was not statistically significant. In conclusion, although no prospective cohort study has yet evaluated the clinical significance of remnant gastric cancer, our literature review suggests that remnant gastric cancer does not adversely affect patient prognosis and postoperative course.

Aims/Introduction Gestational diabetes mellitus (GDM) is a risk for adverse perinatal outcomes, and patients with a history of GDM have an increased risk of impaired glucose tolerance (IGT). Here, we carried out two non‐interventional and retrospective studies of GDM patients in Japan. Materials and Methods In the first study, we enrolled 529 GDM patients and assessed predictors of the need for insulin therapy. In the second study, we enrolled 185 patients from the first study, and assessed predictors of postpartum IGT. Results In the first study, gestational weeks at GDM diagnosis and history of pregnancy were significantly lower, and pregestational body mass index, family history of diabetes mellitus, 1‐ and 2‐h glucose levels in a 75‐g oral glucose tolerance test (OGTT), the number of abnormal values in a 75‐g OGTT, and glycated hemoglobin were significantly higher in participants receiving insulin therapy. In the second study, 1‐ and 2‐h glucose levels in a 75‐g OGTT, the number of abnormal values in a 75‐g OGTT, glycated hemoglobin, and ketone bodies in a urine test were significantly higher in participants with OGT. Logistic regression analysis showed that gestational weeks at GDM diagnosis, 1‐h glucose levels in a 75‐g OGTT and glycated hemoglobin were significant predictors of the need for insulin therapy, and 1‐h glucose levels in a 75‐g OGTT at diagnosis and ketone bodies in a urine test were significant predictors for postpartum IGT. Conclusions Antepartum 1‐h glucose levels in a 75‐g OGTT was a predictor of the need for insulin therapy in pregnancy and postpartum IGT.

Previous studies for surgical audit have focused on short-term outcomes, such as perioperative mortality. There has been no gold standard how to evaluate quality of care for long-term outcomes in surgical oncology. This preliminary study aims to propose a method for surgical audit targeting long-term outcome following gastrectomy for gastric cancer.We prospectively investigated a set of variables relating to physiologic conditions, tumor characteristics and operations in patients who underwent gastrectomy for gastric cancer between June 2005 and July 2008 in 18 referral hospitals in Japan. Overall survival (OS) is the endpoint. Cox hazard regression analysis was used to generate a model to predict OS. The calibration and discrimination power of the model were assessed using the Hosmer-Lemeshow (H-L) test and area under the receiver-operating characteristic curve (AUC), respectively. The ratio of observed-to-estimated 5-year OS rates (OE ratio) was defined as a measure of quality.Among 762 patients analyzed, 697 (91%) completed the 5-year follow-up. The constructed model for OS exhibited a good discrimination power (AUC, 95% confidence interval 0.89, 0.86-0.91), which was significantly better than that for the UICC stage (0.81, 0.77-0.84). This model also demonstrated a good calibration power (H-L: χ(2) = 27.2, df = 8, P = 0.77). The OE ratios among the participating hospitals revealed no significant variation between 0.74 and 1.1.The current study suggests the possibility of surgical audit for postoperative OS in gastric cancer. Further studies including high-volume centers will be necessary to validate this idea.

Background Fournier gangrene due to advanced rectal cancer is a rapidly progressive gangrene of the perineum and buttocks. Emergency surgical debridement of necrotic tissue is crucial, and secondary surgery to resect tumors is necessary for wound healing. However, pelvic exenteration damages the pelvic floor, increasing the likelihood of herniation of internal organs into the infectious wound. The management of pelvic exenteration for rectal cancer with Fournier gangrene has not yet been established. We herein describe the use of a fascia lata free flap in pelvic exenteration for rectal cancer with Fournier gangrene. Case presentation A 66-year-old male who had undergone colostomy for large bowel obstruction due to advanced rectal cancer and continued chemotherapy was referred to our hospital for Fournier gangrene resulting from chemotherapy. Emergency surgical debridement was performed, and the infectious wound around the rectal cancer was treated with intravenous antibiotic agents postoperatively. However, the tumor was exposed by the wound, and exudate persisted. Pelvic exenteration was performed due to tumor infiltration into the bladder and prostate. Tumor resection resulted in a defect in the pelvic floor. A fascia lata free flap (15 × 9 cm) obtained from the left thigh was fixed to the edge of the peritoneum and ileal conduit to close the defect in the pelvic floor and prevent small bowel herniation into the resected space. There was no intraabdominal inflammation or bowel obstruction postoperatively, and outpatient chemotherapy was continued. Conclusions Surgical repair with a fascia lata free flap to close the defect in the pelvic floor led to a good clinical outcome for pelvic exenteration in a patient with Fournier gangrene due to advanced rectal cancer.

Highlights • An omphalomesenteric duct (OMD) remnant is a rare case in an adult. • A ductal structure was found between the distal ileum and the umbilicus in this case. • Laparoscopic surgery was performed by inserting three trocars into the left side of the abdomen. • A good field of view around the umbilicus and adequate working space were provided. • Both diagnosis and treatment were accomplished with minimally invasive laparoscopic surgery., Introduction The presence of an omphalomesenteric duct (OMD) remnant is a rare condition that typically affects the pediatric population. This report describes an extremely rare case of an OMD remnant that was diagnosed and resected by laparoscopic surgery in an adult. Presentation of case A 52-year-old man underwent a medical examination at our hospital for right lower quadrant pain. Laboratory findings showed slight leukocytosis and an elevated C-reactive protein level. A luminal structure connected to the umbilicus was detected in the right pelvic wall by abdominal computed tomography, and an OMD remnant was suspected. Laparoscopic surgery was performed by inserting three trocars into the left side of the abdomen; no trocars were inserted near the umbilicus. This procedure provided both a good field of view around the umbilicus and adequate working space. We definitively diagnosed the structure as an OMD remnant and resected it with minimal invasion. The patient was discharged on postoperative day 7 without complications. Pathologic analysis found the lumen is covered by ileum-like mucosa, and a microabscess is formed in the surrounding fat tissue. Discussion OMD remnants are uncommon, and their diagnosis is difficult. Most reports advocate for prompt surgical resection in symptomatic patients. Conclusion In the present case, definitive diagnosis and treatment were accomplished with minimally invasive laparoscopic surgery.

This study was undertaken to establish a model to predict the post-operative mortality for emergency surgeries. A regression model was constructed to predict in-hospital mortality using data from a cohort of 479 cases of emergency surgery performed in a Japanese referral hospital. The discrimination power of the current model termed the Calculation of post-Operative Risk in Emergency Surgery (CORES), and Portsmouth modification of the Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (P-POSSUM) were validated using the area under the receiver operating characteristic curve (AUC) in another cohort of 494 cases in the same hospital (validation subset). We further evaluated the accuracy of the CORES in a cohort of 1,471 cases in six hospitals (multicenter subset). CORES requires only five preoperative variables, while the P-POSSUM requires 20 variables. In the validation subset, the CORES model had a similar discrimination power as the P-POSSUM for detecting in-hospital mortality (AUC, 95 % CI for CORES: 0.86, 0.80–0.93; for P-POSSUM: 0.88, 0.82–0.93). The predicted mortality rates of the CORES model significantly correlated with the severity of the post-operative complications. The subsequent multicenter study also demonstrated that the CORES model exhibited a high AUC value (0.85: 0.81–0.89) and a significant correlation with the post-operative morbidity. This model for emergency surgery, the CORES, demonstrated a similar discriminatory power to the P-POSSUM in predicting post-operative mortality. However, the CORES model has a substantial advantage over the P-POSSUM in that it utilizes far fewer variables.

Improvements in operative technique and perioperative management have resulted in increasing numbers of elderly patients undergoing gastrectomy for gastric cancer (GC). We evaluated the accuracy of Estimation of Physiologic Ability and Surgical Stress (E-PASS) and modified (m)E-PASS scores in predicting postoperative complications in elderly patients with GC. We retrospectively analyzed short-term outcomes in 413 patients who underwent gastrectomy for GC between 2005 and 2014. They were divided into two groups: Group N comprised 341 non-elderly patients

Although thymomas are the most common anterior mediastinal neoplasm, those causing cardiac tamponade are unusual. To the best of our knowledge, only 13 cases have been proven in the English literature We report thymoma in a 66-year old man that caused cardiac tamponade, for which he underwent an emergency operation. On admission, he presented in a shocked state; his echocardiography results revealed pericardial effusion. Computed tomography scan indicated a thymoma infiltrating the right lung. Initially, pericardial drainage was performed through puncture; however, cardiac tamponade recurred next day. Pericardial drainage, thymectomy, and pericardiectomy were performed, but the tumor was incompletely resected. On postoperative day 2, right upper lobectomy was attempted but discontinued because of the impossibility to manipulate the pulmonary hilum, which was suspected to have tumor infiltration. He was discharged on the 27th day after the first operation, is alive at 10 months after surgery, and is under chemotherapy.

Background and Objectives This study evaluated the ability of general surgical models to predict postoperative morbidity and mortality in liver surgery. Methods The postoperative course and mortality rates predicted by general surgical models were investigated in 960 patients who underwent hepatectomy or ablation therapy for primary or metastatic liver carcinoma. Results The area under the receiver operative characteristic curve (95% confidence intervals) for detecting postoperative liver failure was 0.89 (0.84–0.94), 0.85 (0.78–0.92), and 0.78 (0.72–0.85) for the Estimation of Physiologic Ability and Surgical Stress (E-PASS) model, the modified E-PASS (mE-PASS) model, and the Portsmouth Physiologic and Operative Severity Score for the enUmeration of Mortality and morbidity (P-POSSUM) model, respectively, and those for detecting in-hospital mortality were 0.85 (0.76–0.93), 0.85 (0.78–0.92), and 0.79 (0.71–0.87), respectively. Nevertheless, all of the models overpredicted the overall mortality rate (by 2.3-fold for E-PASS, 2.3-fold for mE-PASS, and 2.9-fold for P-POSSUM). Conclusions The general surgical risk models demonstrated high discriminatory power for predicting postoperative outcomes in liver surgery, but overpredicted the overall mortality rate by more than twofold. Therefore, these models should be refined to make them more suitable for predicting liver surgery outcomes. J. Surg. Oncol. 2012; 106:898–904. © 2012 Wiley Periodicals, Inc.

Prediction of postoperative risk in cardiac surgery is important for cardiac surgeons and anesthesiologists. We generated a prediction rule for elective digestive surgery, designated as Estimation of Physiologic Ability and Surgical Stress (E-PASS). This study was undertaken to evaluate the accuracy of E-PASS in predicting postoperative risk in cardiac surgery.We retrospectively collected data from patients who underwent elective cardiac surgery at a low-volume center (N = 291) and at a high-volume center (N = 784). Data were collected based on the variables required by E-PASS, the European system for cardiac operative risk evaluation (EuroSCORE), and the Ontario Province Risk Score (OPRS). Calibration and discrimination were assessed by the Hosmer-Lemeshow test and the area under the receiver operating characteristic curve (AUC), respectively. The ratio of observed-to-estimated in-hospital mortality rates (OE ratio) was defined as a measure of quality.In-hospital mortality rates were 7.6% at the low-volume center and 1.3% at the high-volume center, accounting for an overall mortality rate of 3.0%. AUC values to detect in-hospital mortality were 0.88 for E-PASS, 0.77 for EuroSCORE, and 0.71 for OPRS. Hosmer-Lemeshow analysis showed a good calibration in all models (P = 0.81 for E-PASS, P = 0.49 for EuroSCORE, and P = 0.94 for OPRS). OE ratios for the low-volume center were 0.83 for E-PASS, 0.70 for EuroSCORE, and 0.83 for OPRS, whereas those for the high-volume center were 0.26 for E-PASS, 0.14 for EuroSCORE, and 0.27 for OPRS.E-PASS may accurately predict postoperative risk in cardiac surgery. Because the variables are different between cardiac-specific models and E-PASS, patients' risks can be double-checked by cardiac surgeons using cardiac-specific models and by anesthesiologists using E-PASS.

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. 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. 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

われわれは，90歳以上の消化器外科緊急手術症例を対象に，外科技術評価法Portsmouth-Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity（P-POSSUM）の在院死亡予測の精度を，receiver operating characteristic曲線下面積（AUC）を用いて検討した．P-POSSUMは，患者の生理機能を表わすphysiological score（PS），手術の大きさを表わすoperative severity score（OSS）と両者から算出される予測死亡率（R）からなるが，AUCはPS：0.872，OSS：0.677，R：0.887で，PSやRの精度は高かった．なかでもPSは術前に算出可能で，麻酔管理上重要な情報となりうる．

Objective: Acute mesenteric ischemia is potentially fatal, but prognostic factors have not yet been established. This study was undertaken to elucidate them. Methods: This is a retrospective cohort study, consisting of 110 patients who had been treated in the past 5 years, from 26 national hospitals in Japan. Results: The overall in-hospital mortality rate was 51%. Logistic regression analysis demonstrated two independent prognostic factors, electrocardiogram scale with an odds ratio of 1.7 (95% CI 1.2–2.4) and shock index of 11 (95% CI 1.5–80). A stepwise analysis gave a prediction equation for in-hospital mortality (R) using these variables and age score. We further modified this equation to a simpler scoring system (S) using the same variables. Both R and S showed a good discriminatory ability as determined by areas under the receiver-operating characteristic curve (0.83, 95% CI: 0.74–0.91 for R; 0.82, 95% CI 0.74–0.91 for S). The observed mortality rates increased as the R or S increased (19% at R Conclusion: The new prediction rules can be used at any hospital and may be promising tools for medical decision-making, informed consent and reviewing quality of care.

The Estimation of Physiologic Ability and Surgical Stress (E-PASS) scoring system was designed on the hypothesis that the balance between the patient’s physiological reverse capacity and the surgical stress of operation was important in the development of postoperative complications. The aim of this study was to evaluate whether the E-PASS scoring system could predict the occurrence of complications after elective esophagectomy for esophageal cancer, including salvage esophagectomy. E-PASS predictor equations were applied retrospectively to 142 patients who had undergone esophagectomy for esophageal squamous cell carcinoma [110 patients without preoperative chemoradiotherapy (CRT), 15 patients with neoadjuvant CRT followed by planned esophagectomy, and 17 patients with definitive CRT followed by salvage esophagectomy]. The incidence rates of postoperative complications were compared with the preoperative risk score (PRS), surgical stress score (SSS), and comprehensive risk score (CRS) of the E-PASS scoring system. Of the 142 patients, 43 (30%) had postoperative complications. The incidence of postoperative complications increased as the CRS score increased. Patients with a CRS > 1.0 were at a particularly high risk of postoperative complications. Definitive CRT increased the incidence of postoperative complications, and the SSS and CRS of patients with definitive CRT were significantly higher than those of patients without preoperative CRT or with neoadjuvant CRT. The E-PASS scoring system was useful in predicting complications after elective esophagectomy for esophageal cancer. The SSS of the E-PASS scoring system could also reflect the maximum invasiveness of salvage esophagectomy.

Misplacement of nasogastric feeding tubes into the respiratory tract often results in tremendous complications such as pneumonia, empyema and pleural effusion. The National Health Service issued advice to prevent these errors in 2005, describing that verification of pH 5.5 or lower of the aspirate fluid or X-ray confirmation is a prerequisite condition for feeding. However, the usefulness and feasibility of this advice has not been well evaluated. Our experience to implement this advice revealed the problem that in about 30% of the instances before feeding, such verification is infeasible. Therefore, we suggest the following recommendations by reviewing the literature and caregivers' opinions. 1. Placement of newly inserted tubes should always be confirmed by X-ray before use for feeding or medication. 2. At re-insertion of the tube, verification of pH 5.5 or lower of the aspirate fluid or X-ray confirmation should essentially be performed before medication or feeding. 3. Before every feeding, checking the external length of the tube from the nostril and observing the inside of the mouth should be done to determine if the tube is partially removed or not. If there is no suspicion of tube removal, feeding can be started.

症例は86歳の男性で, 下血を主訴に精査を行い, 直腸内腔全体を占める全周性のRb直腸癌と診断された. 手術前の検討では肛門機能温存が不可能な低位直腸癌と診断され, 腹会陰式直腸切断術が予定されたが, 手術中に直腸癌による腸重積が判明し, これを解除することにより超低位前方切除術を行うことができた. 下部直腸癌で内腔全体を占める腫瘍の場合, 直腸癌による腸重積を考慮に入れ, 慎重な術式の選択をする必要があることが示唆された. 直腸癌による腸重積は極めてまれであり, 若干の文献的考察を加え報告する.

はじめに: イギリスで開発された外科技術評価法であるPhysiological and Operative Severity Score for the enUmeration of Mortality and morbidity(以下, POSSUM)およびP-POSSUMの精度を, 消化器外科緊急手術で検討する. 方法: 当科で行った消化器外科緊急手術症例295例を対象に, POSSUMおよびP-POSSUMの予測死亡率を算出した. Endpointは原論文に従い, POSSUMでは30日死亡, P-POSSUMでは在院死亡とした. 実際の死亡率と予測死亡率の比(OE ratio)を各モデルの精度の指標とした. 結果: 全対象症例の術後合併症発生率は20.7%, 30日死亡率は6.5%, 在院死亡率7.1%であった. POSSUMは予測死亡率が0-49%の低リスク群で実死亡率が0.80%(2/249)であったにもかかわらず, 予測死亡率は13.3%(33/249)となり, 過大に死亡率を予測した (OE ratio 0.061, 95%信頼区間0.015-0.25). しかし, 予測死亡率が50-100%の高リスク患者では, 実死亡率37.7%(17/45), 予測死亡率51.1%(23/45)と比較的正確に死亡率を予測した(OE ratio 0.74, 95%信頼区間0.46-1.12). P-POSSUMでは, 予測死亡率が0-59%の低リスク群では実死亡率が2.2%(6/267) であるにもかかわらず, 予測死亡率は9.0%(24/267) であった (OE ratio 0.23, 95%信頼区間0.094-0.58).予測死亡率が60-100%の高リスク群では, 実死亡率55.6%(15/27), 予測死亡率81.5%(22/27) であった (OE ratio 0.68, 95%信頼区間0.47-1.00). 考察: POSSUMおよびP-POSSUMでは, 低リスク患者の死亡率を過大に予測する傾向があり, 我が国で使用する場合には注意を要する.

Surgical audit is an essential task for the estimation of postoperative outcome and comparison of quality of care. Previous studies on surgical audits focused on short-term outcomes, such as postoperative mortality. We propose a surgical audit evaluating long-term outcome following colorectal cancer surgery. The predictive model for this audit is designated as ‘Estimation of Postoperative Overall Survival for Colorectal Cancer (EPOS-CC)’. Thirty-one tumor-related and physiological variables were prospectively collected in 889 patients undergoing elective resection for colorectal cancer between April 2005 and April 2007 in 16 Japanese hospitals. Postoperative overall survival was assessed over a 5-years period. The EPOS-CC score was established by selecting significant variables in a uni- and multivariate analysis and allocating a risk-adjusted multiplication factor to each variable using Cox regression analysis. For validation, the EPOS-CC score was compared to the predictive power of UICC stage. Inter-hospital variability of the observed-to-estimated 5-years survival was assessed to estimate quality of care. Among the 889 patients, 804 (90 %) completed the 5-years follow-up. Univariate analysis displayed a significant correlation with 5-years survival for 14 physiological and nine tumor-related variables (p

The purpose of this study was to determine if our predictive scoring system, E-PASS, can estimate the surgical outcome.We conducted a multicenter cohort study for 3 years in four national hospitals. A consecutive series of 731 patients who underwent elective thoracic operations were analyzed. The preoperative risk score (PRS) and the comprehensive risk score (CRS) of the E-PASS were determined preoperatively and immediately after the operation, respectively. The cost of the surgical admission and the severity of the postoperative complications were recorded at the time of discharge.The CRS significantly correlated with the severity of the postoperative complications (rs = 0.728, P0.0001) and the charge (rs = 0.530, P0.0001). When the estimated/real morbidity ratio (MR) among the hospitals was compared, it varied from 0.16 to 0.59. A significant increase in the cost was observed according to the CRS.The E-PASS scoring system may be useful for standardizing the patient population and surgical severity to compare the surgical outcome.

症例は41歳の女性で, 平成15年7月中旬, 右下腹部痛にて来院し, 急性虫垂炎の疑いで当院内科へ入院した. 入院時, 右下腹部に腫瘤を触知し, 同部位に圧痛を認めたが, 筋性防御, 反跳痛は認めなかった. WBC 5,500/mm3, CRP 0.05mg/dl と炎症所見を認めず, 腹部CT, 超音波検査では, 長径が約10cmに腫大した虫垂を認めた. 抗生剤を投与したが, 腹痛は消失せず, 入院後4日目に, 手術目的にて外科転科となった. 虫垂. 腫と診断し, 同日, 腹腔鏡下虫垂切除術を施行した. 虫垂は12cmに腫大していた. 病理組織検査にてsignet-ring cell carcinoma, 切除断端陽性と診断され, 第17病日, 右半結腸切除術 (D2郭清) を施行した. 今回の症例は, 初回手術において虫垂切除断端陽性であったことにより, 播種性転移を来したと思われた. 虫垂. 腫が疑われる症例に対しては, 鏡視下虫垂切除術の適応とするか否かはより慎重に判断すべきであると思われた.

症例は57歳,女性.平成13年11月頃より,心窩部痛を自覚していた.近医を受診したところ,腹部超音波検査にて,膵頭部腫瘍を指摘された.平成13年12月,精査加療目的で当科受診となった.腹部造影CTでは,膵頭部に径4cmの境界明瞭,辺縁整の嚢胞性病変を認め,一部乳頭状にenhanceされる壁在結節様の所見を認めた. MRIでは,腫瘤内部はT2WIでほぼ均一な高信号であり, CTと同様,一部乳頭状にenhanceされる壁在結節様の所見を認めたが,隔壁は明らかではなかった. ERPでは,主膵管の拡張はなく膵管分枝の腫瘤による圧排像を認め,嚢胞との交通は認めなかった.画像上,膵粘液性嚢胞腺癌が疑れ,平成14年1月,幽門輪温存膵頭十二指腸切除を施行した.病理組織検査は,膵神経鞘腫の診断であった.膵神経鞘腫は稀な疾患であり,若干の文献的考察を加えて報告する.

Objective: When a new scoring system, ‘E-PASS’, standing for the Estimation of Physiologic Ability and Surgical Stress that predicts the postoperative surgical risk by quantification of the patient’s reserve and surgical stress applied to a population of general thoracic surgery patients, it should be investigated if this system could help us or not. Methods: The comprehensive risk score (CRS) of the E-PASS and the clinical course were evaluated retrospectively in 282 consecutive patients with primary lung cancer (group A), and in 458 patients who underwent elective thoracic operations (group B). Results: The morbidity and mortality rates in both group A and group B increased as the CRS increased. The CRS correlated significantly with the morbidity score, length of stay and cost of hospitalization. Conclusions: E-PASS scoring system may be useful in surgical decision-making and evaluating quality of care in patients who are tolerable for lung resection.

Objectives : We clarified a distinctive feature of response to surgical stress in elderly patients compared to nonelderly patients. Subjects : Two hundred and ninety-two consecutive patients received elective gastrointestinal surgery. Patients were analyzed for physiological status, cytokine levels, surgical stress parameters and postoperative status of SIRS and complications. Cytokine responses according to patient's age : Plasma levels of interleukin 6 (IL-6) fluctuated in higher concentrations in elderly patients. Peak plasma levels of IL-6 were significantly high in patients aged over 75 years in total gastrectomy, over 65 years in pancreaticoduodenectomy and over 60 years in major hepatectomy. Mechanisms of hypercytokinemia in elderly patients : Renal dysfunction caused hypercytokinemia in elderly patients. Hypercytokinemia and SIRS : SIRS was more frequently encountered and continued for a long time in elderly patients, giving us an early sign of postoperative complications. Conclusions : In order to prevent postoperative complications in elderly patients, we must shorten status of SIRS due to excessive hypercytokinemia.

Background The present study evaluated the utility of general surgical risk models to predict postoperative morbidity and mortality in the specialty field of pancreatic resections for pancreatobiliary carcinomas. Methods We investigated Estimation of Physiologic Ability and Surgical Stress (E-PASS), its modified version (mE-PASS), and Portsmouth Physiologic and Operative Severity Score for the enUmeration of Mortality and morbidity (P-POSSUM) in 231 patients undergoing pancreatoduodenectomy or distal pancreatectomy (Group A). We also analyzed E-PASS and mE-PASS in another cohort of the same procedures (Group B, n = 313). Results Areas under the receiver operating characteristic curve (AUC) for detecting in-hospital mortality in Group A were moderate at 0.75 for E-PASS, 0.69 for mE-PASS, and 0.69 for P-POSSUM. The predicted mortality rates of the models significantly correlated with severity of postoperative complications (ρ = 0.17, P = 0.011 for E-PASS; ρ = 0.15, and P = 0.027 for P-POSSUM). The AUCs were also moderate in Group B at 0.68 for E-PASS and 0.69 for mE-PASS. The predicted mortality rates significantly correlated with severity of postoperative complications (ρ = 0.18, P = 0.0018 for E-PASS; ρ = 0.17, and P = 0.0022 for mE-PASS). Conclusions The present study suggests that the predictive powers of general risk models may be moderate in pancreatic resections. A novel model would be desirable for these procedures.

Adult T-cell leukemia/lymphoma (ATLL) is an incurable neoplasm of mature T-cells with a median survival time of approximately one year. The aim of this study was to compare the clinical value of soluble CD30 (sCD30) levels with soluble IL-2 receptor α chain (sIL-2R) levels in two different clinical settings of ATLL patients; before an initial therapy of chemotherapy or gastric resection (n=32), and before allogeneic hematopoietic stem cell transplantation (HSCT; n=24). All patients completed the 2-year follow-up. Both sIL-2R (p=0.016) and sCD30 (p=0.030) levels were significant predictors of overall survival before the initial therapy. The number of ATLL cells in peripheral blood (PB) was correlated with sCD30 levels (Spearman’s correlation coefficient, ρ=0.46; p=0.009) but not with sIL-2R levels (ρ=0.16; P=0.38). Patients who survived for longer than two years, and for whom the percentage of ATLL cells in PB were

【目的】手術リスク評価法E-PASSを用いて, 腹腔鏡下手術 (LS) の侵襲度を術後合併症発生の観点から評価した.【方法】予定LS症例1,754例で, 術後合併症発生率, 在院死亡率, 術後在院日数, 入院治療費, E-PASSの手術侵襲スコア (SSS), 総合リスクスコア (CRS) を開腹手術 (OS) と比較検討した.【成績】術式別にSSSを検討すると, 全般的にLSはOSより著明に低値を示した. LS全体の術後合併症発生率は3.0%, 在院死亡率は0%であったが, これはCRSから予測される術後合併症発生率および死亡率にほぼ一致した. LSおよびOSを含めた症例で, CRSは術後合併症の重症度や入院治療費と有意な正の相関を示した. LSはOSと比べ, CRSが小さく, 入院治療費も低く, 術後合併症があった場合でも軽症のものが多かった. 急性胆嚢炎の胆摘症例で, LSの術後在院日数はOSより有意に短く, 術後合併症の発生率も低かった. Stage Ia胃癌の幽門側胃切除症例でLSとOSを比較すると, 同様の結果が得られた.【結論】LSは低侵襲であり, high risk患者にも積極的に適用すべきである.

We studied the effect of tumor necrosis factor alpha (TNFalpha), one of the major inflammatory cytokines, on the adhesive reaction of pancreatic cancer cells to human umbilical vein endothelial cells (HUVECs) and on the hepatic metastasis of cancer cells in vivo. After TNFalpha stimulation, the expression of E-selectin, an adhesion molecule to neutrophils on HUVECs, increased. In addition, the adhesion of pancreatic cancer cells to HUVECs increased after TNFalpha stimulation, as was observed with neutrophils. The TNFalpha-induced adhesive response depended on the extent of sialyl Lewis(a) expression on cancer cells. The hepatic metastasis in vivo was often observed when cancer cells expressing a high amount of sialyl Lewis(a) were inoculated intrasplenically after increase in plasma TNFalpha concentration by lipopolysaccharide administration. Because sialyl Lewis(a) on cancer cells is a ligand for E-selectin on HUVECs, as sialyl Lewis(x) on neutrophils, TNFalpha upregulated the adhesive interaction between sialyl Lewis(a) on cancer cells and E-selectin on HUVECs. These results suggest that production of TNFalpha after surgical trauma may stimulate the hematogenic metastasis of cancer cells with a high sialyl Lewis(a) expression.

Human gastric carcinoid tumors had been reported to comprise less than 1% of all stomach tumors and about 3% of all carcinoids (1) . However, recent widespread use of uppe r gastrointestinal endoscopy has revealed that gastric carcinoids are much more commonÐ up to 41% of all gut carcinoids. Most human gastric carcinoids originate from ente rochromaf® n-like (ECL) ce lls exclusive ly locate d in the corpus± fundus region. ECL cells physiolog ically play a crucial role in acid secretion of parie tal cells by rele asing regulating histamine . Gastrin has stimulatory e ffects on histamine re lease and proliferation of ECL cells. Chronic hype rgastrinemia re sults in a varie ty of hype rplasias , from dysplasia to neoplasia of ECL cells in rodents. The subSaharan rodent Mastomys exhibits a genetic propensity for the deve lopment of gastric carcinoids and 30 ± 40% of such animals will spontaneously deve lop gastric carcinoids within two years (2) . In the Mastomys, hype rgastrinemia induced by the administrat ion of H2-receptor antagonists or proton pump inhibito rs re sults in deve lopment of gastric carcinoids within four months. It is reported that this effe ct does not re sult from the action of the drugs, but from secondary hype rgastrinemia due to the comple te inhibition of acid secre tion. Rats require longe r-te rm administration (two years or more) of these acid-inhibitory drugs before they deve lop gastric carcinoids (3). Based on the se expe rimental ® ndings, an achlorhydria± carcinoid sequence has been advocate d. Howeve r, epidemiologic data sugge st that such adve rse effe cts of the acid-inhibitory drugs have be en unlike ly to occur in humans with ordinary treatment (4) . Human gastric carcinoids in association with chronic hype rgastrinemia have been re stricted to patie nts with chronic atrophic gastrit is type A (A-CAG) and Zollinge r-Ellison syndrome (ZES) with multiple endocrine neoplasia type 1 (MEN 1) (1, 5± 8) . A genetic background or chronic in ammation may be necessary for the deve lopment of human gastrindependent carcinoids of the stomach. In this report, we pre sent an extremely rare case of gastric carcinoid detected and grown during the long-te rm administrat ion of a proton pump inhibito r and H2 blocke r in a patient with recurrent peptic ulce rs without signi® cant past or family historie s. To our knowledge , no case of gastric carcinoid has be en reporte d in the lite rature in association with acidinhibito ry drugs for ordinary peptic ulce rs. The ensuing discussion will focus on the possible association of acid-inhibitory drugs and deve lopment of gastric carcinoids. Manuscript rece ived Novembe r 7, 1996; acce pted August 15, 1997. From the Department of Surgery, Mitsui Ohmuta Hospital, 1-1-1 Tenryoh-machi, Ohmuta-shi, Fukuoka-ken 836, Japan; Department of Pathology, St. Mary’ s Hospital, 422 Tsubukuhonmachi, Kurume -shi, Fukuoka-ken 830, Japan; and Department of Surgery II, Kumamoto Unive rsity Medical School, 1-1-1 Honjo, Kumamoto 860, Japan. Address for reprint requests: Dr. Michio Ogawa, Department of Surgery II, Kumamoto Unive rsity Medical School, 1-1-1 Honjo, Kumamoto 860, Japan. Digestive Diseases and Sciences, Vol. 43, No. 2 (February 1998), pp. 253± 257

Objectives Progression from systemic inflammatory response syndrome (SIRS) to sepsis, severe sepsis, and septic shock has been demonstrated in a variety of patients. However, the presence of SIRS alone was not helpful in predicting the development of multiple organ dysfunction syndrome (MODS) since SIRS includes many nonprogressive conditions. This study was conducted to investigate the clinical significance of SIRS in postoperative patients. Design Retrospective study. Setting The surgical department of a university hospital. Patients Two hundred ninety-two consecutive patients who received elective common gastrointestinal surgery (esophagectomy, pancreatoduodenectomy, hepatectomy, gastrectomy, colorectal resection, and laparoscopic cholecystectomy) between 1992 and 1995. Interventions Patients were analyzed for preoperative physiologic status, surgical stress parameters, and postoperative status of SIRS, complications, and end-organ dysfunction. Measurements and main results Duration of SIRS or positive criteria's number of SIRS after surgery significantly correlated with surgical stress parameters (blood loss/body weight and operation time) and peak serum C-reactive protein concentrations. SIRS that continued or reappeared after postoperative day 3 was an early sign of postoperative complications. SIRS continuing consecutively for 2 days after postoperative day 3 had a 70.6% positive predictive value and a 92.5% negative predictive value for postoperative complications. Septic complications and prolongation of SIRS were associated with MODS. Five of six patients who met the SIRS criteria for >30 days developed severe MODS, and three of them died. Conclusions SIRS is a useful criterion for the recognition of postoperative complications and end-organ dysfunctions. Early recovery from SIRS may arrest the progression of organ dysfunction.

Risk factors for catheter-related bloodstream infections (CRBSIs) may change over time with progress in infection control. This study was undertaken to explore the current risk factors for CRBSIs in hospitalized patients.Adult patients with non-tunneled central venous catheters (CVCs) in 12 Japanese referral hospitals were prospectively enrolled between December 2009 and January 2012. Patients were monitored for CRBSIs for up to 8 weeks from CVC insertion; data were collected regarding patient characteristics, the purpose of CVC insertion, insertion methods, mechanical complications during insertion, and post-insertion catheter care.A total of 892 patients were enrolled in this study. The overall incidence of CRBSIs was 0.40 infections per 1000 catheter-days. Univariate analysis using the Fisher's exact test identified one of the participating hospitals (hospital A; p0.001), internal jugular vein catheterization (IJVC) (p = 0.0013), not using maximal sterile barrier precautions (p = 0.030), and the Seldinger technique for catheter insertion (p = 0.025) as significant risk factors for CRBSI. After excluding data from hospital A, only IJVC remained a significant risk factor for CRBSI (p = 0.025). The cumulative probability of remaining without CRBSI was significantly lower in patients with IJVCs than in patients with other catheter routes (p0.001; log-rank test). Similarly, the cumulative probability of remaining without catheter removal due to a suspected infection was significantly lower in patients with IJVCs (p = 0.034; log-rank test).The current study suggests that IJVC might be a risk factor for CRBSI under current infection control conditions.

Objective To develop a set of process-of-care quality indicators (QIs) that would cover a wide range of gastric cancer care modalities and to examine the current state of the quality of care provided by designated cancer care hospitals in Japan. Design A retrospective medical record review. Settings Eighteen designated cancer care hospitals throughout Japan. Participants A total of 1685 patients diagnosed with gastric cancer in 2007. Main Outcome Measures Provision of care to eligible patients as described in the 29 QIs, which were developed using an adaptation of the RAND/UCLA (University of California, Los Angeles) appropriateness method by a panel of nationally recognized experts in Japan. Results Overall, the patients received 68.3% of the care processes recommended by the QIs. While ‘deep venous thrombosis prophylaxis before major surgery’ was performed for 99% of the cases, ‘documentation before endoscopic resection’ was completed for only 12% of the cases. The chemotherapy care was less likely to meet the QI standards (61%) than pre-therapeutic care (76%), surgical treatment (66%) and endoscopic resection (71%; overall difference: P < 0.001). A comparison based on the types of care showed that documentation and patient explanation were performed less frequently (60 and 53%, respectively) than were diagnostic and therapeutic processes as recommended in the QIs (85%; overall P < 0.001). Conclusions Although many required care processes were provided, some areas with room for improvement were revealed, especially with respect to chemotherapy, documentation and patient explanation. Continuous efforts to improve the quality and develop a system to monitor this progress would be beneficial in Japan.

Septic complications have been major problems in the management of patients with obstructive jaundice and neonatal jaundice. This study investigates effects of bilirubin on human T lymphocyte responses against allogeneic mixed lymphocyte reaction. In vitro exposure of human peripheral blood mononuclear cells (PBMNC) with unconjugated bilirubin at pathological levels (6 to 12 mg/dl) did not alter the subsets of CD3, CD4, CD8, CD14, CD19 and CD56 positive populations, or expression of costimulatory surface molecules CD2, CD3, CD4 and CD8. Further incubation of bilirubin-treated PBMNC with irradiated B lymphoid Raji cells after removal of the extracellular bilirubin resulted in a dose-dependent decrease of cytotoxic T lymphocyte (CTL) activity, DNA synthesis, and expression of Tac antigen (CD25) and transferrin receptor (CD71). However, no significant change of interleukin-2 (IL-2) production was observed after this incubation between bilirubin-treated and -untreated PBMNC. These results suggest that bilirubin inhibits the induction of CTL activity, and this defect may result from the impaired responsiveness against IL-2. These observations may help explain the increased infection observed in hyperbilirubinemic patients.

Septic complications have been major problems in the management of patients with obstructive jaundice and neonatal jaundice. This study investigates effects of unconjugated bilirubin on lymphocyte-mediated cytotoxicity against human tumor target cells. In vitro exposure of human peripheral blood lymphocytes (PBL) with bilirubin IX alpha in bovine albumin solution resulted in a dose-dependent decrease of both natural killer activity and antibody dependent cellular cytotoxicity (ADCC) activity. Inhibition of both activities correlated with the amounts of intracellular bilirubin. Expression of cell surface CD16, CD56 antigen, and IL-2 receptor beta chain was unchanged in bilirubin-treated PBL as compared to bilirubin-untreated PBL. When bilirubin-treated PBL were cultured with interleukin-2 (IL-2), a dose-dependent decrease of lymphokine-activated killing activity, ADCC activity, and DNA synthesis was observed. Expression of CD56 antigen and IL-2 receptor alpha chain was unchanged in bilirubin-treated PBL following IL-2 stimulation as compared to bilirubin free control. These results suggest that bilirubin inhibits major histocompatibility complex-unrestricted cytotoxicity in both unstimulated and IL-2 stimulated lymphocytes. These observations may help explain the increased susceptibility to infection observed in hyperbilirubinemic patients.

Background We recently modified Estimation of Physiologic Ability and Surgical Stress, our prediction scoring system. Objective This study evaluated the usefulness of our modified version for colorectal carcinoma in comparison with existing models. Design This investigation studied a multicenter cohort. Settings The study was conducted in regional referral hospitals in Japan. Patients Patients were included who underwent elective surgery for colorectal carcinoma. Main outcome measures Postoperative morbidity, mortality, and predicted mortality rates for original and modified Estimation of Physiologic Ability and Surgical Stress were investigated in 2388 patients in comparison with existing European models. Results Among the models, the modified Estimation of Physiologic Ability and Surgical Stress demonstrated the highest discriminatory power in terms of in-hospital mortality (area under receiver operating characteristic curve: 0.84 for Estimation of Physiologic Ability and Surgical Stress, 0.87 for modified Estimation of Physiologic Ability and Surgical Stress, 0.84 for Portsmouth modification of POSSUM, 0.74 for ASA status-based model), as well as 30-day mortality (area under receiver operating characteristic curve: 0.82 for Estimation of Physiologic Ability and Surgical Stress, 0.84 for modified Estimation of Physiologic Ability and Surgical Stress, 0.81 for POSSUM, 0.78 for colorectal POSSUM, 0.76 for Association of Coloproctology of Great Britain and Ireland score). British models, in general, overpredicted postoperative mortality rates by more than 10 times. Limitations The current study analyzed only the Japanese population treated in medium-volume centers. Conclusions Among the models, modified Estimation of Physiologic Ability and Surgical Stress was the most accurate in predicting postoperative mortality in colorectal carcinoma surgery. These findings should be validated in Western populations, because the Japanese population may differ from Western populations in terms of body shape or reserve capacity.

To prevent catheter-related bloodstream infections (CRBSI), the use of maximal sterile barrier precautions (MSBP) during central venous catheter insertion, using a cap, mask, sterile gown, sterile gloves, and a large sterile sheet, was recommended in the Centers for Disease Control and Prevention Guidelines. However, this recommendation is based on the evidence obtained by only one randomized controlled trial (RCT) in which the subject patients were outpatients for chemotherapy. Nevertheless, the recommendation is applied to any kind of clinical settings. Therefore, we undertook a multi-institutional RCT to evaluate the effectiveness of the MSBP in surgical patients admitted to general wards. Our study could not demonstrate better prevention of CRBSI by MSBP compared with standard sterile barrier precautions (SSBP) where only sterile gloves and a small sterile drape were used. There were 5 out of 211 cases (2.4%) of CRBSI in the MSBP group and 6 out of 213 cases (2.8%) in the SSBP group (P = 0.77). These results suggest that further RCTs should be necessary in many clinical settings to reach a conclusion on this issue. We also address other evidences regarding prevention of CRBSI in this review.