Language：Japanese   Publishing type：Research paper (scientific journal)  

The Japanese gastric cancer clinical practice guideline recommends FOLFOX as one of the first-line chemotherapy for advanced gastric cancer. Since FOLFOX is administered intravenously, it is helpful for patients who have difficulty in oral intake. Herein, we report a patient in which FOLFOX was significantly effective after failure to treatment with S-1 plus CDDP. A 75-year-old gastric cancer patient with paraaortic lymph node metastasis and multiple liver metastases(Stage ⅣB)was treated. Severe stomatitis and impaired consciousness due to dehydration appeared after administration of S-1 plus CDDP. After his general condition recovered, we changed his regimen to FOLFOX. No serious adverse events were observed, and partial response was achieved after 4 courses of treatment. Partial response was maintained until the onset of oxaliplatin drug allergy in the 10th course. FOLFOX is a promising option for patients with difficulties in oral intake.

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BACKGROUND: Transnasal endoscopy has recently become common in Japan. Although transnasal endoscopy has many advantages, nasal pain and epistaxis are common complaints. To reduce nasal pain and epistaxis, we developed a new tube sheath system for transnasal endoscopy. This new tube sheath system (outer sheath and inner tube), called the Nasal Slider, is produced by TOP Corporation, Japan. METHODS: A tube sheath longer than the nasal concha is inserted to reduce pain along the nasal turbinate. Because the sheath is left in place, tubes can be passed through the nose multiple times without causing additional pain. A total of 34 consecutive patients (mean age 68.1 years; 22 men and 12 females) who had undergone transnasal endoscopy in the past were selected for transnasal endoscopy with the Nasal Slider. After the transnasal endoscopy was completed, patients who gave consent for use of the Nasal Slider were interviewed by using 3 questionnaires on nasal discomfort, nasal pain, and epistaxis. RESULTS: Because the transnasal endoscope passes inside the sheath, epistaxis can be prevented. Thirty of 34 selected patients underwent transnasal endoscopy using the Nasal Slider. Twenty-seven and 28 patients reported feeling less nasal discomfort and pain, respectively, with the Nasal Slider than during examinations without the Nasal Slider. No epistaxis developed in any patient examined with the Nasal Slider. CONCLUSIONS: The Nasal Slider appears to reduce nasal pain and epistaxis during transnasal endoscopy and is currently used in many hospitals in Japan.

DOI： 10.1272/jnms.JNMS.2022_89-101

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Language：Japanese   Publisher：(一社)日本消化器外科学会  

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Language：Japanese   Publisher：(一社)日本消化器外科学会  

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BACKGROUND: The traditional National Healthcare Safety Network (previously National Nosocomial Infections Surveillance) risk index is used to predict the risk of surgical site infection across many operative procedures. However, this index may be too simple to predict risk in the various procedures performed in colorectal surgery. The aim of this study was to evaluate the usefulness of the risk index by analyzing the impact of the risk index factors on surgical site infection after abdominal colorectal surgery. METHODS: Using our surgical site infection surveillance database, we analyzed retrospectively 538 consecutive patients who underwent abdominal colorectal surgery between 2005 and 2010. Correlations between surgical site infection and the following risk index factors were analyzed: length of operation, American Society of Anesthesiologists score, wound classification, and use of laparoscopy. The 75th percentile for length of operation was determined separately for open and laparoscopic surgery in the study model. RESULTS: Univariate analyses showed that surgical site infection was more strongly associated with a >75th percentile length of operation in the study model (odds ratio [OR], 2.07) than in the traditional risk index model (OR, 1.64). Multivariable analysis found that surgical site infection was independently associated with a >75th percentile length of operation in the study model (OR, 2.75; 95% confidence interval [CI], 1.66-4.55), American Society of Anesthesiologists score ≥3 (OR, 2.22; 95% CI, 1.10-4.34), wound classification ≥III (OR, 5.29; 95% CI, 2.62-10.69), and open surgery (OR, 2.21; 95% CI, 1.07-5.17). Performance of the risk index category was improved in the study model compared with the traditional model. CONCLUSIONS: The risk index category is sufficiently useful for predicting the risk of surgical site infection after abdominal colorectal surgery. However, the 75th percentile length of operation should be set separately for open and laparoscopic surgery.

DOI： 10.1089/sur.2013.260

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BACKGROUND: Single-incision laparoscopic surgery has gained increasing attention due to its potential to improve the benefits of laparoscopic surgery. However, the technique remains technically challenging for most surgeons. We developed a new technique utilizing a needle grasper held in the surgeon's left hand as an alternative to conventional single-incision laparoscopic cholecystectomy (SILC). PATIENTS AND METHODS: From August 2011 through May 2013, 29 patients at Nippon Medical School Musashi Kosugi Hospital, with gallbladder stones or polyps underwent single-incision laparoscopic cholecystectomy (SILC) with an additional needle grasper that was held in the surgeon's left hand (SILCAN) and introduced in the right subcostal region without a trocar. We analyzed intraoperative and postoperative outcomes of 29 patients for whom SILCAN was performed and retrospectively compared these outcomes to those of 32 patients who underwent conventional 4-port laparoscopic cholecystectomy (CLC) from January 2011 through May 2013. RESULTS: No differences in patient characteristics or intraoperative/postoperative outcomes were observed between the groups. None of the patients in either group required conversion to an open procedure or additional ports. In the SILCAN group, no patients had complications within the first 4 weeks after surgery, with the exception of 1 patient with severe chronic cholecystitis in whom bile duct stenosis developed due to inadvertent clipping of the common hepatic duct. The frequency of postoperative analgesic use was similar in both groups, although none of the patients in the SILCAN group received analgesics for pain from the small, inconspicuous wound in the right subcostal region. CONCLUSIONS: SILCAN is a safe and feasible alternative to SILC which does not compromise the qualities of CLC. It is less technically challenging, and postoperative pain and cosmesis are comparable to those of conventional SILC.

DOI： 10.1272/jnms.82.43

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PURPOSE: Elevation of the serum total bilirubin (STB) level not stemming from hepatic dysfunction or biliary obstruction may be seen in cases of acute appendicitis. This paper deals with the clinical significance of such elevations. METHODS: Data from 410 appendectomized patients classified into two groups (a high preoperative STB group and a normal preoperative STB group) were analyzed to reveal the significance of preoperative hyperbilirubinemia. We also examined whether the preoperative STB level might serve as a risk factor for gangrenous appendicitis by a multivariate analysis. RESULTS: Gangrenous appendicitis was more common in the high preoperative STB group (p < 0.001). The multivariate analysis revealed that an elevated preoperative STB level (odds ratio 1.7919) was a risk factor for gangrenous appendicitis. CONCLUSION: In patients with an elevated preoperative STB level, it is very likely that the inflammation is severe and that the disease has progressed to a severe condition histopathologically; therefore, meticulous attention should be paid to the selection of the surgical procedure, as well as to the postoperative clinical course.

DOI： 10.1007/s00595-013-0659-5

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BACKGROUND: Since 2005, we have been conducting prospective surgical site infection (SSI) surveillance and infection control according to the U.S. Centers for Disease Control and Prevention guidelines for patients who undergo gastrointestinal surgery at our institution. Surgical site infection occurs with greater frequency in emergency than in elective surgery because of factors such as ill-conceived preoperative preparation and "dirty" operations. A large number of studies have been reported on risk factors for SSI in elective colorectal surgery; however, there are few papers on such factors in emergency colorectal surgery. The aim of this study was to identify risk factors for incisional SSI in emergency colorectal surgery. METHODS: Using our SSI surveillance database, we analyzed retrospectively 78 patients who underwent emergency colorectal surgery between 2005 and 2010. Univariable and multivariable analyses were used to identify risk factors for incisional SSI. Moreover, we subclassified dirty-infected operations (class IV) by the extent of contamination according to our own definition to study the incidence of incisional SSI at each degree. RESULTS: The incidence of incisional SSI was 32.1% (25/78 patients). By univariable analysis, seven parameters correlated with a higher risk of incisional SSI: Surgical incision class III-IV, obesity (body mass index ≥25 kg/m(2)), American Society of Anesthesiologists score 3 or 4 points, chronic kidney disease (serum creatinine concentration >1.2 mg/dL), blood loss ≥200 mL, blood transfusion, and ventilator support. Multivariable analyses showed that surgical incision class III-IV (odds ratio [OR] 5.9; 95% confidence interval [CI] 1.7, 25.2) and obesity (OR 11.9; 95% CI 2.1, 87.8) were independent risk factors for incisional SSI. The incidence of incisional SSI in colon perforation with generalized contamination was statistically higher than that in prepared colon perforation and colon perforation with localized contamination (82.4% vs. 25.0%; p<0.001). CONCLUSIONS: The risk factors for incisional SSI in emergency colorectal surgery were incision contamination and obesity. Moreover, the incidence of incisional SSI among the incision class IV operations increased significantly with increasing extents of contamination. As a tactic for management of dirty abdominal wounds, we suggest that primary skin closure is suitable in cases of perforation of a prepared colon or colon perforation with localized contamination. On the other hand, in cases of colon perforation with generalized contamination, delayed primary skin closure or leaving an incision open to heal by secondary intention should be considered.

DOI： 10.1089/sur.2012.154

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True splenic cysts are uncommon and are associated with elevated serum and intracystic tumor marker CA 19-9 levels. A 33-year-old woman presented to our hospital with a chief complaint of epigastralgia. Computed tomography of the abdomen showed a 10-cm cystic lesion in the spleen. The serum carbohydrate antigen (CA) 19-9 level was 3,347 U/mL (normal, <37 U/mL). Total laparoscopic splenectomy was performed, and the serum level of CA 19-9 had normalized 2 weeks later. Pathological examination showed a benign true epidermal cyst of the spleen with strong immunohistological staining for CA 19-9. Splenic epidermoid cysts most often occur in young women, and laparoscopic surgery to remove cysts of this type is minimally invasive. Thus, laparoscopic surgery should be the method of first choice for most cases of splenic benign true cyst.

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