【Objects】Surgical site infection (SSI) in cardiovascular surgery is more likely to be severe and impact clinical outcomes. This study used the registered data of the Japan Cardiovascular Surgery Database (JCVSD) to examine the current status of SSI and its clinical impact.【Methods】 JCVSD data included 253,159 cases of thoracic cardiovascular surgery performed under median sternotomy in 2013〜2017. According to the Japanese Healthcare Associated Infections Surveillance（JHAIS）classification, patients were classified into three groups, CBGB is CABG with SVG (n=72,513), CBGC is CABG without SVG (n=28,579), and CARD is operations other than CABG (n=152,067). The incidence of deep sternum infection, hospital death and long-term hospitalization（more than 90 days）were examined.【Results】The incidence of deep sternum infection is 1.9％ in CBGB, 1.5％ in CBGC, and 1.5％ in CARD, significantly higher in CBGB (P＜0.001). Hospital deaths in deep sternum infection cases were 22.9％, significantly higher than non-infection cases (5％) (P＜0.001). Long–term hospitalization in deep sternum infection cases was 20.8％, higher than non-infection cases (1.6％). 【Conclusion】The incidence of deep sternum infection is low in JCVSD data. But hospital death and long-term hospitalization is still high.

【Objects】Surgical site infection (SSI) in cardiovascular surgery is more likely to be severe and impact clinical outcomes. This study used the registered data of the Japan Cardiovascular Surgery Database (JCVSD) to examine the current status of SSI and its clinical impact.【Methods】 JCVSD data included 253,159 cases of thoracic cardiovascular surgery performed under median sternotomy in 2013〜2017. According to the Japanese Healthcare Associated Infections Surveillance（JHAIS）classification, patients were classified into three groups, CBGB is CABG with SVG (n=72,513), CBGC is CABG without SVG (n=28,579), and CARD is operations other than CABG (n=152,067). The incidence of deep sternum infection, hospital death and long-term hospitalization（more than 90 days）were examined.【Results】The incidence of deep sternum infection is 1.9％ in CBGB, 1.5％ in CBGC, and 1.5％ in CARD, significantly higher in CBGB (P＜0.001). Hospital deaths in deep sternum infection cases were 22.9％, significantly higher than non-infection cases (5％) (P＜0.001). Long–term hospitalization in deep sternum infection cases was 20.8％, higher than non-infection cases (1.6％). 【Conclusion】The incidence of deep sternum infection is low in JCVSD data. But hospital death and long-term hospitalization is still high.

In April 2017, we launched the multidisciplinary Hamamatsu Perioperative Care Team (HOPE) for all surgical patients. We developed a reinforced intervention strategy, particularly for esophagectomy. We investigated risk factors for surgical site infection (SSI) in esophagectomy and report the outcomes of the HOPE. In all, 122 patients underwent esophagectomy and gastric conduit reconstruction for esophageal or esophagogastric junction cancer between January 2012 and December 2017 in the Department of Surgery of Hamamatsu University School of Medicine. The patients were divided into the pre–HOPE group, which included 96 patients who underwent esophagectomy before the introduction of the HOPE, and the HOPE group, which included 26 patients who underwent esophagectomy after the introduction of the HOPE. Complications were graded according to the Clavien–Dindo Classification. Of the 122 patients analyzed, 25 were diagnosed with incisional SSI (＞gradeⅡ) and 24 were diagnosed with organ/space SSI (＞gradeⅡ). A univariate analysis showed that a preoperative Onodera’s prognostic nutritional index ＜45 and a Controlling Nutritional Status ＞2 were risk factors for incisional SSI, and low total protein and cholinesterase levels were risk factors for organ/space SSI. The incidence rates of organ/space SSI were lower in the HOPE group than in the pre–HOPE group (8％ vs. 22％, P=0.066). Preoperative poor nutritional status was a risk factor for SSIs. Therefore, multidisciplinary team care was effective in preventing SSIs.

Anastomotic failure (AF) after esophagectomy for cancer followed by reconstruction is a postoperative infectious complication that worsens the short– and long–term prognosis, and therefore, prevention is of primary importance. However, it is also important to take measures to reduce infection and inflammation immediately after AF occurs and to prevent the complication from becoming severe. In this study, we examined the appropriate measures and nutritional management based on the analyses of clinical course of 10 AF cases out of 200 patients who underwent esophagectomy in our department. Although the incidence of AF after intrathoracic anastomosis is low (4/142 cases: 2.8％), accurate diagnosis is difficult, and decision for highly difficult treatment, including reoperation (3 cases), must be made immediately. The incidence after cervical anastomosis was relatively high (6/56 cases: 10.7％), but 5 cases (83.3％) could be cured by conservative treatment. As a treatment option, enteral nutrition using jejunostomy is highly useful, in addition to redo–surgery, appropriate drainage from outside/inside the gastrointestinal tract and antimicrobial administration. When AF develops after esophagectomy for cancer, it is important to perform timely, individualized treatment and nutritional care in consideration of each patient’s condition as well as the reconstruction method and disease condition.

【Introduction】 The feasibility of using the enhanced recovery after surgery (ERAS) program in patients with gastric cancer remains unclear. We evaluated the safety and efficacy of the ERAS protocol in such patients.【Methods】 This study was a single–center, prospective randomized trial on patients with gastric cancer undergoing curative gastrectomy. The primary end point was the length of postoperative hospital stay. Secondary end points were the postoperative complication rate, readmission rates and weight loss.【Results】 From July 2013 to June 2015, we randomized 148 patients into an ERAS group (n=73) and a conventional group (n=69); six patients withdrew. The completion rates of the protocol were 87.7 ％ for the ERAS group and 81.2 ％ for the conventional group. Postoperative hospital stay in the ERAS group was significantly shorter than that in the conventional group (9 vs. 10 days; P=0.037）. The ERAS group had a significantly lower rate of postoperative complications grade Ⅲ or higher (4 vs. 15 per cent; P=0.042）. The ratio of body weight to preoperative weight at postoperative week 1 and at 1 month was higher in the ERAS group (0.962 vs. 0.957, P=0.020; and 0.951 vs. 0.937, P=0.021, respectively).【Conclusion】 The ERAS program shortened the postoperative hospital stay after gastric cancer surgery, reduced the rate of complications and accelerated the recovery of good physical condition.

The gut barrier plays an essential role in maintaining host homeostasis. The barrier regulates nutrient absorption as well as prevents the invasion of pathogenic bacteria in the host. It is composed of epithelial cells, tight junctions, and a mucus layer. Several factors, such as perioperative fasting, antimicrobial therapy and surgical invasion can affect this barrier. These factors have been shown to increase intestinal permeability, inflammation, and translocation of pathogenic bacteria. Bacterial Translocation into portal blood from the small and large intestine with reduced gut barrier function has influence to liver dysfunction. Therefore, enhancing the gut barrier function may play a central role of therapy because target organ is gut in perioperative period. We have devised the combined therapy with Glutamine/BCAA and synbiotics in the perioperative period for patients undergoing high risk surgery or causing intra–abdominal infections. We concluded that this bundle therapy which improving the gut environment during the perioperative period may prevent the perioperative surgical complication.

Immunonutrition is a powerful tool for the prevention of postoperative infectious complications with several special nutrients modulating host immune–function. We designed “nutritional bundle management”, which inclusively combine the several nutritional managements promising for the improvement of clinical outcome. Nutritional bundle management is composed of perioperative immunonutrition, early postoperative enteral nutrition, and strict glycemic control targeting at blood glucose level of 150mg/dL. When we applied nutritional bundle management to major hepato–biliary–pancreatic surgery, we had better clinical outcome like the reduction of surgical site infections.

New guidelines from European society of parenteral and enteral nutrition recommended individual nutrition–intervention based on biomarker in patients with malignancy. On the other hand, report published in 2011 suggested cancer–promoting inflammation as one of cancer hallmarks. Additionally, systemic inflammation is also described as one of covariates for screening of malnutrition, the so called GLIM criteria, proposed in 2018. Based on these backgrounds, clinical significance of systemic inflammatory response in cancer patients has again come under the global spotlight. In this section, we retrospectively evaluated supporting evidence including our studies to elucidate the correlation between systemic inflammation, sarcopenia, oncological outcome and postoperative infectious complication, especially in patients with gastrointestinal cancer.