Yoshio Haga

Estimation of Physiologic Ability and Surgical Stress (E-PASS) as a new prediction scoring system for postoperative morbidity and mortality following elective gastrointestinal surgery.

Overwhelming surgical stress exceeding a patient’s reserve capacity causes a disruption of homeostasis, leading to various postoperative complications. This study was under-taken to develop a new scoring system, “E-PASS”, standing for the Estimation of Physiologic Ability and Surgical Stress, that predicts the postsurgical risk by quantification of the patient’s reserve and surgical stress. E-PASS comprises the preoperative risk score (PRS), the surgical stress score (SSS), and the comprehensive risk score (CRS) that is determined by both scores. These scores were computed by a multiple regression analysis conducted on 292 consecutive patients who underwent elective common gastrointestinal operations at one hospital between 1992 and 1995 (internal group). The usefulness of the scores was evaluated in 989 consecutive patients who underwent the same surgical procedures during the same period at another hospital (external group). The morbidity and mortality rates increased similarly in both groups as the CRS increased. A marked step-up of both rates was observed at a CRS>1.0, reaching mortality rates of 20% in the internal subjects and 28.5% in the external subjects. These results suggest that the E-PASS scoring system is reproducible, and that it may be useful for surgical decision making. This system requires no special examinations and can be used in every hospital.

Systemic inflammatory response syndrome and organ dysfunction following gastrointestinal surgery.

OBJECTIVES Progression from systemic inflammatory response syndrome (SIRS) to sepsis, severe sepsis, and septic shock has been demonstrated in a variety of patients. However, the presence of SIRS alone was not helpful in predicting the development of multiple organ dysfunction syndrome (MODS) since SIRS includes many nonprogressive conditions. This study was conducted to investigate the clinical significance of SIRS in postoperative patients. DESIGN Retrospective study. SETTING The surgical department of a university hospital. PATIENTS Two hundred ninety-two consecutive patients who received elective common gastrointestinal surgery (esophagectomy, pancreatoduodenectomy, hepatectomy, gastrectomy, colorectal resection, and laparoscopic cholecystectomy) between 1992 and 1995. INTERVENTIONS Patients were analyzed for preoperative physiologic status, surgical stress parameters, and postoperative status of SIRS, complications, and end-organ dysfunction. MEASUREMENTS AND MAIN RESULTS Duration of SIRS or positive criterias number of SIRS after surgery significantly correlated with surgical stress parameters (blood loss/body weight and operation time) and peak serum C-reactive protein concentrations. SIRS that continued or reappeared after postoperative day 3 was an early sign of postoperative complications. SIRS continuing consecutively for 2 days after postoperative day 3 had a 70.6% positive predictive value and a 92.5% negative predictive value for postoperative complications. Septic complications and prolongation of SIRS were associated with MODS. Five of six patients who met the SIRS criteria for >30 days developed severe MODS, and three of them died. CONCLUSIONS SIRS is a useful criterion for the recognition of postoperative complications and end-organ dysfunctions. Early recovery from SIRS may arrest the progression of organ dysfunction.

Evaluation of Serum CA125 Values in Healthy Individuals and Pregnant Women

CA125 is an antigenic determinant associated with human epithelial ovarian carcinoma. This study was undertaken to evaluate the distribution of serum CA125 levels and the effect of smoking on these levels among healthy individuals and clarify the relation of maternal serum CA125 level and pregnancy. Among 552 healthy individuals, the distribution of serum CA125 values was demonstrated to resemble logarithmic normal distribution. Analysis of variance about age and sex revealed apparent elevation of values for women under 49 years of age in comparison with those for women over 50 years of age and men. Values for these two groups were 143 units/ml for the former and 32 units/ml for the latter, with a 99.7% confidence limit. These values exclude 99.3% of the former and 99.7% of the latter. Serum CA125 values were not affected by smoking. The measurement of serum CA125 levels in 71 pregnant women disclosed a significant elevation during the first trimester in comparison with non-pregnant women under 49 years of age. These results indicate that CA125 values must be deliberatively evaluated in young women, especially during first trimester of pregnancy.

Clinical Significance of Serum CA125 Values in Patients with Cancers of the Digestive System

A study of 347 patients with gastrointestinal diseases revealed elevation of CA125 in sera of 63% of patients with pancreatic carcinoma, 46% of patients with carcinoma of the biliary tract, 40% of patients with liver carcinoma and 11–37% of patients with other carcinomas. All of the patients with acute pancreatitis, chronic pancreatitis, cholelithiasis, and peptic ulcer had normal CA125 values, but 35% of patients with liver cirrhosis and 10% of patients with chronic active hepatitis had elevated values. Patients with disseminated carcinomas had significantly higher levels than patients with localized carcinomas. CA125 did not significantly correlate with CA19–9 or carcino-embryonic antigen in patients with pancreatic carcinoma. Ninety-seven percent of patients with pancreatic carcinoma were defined as being positive when both serum CA125 and CA19–9 were evaluated. These results indicate that CA125 is useful for differentiating pancreatic carcinoma from chronic pancreatitis, especially when supplemented with CA19–9.

Evaluation of an Estimation of Physiologic Ability and Surgical Stress (E-PASS) Scoring System to Predict Postoperative Risk : A Multicenter Prospective Study

Abstract We previously reported generating a scoring system termed E-PASS that predicted postsurgical risk. This study was undertaken to evaluate the usefulness of this system. A consecutive series of 902 patients who underwent elective gastrointestinal operations in six national hospitals in Japan were prospectively assessed for a comprehensive risk score (CRS) of the E-PASS, which was compared with their postoperative course. The postoperative morbidity rates linearly increased as the CRS increased. The postoperative mortality rate was only 0.13%, when the CRS was below 0.5; however, it increased to 9.7% when the CRS ranged from 0.5 to <1.0, and to 26.9% when the CRS was ≥1.0. The CRS correlated significantly with the severity of postoperative complications (rs = 0.527, P < 0.0001) and the costs of hospital stay (rs = 0.810, P < 0.0001). When the CRS-adjusted mortality rate at the CRS of ≥0.5 was compared among the hospitals, it was related to the hospital volume of operations, being 44.2% at the volume of <100 cases per year, 20.6% at the range of 100–199 cases, and 8.6% at the volume of ≥200 cases. These results suggest that E-PASS may be useful for predicting postsurgical risk, estimating medical expense, and comparing surgical quality.

Human gastric carcinoid detected during long-term antiulcer therapy of H2 receptor antagonist and proton pump inhibitor

Human gastric carcinoid tumors had been reported to comprise less than 1% of all stomach tumors and about 3% of all carcinoids (1) . However, recent widespread use of uppe r gastrointestinal endoscopy has revealed that gastric carcinoids are much more commonÐ up to 41% of all gut carcinoids. Most human gastric carcinoids originate from ente rochromaf® n-like (ECL) ce lls exclusive ly locate d in the corpus± fundus region. ECL cells physiolog ically play a crucial role in acid secretion of parie tal cells by rele asing regulating histamine . Gastrin has stimulatory e ffects on histamine re lease and proliferation of ECL cells. Chronic hype rgastrinemia re sults in a varie ty of hype rplasias , from dysplasia to neoplasia of ECL cells in rodents. The subSaharan rodent Mastomys exhibits a genetic propensity for the deve lopment of gastric carcinoids and 30 ± 40% of such animals will spontaneously deve lop gastric carcinoids within two years (2) . In the Mastomys, hype rgastrinemia induced by the administrat ion of H2-receptor antagonists or proton pump inhibito rs re sults in deve lopment of gastric carcinoids within four months. It is reported that this effe ct does not re sult from the action of the drugs, but from secondary hype rgastrinemia due to the comple te inhibition of acid secre tion. Rats require longe r-te rm administration (two years or more) of these acid-inhibitory drugs before they deve lop gastric carcinoids (3). Based on the se expe rimental ® ndings, an achlorhydria± carcinoid sequence has been advocate d. Howeve r, epidemiologic data sugge st that such adve rse effe cts of the acid-inhibitory drugs have be en unlike ly to occur in humans with ordinary treatment (4) . Human gastric carcinoids in association with chronic hype rgastrinemia have been re stricted to patie nts with chronic atrophic gastrit is type A (A-CAG) and Zollinge r-Ellison syndrome (ZES) with multiple endocrine neoplasia type 1 (MEN 1) (1, 5± 8) . A genetic background or chronic in ammation may be necessary for the deve lopment of human gastrindependent carcinoids of the stomach. In this report, we pre sent an extremely rare case of gastric carcinoid detected and grown during the long-te rm administrat ion of a proton pump inhibito r and H2 blocke r in a patient with recurrent peptic ulce rs without signi® cant past or family historie s. To our knowledge , no case of gastric carcinoid has be en reporte d in the lite rature in association with acidinhibito ry drugs for ordinary peptic ulce rs. The ensuing discussion will focus on the possible association of acid-inhibitory drugs and deve lopment of gastric carcinoids. Manuscript rece ived Novembe r 7, 1996; acce pted August 15, 1997. From the Department of Surgery, Mitsui Ohmuta Hospital, 1-1-1 Tenryoh-machi, Ohmuta-shi, Fukuoka-ken 836, Japan; Department of Pathology, St. Mary’ s Hospital, 422 Tsubukuhonmachi, Kurume -shi, Fukuoka-ken 830, Japan; and Department of Surgery II, Kumamoto Unive rsity Medical School, 1-1-1 Honjo, Kumamoto 860, Japan. Address for reprint requests: Dr. Michio Ogawa, Department of Surgery II, Kumamoto Unive rsity Medical School, 1-1-1 Honjo, Kumamoto 860, Japan. Digestive Diseases and Sciences, Vol. 43, No. 2 (February 1998), pp. 253± 257

A Multicenter Prospective Study of Surgical Audit Systems

Objective:This study was undertaken to evaluate a modified form of Estimation of Physiologic Ability and Surgical Stress (E-PASS) for surgical audit comparing with other existing models. Background:Although several scoring systems have been devised for surgical audit, no nation-wide survey has been performed yet. Methods:We modified our previous E-PASS surgical audit system by computing the weights of 41 procedures, using data from 4925 patients who underwent elective digestive surgery, designated it as mE-PASS. Subsequently, a prospective cohort study was conducted in 43 national hospitals in Japan from April 1, 2005, to April 8, 2007. Variables for the E-PASS and American Society of Anesthesiologists (ASA) status-based model were collected for 5272 surgically treated patients. Of the 5272 patients, we also collected data for the Portsmouth modification of Physiologic and Operative Severity Score for the enUmeration of Mortality and morbidity (P-POSSUM) in 3128 patients. The area under the receiver operative characteristic curve (AUC) was used to evaluate discrimination performance to detect in-hospital mortality. The ratio of observed to estimated in-hospital mortality rates (OE ratio) was defined as a measure of quality. Results:The numbers of variables required were 10 for E-PASS, 7 for mE-PASS, 20 for P-POSSUM, and 4 for the ASA status-based model. The AUC (95% confidence interval) values were 0.86 (0.79–0.93) for E-PASS, 0.86 (0.79–0.92) for mE-PASS, 0.81 (0.75–0.88) for P-POSSUM, and 0.73 (0.63–0.83) for the ASA status-based model. The OE ratios for mE-PASS among large-volume hospitals significantly correlated with those for E-PASS (R = 0.93, N = 9, P = 0.00026), P-POSSUM (R = 0.96, N = 6, P = 0.0021), and ASA status-based model (R = 0.83, N = 9, P = 0.0051). Conclusion:Because of its features of easy use, accuracy, and generalizability, mE-PASS is a candidate for a nation-wide survey.

Maximal Sterile Barrier Precautions Do Not Reduce Catheter-Related Bloodstream Infections in General Surgery Units: A Multi-Institutional Randomized Controlled Trial

Objective:To investigate whether maximal sterile barrier precautions (MSBPs) during central venous catheter (CVC) insertion are truly effective in preventing catheter-related bloodstream infections (CRBSIs) in patients in general surgical units. Summary Background Data:The reported effectiveness of MSBPs was based on the results of a single-center randomized controlled trial by Raad et al and the majority of the patients (99%) in the study were chemotherapy outpatients. Methods:Between March 14, 2004 and December 28, 2006, the patients scheduled for CVC insertion in surgical units at 9 medical centers in Japan were randomly assigned to either an MSBP group (n = 211) or a standard sterile barrier precaution (SSBP) group (n = 213). This study was registered in the UMIN Clinical Trials Registry (registration ID number: UMIN000001400). Results:The median (range) duration of catheterization was 14 days (0–92 days) in the MSBP group and 14 days (0–112 days) in the SSBP group. There were 5 cases (2.4%) of CRBSI in the MSBP group and 6 cases (2.8%) in the SSBP group (relative risk, 0.84; 95% confidence interval, 0.26–2.7; P = 0.77). The rate of CRBSIs per 1000 catheter days was 1.5 in the MSBP group and 1.6 in the SSBP group. There were 8 cases (3.8%) of catheter-related infections in the MSBP group and 7 cases (3.3%) in the SSBP group (relative risk, 1.2; 95% confidence interval, 0.43–3.1; P = 0.78). The rate of catheter-related infection per 1000 catheter days was 2.4 in the MSBP group and 1.9 in the SSBP group. Conclusions:This study is larger in sample size than the one performed by Raad et al and could not demonstrate better prevention of CRBSIs by MSBP compared with SSBP. A large randomized controlled trial or at least a meta-analysis of any other studies in the literature is necessary to reach to a conclusion on this issue.

Value of general surgical risk models for predicting postoperative liver failure and mortality following liver surgery.

This study evaluated the ability of general surgical models to predict postoperative morbidity and mortality in liver surgery.

Less-invasive surgery for gastric cancer prolongs survival in patients over 80 years of age

This study was undertaken to determine the most appropriate form of surgery for elderly patients with gastric cancer in relation to postoperative complications and long-term survival. A total of 72 consecutive patients over 80 years of age who underwent partial or total gastrectomy were evaluated using an E-PASS scoring system. This system is comprised of a preoperative risk score (PRS), a surgical stress score (SSS), and a comprehensive risk score (CRS) determined by both the PRS and SSS. Patients with a CRS≥0.5 had significantly higher rates of morbidity and mortality at 45.0% and 20.0%, respectively, than those with CRS≤0.5, at 17.0% and 2.1%, respectively. A Cox regression analysis of long-term survival, including death from other causes, identified five significant prognostic factors, namely: stage, curability, SSS, CRS, and allogeneic blood transfusion. Among the patients without any apparent residual cancer, a significantly better survival was seen in those who underwent less invasive surgery (SSS<0.25), those with a CRS≤0.5, and those who had not been given a blood transfusion. These results suggest that less invasive surgery not requiring a blood transfusion is advisable for patients over 80 years of age with gastric cancer. Furthermore, gastrectomy with a CRS≥0.5 may have a poor therapeutic effect on both early and long-term outcome.