Surgical risk model for acute diffuse peritonitis based on a Japanese nationwide database: an initial report on the surgical and 30-day mortality.

PURPOSE: Acute diffuse peritonitis (ADP) is an important surgical complication associated with high morbidity and mortality; however, the risk factors associated with a poor outcome have remained controversial. This study aimed in collecting integrated data using a web-based national database system to build a risk model for mortality after surgery for ADP. METHODS: We included cases registered in the National Clinical Database in Japan. After data cleanup, 8,482 surgical cases of ADP from 1,285 hospitals treated between January 1 and December 31, 2011 were analyzed. RESULTS: The raw 30-day and surgical mortality rates were 9.0 and 14.1 %, respectively. The odds ratios (>2.0) for 30-day mortality were as follows: American Society of Anesthesiologists (ASA) class 3, 2.69; ASA class 4, 4.28; ASA class 5, 8.65; previous percutaneous coronary intervention (PCI), 2.05; previous surgery for peripheral vascular disease (PVD), 2.45 and disseminated cancer, 2.16. The odds ratios (>2.0) for surgical mortality were as follows: ASA class 3, 2.27; ASA class 4, 4.67; ASA class 5, 6.54, and disseminated cancer, 2.09. The C-indices of 30-day and surgical mortality were 0.851 and 0.852, respectively. CONCLUSION: This is the first report of risk stratification after surgery for ADP using a nationwide surgical database. This system could be useful to predict the outcome of surgery for ADP and for evaluations and benchmark performance studies.

Mortality after common rectal surgery in Japan: a study on low anterior resection from a newly established nationwide large-scale clinical database.

BACKGROUND: The health-care system, homogenous ethnicity, and operative strategy for lower rectal cancer surgery in Japan are to some extent unique compared to those in Western countries. The National Clinical Database is a newly established nationwide, large-scale surgical database in Japan. OBJECTIVE: To illuminate Japanese national standards of clinical care and provide a basis for efforts to optimize patient care, we used this database to construct a risk model for a common procedure in colorectal surgery-low anterior resection for lower rectal cancer. DESIGN: Data from the National Clinical Database on patients who underwent low anterior resection during 2011 were analyzed. Multiple logistic regression analyses were performed to generate predictive models of 30-day mortality and operative mortality. Receiver-operator characteristic curves were generated, and the concordance index was used to assess the model's discriminatory ability. RESULTS: During the study period, data from 16,695 patients who had undergone low anterior resection were collected. The mean age was 66.2 years and 64.5% were male; 1.1% required an emergency procedure. Raw 30-day mortality was 0.4% and operative mortality was 0.9%. The postoperative incidence of anastomotic leakage was 10.2%. The risk model showed the following variables to be independent risk factors for both 30-day and operative mortality: BMI greater than 30 kg/m, previous peripheral vascular disease, preoperative transfusions, and disseminated cancer. The concordance indices were 0.77 for operative mortality and 0.75 for 30-day mortality. LIMITATIONS: The National Clinical Database is newly established and data entry depends on each hospital. CONCLUSIONS: This is the first report of risk stratification on low anterior resection, as representative of rectal surgery, with the use of the large-scale national surgical database that we have recently established in Japan. The resulting risk models for 30-day and operative mortality from rectal surgery may provide important insights into the delivery of health care for patients undergoing GI surgery worldwide.

Total gastrectomy risk model: data from 20,011 Japanese patients in a nationwide internet-based database.

OBJECTIVE: To construct a risk model for total gastrectomy outcomes using a nationwide Internet-based database. BACKGROUND: Total gastrectomy is a very common procedure in Japan. This procedure is among the most invasive gastrointestinal procedures and is known to carry substantial surgical risks. METHODS: The National Clinical Database was used to retrieve records on more than 1,200,000 surgical cases from 3500 hospitals in 2011. After data cleanup, 20,011 records from 1623 hospitals were analyzed for procedures performed between January 1, 2011, and December 31, 2011. RESULTS: The average patient age was 68.9 years; 73.7% were male. The overall morbidity was 26.2%, with a 30-day mortality rate of 0.9%, in-hospital mortality rate of 2.2%, and overall operative mortality rate of 2.3%. The odds ratios for 30-day mortality were as follows: ASA (American Society of Anesthesiologists) grade 4 or 5, 9.4; preoperative dialysis requirement, 3.9; and platelet count less than 50,000 per microliter, 3.1. The odds ratios for operative mortality were as follows: ASA grade 4 or 5, 5.2; disseminated cancer, 3.5; and alkaline phosphatase level of more than 600 IU/L, 3.1. The C-index of 30-day mortality and operative mortality was 0.811 (95% confidence interval [CI], 0.744-0.879) and 0.824 (95% CI, 0.781-0.866), respectively. CONCLUSIONS: We have performed the first reported risk stratification study for total gastrectomy, using a nationwide Internet-based database. The total gastrectomy outcomes in the nationwide population were satisfactory. The risk models that we have created will help improve the quality of surgical practice.

[Submucosal bacterial abscesses of the ascending colon and liver associated with portal and superior mesenteric vein thrombosis due to Enterococcus faecalis infection: a case report].

A 72-year-old woman with diabetes mellitus was admitted with fever and general fatigue. Blood biochemistry showed elevated hepatic and biliary enzyme levels, abdominal computed tomography showed multiple liver abscesses with portal and superior mesenteric vein thrombosis, and total colonoscopy revealed a submucosal bacterial abscess in the ascending colon. The abscesses were determined to be associated with Enterococcus faecalis infection. The patient was treated conservatively with antibiotics (meropenem) and anticoagulants (warfarin), which led to a gradual amelioration of symptoms and resolution of thrombosis.

A risk model for esophagectomy using data of 5354 patients included in a Japanese nationwide web-based database.

OBJECTIVE: This study aimed to create a risk model of mortality associated with esophagectomy using a Japanese nationwide database. METHODS: A total of 5354 patients who underwent esophagectomy in 713 hospitals in 2011 were evaluated. Variables and definitions were virtually identical to those adopted by the American College of Surgeons National Surgical Quality Improvement Program. RESULTS: The mean patient age was 65.9 years, and 84.3% patients were male. The overall morbidity rate was 41.9%. Thirty-day and operative mortality rates after esophagectomy were 1.2% and 3.4%, respectively. Overall morbidity was significantly higher in the minimally invasive esophagectomy group than in the open esophagectomy group (44.3% vs 40.8%, P = 0.016). The odds ratios for 30-day mortality in patients who required preoperative assistance in activities of daily living (ADL), those with a history of smoking within 1 year before surgery, and those with weight loss more than 10% within 6 months before surgery were 4.2, 2.6, and 2.4, respectively. The odds ratios for operative mortality in patients who required preoperative assistance in ADL, those with metastasis/relapse, male patients, and those with chronic obstructive pulmonary disease were 4.7, 4.5, 2.3, and 2.1, respectively. CONCLUSIONS: This study was the first, as per our knowledge, to perform risk stratification for esophagectomy using a Japanese nationwide database. The 30-day and operative mortality rates were relatively lower than those in previous reports. The risk models developed in this study may contribute toward improvements in quality control of procedures and creation of a novel scoring system.

A pancreaticoduodenectomy risk model derived from 8575 cases from a national single-race population (Japanese) using a web-based data entry system: the 30-day and in-hospital mortality rates for pancreaticoduodenectomy.

OBJECTIVE: To create a mortality risk model after pancreaticoduodenectomy (PD) using a Web-based national database system. BACKGROUND: PD is a major gastroenterological surgery with relatively high mortality. Many studies have reported factors to analyze short-term outcomes. SUBJECTS AND METHODS: After initiation of National Clinical Database, approximately 1.2 million surgical cases from more than 3500 Japanese hospitals were collected through a Web-based data entry system. After data cleanup, 8575 PD patients (mean age, 68.2 years) recorded in 2011 from 1167 hospitals were analyzed using variables and definitions almost identical to those of American College of Surgeons-National Surgical Quality Improvement Program. RESULTS: The 30-day postoperative and in-hospital mortality rates were 1.2% and 2.8% (103 and 239 patients), respectively. Thirteen significant risk factors for in-hospital mortality were identified: age, respiratory distress, activities of daily living within 30 days before surgery, angina, weight loss of more than 10%, American Society of Anesthesiologists class of greater than 3, Brinkman index of more than 400, body mass index of more than 25 kg/m, white blood cell count of more than 11,000 cells per microliter, platelet count of less than 120,000 per microliter, prothrombin time/international normalized ratio of more than 1.1, activated partial thromboplastin time of more than 40 seconds, and serum creatinine levels of more than 3.0 mg/dL. Five variables, including male sex, emergency surgery, chronic obstructive pulmonary disease, bleeding disorders, and serum urea nitrogen levels of less than 8.0 mg/dL, were independent variables in the 30-day mortality group. The overall PD complication rate was 40.0%. Grade B and C pancreatic fistulas in the International Study Group on Pancreatic Fistula occurred in 13.2% cases. The 30-day and in-hospital mortality rates for pancreatic cancer were significantly lower than those for nonpancreatic cancer. CONCLUSIONS: We conducted the reported risk stratification study for PD using a nationwide surgical database. PD outcomes in the national population were satisfactory, and the risk model could help improve surgical practice quality.

Risk model for right hemicolectomy based on 19,070 Japanese patients in the National Clinical Database.

BACKGROUND: Right hemicolectomy is a very common procedure throughout the world, although this procedure is known to carry substantial surgical risks. The present study aimed to develop a risk model for right hemicolectomy outcomes based on a nationwide internet-based database. METHODS: The National Clinical Database (NCD) collected records on over 1,200,000 surgical cases from 3,500 Japanese hospitals in 2011. After data cleanup, we analyzed 19,070 records regarding right hemicolectomy performed between January 2011 and December 2011. RESULTS: The 30-day and operative mortality rates were 1.1 and 2.3 %, respectively. The 30-day mortality rates of patients after elective and emergency surgery were 0.7 and 6.0 %, respectively (P < 0.001). The odds ratios of preoperative risk factors for 30-day mortality were: platelet <50,000/µl, 5.6; ASA grade 4 or 5, 4.0; acute renal failure, 3.2; total bilirubin over 3 mg/dl, 3.1; and AST over 35 U/l, 3.1. The odds ratios for operative mortality were: previous peripheral vascular disease, 3.1; cancer with multiple metastases, 3.1; and ASA grade 4 or 5, 2.9. Sixteen and 26 factors were selected for risk models of 30-day and operative mortality, respectively. The c-index of both models was 0.903 [95 % confidence interval (CI) 0.877-0.928; P < 0.001] and 0.891 (95 % CI 0.873-0.908; P < 0.001), respectively. CONCLUSION: We performed the first reported risk stratification study for right hemicolectomy based on a nationwide internet-based database. The outcomes of right hemicolectomy in the nationwide population were satisfactory. The risk models developed in this study will help to improve the quality of surgical practice.

Intraductal papillary growth of liver metastasis originating from colon carcinoma in the bile duct: report of a case.

Morphologically, liver metastases from colorectal carcinoma usually form as nodular tumor masses, whereas intraductal papillary growth in the bile duct is rare. A 65-year-old man underwent right hemicolectomy for advanced colon carcinoma, and histology of the primary carcinoma confirmed moderately differentiated adenocarcinoma with subserosal invasion, no vascular infiltration, and no lymph node metastasis. A liver tumor was found in the right paramedian Glisson pedicle and intraductal growth of cholangiocarcinoma was seen on imaging. We performed right hepatectomy and macroscopically, the resected specimen contained a growth in the bile duct lumen similar to cholangiocarcinoma. Histological examination revealed intraductal papillary proliferation of well-differentiated adenocarcinoma without vascular infiltration or lymph node metastasis in the hepatic hilum. Immunohistochemical staining revealed that the tumor cells were negative for cytokeratin-7 and positive for cytokeratin-20. Based on these findings, liver metastasis from colon carcinoma was diagnosed. Liver metastasis from colorectal carcinoma rarely arises as intraductal papillary growth in the bile duct, but the possibility of liver metastases with unusual morphology must be borne in mind for patients with a history of carcinoma in the digestive tract.

Nationwide survey and establishment of a clinical database for gastrointestinal surgery in Japan: Targeting integration of a cancer registration system and improving the outcome of cancer treatment.

As there was no nationwide database for gastrointestinal surgery in Japan at the time, in 2006, a Clinical Database Committee was established in the Japanese Society of Gastrointestinal Surgery (JSGS) to create a clinical database in Japan. The Committee first organized preliminary nationwide Japanese surveys in gastrointestinal surgery in 2006 and 2007. Data from more than 770,000 patients were accumulated from these web-based surveys, including 333,627 patients in 1039 institutions in 2006 and 440,230 patients in 1464 institutions in 2007. The mortality rate was stratified by organ, surgical procedure and hospital volume without using risk-adjustment techniques. The overall mortality rate was 0.95% in the 2006 survey and 0.92% in the 2007 survey. The organ-based analysis found that the mortality rates were almost similar in 2006 and 2007. Hospital volume influenced the mortality rate in six major surgical procedures, namely esophagectomy, gastrectomy, total gastrectomy, low anterior rectal resection, hepatic resection and pancreaticoduodenectomy. A risk reduction of 30-80% was noted in each surgical procedure, at least in our non-risk-adjusted analysis, in hospitals with a high volume of operations. These preliminary surveys indicate that hospital volume might influence the mortality rate after major abdominal surgery. Further analysis using risk-adjustment techniques should be conducted to understand the specific contribution of hospital volume to surgical mortality. A nationwide database of patients who have undergone gastrointestinal surgery and risk-adjustment analysis of the data are currently planned in Japan.

Risk factors preventing success of a minilaparotomy approach in the resection of colorectal cancer.

BACKGROUND: A minilaparotomy approach is technically feasible for the resection of colorectal cancer in select patients. The aim of this study was to clarify the risk factors preventing the success of a minilaparotomy in the resection of colorectal cancer. METHODS: Between April 2005 and August 2008, 141 consecutive patients were enrolled in this prospective study and scheduled to undergo resection of colorectal cancer using a minimal skin incision. The minilaparotomy involved a colorectal resection performed through a skin incision <7 cm in length. Neither a hand-port nor a laparoscope was used. RESULTS: A minilaparotomy was successful in 74 (52.5%) of 141 patients. Multivariate logistic regression analysis revealed that the failure of the minilaparotomy in the remaining 67 (47.5%) was independently related to gender (male), BMI (> or =25.5), tumor location (splenic flexure and rectum), tumor adhesion/invasion on/into adjacent organs and the maximum tumor diameter (> or =7.0 cm). CONCLUSION: Gender (male), BMI (> or =25.5), tumor location (splenic flexure and rectum) and tumor aggressiveness [tumor adhesion/invasion on/into adjacent organs and maximum tumor diameter (> or =7.0 cm)] were independent risk factors preventing the success of the minilaparotomy approach in the resection of colorectal cancer.

[A case of endocrine carcinoma of the sigmoid colon].

We report a case of endocrine carcinoma of the sigmoid colon. A 71-year-old man was admitted to our hospital because of constipation and bloody stool. Colonoscopy showed a mass lesion with irregular ulceration in the sigmoid colon. He was given a diagnosis of the poorly differentiated adenocarcinoma of the colon, and underwent sigmoidectomy with dissection of the lymph nodes. Histological and immunohistochemical examinations of the resected specimen revealed endocrine carcinoma. Endocrine carcinoma of the colon is rare, and the prognosis is very poor. We discuss this case with references.

Laparotomy wound and anastomotic recurrences after resection for cecum cancer: a case report.

We report herein the case of a 46-year-old man who developed recurrences in both the incisional laparotomy wound of the abdominal wall and the stapled anastomotic site following ileo-colonic resection for cecum cancer. The patient had initially undergone laparoscopic surgery but had converted to conventional open surgery. Intestinal reconstruction had been performed by stapled functional end-to-end anastomosis between the ileum and ascending colon. The implantation of exfoliated cancer cells during the operation may have caused recurrence.

Relationship between CT volumetry and functional liver volume using technetium-99m galactosyl serum albumin scintigraphy in patients undergoing preoperative portal vein embolization before major hepatectomy: a preliminary study.

To clarify the relationship between morphological measurements of hepatic volume by computed tomography (CT-vol) and functional volume (RI-vol) by technetium-99m galactosyl human serum albumin (99mTc-GSA) scintigraphy, and its clinical significance, we examined 16 patients with a background liver status of either normal liver function (n=4), chronic hepatitis or cirrhosis (n=7), or obstructive jaundice (n=5). In five patients who underwent preoperative portal vein embolization (PVE), volumetric measurement was performed 2 weeks after PVE. The mean values of CT-vol and RI-vol of the right lobe were 692+/-147 cm3 (66.1+/-10.7%) and 668+/-159 cm3 (67.8+/-13.2%), respectively, and those of the left lobe were 329+/-138 cm3 (33.9+/-10.6%) and 328+/- 170 cm3 (32.2+/-13.2%), respectively. There were no significant differences in the volume measurements between the two volumetric techniques. Correlations between CT-vol and RI-vol in the right and left lobes were positive and significant (r=0.912 and 0.903, respectively; both P's<0.001). The mean values of post-PVE CT-vol and RI-vol of the right lobe in five patients were significantly different (628+/-149 and 456+/-211 cm3, respectively; P=0.033). However, the mean values of post-PVE CT-vol and RI-vol of the left lobe were not different (496+/-124 and 483+/-129 cm3, respectively). We propose that volumetric measurement by 99mTc-GSA scintigraphy is useful for detecting changes in functional volume of individual lobes of the liver and is a more dynamic method compared with detection of morphological changes by CT scan.

Oncological outcome of ultra-low anterior resection with total mesorectal excision for carcinoma of the lower third of the rectum: Comparison of intrapelvic double-stapled anastomosis and transanal coloanal anastomosis.

BACKGROUND/AIMS: The purpose of this study was to determine whether the type of ultra-low anterior resection (intrapelvic double-stapled anastomosis or transanal hand-sewn coloanal anastomosis) with total mesorectal excision for primary adenocarcinoma of the lower third of the rectum affects survival and recurrence after curative surgery. METHODOLOGY: This retrospective study included 112 patients who underwent curative surgery achieved by ultra-low anterior resection in combination with either intrapelvic anastomosis using a double-stapling technique (DST group; n=82) or transanal hand-sewn coloanal anastomosis (CAA group; n=30). Univariate and corrected (multivariate regression) analyses were used to evaluate data. Median follow-up was 51.2 months for patients alive at the conclusion of this study. RESULTS: Disease-free and disease-specific survivals, and the frequency and location of recurrence after surgery did not differ between the two types of operations. Multivariate analyses showed that the type of operation was not a significant independent variable in predicting disease-free survival or in the development of both local and distant recurrences after surgery. Tumor-related factors (stage or histologic grade) were significant predictors of oncological outcome. CONCLUSIONS: The type of ultra-low anterior resection (DST or CAA) did not affect survival and recurrence after curative resection for carcinoma of the lower third of the rectum.

Pseudomyxoma peritonei accompanied by intraductal papillary mucinous neoplasm of the pancreas.

We describe a case of pseudomyxoma peritonei (PMP) successfully managed with intraperitoneal hyperthermic chemoperfusion. This case is unique due to the concurrent presence of intraductal papillary mucinous neoplasm (IPMN) of the pancreas. The patient presented with abdominal fullness. Abdominal computed tomography revealed massive ascites, thickened peritoneum, and a cystic lesion of the pancreas. Cytological examination of ascitic fluid sample showed mucin-rich atypical cells. Endoscopic retrograde pancreatography revealed a cystic lesion with the defect probably due to mural nodule and mucin, communicating with the pancreatic duct. At exploratory laparotomy, massive ascites and multiple nodules were identified within the peritoneal cavity. No primary tumour, including mucinous neoplasm of the appendix, was found. Histopathological examination of the omentum showed mucinous adenocarcinoma in pools of mucoid material, consistent with PMP. The relation between PMP and IPMN of the pancreas was possible, but not conclusive. The patient received intraperitoneal perfusion of saline heated to 42 degrees C containing cisplatin, etoposide, and mitomycin C, followed by 24 courses of postoperative chemotherapy with gemcitabine. The patient remains in good general condition with no signs of progression of PMP for 2 years, but with a gradual and progressive enlargement of the pancreatic cystic lesion.

Comparative analysis of postoperative morbidity according to type and extent of hepatectomy.

BACKGROUND/AIMS: The aim of our retrospective study was to compare the factors contributing to postoperative complications according to the extent of hepatectomy. METHODOLOGY: We examined 166 patients with hepatobiliary carcinoma who underwent hepatectomy. Patients were divided into three groups according to the type and extent of hepatectomy: 1) left lobectomy (n=27), 2) right lobectomy or posterior segmentectomy (n=55) and 3) other hepatectomies (n=84). Patient demographics, major complications (infection, ascites, pleural effusion, atelectasis, static symptoms of the stomach, biliary leakage and hepatic failure) after hepatectomy were analyzed. RESULTS: In patients with obstructive jaundice, lobectomy was the most commonly performed operation due to the extent of tumor along the main hepatic duct. Prolonged ascites or massive pleural effusion was frequently observed after right lobectomy (p=0.001) and posterior segmentectomy (p=0.002). However, the incidences of these complications were similar in patients with chronic viral hepatitis. Symptoms related to gastric stasis and biliary leakage were significantly more common after left lobectomy than other surgeries. The incidence of hepatic failure was higher (p<0.05) after major hepatectomy, particularly right lobectomy, than other surgeries. CONCLUSIONS: Our results emphasize the need to understand characteristics of specific complications occurring after different types of hepatic resection surgery to prevent post-hepatectomy complications.

Adjuvant photodynamic therapy for bile duct carcinoma after surgery: a preliminary study.

BACKGROUND: Photodynamic therapy (PDT) is a new palliative option in patients with non-resectable bile duct carcinoma (BDC). Here, we assessed the efficacy of adjuvant photodynamic therapy in eight patients with BDC who underwent surgical resection. METHODS: Five patients had extrahepatic BDC, two had intrahepatic cholangiocarcinoma, and one had ampullary carcinoma. Cancer cells were microscopically detected in the stump of the hepatic duct in six patients, and biliary stenosis caused by remnant tumor was observed in one patient. One patient had tumor recurrence with occlusion of the bile duct. At 48 h prior to PDT, porfimer sodium was injected intravenously. A pulse laser by an eximer dye laser (50-100 J/cm2) with a wavelength of 630 microm was applied through an endoscope to the hepatic stump or tumor lesion. RESULTS: Marked destruction of the tumor and ductal epithelium was observed on day 1 after PDT. After PDT, four patients developed mild dermatitis, but no severe morbidity or mortality was noted. In patients who underwent PDT for the stump, one patient showed distant metastasis at 31 months, and four patients did not show tumor recurrence at 17, 12, 12, and 6 months, respectively. However, one of the eight patients died at 2 months, of an unrelated cause. In two patients with occlusion caused by tumor growth, resolution of bile duct stenosis was noted on day 7. These patients showed re-occlusion by tumor at 20 and 8 months. CONCLUSIONS: Adjuvant PDT is a safe and useful option for a better survival benefit in patients with BDC undergoing surgical resection.

Preoperative serum hyaluronic acid level as a good predictor of posthepatectomy complications.

PURPOSE: We evaluated the efficiency of measuring hyaluronic acid (HA) levels preoperatively in patients with injured liver disease as a predictor of complications after hepatectomy. METHODS: We examined patients who underwent hepatectomy for liver tumors secondary to chronic viral liver diseases or obstructive jaundice. RESULTS: The preoperative HA level correlated significantly with the indocyanine green retention rate at 15 min, liver activity at 15 min by technetium-99m galactosyl human serum albumin scientigraphy, and the histopathological activity index. It was also significantly elevated in patients with severe fibrosis caused by cirrhosis. After hepatectomy, the HA level was increased on postoperative day (PODS) 7, but had normalized by POD 28. The preoperative HA level tended to correlate with the regeneration rate on POD 28, and was significantly higher in patients with prolonged ascites or hepatic failure postoperatively. Multivariate analysis identified a serum HA level above 200 or 150 ng/ml as the only significant predictor of postoperative hepatic failure or long-term ascites, respectively (P < 0.05). CONCLUSION: Our findings indicate that the preoperative serum HA level is a good predictor of postoperative complications in patients who undergo hepatectomy for injured liver disease.