Early postoperative pulmonary complications after minimally invasive esophagectomy in the prone position: incidence and perioperative risk factors from the perspective of anesthetic management.

OBJECTIVES: To investigate the incidence of and the risk factors for early postoperative pulmonary complications (PPC) after minimally invasive esophagectomy (MIE) in the prone position from the perspective of anesthetic management. METHODS: We conducted a historical cohort study of patients who underwent MIE in the prone position between September 2010 and August 2018. PPC was defined as pneumonia, atelectasis, acute respiratory distress syndrome (ARDS), respiratory failure, and pulmonary embolism (Clavien-Dindo Classification Grade II or higher) that occurred within 7 days after MIE. RESULTS: Out of 489 patients, there were 90 patients (18.4%) with PPC: 75 patients with pneumonia, 24 patients with atelectasis, 13 patients with respiratory failure, 6 patients with ARDS, and 2 patients with pulmonary embolism. Twenty-eight patients suffered from 2 or more components of PPC. PPC patients were older (66.6 vs. 63.6 year, P = 0.038) and had higher amount of crystalloid (4200 vs. 3550 mL, P < 0.0001), and longer duration of anesthesia (670 vs. 625 min, P = 0.0062) than non-PPC patients. PPC patients were more likely to have had chronic obstructive pulmonary disease (COPD) (26.7 vs. 7.8%, P < 0.001). Incidence of PPC was significantly higher in patients with one-lung ventilation than with two-lung ventilation (37.1 vs. 15.3%, P < 0.001). Multivariable logistic regression analysis showed that PPC was associated with age (per 10 years, odds ratio (OR) = 1.41), COPD (OR = 3.43), one-lung ventilation (OR = 1.94), and volume of crystalloid (per 500 mL, OR = 1.22). CONCLUSIONS: Two-lung rather than one-lung ventilation should be chosen and fluid overload should be avoided in patients undergoing MIE in the prone position.

Preoperative Nutritional Assessment by Controlling Nutritional Status (CONUT) is Useful to estimate Postoperative Morbidity After Esophagectomy for Esophageal Cancer.

BACKGROUND: A nutritional indicator suitable for predicting complications after esophagectomy has not been confirmed. The nutritional screening tool CONUT is a potential candidate. METHODS: We retrospectively analyzed 352 patients who underwent elective esophagectomy with lymphadenectomy for esophageal cancer between April 2005 and December 2014. Patients were divided into three groups according to the malnutrition degree in controlling nutritional status (CONUT): normal, light malnutrition, moderate or severe malnutrition. RESULTS: The numbers of patients assigned to the normal, light malnutrition, and moderate or severe malnutrition groups were 205, 126, and 21, respectively. One hundred forty-seven (41.8 %) patients were considered malnourished. Patients with moderate or severe malnutrition had a significantly high incidence of any morbidity, severe morbidities, and surgical site infection. Hospital stay in patients with moderate or severe malnutrition was significantly longer. Logistic regression analysis suggested that moderate or severe malnutrition was an independent risk factor for any morbidity [hazard ratio (HR) 2.75, 95 % confidence interval (CI) 1.081-7.020; p = 0.034] and severe morbidities (HR 3.07, 95 % CI 1.002-9.432; p = 0.049). CONCLUSIONS: CONUT was a convenient and useful tool to assess nutritional status before esophagectomy. Patients with moderate or severe malnutrition according to CONUT are at high risk for postoperative complications.

Surgical Apgar Score Predicted Postoperative Morbidity After Esophagectomy for Esophageal Cancer.

BACKGROUND: Recently, a simple and easy complication prediction system, the Surgical Apgar Sore (SAS) calculated by three intraoperative parameters (estimated blood loss, lowest mean arterial pressure, and lowest heart rate), has been proposed for general surgery. This study aimed to determine if the SAS could accurately predict perioperative morbidity in patients undergoing esophagectomy for esophageal cancer. METHODS: We investigated 399 patients who underwent esophagectomy at the Kumamoto University Hospital between April 2007 and March 2015. Clinical data, including intraoperative parameters, were collected retrospectively. Patients had postoperative morbidities classified as Clavien-Dindo grade III or more. Univariate and multivariate analyses were performed to elucidate factors that affected the development of complications. RESULTS: The mean age of the study population was 65.7 years, 357 patients (89.5 %) were male. The frequency of any morbidity was 32.3 %. Univariate analyses showed that the SAS as well as preoperative chemotherapy, volume of bleeding, and reconstruction of organs were associated with morbidities. Multivariate analysis showed that a SAS < 5 was found to be an independent risk factor for morbidities. CONCLUSION: The SAS is considered to be useful for predicting the development of postoperative morbidities after esophagectomy for esophageal cancer.

Advantages of FDG-PET/CT over CT alone in the preoperative assessment of lymph node metastasis in patients with esophageal cancer.

PURPOSE: The aim of this study was to determine the benefits of (18)F-fluorodeoxyglucose positron emission tomography (PET)/computed tomography (CT) compared to CT alone in the preoperative assessment of lymph node metastasis in patients with esophageal cancer. METHODS: One-hundred and seven patients who underwent esophagectomy with lymph node dissection between March 2007 and December 2009 were eligible. Sixty-seven patients were treated with surgery alone (SA group), while 40 patients received preoperative treatment prior to surgery (PT group). The pathological results of 1,403 dissected lymph node stations were compared with the results obtained using each imaging modality. RESULTS: PET/CT showed a significantly higher specificity and positive predictive value (PPV) than CT alone (97.7 vs. 94.1 % and 64.6 vs. 44.0 %, respectively), when analyzed by the lymph node stations. The PPV of PET/CT for N1 cases was significantly better than that of CT alone (78.9 vs. 53.9 %), particularly in the PT group (91.3 vs. 65.4 %). Among the patients in the SA group, the number of metastatic nodes was significantly higher in PET-N1 cases than in PET-N0 cases (5.78 vs. 1.90). CONCLUSION: PET/CT is useful for selecting patients with multiple lymph node metastases and also for detecting residual metastatic nodes after PT, and thus is beneficial to decide on the appropriate treatment strategy for patients with esophageal cancer.

[Assessment of esophageal cancer with remote metastases treated with multidisciplinary therapy].

We present three cases of patients diagnosed with esophageal cancer with distant metastases. We conducted chemotherapy, radiotherapy, RFA, and operation for main tumor and lymph node, lung, brain metastasis. They were for a long-term survival with multidisciplinary therapy. The longest survival time was about three years. We discussed our cases in light of review of the literature.

Periventricular echodensity measured with the integrated backscatter system: from a qualitative assessment to a quantitative approach.

BACKGROUND: The degree of periventricular white matter echodensity in preterm infants has been utilized as a sign of the early ultrasonographic appearance of periventricular leukomalacia, and this has been called periventricular echodensity (PVE). OBJECTIVES: The aim of this study was to quantitatively measure PVE utilizing a new method which is called calibrated integrated backscatter (calibrated IB). METHODS: Eighty-eight preterm infants (extremely low birth weight infants, n = 17; very low birth weight infants, n = 26; low birth weight infants, n = 45) without any CNS abnormality were enrolled. IB is the returned sound pressure against supersonic waves sent from an ultrasonographic machine. The IB of the choroid plexus and periventricular white matter in the subrolandic area were measured on a parasagittal cerebral image. The degree of PVE was defined by subtracting the IB of the choroid plexus from that of the periventricular white matter in the subrolandic area (calibrated IB of PVE). RESULTS: The intraobserver and interobserver correlations were both excellent (between 0.87 and 0.98 as correlation coefficients). There was a trend for the calibrated IB of PVE to decrease in accordance with time after birth, with a significant difference in very low birth weight and low birth weight infants. CONCLUSIONS: The objectively measured brightness of PVE was comparable to that of the choroid plexus irrespective of the size of the infants. Measurement of the calibrated IB of PVE might be a reliable method to assess PVE.

[Approach to CAPD services by pharmacists].

In Tokai University Hachioji Hospital, a delivery system of peritoneal dialysis fluid has been built and pharmacists have been coordinating the delivery services. This time, we researched and verified the operation status for two years from April 2007 to March 2009. It was considered that a coordination of operation services for peritoneal dialysis fluid by pharmacists has been able to contribute to "medical safety" and "medical cost reduction". Also for a medical staff, changes in prescription and amount of stock have been able to reduce because the delivery system operation of peritoneal dialysis fluid has penetrated. However, as patients' understanding for the delivery system of peritoneal dialysis fluid was not enough, it was considered as the cause of increase in take-home drugs/days. As for issues in the future, we hope to study methods to enhance patient education at the time of hospital admission and confirm patients' understanding at the time of hospital visits.

[The role of pharmacist on coordinating CAPD operation].

Tokai University Hachioji Hospital has built a distribution system which intended to minimize a drug inventory at the hospital, and to reduce the number of drugs when the patient is discharged or when the patient is an outpatient to take-out the drugs in order to facilitate smooth CAPD operation. As a result, the number of take-out drugs for discharged patients or outpatients has been reduced within two days. In addition to that, it has been considered to minimize both the strain to the patient who has to take drugs back to home as well as a level of the drug inventory. The cost of peritoneal dialysate inventory amount corresponds to the amount of one patient's 3-day inventory. Therefore, the amount of money can be suppressed to the minimum. Since the distribution system has not caused any major troubles, we basically assumed the system operation to be successful. Although CAPD operation is performed by clinical nurses in most of the cases, we believe that CAPD operation can be smoothly performed by participation of pharmacist. Further more, it is possible to contribute toward a health cost reduction, and the like.

[Left ventricular volume and ejection fraction by the axius auto ejection fraction method: comparison with manual trace method and visual assessment of ejection fraction].

OBJECTIVES: Visual assessment of the ejection fraction (EF) is often used in clinical practice, but is subjective and requires training and experience. The auto EF method has been newly developed for automated detection of the left ventricular (LV) endocardial border throughout the cardiac cycle. The clinical feasibility was assessed of the auto EF method for measuring LV volumes and EF in patients. Manually traced EF measured by the biplane modified Simpson's rule was used as the reference standard. METHODS: The study population consisted of 30 consecutive patients with normal sinus rhythm. All patients underwent two-dimensional echocardiography. The auto EF method incorporated pattern and shape recognition to automatically locate the LV, track the endocardium, and calculate EF from routine digital images. LV end-diastolic and end-systolic volumes and EF measured by the auto EF method were compared those by the manually traced method. LVEF by the Auto EF method was also compared with visual EF determined by nonattending physicians. RESULTS: Auto EF was more reproducible than visual EF by the expert reader. LVEF by the auto EF method had excellent correlation and close limits of agreement with manually traced EF compared with visual EF(4-chamber view: y = 1.10 x - 4.28, r = 0.94, bias = 1.6%, 2-chamber view: y = 0.88 x + 7.25, r = 0.90, bias = 0.4%). LV volumes by the auto EF method underestimated those by manually traced EF (end-diastolic volume by 4-chamber view: y = 0.72 x + 8.92, r = 0.93, bias = - 16.7 ml, end-systolic volume by 4-chamber view: y = 0.82 x - 0.97, r = 0.98, bias = - 8.5 ml, end-diastolic volume by 2-chamber view: y = 0.73 x + 12.4, r = 0.82, bias = - 12.3 ml, end-systolic volume by 2-chamber view: y = 0.65 x + 6.94, r = 0.90, bias = - 6.8 ml). CONCLUSIONS: The auto EF method is a clinically useful tool for the measurement of LV volumes and EF.