The principle of empiric therapy for patients with intraabdominal infections (IAI) should include antibiotics with activity against Enterobacteriaceae and Bacteroides fragilis group species. Coverage of Psuedomonas aeruginosa, Enterobacter species is recommended for IAI with moderate severity and coverage of Enterococcus faecalis, and extended spectrum β-lactamase producing strains is suggested in critically ill patients. MEPM and DRPM and TAZ/PIPC are recommended for IAI with severe severity, CFPM＋MNZ and IPM/CS are recommended for IAI with moderate severity, and CTX/CTRX＋MNZ and CPFX＋MNZ were recommended for IAI with mild severity. A recent large andomized clinical trial of the treatment of complicated IAIs demonstrated that a fixed 4-day course of antibiotic therapy was as effective as a longer duration of therapy in patients who underwent adequate source control. Considering the poor prognosis and lack of clear evidence for shortening the duration of antibiotic therapy in critically ill patients or those with ongoing signs of sepsis, the duration of therapy for complicated IAIs should be determined individually according to the clinical course. Limiting therapy to no more than 7 days seems to be warranted in critically ill patients with a good clinical response.

【Purpose】Inflammatory bowel disease (IBD) patients have an increased risk of fungal infections owing to fungal translocation and a compromised host. We investigated the incidence of perioperative ocular candidiasis in cases of IBD. 【Method】Ulcerative colitis (UC) and Crohn disease (CD) patients who underwent a laparotomy at Hyogo College of Medicine between January 2010 and November 2016 were enrolled in this study. 【Result】Of 421 UC pa-tients, 5 (1.2％)had ocular candidiasis, while that was seen in 3 (0.7％) of 401 CD patients. All patients had a Cen-tral venous catheter. Fungal testing of blood cultures detected Candida albicans in 7 cases (87％). β.D glucan level was elevated in 6 (75％). 4 (50％) had no eye symptoms. There were 3 with endophthalmitis and 5 with chorioreti-nitis expanding to macula lutea. All patients were monitored by ophthalmologists and received intravenous flucon-azole, and no patients had fluconazole intravitreously or vitreous surgery. 【Conclusion】There were many progres-sive ocular candidiasis in IBD patients. It is important to perform in IBD patients with fungemia screening by ophthalmologists.

【Objective】We examined the effects of neoadjuvant therapy on the post-operative complications in patients with esophageal cancer underwent surgery.【Subjects and Methods】We performed retrospective evaluation of 99 pa-tients who underwent right thoracic esophagectomy between 2006 and 2011. Study groups were consisted of pa-tients without neoadjuvant therapy [surgery alone (SA）group], neoadjuvant chemoradiation therapy (NACRTgroup）, and neoadjuvant chemotherapy (NAC group). 【Results】The rate of postoperative complication was sig-nificantly higher in NACRT and NAC groups than in SA group. In particular, the proportion of severe pulmonary complications that required management on a ventilator.was significantly higher in NACRT and NAC groups than in SA group. PaO2/FiO2ratio (P/F）remained at lower values in the NACRT group compared with the other two groups. Preoperative serum cytokine (IL-10 and IL-6）and HMGB-1 value in patients with NACRT were signifi-cantly higher than those of SA group. 【Conclusion】Neoadjuvant therapy which might increase several mediators caused the postoperative morbidity such as serious respiratory complications in patients with esophageal cancer un-derwent thoracic esophagectomy. The perioperative countermeasures to prevent complications is warranted in these patients

【Aim】To examine the risk factors of perineal wound infection after abdominoperineal resection for rectal cancer. 【Methods】Sixty-one patients who underwent abdominoperineal resection for rectal cancer at our department from January 2005 to December 2017 were included. The incidence of perineal wound infection and risk factors were ana-lyzed. 【Results】Perineal wound infection occurred in 26 cases (43％) . Perineal wound infection more severe than grade Ⅲ (Clavien-Dindo classification) tended to occur more often in the open surgery group, but not to a signifi-cant degree. Among cases without lateral lymph node dissection, the incidence of perineal wound infection was sig-nificantly higher in cases with a high body mass index, open surgery, and massive intraoperative bleeding. Among cases with lateral lymph node dissection, the incidence was significantly high only in cases with preoperative chemo-radiotherapy. Among cases with preoperative chemoradiotherapy, only open surgery was detected as a risk factor in the multivariate analysis. All patients who required pelvic drainage for more than two months received preopera-tive chemoradiotherapy. 【Conclusion】The incidence of perineal wound infection was shown to be high when ab-dominoperineal resection was performed with lateral lymph node dissection or by open surgery.

In recent years, preoperative therapy for pancreatic cancer has been increasing. We retrospectively analyzed 184 consecutive patients with pancreatic head cancer during 2008-2018, 94 patients underwent upfront surgery and 90 patients received preoperative therapy. The rate of preoperative therapy was 72.3％ in last 5 years. The preoperative therapy group had lower age, high smoking rate, anemia, high platelet-lymphocyte ratio, long operative time, high blood transfusion rate, and high portal vein resection rate than upfront surgery group. There was no difference in postoperative complications including SSI, however, Clavien-Dindo Ⅳa was significantly higher in the preoperative therapy group (0.0％ vs 5.5％, P=0.02). In multivariate analysis, age . 68 years, operation time . 548 minutes, BMI . 21.5, and ALB ＜3.5g/dL were independent risk factors for SSI. Preoperative therapy was not a risk factor for SSI in pancreaticoduodenectomy.

Neoadjuvant chemotherapy for gastric cancer is not associated with high incidence of postoperative complications from the results of randomized controlled clinical trials carried out in Western countries and Japan. Similar findings were drawn from literature review of retrospective cohorts. However, as the frailty of patient background, combination chemotherapy with multiple agents, severe toxicity caused by chemotherapy and extensive surgery may affect the incidence of postoperative complication, surgery after neoadjuvant chemotherapy should be done carefully in case with those factors.

Although preoperative chemoradiotherapy (CRT) is used to reduce the risk of local recurrence in patients with rectal cancer, toxic effect of CRT to the surrounding normal healthy tissues remains major drawback. Radiation-induced injury is classified as either acute (early) or chronic (late) one, and patients with radiation therapy for rec-tal cancer can have chronic disease of gastrointestinal tract. Therefore, CRT has known to be negative impact for wound healing, and could cause anastomotic leakage(AL)in patients with rectal cancer. However, several meta-analyses have indicated that CRT for rectal cancer does not increase AL because we usually delay operation after CRT, and construct protective stoma to prevent AL. On the other hand, AL after CRT is difficult to cure due to in-hibition of wound healing mechanism. In the future, developments of new drugs as sensitizer of CRT and radiation modality are urgently needed to decrease adverse effects of CRT, and to achieve complete tumor response for watch and wait therapy in rectal cancer.

Esophagectomy for esophageal cancer is more invasive and more complicated than other gastrointestinal surgery. The limitation of esophagectomy had been discussed because of the high malignant potential of esophageal cancer, and neoadjuvant chemotherapy (CDDP＋5-FU) followed by esophagectomy has become standard therapy for cStage Ⅱ/Ⅲ esophageal cancer from the results of JCOG 9907 trial. Several reports have reported that postopera-tive infectious complications after esophagectomy worsened long-term outcomes, and the meta-analysis also re-ported that postoperative complications after esophagectomy significantly worsened long-term outcomes. There was no significant difference in the incidence of postoperative complications between the neoadjuvant chemotherapy group and the adjuvant chemotherapy group in the JCOG 9907 trial, but postoperative infectious complications after esophagectomy worsened long-term outcomes only in the neoadjuvant chemotherapy group. It is suggested that postoperative infectious complications after esophagectomy becomes serious and significantly worsens long-term outcomes once postoperative complications occur, although neoadjuvant chemotherapy does not significantly in-crease postoperative complications.

We report a case of advanced esophageal cancer with Ramsey Hunt syndrome, which developed to generalized her-pes zoster and meningoencephalitis after neoadjuvant chemotherapy. A 70’s female with locally advanced esophageal cancer was admitted to our hospital for treatment. She received two courses of chemotherapy consisted of 5-fluorouracil and cisplatin as a neoadjuvant therapy. After the second course of chemotherapy, headache, reddening of the pinna, facial palsy and eruptions of the body were observed. Cerebrospinal fluid examination revealed menin-goencephalitis. Based on these findings, she was diagnosed as Ramsey Hunt syndrome concomitant with generalized herpes zoster and meningoencephalitis. She was treated with Aciclovir and steroid. Her facial movement and eruptions of the body were recovered. Then, we planned two-stage operation for esophageal cancer. She underwent esophagectomy and esophagostomy first, and then the secondary reconstruction using gastric tube was performed. At 20 days after the esophageal reconstruction, CT revealed multiple lymph nodes and hepatic metastasis, and she died at 36 days after the operation. In this case, Ramsey Hunt syndrome developed to generalized herpes zoster and meningoencephalitis because of immunosuppressive condition. Ramsey Hunt syndrome during chemotherapy should be taken care, as it may rapidly progress to generalized herpes zoster.

A woman in the 80’s. Pemetrexed, bevacizumab, carboplatin combination therapy was administered to lung cancer. After 4 days, the patient presented lower abdominal pain with diarrhea and melena. Treatment was continued by administration of carbapenem-based antibiotics. General condition was worsened including deterioration of renal function, disturbance of consciousness. Colonoscopy revealed edema and multiple punched-out ulcers in the de-scending colon. Immunohistological examination demonstrated cytomegalovirus positive inclusion body in colonic mucosa. The patient was diagnosed as CMV colitis. After administration of ganciclovir, the fever and the diarrhea were improved, and the renal function was improved, and C7-HRP became negative.