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Frequentist meta-analyses have demonstrated that immunoenhancing parenteral nutrition (IMPN) and enteral nutrition (IMEN) reduce the incidence of infection and shorten the length of hospital stays compared with standard parenteral nutrition (SPN) and enteral nutrition (SEN). The aim of this study was to evaluate which kind of nutrition-SPN, SEN, IMPN, and IMEN-is most efficacious for reducing the incidence of complications after gastrointestinal surgery.An English literature search was carried out for randomized controlled trials published from January 1990 to February 2013 that evaluated the clinical efficacy of 4 kinds of nutrition after gastrointestinal surgery. A Bayesian framework was used to calculate the odds ratio between each treatment and the rank order.Seventy-four studies (7572 participants) were included. According to the surface below the cumulative ranking curve (SUCRA) ordering from the best to the worst, IMEN was ranked first for reducing the incidence of 7 complications-any infection (SUCRA = 0.86), overall complication (SUCRA = 0.88), mortality (SUCRA = 0.81), wound infection (SUCRA = 0.79), intra-abdominal abscess (SUCRA = 0.98), anastomotic leak (SUCRA = 0.79), and sepsis (SUCRA = 0.92). Also, IMEN was ranked second for pneumonia and urinary tract infection. IMPN was ranked first for pneumonia (SUCRA = 0.81) and urinary tract infection (SUCRA = 0.86), third for mortality, and fourth for both intra-abdominal abscess and anastomotic leak. SPN showed an inferior efficacy for almost all outcomes.This study suggests that IMEN outperformed other nutrition types for reducing complications and IMEN should be considered the best available option.

Background The efficacy of antibiotic prophylaxis for the prevention of surgical-site infection (SSI) after open tension-free inguinal hernia repair remains controversial. Methods A double-blind, randomized, placebo-controlled trial was conducted. Patients who underwent elective open mesh-plug hernia repair were eligible for randomization. In the antibiotic prophylaxis group, 1.0 g cefazolin was intravenously administrated 30 minutes before the incision. In the placebo group, an equal volume of sterile saline was administered. The primary end point was the incidence of SSI. Results A total of 200 patients were enrolled. SSI developed in 2 of 100 patients (2%) in the antibiotic prophylaxis group and 13 of 100 patients (13%) in the placebo group, indicating a significant difference between the 2 groups (relative risk ratio, 0.25; 95% confidence interval, 0.070 to 0.92; P = .003). Other complications occurred in 23 patients: 7 (7%) in the antibiotic prophylaxis group and 16 (16%) in the placebo group ( P = .046). Conclusions This study indicates that antibiotic prophylaxis is effective for the prevention of SSI after open mesh-plug hernia repair.

Increasing evidence suggests that variants of common and low-penetrance genes are involved in pancreatic cancer (PC) carcinogenesis. We undertook a meta-analysis of published studies to assess evidence regarding the risk associated with these genes. Medline, Web of Science, ProQuest, Google Scholar, and international conference proceedings were searched and citations in relevant primary and review articles were collected. The studies that we considered eligible included all reports that investigated an association between genetic polymorphisms and PC. We identified 23 studies that evaluated the risk effects on PC of common alleles for 13 gene polymorphisms. A significant association was recognized between ALDH 2*1*2 polymorphisms and PC [odds ratio (OR) = 1.37, 95% confidence interval (CI) = 1.07-1.75, P = 0.01] based on only two studies. Although the overall results for MTHFR T677T are negative, sensitivity analysis stratified by ethnic background showed a significant association between Caucasian and MTHFR T677T polymorphisms and PC (OR = 1.66, 95% CI = 1.10-2.52, P = 0.02). The risk for PC was higher in individuals with MTHFR C677T or TT polymorphisms and a smoking habit (OR = 2.52, 95% CI = 1.05-6.09, P = 0.04). These findings lead us to support the hypothesis that MTHFR T677T and ALDH 2*1*2 polymorphisms may play a carcinogenetic role in PC and represent the candidates for low-penetrance susceptibility alleles identified to date. Although their genetic risks are modest, the high frequency in the population shows that they may have a considerable impact on the incidence of PC. Definite conclusions will be contingent on studies with a larger sample size that determine the risk estimates associated with other variants, gene-gene, and gene-environment interactions.

BACKGROUND AND STUDY AIMS: Pancreatitis is one of the most frequent complications of endoscopic retrograde cholangiopancreatography (ERCP). The placement of a prophylactic pancreatic stent after ERCP can help prevent post-ERCP pancreatitis (PEP). We aimed to provide an up-to-date meta-analysis regarding pancreatic stent placement for prevention of PEP and review the immediate adverse events associated with pancreatic stent placement. METHODS: We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) considering pancreatic stent placement and the subsequent incidence of PEP. The primary outcome measure was the incidence of PEP. We also did a meta-analysis of RCTs and observational studies that reported on immediate adverse events, in order to estimate their incidence. RESULTS: Eight studies, involving 680 patients, were included in the meta-analysis; 336 patients had pancreatic stent placement, and 344 patients formed the control group. Pancreatic stent placement was associated with a statistically significant reduction in PEP (relative risk [RR] 0.32, 95 % confidence interval [CI] 0.19 - 0.52; P < 0.001). Subgroup analysis with stratification according to PEP severity showed that pancreatic stenting was beneficial in patients with mild to moderate PEP (RR 0.36, 95 %CI 0.22 - 0.60; P < 0.001) and in patients with severe PEP (RR 0.23, 95 %CI 0.06 - 0.91; P = 0.04). Subgroup analysis according to patient selection demonstrated that pancreatic stenting was effective for both high risk and mixed-case groups. Weighted pooled estimates from between one and 17 studies for incidences of immediate adverse events were: overall complications 4.4 %; any infection 3.0 %; bleeding 2.5 %; cholangitis or cholecystitis 3.1 %; necrosis 0.4 %; pancreatic stent migration 4.9 % and occlusion 7.9 %; perforation 0.8 %; pseudocysts 3.0 %; and retroperitoneal perforation 1.2 %. CONCLUSIONS: The meta-analysis shows that pancreatic stent placement after ERCP reduces the risk of PEP.

症例は80歳，女性．既往歴に特記すべきことなし．前日の午後10時より腹部膨満・腹痛・嘔吐が出現した．腹部CT検査で大腸の著明な拡張を認めたが，大腸内視鏡では閉塞の原因は認めなかった．禁飲食・補液による保存的治療を継続したが改善せず，血圧低下・意識障害が出現しショックとなったため当科に転院となった．注腸造影でも通過障害や穿孔の所見は認めなかったが，ショックを呈していたため緊急手術を行った．開腹所見では盲腸から下行結腸まで著明な拡張を認めたが，S状結腸や直腸に病変は認めず，横行結腸に双孔式人工肛門を造設した．術後，人工肛門による減圧は良好で第19病日に退院した．人工肛門から腸管全層の病理組織診断を行ったが神経叢に異常はなかった．急激に発症し緊急手術を必要とする腸閉塞の原因として，急性大腸偽閉塞症を考慮する必要があると考えられた．

症例は68歳，男性．10年前より左鼠径部ヘルニアを認め，用手還納していた．起床後にヘルニアの脱出を認め，還納したところ直後より腹痛が出現した．当科を受診し腹部CTでfree airを認め，消化管穿孔の診断で緊急手術を行った．S状結腸穿孔で，同部を挙上して双孔式人工肛門を造設した．左鼠径ヘルニアは修復せずに洗浄のみを行った．第7病日にヘルニア嚢内に膿瘍を形成したため穿刺吸引した．第16病日にヘルニア膿瘍が再発したため，ペンローズドレーンを留置しドレナージを行った．その後は膿瘍の再発なく，ドレーンは退院後に外来で抜去した．術後から鼠径ヘルニアの脱出はなくなり，人工肛門閉鎖時の手術所見からヘルニア門にS状結腸が癒着したためと考えられた．鼠径ヘルニア合併の腹膜炎手術では術後ヘルニア膿瘍に留意すべきで，ヘルニア内のドレナージが重要である．本症例は術後のドレナージが有効であった．

71歳，男性．平成6年6月に直腸癌のため腹会陰式直腸切断術を受けている．術後再発徴候は無く，定期検診を続けていた．平成17年7月頃より人工肛門部からの出血が度々認められ，平成18年4月には，同部位に顆粒状の粘膜異常を伴う1.5cm大の粘膜下腫瘤を認めるようになったため，平成18年5月に腫瘍摘出術を施行した．病理組織学的診断では粘膜下に高度の炎症細胞浸潤を認め，結節状の腫瘤を形成していた．腫瘍性変化は認めず，炎症性偽腫瘍と診断した．直腸癌術後から隔日で洗腸を続けていたことが，炎症性偽腫瘍の原因になったと推察された．大腸原発の炎症性偽腫瘍では稀であり，人工肛門部での発症例はこれまでに報告がない．

子宮広間膜裂孔ヘルニアは稀な疾患である．本邦 79 例の集計とともに，若干の文献的考察を加え報告する．症例は 40 歳女性．腹痛と嘔吐を主訴に近医を受診，イレウスの診断で当院紹介となった．入院時骨盤 CT にて骨盤内に拡張した小腸と少量の腹水を認めイレウスの診断で保存的加療を行った．入院 2 日目にイレウス症状の増悪を認めたため再度骨盤 CT 施行，子宮左側に小腸の狭窄像を認めたため，内ヘルニアによる絞扼性イレウスと診断，緊急手術を施行した．開腹所見では，左子宮広間膜に約 3 cm 大の裂孔を認め，回腸末端から約 90 cmの回腸が約 90 cm にわたり陥入し，絞扼されていた．絞扼を解除し，壊死小腸を約 100 cm 切除，裂孔を単純閉鎖し手術を終了した．術後経過は順調で，術後 10 日目に軽快退院となった．

Background Efficacy of antibiotic prophylaxis for the prevention of surgical site infection (SSI) after open tension-free hernia repair remains controversial. In light of additional data, the aim of this study was to determine whether antibiotic prophylaxis reduces SSI after hernia repair. Study Design We conducted a systematic review and meta-analysis to identify randomized controlled trials comparing antibiotic prophylaxis and the subsequent incidence of SSI after inguinal or femoral hernia repair. The primary outcomes measure was the incidence of SSI. Subgroup analysis was evaluated by stratifying the categories of SSI. The meta-analysis was performed using Bayesian and frequentist methods. Results Twelve studies were included in this meta-analysis; 1,902 patients received antibiotic prophylaxis and the other 1,936 patients were allocated to the control group. Incidence of SSI was 47 (pooled rate 3.0%) in the antibiotic group and 91 (6.0%) in the control group. The number needed to treat to prevent 1 episode of SSI is 41. The Bayesian meta-analysis yielded a significant reduction of SSI in the antibiotic group (odds ratio = 0.49; 95% credible interval 0.25–0.81). Subgroup analysis showed that an antibiotic prophylaxis was beneficial for the prevention of superficial SSI (odds ratio = 0.40; 95% credible interval 0.12–0.98), but not beneficial for prevention of deep SSI (odds ratio = 0.59; 95% credible interval 0.11–3.20). Also, the results were similar to those with frequentist methods. Conclusions This meta-analysis suggests that antibiotic prophylaxis is efficacious for the prevention of SSI after open mesh hernia repair.

Pancreatitis is one of the most frequent post-endoscopic retrograde cholangiopancreatography (ERCP) complications. Previous meta-analyses show that prophylactic pancreatic stent (PS) placement after ERCP is beneficial for the prevention of post-ERCP pancreatitis (PEP). However, the results of these meta-analyses are controversial due to the limited sample size of the eligible studies, in which six additional randomized controlled trials (RCTs) are not included. Our aim is, therefore, to update the current meta-analyses regarding PS placement for prevention of PEP. We conducted a meta-analysis to identify RCTs comparing PS placement and the subsequent incidence of PEP. The primary outcome was the incidence of PEP. Fourteen studies were enrolled in this meta-analysis. Of the 1,541 patients, 760 patients received a PS and 781 patients were allocated to the control group. PS placement was associated with a statistically significant reduction of PEP [relative risk (RR) 0.39; 95 % confidence interval (CI) 0.29–0.53; P

壊死型虚血性大腸炎2例を報告する.症例1は64歳の男性.症例2は60歳の女性であった.2例とも腹膜刺激症状を認め, 基礎疾患に症例1は肝硬変症, 症例2は慢性腎不全を有していた.注腸造影, 超音波検査, computed tomography (CT) にて壊死型虚血性大腸炎と診断し, 症例1に右半結腸切除術, 症例2に左半結腸切除術, 横行結腸人工肛門造設術を施行した.組織学的に症例1は粘膜固有層の壊死, 粘膜下膿瘍および漿膜下組織に及ぶ強い炎症細胞浸潤, 症例2は腸管全層壊死を認めた.症例1は軽快退院したが, 症例2は術後人工肛門壊死, 腹膜炎を合併し術後肺炎にて死亡した.本症は早期診断, 手術時期を逸しない事が重要であり, 基礎疾患を有することが多いため術後管理に留意しなくてはならない.

We report three cases with liver metastasis from gastric or colon cancer successfully treated with S-1 with CPT-11. Case 1: A total gastrectomy was performed for a gastric cancer located in the lower to upper body of the stomach (T3 (SE), N2, H0, P0, por 2, stage III B). Abdominal computed-tomography (CT) revealed a solitary liver metastasis in the S8 subsegment of the liver. We treated the patient with S-1 combined with CPT-11. Abdominal CT revealed a complete response (CR) after 5 courses. Case 2: Sigmoidectomy and partial resection of small intestine and abdominal wall were performed for sigmoid colon cancer. The intraoperative findings revealed liver metastases in left lobe of the liver (Si, N1, H1, P0, M0, tub 1, stage IV). After surgery, the patient was treated with S-1 combined with CPT-11. Abdominal CT demonstrated CR after 5 courses. Case 3: Laparoscopic right hemicolectomy was performed for ascending colon cancer (SE, N1, H0, P0, M0, tub 1, stage III a). Abdominal CT showed a solitary liver metastasis in the S6 subsegment of the liver 3 months after surgery. We treated the patient with S-1 combined with CPT-11. Abdominal CT revealed CR after 3 courses. The three cases are alive without any signs of recurrence.

Although previous studies recommend the use of enteral nutrition (EN), the benefit of EN after elective gastrointestinal surgery has not been comprehensively demonstrated as through a meta-analysis. Our aim is to determine whether enteral nutrition is more beneficial than parenteral nutrition. A search was conducted on Medline, Web of Science, the Cochrane Library electronic databases, and bibliographic reviews. The trials were based on randomization, gastrointestinal surgery, and the reporting of at least one of the following end points: any complication, any infectious complication, mortality, wound infection and dehiscence, anastomotic leak, intraabdominal abscess, pneumonia, respiratory failure, urinary tract infection, renal failure, any adverse effect, and duration of hospital stay. Twenty-nine trials, which included 2,552 patients, met the criteria. EN was beneficial in the reduction of any complication (relative risk (RR), 0.85; 95% confidence interval (CI), 0.74–0.99; P = 0.04), any infectious complication (RR, 0.69; 95% CI, 0.56–0.86; P = 0.001), anastomotic leak (RR, 0.67; 95% CI, 0.47–0.95; P = 0.03), intraabdominal abscess (RR, 0.63; 95% CI, 0.41–0.95; P = 0.03), and duration of hospital stay (weighted mean difference, −0.81; 95% CI, −1.25–0.38; P = 0.02). There were no clear benefits in any of the other complications. The present findings would lead us to recommend the use of EN rather than PN when possible and indicated.

Background An oral combined fluoropyrimidine anticancer drug, tegafur/gimeracil/oteracil potassium (S-1), has recently been used alone or in combination for colon cancer. Case presentation The patient was a 42-year-old man with sigmoid colon cancer with direct invasion of the urinary bladder and multiple costal metastases. A diagnosis of T4, M1, stage IV sigmoid colon cancer was made, and curative resection was considered impossible. S-1 at 50 mg/m2 was administered by oral route from day 1 to day 14. Irinotecan (CPT-11) at 40 mg/m2 was administered by intravenous day 1 and 15. This treatment was followed by 2 weeks absent period, and repeated every 4 weeks. Six cycles of administration were performed in total. Following this treatment, the multiple costal metastases resolved. Down-staging to T3, M0, stage IIA was achieved, and curative resection was judged to be possible. Conclusion Occasional cases in which S-1/CPT-11 therapy was effective have been recently reported. The patient's tumor became resectable despite the discovery of colon cancer associated with bone metastasis at the initial examination, offering hope for cancer patients.

A 78-years-old man presented with right lower quadrant pain for 2 months. Computed tomography revealed an irregular and multicystic mass near the cecum like as appedeceal mucocle. The lesion was diagnosed xanthogranulomatous appendicitis by histopathological findings of surgical specimen. Xanthogranuloma is uncommon disease, especially in the appendix. We report an interesting case of xanthogranulomatous appendicitis mimicking appendiceal mucocele in radiological images.

Sarcoma of the breast constitutes1% of all malignant breast tumors, and liposarcoma of the breast represents 3-24% of the primary breast sarcomas. We report a case of a 74-year-old woman presenting with liposarcoma of the left breast. The patient presented with a fibrous and hard mass measuring approximately 10 x 5 cm in diameter in the upper part of the left breast. Aspiration breast cytology showed inflammatory changes and had no malignant element. Differential diagnosis with sonography, computed tomography, and magnetic resonance imaging was not successful. A wide excision was performed with a 2-cm margin of healthy tissue. The tumor was diagnosed histologically as a well-differentiated liposarcoma (sclerosing type). The patient was discharged and her recovery was uneventful. We report a case of liposarcoma of the breast and discuss this rare malignant tumor and other types of sarcoma of the breast in light of the previously published literature.

A pheochromocytoma is a rare tumor derived from the adrenal medulla (or from chromaffin cells of sympathetic ganglia). Its symptoms derive mostly from the excessive release of catecholamines (adrenaline and noradrenaline). Hypertension is the most recognized feature of this disease, but gastrointestinal manifestations can on rare occasions be just as serious and life threatening. This report describes a rare case of a 70-year-old woman with pheochromocytoma who developed an acute abdominal emergency with shock and panperitonitis as a result of perforation of the descending colon which was effectively treated by surgical removal of the tumor and the perforated colon. There have been 2 such cases in the English literature in whom a pheochromocytoma was associated with perforation of the colon. Successful surgical removal of such a pheochromocytoma has been not reported previously. Our case demonstrates the importance of recognizing that a pheochromocytoma presents with a wide spectrum of manifestations, and rapid treatment brings improvement to the patient.