Current status of the surgical training system in Japan: results of a nationwide questionnaire survey of graduating surgical trainees.

PURPOSE: To identify the problems trainees face during surgical training in Japan. METHODS: A nationwide online questionnaire survey was conducted targeting newly certified surgical trainees. RESULTS: The response rate was 53.8% (758/1410). Among those respondents, 25.6% were women, 71.4% were either married or had a partner, 41.3% had children, 72.7% had performed over 200 surgeries under general anesthesia, and 54.1% had chosen, before graduating from medical school, to become a surgeon. While 88.8% were interested in learning surgical techniques, 63.8% were hesitant to become a surgeon for fear of a compromised quality of private life (QOL). Conversely, only 1.4% chose their surgical training programs based on QOL. Overall, 84.6% of the trainees were satisfied with their training and this correlated with the number of surgeries performed. Only 29.9% received non-technical skill training. The average number of night shifts per month was 5.6, and 10.6% worked over 80 h per week. Harassment was reported by 41.5% of the respondents. Moreover, 33.0% had considered dropping out at some time, primarily because of their QOL (51.1%) or the harassment they had encountered (50.4%). CONCLUSION: This survey revealed that while trainees were satisfied with the overall training system, issues such as long working hours and harassment are prevalent. Working to improve these issues could make surgery more attractive for young trainees.

[A Case of Locally Advanced, Unresectable Pancreatic Cancer with Superior Mesenteric Artery Invasion Treated with FOLFIRINOX plus Radiation Therapy, followed by Conversion Surgery].

We report a case of a woman in her 70s who underwent conversion surgery after FOLFIRINOX, followed by radiation therapy for initially locally advanced unresectable pancreatic cancer. She visited her local doctor with a chief complaint of upper abdominal pain. Contrast-enhanced CT scan of the abdomen revealed an irregular mass invading the superior mesenteric artery, and the first and second jejunal arteries(>180°)in the pancreatic uncinate region. Based on imaging, she was diagnosed as UR-LA(sm), cT4N0M0, cStage Ⅲ pancreatic cancer, and underwent 5 courses of modified FOLFIRINOX. Radiation therapy of 50.4 Gy was added for local control, and CA19-9 decreased from 394.1 U/mL to 10.5 U/mL. The treatment effect was judged as RECIST: partial response. The tumor was considered to be potentially curative, and a subtotal stomach preserving pancreaticoduodenectomy was performed 8 months after the initial treatment. The tumor was found to be 3× 2 mm in size, pStage ⅠA, R0, and the response to preoperative chemotherapy: Evans Grade Ⅲ. The patient is alive at 5 months postoperatively without recurrence.

[A Case of Local Recurrent Liver Metastasis from Sigmoid Colon Cancer after Complete Histological Remission, Treated with Rehepatectomy].

We report a case of a patient with sigmoid colon cancer and multiple liver metastases who underwent hepatectomy after chemotherapy and pathological results showed complete remission. However, after chemotherapy was discontinued, the patient developed a local recurrence of the liver metastasis and underwent rehepatectomy. The patient came to our hospital with lower abdominal pain. Colonoscopy revealed a circumferential type Ⅱ, well-differentiated adenocarcinoma. Laparoscopic sigmoidectomy with lymph node dissection was performed. Postoperative CT scan showed multiple liver metastases at S5, S7, and S8. 11 cycles of bevacizumab plus modified FOLFOX(mFOLFOX)were subsequently performed. The liver metastases shrank at all sites, and the patient underwent right hepatectomy. The resected specimen was considered to be in complete remission, with no evidence of viable malignant cells. Postoperatively, bevacizumab plus mFOLFOX was resumed for 6 cycles and the patient remained in remission. However, 3 months after stopping chemotherapy and 1 year and 6 months after hepatectomy, a follow-up CT scan showed local recurrence of the liver edge, and a diagnosis of local recurrence of liver metastasis was made, and a partial hepatectomy was performed. The patient is recurrence-free and resuming modified FOLFOX 9 months after surgery.

Natural history of intracholecystic papillary neoplasm (ICPN): a rare case of ICPN whose natural history was closely followed by ultrasound.

The natural history of intracholecystic papillary neoplasm (ICPN), especially the speed of growth from small benign to a carcinomatous lesion, is quite unrevealed. Here, we report an extremely rare case of ICPN, in which the papillary lesion was observed transforming from small and benign to malignant using abdominal ultrasound (AUS) over 2 years during routine health checks. A 44-year-old man underwent a routine health check-up. The initial AUS showed a small sessile polyp in the gallbladder, which enlarged slightly at the next AUS, a year later. In the third year, the polypoid lesion enlarged markedly, with a maximum diameter of 10 × 9 × 7 mm. Therefore, a laparoscopic cholecystectomy was performed. Microscopically, the 10 mm tumor had intracytoplasmic mucus, and a clear cytoplasm compatible with gastric-type features. Immunohistochemical analysis showed positive staining of atypical cells for MUC6 and PAS. These findings led to the diagnosis of ICPN with high-grade intraepithelial neoplasia of the gastric type. In conclusion, sessile polyps with rapid growth might be a crucial finding in the early stage of ICPN.

Implementation strategies for the patient safety reporting system using Consolidated Framework for Implementation Research: a retrospective mixed-method analysis.

BACKGROUND: Healthcare-related adverse events occur because of complex healthcare systems. The patient safety reporting system is a core component of patient safety initiatives in hospitals. However, hospital management often encounters a cultural barrier with its implementation and struggles to overcome the same. Implementation science would be useful for analysing implementation strategies. This study determines the effects of the implemented strategy on an increase in the number of patient safety reports and the determinants of successful implementation, using the implementation framework. METHODS: Mixed method analysis was performed in Fujita Health University Hospital (FHUH), a large volume hospital in Japan. We identified strategies to implement the patient safety reporting system by scrutinising internal documents using the Consolidated Framework for Implementation Research (CFIR). The electronic reporting systems developed in 2004 in the FHUH and the number of reports were analysed using the staff data and hospital volumes. RESULTS: Reports (n = 110,058) issued between April 2004 and March 2020 were analysed. The number of reports increased from 2004 to 2008 and from 2013 to 2019, reaching 14,037 reports per year. Between 2009 and 2012, the FHUH experienced a stagnation period where the number of reports were not increasing. From the qualitative materials, we identified 74 strategies which contributed to the implementation of the patient safety reporting system. Among these, the domain of 'intervention characteristics' in the CFIR contained 12 strategies, 'outer settings' contained 20, 'inner settings' contained 21, 'characteristics of individuals' contained 8, and 'process' contained 13. There were two concentrated periods of the implemented strategies, the number was 17 in 2007 and 10 in 2016. These concentrated periods preceded a remarkable increase in the number of patient safety reports. CONCLUSIONS: A safety culture had been fostered in FHUH in the study period. A relationship between number of strategies and development of a reporting culture was observed. The intensity of adequate strategies was needed for implementation of patient safety reporting system. Therefore, the implementation framework is useful for analysing patient safety initiatives for safety culture.

Combining failure modes and effects analysis and cause-effect analysis: a novel method of risk analysis to reduce anaphylaxis due to contrast media.

BACKGROUND: Contrast media agents are essential for computed tomography (CT)-based diagnoses. However, they can cause fatal adverse effects such as anaphylaxis in patients. Although it is rare, the chances of anaphylaxis increase with the number of examinations. OBJECTIVE: We aimed to design a quality improvement initiative to reduce patient risk to contrast media agents. METHODS: We analysed CT processes using contrast iodine in a tertiary-care academic hospital that performs approximately 14 000 CT scans per year in Japan. We applied a combination of failure modes and effects analysis (FMEA) and cause-effect analysis to reduce the risk of patients developing allergic reactions to iodine-based contrast agents during CT imaging. RESULTS: Our multidisciplinary team comprising seven professionals analysed the data and designed a 56-process flowchart of CT imaging with iodine. We obtained 177 failure modes, of which 15 had a risk-probability number higher than 100. We identified the two riskiest processes and developed cause-and-effect diagrams for both: one was related to the exchange of information between the radiation and hospital information system regarding the patient's allergy, the other was due to education and structural deficiencies in observation following the exam. CONCLUSION: The combined method of FMEA and cause-and-effect analysis reveals high-risk processes and suggests measures to reduce these risks. FMEA is not well-known in healthcare but has significant potential for improving patient safety. Our findings emphasise the importance of adopting new techniques to reduce patient risk and carry out best practices in radiology.

A case of Vp4 hepatocellular carcinoma with tumor thrombosis extending into the confluence of the splenic/portal vein achieved a good prognosis with emergent hepatectomy and postoperative adjuvant therapy with lenvatinib.

In this report, we describe a case of highly advanced hepatocellular carcinoma with tumor thrombosis extending into the main portal vein of the pancreas that was successfully treated with adjuvant lenvatinib after right hepatic resection with thrombectomy. A 70-year-old woman was referred from the clinic because of elevated hepatobiliary enzymes. The patient was positive for the hepatitis B virus antigen at our hospital. The tumor markers were highly elevated with alpha-fetoprotein (14.5 U/mL) and protein induced by vitamin K absence (PIVKAII) (1545 ng/mL), suggesting hepatocellular carcinoma. Dynamic abdominal computed tomography showed an early enhanced tumor approximately 6 cm in size and portal vein tumor thrombosis filling the main portal vein, but not extending into the splenic or superior mesenteric vein (SMV). On magnetic resonance imaging 1 week after CT, portal vein tumor thrombosis had extended to the confluence of the splenic vein with the SMV, indicating rapid tumor growth. Thus, we performed emergent right hepatectomy with tumor thrombectomy. Postoperatively, we treated the patient with lenvatinib for a tumor reduction surgery. Fortunately, the patient was alive 2 years postoperatively without recurrence. This case report suggests that a favorable outcome may be achieved with multidisciplinary treatment including resection and postoperative treatment with lenvatinib.

A preserved pancreatic exocrine function after pancreatectomy may be a crucial cause of pancreatic fistula: paradoxical results of the 13C-trioctanoin breath test in the perioperative period.

PURPOSE: The aim of this study was to elucidate the association between pancreatic fistula (PF) and the sequential changes in the perioperative exocrine function after pancreatectomy. METHODS: The subjects were 96 patients who underwent a 13C-trioctanoin breath test before and 1 month after pancreatectomy, between 2006 and 2018. We retrospectively compared the pre- and postoperative fat absorption levels between patients with PF (PF group; n = 17) and without PF (non-PF group; n = 79) using the breath test. RESULTS: The preoperative level of 13C-trioctanoin absorption (%dose/h) was comparable between the non-PF and PF groups (36.5 vs. 36.9). In the non-PF group, 13C-trioctanoin absorption was significantly decreased after surgery in comparison to the preoperative setting (post-operative 28.5; pre-operative 36.5; p < 0.0001), whereas these values were comparable (post-operative 36.9; pre-operative 34.5; p = 0.129) in the PF group. Moreover, postoperative absorption in the PF group was significantly better than that in the non-PF group (34.5 vs. 28.5%, p = 0.0003). The maximum drain amylase level was significantly higher in patients with a 13C-trioctanoin absorption level (%dose/h) of ≥ 30 in comparison to patients with levels of < 30 (2502 vs. 398 U/L, p = 0.001). CONCLUSION: PF did not exacerbate the pancreatic exocrine function in the early postoperative period, and the acceleration or preservation of the exocrine function after surgery may be an important cause of PF.

Right hepatectomy with preservation of the entire caudate lobe in patients with metastatic liver tumors: a case of a new hepatectomy technique and treatment strategy for patients with marginal liver function.

BACKGROUND: Performing major hepatectomy for patients with marginal hepatic function is challenging. In some cases, the procedure is contraindicated owing to the threat of postoperative liver failure. In this case report, we present the first case of marginal liver function (indocyanine green clearance retention rate at 15 min [ICGR15]: 28%) successfully treated with right hepatectomy, resulting in total caudate lobe preservation. CASE PRESENTATION: A 71-year-old man was diagnosed with sigmoid colon cancer with three liver metastases (S5, S7, and S8). All of metastatic lesions shrunk after chemotherapy, but his ICGR15 and indocyanine green clearance rate (ICGK) were 21% and 0.12, respectively. Moreover, the remnant liver volume was only 39%. Therefore, portal venous embolism (PVE) of the right portal vein was suggested. Portography showed divergence of the considerably preserved right caudate lobe branch (PV1R) from the root of the right portal vein. The liver function was reevaluated 18 days after PVE was suggested. During this time, the ICGR15 (21-28%) and ICGK rate (0.12-0.10) deteriorated. The right caudate lobe was significantly enlarged; thus, a total caudate lobe-preserving hepatectomy (TCPRx) was performed. Patients eligible for TCPRx included those with (1) hepatocellular carcinoma or metastatic liver cancer, (2) no tumor in the caudate lobe, (3) marginal liver function (ICG Krem greater than 0.05 if TCPRx was adapted; otherwise, less than 0.05) and Child-Pugh classification category A, and (4) preserved PV1R and right caudate bile duct branch. The procedure was performed through (A) precise estimation of the remnant liver volume preoperatively, (B) repeated intraoperative cholangiography to confirm the biliary branch of the right caudate lobe (B1R) conservation, and (C) stapler division of posterior and anterior Glisson's pedicles laterally to avoid injuries to the PV1R and B1R. CONCLUSIONS: Right hepatectomy with total caudate lobe preservation, following PVE, was a safe and viable surgical technique for patients with marginal liver function.

The usefulness of preoperative exocrine function evaluated by the 13C-trioctanoin breath test as a significant physiological predictor of pancreatic fistula after pancreaticoduodenectomy.

BACKGROUND: The association between pancreatic fistula (PF) after pancreaticoduodenectomy (PD) and preoperative exocrine function is yet to be elucidated. This study aimed to evaluate the association between the preoperative results of the 13C-trioctanoin breath test and the occurrence of PF, showing the clinical relevance of the breath test in predicting PF. METHOD: A total of 80 patients who underwent 13C-trioctanoin breath tests prior to PD from 2006 to 2018 were included in this study. Univariate and multivariate analyses were conducted to reveal the preoperative predictors of PF, showing the association between 13C-trioctanoin absorption and PF incidence. RESULTS: Among 80 patients (age, 68.0 ± 11.9 years, 46 males and 34 females; 30 pancreatic ductal adenocarcinoma [PDAC]/50 non-PDAC patients), the incidence of PF was 12.5% (10/80). Logistic regression analysis results revealed that the frequency of PF increased significantly as the 13C-trioctanoin breath test value (Aa% dose/h) increased (odd's ratio: 1.082, 95% confidence interval: 1.007-1.162, p = 0.032). Moreover, the optimal cutoff value of the preoperative fat absorption level to predict PF was 38.0 (sensitivity, 90%; specificity, 74%; area under the curve, 0.78; p = 0.005). Indeed, the incidence of PF was extremely higher in patients whose breath test value was greater than 38.0 (33%, 9/27) compared with that in patients with values less than 38.0 (1.8%, 1/53). CONCLUSIONS: Favorable preoperative fat absorption evaluated using the 13C-trioctanoin breath test is a feasible and objective predictor of PF after PD.

[A Case of Resection of Pancreatic Body Cancer Successfully Treated with GEM plus Nab-PTX].

The case was a 72-year-old man who had been on medication due to chronic pancreatitis since 2009 and was referred to our hospital because dilation of the main pancreatic duct was shown by abdominal ultrasonography. The contrast CT scan of the abdomen showed a 30 mm in size, poorly enhanced tumor at the body of the pancreas, which was suspected to invasion the celiac artery, common hepatic artery, and splenic artery. EUS showed a hypoechoic tumor with a diameter of 29× 24 mm. ERCP showed disruption of the pancreatic duct in the body of the pancreas, and cytological examination of the pancreatic juice showed a suspicious positive result. We diagnosed unresectable locally advanced pancreatic cancer in the body of the pancreas and underwent chemotherapy(gemcitabine plus nab-paclitaxel: GnP). Contrast-enhanced CT after 6 courses of GnP showed tumor shrinkage. FDG-PET/CT revealed a slightly in fluorine-18-deoxyglucose(FDG)accumulation in the tumor, but no accumulation around the blood vessels. Based on the above, it was judged that the tumor was possible radical resection, and surgery was performed. Intraoperative frozen section examination revealed no malignant findings in the tissues surrounding the main artery near the pancreatic body cancer, and distal pancreatectomy was performed. Histopathologically, the tumor showed findings of tubular adenocarcinoma, and the histological response to neoadjuvant therapy was Grade 2. We report a case in which conversion surgery was possible by chemotherapy.

[Efficacy of Hepatic Artery Resection without Reconstruction in Pancreaticoduodenectomy, Paying Attention to the Anomaly of the Artery].

In performing PD, it is very important to understand the running and anatomy of the hepatic artery and the positional relation with the tumor before surgery, leading to planning a proper surgical procedure. In this case series, we report 2 cases in which radical resection was achieved by pancreaticoduodenectomy(PD)with combined hepatic artery resection(without reconstruction)while paying attention to the positional relationship between the bifurcated hepatic artery and the tumor in the head of the pancreas. Case 1: A 73-year-old man. He visited the hospital with jaundice and was diagnosed with distal bile duct cancer. Preoperative contrast-enhanced CT showed that the replaced right hepatic artery(RRHA)was involved by the tumor. Intraoperatively, it was confirmed by ultrasonography that the arterial blood flow in the right lobe of the liver was flowing from the left hepatic artery through the hepatic hilar plate after clamping the right hepatic artery. Thus, PD with combined RRHA resection(without reconstruction)was performed. After the operation, there was no problem with hepatic artery blood flow, and R0 resection was achieved. Case 2: A 65-year-old man. He visited the hospital with jaundice as the chief complaint and was diagnosed with pancreatic head cancer with encasement in the proper hepatic artery(PHA). In this case, the right hepatic artery branches from the SMA and the left hepatic artery branches from the left gastric artery. Intraoperative findings showed no problem with hepatic artery blood flow even after test-clamping the common hepatic artery, and the common hepatic artery was not reconstructed. There is no postoperative complication, and R0 resection was achieved pathologically. Conclusion: For pancreatic head tumors with hepatic artery infiltration, it is important to understand the anatomy of hepatic artery preoperatively and to confirm the intraoperative blood flow. In such cases, pancreaticoduodenectomy with hepatic artery resection may contribute to achieving R0.

[Resection of Multiple Metastases after Liver Resection from Colon Cancer-A Case Report].

A 49-year-old female was underwent laparoscopic right hemicolectomy for ascending colon cancer and liver metastasis. Then, she was underwent laparoscopic hepatectomy. She received BEV plus mFOLFOX6 therapy as postoperative adjuvant chemotherapy, but she had liver recurrence. She received FOLFOXIRI therapy. Although tumor tended to progressive, it was localized, so laparoscopic hepatectomy was performed again. She received AFL plus FOLFIRI therapy. Fourteen months after hepatic resection, disseminated nodules and lung metastases were found. However, both of peritoneal dissemination, and lung metastasis were localized, so it was judged that peritoneal dissemination and lung metastasis could be resectable. Then, peritoneal dissemination resection and sigmoid colectomy were performed, and then lung resection was performed to perform R0 resection. R0 resection and multimodal therapy for simultaneous and heterotopic metastases of colorectal cancer can contribute to provide a long-term prognosis.

[Lymph Node Dissection and Postoperative Follow-Up for T2 Cancer of the Lower Rectum].

The outcomes of 88 patients with lower rectal T2 cancer who underwent radical A surgery(T2)were compared with those of 340 patients with T3 or T4a cancer(T3/T4a)and 51 patients with T1 cancer(T1). The rates of all lymph node(LN) metastasis, paraintestinal LN metastasis, intermediate and main LN metastasis, and lateral LN metastasis in T2 were all significantly lower than in T3/T4a and not different from those in T1. The recurrence rate of T2 was 15.9%, significantly lower than that of T3/T4a and not different from that of T1. Fifty percent of T2 recurrences were observed after 30 months postoperatively, significantly higher than that of T3/T4a and not different from that of T1. The 5-year survival rate of T2 was significantly higher than that of T3/T4a and did not differ from that of T1. In lower rectal T2, cancer LN dissection similar to that in T1 is appropriate, and high preoperative serum CA19-9 level is a risk factor for recurrence, suggesting the need for follow-up after 30 months postoperatively to take recurrence into consideration.

Subcutaneous abscess caused by Streptococcus pneumoniae serotype 28F in an infant: a case report.

BACKGROUND: Invasive pneumococcal disease (IPD) is defined by the detection of Streptococcus pneumoniae on culture from samples obtained from a normally sterile site. Pneumococcal conjugate vaccines (PCV) have been developed for the prevention of IPD that is caused by highly virulent serotypes. Despite the effective reduction of IPD caused by vaccine serotypes after the introduction of PCV, there has been a rapid increase in the incidence of IPD caused by non-vaccine serotypes, and serotype replacement has become a global issue. CASE PRESENTATION: We report a previously healthy 4-month-old girl presenting with a large subcutaneous abscess caused by S. pneumoniae, identified as non-vaccine serotype 28F. The patient had received routine vaccination, including PCV vaccination. After the incision and drainage of the subcutaneous abscess, the patient was treated with antibiotics. She was discharged on Day 7 of hospitalization without any residual sequelae. CONCLUSIONS: Subcutaneous abscess is a common pediatric skin and soft tissue infection, whereas pneumococcal subcutaneous abscesses are quite rare. As the pneumococcal serotype 28F caused a subcutaneous abscess, this serotype possibly has a high virulence. The incidence of IPD caused by non-vaccine serotypes, such as 28F, is expected to increase in the future. The consolidation of international data on pneumococcal serotypes is important for the development of novel PCV.

[Cooperative Surgery with Gastroenterological Surgeons in Gynecologic Malignant Tumors].

Secondary debulking surgery(SDF)for gynecologic malignancies may improve prognosis. However, recurrent lesions may be invasions of the intestinal tract and observed peritoneal dissemination. SDF can be safely carried out by performing cooperative surgery with a gastroenterological surgeon and gynecologists. Precise cooperation is indispensable for the operation, especially when it comes to aspects such as the contact method and perioperative management at that time. In our hospital, if the gynecologist suspects other organs invasion during a preoperative examination, they contact the gastroenterological surgeon in an elective manner. If other organs invasion is not clear during a preoperative examination or bowel injury occurs during surgery, the gastroenterological surgeon would be contacted urgently. To ensure smooth cooperation, it is necessary to run regular joint conferences. By sharing in planned and combining the expertise of all the department of interest, it is possible to perform highly curative and safe surgery.

Bundle interventions including nontechnical skills for surgeons can reduce operative time and improve patient safety.

OBJECTIVE: This study aimed to determine if introducing nontechnical skills to surgical trainees during surgical education can reduce the operation time and contribute to patient safety. DESIGN: Quality improvement initiatives using the KAIZEN as a problem-solving method. SETTING: Department of surgery in a referral and educational hospital. PARTICIPANTS: Surgical team and quality management team. INTERVENTION: The KAIZEN was used as a problem-solving method between 2015 and 2018 to reduce the operation time. First, baseline measurement was performed to understand the current situations in our department. To achieve continuous improvement, periodical feedback of the current status was obtained from all staff. Bundles, including nontechnical skills, were established. Briefing and debriefing were performed by the surgical team. MAIN OUTCOME MEASURES: Excessively long operation rates with a standard procedure. RESULTS: We included 1573 operations in this initiative. Excessively long operation rates were reduced in all types of surgeries, from 27.1% to 15.2% for herniorrhaphy (P = 0.005), 58.3-40.0% for gastrectomy (P = 0.03), 50.0-4.1% for total gastrectomy (P = 0.12), 65.6-45.0% for colectomy (P = 0.004), 67.8-43.2% for high anterior resection (P = 0.02) and 69.6-47.9% for low anterior resection (P = 0.03). The adherence to briefing and debriefing were improved, and majority of the surgeons favored the bundle elements. CONCLUSIONS: The KAIZEN initiative was effective in clinical healthcare settings. In the event of scaling-up this initiative, the educational program for physicians should include project management strategies and leadership skills.

Lower risk of postoperative delirium using laparoscopic approach for major abdominal surgery.

BACKGROUND: A laparoscopic approach is increasingly being used for major abdominal surgeries and is reportedly associated with a lower incidence of postoperative complications. However, the association of laparoscopic approach and postoperative delirium remains unclear. We aimed to retrospectively investigate risk factors for postoperative delirium after abdominal surgery particularly assessing the association between a laparoscopic approach and postoperative delirium. METHODS: We retrospectively studied 801 patients who underwent major abdominal surgery between April 2012 and December 2013. Among these, 181 (22.6%) patients underwent a laparoscopic and 620 (77.4%) patients underwent an open procedure. A Cox proportional hazard model analysis was used to identify risk factors for the development of postoperative delirium or overall survival within 180 days after surgery. Cumulative incidence of postoperative delirium was assessed using a propensity score-matching analysis. RESULTS: Postoperative delirium occurred in 56 patients (7.0%). A Multivariate Cox proportional hazard model analysis revealed that a laparoscopic approach reduced the risk of postoperative delirium [hazard ratio (HR) 0.30, 95% confidence interval (CI) 0.07-0.84, p = 0.019]. Postoperative delirium was associated with worse overall survival within 180 days (HR 4.91, 95% CI 1.96-12.22, p = 0.001) after adjusting for other confounders using the Cox proportional hazard model analysis. Patients who developed postoperative delirium showed worse outcomes including higher rate of morbidity except delirium (p < 0.001), longer hospitalization (p < 0.001), and post-discharge institutionalization (p < 0.001). After propensity score-matching, cumulative incidence rates of postoperative delirium were significantly lower in the laparoscopic group compared to the open group (30-day cumulative incidence rate, 1.7% vs. 7.8%, p = 0.006). CONCLUSIONS: The risk of postoperative delirium after major abdominal surgery is reduced using laparoscopic approach. Postoperative delirium should be prevented as it precipitates adverse postoperative events.

Increased community-acquired upper urinary tract infections caused by extended-spectrum beta-lactamase-producing Escherichia coli in children and the efficacy of flomoxef and cefmetazole.

BACKGROUND: Urinary tract infections caused by extended-spectrum beta-lactamase-producing bacteria are increasing worldwide. At our hospital, the number of pediatric patients hospitalized because of an upper urinary tract infection has dramatically increased since 2016. In total, 60.5% of urinary tract infections are caused by extended-spectrum beta-lactamase-producing Escherichia coli. Such a high prevalence of extended-spectrum beta-lactamase-producing E. coli has not been detected previously in Japan. Therefore, we evaluated the clinical and bacteriologic characteristics and efficacy of antibiotics against upper urinary tract infections caused by E. coli in children. METHODS: This retrospective study surveyed 152 patients who were hospitalized in the pediatric department of Shimane Prefectural Central Hospital because of upper urinary tract infections caused by E. coli. Medical records were reviewed to examine patient characteristics. O antigens, antibiotic susceptibility, gene typing, and pulse-field gel electrophoresis were studied at the Shimane Prefectural Institute of Public Health and Environmental Science. RESULTS: Urine sample analyses showed extended-spectrum beta-lactamase types such as CTX-M-9 and plural virulence genes. We changed the primary antibiotic treatment to flomoxef or cefmetazole to treat upper urinary tract infections caused by Gram-negative bacilli. After changing treatment, the time to fever alleviation was significantly shortened. CONCLUSION: Extended-spectrum beta-lactamase-producing E. coli should be suspected in community-acquired upper urinary tract infections. Therefore, when treating patients, it is necessary to focus on antibiotic susceptibility and the prevalence of extended-spectrum beta-lactamase-producing bacteria found in each area. Flomoxef and cefmetazole are useful primary treatments for upper urinary tract infections caused by extended-spectrum beta-lactamase-producing E. coli.

Long-term renal follow up of preterm neonates born before 35 weeks of gestation.

BACKGROUND: The hypothesis of the Developmental Origins of Health and Disease states that environmental factors during fetal and infantile life are risk factors for some chronic diseases in adulthood. Few studies, however, have confirmed this hypothesis early in childhood. Therefore, we assessed how premature birth and low-birthweight (LBW) affect the renal function of Japanese children. METHODS: This retrospective study surveyed 168 patients who were born before 35 weeks of gestation and were cared for at the present neonatal intensive care unit. Follow-up duration was >2 years. Serum creatinine (sCr) and estimated glomerular filtration rate (eGFR) recorded in medical records were reviewed. RESULTS: The eGFR at 2 years of age was significantly correlated with birthweight and gestational age (P < 0.01). Approximately 10.7% of the children had low eGFR (<90 mL/min/1.73 m2 ) without clinical symptoms or abnormal urine examination. These children had high sCr on day 7 after birth (P < 0.01) and delayed recovery of these levels during the first month after birth. CONCLUSION: Premature gestational age and LBW directly affect renal function in young children. High sCr on day 7 after birth is a risk factor for chronic kidney disease in children. Careful follow up of renal function is therefore required for premature infants and infants with LBW beginning in early childhood to prevent renal dysfunction.