Evaluation after implementation of chemical bowel preparation for surgical site infections in elective colorectal cancer surgery and role of antimicrobial stewardship pharmacist: Retrospective cohort study.

BACKGROUND: We evaluated the predictive factors for surgical site infections (SSIs) in elective colorectal cancer surgery and the role of antimicrobial stewardship (AS) pharmacists in modifying the clinical pathway. MAIN BODY: Between February 2017 and January 2022, 414 elective colorectal cancer surgeries were performed. The results of multivariate analysis by SSI incidence were adjusted odds ratio (aOR): 0.45; 95% confidence interval (CI): 0.22-0.96 (P = 0.039) for sex (female), aOR: 0.27; 95% CI: 0.13-0.58 (P < 0.001) for laparoscopy, aOR: 0.42; 95% CI: 0.19-0.91 (P = 0.029) for chemical bowel preparation. The median (interquartile range) postoperative length of stay was 12 (10.0-18.5) vs. 10 (9.0-13.0) days before and after the clinical pathway was modified (P < 0.001). CONCLUSION: The role of AS pharmacists was primarily to conduct a literature search to explore whether SSIs could be ameliorated by pharmacotherapy, coordinate the addition of chemical bowel preparation, and epidemiologically confirm their effectiveness.

[Three Cases of No. 16 Lymph Node Metastasis-Positive Gastric Cancer Successfully Treated with Chemotherapy and Para-Aortic Lymph Node Dissection].

Chemotherapy is standard treatment for Stage Ⅳ advanced gastric cancer(AGC)positive for No. 16 lymph node(LN) metastasis, but the significance of conversion surgery remains unclear. S-1 plus CDDP(SP), primary lesion resection+ para-aortic LN dissection(PAND), and postoperative recurrence-free survival are reported. Case 1: A 70-year-old woman had AGC with para-aortic LN metastases(tub1, HER2 score 3+, cT3N2M1, cStage Ⅳ). Four courses of SP plus trastuzumab were administered, which shrank the primary tumor and metastatic LNs. She underwent distal gastrectomy with D2+PAND (No. 16a2 int-b1 int). Histopathology showed metastasis to No. 16 LN, with Grade 2 histological effect. She underwent adjuvant chemotherapy with S-1 and 4-year recurrence-free follow-up. Case 2: An 80-year-old man with AGC rand para- aortic LN metastases(por, cT3N2M1, cStage Ⅳ)underwent 4 courses of SP, which shrank the primary tumor and metastatic LNs. He underwent total gastrectomy with D2+PAND(No. 16a2 lat)dissection. Histopathology showed no residual tumor cells in LNs. Follow-up for 3 years has shown no recurrence without chemotherapy. Case 3: A 50-year-old woman with epigastric pain and anemia had AGC with para-aortic LN metastases(tub2, cT3N3M1, cStage Ⅳ). She underwent distal gastrectomy with D2+PAND(No. 16a2 int-b1 lat). After 1-year chemotherapy with SP, follow-up for 5 years showed no recurrence. In AGC with para-aortic LN metastases, long-term survival can be expected by combining selective PAND with SP therapy.

[A case of multiple liver metastases from colon cancer treated with complete resection via two-stage hepatectomy after regeneration of the liver].

A 55-year-old woman underwent low anterior resection for sigmoid colon cancer with multiple bilobar metastases. She then received 23 courses of Leucovorin, fluorouracil, and oxaliplatin (mFOLFOX) plus bevacizumab and 13 courses of Leucovorin, fluorouracil, and irinotecan (FOLFIRI) plus bevacizumab as down staging chemotherapy. A two-stage hepatectomy was planned to avoid the risk of hepatic failure due to radial resection of bilobar metastases. Therefore, a right lobectomy was performed, and curative resection was achieved 54 days after the first hepatectomy. Two-stage hepatectomy as well as a combination of induction chemotherapy and portal vein embolization may have contributed to the improved prognosis of the initially unresectable multiple bilobar liver metastases.

[Report of two cases successfully treated by chemo-radiation against lymph node metastasis after gastric cancer surgery].

A 68-year-old male patient with mediastinal node metastasis 40 months after total gastrectomy for advanced gastric cancer, and a 72-year-old male patient with para aortic node metastasis were treated with concurrent chemo-radiotherapy of 1.8 Gy × 5 × 6 week with S-1 (100 mg/body, days 1-14 and 22-35) + docetaxel (30 mg/body, days 1, 8, 22, 29). Although two patients developed a lymph node recurrence during multiple chemotherapies including S-1, they have responded well and demonstrated complete response after chemo-radio therapy. Grade 3 esophagitis was sole adverse side effect. In contrast to the western countries, chemo-radio therapy was not recognized as a standard treatment for gastric cancer in Japan. However, our report suggested that chemo-radio therapy can be an option for the treatment of advanced gastric cancer.

[A case of unresectable cardiac gastric cancer patient who maintained a long-term QOL with chemotherapy and detention of metallic stent].

A case was a 66-year-old man. He visited our hospital for dysphagia, abdominal distention and body weight loss. He was underwent gastro-endoscopy and made a diagnosis of the advanced cardiac gastric cancer. The early esophageal and gastric cancer also detected. Furthermore, computed tomography was performed and detected multiple liver and spleen, para-aortic lymph-node metastases and the ascites (suspected for dissemination). We decided that curative resection was impossible. Therefore, we performed an abdominal puncture to remove the ascites and combination chemotherapy with S-1 and docetaxel. The combination therapy was effective. The main tumor and multiple metastatic lesions were reduced. But after six months, a tumor marker was increased. The anticancer drug was changed to S-1 and CDDP. After eight months from the first-line chemotherapy started, the stenosis was appeared at esophago-gastric junction. We performed balloon dilation, and a metallic stent was detention with gastroscopy and radiography at stenotic lesion. He improved swallowing and discharged from hospital. After eleven months from the first-line chemotherapy started, he was died of increased liver metastases and peritonitis carcinomatousa.

[A case report of un-resectable pancreas body carcinoma successfully treated by chemoradiotherapy].

We report a case of unresectable pancreatic cancer who survived for 29 months after a successful treatment by concurrent chemo-radiotherapy by gemcitabine and systemic administration of gemcitabine. A 65-year-old woman who was diagnosed as unresectable pancreas body cancer received concurrent chemo (gemcitabine 800 mg/body/w) -radiotherapy (1.8x30 Gy) and systemic chemotherapy (gemcitabine 1,000 mg/body/w) at an outpatient clinic. Twenty nine months after the initial treatment, she was died of peritoneal dissemination. Recently, there are some reports of synergistic effect for combined treatment of gemcitabine and radiation. Clinical course of our case supports the synergistic effect of radiation and gemcitabine.

[The colon cancer patient with multiple hepatic metastases and peritoneal disseminations was treated by hepatic arterial infusion chemotherapy and resection of the metastatic peritoneal dissemination with successive systemic chemotherapy--a case report of the long term survivor].

A 33-year-old man, who underwent ileo-cecal resection and sigmoidectomy for concomitant cecal cancer and sigmoid colon cancer which was diagnosed during the emergent operation for the perforated acute appendicitis, suffered simultaneous multiple hepatic metastases. Postoperative hepatic aerial infusion chemotherapy with 5-FU was done (total dose 63 g), and the metastases were successfully disappeared (CR). Although 16-month passed from the operation, locoregional recurrence at the colorectal anastomosis and peritoneal dissemination were occurred. Aggressive resections of the recurrent sites (anterior resection of the rectum, ileum, ascending colon and other recurrent sites) and successive systemic administration of FOLFOX4(9-course), FOLFIRI (20-course) and capecitabine (15-course) were achieved. The patient survived for 4.5 years after the initial treatment.