Perioperative corticosteroid supplementation therapy is considered as the standard of care for patients with steroids＜12 months before surgery. However, there is no biochemical or clinical evidence to support this therapy. The aim of this study was to evaluate the necessity of not perioperative corticosteroid supplementation therapy in patients with ulcerative colitis undergoing ostomy closure. A total of 43 patients with ulcerative colitis who underwent sur-gery at our institution between July 2015 and June 2018 were included. The median total steroid dose was 8,000mg (1,000～35,000mg), and median steroid free duration was 43 days (2～166 days). Early morning cortisol levels ＜18μg/dL was found in 41 (95.3%) patients. A peak cortisol response of the High Dose Adrenocorticotropic Hor-mone (ACTH) stimulation test ＜18μg/dL was found in 7 (17.1%) patients. This 7 patients received further evalu-ation and were denied secondary adrenal insufficiency. There were no patients who had acute adrenal insufficiency or adrenal crisis after stoma closure. In the case of steroid-treated patients with ulcerative colitis who underwent 2-staged surgery, it was suggested that perioperative corticosteroid supplementation therapy may not be necessary if off steroids at the time of ostomy closure.

Purpose: To elucidate risk factors on the onset of Pneumocystis Pneumonia (PCP) in patients with ulcerative colitis (UC) treated by immunosuppressants. Materials & Methods: Of the 1,669 patients with UC during 2007 to 2017, 70 patients experienced pneumonia including that 9 patients experienced PCP. Retrospective case-control study was conducted using PCP group (n=9) and non-PCP group (n=36). Results: Two patients in PCP group died. Age and dose of prednisolone (PSL) mg/day were significantly greater (P=0.02 and P=0.002, respectively), three im-munosuppressants were significantly moreused (P=0.004), and the count of lymphocytes during treatment was significantly less (P＜0.001) in PCP group than in non-PCP group. The cut-off counts of lymphocytes were 570/μL, according to ROC analysis. Conclusion: Senior age, greater dose of PSL (mg/day), less counts of lymphocytes dur-ing treatment were risk factors of the onset of PCP. Prophylactic medicine of sulfamethoxazole/trimethoprim should be used for UC patients with risk factors.

Infection and malnutrition are often associated with patients undergoing livertransplantation (LT) . We clarified that preoperative malnutrition was an independent risk factor for sepsis, and death due to infection after LT. There-fore, perioperative nutritional intervention is crucial to improve outcomes after LT. In the present review article, we would like to introduce our efforts to reduce infection and improve outcomes after LT focusing on nutrition and body composition. We established bundled strategy against postoperative infection LT consisting of 4factors: 1) Revised criteria for LT, 2) Increased hand hygiene compliance rate and contact precautions, 3) Aggressive periop-erative nutritional and rehabilitation intervention, and 4) Procalcitonin measurement for more precise determination of bacterial infection. After implementation of this bundled strategy, incidence ofbacteremia (P=0.02), detection rate of multiple bacteria (P=0.01) and deaths from infections (P=0.04) were significantly reduced. Most recently, we have implemented new criteria for LT considering body composition：to exclude patients who have low skeletal muscle mass, muscle steatosis, and visceral adiposity together. After implementation of the new criteria, 1-year overall survival was 98％. In conclusion, the bundled strategy and new criteria for LT considering body composition are useful in preventing infections and lengthening overall survival after LT.

Although various medical treatments are recently available for patients with inflammatory bowel disease, some pa-tients remain refractory to current therapeutic strategies such as systemic steroid treatment, immunosuppresives, or treatment with biologics. High-dose perioperative steroids were previously considered the standard of care for steroid-treated patients undergoing major colorectal surgery but it is recently considered doses of steroids in the perioperative period should be determined based on the magnitude of surgical stress. Surgery for inflammatory bowel disease is frequently performed in patients with factors suspected of increasing the risk of postoperative com-plications especially postoperative infectious complications, such as concomitant active inflammation, impaired nutri-tional status, and chronic therapy with immunosuppressives. Many studies reported preoperative use of high dose of steroids in patients with inflammatory bowel disease undergoing abdominal surgery is associated with an increased risk of postoperative complications.

In the treatment of inflammatory bowel disease, various types of immunosuppressive therapies are performed. Post-operative infectious complications may become a problem in IBD patients receiving immunosuppressive therapies. Many studies have been carried out about the influence of these immunosuppressive therapies on early postopera-tive complications. Postoperative complications after surgery for IBD are not associated with the use of azathio-prine/6-mercaptopurine or calcineurin inhibitors, but are associated with the steroid use and prolonged medical therapy before surgery. Increasing preoperative serum anti-TNFalpha antibody levels are associated with postop-erative complications in Crohn disease patients, but not in ulcerative colitis patients. As for the other biological and molecular-targeted therapies, there are few studies about the association of these therapies and postoperative com-plications. In perioperative management of the patients with IBD receiving immunosuppressive therapies, it is im-portant to perform adequate preventive measures including preoperative oral administration of antibiotics for the prevention of SSI. In addition, the prevention of opportunistic infection such as pneumocystis pneumonia by adminis-tration of trimethoprim-sulfamethoxazole is also important.

Several aspects regarding perioperative management in kidney transplantation should be carefully considered, but the following three points need special attention: ① surgery performed under immunosuppressive therapy; ② sur-gery in patients with renal failure; and ③ acute rejection. Attention should be paid to infections because the im-mune function is suppressed by using an immunosuppressive agent. Prevention of infection is important because in-fections tend to become severe once they occur and may cause acute rejection. Both donors and recipients should be screened for infection prior to surgery, and it is important to focus on vaccination as much as possible. Patients with renal insufficiency (especially those who undergo living donor kidney transplants) suffer from diuresis relative-ly early after undergoing renal transplant surgery. Systemic management, including the control of blood pressure, is necessary, and the volume of urine output should be maintained with sufficient replacement fluid. The occurrence of acute rejection has decreased in recent years due to the advances in immunosuppressant therapy. However, renal transplantation in patients with high immunologic risk is still being carried out, and rejection is still an important as-pect of renal transplant surgery. Successful survival without any surgery will greatly affect the prognosis of the transplanted kidney; therefore, it is necessary to familiarize oneself with complications such as infections specific to transplant and acute rejection in order to manage unexpected events that may occur with immunosuppressive therapy.

We report a very rare case of amoebiasis, presenting with acute appendicitis and liver abscess. A 45-year-old man visited a nearby hospital because of fever and was administered oral antibiotics for 5 days. But his fever did not re-lieved and he was referred to our hospital. On admission, his temperature was 38.1 degree with elevation of white blood-cell count and serum CRP. CT scan showed a swelling and wall enhancement of appendix and a low density mass, 60 mm in diameter, in the anterior-superior segment of the liver. We started an intravenous administration of SBT/CPZ with a diagnosis of acute appendicitis and subsequent abscess of the liver. Dspite of administration of anti-biotics, his fever continued and we changed SBT/CPZ to TAZ/PIPC and performed echo-guided drainage of the liver abscess on hospital day 4. However, his fever never subsided, therefore, we performed laparoscopic appendec-tomy on hospital day 6 and started an oral administration of metronidazole 1.5 g a day since hospital day 7, doubting an amoebic infection. Anti-amoebic therapy immediately achieved an alleviation fever and we stopped metronida-zole in 10 days. He was discharged on hospital day 18. Amoebiasis was proved by blood examination of antibody ti-ter and pathological examination of appendix.

An 84-year-old woman was admitted for abdominal pain with high fever. Abdominal CT revealed a liver abscess which contained gas in the right hepatic lobe. Moreover, massive ascites and free air were present in the abdominal cavity. Based on those findings, we suspected diffuse peritonitis due to gastrointestinal perforation and liver abscess. Thus, emergency operation was performed. A ruptured abscess was recognized in the segment 8 of the liver with-out perforated intestine. Thus, peritoneal lavage and drainage were performed. Bacterial examination of the abscess demonstrated Klebsiella pneumoniae. The patient received intensive care after surgery due to septic shock, and recov-ered gradually despite recurrence liver abscess of in same location, and was discharged on the 67th day after the operation. It is important to consider perforated liver abscess as a differential diagnosis of peritonitis with free air.