渡部 純

Background The outcomes after liver transplantation have greatly improved, which has resulted in greater focus on improving non-hepatic outcomes of liver transplantation. The present study aimed to evaluate thoracic spine radio density in children and adolescents after liver transplantation. Methods A total of 116 patients who underwent living donor liver transplantation were retrospectively analyzed. The radio density at the eleventh thoracic vertebra was measured using computed tomography scan performed preoperatively then annually for 5 years postoperatively and subsequently every 2 or 3 years. Results The mean thoracic radio density of male recipients of male grafts had the lowest values during the study. The radio density of patients receiving a graft from a female donor was higher than in recipients with grafts from males. Total mean radio density decreased for first 5 years postoperatively and then increased. Changes in radio density were equally distributed in both steroid withdrawal and no steroid withdrawal groups for 5 years, after which patients with steroid withdrawal had a greater increase. Changes in radio density were equally distributed in both the steroid withdrawal and no steroid withdrawal groups up to age 20, after which patients in the steroid withdrawal group had a greater increase. Conclusions Gender differences may affect the outcome of radio density changes after transplantation. Given the moderate association between thoracic radio density and bone mineral density in skeletally mature adults and further studies are needed to validate this relationship between thoracic radio density and bone mineral density changes in pediatric liver transplantation.

Objectives Lymphovascular invasion (LVI) is a critical risk factor for lymph node metastasis (LNM), which requires additional surgery after endoscopic resection of T1 colorectal cancer (CRC). However, the impact of additional staining on estimating LNM is unclear. This systematic review aimed to evaluate the impact of additional staining on determining LNM in T1 CRC. Methods We searched five electronic databases. Outcomes were diagnostic odds ratio (DOR), assessed using hierarchical summary receiver operating characteristic curves, and interobserver agreement among pathologists for positive LVI, assessed using Kappa coefficients (κ). We performed a subgroup analysis of studies that simultaneously included a multivariable analysis for other risk factors (deep submucosal invasion, poor differentiation, and tumor budding). Results Among the 64 studies (18,097 patients) identified, hematoxylin–eosin (HE) and additional staining for LVI had pooled sensitivities of 0.45 (95% confidence interval [CI] 0.32–0.58) and 0.68 (95% CI 0.44–0.86), specificities of 0.88 (95% CI 0.78–0.94) and 0.76 (95% CI 0.62–0.86), and DORs of 6.26 (95% CI 3.73–10.53) and 6.47 (95% CI 3.40–12.32) for determining LNM, respectively. In multivariable analysis, the DOR of additional staining for LNM (DOR 5.95; 95% CI 2.87–12.33) was higher than that of HE staining (DOR 1.89; 95% CI 1.13–3.16) (P = 0.01). Pooled κ values were 0.37 (95% CI 0.22–0.52) and 0.62 (95% CI 0.04–0.99) for HE and additional staining for LVI, respectively. Conclusion Additional staining for LVI may increase the DOR for LNM and interobserver agreement for positive LVI among pathologists.

Purpose Spinal nerve injections have traditionally been performed under fluoroscopic (FL) and computed tomography (CT) guidance. Recently, ultrasound (US)-guided procedures have provided an alternative guidance approach that does not expose the patient and operator to radiation. The aim of this study was to compare the efficacy and safety of US-guided spinal nerve injections compared with FL- or CT-guided spinal nerve injections. Methods MEDLINE, Cochrane Library, EMBASE, international clinical trials registry platform (ICTRP) and ClinicalTrials.gov database searches for inclusion until February 2023 were independently performed by two authors using predefined criteria. Randomized controlled trials (RCTs) were included. Primary outcomes were change in pain score (numeric rating scale or visual analogue scale) and major adverse events. Secondary outcomes were procedure time, change in functional disability score and minor adverse events. Meta-analysis was performed using random-effect model. We evaluated the certainty of evidence based on the Grading of Recommendations, Assessment and Development (GRADE) approach. Results Eight RCTs involving 962 patients were included. There might be little to no difference in the mean score of the pain change between the US-guided methods and the FL- or CT-guided injections (standard mean difference -0.06; 95% confidence interval [CI] −0.26 to 0.15). US guidance probably reduced major adverse events (0.7% [3/433] and 6.5% [28/433], respectively), reduced procedure time (mean difference −4.19 min; 95% CI −5.09 to −3.30), and probably reduced minor adverse events (2.1% [9/433] and 4.2% [18/433], respectively) compared with FL or CT guidance. There was probably little to no difference in the change in functional disability score with either method. Conclusion US-guided spinal nerve injections remained effective and reduced adverse events compared with conventional FL- or CT-guided spinal nerve injections. Further RCTs are required to verify our results. Study registration Open Science Forum (Available from: https://osf.io/vt92w/).

Background: The prognostic importance of osteopenia in patients with intrahepatic cholangiocarcinoma (ICC) undergoing hepatectomy is unclear. The aim of this study was to evaluate the impact of osteopenia on survival in patients with ICC. Methods: A total of 71 patients who underwent hepatectomy at Jichi Medical University between July 2008 and June 2022 were included in this study. Non-contrast computed tomography scan images at the eleventh thoracic vertebra were used to assess bone mineral density. The cutoff value was calculated using a threshold value of 160 Hounsfield units. Overall survival curves were made using the Kaplan–Meier method and the log-rank test was used to evaluate survival. The hazard ratio (HR) and 95% confidence interval (CI) for overall survival were calculated using Cox’s proportional hazard model. Results: In multivariable analysis, osteopenia (HR 3.66, 95%CI 1.16–14.1, p = 0.0258) and the platelet–lymphocyte ratio (HR 6.26, 95%CI 2.27–15.9, p = 0.0008) were significant independent factors associated with overall survival. There were no significant independent prognostic factors for recurrence-free survival. Conclusions: Preoperative osteopenia is significantly associated with postoperative survival in patients with ICC undergoing hepatectomy.

Oxidative stress is known to be associated with the pathophysiology of chronic kidney disease (CKD). Paraoxonase 1 (PON1) is an antioxidant enzyme that has been proposed as a biomarker for CKD. While several studies have reported an association between serum PON1 activity and CKD, consensus based on systematically analyzed data remains necessary. We set out to conduct a meta-analysis of literature on PON1 in CKD. Electronic databases, such as MEDLINE, Embase and CENTRAL, were searched for available studies on PON1 activity in patients with CKD (without dialysis) as published before December 2022. A random-effects meta-analysis was performed. In total, 24 studies (22 studies on paraoxonase and 11 on arylesterase activity) were eligibly identified. Patients with CKD showed a lower activity of paraoxonase (standard mean difference [SMD], −1.72; 95% confidence interval [CI], −2.15 to −1.29) and arylesterase (SMD, −2.60; 95%CI, −3.96 to −1.24) than healthy controls. In the subgroup analyses, paraoxonase activity was lower in chronic kidney failure (CKF), an advanced stage of CKD, than in non-CKF. In summary, PON1 activity is low in patients with CKD, suggesting that the antioxidant defense by PON1 is impaired in CKD. The decrease in enzyme activity is pronounced in advanced CKD showing some variability depending on the substrate employed to measure PON1 activity. Further studies are warranted.

Background: For people who are malnourished and unable to consume food by mouth, nasoenteral feeding tubes are commonly used for the administration of liquid food and drugs. Postpyloric placement is when the tip of the feeding tube is placed beyond the pylorus, in the small intestine. Endoscopic-guided placement of postpyloric feeding tubes is the most common approach. Usually, an endoscopist and two or more medical professionals perform this procedure using a guidewire technique. The position of the tube is then confirmed with fluoroscopy or radiography, which requires moving people undergoing the procedure to the radiology department. Alternatively, electromagnetic-guided placement of postpyloric nasoenteral feeding tubes can be performed by a single trained nurse, at the bedside and with less equipment than endoscopic-guided placement. Hence, electromagnetic-guided placement may represent a promising alternative to endoscopic-guided placement, especially in settings where endoscopy and radiographic facilities are unavailable or difficult to access. Objectives: To assess the efficacy and safety of electromagnetic-guided placement of postpyloric nasoenteral feeding tubes compared to endoscopic-guided placement. Search methods: We searched the Cochrane Library, MEDLINE, Embase, CINAHL, ClinicalTrials.gov, World Health Organization International Clinical Trials Registry Platform, and OpenGrey until February 2021. We screened the reference lists of relevant review articles and current treatment guidelines for further literature. We contacted the study authors for missing data. Selection criteria: We included randomised trials comparing electromagnetic-guided placement with endoscopic-guided placement of nasoenteral feeding tubes. We excluded prospective cohort studies, retrospective cohort studies, (nested) case-control studies, cross-sectional studies, and case series or case reports. Data collection and analysis: Two review authors independently assessed the methodological quality of potentially eligible trials and extracted data from the included trials. The primary outcomes were technical success in insertion and aspiration pneumonitis. The secondary outcomes were the time for postpyloric placement of nasoenteral feeding tubes, direct healthcare costs, and adverse events. We performed a random-effects meta-analysis. We calculated risk ratios (RRs) with 95% confidence intervals (CIs) for dichotomous outcomes and mean differences (MDs) with 95% CIs for continuous outcomes. We evaluated the certainty of evidence based on the GRADE approach. Main results: We identified four randomised controlled trials with 541 participants which met our inclusion criteria. All trials had methodological limitations, and lack of blinding of participants and investigators was a major source of bias. We had 'some concerns' for the overall risk of bias in all trials. Electromagnetic-guided postpyloric placement of nasoenteral feeding tubes may result in little to no difference in technical success in insertion compared to endoscopic-guided placement (RR 1.09, 95% CI 0.88 to 1.35; I2 = 81%; low-certainty evidence). Electromagnetic-guided placement may result in a difference in the proportion of participants with aspiration pneumonitis compared to endoscopic-guided placement, but these results are unclear (RR 0.24, 95% CI 0.03 to 2.18; I2 = 0%; low-certainty evidence). Electromagnetic-guided placement may result in little to no difference in the time for postpyloric placement of nasoenteral feeding tubes compared to endoscopic-guided placement (MD 4.06 minutes, 95% CI -0.47 to 8.59; I2 = 97%; low-certainty evidence). Electromagnetic-guided placement likely reduces direct healthcare costs compared to endoscopic-guided placement (MD -127.69 US dollars, 95% CI -135.71 to -119.67; moderate-certainty evidence). Electromagnetic-guided placement likely results in little to no difference in adverse events compared with endoscopic-guided placement (RR 0.78, 95% CI 0.41 to 1.49; moderate-certainty evidence). Authors' conclusions: We found low-certainty evidence that electromagnetic-guided placement at the bedside results in little to no difference in technical success in insertion and aspiration pneumonitis, compared to endoscopic-guided placement. The heterogeneity of the healthcare professionals who performed the procedures and the small sample sizes limited our confidence in the evidence. Future research should be based on large studies with well-defined endpoints to potentially elucidate the differences between these two procedures.

BACKGROUND: There is no consensus on the relationship between visceral fat mass and long-term postoperative prognosis in patients with upper gastrointestinal (GI) cancer. OBJECTIVE: : The purpose of this study was to investigate the association of preoperative visceral fat mass with postoperative complications and overall survival (OS) in patients with upper GI cancer. METHODS: We searched MEDLINE, the Cochrane Central Register of Controlled Trials, EMBASE (Dialog), the World Health Organization International Clinical Trials Platform Search Portal, and ClinicalTrials.gov and identified observational studies published from inception through July 20, 2022. We conducted a systematic review and random-effects meta-analysis of studies including patients who were surgically treated for upper GI cancer and whose visceral fat mass was assessed on the basis of body composition. We independently assessed the risk of bias and quality of evidence using Quality In Prognosis Studies and the Grading of Recommendations, Assessment, Development, and Evaluation approach, respectively. The primary outcome was OS. Hazard ratios and 95% confidence intervals (CIs) for OS were pooled. RESULTS: Ninety-one studies (N=20583) were included. All studies used computed tomography (CT) to assess the body composition of patients. Twenty-four studies reported the relationship between high visceral fat and postoperative outcomes, and their results were synthesized. Compared with low visceral adipose tissue, high visceral adipose tissue assessed by CT may improve OS (hazard ratio: 0.69; 95%CI: 0.55, 0.87; I2 = 65%; n=3407). The risk of bias for OS in each study was moderate or high. The certainty of evidence for OS was very low because of inconsistency in the forest plot, the moderate or high risk of bias and publication bias. CONCLUSIONS: High visceral fat may be associated with improved OS after radical resection in patients with upper GI cancer. Further studies are needed to confirm these findings and mitigate the risk.

The Surgical Patient Safety System (SURPASS) has been proven to improve patient outcomes. However, few studies have evaluated the details of litigation and its prevention in terms of systemic and diagnostic errors as potentially preventable problems. The present study explored factors associated with accepted claims (surgeon-loss). We retrospectively searched the national Japanese malpractice claims database between 1961 and 2017. Using multivariable logistic regression models, we assessed the association between medical malpractice variables (systemic and diagnostic errors, facility size, time, place, and clinical outcomes) and litigation outcomes (acceptance). We evaluated whether or not the factors associated with litigation could have been prevented with the SURPASS checklist. We identified 339 malpractice claims made against general surgeons. There were 159 (56.3%) accepted claims, and the median compensation paid was 164,381 USD. In multivariable analyses, system (odds ratio, 27.2 95% confidence interval 13.8-53.5) and diagnostic errors (odds ratio 5.3, 95% confidence interval 2.7-10.5) had a significant statistical association with accepted claims. The SURPASS checklist may have prevented 7% and 10% of the accepted claims and systemic errors, respectively. It is unclear what proportion of accepted claims indicated that general surgeon loses should be prevented from performing surgery if the SURPASS checklist were used. In conclusion, systemic and diagnostic errors were associated with accepted claims. Surgical teams should adhere to the SURPASS checklist to enhance patient safety and reduce surgeon risk.

Background and Objectives: Adequate initial fixation of the uncemented acetabular component in total hip arthroplasty is necessary to achieve long-term survival. Although screw fixation contributes to improved cup stability, there is currently no consensus on the use of this method. This study aimed to assess the existing randomized controlled trials (RCTs) on the efficacy and safety of cup fixation in total hip arthroplasty without screws. Materials and Methods: We searched the EMBASE, MEDLINE, Cochrane Central Register of Controlled Trials, World Health Organization International Clinical Trials Registry Platform, and ClinicalTrials.gov databases to identify RCTs published before February 2022. Primary outcomes were reoperation, cup migration, and Harris Hip Score. Secondary outcomes were the presence of a radiolucent line in the acetabular region, translation and rotation movement, and polyethylene wear. We conducted meta-analyses using the random-effects models. The revised Cochrane risk-of-bias tool was used to assess the risk of bias for outcomes of interest; the Grading of Recommendations, Assessment, Development, and Evaluation approach was used to summarize the body of evidence. Results: We included six reports from four studies. Total hip arthroplasty without screw fixation to the acetabular cup had little to no effect on reoperation (pooled relative risk, 0.98; 95% confidence interval, 0.14–6.68; I2 = 0%), cup migration (pooled relative risk, 1.72; 95% confidence interval, 0.29–10.33; I2 = 1%), Harris Hip Score (mean difference, 1.19; 95% confidence interval, −1.31–3.70; I2 = 0%), radiolucent line (pooled relative risk, 5.91; 95% confidence interval, 0.32–109.35), translation and rotation of all axes, and polyethylene wear (mean difference, 0.01; 95% confidence interval, −0.01–0.04; I2 = 0%), with very low certainty of evidence on all measures. Conclusions: The efficacy of acetabular cups without screw fixation in total hip arthroplasty remains uncertain, suggesting the need for prudent clinical application. Further large-scale, well-designed studies with low risk of bias are required.

We read the article by Gulacti et al. [1] with great interest, and we appreciate the authors' efforts to determine the analgesic efficacy of transcutaneous electrical nerve stimulation (TENS) for renal colic. However, we would like to point out two concerns. First, the absence of analgesic therapy for the control group in this study may be ethically questionable due to the high degree of patient pain [2]. The efficacy of pharmacotherapy such as NSAIDs, acetaminophen, and opioids as analgesic methods for renal colic is well established [3,4]. We suggest that the participants be randomly assigned into either a control group receiving analgesic pharmacotherapy and sham TENS, an intervention group receiving TENS only, and another intervention group receiving TENS combined with analgesic pharmacotherapy. Second, we would like to caution the readers about interpreting the results becausewe do not knowif themean difference in the Visual Analog Scale (VAS) scores shown in this study is clinically significant. Although there is no established minimally important difference in analgesic therapy for renal colic, we believe it is useful to be aware of minimally important difference and report results [5]. For example, it might be informative to indicate the percentage of patients whose VAS score improved with TENS, referring to the degree of improvement in the VAS scorewith pharmacotherapy for renal colic in previous studies. Some past studies have shown the percentage of patients whose VAS score improved by 50% or more after 30 min [3,4]. However, we suggest that this should be shown in addition to the results of this study to avoid misclassification by dividing the patients into two groups.

In 2018, the Global Leadership Initiative on Malnutrition consortium published global consensus diagnostic criteria for malnutrition and highlighted the association between malnutrition and poor postoperative outcomes in patients with gastrointestinal cancer. The aforementioned criteria consist of phenotypic and etiologic criteria to diagnose malnutrition in individuals who undergo conventional screening to determine the at-risk population. Recent studies have reported the usefulness of prediction of postoperative outcomes using body mass index, weight loss, and reduced muscle mass as phenotypic criteria. Reduced muscle mass is an essential diagnostic criterion for sarcopenia, which is associated with poor outcomes in patients with cancer. The Global Leadership Initiative on Malnutrition criteria define reduced muscle mass as undernutrition. Malnutrition diagnosed based on the Global Leadership Initiative on Malnutrition criteria is an important risk factor for postoperative complications and also an independent poor prognostic factor for long-term outcomes; greater severity of malnutrition is associated with poorer outcomes. The current Global Leadership Initiative on Malnutrition criteria for malnutrition accurately predict outcomes, including postoperative complications and long-term prognosis; however, a revision may be warranted to ensure consistency with the diagnostic criteria for sarcopenia. Patients diagnosed with malnutrition based on the Global Leadership Initiative on Malnutrition criteria should be targeted for nutritional intervention. Further accumulation of evidence is necessary to conclusively establish the role of nutritional interventions in patients with malnutrition to improve postoperative complications and long-term outcomes.