Hiroaki Hata

Oral and Parenteral Versus Parenteral Antibiotic Prophylaxis in Elective Laparoscopic Colorectal Surgery (JMTO PREV 07-01): A Phase 3, Multicenter, Open-label, Randomized Trial.

Objective:To confirm the efficacy of oral and parenteral antibiotic prophylaxis (ABX) in the elective laparoscopic colorectal surgery. Background:There is no evidence for the establishment of an optimal ABX regimen for laparoscopic colorectal surgery, which has become an important choice for the colorectal cancer patients. Methods:The colorectal cancer patients scheduled to undergo laparoscopic surgery were eligible for this multicenter, open-label, randomized trial. They were randomized to receive either oral and parenteral prophylaxis (1 g cefmetazole before and every 3 h during the surgery plus 1 g oral kanamycin and 750 mg metronidazole twice on the day before the surgery; Oral-IV group) or parenteral prophylaxis alone (the same IV regimen; IV group). The primary endpoint was the incidence of surgical site infections (SSIs). Secondary endpoints were the incidence rates of Clostridium difficile colitis, other infections, and postoperative noninfectious complications, as well as the frequency of isolating specific organisms. Results:Between November 2007 and December 2012, 579 patients (289 in the Oral-IV group and 290 in IV group) were evaluated for this study. The incidence of SSIs was 7.26% (21/289) in the Oral-IV group and 12.8% (37/290) in the IV group with an odds ratio of 0.536 (95% CI, 0.305–0.940; P = 0.028). The 2 groups had similar incidence rates of C difficile colitis (1/289 vs 3/290), other infections (6/289 vs 5/290), and postoperative noninfectious complications (11/289 vs 12/290). Conclusions:Our oral-parenteral ABX regimen significantly reduced the risk of SSIs following elective laparoscopic colorectal surgery.

Introduction of laparoscopic low anterior resection for rectal cancer early during residency: a single institutional study on short-term outcomes

BackgroundLaparoscopic surgery for rectal cancer is unpopular because it is technically challenging. Suitable training systems have not been widely studied or established despite the steep learning curve for this procedure. We developed a systematic training program that enables resident surgeons to perform laparoscopic low anterior resection (LLAR) for rectal cancer and evaluated the safety and feasibility of this training program.MethodsWe analyzed prospectively gathered data on all LLARs for rectal cancer performed at a single center over a 7-year period. Patients were assessed for demographic characteristics, tumor characteristics, operative procedure, operative time, blood loss, conversion to open surgery, complications, time to bowel recovery, distal margin, and number of lymph nodes harvested. We compared the early surgical, oncological, and functional outcomes of LLARs performed by expert surgeons with those of LLARs performed by resident surgeons for both intraperitoneal and extraperitoneal rectal cancer. All analyses were performed on an intention-to-treat basis.ResultsA total of 137 patients met the inclusion criteria for this study. Of the 75 LLARs for intraperitoneal rectal cancer, 40 were performed by expert surgeons (I-E group) and 35 by resident surgeons (I-R group). Of the 62 LLARs for extraperitoneal rectal caner, 51 were performed by expert surgeons (E-E group) and 11 by resident surgeons (E-R group). The operative time was longer in the E-R group than in the E-E group. The time to resumption of diet was longer in the I-E group than in the I-R group. The other early outcomes, including blood loss, anastomotic leakage, conversion to open surgery, and number of lymph nodes harvested, were similar in the I-E and I-R groups and in the E-E and E-R groups.ConclusionOur systematic training program on LLAR for rectal cancer enables resident surgeons to perform this procedure safely early during residency, with acceptable short-term outcomes.

Risk Factors for Complications After Laparoscopic Surgery in Colorectal Cancer Patients: Experience of 401 Cases at a Single Institution

BackgroundLaparoscopic surgery is widely used for the treatment of colorectal cancer, but little is known about perioperative risk factors for complications.MethodsClinical data were reviewed for 401 consecutive unselected colorectal cancer patients who underwent laparoscopic surgery at Kyoto Medical Center between 1998 and 2005. The outcome variable was incidence of postoperative complications. Using logistic regression analysis, 58 background, clinical, preoperative, and intraoperative factors were assessed as potential predictors of complications.ResultsThe set of independent protective factors that had the greatest influence on the incidence of local complications after colon surgery was as follows: cefmetazole use for prophylaxis (versus oral only; adjusted odds ratio (OR) 0.18, 95% confidence interval (CI) 0.06–0.54), high operative infusion rate (per ml/min; OR 0.82, 95% CI 0.70–0.95), regular laxative use (OR 0.33, 95% CI 0.12–0.79), and double-stapled anastomosis (versus hand-sewn; OR 0.15, 95% CI 0.03–0.83). Independent risk factors for local complications after rectal surgery were abdominoperineal resection (versus low anterior resection, OR 4.84, 95% CI 1.64–14.9), long operative time (per hour, OR 1.55, 95% CI 1.11–2.23), and history of heart disease (OR 5.18, 95% CI 1.34–21.5). The occurrence of complications was not found to be associated with overall survival in this study.ConclusionsWe identified intraoperative management such as low operative infusion rate is one of the independent significant risk factors for complications after laparoscopic surgery for colorectal cancer in addition to patient characteristics and surgical procedure.

Successful treatment of gastric perforation with thyrotoxic crisis

Patients with thyrotoxic crisis presenting with another emergency are at a considerable risk. We report the successful treatment of a 55-year-old woman having gastric perforation with thyrotoxic crisis; the principle of treatment was delayed surgery after rapid preoperative restoration of thyroid function and cardiovascular status. The patient was admitted for severe abdominal pain and nausea with delirium, exophthalmos, diffuse goiter, tremulousness, diaphoresis, tabescence, pretibial edema, and atrial fibrillation. Computed tomography revealed free air over the liver surface. She had been diagnosed with uncontrolled hyperthyroidism 3 days before admission, with a free liothyronine (T(3)) of 23.2 pg/mL, a free levothyroxine sodium (T(4)) of greater than 7.78 ng/dL, and thyrotropin of less than 0.01 ng/mL. She was diagnosed with gastroduodenal perforation and thyrotoxic crisis, and we planned nonoperative management comprising nasogastric aspiration, cefmetazole sodium, omeprazole, thiamazole, and Lugols solution. We also used landiolol, an ultrashort-acting beta(1)-adrenoceptor antagonist, and hydrocortisone. On the third day of admission, her thyroid function had improved with a free T(3) of 4.7 pg/mL and a free T(4) of 2.9 ng/dL; however, perforative peritonitis had worsened, and hence, omental patch repair was performed. She recovered uneventfully and was discharged after radioiodine administration. We discuss the management of a thyrotoxic patient with gastric perforation and focus on the importance of changing the management according to the patients clinical course considering his thyroid function status and comparing the stress of surgery with that of perforative peritonitis in nonoperative management.

Laparoscopic resection for sigmoid and rectosigmoid colon cancer performed by trainees: impact on short-term outcomes and selection of suitable patients

PurposeThis study aimed (1) to evaluate the impact of clinical factors, particularly operation by trainees, on the short-term outcomes of laparoscopic resection for sigmoid and rectosigmoid cancer, and (2) to determine patients suitable for operation by trainees.MethodsFrom a prospectively maintained single-institution database, we identified 133 patients who underwent laparoscopic resection for sigmoid or rectosigmoid cancer between 2007 and 2010. Gender, age, body mass index (BMI), previous abdominal surgery, tumor location, tumor size, tumor stage, extent of lymph node dissection, and primary surgeon were evaluated using univariate and multivariate analyses to determine the predictive significance of these variables on surgical outcomes including operative time, blood loss, complication, postoperative stay, and retrieved lymph nodes.ResultsMultivariate analysis showed that location of the tumor in the rectosigmoid (p < 0.001), higher BMI (p < 0.001), operation by trainees (p < 0.001), male gender (p = 0.002), and greater tumor depth (p = 0.011) were independently predictive of longer operative time. Larger tumor size (p = 0.025) and higher BMI (p = 0.040) were independently predictive of greater blood loss. Larger tumor size was also related to longer postoperative stay (p = 0.001) and a greater number of retrieved lymph nodes (p = 0.001).ConclusionsThis study identified operation by trainees as an independent risk factor for longer operative time but with no negative impact on any of the other outcomes. Female patients with a low BMI, sigmoid cancer, shallow tumor depth, and/or small tumor are suitable for operation by trainees.

A phase II study of neoadjuvant chemotherapy with S‐1 and cisplatin for stage III gastric cancer: KUGC03

A multi‐center phase II study was conducted to evaluate the safety and efficacy of neoadjuvant chemotherapy (NAC) with S‐1 plus cisplatin for advanced gastric cancer.