Cost of postoperative complications of lower anterior resection for rectal cancer: a nationwide registry study of 15,187 patients.

PURPOSE: To assess the increase in hospital costs associated with postoperative complications after lower anterior resection (LAR) for rectal cancer. METHODS: The subjects of this retrospective analysis were patients who underwent elective LAR surgery between April, 2015 and March, 2017, collected from a Japanese nationwide gastroenterological surgery registry linked to hospital-based claims data. We evaluated total and category-specific hospitalization costs based on the level of postoperative complications categorized using the Clavien-Dindo (CD) classification. We assessed the relative increase in hospital costs, adjusting for preoperative factors and hospital case volume. RESULTS: We identified 15,187 patients (mean age 66.8) treated at 884 hospitals. Overall, 71.8% had no recorded complications, whereas 7.6%, 10.8%, 9.0%, 0.6%, and 0.2% had postoperative complications of CD grades I-V, respectively. The median (25th-75th percentiles) hospital costs were $17.3 K (16.1-19.3) for the no-complications group, and $19.1 K (17.3-22.2), $21.0 K (18.5-25.0), $27.4 K (22.4-33.9), $41.8 K (291-618), and $22.7 K (183-421) for the CD grades I-V complication groups, respectively. The multivariable model identified that complications of CD grades I-V were associated with 11%, 21%, 61%, 142%, and 70% increases in in-hospital costs compared with no complications. CONCLUSIONS: Postoperative complications and their severity are strongly associated with increased hospital costs and health-care resource utilization. Implementing strategies to prevent postoperative complications will improve patients' clinical outcomes and reduce hospital care costs substantially.

Japanese clinical practice guidelines for vascular anomalies 2017.

The objective was to prepare guidelines to perform the current optimum treatment by organizing effective and efficient treatments of hemangiomas and vascular malformations, confirming the safety, and systematizing treatment, employing evidence-based medicine (EBM) techniques and aimed at improvement of the outcomes. Clinical questions (CQs) were decided based on the important clinical issues. For document retrieval, key words for literature searches were set for each CQ and literature published from 1980 to the end of September 2014 was searched in Pubmed, Cochrane Library, and Japana Centra Revuo Medicina (JCRM). The strengths of evidence and recommendations acquired by systematic reviews were determined following the Medical Information Network Distribution System (MINDS) technique. A total of 33 CQs were used to compile recommendations and the subjects included efficacy of resection, sclerotherapy/embolization, drug therapy, laser therapy, radiotherapy, and other conservative treatment, differences in appropriate treatment due to the location of lesions and among symptoms, appropriate timing of treatment and tests, and pathological diagnosis deciding the diagnosis. Thus, the Japanese Clinical Practice Guidelines for Vascular Anomalies 2017 have been prepared as the evidence-based guidelines for the management of vascular anomalies.

Evaluating the quality of data from the Japanese National Clinical Database 2011 via a comparison with regional government report data and medical charts.

PURPOSE: The aim of this study was to examine the quality of data from the National Clinical Database (NCD) via a comparison with regional government report data and medical charts. METHODS: A total of 1,165,790 surgical cases from 3007 hospitals were registered in the NCD in 2011. To evaluate the NCD's data coverage, we retrieved regional government report data for specified lung and esophageal surgeries and compared the number with registered cases in the NCD for corresponding procedures. We also randomly selected 21 sites for on-site data verification of eight demographic and surgical data components to assess the accuracy of data entry. RESULTS: The numbers of patients registered in the NCD and regional government report were 46,143 and 48,716, respectively, for lung surgeries and 7494 and 8399, respectively, for esophageal surgeries, leading to estimated coverages of 94.7% for lung surgeries and 89.2% for esophageal surgeries. According to on-site verification of 609 cases at 18 sites, the overall agreement between the NCD data components and medical charts was 97.8%. CONCLUSION: Approximately, 90-95% of the specified lung surgeries and esophageal surgeries performed in Japan were registered in the NCD in 2011. The NCD data were accurate relative to medical charts.

Indications for tracheostomy in children with head and neck lymphatic malformation: analysis of a nationwide survey in Japan.

PURPOSE: Airway obstruction caused by lymphatic malformation (LM) in the head and neck may require a tracheostomy. We present the results of our analysis of a nationwide survey on the indications for tracheostomy in children with head and neck LM. METHODS: We analyzed data in relation to tracheostomy based on a questionnaire about 518 children with head and neck LM without mediastinal involvement. RESULTS: Tracheostomy was performed for 43 of the 518 children. Most (32/43) of these children were younger than 1 year of age and the tracheostomy was almost always performed for airway obstruction (40/43). The lesion was in contact with the airway in 32 (72%) of these children, but in only 58 (12%) of the 473 children who were managed without tracheostomy. When the maximum circumferential area of contact was compared, only 20 (27%) of 74 patients with maximum contact of less than a half-circle required tracheostomy, whereas 11 of 13 with maximum contact of more than a half-circle required tracheostomy (P = 0.0001). Six patients without airway contact required tracheostomy because of acute swelling caused by hemorrhage, infection, or both. CONCLUSIONS: Children with head and neck LM required tracheostomy to relieve airway obstruction. Tracheostomy should be considered if the lesion is in contact with the airway and surrounds more than a half-circle, and when it causes acute swelling.

Treatment of mediastinal lymphatic malformation in children: an analysis of a nationwide survey in Japan.

PURPOSE: Clinical guidelines on lymphatic malformation (LM) influencing the airway have been crafted in the Research Project for Intractable Diseases. We herein report an analysis of a nationwide survey of mediastinal LM and the therapeutic recommendations. METHODS: Eighty-seven registered cases with mediastinal involvement were analyzed with a review of the literature. RESULTS: Mediastinal LM was located more often in the upper and anterior mediastinum and was found without any accompanying symptoms in 56/87 cases. Tracheostomy was required in 23/87 cases, mostly < 2 years of age (87%). All patients who needed tracheostomy had a lesion in contact with the airway, while only 55% of those without tracheostomy had contact. Tracheostomy tended to be placed more when the longer segment of the airway was in contact with the LM. Multimodal treatments were performed in 29 patients, but the lesions remained in most cases, and chylothorax, hemorrhaging, nerve palsy, and infections were noted as complications. CONCLUSIONS: In patients with mediastinal LM, tracheostomy may be necessary, especially when the lesion is extensive and contacts the airway. Extirpation of the mediastinal LM may be the only therapeutic option, but in cases with few or no symptoms, non-surgical treatment should be considered in light of potential postoperative complications.

Comparison of single-incision laparoscopic percutaneous extraperitoneal closure (SILPEC) and open repair for pediatric inguinal hernia: a single-center retrospective cohort study of 2028 cases.

BACKGROUD: Recently, laparoscopic percutaneous extraperitoneal closure (LPEC) has gained increased popularity for pediatric inguinal hernia repair. To improve cosmesis, we developed single incision LPEC (SILPEC). The aim of this study was to assess the safety and feasibility of SILPEC compared with traditional open repair (OR). METHODS: This was a single-center retrospective cohort study of 2028 children who underwent inguinal hernia repair between April 2005 and August 2014. Nine hundred and ninety-five patients underwent OR and 1033 patients underwent SILPEC. Medical records were reviewed with respect to operative time, recurrence, incidence of contralateral metachronous inguinal hernia (CMIH), and complications. Patient satisfaction with cosmetic result was also investigated using questionnaires sent by mail. RESULTS: All SILPEC procedures were completed without conversion. Operative time was longer in the SILPEC group than in the OR group for both unilateral and bilateral surgery regardless of sex (unilateral male: p = 0.0006, unilateral female: p < 0.0001, bilateral male: p < 0.0001, bilateral female: p < 0.0001). There was no statistically significant difference in recurrence rate (p = 0.43). The incidence of CMIH was significantly higher in the OR than in the SILPEC group (p < 0.0001). No postoperative testicular atrophy was found in either group. There was no statistically significant difference in ascending testis (p = 0.09), but the frequency of surgical site infection was higher in the SILPEC than in the OR group (p = 0.0013). According to the questionnaire, operative scar was more invisible in the SILPEC than in the OR group (p < 0.0001), but both procedures had equally high levels of satisfaction for cosmetic results (p = 0.58). CONCLUSION: SILPEC proved to be a safe and feasible procedure compared with OR with an equally low recurrence rate, more effectiveness for preventing CMIH, and more invisible scar.

Mosapride for gastroesophageal reflux disease in neurologically impaired patients.

BACKGROUND: The prokinetic agent cisapride is effective for the treatment of gastroesophageal reflux disease (GERD) in infants and children, but is no longer used for this purpose because of safety concerns. Therefore, other pharmacological agents need to be investigated for efficacy in GERD treatment. In this study, we examined the effectiveness and safety of mosapride for the treatment of neurologically impaired children and adolescents with GERD. METHODS: Mosapride (0.3 mg/kg/day) was administered to 11 neurologically impaired patients with GERD (five male; median age, 12.3 years). Esophageal acid exposure was measured using esophageal pH monitoring before and at >5 days after the start of mosapride treatment. The pressure and length of the lower esophageal sphincter were compared before and after mosapride treatment. RESULTS: In the 11 patients, median reflux index (percentage of the total monitoring period during which recorded pH was <4.0) was 17.5% (range, 4.4-59%) before and 8.2% (range, 2.8-20.7%) after mosapride treatment (P = 0.02). Median esophageal clearance was 1.0 min/reflux (range, 0.5-2.1 min/reflux) before and 0.7 min/reflux (range, 0.4-1.2 min/reflux) after treatment with mosapride (P = 0.02). The median number of reflux episodes before (219) and after (122) drug treatment did not differ significantly. CONCLUSION: The decreased reflux index in neurologically impaired patients with GERD is due to mosapride, therefore mosapride may be a candidate for GERD treatment.

Mesh hiatal reinforcement in laparoscopic Nissen fundoplication for neurologically impaired children is safe and feasible.

Fundoplication is a standard treatment for gastroesophageal reflux disease (GERD) in neurologically impaired children. However, it has a high recurrence rate due to wrap herniation and disruption resulting from the failure or enlargement of the esophageal hiatus suture site. In adult patients with GERD, reinforcement of the sutured esophageal hiatus with a mesh significantly reduces the recurrence rate after surgery for esophageal hiatus hernia. In children, there are no big series of fundoplication with mesh reinforcement. Therefore, we confirmed the safety and feasibility of an expanded polytetrafluoroethylene mesh hiatal reinforcement with fundoplication as an additional procedure for neurologically impaired children. Neurologically impaired children (age, ≥5 years) who underwent laparoscopic fundoplication and gastrostomy at our institution between 2011 and 2013 were included in this study. The operative time, bleeding amount, complications, and recurrence were retrospectively evaluated. Thirteen patients were included in this study. The mean age at operation was 147.2 ± 37.8 months, and mean body weight was 18.5 ± 7.9 kg. The complication rate of epilepsy and scoliosis was 100% and 84.6%, respectively. The operative time was 265.1 ± 38.1 minutes, and mean blood loss was 26.5 ± 34.7 mL. There were no peri- or postoperative complications. None of the patients showed recurrent symptoms such as repeated vomiting and aspiration pneumonia during the mean follow-up period of 2.5 ± 0.6 years. The mesh hiatal reinforcement with fundoplication for neurologically impaired children is safe and feasible.

[Past, Present, and Future of National Clinical Database].

The National Clinical Database of Japan( NCD) was established in April 2010 in the collaboration of 9 surgical subspecialty societies on the platform of the Japan Surgical Society(JSS). Registrations began in 2011, and because NCD is strongly linked to the board certification system by JSS, the ratio of registration of surgical procedures is very high, over than 97%. To date, more than 4,000 facilities have enrolled and over 7 million cases were registered over a 5-year period. The analyses of NCD are compared to the foreign database, such as American College of Surgeon National Surgical Quality Improvement Program in the gastrointestinal (GI) surgical field, and the Society of Thoracic Surgeons National Adult Cardiac Database in the cardiovascular surgical field, with a goal of creating a standardized surgery database for quality improvement. Also, from 2014, NCD has started to send feedback reports of mortality and morbidity to participants in the 8 GI procedures, namely esophagectomy, gastrectomy, hepatectomy and so on. Furthermore, NCD supports many clinical researches for providing high-quality healthcare to patients and the general public. NCD's activities are conducted lawfully and ethically with due consideration of its effects on society. NCD will continue to ensure the reliability of collected data, to guarantee the scientific analysis, and to discuss the future evolution.

A multi-degree-of-freedom needle driver with a short tip and small shaft for pediatric laparoscopic surgery: in vivo assessment of multi-directional suturing on the vertical plane of the liver in rabbits.

BACKGROUND: Laparoscopic Kasai portoenterostomy has been performed in infants with biliary atresia at several institutions, but laparoscopic anastomosis requiring multi-directional suturing on a vertical plane of the liver remains a challenge. To assist multi-directional suturing, we developed a multi-degree-of-freedom (DOF) needle driver whose tip length was 15 mm and shaft diameter was 3.5 mm. The tip of the multi-DOF needle driver has three DOFs for grasp, flection and rotation. The aim of this study was to evaluate the performance of the multi-DOF needle driver in two kinds of in vivo experiments. METHODS: Surgeons were asked to perform four-directional laparoscopic suturing on a vertical plane of the liver in six rabbits using the multi-DOF needle driver or a conventional needle driver. The needle grasping time, the needle handling time, the number of needle insertions, the number of liver lacerations, the suturing width and depth, and the area of necrotic tissues were analyzed and compared. Additionally, one surgeon was asked to perform laparoscopic hepato-jejunostomy in four rabbits to assess the feasibility of Kasai portoenterostomy using the multi-DOF needle driver. RESULTS: The suturing depth using the multi-DOF needle driver was significantly larger than that using the conventional needle driver in both the right and downward suturing directions. No statistically significant differences were found in other metrics. Liver lacerations were observed only when suturing was performed using the conventional needle driver. The experimental laparoscopic hepato-jejunostomy using the multi-DOF needle driver was successful. CONCLUSIONS: Using the multi-DOF needle driver, uniform multi-directional suturing on a vertical plane of the liver could be performed. The short distal tip of the multi-DOF needle driver demonstrated its advantages in multi-directional suturing in a small body cavity. The multi-DOF needle driver may be able to be used to perform complex tasks in laparoscopic Kasai portoenterostomy.

Minimally invasive surgery for diaphragmatic diseases in neonates and infants.

Owing to recent advances in minimally invasive surgery (MIS), laparoscopic and thoracoscopic surgery have been gradually introduced for use in neonates and infants. This review focuses on two popular MIS procedures for diaphragmatic diseases in neonates and infants: congenital diaphragmatic hernia (CHD) repair and plication for diaphragmatic eventration. While several advantages of MIS are proposed for CDH repair in neonates, there are also some concerns, namely intraoperative hypercapnia and acidosis and a higher recurrence rate than open techniques. Thus, neonates with severe CDH, along with an unstable circulatory and respiratory status, may be unsuitable for MIS repair, and the use of selection criteria is, therefore, important in these patients. It is generally believed that a learning curve is associated with the higher recurrence rate. Contrary to CDH repair, no major disadvantages associated with the use of MIS for diaphragmatic eventration have been reported in the literature, other than technical difficulty. Thus, if technically feasible, all pediatric patients with diaphragmatic eventration requiring surgical treatment are potential candidates for MIS. Due to a shortage of studies on this procedure, the potential advantages of MIS compared to open techniques for diaphragmatic eventration, such as early recovery and more rapid extubation, need to be confirmed by further studies.

National Clinical Database feedback implementation for quality improvement of cancer treatment in Japan: from good to great through transparency.

The National Clinical Database (NCD) of Japan was established in April, 2010 with ten surgical subspecialty societies on the platform of the Japan Surgical Society. Registrations began in 2011 and over 4,000,000 cases from more than 4100 facilities were registered over a 3-year period. The gastroenterological section of the NCD collaborates with the American College of Surgeons' National Surgical Quality Improvement Program, which shares a similar goal of developing a standardized surgical database for surgical quality improvement, with similar variables for risk adjustment. Risk models of mortality for eight procedures; namely, esophagectomy, partial/total gastrectomy, right hemicolectomy, low anterior resection, hepatectomy, pancreaticoduodenectomy, and surgery for acute diffuse peritonitis, have been established, and feedback reports to participants will be implemented. The outcome measures of this study were 30-day mortality and operative mortality. In this review, we examine the eight risk models, compare the procedural outcomes, outline the feedback reporting, and discuss the future evolution of the NCD.

Contraindications and image-defined risk factors in laparoscopic resection of abdominal neuroblastoma.

PURPOSE: Minimally invasive surgery (MIS) has become widely accepted as a technique for abdominal neuroblastoma resection. However, the indications for MIS are still controversial. The aim of this study was to evaluate image-defined risk factors (IDRFs), complications, and oncologic outcomes in patients with abdominal neuroblastomas treated with MIS. METHODS: Between August 1998 and February 2016, MIS was planned for 20 children with abdominal neuroblastomas. Clinical data were retrospectively reviewed and compared between the IDRF-negative and IDRF-positive patients. RESULTS: On the basis of the latest IDRF guidelines, five patients were classified as IDRF-positive and four of them had operative complications; namely, partial infarction of the ipsilateral kidney or open conversion. Concerning the two patients who needed open conversion, the primary reason for open conversion was difficulty in dissection of the tumor from the vena cava. Preoperative images of these cases showed either deformation or subtotal encasement of the vena cava. Relapse occurred in three high-risk patients and in none of the low/intermediate-risk patients. No complication occurred in the IDRF-negative cases. CONCLUSIONS: IDRF-negative might be a good indication for MIS for abdominal neuroblastoma. However, deformation or subtotal encasement of the vena cava should be considered as IDRF-positive for MIS.

Laparoscopic partial gastrectomy of a huge gastric duplication cyst in an infant.

Gastric duplication cyst is a rare anomaly, and most cases are recognized during childhood. Recently, several pediatric cases with small gastric duplication cysts treated by laparoscopic resection have been reported. Here, we describe an infant in whom we successfully performed laparoscopic partial gastrectomy for the treatment of a huge gastric duplication cyst. To the best of our knowledge, this is the largest gastric duplication cyst treated by laparoscopic surgery among infants. We introduce our procedure and some tips.

A case of alpha-fetoprotein-producing gastric cancer in a child presenting with rupture of multiple liver metastases.

We report a 14-year-old boy with alpha-fetoprotein-producing gastric cancer (AFPGC) who was found with ruptured metastatic tumor in the liver. AFPGC is exceedingly rare in pediatric age. It often shows metastases to the liver and should be included in differential diagnoses of liver tumors with increased serum AFP.

Quantitative pediatric surgical skill assessment using a rapid-prototyped chest model.

INTRODUCTION: Though minimally invasive pediatric surgery has become more widespread, pediatric-specific surgical skills have not been quantitatively assessed. MATERIAL AND METHODS: As a first step toward the quantification of pediatric-specific surgical skills, a pediatric chest model comprising a three-dimensional rapid-prototyped pediatric ribcage with accurate anatomical dimensions, a suturing skin model with force-sensing capability, and forceps with motion-tracking sensors were developed. A skill assessment experiment was conducted by recruiting 16 inexperienced pediatric surgeons and 14 experienced pediatric surgeons to perform an endoscopic intracorporeal suturing and knot-tying task in both the pediatric chest model setup and the conventional box trainer setup. RESULTS: The instrument motion measurement was successful in only 20 surgeons due to sensor failure. The task completion time, total path length of instruments, and applied force were compared between the inexperienced and experienced surgeons as well as between the box trainer and chest model setups. The experienced surgeons demonstrated better performance in all parameters for both setups, and the pediatric chest model was more challenging due to the pediatric features replicated by the model. CONCLUSION: The pediatric chest model was valid for pediatric skill assessment, and further analysis of the collected data will be conducted to further investigate pediatric-specific skills.

Cyclic fluctuation of blood pressure in neonatal neuroblastoma.

Herein is described a case of neonatal neuroblastoma with cyclic blood pressure fluctuation and elevated catecholamines. The fluctuations stabilized after treatment with α-adrenergic blocker and the perioperative course was uneventful. The possibility of catecholamine-related symptoms including hypertension, heart failure, and blood pressure fluctuations should be considered in the treatment for neuroblastoma; if they are present, treatment with α-blockers is effective.

Detection of a metastatic lesion and tiny yolk sac tumors in two teenage patients by FDG-PET: report of two cases.

We herein report the efficacy of FDG-PET for detecting yolk sac tumors in two teenage patients. One patient had a rare bone metastasis and the other had tiny recurrent lesions at the mediastinum. Both lesions were difficult to detect by conventional diagnostic modalities. In contrast, FDG-PET was very effective for detecting these lesions. Furthermore, the SUVmax of the lesion reflected the tumor activity, which was also suggested by the fluctuating values of serum alpha-fetoprotein (AFP), an established marker of yolk sac tumors. FDG-PET may be a useful procedure to detect tiny and metastatic, pediatric yolk sac tumors.

Management of extremely low birth weight neonates with bowel obstruction within 2 weeks after birth.

PURPOSE: The majority of bowel obstructions in extremely low birth weight (ELBW) neonates are meconium-related ileus (MRI). ELBW neonates with bowel obstruction may recover by conservative treatment, but some do not. Considering the high surgical morbidity rates, unnecessary surgery should be avoided. We sought to identify a reasonable treatment strategy under these conditions. METHODS: ELBW neonates who started to have bowel obstruction with an unclear cause within 14 days of age were enrolled. The study period was from January 2009 to August 2011. The enrolled patients had daily Gastrografin(®) enemas until 14 days of age or until the obstruction resolved. If the obstruction lasted beyond around 14 days of age, the patient underwent surgical intervention. The clinical data of the patients were collected and analyzed. RESULTS: Fourteen patients were enrolled. Twelve patients had MRI, which resolved within 14 days without surgery. Two patients with persistent obstruction underwent surgery, and they were found to have Hirschsprung's disease and ileal volvulus, respectively. CONCLUSION: For ELBW neonates with bowel obstruction of unclear etiology, the early and frequent administration of a Gastrografin(®) enema is reasonable. Surgery should be considered if the obstruction lasts beyond approximately 14 days after birth.

Massive hemorrhage after Kasai portoenterostomy in a patient with a congenital extrahepatic portosystemic shunt, malrotation and a double aortic arch: report of a case.

A newborn female was transferred to our hospital presenting with severe respiratory distress. She underwent tracheal intubation and nasogastric tubing. Investigations revealed a congenital extrahepatic portosystemic shunt (CEPS) type 1, biliary atresia, heterotaxia, polysplenia, malrotation and a double aortic arch (DAA). She underwent the Kasai portoenterostomy and the Ladd procedure when she was 29 days old. On postoperative day 20, she developed sudden hematemesis with bright red blood. Endoscopy showed massive bleeding from an esophageal ulcer, and endoscopic therapy was performed successfully. During left thoracotomy, an aortoesophageal fistula (AEF) was detected and repaired by direct suturing. The postoperative course was uneventful. CEPS type 1 is commonly associated with other congenital malformations; however, there have been no previous reports of an association between CEPS and DAA. Nasogastric tube insertion in a patient with DAA can result in catastrophic AEF. The treatment strategy should be carefully considered in patients with CEPS type 1 and multiple congenital fetal anomalies.