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Remnant gastric cancer, most frequently defined as cancer detected in the remnant stomach after distal gastrectomy for benign disease and those cases after surgery of gastric cancer at least 5 years after the primary surgery, is often reported as a tumor with poor prognosis. The Task Force of Japanese Gastric Cancer Association for Research Promotion evaluated the clinical impact of remnant gastric cancer by systematically reviewing publications focusing on molecular carcinogenesis, lymph node status, patient survival, and surgical complications. A systematic literature search was performed using PubMed/MEDLINE with the keywords “remnant,” “stomach,” and “cancer,” revealing 1154 relevant reports published up to the end of December 2014. The mean interval between the initial surgery and the diagnosis of remnant gastric cancer ranged from 10 to 30 years. The incidence of lymph node metastases at the splenic hilum for remnant gastric cancer is not significantly higher than that for primary proximal gastric cancer. Lymph node involvement in the jejunal mesentery is a phenomenon peculiar to remnant gastric cancer after Billroth II reconstruction. Prognosis and postoperative morbidity and mortality rates seem to be comparable to those for primary proximal gastric cancer. The crude 5-year mortality for remnant gastric cancer was 1.08 times higher than that for primary proximal gastric cancer, but this difference was not statistically significant. In conclusion, although no prospective cohort study has yet evaluated the clinical significance of remnant gastric cancer, our literature review suggests that remnant gastric cancer does not adversely affect patient prognosis and postoperative course.

Purpose The impact of postoperative complications on survival after radical surgery for esophageal, gastric, and colorectal cancers remains controversial. We conducted a systematic review of recent publications to examine the effect of postoperative complications on oncological outcome. Methods A literature search of PubMed/MEDLINE was performed using the keywords “esophageal cancer,” “gastric cancer,” and “colorectal cancer,” obtaining 27 reports published online up until the end of April 2016. Articles focusing on (i) postoperative morbidity and oncological outcome; and (ii) body mass index (BMI), postoperative morbidity, and oncological outcome, were selected. Univariate and multivariate analyses (Cox proportional hazards model) were performed. Results Patients with postoperative complications had significantly poorer long‐term survival than those without complications. Complications were associated with impaired oncological outcomes. The hazard ratios for overall survival were 1.67 (95% confidence interval [CI], 1.31‐2.12), 1.59 (95% CI, 1.13‐2.24), and 1.55 (95% CI, 1.28‐1.87) in esophageal, gastric, and colorectal cancers, respectively. High BMI was associated with postoperative morbidity rate but not with poor oncological outcome. Low BMI was significantly associated with inferior oncological outcome. Conclusions Complications after radical surgery for esophageal, gastric, and colorectal cancers are associated with patient prognosis. Avoiding such complications might improve the outcomes. A systematic review of the impact of postoperative complications on long‐term survival of patients with gastrointestinal cancers showed that infectious complications, particularly pneumonia, were significant risk factors with negative impacts on patient survival.

Aim Clinical staging is vital for selecting appropriate candidates and designing neoadjuvant treatment strategies for advanced tumors. The aim of this review was to evaluate diagnostic abilities of clinical TNM staging for gastrointestinal, gastrointestinal cancers. Methods We conducted a systematic review of recent publications to evaluate the accuracy of diagnostic modalities on gastrointestinal cancers. A systematic literature search was performed in PubMed/MEDLINE using the keywords “TNM staging,” “T4 staging,” “distant metastases,” “esophageal cancer,” “gastric cancer,” and “colorectal cancer,” and the search terms used in Cochrane Reviews between January 2005 to July 2020. Articles focusing on preoperative diagnosis of: (a) depth of invasion; (b) lymph node metastases; and (c) distant metastases were selected. Results After a full‐text search, a final set of 55 studies (17 esophageal cancer studies, 26 gastric cancer studies, and 12 colorectal cancer studies) were used to evaluate the accuracy of clinical TNM staging. Positron emission tomography–computed tomography (PET‐CT) and/or magnetic resonance imaging (MRI) were the best modalities to assess distant metastases. Fat and fiber mode of CT may be useful for T4 staging of esophageal cancer, CT was a partially reliable modality for lymph node staging in gastric cancer, and CT combined with MRI was the most reliable modality for liver metastases from colorectal cancer. Conclusion The most reliable diagnostic modality differed among gastrointestinal cancers depending on the type of cancer. Therefore, we propose diagnostic algorithms for clinical staging for each type of cancer. We conducted a systematic review of recent publications to evaluate the accuracy of diagnostic modalities on gastrointestinal cancers. Such systematic review on all three cancer types—esophageal cancer, gastric cancer, colorectal cancer—cannot be found in recent publications on PubMed. We believe that this review may be fundamental information to design clinical studies related to neoadjuvant therapy for gastrointestinal cancers.

Aims/Introduction Gestational diabetes mellitus (GDM) is a risk for adverse perinatal outcomes, and patients with a history of GDM have an increased risk of impaired glucose tolerance (IGT). Here, we carried out two non‐interventional and retrospective studies of GDM patients in Japan. Materials and Methods In the first study, we enrolled 529 GDM patients and assessed predictors of the need for insulin therapy. In the second study, we enrolled 185 patients from the first study, and assessed predictors of postpartum IGT. Results In the first study, gestational weeks at GDM diagnosis and history of pregnancy were significantly lower, and pregestational body mass index, family history of diabetes mellitus, 1‐ and 2‐h glucose levels in a 75‐g oral glucose tolerance test (OGTT), the number of abnormal values in a 75‐g OGTT, and glycated hemoglobin were significantly higher in participants receiving insulin therapy. In the second study, 1‐ and 2‐h glucose levels in a 75‐g OGTT, the number of abnormal values in a 75‐g OGTT, glycated hemoglobin, and ketone bodies in a urine test were significantly higher in participants with OGT. Logistic regression analysis showed that gestational weeks at GDM diagnosis, 1‐h glucose levels in a 75‐g OGTT and glycated hemoglobin were significant predictors of the need for insulin therapy, and 1‐h glucose levels in a 75‐g OGTT at diagnosis and ketone bodies in a urine test were significant predictors for postpartum IGT. Conclusions Antepartum 1‐h glucose levels in a 75‐g OGTT was a predictor of the need for insulin therapy in pregnancy and postpartum IGT. We performed two non‐interventional and retrospective studies of GDM patients in Japan to assess predictors of the need for insulin therapy in pregnancy, and predictors of postpartum impaired glucose tolerance. Gestational weeks at GDM diagnosis, plasma glucose levels in a 75 g OGTT at 1 hour, and HbA1c were significant predictors of the need for insulin therapy, and 1‐hour glucose levels in a 75 g OGTT at diagnosis and ketone bodies in a urine test were significant predictors for impaired glucose tolerance during the 6‐to‐12‐weeks postpartum period. In particular, antepartum 1‐hour glucose levels in a 75 g OGTT was a predictor of both the need for insulin therapy in pregnancy and postpartum impaired glucose tolerance.

Background Anastomotic leak (AL) is a dangerous postoperative complication in gastrointestinal surgery. The present study focuses on whether our prediction scoring system, “Estimation of Physiologic Ability and Surgical Stress” (E-PASS), could predict occurrence of AL and its prognosis in various kinds of gastrointestinal surgical procedures. Methods We prospectively investigated parameters of E-PASS, absence or presence of AL, and in-hospital mortality in 6,005 patients who underwent elective digestive surgery with alimentary tract reconstruction in 45 acute care hospitals in Japan between 1 April 2002 and 31 March 2007. Results Incidences of AL were 19.6% for esophagectomy via right thoracotomy and laparotomy, 11.7% for pancreaticoduodenectomy, 7.4% for low anterior resection, 4.0% for total gastrectomy, 1.8% for open distal gastrectomy, 1.3% for open colectomy, for an overall incidence of 4.1%. The incidence in each procedure significantly correlated with median value of surgical stress score of the E-PASS ( R  = 0.78, n  = 11, p  = 0.0048). The incidences of AL increased when Total Risk Points (TRP) of the E-PASS increased; 1.1% at the TRP range of <500, 2.8% at 500 to <1,000, 4.8% at 1,000 to <1,500, and 13.6% at ≥1,500 ( p  < 0.0001). In patients who suffered from AL, an in-hospital mortality rate at TRP < 1,000 was significantly lower than that at TRP of ≥1,000 (1.1 vs. 15.9%; p  = 0.00019). Conclusions The E-PASS, requiring only nine variables, may be useful in predicting AL and its prognosis.

Aim The quick sequential organ failure assessment (qSOFA) score, shock index (SI), and systemic inflammatory response syndrome (SIRS) criteria are simple indicators for the mortality of patients in the emergency department (ED). These simple indicators using only vital signs might be more useful in prehospital care than in the ED due to their quick calculation. However, these indicators have not been compared in prehospital settings. The aim of the present study is to compare these indicators measured in prehospital care and verify whether the qSOFA score is useful for prehospital triage. Methods We undertook a single‐site retrospective study on patients transferred by ambulance to the Kumamoto Medical Center ED (Kumamoto, Japan) between January 2015 and December 2016. We compared areas under the receiver operating characteristic (AUROC) curves of the qSOFA score, SI, and SIRS criteria measured in prehospital care. We also carried out sensitivity and specificity analyses using the Youden index. Results A total of 4,827 patients were included in the present study. The AUROC (95% confidence interval) of the qSOFA score for in‐hospital mortality was 0.64 (0.61–0.67), which was significantly higher than those of the SIRS criteria (0.59 [0.56–0.62]) and SI (0.58 [0.54–0.62]). According to the optimal cut‐off values (qSOFA ≥ 2) decided on as the Youden index, the sensitivity of the qSOFA score was 52.3% and its specificity was 69.9%. Conclusions The qSOFA score had the highest AUROC among three indicators. However, it might not be practical in actual prehospital triage due to its low sensitivity. We undertook a single‐site retrospective study about prehospital emergency patients. We compared three major simple indicators (quick sequential organ failure assessment score, systemic inflammatory response syndrome criteria, and shock index) in the patients transferred by ambulance for in‐hospital mortality. The quick sequential organ failure assessment score had the highest accuracy among the three indicators.

Background The incidence of complicated choledochocystolithiasis is increasing with the aging of society in Japan. We evaluated the utility of our prediction rule modified estimation of physiologic ability and surgical stress (mE-PASS) in predicting postoperative adverse events in patients with choledochocystolithiasis. Methods A total of 4,329 patients who underwent elective surgery for choledochocystolithiasis in 44 referral hospitals between April 1987 and April 2007 were analyzed for mE-PASS along with postoperative events. The discrimination power of mE-PASS was assessed by the area under the receiver operating characteristic curve (AUC). The correlation between ordinal and interval variables was quantified by the Spearman rank correlation ( ρ ). The ratio of observed-to-estimated mortality rates (OE ratio) was used as a metric of surgical quality. Results Postoperative in-hospital mortality rates were 0 % (0/3,442) for laparoscopic cholecystectomy, 0.19 % (1/521) for open cholecystectomy, 1.6 % (1/63) for laparoscopic choledochotomy, 1.1 % (3/264) for open choledochotomy, and 5.1 % (2/39) for plasty or resection of the common bile duct. mE-PASS demonstrated a high discrimination power to predict in-hospital mortality; AUC, 95 % confidence interval (CI) of 0.96, 0.94–0.99. The predicted mortality rates significantly correlated with the severity of postoperative complications ( ρ  = 0.278, p  < 0.0001) and length of hospital stay ( ρ  = 0.479, p  < 0.0001). The OE ratios (95 % CI) improved slightly over time; 1.5 (0.25–9.0) between 1987 and 2000, and 0.40 (0.078–2.1) between 2001 and 2007. Conclusions The present study suggests that mE-PASS can predict postoperative risks in patients who have undergone choledochocystolithiasis. mE-PASS may be useful in surgical decision making and evaluating the quality of care.

Background Improvements in operative technique and perioperative management have resulted in increasing numbers of elderly patients undergoing gastrectomy for gastric cancer (GC). We evaluated the accuracy of Estimation of Physiologic Ability and Surgical Stress (E-PASS) and modified (m)E-PASS scores in predicting postoperative complications in elderly patients with GC. Methods We retrospectively analyzed short-term outcomes in 413 patients who underwent gastrectomy for GC between 2005 and 2014. They were divided into two groups: Group N comprised 341 non-elderly patients <80 years of age and Group E comprised 72 elderly patients ≥80 years of age. We calculated the E-PASS and mE-PASS scores and evaluated the correlation between the comprehensive risk score (CRS) and occurrence of postoperative complications. Results Morbidity rates were 25.5 % in Group N and 31.9 % in Group E. In Group N, the CRS values of both the E-PASS ( P  < 0.0001) and mE-PASS ( P  < 0.0001) scores were significantly higher in patients with complications than in those without complications. In Group E, although the E-PASS CRS was significantly higher in patients with complications than in patients without complications ( P  = 0.01), the mE-PASS CRS fixed (CRSf) score was not significantly correlated with the occurrence of postoperative complications ( P  = 0.08). Conclusion Both E-PASS and mE-PASS can be used to predict the occurrence of postoperative complications in GC patients undergoing gastrectomy. However, the E-PASS CRS is more accurate for elderly patients because variations in intraoperative parameters such as operation time, blood loss, and extent of skin incision have a strong influence on the occurrence of postoperative complications.

Aim The American Society of Anesthesiologists Physical Status (ASA‐PS) classification system is used worldwide and has also been incorporated into various prediction rules. However, concerns have been raised regarding inter‐rater agreement in various surgical fields. Although emergency gastrointestinal surgery is relatively common and associated with high postoperative mortality, a reliability study has not yet been undertaken in this field. The aim of the present study was to investigate the inter‐rater reliability of ASA‐PS for emergency gastrointestinal surgery. Methods Three sets of scenarios were generated for each ASA‐PS class (2E, 3E, and 4E) in emergency gastrointestinal surgery, resulting in nine scenarios. These scenarios described the preoperative profiles of patients in one hospital. Two or three anesthesiologists from 18 other hospitals provided scores for ASA‐PS for each scenario. Results Fifty anesthesiologists scored the ASA‐PS class. Between 66% and 90% of these anesthesiologists assigned the same ratings as the reference ratings for the individual scenarios. Inter‐rater reliability was assessed using Fleiss’ kappa (95% confidence interval) of 0.55 (0.54–0.56, P < 0.001) and an intraclass correlation coefficient (95% confidence interval) of 0.79 (0.63–0.93, P < 0.001). Conclusion The results of the present study revealed the consistency of ASA‐PS ratings between anesthesiologists for emergency gastrointestinal surgery. The ASA‐PS may serve as a reliable variable in the prediction rules for this field.

Background Surgical audit is an essential task for the estimation of postoperative outcome and comparison of quality of care. Previous studies on surgical audits focused on short-term outcomes, such as postoperative mortality. We propose a surgical audit evaluating long-term outcome following colorectal cancer surgery. The predictive model for this audit is designated as ‘Estimation of Postoperative Overall Survival for Colorectal Cancer (EPOS-CC)’. Methods Thirty-one tumor-related and physiological variables were prospectively collected in 889 patients undergoing elective resection for colorectal cancer between April 2005 and April 2007 in 16 Japanese hospitals. Postoperative overall survival was assessed over a 5-years period. The EPOS-CC score was established by selecting significant variables in a uni- and multivariate analysis and allocating a risk-adjusted multiplication factor to each variable using Cox regression analysis. For validation, the EPOS-CC score was compared to the predictive power of UICC stage. Inter-hospital variability of the observed-to-estimated 5-years survival was assessed to estimate quality of care. Results Among the 889 patients, 804 (90 %) completed the 5-years follow-up. Univariate analysis displayed a significant correlation with 5-years survival for 14 physiological and nine tumor-related variables ( p  < 0.005). Highly significant p -values below 0.0001 were found for age, ASA score, severe pulmonary disease, respiratory history, performance status, hypoalbuminemia, alteration of hemoglobin, serum sodium level, and for all histological variables except tumor location. Age, TNM stage, lymphatic invasion, performance status, and serum sodium level were independent variables in the multivariate analysis and were entered the EPOS-CC model for the prediction of survival. Risk-adjusted multiplication factors between 1.5 (distant metastasis) and 0.16 (serum sodium level) were accorded to the different variables. The predictive power of EPOS-CC was superior to the one of UICC stage; area under the curve 0.87, 95 % CI 0.85–0.90 for EPOS-CC, and 0.80, 0.76–0.83 for UICC stage, p  < 0.001. Quality of care did not differ between hospitals. Conclusions The EPOS-CC score including the independent variables age, performance status, serum sodium level, TNM stage, and lymphatic invasion is superior to the UICC stage in the prediction of 5-years overall survival. This higher accuracy might be explained by the inclusion of physiological factors, thus also taking non-tumor-associated deaths into account. Furthermore, EPOS-CC score may compare quality of care among different institutions. Future studies are necessary to further evaluate this score and help improving the prediction of long-term survival following colorectal cancer surgery.