Yasunori Iso

Risk Factors Associated with Surgical Site Infection in Upper and Lower Gastrointestinal Surgery

PurposeTo assess the risk factors of surgical site infection (SSI) in gastrointestinal surgery.MethodsSurgical site infection surveillance was conducted in 27 hospitals.ResultsThe incidence of SSI in the 941 patients studied was 15.5%. The factors associated with SSI were body mass index (BMI), comorbidity, emergency procedures, wound classification, blood loss, the suture material used for intra-abdominal ligation, the method of subcutaneous incision, the frequency of glove changes, and the absence of subcutaneous sutures. In lower alimentary tract procedures, additional factors influencing the incidence of SSI were sex, smoking status, operating time, the suture material used for abdominal wound closure and seromuscular sutures, and the combined resection procedures. According to a multiple logistic regression analysis, the independent risk factors for SSI were as follows: the type of operation, blood loss, wound classification, emergency procedures, the frequency of glove changes, the use of subcutaneous sutures, combined resection procedures, and the material used for seromuscular suturing.ConclusionStrict asepsis and minimal blood loss were associated with a lower incidence of SSI following gastrointestinal surgery. The use of absorbable suture material may be involved in reducing the risk of SSI.

Epstein-Barr virus-associated gastric carcinoma

Epstein-Barr virus (EBV) is associated with certain types of gastric carcinoma. We report a case of EBV-positive undifferentiated carcinoma of the stomach in a 59-year-old woman with a well-demarcated ulcerating tumor in the gastric body. Examination of the resected stomach revealed that the tumor was undifferentiated carcinoma with lymphoid stroma, or lymphoepithelioma-like carcinoma. Tumor cells were positive for EBV by in situ hybridization. Gastroenterologists must keep in mind that localized ulcerating tumors of the stomach histologically seen as undifferentiated carcinnoma with lymphoid stroma are linked to EBV infection.

Temporary Deterioration of Pulmonary Functions after Injection Sclerotherapy for Cirrhotic Patients with Esophageal Varices

In 34 cirrhotic patients with esophageal varices, a significant but temporary deterioration in pulmonary function tests occurred 24 h after endoscopic injection sclerotherapy using 5% ethanolamine oleate. Included were vital capacity, forced expiratory volume in 1 s, closing volume/vital capacity and arterial oxygen content. Twenty-four hours after the sclerotherapy, the patients complaining of postinjection retrosternal pain had a larger fall in vital capacity and forced expiratory volume in 1 s than did the patients without pain. Before the injection sclerotherapy, 11 of 34 patients had an arterial hypoxemia (PaO2 less than 80 mm Hg). In these patients, there was a significantly (p less than 0.001) higher value of closing volume before sclerotherapy and there were larger changes in both closing volume (p less than 0.01) and arterial oxygen content (p less than 0.01) 24 h after the injection sclerotherapy than in the patients without hypoxemia. Reversion to a state before sclerotherapy was attained 7 days after the sclerotherapy. Thus, patients undergoing sclerotherapy for bleeding esophageal varices should be closely monitored with regard to pulmonary function.

Increased platelet count as a screening test for distal splenorenal shunt patency.

Hypersplenism was not relieved by distal splenorenal shunting in 46 of 47 Japanese patients with nonalcoholic cirrhosis of the liver. However, the platelet count significantly increased by 40 percent of the preoperative value, whereas the increment in the white blood cell count was nil. Though the platelet count in 47 patients with a patent shunt did not significantly differ from that in another 7 patients with an occluded shunt, the rate of increase was significantly higher in those with patency than in those with early occlusion throughout the postoperative period and in those with late occlusion 6 months after operation. The increased rate of the platelet count can thus serve to screen patients for shunt patency.

Comparative effects of 5% ethanolamine oleate versus 5% sodium morrhuate for sclerotherapy of oesphageal varices

Forty‐five cirrhotic patients with oesophageal varices were randomized to receive endoscopic injection sclerotherapy with either 5% ethanolamine oleate (EO), or 5% sodium morrhuate (SM). In the EO group, there was a statistically significant higher rate of disappearance of red colour signs on the varices a week after the initial session of sclerotherapy than in the SM group (91.3%vs 45.5%, P < 0.05). A jet‐like bleeding from injection sites at the second session of sclerotherapy occurred in three patients in the SM group and they experienced blurred vision. There was no such occurrence in the EO group. Oesophageal bleeding requiring blood transfusion during the course of repeated sclerotherapy occurred only in the SM group (five patients): bleeding was from a partly thrombosed varix and in four was from oesophageal ulcers.

Eradication of esophageal varices with repeated injection sclerotherapy in inoperable patients.

SummaryEsophageal varices in 50 cirrhotic patients were treated with repeated injection sclerotherapy. Eradication of varices was achieved in 27 patients (54.0%) with a mean of 4.5 injections (range 2–12) after a mean period of 3.1 months (range 1–11). There was no variceal bleeding in these 27 patients once eradication had been achieved, with a mean follow up period of 5.6 months, although bleeding occurred in 5 of the same group before eradication of the varices had been achieved, during an average of 3.1 months, and in 6 of the remaining 23 patients (10 episodes) with residual varices after a mean of 4.7 injections (range 2–12) in a mean period of 12.2 months (range 1–33).Esophageal varices can thus be eradicated with repeated injections and bleeding from recurrent esophageal varices can be prevented in many patients after eradication has been achieved.

Morphological and Hemodynamic Changes of the Lung after Injection of 5% Ethanolamine Oleate into Dogs

We examined the pulmonary hemodynamics and morphology after injection of a sclerosing solution of 5% ethanolamine oleate (EO) into 24 normal dogs. EO of 0.5 ml/kg (n = 5), 1.0 ml/kg (n = 6), and 3.0 ml/kg (n = 7) was injected through the jugular vein into the right atrium for pathological examination and gravimetric study of the lung, while monitoring the pulmonary hemodynamics for 12 h. Normal saline of 3.0 ml/kg was injected into the remaining 6 control dogs, using the same method. Cardiac output significantly decreased immediately after injection of the sclerosant in all dogs given 0.5 ml/kg, 1.0 ml/kg and 3.0 ml/kg injections of EO; however, there was a tendency toward recovery from 6 h after injection in dogs given 0.5 ml/kg and from 9 h in dogs given 1.0 ml/kg. Pulmonary hypertension just after injection and hypoxia at 9-12 h occurred only when 3.0 ml/kg was injected. Irreversible pulmonary hemorrhage was present in the excised lungs in 4 of 7 dogs given 3.0 ml/kg, while there were no significant lesions in the other dogs. The lung water content in cases of 1.0 and 3.0 ml/kg injections was significantly higher than that in the controls, while there was no significant difference between those given 0.5 ml/kg and of the controls. The findings obtained in this study suggest that EO less than 0.5 ml/kg used for sclerosing esophageal varices seems to have little untoward influence on pulmonary hemodynamics and morphology.

Clinical results and prognostic factors of radiologically node-positive gastric carcinoma.

Lymph node metastasis determined by histologic examination is an important prognostic indicator in gastric carcinoma. However, prognostic value of lymph node metastasis detected by computed tomography (CT) is unknown. The aim of this study was to evaluate clinical results and prognostic factors of patients with radiologically node-positive gastric carcinoma. The study included 78 patients with primary gastric carcinoma and lymph node metastasis confirmed by CT. The level of lymph node metastasis was simply graded as follows: level I included perigastric nodes; level II included intermediate nodes along the left gastric, common hepatic, and celiac arteries; and level III included distant nodes along the hepatoduodenal ligament, pancreas, spleen, and abdominal aorta. Sixty patients (79%) had stage IV tumors showing one or more of the following: level III lymph node metastasis in 37, pancreatic invasion in 27, peritoneal dissemination in 23, and liver metastasis in 19. Overall 1- and 5-year survival rates were 29% and 6%, respectively, and the 1-year survival rate was significantly influenced by the level of lymph node metastasis on CT (55% for level I, 27% for level II, 7% for level III, P < 0.01). In patients with gastrectomy, prognostic factors were tumor size (<10 cm versus >10 cm, P < 0.01), gross type (localized versus infiltrative, P < 0.01), histologic type (well differentiated versus poorly differentiated, P < 0.01), and curability of the disease (curative versus noncurative, P < 0.01). Our study indicates that prognosis of patients with radiologically node-positive gastric carcinoma is poor because of high frequency of extensive tumor spreads. Patients having only positive level I nodes on CT are candidates for curative gastrectomy, which may offer long-term survival.

Long Tube for Obstructing Left-Sided Colon Cancer

Background: Obstructing left-sided colon cancer is now managed by immediate resection and primary anastomosis using intraoperative mechanical bowel irrigation. The aim of this study was to describe our new technique using a long tube for preoperative bowel decompression and intraoperative antegrade irrigation. Methods: A long nasointestinal tube was inserted and a balloon was inflated with distilled water. The tube gradually went forward to the ileum end by peristalsis, and the small intestine became fully decompressed. At operation, antegrade colonic irrigation with warm saline was performed through this long tube without insertion of a Foley catheter. Results: Immediate colonic resection and primary end-to-end anastomosis using layer-to-layer interrupted sutures was successfully performed in 4 patients with obstructing sigmoid colon cancer. Conclusions: This method avoids opening and closure of the cecum or ileum, and minimizes bacterial contamination. The technique is simple and easy, and useful for immediate resection and primary anastomosis of obstructing left-sided colon cancer.

Esophageal transection may well be the approach of choice for patients with portal venous obstruction and esophageal varices

Thirty patients with esophageal varices, portal venous obstruction and a histologically proven normal liver underwent either one of 2 different types of surgery. Shunt surgery was performed on 20 patients: 9 had a mesocaval shunt, 3, a splenorenal shunt, 4, a left gastric venacaval shunt, and 4, a distal splenorenal shunt. Conversely, direct interruption was performed on the other 10 patients: 6 underwent an esophageal transection, and 4 underwent a resection of the proximal stomach. Re-hemorrhage occurred in 7 of the former 20 patients but not in any of the 10 on whom the direct interruption method was used. In 6 of these 7 patients who experienced rebleeding, subsequent direct interruption surgery led to control of the bleeding. One patient died of a variceal hemorrhage one month postoperatively. The total 10 year cumulative survival rate was 86.3 per cent. In the light of these findings, we believe that methods of direct interruption, such as esophageal transection, may well be the approach of choice for patients with esophageal varices caused by extrahepatic portal venous obstruction.