Neoadjuvant Triplet Chemotherapy with Docetaxel, Cisplatin plus 5-Fluorouracil versus Docetaxel, Cisplatin plus S-1 for Advanced Esophageal Squamous cell Carcinoma: Propensity Score Matched Analysis.

INTRODUCTION: This study examines whether neoadjuvant docetaxel, cisplatin plus S-1 (DCS) therapy is superior to docetaxel, cisplatin plus 5-fluorouracil (DCF) therapy for resectable advanced esophageal squamous cell carcinoma (ESCC). METHODS: Patients diagnosed with resectable advanced ESCC at our hospital between January 2010 and December 2019 underwent either neoadjuvant DCF therapy or DCS therapy, followed by radical esophagectomy. Prior to August 2014, we usually used neoadjuvant DCF therapy; we then completely transitioned to using neoadjuvant DCS therapy. RESULTS: A total of 144 patients received one of these triplet regimens as neoadjuvant chemotherapy: DCF therapy to 67 patients and DCS therapy to 77 patients. After propensity score matching, 55 patients in each group were selected as matched cohorts. There was no significant difference between the groups in complete response (DCF = 7.3%, DCS = 9.1%) or in partial response (DCF = 45.4%, DCS = 52.7%). The pathological response rate was 23.8% for grade 2 and 18.2% for grade 3 in the DCF group, compared with 30.9% and 14.5% in the DCS group. Independent predictive factors for recurrence-free survival were poor clinical response and pathological response ≤1b. Independent prognostic factors for overall survival were poor clinical response, anastomotic leakage, and pathological response ≤1b. Duration of hospital stays in the DCS group was significantly shorter than those of the DCF group (6.0 vs. 15.0 days, p < 0.001). Expenses of drug and hospitalization for the neoadjuvant chemotherapy in the DCS group were also significantly lower than those of the DCF group (265.7 vs. 550.3 USD, p < 0.001). CONCLUSIONS: Neoadjuvant DCS therapy for resectable advanced ESCC did not result in significantly higher clinical and pathological response than neoadjuvant DCF therapy. However, neoadjuvant DCS therapy for resectable ESCC required comparatively shorter hospital stays and incurred lower costs, making it an attractive therapeutic option.

Impact of zero anastomotic leakage after esophagectomy followed by whole stomach reconstruction for esophageal cancer: prospective cohort study.

PURPOSE: The stomach is the most common organ which is used for reconstruction after esophagectomy for esophageal cancer. It is controversial which is better narrow gastric tube reconstruction or whole stomach reconstruction to prevent anastomotic leakage. METHODS: From August 2022 to March 2023, we started a prospective cohort study of whole stomach reconstruction after esophagectomy. Until then (from January 2018 to July 2022), narrow gastric tube reconstruction was performed as a standard reconstruction. RESULTS: Narrow gastric tube reconstruction and whole stomach reconstruction were performed in 183 patients and 20 patients, respectively. The patient's characteristics were not significantly different between the narrow gastric tube group and the whole stomach group. In particular, for all patients in the whole stomach reconstruction group, retrosternal route and esophagogastrostomy by hand sewn were applied. There were no occurrences of AL through the continuous 20 cases in the whole stomach group, otherwise 42 (22.9%) patients in the narrow gastric group (P = 0.016). Postoperative hospital stays were significantly shorter in the whole stomach group than in the narrow gastric group (21 days vs. 28 days, P < .001). Blood perfusions were evaluated by indocyanine green for all cases, which had very good blood perfusion in all cases. Additionally, quantitative blood perfusion was examined by SPY-QP (Stryker, USA) for one case. Even the edge of the fornix showed more than 90% blood perfusion levels when the antrum was fixed as the reference point. CONCLUSION: Whole stomach reconstruction with excellent blood perfusion is considered to be safe and has the possibility to prevent from occurring AL after esophagectomy for esophageal cancer patients.

Laparoscopic reconstruction in McKeown esophagectomy is a risk factor for postoperative diaphragmatic hernia.

Diaphragmatic hernia is a very rare but high-risk complication after esophagectomy. Although there are many studies on the Ivor Lewis esophagectomy procedure for diaphragmatic hernia, there are fewer studies on the McKeown procedure. The present study aimed to estimate the incidence of diaphragmatic hernia after esophagectomy, describing its presentation and management with the McKeown procedure. We retrospectively evaluated the 622 patients who underwent radical esophagectomy between January 2002 and December 2020 at the Wakayama Medical University Hospital. Statistical analyses were performed to evaluate risk factors for diaphragmatic hernia. Emergency surgery for postoperative diaphragmatic hernia was performed in nine of 622 patients (1.45%). Of these nine patients, one developed prolapse of the small intestine into the mediastinum (11.1%). The other eight patients underwent posterior mediastinal route reconstructions (88.9%), one of whom developed prolapse of the gastric conduit, and seven of whom developed transverse colon via the diaphragmatic hiatus. Laparoscopic surgery was identified in multivariate analysis as the only independent risk factor for diaphragmatic hernia (odd's ratio [OR] = 9.802, p = 0.034). In all seven cases of transverse colon prolapse into the thoracic cavity, the prolapsed organ had herniated from the left anterior part of gastric conduit. Laparoscopic surgery for esophageal cancer is a risk factor for diaphragmatic hernia. The left anterior surface of gastric conduit and diaphragmatic hiatus should be fixed firmly without compromising blood flow to the gastric conduit.

Laparoscopic-Assisted Total Resection and Endorectal Pull-Through Technique for Congenital Megarectum with Anorectal Malformation.

BACKGROUND/PURPOSE: Congenital megarectum (CMR) is sometimes associated with anorectal malformations (ARM), although there is no established therapeutic strategy. This study aims to clarify the clinical features of ARM with CMR, and to demonstrate the effectiveness of a surgical treatment, namely laparoscopic-assisted total resection and endorectal pull-through technique. METHODS: We conducted a review of the clinical records of the patients with ARM with CMR treated at our institution between January 2003 and December 2020. RESULTS: Seven of 33 cases of ARM (21.2%) were diagnosed with CMR, four males and three females. The types of ARM were 'intermediate' in four, and 'low' in three patients. Five of the seven patients (71.4%) required resection of megarectum for intractable constipation and underwent laparoscopic-assisted total resection and endorectal pull-through technique. Bowel function was improved after resection in all five cases. All five specimens showed hypertrophy of the circular fibers, and three of them showed abnormal location of ganglion cells within the circular muscle fibers. CONCLUSIONS: CMR often causes intractable constipation and requires resection of the dilated rectum. Laparoscopic-assisted total resection and endorectal pull-through technique for ARM with CMR considered to be an effective, minimally invasive treatment for intractable constipation. LEVEL OF EVIDENCE FOR CLINICAL RESEARCH PAPERS: Level Ⅳ. TYPE OF STUDY: Treatment study.

Feeding jejunostomy following esophagectomy may increase the occurrence of postoperative small bowel obstruction.

This study aimed to clarify the characteristics and treatment of bowel obstruction associated with feeding jejunostomy in patients who underwent esophagectomy for esophageal cancer. In this single-center retrospective study, 363 patients underwent esophagectomy with mediastinal lymph node dissection for esophageal cancer at the Wakayama Medical University Hospital between January 2014 and June 2021. All patients who underwent esophagectomy routinely underwent feeding jejunostomy or gastrostomy. Feeding jejunostomy was used in the cases of gastric tube reconstruction through the posterior mediastinal route or colon reconstruction, while feeding gastrostomy was used in cases of retrosternal route gastric tube reconstruction. Nasogastric feeding tubes and round ligament technique were not used. Postoperative small bowel obstruction occurred in 19 of 197 cases of posterior mediastinal route reconstruction (9.6%), but in no cases of retrosternal route reconstruction because of the feeding gastrostomy (P < .0001). Of the 19 patients who had bowel obstruction after feeding jejunostomy, 10 patients underwent reoperation (53%) and the remaining 9 patients had conservative treatment (47%). The cumulative incidence of bowel obstruction after feeding jejunostomy was 6.7% at 1 year and 8.7% at 2 years. Feeding jejunostomy following esophagectomy is a risk factor for small bowel obstruction. We recommend feeding gastrostomy inserted from the antrum to the jejunum in the cases of gastric tube reconstruction through the retrosternal route or nasogastric feeding tube in the cases of reconstruction through the posterior mediastinal route.

Nutritional benefit of remnant gastric preservation in patients with esophageal cancer undergoing radical esophagectomy and ileo-colon interposition.

BACKGROUND: This retrospective study aimed to investigate the short-term surgical outcomes and nutritional status of ileo-colon interposition in patients with esophageal cancer who could not undergo gastric tube reconstruction. METHODS: Sixty-four patients underwent subtotal esophagectomy with reconstruction using ileo-colon interposition for esophageal cancer at the Wakayama Medical University Hospital between January 2001 and July 2020. Using propensity scores to strictly balance the significant variables, we compared treatment outcomes. RESULTS: Before matching, 18 patients had cologastrostomy and 46 patients had colojejunostomy. After matching, we enrolled 34 patients (n = 17 in cologastrostomy group, n = 17 in colojejunostomy group). Median operation time in the cologastrostomy group was significantly shorter than that in the colojejunostomy group (499 min vs. 586 min; P = 0.013). Perforation of the colon graft was observed in three patients (7%) and colon graft necrosis was observed in one patient (2%) in the gastrojejunostomy group. Median body weight change 1 year after surgery in the cologastrostomy group was significantly less than that of the colojejunostomy group (92.9% vs. 88.5%; P = 0.038). Further, median serum total protein level 1 year after surgery in the cologastrostomy group was significantly higher than that of the colojejunostomy group (7.0 g/dL vs. 6.6 g/dL, P = 0.030). CONCLUSIONS: Subtotal esophagectomy with reconstruction using ileo-colon interposition is a safe and feasible procedure for the patients with esophageal cancer in whom gastric tubes cannot be used. Cologastrostomy with preservation of the remnant stomach had benefits in the surgical outcomes and the postoperative nutritional status.

Neonatal congenital mesoblastic nephroma that caused respiratory oncologic emergency early after birth: a case report.

BACKGROUND: Congenital mesoblastic nephromas mainly present as asymptomatic abdominal masses, but some present hematuria, hypertension or hypercalcemia. Neonatal dyspnea in an early-birth neonate due to rapid tumor growth is reported here for the first time. CASE PRESENTATION: A renal tumor and polyhydramnios were detected by ultrasonography of a male fetus at 32 weeks and 3 days of gestation. The mother had abdominal distension due to the polyhydramnios and signs of imminent premature birth. Amniocentesis was performed and the signs of imminent preterm birth subsided, but growth of the renal tumor was noted as a potential cause of respiratory dysfunction. Cesarean section was performed at 36 weeks and 2 days of gestation. His birthweight was 2638 g and his 1 and 5 min APGAR scores were 2 and 4 points, respectively. There was no spontaneous breathing at birth and he had remarkable abdominal distention. He underwent cardiopulmonary resuscitation. After circulation stabilized, emergency surgery was performed because of progressive hypoxemia and respiratory acidosis. Laparotomy revealed a huge tumor arising from the right kidney and right nephrectomy was performed. Histopathological examination led to diagnosis of congenital mesoblastic nephroma. The respiratory condition and circulatory dynamics stabilized after the pressure on the thorax from the tumor was relieved by surgery. The postoperative course was uneventful. No recurrence or complications have been observed in the 36 months since the surgery. CONCLUSIONS: Congenital mesoblastic nephroma can rapidly increase in size from the fetal period and may cause respiratory oncologic emergency, although there is relatively good prognosis.

Laparoscopic sleeve gastrectomy for morbid obesity improves gut microbiota balance, increases colonic mucosal-associated invariant T cells and decreases circulating regulatory T cells.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) for morbid obesity may improve gut microbiota balance and decrease chronic inflammation. This study examines the changes in gut microbiota and immune environment, including mucosal-associated invariant T cells (MAIT cells) and regulatory T cells (Treg cells) caused by LSG. METHODS: Ten morbidly obese patients underwent LSG at our institution between December 2018 and March 2020. Flow cytometry for Th1/Th2/Th17 cells, Treg cells and MAIT cells in peripheral blood and colonic mucosa and 16S rRNA analysis of gut microbiota were performed preoperatively and then 12 months postoperatively. RESULTS: Twelve months after LSG, the median percent total weight loss was 30.3% and the median percent excess weight loss was 66.9%. According to laboratory data, adiponectin increased, leptin decreased, and chronic inflammation improved after LSG. In the gut microbiota, Bacteroidetes and Fusobacteria increased after LSG, and indices of alpha diversity increased after LSG. In colonic mucosa, the frequency of MAIT cells increased after LSG. In peripheral blood, the frequency of Th1 cells and effector Treg cells decreased after LSG. CONCLUSIONS: After LSG for morbid obesity, improvement in chronic inflammation in obesity is suggested by change in the constituent bacterial species, increase in the diversity of gut microbiota, increase in MAIT cells in the colonic mucosa, and decrease in effector Treg cells in the peripheral blood.

Venous Invasion Is a Risk Factor for Recurrence of pT1 Gastric Cancer with Lymph Node Metastasis.

BACKGROUND: Postoperative adjuvant therapy for early gastric cancer (EGC) has not been widely studied, and there are differing indications for postoperative adjuvant therapy between Western and Asian countries. Japanese gastric cancer treatment guidelines do not recommend adjuvant chemotherapy for EGC, but it is unclear whether surgery alone is the most appropriate treatment. METHODS: This is a single-center retrospective study of 1001 consecutive patients who underwent radical gastrectomy for pT1 gastric cancer between 1999 and 2013 at the Wakayama Medical University Hospital. RESULTS: Recurrence was observed in 12 patients, nine of whom as the result of hematogenous metastasis. In all patients with pT1 gastric cancer (n = 1001), lymph node metastasis was identified as an independent predictive factor for recurrence (hazard ratio [HR] = 10.910, P = 0.002). In patients with pT1N + gastric cancer, however, the 5-year disease-specific survival (DSS) rate was still high, 90.8%. In patients with pT1N + gastric cancer (n = 97), the presence of venous invasion (pT1N + v +) was identified by univariate and multivariate analyses as an independent risk factor for recurrence (HR = 4.791, P = 0.032). In patients with venous invasion, the 5-year DSS rate was significantly lower than that in those without venous invasion (79.3% vs. 95.2%, P = 0.018). CONCLUSIONS: Long-term prognosis of patients with EGC with lymph node metastasis is good, but venous invasion is associated with a higher risk of recurrence. Selective application of postoperative adjuvant chemotherapy for pT1N + v + gastric cancer may efficiently improve prognosis among patients with EGC.

Pharyngolaryngectomy with thoracoscopic esophagectomy via the left thoracic approach for cervical esophageal cancer with right aortic arch: Case report.

We performed pharyngolaryngectomy with thoracoscopic esophagectomy via the left thoracic approach and reconstruction of the elongated gastric conduit with microvascular anastomosis for an 83-year-old male patient with esophageal cancer and right aortic arch. For such cases, a surgical approach via the left thoracic cavity is rational, and cases of pharyngolaryngectomy with thoracoscopic esophagectomy require a long reconstruction organ. Also, in cases of right aortic arch, a longer reconstruction route is made to avoid Kommerell's diverticulum. The patient had laryngeal cancer and was diagnosed with cervical esophageal cancer and preoperative computed tomography revealed right aortic arch. There were no complications after surgery, and food intake was good. Pharyngolaryngectomy with thoracoscopic esophagectomy via the left thoracic approach and reconstruction of the elongated gastric conduit with microvascular anastomosis is suggested to be a safe and feasible technique for cases of cervical esophageal cancer with right aortic arch.

Optimum therapeutic strategy for meconium-related ileus in very-low-birth-weight infants.

BACKGROUND/PURPOSE: therapeutic strategy for meconium-related ileus (MRI) in very-low-birth-weight infants (VLBWs) has not been established. This study aims to clarify the optimum therapeutic strategy for MRI in VLBWs. METHODS: MRI was defined as delayed meconium excretion and microcolon on contrast enema with Gastrografin (diatrizoate acid). Forty-two infants with MRI were treated at our institution between 2009 and 2019, and are reviewed here. They were classified into two groups: in group A (n=21), Gastrografin regurgitated into the dilated intestine during the first or second round of Gastrografin enema (GaE), while in group B (N = 21), Gastrografin did not regurgitate. Laparotomy was indicated if the intestine was perforated, or if abdominal distention was not relieved by two rounds of GaE. RESULTS: in group A, meconium was excreted in all cases within 24 h after GaE, and no cases required laparotomy. In group B, twelve cases (57%) underwent laparotomy (P < 0.01), six cases in this group (29%), showed free air on X-ray images (P < 0.01). The median hospital stay in groups A and B were 89.0 and 136.5 days, respectively (P < 0.05). Overall mortality was 2.4%. CONCLUSIONS: early therapeutic diagnosis by GaE followed by early surgery is suggested as the optimum strategy for MRI in VLBWs.

Concomitant Gallbladder Agenesis with Methimazole Embryopathy.

BACKGROUND Methimazole embryopathy is caused by maternal methimazole intake during early pregnancy. It causes fetal malformations such as choanal atresia, esophageal atresia, aplasia cutis, omphalomesenteric duct remnants, urachal remnants, and omphalocele. Gallbladder agenesis is sometimes complicated with other malformations, but there have been no reports of gallbladder agenesis due to methimazole or concomitant methimazole embryopathy with gallbladder agenesis. CASE REPORT The mother of a male neonate had taken methimazole for hyperthyroidism until pregnancy was recognized at 7 weeks of gestation. Ultrasonography at 12 weeks and 4 days of gestation showed the fetus had a cystic lesion in the umbilical region. The child was born at the gestational age of 38 weeks and 5 days. At birth there was omphalocele, omphalomesenteric fistula, and a scalp defect, and the child was diagnosed with methimazole embryopathy. Ultrasonography could not identify the gallbladder. Emergency surgery was performed for omphalocele with omphalomesenteric fistula on day 0. The intestine, including the omphalomesenteric fistula, was resected. Postoperative blood testing revealed hypothyroidism, so the patient was administered levothyroxine. Although MRI did not detect the gallbladder, it showed dilatation of the biliary duct. Hypothyroidism was well controlled by levothyroxine, so the patient was discharged with outpatient follow-up for the gallbladder agenesis. Six months later, the patient is asymptomatic. CONCLUSIONS Concomitant gallbladder agenesis with methimazole embryopathy has not been previously reported. In the case of a dilated common bile duct, even when asymptomatic in the neonatal period, gallbladder agenesis demands long-term follow-up because of possible manifestation of choledocholithiasis or biliary malignant tumors.

A case of pediatric duodenal transection caused by abuse successfully treated by duodenojejunostomy.

BACKGROUND: Abuse can be a cause of pediatric duodenal injury. Patients who have been injured by abuse tend to have delay before medical examination, they may therefore have especially poor prognosis. CASE PRESENTATION: A 3-year-old boy presented with abdominal pain and was diagnosed with duodenal perforation. He was urgently transferred to our hospital for surgery. There was no clear history of trauma according to initial parent interviews, but old bruises were observed in several places. Paternal remarks about the injury mechanism were contradictory to bruit findings. Eventually, the mother reported daily paternal domestic violence against the patient. Duodenal perforation was considered to be caused by physical abuse, and emergent surgery was carried out. Intraoperative findings revealed transection at the horizontal part of the duodenum. Primary repair was difficult due to severe damage, so duodenojejunostomy was undertaken. CONCLUSION: Duodenojejunostomy was successfully carried out as emergent surgery for severely damaged duodenal transection.

Hepatic Inflammatory Myofibroblastic Tumor Detected in the Fetal Period That Caused an Oncologic Emergency.

A huge abdominal cystic lesion with ascites was detected in a male neonate at 31 weeks of gestation. Increasing ascites and the appearance of subcutaneous edema were detected, which caused fetal hydrops. The patient was delivered by emergency cesarean section at 33 weeks of gestation. The birth weight was 2,407 g, and the Apgar score was 8/9 points (1-/5-min values). Breathing at birth was stable, but the patient presented with remarkable abdominal distention due to the ascites. Later, the patient presented with tachypnea, and breathing gradually worsened, so an emergency operation was performed. There were no intraoperative findings within the small intestine, but there was a large amount of ascites and a cystic mass arising from the liver. The patient's breathing and circulation dynamics could only be stabilized by ascites removal, so only a tumor biopsy was performed. The pathological findings led to the diagnosis of an inflammatory myofibroblastic tumor, and steroids were administered early after surgery for the purpose of an anti-inflammatory effect and tumor shrinkage. The abdominal distention was alleviated, and blood examinations showed a reduced inflammatory response. There was no apparent shrinkage of the tumor, however; thus, radical surgical treatment was performed on day 24. The postoperative course was uneventful, so the patient was discharged on day 36. Seven years after the operation there has been no recurrence or distant metastasis.

Human thioredoxin-1 attenuates the rate of lipopolysaccharide-induced preterm delivery in mice in association with its anti-inflammatory effect.

BACKGROUND: Maternal intrauterine infection/inflammation represents the major etiology of preterm delivery and the leading cause of neonatal mortality and morbidity. The aim of this study was to investigate the anti-inflammatory properties of thioredoxin-1 in vivo and its potential ability to attenuate the rate of inflammation-induced preterm delivery. METHODS: Two intraperitoneal injections of lipopolysaccharide from Escherichia coli were administered in pregnant mice on gestational day 15, with a 3-h interval between the injections. From either 1 h before or 1 h after the first lipopolysaccharide injection, mice received three intravenous injections of either recombinant human thioredoxin-1, ovalbumin, or vehicle, with a 3-h interval between injections. RESULTS: Intraperitoneal injection of lipopolysaccharide induced a rise of tumor necrosis factor-α, interferon-γ, monocyte chemotactic protein 1, and interleukin-6 in maternal serum levels and provoked preterm delivery. Recombinant human thoredoxin-1 prevented the rise in these proinflammatory cytokine levels. After the inflammatory challenge, placentas exhibited severe maternal vascular dilatation and congestion and a marked decidual neutrophil activation. These placental pathological findings were ameliorated by recombinant human thioredoxin-1, and the rate of inflammation-induced preterm delivery was attenuated. CONCLUSION: Thioredoxin-1 may thus represent a novel effective treatment to delay inflammation-induced preterm delivery.

Parenteral nutrition-associated liver disease in extremely low-birthweight infants with intestinal disease.

BACKGROUND: The aim of this study was to investigate factors associated with the development of parenteral nutrition-associated liver disease (PNALD) and to examine the clinicopathological relationship of PNALD in extremely low-birthweight infants (ELBWI). METHODS: The subjects were 13 ELBWI who had received PN because of intestinal perforation or functional ileus between 2000 and 2013. We measured the serum levels of biochemical parameters, including aspartate aminotransferase, alanine aminotransferase, and direct bilirubin. Liver histopathology was examined in relation to outcome. The subjects were categorized into two groups on liver histopathology: F(+), development of hepatic fibrosis and necrosis with/without cholestasis; and F(-), no hepatic fibrosis. RESULTS: Of 13 ELBWI, five died of hepatic failure, five died of sepsis, and the other three were alive at the time of the study. Of the five infants who died of hepatic failure, two developed fulminant hepatitis without cholestasis, and the other three developed chronic cholestasis and finally hepatic failure. Postmortem histopathology in F(+) indicated not only massive hepatic necrosis, but also massive hepatic fibrosis. These histopathological findings explained the clinical presentation of portal hypertension. There were significant differences in the fasting period after intestinal disease onset between the two groups. CONCLUSION: The prolonged fasting with PN is responsible for severe hepatocellular necrosis with fibrosis and consequent lethal portal hypertension.

Efficacy and safety of strong acid electrolyzed water for peritoneal lavage to prevent surgical site infection in patients with perforated appendicitis.

PURPOSE: Our previous experimental study of perforated peritonitis in rats proved that peritoneal lavage with strong acid electrolyzed water (SAEW) has no adverse effects, reduces the bacteria count in the ascitic fluid more effectively than saline, and increases the survival rate significantly. Thus, we conducted a randomized controlled study, applying SAEW in the treatment of perforated appendicitis in children. METHODS: Forty-four patients, aged 3-14 years, were randomly divided into two groups: Group S (n = 20), in which the peritoneal cavity was lavaged with 100 ml/kg saline and the wound was washed out with 200 ml saline; and Group E (n = 24), in which the peritoneal cavity was lavaged with 100 ml/kg SAEW and the wound was washed out with 200 ml SAEW. RESULTS: No adverse effect of SAEW was observed in Group E. There was no difference in the bacterial evanescence ratio of ascitic fluid after lavage between Groups S and E (11.1 and 15.8%, respectively). A residual abscess developed in one patient from each group (5.0 and 4.2%, respectively). The incidence of surgical site infection (SSI) was significantly lower in Group E than in Group S (0 and 20%, respectively; P < 0.05). There was no difference in the duration of pyrexia, positive C-reactive protein, leukocytosis, or hospital stay between the groups. CONCLUSION: Peritoneal lavage and wound washing with SAEW have no adverse effects and are effective for preventing SSI.

The most reliable early predictors of outcome in patients with biliary atresia after Kasai's operation.

BACKGROUND/PURPOSE: The purpose of this study was to determine reliable predictors of outcome of biliary atresia (BA) after Kasai's operation. PATIENTS AND METHODS: Fifty-four BA cases that underwent Kasai's operation at our institution over two decades were reviewed. The cases were divided into two groups: Group I: cases that required liver transplantation or died (n=30) and Group II: cases alive with the native liver. Serum levels of total bilirubin (TB), direct bilirubin (DB), aspartate aminotransferase (AST), alanine aminotransferase (ALT), and gamma-glutamyltransferase (GGT) were measured sequentially after surgery. For cut-off determination, receiver operating characteristic (ROC) analysis was employed. RESULTS: Serum TB, DB, AST, and ALT in Group I were significantly higher than those in Group II at 1, 2, and 3 months after surgery (p<.05). The most reliable cut-offs determined by ROC analysis were DB of 0.7 mg/dl at 2 months (sensitivity; 93%, specificity; 75%) and AST of 94 IU/L at 2 months (sensitivity; 87%, specificity; 71%). The 54 cases were re-divided into three groups according to the cut-off values: group G (good) with DB and ASTcut-offs (n=9; Group I:II=4:5), and group P (poor) with DB and AST ≥ cut-offs (n=29; Group I:II=25:4). The 15-year survival rate in groups G, M, and P was 94%, 44%, and 22%, respectively (p<.001). CONCLUSION: The combination of serum DB and AST at 2 months after Kasai's operation is a reliable predictor of long-term BA outcome.