Effect of Changing Surgical Instruments Before Wound Closure to Prevent Wound Infection in Lower GI Surgery: A Randomized Controlled Trial.

BACKGROUND: Surgical site infection is a major surgical complication and has been studied extensively. However, the efficacy of changing surgical instruments before wound closure remains unclear. OBJECTIVE: The aim of this study was to investigate the efficacy of changing surgical instruments to prevent incisional surgical site infection during lower GI surgery. DESIGN: This was a randomized controlled trial. SETTINGS: This study was conducted at the Hyogo College of Medicine in Japan. PATIENTS: Patients undergoing elective lower GI surgery with open laparotomy were included. INTERVENTIONS: Patients were randomly assigned to 1 of 2 groups. In group A, the surgeon changed surgical instruments before wound closure, and in group B, the patients underwent conventional closure. MAIN OUTCOME MEASURES: The primary end point was the incidence of incisional surgical site infection. The secondary end point was the incidence of surgical site infection restricted to clean-contaminated surgery. RESULTS: A total of 453 patients were eligible for this trial. The incidence of incisional surgical site infection was not significantly different between group A (18/213; 8.5%) and group B (24/224; 10.7%; p = 0.78). In the clean-contaminated surgery group, the incidence of incisional surgical site infection was 13 (6.8%) of 191 in group A and 9 (4.7%) of 190 in group B (p = 0.51). LIMITATIONS: This was a single-center study. CONCLUSIONS: Changing surgical instruments did not decrease the rate of incisional surgical site infection in patients undergoing lower GI surgery in either all wound classes or clean-contaminated conditions. See Video Abstract at http://links.lww.com/DCR/B701. EFECTO DE REALIZAR CAMBIO DE LOS INSTRUMENTOS QUIRRGICOS ANTES DEL CIERRE DE LA INCISIN EN LA INFECCIN DE LA HERIDA DEL SITIO QUIRRGICO EN CIRUGA DEL TUBO DIGESTIVO BAJO ESTUDIO ALEATORIO CONTROLADO: ANTECEDENTES:La infección del sitio quirúrgico es una complicación importante y se ha estudiado ampliamente. Sin embargo, la eficacia de cambiar los instrumentos quirúrgicos antes del cierre de la herida sigue sin estar clara.OBJETIVO:El objetivo de este estudio es investigar la eficacia de cambiar el instrumental quirúrgico en la prevención de la infección del sitio quirúrgico en cirugía gastrointestinal inferior.DISEÑO:Estudio aleatorio controlado.AJUSTE:Este estudio se realizó en la Facultad de Medicina de Hyogo en Japón.PACIENTES:Se incluyeron pacientes sometidos a cirugía electiva de tubo digestivo bajo con laparotomía abierta.INTERVENCIONES:Los pacientes fueron asignados aleatoriamente a uno de dos grupos. En el grupo A, el cirujano cambió el instrumental quirúrgico antes del cierre de la herida, y en el grupo B, los pacientes se sometieron a un cierre convencional.PRINCIPALES MEDIDAS DE RESULTADO:El criterio de valoración principal fue la incidencia de infección del sitio quirúrgico de la incisión. El criterio de valoración secundario fue la incidencia de infección del sitio quirúrgico restringida a la cirugía limpia contaminada.RESULTADOS:Un total de 453 pacientes fueron elegibles para este ensayo. La incidencia de infección del sitio quirúrgico no fue significativamente diferente entre el grupo A (18/213; 8,5%) y el grupo B (24/224; 10,7%) (p = 0,78). En el grupo de cirugía limpia-contaminada, la incidencia de infección del sitio quirúrgico incisional fue 13/191 (6,8%) en el grupo A y 9/190 (4,7%) en el grupo B (p = 0,51).LIMITACIÓN:Estudio de un solo centro.CONCLUSIÓNES:El cambio de instrumentos quirúrgicos no disminuyó la tasa de infección del sitio quirúrgico en todas las clases de heridas o condiciones limpias-contaminadas. Consulte Video Resumen en http://links.lww.com/DCR/B701.

Association between preoperative biologic use and surgical morbidity in patients with Crohn's disease.

PURPOSE: We evaluated the influence of preoperative treatments with biologics on surgical morbidity in patients with Crohn's disease (CD). METHODS: We reviewed the surveillance data of patients with CD who underwent surgery between April 2018 and April 2021. The possible risk factors for morbidity were analyzed. RESULTS: A total of 305 surgically treated patients were included. Anti-TNF alpha agents and ustekinumab were used in 92 and 27 patients, respectively, within 12 weeks before surgery. There were no cases of mortality. In total, 70/305 (23.0%) patients developed a complication, and 42/305 (13.8%) patients developed a surgical site infection (SSI) (17 incisional SSIs and 35 organ/space SSIs). Current smoking status (OR 3.44), emergent/urgent surgery (OR 6.85), and abdominoperineal resection (APR) (OR 14.93) were identified as risk factors for total complications. Penetrating disease (OR 14.55) was identified as a risk factor for incisional SSIs. Current smoking status (OR 7.09), an American Society of Anesthesiologists (ASA) score greater than 3 (OR 5.85), a postoperative blood sugar level over 155 mg/dL (OR 4.37), and APR (OR 207.95) were identified as risk factors for organ/space SSIs. CONCLUSIONS: No correlation between preoperative treatment with biologics and surgical mortality or morbidity was found. However, we should perform further analyses on a larger number of patients because the analyses may be limited by selection bias for treatment and several confounding factors.

Clinical results following colonic resection for ulcerative colitis in elderly individuals (elderly-onset vs. nonelderly onset).

BACKGROUND: The incidence of ulcerative colitis (UC) is increasing, but there are few reports comparing elderly UC patients undergoing colectomy for elderly-onset UC (EO) and nonelderly-onset UC (NEO). The aim of this study was to analyze the differences between EO and NEO patients who underwent UC-related surgery. METHODS: We identified 1973 patients with UC who underwent colectomy at Hyogo College of Medicine between January 1, 1984, and December 31, 2018. Only patients aged 65 years old and older who underwent colectomy were enrolled in this study (n = 221, 11.2%), and their clinical records were retrospectively reviewed. Patients were divided into two groups according to their age at disease onset: those with onset at younger than 60 years old (NEO) and at 60 years old or older (EO). RESULTS: In the 221 UC patients who underwent colectomy at 65 years old or older, there were 155 cases of EO and 66 cases of NEO. The main surgical indication in NEO patients was colitis-associated cancer/dysplasia (32/66, 47%). In contrast, refractory to medical treatment was the leading cause of surgery in EO patients (80/155, 52%). The distributions of surgical indications were different between the two groups (p < 0.01). The preoperative daily dose of steroids was significantly higher in the EO group than in the NEOgroup (0 mg vs. 10 mg, p < 0.01). The rates of immunosuppressant, infliximab (IFX) and adalimumab use did not differ significantly between the groups. Significantly more patients underwent emergency surgery in the EO group than in the NEO group (14% vs. 35%, p < 0.01). The proportions of patients with postoperative morbidity (Clavien-Dindo grade III or higher) were 17.4% (27/155) in the EO group and 13.6% (9/66) in the NEO group. There was no significant difference between the two groups (p = 0.48). The prognosis of the EO patients who underwent UC-related emergency surgery was worse than that of the NEO patients (p < 0.01). In the EO group, 8 (14.8%) of 54 patients died within 30 postoperative days, while there were no deaths in the NEO group. CONCLUSION: Among elderly UC patients undergoing UC-related surgery, EO patients undergoing emergency surgery had very poor outcomes, and the mortality rate was 14.8%. In such cases, it is important for physicians and surgeons to begin communication at an early stage so that the optimal surgical timeframe is not missed.

Localization of recurrent lesions following ileocolic resection for Crohn's disease.

BACKGROUND: Crohn's disease (CD) recurrence can occur not only at the site of anastomosis but also elsewhere in the bowel following an ileocolic resection (ICR) procedure. The aims of the present study were to assess long-term outcomes of a primary ICR procedure for CD in consecutive patients and examine the location of the reoperation causative lesion. METHODS: We examined cases of surgery with ICR initially performed at our institution. Those with simultaneous multiple bowel resection or bowel resection with strictureplasty were excluded. RESULTS: A total of 169 patients who underwent ICR due to CD were enrolled. The median follow-up period was 12.6 years (range 4-27 years). A reoperation was needed in 45 (26.6%), of whom 14 had lesions causative of the reoperation at other than the anastomotic site. The most common causative lesion location was in the colon rather than the oral side of the small intestine. Furthermore, we investigated the relationship between presence of residual lesions following the initial surgery and lesions causative of reoperation. In the group without residual disease (n = 31), 29.0% (n = 9) had non-anastomotic lesions involved in indications for reoperation, while that was 35.7% (n = 5) in the group with residual disease (n = 14). CONCLUSIONS: Anastomotic site lesion is not the only causative factor for reoperation following ICR. Regular examinations and applicable treatment with awareness that the cause of reoperation is not limited to the site of anastomosis are important in these cases.

Associations between multiple immunosuppressive treatments before surgery and surgical morbidity in patients with ulcerative colitis during the era of biologics.

PURPOSE: It is unclear whether immunomodulators or biologics, with the exception of corticosteroids, can be risk factors for postoperative infectious complications of ulcerative colitis (UC). Moreover, many immunosuppressive therapies including some biologics are used mainly to treat UC, and many patients are on multi-agent immunosuppressive therapy at the time of surgery. Therefore, we evaluated the influence of pre-operative multiple immunosuppressive agents on the occurrence of surgical site infection (SSI) in UC during the era of biologics. METHODS: We reviewed surveillance data from 301 patients who underwent surgery between January 2015 and April 2018. The incidences of SSI and possible risk factors among patients receiving different immunosuppressive therapies were compared and analyzed. RESULTS: The incidence of incisional SSI was 6.6%, and that of organ/space SSI was 7.0%. Doses of corticosteroids were significantly decreased because of the recent shift toward the use of biologics. The types and numbers of immunosuppressive agents did not significantly correlate with each incidence. Age ≥ 65 years (odds ratio (OR) 3.0), total prednisolone dose ≥ 9000 mg (OR 2.7), and perioperative blood transfusion (OR 3.6) were shown to be independent risk factors for incisional SSI, whereas duration of surgery ≥ 252 min (OR 3.8), urgent/emergent surgery (OR 2.9), and perioperative blood transfusion (OR 2.6) were identified as independent risk factors for organ/space SSI. CONCLUSIONS: Although no correlation between pre-operative immunosuppressive therapies, except for corticosteroids, was found, selection bias may have occurred due to treatment before surgery. However, biologics, calcineurin inhibitors, and thiopurines did not affect surgical morbidity in UC.

Delivery Mode after Ileal Pouch-Anal Anastomosis among Pregnant Women with Ulcerative Colitis.

OBJECTIVES: The appropriate and recommended delivery mode after ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) has not been sufficiently evaluated. This study was designed to compare the delivery outcomes associated with cesarean section (CS) and vaginal delivery (VD) after IPAA. METHODS: We conducted a questionnaire-based survey of female patients who underwent IPAA for UC between July 1987 and May 2018. Additionally, we reviewed clinical data and collected information regarding pouch function and postpartum complications. RESULTS: In total, 45 patients had 68 deliveries, including 64 CS deliveries and four VDs. Fecal incontinence worsened in seven patients, including six CS patients and one VD patient. The Wexner scores of these patients before and after delivery were 5.4 ± 0.4 and 14.8 ± 1.0, respectively (p = 0.005). Four patients in the CS group and one in the VD group (p = 0.32) had increased stool frequency. Bowel obstructions developed during 11/64 (17.2%) deliveries, and one patient required surgical intervention. One patient with four VDs (three before IPAA and one after IPAA) developed vaginal fistula 5 months after the final VD. Information on episiotomies could not be obtained. CONCLUSIONS: Pouch function can decline even after CS. Notably, bowel obstruction can develop after CS. However, we cannot recommend a particular delivery method after IPAA. Further analyses to elucidate the relationship between CS and postoperative complications or vaginal fistula and episiotomy in VDs should be conducted.

Clinical Results of One-stage Restorative Proctocolectomy with J-pouch Anal Anastomosis in 300 Ulcerative Colitis Patients.

OBJECTIVES: Restorative proctocolectomy and ileal pouch anal anastomosis (IPAA), with diverting ileostomy, are established ulcerative colitis (UC) treatments. The routine use of diverting ileostomy is controversial because of the risk of stoma closure and stoma related complications. In our institution, proctocolectomy and IPAA, with mucosectomy and handsewn anastomosis without diversion (one-stage IPAA), were performed for select patients with UC. The present study aimed to evaluate the clinical and functional outcomes of patients undergoing one-stage IPAA. METHODS: Between April 1999 and July 2017, 300 patients underwent one-stage IPAA in our institution. The clinical notes and prognosis were reviewed retrospectively. RESULTS: Postoperative complications (Clavien-Dindo classification grade ≥III) occurred in 18 patients (6.0%). The most common complication was anastomotic leakage (n = 9, 3%). There were 15 patients (5.0%) who required a defunctioning ileostomy. However, 13 patients successfully underwent ileostomy closure and achieved acceptable pouch function. Finally, two patients (0.6%) required pouch excision in this series. The cumulative pouch functional rate was 99.6% / 5 years and 99.2% / 10 years. CONCLUSIONS: One-stage IPAA is a good strategy for carefully selected patients with UC.

Incidence, Risk Factors and Outcomes of Cancer of the Anal Transitional Zone in Patients with Ulcerative Colitis.

BACKGROUND AND AIMS: Performing a mucosectomy with a hand-sewn ileal pouch-anal anastomosis [IPAA] for ulcerative colitis [UC] theoretically reduces the risk of carcinoma arising from the anal transitional zone [ATZ]. Although current guidelines suggest a stapled anastomosis due to the low incidence of cancer after pouch surgery in UC patients, only a few small series have addressed the oncological advantage of mucosectomy. Therefore, we aimed to investigate the incidence of ATZ/pouch cancer. METHODS: A total of 1970 UC patients who underwent surgery between April 1987 and December 2018 were included. We retrospectively analysed the incidences of primary ATZ cancer in the original operative specimen and de novo ATZ/pouch cancer after surgery. Possible risk factors for primary ATZ cancer and the pouch survival rate were assessed. RESULTS: Fourteen [6.4%] primary ATZ cancers developed in 220 UC-colorectal cancer [CRC] cases. Multiple (odds ratio [OR] = 8.79, 95% confidence interval [CI] 2.77-27.83, p < 0.01) and rectal [OR = 6.48, 95% CI 1.41-29.7, p = 0.01] cancers were identified as independent risk factors for primary ATZ cancer. Four of 1970 [0.2%] patients developed de novo ATZ/pouch cancer and dysplasia. The 10-year estimated cumulative pouch survival rate was not significantly different between stapled IPAA and hand-sewn IPAA cases [95.9% and 97.3%, p = 0.25]. CONCLUSION: The risk of de novo ATZ/pouch cancer and dysplasia was rare. The decision to perform a hand-sewn or a stapled IAA should be made on a case-by-case basis. However, the relatively high incidence of primary ATZ cancer in UC patients with CRC suggests that mucosectomy should be recommended for this patient group.

Chemical and apoptotic properties of hydroxy-ceramides containing long-chain bases with unusual alkyl chain lengths.

We analysed four types of free ceramides (Cer 1, Cer 2, Cer 3 and Cer 4) from equine kidneys by electrospray ionization mass spectrometry. Cer 1 was composed of dihydroxy long-chain bases (dLCBs) of (4E)-sphingenine (d18:1), sphinganine and non-hydroxy fatty acids (NFAs); Cer 2 was composed of trihydroxy LCBs (tLCBs) of 4-hydroxysphinganine, t16:0, t18:0, t19:0 and t20:0, and NFAs; Cer 3 was composed of dLCBs, d16:1, d17:1, d18:1, d19:1 and d20:1, and hydroxy FAs (HFAs); and Cer 4 was composed of tLCBs, t16:0, t17:0, t18:0, t19:0 and t20:0, and HFAs. The results indicate all ceramide species containing LCBs with non-octadeca lengths (NOD-LCBs) can be classified into hydroxy-ceramides since these species always consist of tLCBs, and/or HFAs. Furthermore, such species tend to contain FAs with longer acyl chains but contain neither palmitate (C16:0) nor its hydroxylated form (C16:0h). The apoptosis-inducing activities of these hydroxyl-ceramides towards tumour cell lines were compared with that of non-hydroxy-ceramides, dLCB-NFA (Cer 1). Monohydroxy-ceramides, tLCB-NFA (Cer 2) and dLCB-HFA (Cer 3), exhibited stronger activities, whereas dihydroxy-ceramides, tLCB-HFA (Cer 4), exhibited similar or weaker activity than dLCB-NFA (Cer 1), depending on cell lines.

Neonatal behavioral assessment scale as a predictor of later developmental disabilities of low birth-weight and/or premature infants.

The purpose of this study was to evaluate the usefulness of the Neonatal Behavioral Assessment Scale (NBAS) as a tool to assess the risk of later developmental disabilities. The study subjects were 209 low birth-weight and/or premature infants admitted to the NICU at the Nagasaki University Hospital, Nagasaki, Japan. These infants were examined using the NBAS at 36-38 (NBAS36), 40-42 (NBAS40) and 44-46 weeks (NBAS44) of postmenstrual age, and their developmental outcome was measured using standardized assessments at 5 years of age. Based on the results of diagnosis at 5 years of age, subjects were classified into three groups: Normal, Mild Disability and Severe Disability groups. Multinomial logistic regression analysis showed that lower Motor cluster scores for all assessment periods and lower Orientation cluster scores in the NBAS40 and NBAS44 were significantly associated with an increased risk of both Mild and Severe Disability. Also, the Range of State cluster scores for the NBAS44 were significantly related to the risk of Mild Disability, and the Reflexes cluster scores in the NBAS40 and NBAS44 were the best predictor of Severe Disability. In outcome prediction using the estimated regression coefficients, 94-97% of the subjects in the Normal group, 50-78% in the Mild Disability group and 71-85% in the Severe Disability group were correctly classified. The NBAS could help clinicians to develop a management protocol for infants at risk for developmental disabilities as well as to identify neonates at risk of developmental disabilities.

Expression of CC-chemokine receptor 7 (CCR7) and CXC-chemokine receptor 4 (CXCR4) in head and neck squamous cell carcinoma.

OBJECTIVES: We tried to clarify the correlation of the expression of CCR7 and CXCR4 with lymph node and distant metastasis. MATERIALS AND METHODS: We examined expression of CCR7 and CXCR4 in 9 HNSCC cell lines and 25 HNSCC tissues by semi-quantitative RT-PCR and immunohistochemistry study. We examined the expression levels of CCR7 and CXCR4 in undifferentiated and differentiated human normal keratinocyte. RESULTS: All cell lines expressed CCR7 mRNA, and three expressed CXCR4 mRNA. CCR7 and CXCR4 mRNAs were significantly higher in HNSCC tissues than in non-neoplastic tissues (p<0.05, respectively) and correlated with lymph node metastasis (p<0.05, respectively). The level of CXCR4 mRNA also correlated with distant metastasis (p<0.05). Immunohistochemistry demonstrated localization of CCR7 and CXCR4 to carcinoma cells and lymphocytes and immunohistochemical staining scores of CCR7 and CXCR4 also showed similar correlation to lymph node and distant metastasis with CCR7 and CXCR4 mRNA levels. The level of CCR7 mRNA was significantly higher in poorly and moderately differentiated than in well-differentiated HNSCC (p<0.05). The level of CCR7 mRNA in undifferentiated keratinocyte was significantly higher than that in differentiated keratinocyte. CONCLUSION: The expression of CCR7 in HNSCC increases by dedifferentiation and plays an important role in lymph node metastasis of HNSCC and CXCR4 plays an important role in lymph node metastasis as well as distant metastasis.

6-Sulfo LacNAc, a novel carbohydrate modification of PSGL-1, defines an inflammatory type of human dendritic cells.

The monoclonal antibody M-DC8 defines a major subset of human blood dendritic cells (DCs). Here we identify the M-DC8 structure as 6-sulfo LacNAc, a novel carbohydrate modification of the P selectin glycoprotein ligand 1 (PSGL-1). In contrast to previously described blood DCs, M-DC8+ DCs lack the cutaneous lymphocyte antigen (CLA) on PSGL-1 and fail to bind P and E selectin. Yet they express anaphylatoxin receptors (C5aR and C3aR) and the Fcgamma receptor III (CD16), which recruit cells to inflammatory sites. While sharing with DC1 the expression of myeloid markers and a potent capacity to prime T cells in vitro, M-DC8+ DCs produce far more TNF-alpha in response to the bacterial endotoxin lipopolysaccharide (LPS). Thus, 6-sulfo LacNAc-expressing DCs appear as a novel proinflammatory DC subset.