Naoki Hirabayashi

Using the Objective Structured Assessment of Technical Skills (OSATS) global rating scale to evaluate the skills of surgical trainees in the operating room.

PurposeThe education of surgical trainees should be based on an accurate evaluation of their surgical skill levels. In our hospital, the Objective Structured Assessment of Technical Skills (OSATS) is used for this purpose. We conducted this study to demonstrate the validity and accuracy of the OSATS for assessing surgical skills in the operating room (OR) setting.MethodsBetween January, 2007 and December, 2010, the OSATS global rating scale was used to assess several operations in which surgical trainees participated. We assessed ten surgical trainees who participated as the main surgeon or first assistant, and studied the correlation between their postgraduate year and their OSATS score.ResultsThe median score of the global rating scale for each trainee improved with each year of experience. The median scores of all trainees in postgraduate years 3, 4, and 5 were significantly different (pxa0<xa00.001 for both the main surgeon and first assistant roles; Kruskal–Wallis test).ConclusionUsing the OSATS global rating scale to assess the surgical skills of trainees in the OR was feasible and effective.

C-Reactive protein is an independent surgical indication marker for appendicitis: a retrospective study

BackgroundThis study is an attempt to clarify the role of C-reactive protein (CRP) as a surgical indication marker for appendicitis.MethodsOne hundred and fifty patients who underwent appendectomies and had pathologically confirmed appendicitis were reviewed between May 1, 1999 and September 31, 2007. The correlation between preoperative clinical factors and the actual histological severity, and identify surgical indication markers were assessed by univariate and multivariate analyses.ResultsUnivariate analysis showed that only the CRP level significantly differ between the surgical treatment necessary group (gangrenous appendicitis) and the possible non-surgical treatment group (catarrhalis and phlegmonous appendicitis). Multivariate analysis indicated only the CRP level to be a surgical indication marker for acute appendicitis. The receiver-operating characteristic (ROC) curve indicated that the cutoff value of CRP for surgical indication of appendicitis is 4.95 mg/dl.ConclusionOnly the CRP level is consistent with the severity of appendicitis, and considered to be a surgical indication marker for acute appendicitis.

Nitrite/Nitrate Oxide and Cytokines Changes in Patients with Surgical Stress

Nitric oxide (NO) produced by inducible nitric oxide synthase (iNOS) is implicated in immunolog-ical and inflammatory processes. Inflammatory cytokines and endotoxin induce a large amount of NO from various cells. Surgical stress produces cytokines, which leads to systemic inflammatory response syndrome (SIRS). Continuously high production of cytokines causes a variety of complications including pneumonia, intraabdominal abscess and sepsis. We investigated the relationships between the nitrite/nitrate (NOx) concentration and the level of cytokines in 50 patients undergoing gastroenterological surgery. We measured the levels of cytokines, including interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α) interleukin-1 receptor antagonist (IL- 1ra), and nitrite/nitrate (NOx) concentration in the serum and exudative fluid from the thoracic or abdominal cavity of 50 patients undergoing gastroenterological surgery in order to make clear the relationship between cytokines and NO.NOx levels in the serum of the group with complications were higher on days 3 and 7 than in the group with no complications (P < 0.05). In the complications group, IL-6 was more elevated, and the NOx level was synchronously elevated. In conclusion, surgical stress caused inflammatory cytokinemia. NOx was produced during surgical stress, and when complications occurred, more NOx was produced.

A Case of an Acute Cervicomediastinal Hematoma Secondary to the Spontaneous Rupture of a Parathyroid Adenoma

We herein report the case of a patient with an acute cervicomediastinal hematoma secondary to the spontaneous rupture of a parathyroid adenoma. A 47-year-old female presented with swelling and pain in the neck. She had no history of trauma or of having undergone any medical or odontological procedures. An ultrasound examination revealed the presence of an obscure mass located behind the right lobe of the thyroid gland. A computed tomography scan showed the presence of a low-density lesion extending from the retropharynx to the mediastinum, a high-density lesion located behind the right lobe of the thyroid gland and a right pleural effusion. Because the patients neck swelling and anemia gradually worsened, she underwent emergency surgery. The neck was found to be swollen due to a hematoma; however, no abscesses were detected in the operative field.Thoracoscopy of the right chest showed no active bleeding. The fragmented mass was histopathologically diagnosed as a parathyroid adenoma with acute hemorrhage, which is quite rare. Our experience suggests that, in patients with severe cervicomediastinal hematomas without any trauma or trigger, a diagnosis of spontaneous rupture of a parathyroid gland lesion should be considered.

Combination chemotherapy with S-1 plus cisplatin for gastric cancer that recurs after adjuvant chemotherapy with S-1: multi-institutional retrospective analysis

BackgroundIt is unclear whether S-1 plus cisplatin is effective for patients with recurrent gastric cancer after adjuvant S-1 chemotherapy.MethodsWe retrospectively evaluated the efficacy of S-1 plus cisplatin in patients whose gastric cancer recurred after adjuvant S-1 chemotherapy.ResultsIn the 52 patients evaluated, the median duration of adjuvant S-1 chemotherapy was 8.1xa0months, and the median recurrence-free interval (RFI) since the last administration of adjuvant S-1 was 6.4xa0months. Among the 36 patients with measurable lesions, 7 achieved a complete or partial response, and 13 were evaluated as having stable disease, for an overall response rate of 19.4% and a disease control rate of 55.6%. For all patients, the median progression-free survival (PFS) was 4.8xa0months, and the median overall survival (OS) was 12.2xa0months. Compared with patients with an RFI of <6xa0months (nxa0=xa025), patients with an RFI of ≥6xa0months (nxa0=xa027) had a significantly higher response rate (5.0 vs. 37.5%, respectively), longer PFS (2.3 vs. 6.2xa0months, respectively), and longer overall survival (7.3 vs. 16.6xa0months, respectively). According to a multivariate Cox model including performance status (PS) and reason for discontinuation of adjuvant S-1, an RFI of 6xa0months was still significantly associated with PFS and OS.ConclusionsS-1 plus cisplatin is effective for patients with gastric cancer that recurs after adjuvant S-1 chemotherapy, especially for those with an RFI of ≥6xa0months.

Synchronous Bilateral Solid Papillary Carcinomas of the Breast

We herein report a case of synchronous bilateral solid papillary carcinoma of the breast. A 73-year-old female had a mass that was detected in the right breast on mammography. An ultrasound examination revealed one intracystic tumor in the right breast and two tumors in the left breast. A fine-needle aspiration biopsy of these three tumors was performed, which revealed a diagnosis of malignancy. A magnetic resonance imaging examination of the breasts showed diffuse small nodules surrounding these tumors bilaterally. Bilateral partial mastectomy and a sentinel lymph node biopsy were performed. Lymph node metastasis was detected in the right axilla, and additional lymph node dissection was performed. The pathological diagnosis was synchronous bilateral breast cancer, invasive ductal carcinoma NOS of the right breast, mucinous carcinomas of the left breast, and bilateral SPCs. A wide range of surgical margins were positive for SPCs, and additional bilateral total mastectomy was then performed. To the best of our knowledge, little is known about synchronous bilateral SPCs. Our case indicates that some SPCs can be widely scattered and make up a variety of invasive carcinomas. It is difficult to make a correct preoperative evaluation in such cases.

2221 Randomized phase III trial of gastrectomy with or without neoadjuvant S-1 plus cisplatin for type 4 or large type 3 gastric cancer; short-term safety and surgical results: Japan Clinical Oncology Group Study (JCOG 0501)

Background The prognosis of patients with linitis plastica (type 4) and large (≥ 8 cm) ulcero-invasive-type (type 3) gastric cancer is extremely poor, even after extended surgery and adjuvant chemotherapy. Given the promising results of our previous phase II study evaluating neoadjuvant chemotherapy (NAC) with S-1 plus cisplatin (JCOG0210), we performed a phase III study to confirm the efficacy of NAC in these patients, with the safety and surgical results are presented here. Methods Eligible patients were randomized to gastrectomy plus adjuvant chemotherapy with S-1 (Arm A) or NAC followed by gastrectomy + adjuvant chemotherapy (Arm B). The primary endpoint was the overall survival (OS). This trial is registered at the UMIN Clinical Trials Registry as C000000279. Results From February 2007 to July 2013, 300 patients were randomized (Arm A 149, Arm B 151). NAC was completed in 133 patients (88%). Major grade 3/4 adverse events during NAC were neutropenia (29.3%), nausea (5.4%), diarrhea (4.8%), and fatigue (2.7%). Gastrectomy was performed in 147 patients (99%) in Arm A and 139 patients (92%) in Arm B. The operation time was significantly shorter in Arm B than in Arm A (median 255 vs. 240 min, respectively; p = 0.024). There were no significant differences in Grade 2–4 morbidity and mortality (25.2% and 1.3% in Arm A and 15.8% and 0.7% in Arm B, respectively). Conclusions NAC for type 4 and large type 3 gastric cancer followed by D2 gastrectomy can be safely performed without increasing the morbidity or mortality.

Inguinal hernia repair with the mesh plug method is safe after radical retropubic prostatectomy.

AbstractPurposenWe evaluated the safety and efficiency of using the mesh plug method (MP) to repair inguinal hernias in patients with a history of radical retropubic prostatectomy (RRP). We also investigated how RRP influences the development of inguinal hernias and impacts their repair.MethodsnAmong 488 adult male patients who underwent inguinal hernia repair during a recent 5-year period, 37 had a history of RRP. We compared the characteristics and surgical outcomes of the patients who had undergone RRP (post-RRP group) with those who had not (non-RRP group).ResultsAll post-RRP hernias were treated by MP. The 37 post-RRP patients had a collective 41 hernias, 40 of which were of the indirect type. The side affected by the hernia did not differ significantly between the groups. We compared the short-term surgical outcomes of the indirect post-RRP hernias vs. the indirect non-RPP hernias without recurrence and incarceration. The operation times, postoperative hospital stay, and mobility rates did not differ significantly between the two groups. The blood loss was almost equal in both groups.ConclusionInguinal hernia repair after RRP may be difficult because of inflammatory changes in the preperitoneal cavity, but the surgical outcomes of MP were equivalent in patients with or without a history of RPP in this study. MP is a safe and effective method for post-RPP hernia repair.

A randomised phase II trial of capecitabine plus cisplatin versus S-1 plus cisplatin as a first-line treatment for advanced gastric cancer: Capecitabine plus cisplatin ascertainment versus S-1 plus cisplatin randomised PII trial (XParTS II)

BACKGROUNDnCapecitabine plus cisplatin (XP) is a standard global regimen, while S-1 plus cisplatin (SP) is a Japanese standard for first-line treatment of advanced gastric cancer (AGC). We conducted a phase II trial comparing XP with SP for patients with AGC to confirm whether these regimens can be used as controls in a phase III study and to explore whether histological subtypes favour XP or SP.nnnPATIENTS AND METHODSnEligible patients were randomised to receive either S-1 40xa0mg/m2 for 21 days plus cisplatin 60xa0mg/m2 (q5w) or capecitabine 1000xa0mg/m2 for 14 days plus cisplatin 80xa0mg/m2 (q3w). The primary end-point was progression-free survival (PFS). The secondary end-points were overall survival (OS), overall response rate (ORR)xa0and safety.nnnRESULTSnIn 110 eligible patients, 24-week PFS was higher in both groups (SP 50.9%, XP 43.5%) than the protocol-specified threshold of 40%. The median PFS for SP versus XP was 5.6 and 5.1 months (hazard ratio [HR], 1.126; pxa0=xa00.5626); OS was 13.5 and 12.6 months (HR, 0.942; pxa0=xa00.7769)xa0and the ORR was 42.4% and 69.4% (pxa0=xa00.0237), respectively. The most common grade ≥3 adverse events with SP/XP were anaemia (16%/20%), neutropenia (9%/18%) and anorexia (18%/13%). Subgroup analysis by histological classification showed no statistical difference between treatments.nnnCONCLUSIONSnXP and SP are comparable and can be recommended as control arms in a phase III study for AGC. Histological subtypes were not sensitive markers for the selection of XP or SP.nnnCLINICAL TRIAL REGISTRATIONnNCT00140624.

Invasive micropapillary carcinoma component is an independent prognosticator of poorer survival in Stage III colorectal cancer patients

BackgroundnInvasive micropapillary carcinoma (IMPC) is an aggressive variant of adenocarcinoma found in several organs. Recent studies showed that IMPC in colorectal cancer leads to poorer prognosis than conventional colorectal cancer; however, the influence of IMPC on outcomes remains unclear. The present study aimed to identify the clinicopathological characteristics of colorectal cancers with IMPCs, and to evaluate the prognostic significance of IMPCs per se.nnnMethodsnWe retrospectively analyzed data from 837 patients with colorectal cancer who underwent surgical treatment. We compared the clinicopathological characteristics and survival outcomes of colorectal cancer patients with IMPCs to those without.nnnResultsnAmong 837 patients, 130 (16%) had an IMPC component, including 0 (0%) of 18, 9 (4.2%) of 215, 34 (13%) of 254, 59 (24%) of 249 and 28 (27%) of 101 patients with TNM Stages 0, I, II, III and IV, respectively. The 3-year disease-free survival (DFS) rates were significantly worse for Stage III patients with IMPC than for those without (55.3% vs. 78.7% respectively, P < 0.001), but not in patients with other stages. Multivariate analyses of patients with Stage III colorectal cancer found IMPC to be associated with significantly worse DFS (P = 0.026), as were high CEA levels, tumor budding and TNM staging. IMPC was only significantly associated with tumor invasion (P = 0.045) and venous invasion (P = 0.045) in Stage III tumors.nnnConclusionsnIdentifying IMPC components in Stage III colorectal cancer is crucial, as their presence is significantly associated with poorer survival.