Showing papers in "Surgery Today in 2016"

Extended Clavien-Dindo classification of surgical complications: Japan Clinical Oncology Group postoperative complications criteria

Abstract: Prior to publication of the Clavien-Dindo classification in 2004, there were no grading definitions for surgical complications in either clinical practice or surgical trials. This report establishes supplementary criteria for this classification to standardize the evaluation of postoperative complications in clinical trials. The Japan Clinical Oncology Group (JCOG) commissioned a committee. Members from nine surgical study groups (gastric, esophageal, colorectal, lung, breast, gynecologic, urologic, bone and soft tissue, and brain) specified postoperative complications experienced commonly in their fields and defined more detailed grading criteria for each complication in accordance with the general grading rules of the Clavien-Dindo classification. We listed 72 surgical complications experienced commonly in surgical trials, focusing on 17 gastroenterologic complications, 13 infectious complications, six thoracic complications, and several other complications. The grading criteria were defined simply and were optimized for surgical complications. The JCOG postoperative complications criteria (JCOG PC criteria) aim to standardize the terms used to define adverse events (AEs) and provide detailed grading guidelines based on the Clavien-Dindo classification. We believe that the JCOG PC criteria will allow for more precise comparisons of the frequency of postoperative complications among trials across many different surgical fields.

National Clinical Database feedback implementation for quality improvement of cancer treatment in Japan: from good to great through transparency

Abstract: 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.

The effect of Clostridium butyricum MIYAIRI on the prevention of pouchitis and alteration of the microbiota profile in patients with ulcerative colitis.

Abstract: Ulcerative colitis (UC) is a chronic, relapsing, and refractory disorder of the intestine. Total proctocolectomy with ileal pouch anal anastomosis (IPAA) is the preferred and standard surgical procedure for patients’ refractory to medical therapy. Pouchitis is one of the most common long-term complications after IPAA. In the present study, the safety and efficacy of Clostridium butyricum MIYAIRI (CBM) as a probiotic were examined. A randomized and placebo-controlled study was performed. Seventeen patients were recruited from 2007 to 2013. Nine tablets of MIYA-BM® or placebo were orally administered once daily. The cumulative pouchitis-free survival, pouch condition (using the modified pouch disease activity index), and blood parameters were evaluated. A fecal sample analysis was also performed. Subjects were randomly allocated to receive MIYA-BM or placebo (9 and 8 subjects, respectively). One subject in the MIYA-BM group and four subjects in the placebo group developed pouchitis. No side effects occurred in either group. Characteristic intestinal flora was observed in each group. Our results suggest that probiotic therapy with CBM achieved favorable results with minimal side effects and might be a useful complementary therapy for the prevention of pouchitis in patients with UC who have undergone IPAA.

Closure versus non-closure of fascial defects in laparoscopic ventral and incisional hernia repairs: a review of the literature.

Abstract: The laparoscopic technique for repairing ventral and incisional hernias (VIH) is now well established. However, several issues related to laparoscopic VIH repair, such as the high recurrence rate for hernias with large fascial defects and in extremely obese patients, are yet to be resolved. Additional problems include seroma formation, mesh bulging/eventration, and non-restoration of the abdominal wall rigidity/function with only bridging of the hernial orifice using standard laparoscopic intraperitoneal onlay mesh repair (sIPOM). To solve these problems, laparoscopic fascial defect closure with IPOM reinforcement (IPOM-Plus) has been introduced in the past decade, and a few studies have reported satisfactory outcomes. Although detailed techniques for fascial defect closure and handling of the mesh have been published, standardized techniques are yet to be established. We reviewed the literature on IPOM-Plus in the PubMed database and identified 16 reports in which the recurrence rate, incidence of seroma formation, and incidence of mesh bulging were 0–7.7, 0–11.4, and 0 %, respectively. Several comparison studies between sIPOM and IPOM-Plus seem to suggest that IPOM-Plus is associated with more favorable surgical outcomes; however, larger-scale studies are essential.

Robotic-assisted vs. conventional laparoscopic surgery for rectal cancer: short-term outcomes at a single center

Abstract: Purposes Several retrospective studies have demonstrated the safety and technical feasibility of robotic-assisted laparoscopic surgery (RALS). The aim of the present study was to clarify the advantages of RALS for rectal cancer by comparing its short-term outcomes with those of conventional laparoscopic surgery (CLS).

Prognostic indicators based on inflammatory and nutritional factors after pancreaticoduodenectomy for pancreatic cancer

Abstract: We evaluated prognostic indicators based on inflammatory and nutritional factors, namely, the modified Glasgow Prognostic Score (mGPS), the Prognostic Nutritional Index (PNI), the neutrophil/lymphocyte ratio (NLR), and the platelet/lymphocyte ratio (PLR), to determine their efficiency and significance after pancreaticoduodenectomy for pancreatic cancer. The subjects of this study were 46 patients who underwent pancreaticoduodenectomy for pancreatic cancer between October 2007 and December 2014. Patients were divided into preoperative mGPS (0/1 and 2), PNI (<40 and ≥40), NLR (<2.5 and ≥2.5), and PLR (<200 and ≥200) groups, to evaluate various perioperative outcomes. Hemoglobin concentrations were significantly lower (P = 0.019), whereas intra-abdominal bleeding was significantly higher (P = 0.040) in the PNI (<40) group than in the PNI (≥40) group. The incidence of postoperative pneumonia was significantly higher in the mGPS (2) group (P = 0.009), and surgical complications greater than grade 3 (Clavien–Dindo classification) were significantly increased in the NLR (≥2.5) group (P = 0.041). Overall survival rates in the PNI (<40) (P = 0.019), NLR (≥2.5) (P = 0.001), and PLR (≥200) (P < 0.001) groups were significantly lower than those in the other groups. The PLR was the only independent prognostic indicator (P = 0.002) according to multivariate analysis. The mGPS, PNI, and NLR were effective predictive indicators of postoperative complications. The PLR was the most useful prognostic indicator for pancreatic cancer patients after pancreaticoduodenectomy.

Sublobar resection versus lobectomy for stage I non-small cell lung cancer: an appropriate choice in elderly patients?

Abstract: The aim of this study was to evaluate whether sublobar resection could achieve recurrence and survival rates equivalent to lobectomy in high-risk elderly patients. We conducted a retrospective multicenter study that including all consecutive patients (aged >75 years) who underwent operation for clinical stage I non-small cell lung cancer (NSCLC). The clinicopathological data, postoperative morbidity and mortality, recurrence rate and vital status were retrieved. The overall survival, cancer-specific survival and disease-free survival were also assessed. Two hundred and thirty-nine patients (median age 78 years) were enrolled. Lobectomies were performed in 149 (62.3 %) patients and sublobar resections in 90 (39 segmentectomies, 51 wedge resections). There were no differences in the recurrence rates following lobar versus sublobar resections (19 versus 23 %, respectively; p = 0.5) or the overall survival (p = 0.1), cancer-specific survival (p = 0.3) or disease-free survival (p = 0.1). After adjusting for 1:1 propensity score matching and a matched pair analysis, the results remained unchanged. A tumor size >2 cm and pN2 disease were independent negative prognostic factors in unmatched (p = 0.01 and p = 0.0003, respectively) and matched (p = 0.02 and p = 0.005, respectively) analyses. High-risk elderly patients may benefit from sublobar resection, which provides an equivalent long-term survival compared to lobectomy.

Reconstruction after proximal gastrectomy for gastric cancer in the upper third of the stomach: a review of the literature published from 2000 to 2014

Abstract: Proximal gastrectomy (PG) is occasionally performed to preserve the physiological function of the remnant stomach with the aim of maintaining a gastric reservoir for patients with early gastric cancer in the upper third of the stomach. Many reconstructive procedures after PG have been reported, including esophagogastrostomy (EG), jejunal interposition, jejunal pouch interposition, and double tract. However, no general agreement exists regarding the optimal reconstructive procedure. This article reviews the current reconstructive procedures available for PG. We examined the surgical outcomes, postoperative complications, endoscopic findings, and quality of life (QOL) according to the reconstructive procedures. We found no significant difference in anastomotic leakage and anastomotic stricture among the procedures. The frequency of reflux esophagitis was higher with simple EG compared with the other reconstructive procedures. Some additional procedures, such as fundoplication, the use of a narrow gastric conduit, and placement of a gastric tube in the lower mediastinum on EG, could decrease the frequency of reflux esophagitis and reflux symptoms. These additional procedures may improve the QOL; however, the previous studies were small and could not adequately compare the reconstructive procedures. Prospective randomized controlled trials that involve a longer trial period and more institutions are needed to clarify the optimal reconstructive procedures after PG.

Preoperative independent prognostic factors in patients with borderline resectable pancreatic ductal adenocarcinoma following curative resection: the neutrophil-lymphocyte and platelet-lymphocyte ratios.

Abstract: The therapeutic strategy for borderline resectable pancreatic ductal adenocarcinoma (BR-PDAC) has remained unestablished because the preoperative prognostic factors have not been determined. One hundred eighty-four consecutive PDAC patients who underwent upfront surgery with a curative resection between January 2000 and June 2013 at Kobe University Hospital were retrospectively studied. The PDAC patients were stratified into resectable (R)-PDAC (n = 147) and BR-PDAC patients (n = 37). We evaluated the independent prognostic significance of the neutrophil-lymphocyte ratio (NLR) and the platelet-lymphocyte ratio (PLR) in the BR-PDAC patients. BR-PDAC patient survival was significantly worse than R-PDAC patient survival (median survival time: 22.1 months vs. 24.3 months; 5-year survival rate 6 vs. 21 %; P = 0.042). The median survival in BR-PDAC patients with a preoperative NLR of >3 (n = 12) was 10.2 months, while that in patients with preoperative NLR of ≤3 (n = 25) was 24.9 months (P = 0.002). Moreover, the median survival in BR-PDAC patients with a preoperative PLR of >225 (n = 8) was 10.2 months, while that in patients with a preoperative PLR of ≤225 (n = 29) was 24.7 months (P = 0.003). Preoperative NLR >3 (HR = 2.980, 95 % CI 1.251–6.920; P = 0.015) and PLR >225 (HR = 3.050, 95 % CI 1.169–7.468; P = 0.024) were independent prognostic factors in BR-PDAC patients. Higher preoperative NLR and PLR can be independent predictive risk factors in BR-PDAC patients following curative resection.

Risk factors for postoperative pneumonia after gastrectomy for gastric cancer

Abstract: The number of elderly patients undergoing gastrectomy for gastric cancer is increasing. Yet, although elderly patients are at high risk of postoperative pneumonia, no study has sufficiently investigated which clinicopathological factors are significant risk factors for the development of this complication after gastrectomy with lymph node dissection. We reviewed the medical records of 750 patients who underwent gastrectomy between January 2010 and May 2012, to establish the incidence of postoperative pneumonia (Clavien–Dindo grade II or higher). Univariate and multivariate analyses were performed to identify the risk factors for postoperative pneumonia. Thirty-two patients (4.3 %) suffered postoperative pneumonia, diagnosed as grades I, II, IIIa, and IVa, in 2 (0.3 %), 28 (3.7 %), 1 (0.2 %), and 1 (0.2 %) patient(s), respectively. Univariate analysis revealed that age (≥75 years), sex (male), diabetes mellitus (DM), a history of smoking, and impairment of respiratory function were significantly associated with postoperative pneumonia. Multivariate analysis revealed that age, impaired postoperative respiratory function, DM, and blood transfusion were independent risk factors for postoperative pneumonia. Age, impaired postoperative respiratory function, DM, and blood transfusion were identified as independent risk factors for postoperative pneumonia after gastrectomy.

A lower neutrophil to lymphocyte ratio is closely associated with catarrhal appendicitis versus severe appendicitis.

Abstract: Catarrhal appendicitis (CA) could be treated effectively with antibiotics in some patients because of the milder inflammation associated with this form of appendicitis. Although several trials have compared surgery with antibiotic therapy for acute appendicitis (AA), the indications for antibiotic therapy remain controversial. The subjects of this study were 342 patients who underwent appendectomy at our hospital between January, 2000 and March, 2013. The patients were divided into two groups based on the severity of their appendicitis: Group A comprised patients with severe appendicitis and Group B comprised patients with CA. Statistical analyses were performed to assess the clinical features associated with CA. Multivariate analysis of the eight clinical features correlated with CA according to univariate analysis revealed that the neutrophil to lymphocyte ratio (NLR) ( 5), age ( 38 years), fever ( 38 °C), white blood cell count ( 11.5 × 103/mm3) and serum level of C-reactive protein ( 110 mg/L) were significantly associated with CA. The NLR ( 5) (OR 0.421; 95 % CI 0.218–0.811; P = 0.010) was the most useful predictor of CA, because the area under the ROC curve of NLR was the lowest of all these features. The preoperative NLR in patients undergoing appendectomy is closely associated with CA.

Efficacy of perioperative synbiotics treatment for the prevention of surgical site infection after laparoscopic colorectal surgery: a randomized controlled trial

Abstract: The aim of this study was to assess the effect of perioperative oral administration of synbiotics on the surgical outcome in patients undergoing laparoscopic colorectal resection. In this single-center randomized, controlled trial, patients scheduled to undergo elective laparoscopic colorectal surgery were eligible to participate and randomly assigned to a synbiotics group or a control group. The primary study outcome was the development of infectious complications, particularly surgical site infection (SSI), within 30 days of surgery. In this study, 379 patients were enrolled and randomly assigned (173 to the synbiotics group and 206 to the control group), of whom 362 patients (168 to the synbiotics group and 194 to the control group) were eligible for this study. SSI occurred in 29 (17.3 %) patients in the synbiotics group and 44 (22.7 %) patients in the control group (OR: 0.761, 95 % CI 0.50–1.16; p = 0.20). Overall, the rate of postoperative complications, including anastomotic leakage, did not differ significantly between the two groups. Synbiotics treatment reversed the changes in fecal bacteria and organic acids after surgery and suppressed the increases in potentially pathogenic species, such as Clostridium difficile. The efficacy of perioperative administration of synbiotics was not validated as a treatment for reducing the incidence of infectious complications after laparoscopic colorectal resection. However, the microbial imbalance, in addition to the reduction in organic acids, could be improved by perioperative synbiotics treatment.

Is left upper lobectomy for lung cancer a risk factor for cerebral infarction

Abstract: Cerebral infarction is a rare complication of lung resection that can result in severe sequelae. Our aim was to investigate the characteristics of patients who suffer from cerebral infarction after surgery for lung cancer. We retrospectively reviewed all patients who underwent resection of at least a single lobe for lung cancer at our institution between January 2008 and October 2013. We compared the patients who presented with cerebral infarction with those patients who did not within 30 days of surgery. A total of 562 patients underwent surgery, with five males and one female subsequently experiencing cerebral infarction. Five patients underwent left upper lobectomy and one underwent left lower lobectomy. Patient age, sex, body mass index, smoking index, and operative time were not significantly different between the six patients with postoperative cerebral infarction and the other 556 patients; only the type of operative procedure was significantly different (p < 0.001). Contrast-enhanced computed tomography revealed thrombosis in the stump of the left superior pulmonary vein in patients with postoperative cerebral infarction. Cerebral infarction occurs at a high frequency in patients who undergo left upper lobectomy for lung cancer. Thrombosis in the left superior pulmonary-vein stump might cause cerebral infarction.

Perioperative circulating tumor cells in surgical patients with non-small cell lung cancer: does surgical manipulation dislodge cancer cells thus allowing them to pass into the peripheral blood?

Abstract: We herein evaluated the status of circulating tumor cells (CTC) dislodged from the tumor during surgery in patients who underwent pulmonary resection for non-small cell lung cancer (NSCLC) to assess the clinical implications. Tumor cells in the peripheral arterial blood before surgery (Before) and immediately after lung resection (After) and in the blood from the pulmonary vein of the resected lung were detected using a size selective method. The clinicopathological characteristics and the prognosis were then analyzed according to the CTC status: no tumor cells detected (N), single tumor cell or total number less than 4 cells (S), and existence of clustered cells (C). According to the CTC status, the patients were classified into the following three groups: Before-C and After-C, Group I (n = 6); Before-S or N and After-C, Group II (n = 9); and Before-S or N and After-S or N, Group III (n = 8). Group III showed a high rate of p-stage IA, smaller tumor size, lower CEA level, lower SUVmax level, and a higher relapse-free survival rate than the other groups. CTCs were detected in patients after undergoing lung resection, some of which may have been dislodged by the surgical procedure. The presence of clustered CTCs after the operation indicated an unfavorable outcome.

A non-smooth tumor margin on preoperative imaging predicts microvascular invasion of hepatocellular carcinoma

Abstract: Microvascular invasion (mVI) is known to be a risk factor of hepatocellular carcinoma (HCC) recurrence. Several factors such as the tumor grade, tumor size, tumor margin status on imaging studies, fluorine-18 fluorodeoxyglucose-positron emission tomography (18F-FDG-PET) results, and tumor markers have been proposed to predict mVI of HCC. However, the values of these factors have not yet been validated. Among the patients evaluated using enhanced CT/MRI, 18F-FDG-PET, and tumor markers prior to hepatectomy from 2007 to 2012, 79 HCC patients without apparent macrovascular invasion in preoperative imaging were enrolled in this study. The image tumor margin status (smooth/non-smooth), 18F-FDG-PET, and tumor markers, which were previously described as predictors for mVI, were evaluated. Fifteen patients had mVI (mVI+ group) and 64 patients had no evidence of mVI (mVI− group) on pathological examinations. A univariate analysis showed that the mVI+ group had a higher SUV and TNR (5.2 vs 3.8, p = 0.02 and 1.8 vs 1.3, p = 0.02, respectively) and a higher portion of non-smooth tumor margin (87 vs 27 %, p = 0.0001). There was no significant difference in the tumor markers. A multivariate analysis showed that non-smooth tumor margin alone could independently predict mVI (odds ratio 18.3, 95 % CI 3.27–102.6, p = 0.0009). A non-smooth tumor margin on preoperative imaging predicts microvascular invasion of HCC.

Neutrophil/lymphocyte ratio predicts the prognosis in esophageal squamous cell carcinoma patients

Abstract: As cancer advances, changes in the systemic inflammatory response alter the relative levels of circulating white blood cell types and may contribute to the progression and outcomes of cancer. The aim of the current study is to clarify the impact of the preoperative neutrophil/lymphocyte ratio (NLR) on the prognosis and whether clinical and pathological features modify the influence of the NLR on the prognosis of esophageal squamous cell carcinoma (ESCC) patients. We retrospectively analyzed the mortality hazard ratios (HRs), including the preoperative NLR, obtained from data for 283 ESCC patients undergoing resection in the period from 2005 to 2011, adjusting for clinical and pathological features. A high NLR was associated with a significantly shorter overall survival (p = 0.0018) and cancer-specific survival (p = 0.0097). In the multivariate Cox model, we confirmed that the NLR was an independent prognostic marker for both overall survival (p = 0.0081) and cancer-specific survival (p = 0.028). The outcomes were not significantly modified by other diagnostic factors, including the tumor stage, in the survival analysis. The preoperative NLR is significantly associated with a poor prognosis in patients with ESCC, suggesting the utility of NLR as a cost-effective and broadly available independent prognostic marker of ESCC.

Minimally invasive esophagectomy performed with the patient in a prone position: a systematic review.

Abstract: We reviewed the surgical results of minimally invasive esophagectomy for esophageal cancer, performed with the patient in a prone position (MIE-PP), to assess its benefits. A systematic literature search was performed, and articles that fully described the surgical results of MIE-PP were selected. Parameters such as operative time, blood loss, and postoperative outcomes were compared with those obtained for open transthoracic esophagectomy (OE) and minimally invasive esophagectomy in a lateral decubitus position (MIE-LP). The conversion rate from MIE-PP to open surgery was very low. MIE-PP was associated with longer operative time and lower blood loss than OE. Although studies from a single institution did not show an apparent difference in morbidity or mortality among the three operative groups, results of a multicenter randomized controlled trial showed a reduction in pulmonary infection and recurrent laryngeal nerve palsy in MIE-PP, compared with OE. The benefits of MIE-PP vs. those of MIE-LP remain controversial. Theoretically, the operative results of MIE-PP might be better than those of MIE-LP for patients with esophageal cancer; however, studies have not yet verified this. Further clinical studies are required to establish whether the advantages of MIE-PP can be translated into clinical outcome.

Current status of robotic gastrectomy for gastric cancer

Abstract: Although over 3000 da Vinci Surgical System (DVSS) devices have been installed worldwide, robotic surgery for gastric cancer has not yet become widely spread and is only available in several advanced institutions. This is because, at least in part, the advantages of robotic surgery for gastric cancer remain unclear. The safety and feasibility of robotic gastrectomy have been demonstrated in several retrospective studies. However, no sound evidence has been reported to support the superiority of a robotic approach for gastric cancer treatment. In addition, the long-term clinical outcomes following robotic gastrectomy have yet to be clarified. Nevertheless, a robotic approach can potentially overcome the disadvantages of conventional laparoscopic surgery if the advantageous functions of this technique are optimized, such as the use of wristed instruments, tremor filtering and high-resolution 3-D images. The potential advantages of robotic gastrectomy have been discussed in several retrospective studies, including the ability to achieve sufficient lymphadenectomy in the area of the splenic hilum, reductions in local complication rates and a shorter learning curve for the robotic approach compared to conventional laparoscopic gastrectomy. In this review, we present the current status and discuss issues regarding robotic gastrectomy for gastric cancer.

Transanal drainage tube placement to prevent anastomotic leakage following colorectal cancer surgery with double stapling reconstruction.

Abstract: Anastomotic leakage (AL) is a critical complication of colorectal cancer surgery. The transanal drainage tube (TDT) is designed to prevent AL caused by decompression and stasis at the anastomosis. We conducted this study to investigate the feasibility of using the TDT to prevent AL following double-stapling technique reconstruction (DST). The subjects of this study were 179 patients who underwent curative resection and DST reconstruction for sigmoid colon and rectal cancer in our institution between 2008 and 2013. We analyzed the effectiveness of the TDT for preventing AL. A TDT was placed in 78 patients (43.6 %, TDT group) and not placed in the remaining 101 patients (56.4 %, NTDT group). AL developed in 2 (2.6 %) patients from the TDT group and in 14 (13.9 %) patients from the NTDT group (p = 0.009). Univariate analysis revealed that AL was significantly correlated with tumor distance from the anal verge (AV), the number of staples, and TDT placement. Multivariate analysis revealed a significantly positive correlation between AL and AV [OR 0.877 (0.783–0.982) p = 0.023] and a significantly negative correlation between AL and TDT placement [OR 0.07 (0.013–0.374) p = 0.002]. Anastomotic decompression with TDT placement may prevent AL after colorectal cancer surgery with DST reconstruction.

The current status and future perspectives of organ donation in Japan: learning from the systems in other countries

Abstract: The revised Organ Transplant Law came into effect in Japan in July 2010. The law allows for organ procurement from brain-dead individuals, including children, with family consent from subjects who had not previously rejected organ donation. Nevertheless, the number of cadaveric organ donations has not increased as expected. The Spanish Model is widely known as the most successful system in the field of organ donation. The system includes an earlier referral of possible donors to the transplant coordination teams, a new family-based approach and care methods, and the development of additional training courses aimed at specific groups of professionals, which are supported by their corresponding societies. South Korea, a country which neighbors Japan, has recently succeeded in increasing the rates of organ donation by introducing several systems, such as incentive programs, an organ procurement organization, a donor registry, and a system to facilitate potential donor referral. In this review, we present the current status of organ donation in Japan and also explore various factors that may help to improve the country's low donation rate based on the experiences of other developed countries.

Hyperfibrinogenemia is associated with inflammatory mediators and poor prognosis in patients with gastric cancer.

Abstract: Hyperfibrinogenemia is associated with poor prognosis in various cancers; however, its clinical relevance in gastric cancer has not been well analyzed. We conducted this study to assess the clinicopathological significance and prognostic value of hyperfibrinogenemia in patients with gastric cancer. Plasma fibrinogen levels were measured preoperatively in 315 patients undergoing surgery for gastric cancer. We then evaluated the clinicopathological significance of hyperfibrinogenemia and its relationship with several biomarkers, including white blood cell (WBC), C-reactive protein (CRP), platelet count, prothrombin time (PT) and activated partial thromboplastin time (APTT). Postoperative plasma levels were compared with preoperative levels. The multivariate prognostic value of hyperfibrinogenemia was calculated using the Cox proportional hazards model. Tumor progression was significantly associated with hyperfibrinogenemia, as were the CRP level and platelet counts. Plasma fibrinogen levels decreased significantly after radical surgery. Adjusting for TNM factors, multivariate analysis indicated that hyperfibrinogenemia was an independent prognostic factor for poor survival (hazard ratio = 2.607, 95 % confidence interval = 1.180–5.761, P = 0.018). Preoperative hyperfibrinogenemia was associated with tumor progression, inflammatory mediators, and poor overall survival in patients with gastric cancer.

Correlation between histological invasiveness and the computed tomography value in pure ground-glass nodules

Abstract: Purpose The purpose of this study was to evaluate the correlation between histological invasiveness and the computed tomography (CT) value and size in pure ground-glass nodules (GGNs) to determine optimal “follow-up or resection” strategies.

Colonic stenting as a bridge to surgery for obstructive colorectal cancer: advantages and disadvantages

Abstract: To clarify the advantages and disadvantages of stenting as a bridge to surgery (BTS) by comparing the clinical features and outcomes of patients who underwent BTS with those of patients who underwent emergency surgery (ES). We assessed technical success, clinical success, surgical procedures, stoma formation, complications, clinicopathological features, and Onodera’s prognostic nutritional index (OPNI) in patients who underwent BTS and those who underwent ES. Twenty-six patients underwent stenting, which was successful in 22 (BTS group). The remaining four patients with unsuccessful stenting underwent emergency surgery. A total of 22 patients underwent emergency surgery (ES group). The rates of technical and clinical success were 85.0 and 81.0 %, respectively. The proportion of patients able to be treated by laparoscopic surgery (P = 0.0001) and avoid colostomy (P = 0.0042) was significantly higher in the BTS group. Although the incidence of anastomotic leakage in the two groups was not significantly different, it was significantly reduced by colonoscopic evaluation of obstructive colitis (P = 0.0251). The mean number of harvested lymph nodes (P = 0.0056) and the proportion of D3 lymphadenectomy (P = 0.0241) were significantly greater in the BTS group. Perineural invasion (PNI) was noted in 59.1 and 18.2 % of the BTS group and ES group patients, respectively (P = 0.0053). OPNI and serum albumin decreased significantly after stenting (P = 0.0084). The advantages of stenting as a BTS were that it avoided colostomy and allowed for laparoscopic surgery and lymphadenectomy, whereas its disadvantage lay in the decreased PNI and OPNI levels. A larger study including an analysis of prognosis is warranted.

Analysis of anatomical risk factors for persistent type II endoleaks following endovascular abdominal aortic aneurysm repair using CT angiography.

Abstract: To predict persistent type II endoleaks (pT2Es) following endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms, we examined factors related to post-EVAR pT2Es. Eighty-four cases of EVAR were analyzed. T2Es that persisted for ≥6 months were defined as pT2Es. pT2Es flowing from an inferior mesenteric artery (IMA) and lumbar artery (LA) were termed pIMA-T2Es and pLA-T2Es, respectively. The anatomical factors concerning the aneurysm, IMA and LAs were assessed in the preoperative CT angiography images. A statistical analysis was performed on the factors associated with pT2Es. The incidence of pT2Es was 25 %. pT2Es were associated with postoperative changes in the aneurysm diameter. A univariate analysis showed that a sac thrombus and the number of patent side branches arising from an aneurysm were significant factors associated with pT2Es. The IMA diameters were significantly larger in cases of pIMA-T2Es. The significant factors associated with pLA-T2Es were a circumferential thrombus, the number of patent LAs and the mean LA diameter. Multivariate analyses indicated that a circumferential thrombus was a protective factor for pT2Es, whereas an IMA ≥2.6 mm and each additional LA branch ≥1.9 mm were powerful risk factors for a pT2E. Significant anatomical factors associated with pT2E were found in this study. These factors may be useful in selecting patients for perioperative intervention.

Risk factors predictive of atrial fibrillation after lung cancer surgery

Abstract: Postoperative atrial fibrillation (POAF), the most frequent arrhythmia after pulmonary resection, is a cause of both morbidity and mortality. Being able to predict the risk of POAF before surgery would help us evaluate the surgical risk and plan prophylaxis. We investigated the reported preoperative risk factors associated with the incidence of POAF and found that the recommended predictive factors were quite variable. Therefore, we evaluated the previously reported preoperative risk factors for POAF using our institutional data. We discuss our findings in this short review. Male gender, resected lung volume, brain natriuretic peptide (BNP), and left ventricular early transmitral velocity/mitral annular early diastolic velocity (E/e′) calculated by echocardiography were suggested as independent predictors for POAF, but the predictive values of each individual parameter were not high. The lack of definitive predictors for POAF warrants further investigations by gathering the reported knowledge, to establish an effective preoperative examination strategy.

Transanal total mesorectal excision for rectal cancer.

Abstract: Although laparoscopic surgery for rectal cancer has been gaining acceptance with the gradual accumulation of evidence, it remains a technically demanding procedure in patients with a narrow pelvis, bulky tumors, or obesity. To overcome the technical difficulties associated with laparoscopic rectal dissection and transection, transanal endoscopic rectal dissection, which is also referred to as transanal (reverse, bottom-up) total mesorectal excision (TME), has recently been introduced. Its potential advantages include the facilitation of the dissection of the anorectum, regardless of the patient body habitus, and a clearly defined safe distal margin and transanal extraction of the specimen. This literature review shows that this approach seems to be feasible with regard to the operative and short-term postoperative outcomes. In experienced hands, transanal TME is a promising method for the resection of mid- and low-rectal cancers. Further investigations are required to clarify the long-term oncological and functional outcomes.

Fibrinogen and base excess levels as predictive markers of the need for massive blood transfusion after blunt trauma.

Abstract: Background Assessment blood consumption and trauma-associated severe hemorrhage scores are useful for predicting the need for massive transfusion (MT) in severe trauma patients. However, fibrinogen (Fbg) and base excess (BE) levels might also be useful indicators for the need for MT. We evaluated the accuracy of prediction for MT of the scoring system vs. Fbg and BE.

Laparoscopic versus open distal gastrectomy for early gastric cancer in Japan: long-term clinical outcomes of a randomized clinical trial.

Abstract: We report the long-term clinical outcomes of a randomized clinical trial comparing laparoscopy-assisted distal gastrectomy (LADG) with open DG (ODG). Between 2005 and 2008, 63 patients with clinical T1 (cT1) gastric cancer were randomly assigned to undergo either LADG or ODG. Long-term clinical outcomes included prospective questionnaire-based symptoms and survival. Based on the responses to the prospective questionnaires, patients who underwent LADG reported greater satisfaction and were more likely to favor the procedure than those who underwent ODG. The most notable difference in symptoms was related to wound pain and diarrhea. After ODG, wound pain reduced in intensity but persisted throughout the follow-up. Surprisingly, diarrhea was more frequent after LADG than after ODG, possibly due to overeating, because symptoms elicited by overeating, such as vomiting after a meal or heartburn, were also more frequent after LADG. In terms of long-term survival, there were no cases of recurrence in either group. LADG was associated with less wound pain during long-term follow-up after surgery, whereas symptoms related to overeating were common. Based on our findings and the patients’ reported satisfaction, we recommend LADG for cT1 gastric cancer as an effective procedure with excellent long-term survival.

An increased number of PD-1+ and Tim-3+ CD8+ T cells is involved in immune evasion in gastric cancer.

Abstract: Co-signaling molecules play an important role in T cells. This study was designed to investigate PD-1 and Tim-3 expression on T cells and the relationships between PD-1 and Tim-3 expression and immune evasion in patients with gastric cancer. Using multicolor flow cytometry, we analyzed PD-1 and Tim-3 expression on CD8+ T cells obtained from peripheral blood mononuclear cells (PBMCs) and gastric cancer tissue. Significantly more PD-1+ and Tim-3+ CD8+ T cells in peripheral blood were found in gastric cancer patients than in healthy controls. PD-1+ CD8+ T cells were significantly correlated with Tim-3+ CD8+ T cells in peripheral blood from the gastric cancer patients (r = 0.29, p = 0.036). Furthermore, significantly greater numbers of PD-1+ and Tim-3+ CD8+ T cells were seen in the gastric cancer tissue samples than in the PBMCs. CD8+ T cells positive for both PD-1 and Tim-3 produced significantly less IFN-gamma than cells negative for both and cells positive for PD-1 and negative for Tim-3. An increased number of PD-1+ and Tim-3+ CD8+ T cells is closely related to impaired function of CD8+ T cells in gastric cancer patients.

Prospective validation study of Cernea classification for predicting EMG alterations of the external branch of the superior laryngeal nerve

Abstract: Cernea classification is applied to describe the external branch of the superior laryngeal nerve (EBSLN). Using intraoperative neural monitoring we evaluated whether or not this classification is useful for predicting which EBSLN subtype has an increased risk of injury. An analysis of 400 EBSLN. The identification of EBSLN was achieved with both cricothyroid muscle twitch and the glottis evoked electromyography response. We defined S1 initial EBSLN stimulation at identification and S2 final nerve stimulation achieved in the most cranial aspect of the nerve exposed above the area of surgical dissection after superior artery ligation. The mean S1 amplitude acquired was 259+/67 (180–421), 321 +/79 (192–391), 371 +/38 (200–551) μV, respectively, for type 1, 2A, 2B (p = 0.08). The S1 and S2 amplitudes were similar in type 1 (p = 0.3). The S1 and S2 determinations changed significantly in type 2A and 2B (p = 0.04 and 0.03). EBSLN which demonstrated a >25 % decreased amplitude in S2 increased significantly from Type 1 (4.9 %) to Type 2A (11.2 %) and 2B (18 %) (p = 0.01). None of type 1, 2.8 % type 2A and 3 % type 2B showed a loss of EBSLN conductivity. The latency determinations did not vary significantly for any parameter compared. The Cernea classification was, therefore, found to predict the risk of EBSLN stress. We identified amplitude differences between S1 and S2 determinations in type 2A and 2B, thus confirming that surgical dissection in these subtypes is, therefore, extremely difficult to perform.