＜Aim＞ To reveal current cholecystitis with positive bacterial culture, cases with acute cholecystitis were surveyed. ＜Material and methods＞ Twenty -eight cases treated cholecystectomy and percutaneous transhepatic gallbladder aspiration/drainage (PTGBA/D) were investigated on the viewpoints of medical history, grade of cholecystitis, bacterial infection, antibiotics, clinical course, and prognosis. <Results> The cases consisted of 20 men and 8 women, average age was 70-year-old, and 12 cases had serious medical history. Cholecystitis grade of the cases is composed of 6 mild, 14 moderate, and 8 severe cases, and mean hospitalization was 27 days. Two cases complicated surgical site infection, one sepsis, and one portal thrombosis. Although all cases were alive, 5 cases became lower activities of daily living. Seventeen patients presented positive biliary culture of enterobacteria（E. coli, Enterococcus, Enterobacter, Klebsiella, and Clostridium). Nine cases had multidrug-resistant bacterium, and 7 cases were initially administrated ineffective antibiotics for the bacteria. Correlations between strain of bacterium, age, past illness, postoperative complication, and hospitalization were examined, and correlation between serious medical history and multi-drug-resistant bacterium was demonstrated. <Conclusion> More than half of the total cases suffering from cholecystitis had multidrug -resistant bacteria. This indicates that early cholecystectomy or PTGBA/D might provide better prognosis than empiric antibiotics.

[Introduction] Based on the analysis of SSI surveillance, the effect of closed subcutaneous drainage and skin adhesive added to subcuticular suture for wound closure in a surgery with stoma creation on the prevention of incisional SSI was investigated. [Patients and method] Seventy six patients who underwent surgery with stoma creation since 2012 were enrolled. As measures for SSI prevention subcutaneous high pressure lavage was started from the beginning of surveillance, subcuticular suture was added since 2014 and closed subcutaneous drain plus tissue adhesive were added from April 2015. [Results] Median age of patients was 70 (32-94) year old including 52 males and 24 females. The median operation time was 132.5 minutes. There were 28 cases with ASA 3 or more, 23 cases with risk index 2 or more, 31 cases with wound classification 3.4, and 34 cases with emergency operation. There were 47 cases after the induction of subcuticular suture and 18 cases after the addition of subcutaneous drain plus tissue adhesive. The incidence of incisional SSI was 31.6% in all cases. Factors of Wound classification 3.4, ASA 3 or more, risk index 2 or more and emergency operation were not significant risk factors. Since the incidence of incisional SSI in a period before induction of subcuticular suture was 41.4%, 34.5% in a period before induction of subcutaneous drain plus tissue adhesive after subcuticular suture, and 11.1% in a period after subcutaneous drain plus tissue adhesive, the incidence tended to decrease. The incidence of incisional SSI was not significant in the patients with or without subcuticular suture, however incidence was significantly lower with subcutaneous drain plus tissue adhesive (P＝0.0220). [Conclusions] By the analyses of SSI surveillance, closed subcutaneous drainage and skin adhesive added to subcuticular suture might be considered to be a good wound closure for prevention of incisional SSI in a surgery with stoma creation at the present time.

Despite various measures to prevent surgical site infection (SSI), the incidence of SSI remained high in patients undergoing colorectal surgery. We reviewed the records of the patients who underwent lower gastrointestinal surgery at our hospital between April 2012 and March 2016 and identified the following five risk factors for SSI: female sex, wound class ≥3, open surgery, emergency surgery, and colostomy. We then discussed measures to control these risk factors with our staff members involved in the perioperative management of patients and developed/introduced a preventive SSI bundle. The incidence of SSI in patients who underwent lower gastrointestinal surgery decreased from 26.5％ before introduction of the bundle (from April 2012 to March 2016) to 18.2％ thereafter (from April 2016 to March 2017) (P=0.07). This reduced incidence of SSI was achieved by identifying the risk factors for SSI and developing/introducing a preventive SSI bundle to control the risk factors.

We retrospectively assessed the effect of compliance of hand hygiene guideline in health-care settings in the operation room to reduce the surgical site infection (SSI) rate in 706 patients who underwent operation of appendix, liver, bile ducts, gallbladder, pancreas, colorectum, small bowel, and stomach at Saiseikai Kurihashi Hospital from 2011 to 2014. The frequency of SSI was 17.7％ (SSI group: 125 cases; Non-SSI group: 581 cases). We compared fifteen risk factors for SSI (patient's age, sex, Body Mass Index, preoperative and postoperative serum albumin level, estimated blood loss, wound classification, American Society of Anesthesiologists-physical status classification, duration of operation, endoscopic operation, emergency operation, multiple organ operation, colostomy, subcuticular suture, and compliance of hand hygiene guideline in health-care settings) between the groups. The logistic regression analysis indicated that patient's age, postoperative serum albumin level, wound classification greater than 2, and endoscopic operation were significant risk factors for SSI (OR 0.475～2.251, P＜0.05). In addition, we found that compliance of hand hygiene guideline in health ─care settings could decrease the frequency of SSI after abdominal surgery (OR 0.659, P=0.051).

【Background】Since July 2011, we have used low-pressure vacuum drain after gastrectomy with lymph nodes dissection for gastric cancer to reduce intraabdominal postoperative complication. 【Method】We evaluated the efficacy of drainage for prevention and therapy of postoperative intraabdominal complications in previous open drainage group (n=1,399) and in low-pressure vacuum drain group (n=1,071) . Amylase concentration in the drainage fluid (D-AMY) was measured on the third postoperative day in low-pressure vacuum drain group (n=173) to diagnose the pancreatic fistula (PF) .【Result】There was no significant difference in the ratio of anastomosis leakage and postoperative bleeding between open drainage group and low─pressure vacuum drain group, but PF amounting to Clavien-Dindo (CD) gradeⅢ were reduced to 2.0％ from 7.1％. The multivariate analysis indicated that man, obesity, total gastrectomy, splenectomy, and intraoperative bleeding were significant risk factors for CD gradeⅢ PF in open drainage group, while intraoperative bleeding and laparoscopic surgery were significant risk factors in low- pressure vacuum drain group. Median vale of D-AMY was 176 IU/L (range21-40,962) . PF amounting to CD gradeⅠ (D-AMY＞375IU/L) were observed in 26.6％. There was relationship between D- AMY and CD gradeⅢ PF. 【Conclusion】The low-negative-pressure drain can be considered a useful method to prevent PF and pancreatitis after gastrectomy with lymph nodes dissection for gastric cancer. Drainage might be especially important in case of large amount of intraoperative bleeding. D-AMY is useful predictive risk factor for PF.

Background: Many studies have reported that prophylactic abdominal drainage is unnecessary after liver resection, but it is required in some cases. This study aimed to elucidate risk factors for abdominal drainage after liver resection. Methods: This study included 182 patients who underwent liver resection for hepatocellular carcinoma. We compared clinical outcomes between patients with abdominal drainage (drainage group, n=110) and those without (non-drainage group, n=72). A total of 20 patients (drainage group: 12 in whom it was difficult to remove the drain and six in whom a drain was reinserted; non-drainage group: two in whom a drain was inserted) were included in the drain necessary group versus 162 in the drain unnecessary group. We analyzed the risk factors for abdominal drainage. Results：In the drainage group, anatomical hepatic resection was performed significantly more frequently (61％ vs 44％, P=0.034), operative time was significantly longer (344 vs 264.5min, P=0.004), and operative blood loss was significantly greater (879.5 vs 328mL, P<0.001). Complications occurred in 22 patients (20％) of the drainage group (P=0.008). In the drain necessary group, preoperative aspartate transaminase (AST) and total bilirubin levels were significantly higher (44.0 vs 31.5IU/L, P=0.031; 1.0 vs 0.8mg/dL, P=0.050), as was the American Society of Anesthesiologists Physical Status (ASA-PS) (P=0.043). Furthermore, in the drain necessary group, hemi-hepatectomy was performed significantly more frequently (55％ vs 23％, P=0.005), operative time was significantly longer (404 vs 288min, P<0.001), and operative blood loss was significantly greater (1293 vs 532mL, P<0.001). Multivariate analysis indicated that ASA-PS (Class 3), elevated AST, and massive blood loss were risk factors for abdominal drainage (P=0.045, 0.040, and 0.029, respectively). Conclusions: outine use of abdominal drainage is unnecessary, but it is likely necessary in cases of high ASA-PS, liver dysfunction, longer operation time, or massive blood loss.

【Aim】The aim of this study was to evaluate characteristics of the patients who required invasive drainage after pancreaticoduodenectomy (PD), and to analyze the risk factors for postoperative pancreatic fistula (POPF).【Meth-od】There were 205 patients undergoing PD at our institution, between January 2015 and December 2017. Subtotal stomach preserving PD and modified Child reconstruction were generally performed. Closed suction drains were placed near the pancreatic and biliary anastomosis. Drains were kept placed ＞5 days if infection or major leak was suspected.【Result】There were 44 patients who required exchange or addition of drain (s). Among them, there were 35 patients with POPF grade B and no patients with grade C. Only in the soft pancreas cases, drain amylase (D-AMY)>800 IU/L on the 3rd postoperative day was an independent risk factor for POPF grade B. 【Conclusion】 Majority of the patients who required invasive drainage after PD had POPF grade B. Soft pancreas and D-AMY were risk factors for POPF grade B. It is important to manage drains carefully, in consideration of the risk for POPF, including D-AMY value, and to avoid critical complications after PD.

Many of the current esophageal surgeries are esophagectomy followed by reconstruction with lymphadenectomy for cancer. With the spread of minimal invasive esophagectomy, various approaches and reconstruction methods are adopted depending on facilities and surgeons. However, there is less opportunity for intraoperative bacterial contamination. Drainage is generally placed mainly in the chest and neck, at sites of anastomosis of esophageal reconstruction and lymphadenectomy performed. Since the sites for drainage are continuous with the thoracic cavity after surgery, closed-type drains are usually placed with negative pressure management. After esophagectomy, most drains are at first used for preventive/diagnostic purposes, but proper placement and management is important in case of treatment for the onset of postoperative infectious complications. However, there is no definitely the best of drainage due to the diversity of the operative procedures, and we should establish our own proper usage method based on the results at each facility. Recently, new drainage systems that are thinner, smaller and lighter are available and novel drainage methods have been reported, along with the progress of surgical techniques. Therefore, it is necessary to always think about better care of drainage which is safe and useful for early recovery after surgery.

Prophylactic drainage after hepatobiliary pancreatic surgery is thought to be useful for early diagnosis of postoperative bleeding and treatment of bile leakage and pancreatic fistula, but since drainage causes retrograde infection, its preventive benefit is still controversial. Here, we overview randomized controlled trials on drainage in hepatobiliary pancreatic surgery, and the usefulness of postoperative drain is discussed. Numerous trials have been conducted in the cholecystectomy, and the usefulness of postoperative drain was not recognized in both laparotomy and laparoscopic surgery. Even in hepatic resection surgery, there was no research that confirmed the usefulness of drain placement. However, because there is no study on hepatic resection with biliary tract reconstruction, the usefulness of drain is unknown. Regarding pancreatectomy, a randomized controlled trial of distal pancreatectomy concluded that drainage is unnecessary without any difference depending on the presence or absence of drain. There were two randomized controlled trials of pancreaticoduodenectomy, but the results were contradictory. At present, it seems unnecessary to carry out preventive drainage in cholecystectomy or hepatectomy without biliary tract reconstruction, but drainage placement might be useful for hepatectomy with biliary tract reconstruction and pancreatectomy.

Although insertion of a chest drainage tubes is considered to be an indispensable treatment after lung surgery, optimizing management of the chest drainage tubes is important since it causes pain and thus limit patient’s movements. Postoperative enhanced recovery protocols for lung lobectomy are yet to be established, but it is useful for standardization of perioperative management. Based on evidences we recommend the following seven issues for standardization of chest drainage tube management protocol. 1) Use of single chest drainage tube, 2) Not to use intra-pleural suction over water seal, 3) Selective use of chest X-rays in care of lung resection patients with chest drainage tubes, 4) Routine milking of chest drainage tubes is unnecessary, 5) Chest tubes can be removed safely with daily collection of pleural fluid at an amount of up to 5 times of body weight in 24 hours, 6) There is no difference in incidence rate of pneumothorax after removal of chest drainage tubes using Valsalva method either with inhalation or exhalation, 7） Digital chest drainage tubes can be evaluated and accordingly management can be optimized.

Between September 2012 and March 2016, we performed sutured omentoplasty (SOMP) in addition to closed suction drainage (CSD) (SOMP+CSD) in an attempt to reduce pelvic abscess and perineal wound infection after ab-dominoperineal resection (APR) . We performed SOMP when closing the perineal wound by passing the greater omentum on the left side and the gastrocolic ligament through the transverse mesocolon (adjacent to the ligament of Treitz) , and suturing the stump to the levator ani muscle group. As a rule, we removed the drain placed using a transperitoneal approach by postoperative day (POD)5. To assess surgical site infection (SSI) we adopted the cases in which APR had been performed (in all of which CSD had also been performed)in our department during the period from January 2003 to September 2011 (as a control group) for comparison. The overall SSI rate tended to be lower in the SOMP＋CSD group (n=30) than in the control group (n=37) (16.7% vs. 37.8%, P=0.06). No significant difference between the two groups was found in the rates of midline wound SSI (10.0% vs. 5.4%, P=0.65), perineal wound SSI (3.3% vs. 10.8%, P=0.37), or pelvic abscess (10.0% vs. 27.0%, P=0.12). Median drain removal time in the omentoplasty group was POD 4 (2～40), and in 70% of the cases it had been removed by POD 5. Based on the results of this study, by reducing perineal wound infection and pelvic abscess formation, SOMP＋CSD may prevent long-term drain placement after APR and reduce SSI as a whole. In the future it will be necessary to plan a randomized controlled study on a larger number of cases and prospectively assess the usefulness of SOMP+CSD, drain removal time, and ways of using antimicrobial agents.

Raoultella planticola (R. planticola) is an environmental microorganism inhabiting soil. R. planticola infection to normal immune patients is very rare. We report a case of R. planticola bacteremia of a normal immune patient. A 86 year-old man was admitted to our hospital complaining of abdominal distension, abdominal pain, and vomiting. Because a part of niveau was formed in an abdominal X-ray, We began conservative treatment as postoperative adhesive ile-us. Though the digestive symptom was rapidly improved, and the fever which accompanied the exothermic reaction with chills on 4th day of hospitalization appeared. The patient was treated with sulbacam/ampicillin, which was treated with cholangitis in the differential disease, because the gram-negative bacilli were recognized by blood culture microscopy. The antibiotic drug was de-escalated to cefazolin because of the pyretolysis fever on 6th day of hospitalization and R. planticola from blood culture. Change to cefaclor internal use, and the duration of antibiotic administration is 14 days. After that, fever and digestive symptoms have not been recognized.