Treatment option of endoscopic stent insertion or gastrojejunostomy for gastric outlet obstruction due to gastric cancer: a propensity score-matched analysis.

BACKGROUND: There are currently two treatment options for gastric outlet obstruction (GOO) due to gastric cancer, endoscopic stenting and surgical gastrojejunostomy. However, their therapeutic effects have not yet been established. Therefore, the present study was undertaken to examine these effects. METHODS: The Japanese Gastric Cancer Association invited its delegates to participate in a retrospective multicenter cohort study on patients with GOO due to gastric cancer who underwent stent therapy or gastrojejunostomy in 2015. RESULTS: We obtained data from 85 patients undergoing stent therapy and 94 undergoing gastrojejunostomy from 42 hospitals. Baseline data revealed that stent patients had lower food intake, poorer performance status, and worse prognostic indices than gastrojejunostomy patients. Postoperative food intake and survival times were worse in stent patients than in gastrojejunostomy patients. We performed propensity score matching to select pairs of patients with similar baseline characteristics in the two treatment groups. After matching, the frequency of postoperative complications was significantly less in stent patients (3%, 1/33) than in gastrojejunostomy patients (21%, 7/34; p = 0.03). A low residue or full diet was achieved by 97% of stent patients (32/33) and 97% of gastrojejunostomy patients (33/34) (p = 0.98). Median survival times were 7.8 months in stent patients and 4.0 months in gastrojejunostomy patients (p = 0.38). CONCLUSIONS: Propensity score matching demonstrated that endoscopic stent placement resulted in less postoperative morbidity than and a similar food intake and equivalent survival times to gastrojejunostomy. These results suggest the utility of stent therapy.

Estimation of Physiologic Ability and Surgical Stress (E-PASS) versus modified E-PASS for prediction of postoperative complications in elderly patients who undergo gastrectomy for gastric cancer.

BACKGROUND: Improvements in operative technique and perioperative management have resulted in increasing numbers of elderly patients undergoing gastrectomy for gastric cancer (GC). We evaluated the accuracy of Estimation of Physiologic Ability and Surgical Stress (E-PASS) and modified (m)E-PASS scores in predicting postoperative complications in elderly patients with GC. METHODS: We retrospectively analyzed short-term outcomes in 413 patients who underwent gastrectomy for GC between 2005 and 2014. They were divided into two groups: Group N comprised 341 non-elderly patients <80 years of age and Group E comprised 72 elderly patients ≥80 years of age. We calculated the E-PASS and mE-PASS scores and evaluated the correlation between the comprehensive risk score (CRS) and occurrence of postoperative complications. RESULTS: Morbidity rates were 25.5 % in Group N and 31.9 % in Group E. In Group N, the CRS values of both the E-PASS (P < 0.0001) and mE-PASS (P < 0.0001) scores were significantly higher in patients with complications than in those without complications. In Group E, although the E-PASS CRS was significantly higher in patients with complications than in patients without complications (P = 0.01), the mE-PASS CRS fixed (CRSf) score was not significantly correlated with the occurrence of postoperative complications (P = 0.08). CONCLUSION: Both E-PASS and mE-PASS can be used to predict the occurrence of postoperative complications in GC patients undergoing gastrectomy. However, the E-PASS CRS is more accurate for elderly patients because variations in intraoperative parameters such as operation time, blood loss, and extent of skin incision have a strong influence on the occurrence of postoperative complications.

Does remnant gastric cancer really differ from primary gastric cancer? A systematic review of the literature by the Task Force of Japanese Gastric Cancer Association.

Remnant gastric cancer, most frequently defined as cancer detected in the remnant stomach after distal gastrectomy for benign disease and those cases after surgery of gastric cancer at least 5 years after the primary surgery, is often reported as a tumor with poor prognosis. The Task Force of Japanese Gastric Cancer Association for Research Promotion evaluated the clinical impact of remnant gastric cancer by systematically reviewing publications focusing on molecular carcinogenesis, lymph node status, patient survival, and surgical complications. A systematic literature search was performed using PubMed/MEDLINE with the keywords "remnant," "stomach," and "cancer," revealing 1154 relevant reports published up to the end of December 2014. The mean interval between the initial surgery and the diagnosis of remnant gastric cancer ranged from 10 to 30 years. The incidence of lymph node metastases at the splenic hilum for remnant gastric cancer is not significantly higher than that for primary proximal gastric cancer. Lymph node involvement in the jejunal mesentery is a phenomenon peculiar to remnant gastric cancer after Billroth II reconstruction. Prognosis and postoperative morbidity and mortality rates seem to be comparable to those for primary proximal gastric cancer. The crude 5-year mortality for remnant gastric cancer was 1.08 times higher than that for primary proximal gastric cancer, but this difference was not statistically significant. In conclusion, although no prospective cohort study has yet evaluated the clinical significance of remnant gastric cancer, our literature review suggests that remnant gastric cancer does not adversely affect patient prognosis and postoperative course.

Value of E-PASS models for predicting postoperative morbidity and mortality in resection of perihilar cholangiocarcinoma and gallbladder carcinoma.

BACKGROUND: It has previously been reported that a general risk model, Estimation of Physiologic Ability and Surgical Stress (E-PASS), and its modified version, mE-PASS, had a high predictive power for postoperative mortality and morbidity in a variety of gastrointestinal surgeries. This study evaluated their utilities in proximal biliary carcinoma resection. METHODS: E-PASS variables were collected in patients undergoing resection of perihilar cholangiocarcinoma and gallbladder carcinoma in Japanese referral hospitals. RESULTS: Analysis of 125 patients with gallbladder cancer and 97 patients with perihilar cholangiocarcinoma (n = 222). Fifty-six patients (25%) underwent liver resection with either hemihepatectomy or extended hemihepatectomy. The E-PASS models showed a high discrimination power to predict in-hospital mortality; areas under the receiver operating characteristic curve (95% confidence intervals) were 0.85 (0.76-0.94) for E-PASS and 0.82 (0.73-0.91) for mE-PASS. The predicted mortality rates correlated with the severity of postoperative complications (Spearman's rank correlation coefficient: ρ = 0.51, P < 0.001 for E-PASS; ρ = 0.47, P < 0.001 for mE-PASS). CONCLUSIONS: The E-PASS models examined herein may accurately predict postoperative morbidity and mortality in proximal biliary carcinoma resection. These models will be useful for surgical decision-making, informed consent, and risk adjustments in surgical audits.

Preliminary study of surgical audit for overall survival following gastric cancer resection.

BACKGROUND: Previous studies for surgical audit have focused on short-term outcomes, such as perioperative mortality. There has been no gold standard how to evaluate quality of care for long-term outcomes in surgical oncology. This preliminary study aims to propose a method for surgical audit targeting long-term outcome following gastrectomy for gastric cancer. METHODS: We prospectively investigated a set of variables relating to physiologic conditions, tumor characteristics and operations in patients who underwent gastrectomy for gastric cancer between June 2005 and July 2008 in 18 referral hospitals in Japan. Overall survival (OS) is the endpoint. Cox hazard regression analysis was used to generate a model to predict OS. The calibration and discrimination power of the model were assessed using the Hosmer-Lemeshow (H-L) test and area under the receiver-operating characteristic curve (AUC), respectively. The ratio of observed-to-estimated 5-year OS rates (OE ratio) was defined as a measure of quality. RESULTS: Among 762 patients analyzed, 697 (91%) completed the 5-year follow-up. The constructed model for OS exhibited a good discrimination power (AUC, 95% confidence interval 0.89, 0.86-0.91), which was significantly better than that for the UICC stage (0.81, 0.77-0.84). This model also demonstrated a good calibration power (H-L: χ(2) = 27.2, df = 8, P = 0.77). The OE ratios among the participating hospitals revealed no significant variation between 0.74 and 1.1. CONCLUSIONS: The current study suggests the possibility of surgical audit for postoperative OS in gastric cancer. Further studies including high-volume centers will be necessary to validate this idea.

The EPOS-CC Score: An Integration of Independent, Tumor- and Patient-Associated Risk Factors to Predict 5-years Overall Survival Following Colorectal Cancer Surgery.

BACKGROUND: Surgical audit is an essential task for the estimation of postoperative outcome and comparison of quality of care. Previous studies on surgical audits focused on short-term outcomes, such as postoperative mortality. We propose a surgical audit evaluating long-term outcome following colorectal cancer surgery. The predictive model for this audit is designated as 'Estimation of Postoperative Overall Survival for Colorectal Cancer (EPOS-CC)'. METHODS: Thirty-one tumor-related and physiological variables were prospectively collected in 889 patients undergoing elective resection for colorectal cancer between April 2005 and April 2007 in 16 Japanese hospitals. Postoperative overall survival was assessed over a 5-years period. The EPOS-CC score was established by selecting significant variables in a uni- and multivariate analysis and allocating a risk-adjusted multiplication factor to each variable using Cox regression analysis. For validation, the EPOS-CC score was compared to the predictive power of UICC stage. Inter-hospital variability of the observed-to-estimated 5-years survival was assessed to estimate quality of care. RESULTS: Among the 889 patients, 804 (90%) completed the 5-years follow-up. Univariate analysis displayed a significant correlation with 5-years survival for 14 physiological and nine tumor-related variables (p < 0.005). Highly significant p-values below 0.0001 were found for age, ASA score, severe pulmonary disease, respiratory history, performance status, hypoalbuminemia, alteration of hemoglobin, serum sodium level, and for all histological variables except tumor location. Age, TNM stage, lymphatic invasion, performance status, and serum sodium level were independent variables in the multivariate analysis and were entered the EPOS-CC model for the prediction of survival. Risk-adjusted multiplication factors between 1.5 (distant metastasis) and 0.16 (serum sodium level) were accorded to the different variables. The predictive power of EPOS-CC was superior to the one of UICC stage; area under the curve 0.87, 95% CI 0.85-0.90 for EPOS-CC, and 0.80, 0.76-0.83 for UICC stage, p < 0.001. Quality of care did not differ between hospitals. CONCLUSIONS: The EPOS-CC score including the independent variables age, performance status, serum sodium level, TNM stage, and lymphatic invasion is superior to the UICC stage in the prediction of 5-years overall survival. This higher accuracy might be explained by the inclusion of physiological factors, thus also taking non-tumor-associated deaths into account. Furthermore, EPOS-CC score may compare quality of care among different institutions. Future studies are necessary to further evaluate this score and help improving the prediction of long-term survival following colorectal cancer surgery.

Evaluation of modified estimation of physiologic ability and surgical stress in patients undergoing surgery for choledochocystolithiasis.

BACKGROUND: The incidence of complicated choledochocystolithiasis is increasing with the aging of society in Japan. We evaluated the utility of our prediction rule modified estimation of physiologic ability and surgical stress (mE-PASS) in predicting postoperative adverse events in patients with choledochocystolithiasis. METHODS: A total of 4,329 patients who underwent elective surgery for choledochocystolithiasis in 44 referral hospitals between April 1987 and April 2007 were analyzed for mE-PASS along with postoperative events. The discrimination power of mE-PASS was assessed by the area under the receiver operating characteristic curve (AUC). The correlation between ordinal and interval variables was quantified by the Spearman rank correlation (ρ). The ratio of observed-to-estimated mortality rates (OE ratio) was used as a metric of surgical quality. RESULTS: Postoperative in-hospital mortality rates were 0 % (0/3,442) for laparoscopic cholecystectomy, 0.19 % (1/521) for open cholecystectomy, 1.6 % (1/63) for laparoscopic choledochotomy, 1.1 % (3/264) for open choledochotomy, and 5.1 % (2/39) for plasty or resection of the common bile duct. mE-PASS demonstrated a high discrimination power to predict in-hospital mortality; AUC, 95 % confidence interval (CI) of 0.96, 0.94-0.99. The predicted mortality rates significantly correlated with the severity of postoperative complications (ρ = 0.278, p < 0.0001) and length of hospital stay (ρ = 0.479, p < 0.0001). The OE ratios (95 % CI) improved slightly over time; 1.5 (0.25-9.0) between 1987 and 2000, and 0.40 (0.078-2.1) between 2001 and 2007. CONCLUSIONS: The present study suggests that mE-PASS can predict postoperative risks in patients who have undergone choledochocystolithiasis. mE-PASS may be useful in surgical decision making and evaluating the quality of care.

Development and validation of the Calculation of post-Operative Risk in Emergency Surgery (CORES) model.

PURPOSE: This study was undertaken to establish a model to predict the post-operative mortality for emergency surgeries. METHODS: A regression model was constructed to predict in-hospital mortality using data from a cohort of 479 cases of emergency surgery performed in a Japanese referral hospital. The discrimination power of the current model termed the Calculation of post-Operative Risk in Emergency Surgery (CORES), and Portsmouth modification of the Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (P-POSSUM) were validated using the area under the receiver operating characteristic curve (AUC) in another cohort of 494 cases in the same hospital (validation subset). We further evaluated the accuracy of the CORES in a cohort of 1,471 cases in six hospitals (multicenter subset). RESULTS: CORES requires only five preoperative variables, while the P-POSSUM requires 20 variables. In the validation subset, the CORES model had a similar discrimination power as the P-POSSUM for detecting in-hospital mortality (AUC, 95 % CI for CORES: 0.86, 0.80-0.93; for P-POSSUM: 0.88, 0.82-0.93). The predicted mortality rates of the CORES model significantly correlated with the severity of the post-operative complications. The subsequent multicenter study also demonstrated that the CORES model exhibited a high AUC value (0.85: 0.81-0.89) and a significant correlation with the post-operative morbidity. CONCLUSIONS: This model for emergency surgery, the CORES, demonstrated a similar discriminatory power to the P-POSSUM in predicting post-operative mortality. However, the CORES model has a substantial advantage over the P-POSSUM in that it utilizes far fewer variables.

Risk factors for catheter-related bloodstream infections in adult hospitalized patients - multicenter cohort study.

BACKGROUND: Risk factors for catheter-related bloodstream infections (CRBSIs) may change over time with progress in infection control. This study was undertaken to explore the current risk factors for CRBSIs in hospitalized patients. METHODS: Adult patients with non-tunneled central venous catheters (CVCs) in 12 Japanese referral hospitals were prospectively enrolled between December 2009 and January 2012. Patients were monitored for CRBSIs for up to 8 weeks from CVC insertion; data were collected regarding patient characteristics, the purpose of CVC insertion, insertion methods, mechanical complications during insertion, and post-insertion catheter care. RESULTS: A total of 892 patients were enrolled in this study. The overall incidence of CRBSIs was 0.40 infections per 1000 catheter-days. Univariate analysis using the Fisher's exact test identified one of the participating hospitals (hospital A; p < 0.001), internal jugular vein catheterization (IJVC) (p = 0.0013), not using maximal sterile barrier precautions (p = 0.030), and the Seldinger technique for catheter insertion (p = 0.025) as significant risk factors for CRBSI. After excluding data from hospital A, only IJVC remained a significant risk factor for CRBSI (p = 0.025). The cumulative probability of remaining without CRBSI was significantly lower in patients with IJVCs than in patients with other catheter routes (p < 0.001; log-rank test). Similarly, the cumulative probability of remaining without catheter removal due to a suspected infection was significantly lower in patients with IJVCs (p = 0.034; log-rank test). CONCLUSIONS: The current study suggests that IJVC might be a risk factor for CRBSI under current infection control conditions.

Quality of gastric cancer care in designated cancer care hospitals in Japan.

OBJECTIVE: To develop a set of process-of-care quality indicators (QIs) that would cover a wide range of gastric cancer care modalities and to examine the current state of the quality of care provided by designated cancer care hospitals in Japan. DESIGN: A retrospective medical record review. SETTING: Eighteen designated cancer care hospitals throughout Japan. PARTICIPANTS: A total of 1685 patients diagnosed with gastric cancer in 2007. MAIN OUTCOME MEASURES: Provision of care to eligible patients as described in the 29 QIs, which were developed using an adaptation of the RAND/UCLA (University of California, Los Angeles) appropriateness method by a panel of nationally recognized experts in Japan. RESULTS: Overall, the patients received 68.3% of the care processes recommended by the QIs. While 'deep venous thrombosis prophylaxis before major surgery' was performed for 99% of the cases, 'documentation before endoscopic resection' was completed for only 12% of the cases. The chemotherapy care was less likely to meet the QI standards (61%) than pre-therapeutic care (76%), surgical treatment (66%) and endoscopic resection (71%; overall difference: P < 0.001). A comparison based on the types of care showed that documentation and patient explanation were performed less frequently (60 and 53%, respectively) than were diagnostic and therapeutic processes as recommended in the QIs (85%; overall P < 0.001). CONCLUSIONS: Although many required care processes were provided, some areas with room for improvement were revealed, especially with respect to chemotherapy, documentation and patient explanation. Continuous efforts to improve the quality and develop a system to monitor this progress would be beneficial in Japan.

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

BACKGROUND AND OBJECTIVES: This study evaluated the ability of general surgical models to predict postoperative morbidity and mortality in liver surgery. METHODS: The postoperative course and mortality rates predicted by general surgical models were investigated in 960 patients who underwent hepatectomy or ablation therapy for primary or metastatic liver carcinoma. RESULTS: The area under the receiver operative characteristic curve (95% confidence intervals) for detecting postoperative liver failure was 0.89 (0.84-0.94), 0.85 (0.78-0.92), and 0.78 (0.72-0.85) for the estimation of physiologic ability and surgical stress (E-PASS) model, the modified E-PASS (mE-PASS) model, and the Portsmouth Physiologic and Operative Severity Score for the enUmeration of Mortality and morbidity (P-POSSUM) model, respectively, and those for detecting in-hospital mortality were 0.85 (0.76-0.93), 0.85 (0.78-0.92), and 0.79 (0.71-0.87), respectively. Nevertheless, all of the models overpredicted the overall mortality rate (by 2.3-fold for E-PASS, 2.3-fold for mE-PASS, and 2.9-fold for P-POSSUM). CONCLUSIONS: The general surgical risk models demonstrated high discriminatory power for predicting postoperative outcomes in liver surgery, but overpredicted the overall mortality rate by more than twofold. Therefore, these models should be refined to make them more suitable for predicting liver surgery outcomes.

Evaluation of modified Estimation of Physiologic Ability and Surgical Stress in gastric carcinoma surgery.

BACKGROUND: We recently modified our prediction scoring system "Estimation of Physiologic Ability and Surgical Stress" and have designated the current version mE-PASS. This scoring system has been designed to obtain predicted postoperative mortality rates before surgery and this study was performed to assess its usefulness in elective surgery for gastric carcinoma. METHODS: We investigated seven variables for mE-PASS and evaluated the postoperative course in 3,449 patients who underwent elective surgery for gastric carcinoma in Japan between August 20, 1987 and April 9, 2007, in order to quantify the predicted in-hospital mortality rates (R). The calibration and discrimination power of R were assessed using the Hosmer-Lemeshow test and the area under the receiver operating characteristic curve (AUC), respectively. The ratios of observed-to-estimated mortality rates (OE ratios) were quantified as a measure of quality. RESULTS: The overall postoperative morbidity and mortality rates were 19.0 and 2.0%, respectively. R demonstrated good power in calibration (χ(2) value, 12.5; df 8; P = 0.89) as well as discrimination (AUC, 95% confidence intervals: 0.80, 0.75-0.85). The OE ratios between hospitals ranged from 0.44 to 1.8. Overall, the OE ratios seemed to improve with time (OE ratio, 95% confidence intervals: 1.3, 0.73-2.4 for the early period between 1987 and 2000; 1.0, 0.59-1.7 for the middle period between 2001 and 2004; and 0.65, 0.36-1.2 for the late period between 2005 and 2007). CONCLUSION: Based on these findings, mE-PASS might be useful for medical decision-making and for assessing the quality of care in elective surgery for gastric carcinoma.

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.

Evaluation of modified estimation of physiologic ability and surgical stress in colorectal carcinoma surgery.

BACKGROUND: We recently modified Estimation of Physiologic Ability and Surgical Stress, our prediction scoring system. OBJECTIVE: This study evaluated the usefulness of our modified version for colorectal carcinoma in comparison with existing models. DESIGN: This investigation studied a multicenter cohort. SETTINGS: The study was conducted in regional referral hospitals in Japan. PATIENTS: Patients were included who underwent elective surgery for colorectal carcinoma. MAIN OUTCOME MEASURES: Postoperative morbidity, mortality, and predicted mortality rates for original and modified Estimation of Physiologic Ability and Surgical Stress were investigated in 2388 patients in comparison with existing European models. RESULTS: Among the models, the modified Estimation of Physiologic Ability and Surgical Stress demonstrated the highest discriminatory power in terms of in-hospital mortality (area under receiver operating characteristic curve: 0.84 for Estimation of Physiologic Ability and Surgical Stress, 0.87 for modified Estimation of Physiologic Ability and Surgical Stress, 0.84 for Portsmouth modification of POSSUM, 0.74 for ASA status-based model), as well as 30-day mortality (area under receiver operating characteristic curve: 0.82 for Estimation of Physiologic Ability and Surgical Stress, 0.84 for modified Estimation of Physiologic Ability and Surgical Stress, 0.81 for POSSUM, 0.78 for colorectal POSSUM, 0.76 for Association of Coloproctology of Great Britain and Ireland score). British models, in general, overpredicted postoperative mortality rates by more than 10 times. LIMITATIONS: The current study analyzed only the Japanese population treated in medium-volume centers. CONCLUSIONS: Among the models, modified Estimation of Physiologic Ability and Surgical Stress was the most accurate in predicting postoperative mortality in colorectal carcinoma surgery. These findings should be validated in Western populations, because the Japanese population may differ from Western populations in terms of body shape or reserve capacity.

Prediction of anastomotic leak and its prognosis in digestive surgery.

BACKGROUND: Anastomotic leak (AL) is a dangerous postoperative complication in gastrointestinal surgery. The present study focuses on whether our prediction scoring system, "Estimation of Physiologic Ability and Surgical Stress" (E-PASS), could predict occurrence of AL and its prognosis in various kinds of gastrointestinal surgical procedures. METHODS: We prospectively investigated parameters of E-PASS, absence or presence of AL, and in-hospital mortality in 6,005 patients who underwent elective digestive surgery with alimentary tract reconstruction in 45 acute care hospitals in Japan between 1 April 2002 and 31 March 2007. RESULTS: Incidences of AL were 19.6% for esophagectomy via right thoracotomy and laparotomy, 11.7% for pancreaticoduodenectomy, 7.4% for low anterior resection, 4.0% for total gastrectomy, 1.8% for open distal gastrectomy, 1.3% for open colectomy, for an overall incidence of 4.1%. The incidence in each procedure significantly correlated with median value of surgical stress score of the E-PASS (R = 0.78, n = 11, p = 0.0048). The incidences of AL increased when Total Risk Points (TRP) of the E-PASS increased; 1.1% at the TRP range of <500, 2.8% at 500 to <1,000, 4.8% at 1,000 to <1,500, and 13.6% at ≥ 1,500 (p < 0.0001). In patients who suffered from AL, an in-hospital mortality rate at TRP < 1,000 was significantly lower than that at TRP of ≥ 1,000 (1.1 vs. 15.9%; p = 0.00019). CONCLUSIONS: The E-PASS, requiring only nine variables, may be useful in predicting AL and its prognosis.

Evaluation of estimation of physiologic ability and surgical stress to predict in-hospital mortality in cardiac surgery.

PURPOSE: Prediction of postoperative risk in cardiac surgery is important for cardiac surgeons and anesthesiologists. We generated a prediction rule for elective digestive surgery, designated as Estimation of Physiologic Ability and Surgical Stress (E-PASS). This study was undertaken to evaluate the accuracy of E-PASS in predicting postoperative risk in cardiac surgery. METHODS: We retrospectively collected data from patients who underwent elective cardiac surgery at a low-volume center (N = 291) and at a high-volume center (N = 784). Data were collected based on the variables required by E-PASS, the European system for cardiac operative risk evaluation (EuroSCORE), and the Ontario Province Risk Score (OPRS). Calibration and discrimination were assessed by the Hosmer-Lemeshow test and the area under the receiver operating characteristic curve (AUC), respectively. The ratio of observed-to-estimated in-hospital mortality rates (OE ratio) was defined as a measure of quality. RESULTS: In-hospital mortality rates were 7.6% at the low-volume center and 1.3% at the high-volume center, accounting for an overall mortality rate of 3.0%. AUC values to detect in-hospital mortality were 0.88 for E-PASS, 0.77 for EuroSCORE, and 0.71 for OPRS. Hosmer-Lemeshow analysis showed a good calibration in all models (P = 0.81 for E-PASS, P = 0.49 for EuroSCORE, and P = 0.94 for OPRS). OE ratios for the low-volume center were 0.83 for E-PASS, 0.70 for EuroSCORE, and 0.83 for OPRS, whereas those for the high-volume center were 0.26 for E-PASS, 0.14 for EuroSCORE, and 0.27 for OPRS. CONCLUSIONS: E-PASS may accurately predict postoperative risk in cardiac surgery. Because the variables are different between cardiac-specific models and E-PASS, patients' risks can be double-checked by cardiac surgeons using cardiac-specific models and by anesthesiologists using E-PASS.

[Central venous catheter-related infection].

To prevent catheter-related bloodstream infections (CRBSI), the use of maximal sterile barrier precautions (MSBP) during central venous catheter insertion, using a cap, mask, sterile gown, sterile gloves, and a large sterile sheet, was recommended in the Centers for Disease Control and Prevention Guidelines. However, this recommendation is based on the evidence obtained by only one randomized controlled trial (RCT) in which the subject patients were outpatients for chemotherapy. Nevertheless, the recommendation is applied to any kind of clinical settings. Therefore, we undertook a multi-institutional RCT to evaluate the effectiveness of the MSBP in surgical patients admitted to general wards. Our study could not demonstrate better prevention of CRBSI by MSBP compared with standard sterile barrier precautions (SSBP) where only sterile gloves and a small sterile drape were used. There were 5 out of 211 cases (2.4%) of CRBSI in the MSBP group and 6 out of 213 cases (2.8%) in the SSBP group (P = 0.77). These results suggest that further RCTs should be necessary in many clinical settings to reach a conclusion on this issue. We also address other evidences regarding prevention of CRBSI in this review.

Clinical TNM staging for esophageal, gastric, and colorectal cancers in the era of neoadjuvant therapy: A systematic review of the literature.

AIM: Clinical staging is vital for selecting appropriate candidates and designing neoadjuvant treatment strategies for advanced tumors. The aim of this review was to evaluate diagnostic abilities of clinical TNM staging for gastrointestinal, gastrointestinal cancers. METHODS: We conducted a systematic review of recent publications to evaluate the accuracy of diagnostic modalities on gastrointestinal cancers. A systematic literature search was performed in PubMed/MEDLINE using the keywords "TNM staging," "T4 staging," "distant metastases," "esophageal cancer," "gastric cancer," and "colorectal cancer," and the search terms used in Cochrane Reviews between January 2005 to July 2020. Articles focusing on preoperative diagnosis of: (a) depth of invasion; (b) lymph node metastases; and (c) distant metastases were selected. RESULTS: After a full-text search, a final set of 55 studies (17 esophageal cancer studies, 26 gastric cancer studies, and 12 colorectal cancer studies) were used to evaluate the accuracy of clinical TNM staging. Positron emission tomography-computed tomography (PET-CT) and/or magnetic resonance imaging (MRI) were the best modalities to assess distant metastases. Fat and fiber mode of CT may be useful for T4 staging of esophageal cancer, CT was a partially reliable modality for lymph node staging in gastric cancer, and CT combined with MRI was the most reliable modality for liver metastases from colorectal cancer. CONCLUSION: The most reliable diagnostic modality differed among gastrointestinal cancers depending on the type of cancer. Therefore, we propose diagnostic algorithms for clinical staging for each type of cancer.

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.