Risk assessment of morbidities after right hemicolectomy based on the National Clinical Database in Japan

Intracorporeal versus Extracorporeal Anastomosis for Laparoscopic Right Hemicolectomy: Short-Term Outcomes

Laparoscopic right hemicolectomy represents an effective therapeutic approach for right colon cancer (RCC). The primary aim of this study was to evaluate bowel function recovery, length of hospital stay, operative time, and the number of general and anastomosis-related postoperative complications from intracorporeal anastomosis (ICA) vs. extracorporeal anastomosis (ECA); the secondary outcome was the number of lymph nodes retrieved. This observational study was conducted on 108 patients who underwent right hemicolectomy for RCC; after surgical resection, 64 patients underwent ICA and 44 underwent ECA. The operative time was slightly longer in the ICA group than in the ECA group, even though the difference was not significant (199.31 ± 48.90 min vs. 183.64 ± 35.80 min; p = 0.109). The length of hospital stay (7.53 ± 1.91 days vs. 8.77 ± 3.66 days; p = 0.036) and bowel function recovery (2.21 ± 1.01 days vs. 3.45 ± 1.82 days; p < 0.0001) were significantly lower in the ICA group. There were no significant differences in postoperative complications (12% in ICA group vs. 9% in ECA group), wound infection (6% in ICA group vs. 7% in ECA group), or anastomotic leakage (6% in ICA group vs. 9% in ECA group). We did not observe a significant difference between the two groups in the number of lymph nodes collected (19.46 ± 7.06 in ICA group vs. 22.68 ± 8.79 in ECA group; p = 0.086). ICA following laparoscopic right hemicolectomy, compared to ECA, could lead to a significant improvement in bowel function recovery and a reduction in the length of hospital stay in RCC patients.

Surgical outcomes in gastroenterological surgery in Japan: Report of the National Clinical Database 2011-2019

BACKGROUND

We aimed to present the 2019 annual report of the gastroenterological section of the National Clinical Database (NCD).

METHODS

We reviewed 609,589 cases recorded in 2019 and 5,029,764 cases registered from 2011 to 2019 for the 115 selected gastroenterological surgical procedures.

RESULTS

The main features of gastroenterological surgery in Japan were similar to those described in the 2018 annual report, namely, that 1) operative numbers gradually increased in all procedures, except gastrectomy and hepatectomy, which decreased in these years; 2) in all eight major gastroenterological surgeries, the age distribution tended toward older patients; 3) the morbidity of esophagectomy, hepatectomy, and pancreaticoduodenectomy increased, but mortality was minimized in all procedures; 4) all eight major gastroenterological procedures have increasingly been performed under laparoscopy; and 5) board-certified surgeons were increasingly involved. These trends in recent years were more prominent in 2019.

CONCLUSIONS

Thanks to the continuous cooperation and dedication of the surgeons, medical staff, and surgical clinical reviewers who registered the clinical data into the NCD, it is possible to understand the comprehensive landscape of surgery in Japan and to disclose new evidence in this field. The Japanese Society of Gastroenterological Surgery will continue to promote the value of this database and encourage the use of feedback and clinical studies using the NCD, now and in the future. Generating further approaches to surgical quality improvement are important directions for future research.

Significance of the Glasgow prognostic score for short-term surgical outcomes: A nationwide survey using the Japanese National Clinical Database

AIM

Preoperative inflammation-based Glasgow prognostic score (GPS) is a useful tool for predicting long-term prognosis in cancer patients. However, its association with postoperative short-term outcomes remains unknown. The aim of this study is to investigate the association between GPS and postoperative morbidity and mortality among patients undergoing surgery for various gastrointestinal malignancies.

METHODS

Using the Japanese National Clinical Database, we analyzed the records of 312 357 patients with gastrointestinal malignancy who underwent six typical elective surgeries, including esophagectomy, distal gastrectomy, total gastrectomy, right hemicolectomy, low anterior resection, and pancreaticoduodenectomy, between January 2015 and December 2018. We assigned GPS of 0, 1, or 2 to patients with no, one, or both decreased albumin and elevated C-reactive protein levels, respectively. We investigated the relationship of GPS with operative morbidity and mortality for each procedure with adjustments for patients' demographics, preoperative status, comorbidities, and cancer stages.

RESULTS

Crude operative morbidity was significantly higher for GPS 1 and 2 than GPS 0 patients in all procedures except pancreaticoduodenectomy. The postoperative length of hospital stay was significantly longer for GPS 1 and 2 patients in all procedures (P < .001). Operative mortality was also higher for GPS 1 and 2 patients in all procedures. The associations remained significant after adjustments for potential confounders of age, sex, physical status, tumor classification, use of preoperative therapy, and comorbidities.

CONCLUSION

This nationwide study provides solid evidence on the strong association between GPS and postoperative outcomes.

C-reactive protein level on postoperative day 3 as a predictor of anastomotic leakage after elective right-sided colectomy

PURPOSE

To investigate the factors predictive of anastomotic leakage in patients undergoing elective right-sided colectomy.

METHODS

The subjects of this retrospective study were 247 patients who underwent elective right hemicolectomy or ileocecal resection with ileocolic anastomosis between April 2012 and March 2019, at our institution.

RESULTS

Anastomotic leakage occurred in 9 of the 247 patients (3.6%) and was diagnosed on median postoperative day (POD) 7 (range POD 3-12). There were no significant differences in the background factors or preoperative laboratory data between the patients with anastomotic leakage (anastomotic leakage group) and those without anastomotic leakage (no anastomotic leakage group). Open surgery was significantly more common than laparoscopic surgery (P = 0.027), and end-to-side anastomosis was less common (P = 0.025) in the anastomotic leakage group. The C-reactive protein (CRP) level in the anastomotic leakage group was higher than that in the no anastomotic leakage group on PODs 3 (P < 0.001) and 5 (P < 0.001). ROC curve analysis revealed that anastomotic leakage was significantly more frequent in patients with a serum CRP level ≥ 11.8 mg/dL [area under the curve (AUC) 0.83].

CONCLUSION

A serum CRP level ≥ 11.8 mg/dL on POD 3 was predictive of anastomotic leakage being detected on median POD 7.

Profiles of institutional departments affect operative outcomes of eight gastroenterological procedures

AIM

We evaluated the association of profiles of institutional departments with operative outcomes of eight major gastroenterological procedures.

METHODS

We administered a 15-item online survey to 2634 institutional departments in 2016 to investigate the association of questionnaire responses with operative mortality for the procedures. The proportions of conditions met were listed according to institutional volume and classified according to annual operative cases in 1464 departments. Group A included departments with annual performance of <40 cases of the eight procedures, B 40-79 cases, C 80-199 cases, D 200-499 cases, and E ≥ 500 cases. We evaluated the number of conditions met for 10 of 15 items that could be improved by efforts of institutional departments, to assess whether the profiles of institutional departments had impacts on operative mortality. We built a multivariable logistic regression model for operative mortality with facilities categorized based on the number of conditions met and procedure-specific predicted mortality as explanatory variables using generalized estimating equation to account for facility-level clustering. We also examined how operative outcomes differed between facilities meeting nine or more conditions and those that did not.

RESULTS

We recognized meeting nine out of the 10 conditions as being a good indicator for having appropriate structural and process measures for gastroenterological surgery. The facilities meeting nine or more of the conditions had better operative mortality for all eight procedures.

CONCLUSIONS

Our findings reveal that the profiles of institutional departments can reflect the outcomes of gastroenterological surgery in Japan.

Prognostic impact of LY6K and CDCA1 expression for patients with esophageal squamous cell carcinoma

AIM

In the present study, we investigated the relationship between the expressions of two cancer testis antigens (CTA), LY6K (lymphocyte antigen 6 complex locus K) and CDCA1 (cell division cycle associated 1), in esophageal squamous cell carcinoma (ESCC) tumors and the long-term outcomes of patients with ESCC to clarify the clinical significance of LY6K and CDCA1 expression in ESCC tumors.

METHODS

A total of 175 patients with thoracic ESCC who had undergone a thoracic esophagectomy with three-field lymphadenectomy without neoadjuvant therapy were retrospectively reviewed in this study. LY6K and CDCA1 expressions were evaluated in tumor tissues using immunohistochemical (IH) staining.

RESULTS

Median patient age was 63 years; 159 patients (90.9%) were men. Ninety-four patients (55.3%) were LY6K-positive, and 85 patients (48.6%) were CDCA1-positive. The LY6K-positive group had a significantly worse overall survival (OS) than the LY6K-negative group (P = 0.012), and the CDCA1-positive group had a significantly worse OS than the CDCA1-negative group (P = 0.010). A multivariate analysis suggested that pathological N stage, venous invasion, LK6Y-positive and CDCA1-positive were independent prognostic factors. The patients were classified into four groups according to the staining pattern combinations of the two CTA. The LY6K-positive and CDCA1-positive group was found to have a significantly poorer outcome than the other groups.

CONCLUSION

ESCC patients with a combination of LY6K and CDCA1 expression in their tumor tissues had a worse prognosis than all the other ESCC patients and it was an independent factor associated with prognosis for patients with ESCC.

Geriatric Risk Prediction Models for Major Gastroenterological Surgery using the National Clinical Database in Japan: A Multicenter Prospective Cohort Study

OBJECTIVES

To investigate the effect of geriatric variables on five newly added outcomes and create risk models for predicting these outcomes.

SUMMARY BACKGROUND DATA

Because there is a current lack of geriatric research focusing on geriatric outcomes using a national surgical database in Japan, there is a need to investigate outcomes associated with major gastroenterological surgery using these data.

METHODS

This multicenter prospective cohort study was conducted at 26 surgery departments across 21 institutions in Japan using the National Clinical Database (NCD) surgical registry. In total, 22 new geriatric variables were imported from the ACS NSQIP geriatric pilot study. The following five geriatric outcomes were defined: 1) postoperative delirium, 2) physical function on postoperative day 30, 3) fall risk on discharge, 4) discharge other than home with social service, and 5) functional decline on discharge, and geriatric risk prediction models for major gastroenterological surgery were created.

RESULTS

Between January 2018 and December 2018, data on 3,981 procedures from seven major gastroenterological surgeries were collected and analyzed. Older age and preoperative geriatric variables (Origin status from home, History of dementia, Use of mobility aid, Fall history, and Not competent on admission) were strongly associated with postoperative outcomes. Geriatric risk prediction models for these outcomes were created, with C-statistic values ranging from 0.74 to 0.90, demonstrating model validity and sufficiency of fit.

CONCLUSIONS

The risk models for the newly defined five geriatric outcomes that we created can be used in the decision-making process or provision of care in geriatric patients.

Development of gastroenterological surgery over the last decade in Japan: analysis of the National Clinical Database

The National Clinical Database (NCD) of Japan was established in 2010 with the board certification system. A joint committee of 16 gastroenterological surgery database-affiliated organizations has been nurturing this nationwide database and utilizing its data for various analyses. Stepwise board certification systems have been validated by the NCD and are used to improve the surgical outcomes of patients. The use of risk calculators based on risk models can be particularly helpful for establishing appropriate and less invasive surgical treatments for individual patients. Data obtained from the NCD reflect current developments in the surgical approaches used in hospitals, which have progressed from open surgery to endoscopic and robot-assisted procedures. An investigation of the data acquired by the NCD could answer some relevant clinical questions and lead to better surgical management of patients. Furthermore, excellent surgical outcomes can be achieved through international comparisons of the national databases worldwide. This review examines what we have learned from the NCD of gastroenterological surgery and discusses what future developments we can expect.

Surgical outcomes in gastroenterological surgery in Japan: Report of the National Clinical Database 2011-2018

The National Clinical Database (NCD) of Japan grew rapidly, harvesting over 11 million cases of data between 2011 and 2018 from more than 5000 facilities. This is the Report of the NCD based upon gastrointestinal surgery information in 4 420 175 cases from 2011 to 2018. More than 70% of all gastrointestinal surgeries were performed at certified institutions, and the percentage of surgeries performed at certified institutions was particularly high for the esophagus (93.8% in 2018), liver (89.4%), pancreas (91.3%), and spleen (86.9%). Also, more than 70% of the surgeries were performed with the participation of the board-certified surgeon. As the patients have been getting older, the morbidities have been increasing. However, the mortalities have been kept at a low level. The rates of endoscopic surgery have been increasing year by year, especially high in low anterior resection (67.0%) and esophagectomy (61.0%). Nationwide, this database is surely expecting to ensure the quality of board certification system and surgical outcomes in gastroenterological surgery.

Surgical outcomes of gastroenterological surgery in Japan: Report of the National Clinical Database 2011-2017

BACKGROUND

The Japanese National Clinical Database (NCD) is a large-scale, nationwide, web-based data entry system that is linked to the surgical board certification system and covers almost all surgical cases carried out in Japan.

AIM

To evaluate outcomes according to the gastroenterological section of the NCD.

METHODS

The 115 surgical procedures stipulated by the "Training Curriculum for Board-Certified Surgeons in Gastroenterology" were registered from 2011 to 2017. The number of surgeries, preoperative comorbidities, and short-term outcomes were compared between registration periods.

RESULTS

In total, 3 818 414 cases have been registered. More than 70% of all surgeries were carried out at certified institutions. The annual number of cases has been increasing year after year, and the aged population has also been increasing. Although the rates of preoperative comorbidities and postoperative complications have been increasing, the postoperative mortality rate has remained relatively low; in 2017, the 30-day mortality rate was 1.0% among those who underwent esophagectomy, 0.7% among those who underwent distal gastrectomy, 1.1% among those who underwent total gastrectomy, 1.3% among those who underwent right hemicolectomy, 0.5% among those who underwent low anterior resection, 1.3% among those who underwent hepatectomy, and 1.3% among those who underwent pancreaticoduodenectomy. The annual rate of endoscopic surgery dramatically increased over 7 years between 2011 and 2017, especially for low anterior resection (29.5%-62.6%) and esophagectomy (31.0%-56.1%).

CONCLUSION

This database is expected to ensure the quality of the board-certification system and surgical outcomes in gastroenterological surgery.