ABSTRACT
Aim
The clinical characteristics of colonic diverticular perforation are poorly understood. We aimed to clarify the clinical characteristics of colonic diverticular perforation.
Methods
Patients who underwent surgery for colonic diverticular perforation from 2011 to 2021 were retrospectively evaluated. The patients were divided into right‐ and left‐sided colon cohorts according to their perforation location.
Results
Of 1129 patients with gastrointestinal perforation, 138 had colonic diverticular perforation. The sigmoid colon was the most common perforation site. The patients were categorized into right‐sided (20 patients) and left‐sided (118 patients) colon cohorts. The number of patients with colonic diverticular perforation increased with age, as did the proportion of left‐sided perforations. The left‐sided cohort had significantly higher mean age, hemoglobin, and serum albumin levels than the right‐sided cohort. The blood urea nitrogen and serum creatinine levels were significantly lower in the right‐sided cohort. The proportion of patients with colostomy, the proportion of patients with postoperative complications, and the length of intensive care unit stay during hospitalization were significantly longer in the left‐sided cohort. The left‐sided cohort also had a considerably longer mean hospital stay and higher mean hospitalization costs than the right‐sided colon cohort. An age of ≥ 75 years tended to be associated with a prolonged hospital stay and high hospitalization costs in the left‐sided colon cohort.
Conclusions
The patients' conditions, length of hospital stay, and hospitalization costs were significantly worse in the left‐ than right‐sided colon cohort. The clinical characteristics differed according to the location of the diverticular perforation.
Keywords: colonic diverticulum, hospitalization costs, length of hospital stay, perforation, surgery
The sigmoid colon was the most common perforation site among patients with colonic diverticular perforation. The patients' conditions, length of hospital stay, and hospitalization cost were significantly worse in left‐sided colon diverticular perforation than in right‐sided colon diverticular perforation. The clinical characteristics differed according to diverticulum perforation location.
Abbreviations
- CRP
C‐reactive protein
- GI
gastrointestinal
- USD
United States dollars
1. Introduction
Previous European research comparing the clinical characteristics of upper and lower gastrointestinal (GI) events (e.g., bleeding, perforation) from 1996 to 2005 reported a rapid decrease in upper GI events. By contrast, lower GI events have increased, particularly in patients older than 60 years. Moreover, lower GI events are associated with longer hospital stays and higher mortality rates than upper GI events [1, 2]. This trend may be attributed to a decrease in Helicobacter pylori infection, which is commonly associated with peptic ulcers, or a progressive increase in preventive measures for ulcer formation in patients taking nonsteroidal anti‐inflammatory drugs [3, 4]. Conversely, lower GI events frequently occur in elderly individuals with more comorbid conditions, and preventive methods have not yet been established. Although lower GI perforation is a major lower GI event, it is much less frequent than lower GI bleeding [1]. However, lower GI perforation can become serious if appropriate diagnosis and treatment are delayed. As a result, the length of hospital stay for lower GI perforation is longer than that for upper GI perforation [5, 6].
Colonic diverticulum is a common colon abnormality. In Western patients, it primarily involves the left‐sided colon. By contrast, East Asian patients often have right‐sided colonic diverticulosis, with the incidence of left‐sided colonic diverticulosis increasing with age [7, 8]. Although colonic diverticulitis is a major complication of colonic diverticulosis and can lead to perforation, the exact mechanism by which diverticulitis develops from diverticulosis remains unclear. Detailed reports on the clinical characteristics of colonic diverticular perforation are lacking. Therefore, understanding the clinical characteristics of patients with colonic diverticular perforation is crucial.
Many previous studies involving Japanese cohorts have thoroughly investigated the clinical characteristics of patients with lower GI bleeding. These include bleeding etiology [9], weekend‐ or inpatient‐onset cases [10, 11], patients requiring surgery [12], clinical differences compared with upper GI bleeding [13], and the risk of recurrent bleeding [14]. Additionally, several risk models for lower GI bleeding have been developed [15, 16, 17, 18]. By contrast, the clinical characteristics of colonic diverticular perforation requiring surgery remain unclear. Only one prior study in Japan has examined the clinical characteristics of colonic diverticulitis [19]. Consequently, the guidelines for colonic diverticular bleeding and colonic diverticulitis published by the Japan Gastroenterological Association include limited information on diverticulitis compared with diverticular bleeding, and the evidence level for colonic diverticulitis remains low [7].
In a Japanese cohort, complicated diverticulitis (e.g., diverticulitis with abscess or perforation) was observed in 16.1% of patients with colonic diverticulitis and was significantly associated with prolonged hospital stays and increased mortality [19]. While several Japanese studies on lower GI bleeding have examined the risk of extended hospitalization and high medical costs [18, 20, 21, 22], no study has specifically investigated these factors in patients with colonic diverticular perforation requiring surgery. As Japan's population continues to age, understanding the clinical characteristics and healthcare burden of colonic diverticular perforation is essential for anticipating the country's future medical and economic landscape [23].
This study aimed to clarify the clinical characteristics, including medical economics (e.g., length of hospital stay and hospitalization costs), in patients with colonic diverticular perforation requiring surgery.
2. Methods
2.1. Patients
This dual‐center retrospective observational study included 1129 consecutive patients hospitalized for upper or lower GI perforation at Kawasaki Medical School Hospital (Kurashiki City) and Kawasaki Medical School General Medical Center (Okayama City) from January 2011 to December 2021. Patients who underwent only conservative treatment, including puncture drainage (n = 313), those with onset during hospitalization in other departments at our facilities (n = 46), those younger than 20 years (n = 20), and those with insufficient clinical information (n = 18) were excluded. The remaining patients (basic cohort, n = 732) who underwent laparotomy or thoracotomy, including endoscopy‐assisted surgery, and in whom the perforation sites were surgically visible, were enrolled. Among the basic cohort, there were 6 patients (0.8%) with esophageal perforation, 236 patients (32.2%) with gastroduodenal perforation, 119 patients (16.3%) with small intestinal perforation, and 371 patients (50.7%) with colonic perforation (Figure 1). In this study, we focused on the 371 patients with colonic perforation. All variables were collected from the medical records at our facilities by gastroenterologists or dedicated researchers. This study was approved by the research ethics committee of Kawasaki Medical School Hospital (approval number 5980‐1).
FIGURE 1.
Study flow chart. GI, gastrointestinal.
2.2. Variables and Outcome
The study flowchart is shown in Figure 1.
In Study 1, patients with colorectal perforation were divided into two groups: the non‐diverticulum cohort, which comprised patients with colorectal perforation caused by factors other than a colonic diverticulum, and the diverticulum cohort, which comprised patients with colorectal perforation caused by a colonic diverticulum. Subsequently, the proportion of perforation sites in each colonic segment, including the cecum, appendix, ascending colon, transverse colon, descending colon, sigmoid colon, and rectum, was evaluated. Clinical baseline characteristics were analyzed by comparing patients in the non‐diverticulum and diverticulum cohorts.
In Study 2, the location of colonic diverticular perforation was classified as either the right‐sided colon (from the cecum to the splenic flexure) or the left‐sided colon (from the splenic flexure to the rectum), as previously reported [8, 14, 19]. Baseline characteristics (e.g., sex, age, performance status, body mass index, drinking and smoking habits, comorbidities, and medication), vital signs and blood test results at hospital admission, surgical procedures, postoperative complications, length of hospital stay, postoperative in‐hospital mortality rate, and hospitalization costs were compared between the right‐ and left‐sided colon cohorts. C‐reactive protein (CRP) levels were assessed both at hospital admission and at their highest postoperative values until discharge. Hospitalization costs were calculated using an exchange rate of 140 yen per 1 United States dollar (USD), as previously reported [18].
2.3. Statistical Analysis
Values are expressed as mean ± standard deviation. The Pearson chi‐squared test was used to compare proportions. A two‐sided p value of < 0.05 was considered statistically significant. The Jonckheere–Terpstra trend test was applied to identify trends between the number of patients and age groups. The odds ratio and 95% confidence interval were calculated using Mantel–Haenszel statistics and multiple logistic regression analysis to identify factors at hospital admission associated with a prolonged hospital stay and high hospitalization costs. All statistical analyses were performed using IBM SPSS Statistics version 27.0 (IBM Corp., Armonk, NY, USA).
3. Results
3.1. Study 1: Causes of Perforation in the Non‐Diverticulum Cohort and Comparison of Perforation Sites Between Non‐Diverticulum and Diverticulum Cohorts
The causes of perforation in the non‐diverticulum cohort are presented in Table 1, which shows that acute appendicitis was the most common cause. The comparison of colorectal perforation sites between the non‐diverticulum and diverticulum cohorts is shown in Figure 2. The appendix (p < 0.001), transverse colon (p = 0.014), and rectum (p < 0.001) were significantly more frequent perforation sites in the non‐diverticulum cohort than in the diverticulum cohort. By contrast, sigmoid colon perforations were more frequent in the diverticulum cohort than in the non‐diverticulum cohort (p < 0.001).
TABLE 1.
Cause of perforation in the non‐diverticulum cohort (n = 233).
| n (%) | |
|---|---|
| Acute appendicitis | 75 (32.2) |
| Malignant tumors | 62 (26.6) |
| Ischemia | 29 (12.4) |
| Iatrogenic injuries | 26 (11.1) |
| Ulcers of unclear origin | 21 (9.0) |
| Crohn's disease | 7 (3.0) |
| Appendiceal mucocele | 4 (1.7) |
| Ulcerative colitis | 3 (1.3) |
| Foreign bodies | 3 (1.3) |
| Traumatic injuries | 3 (1.3) |
Note: Iatrogenic injuries include complications of endoscopic or surgical procedures. Ulcers of unclear origin include suspected drug‐induced ulcers or ulcer‐associated viral infections.
FIGURE 2.
Comparison of proportion of colorectal perforation sites across each colonic segment between non‐diverticulum and diverticulum cohorts.
3.2. Study 2: Evaluation of Patients With Colonic Diverticular Perforation in Right‐ and Left‐Sided Colon Cohorts
To evaluate the incidence of diverticular perforation by age group, we classified the patients into six age groups: ≤ 40 years, 41–50 years, 51–60 years, 61–70 years, 71–80 years, and ≥ 81 years. The incidence of colonic diverticular perforation significantly increased with age (p = 0.005 for trend) (Figure 3a). Additionally, the proportion of patients in the left‐sided colon cohort showed a tendency to increase with age (p = 0.048 for trend) (Figure 3b).
FIGURE 3.
Incidence of colonic diverticular perforation by age group. (a) Number of patients with colonic diverticular perforation by age group. (b) Comparison of proportions of patients between right‐ and left‐sided colon cohorts by age group.
The demographic data of the right‐sided (n = 20) and left‐sided (n = 118) colon cohorts are presented in Table 2. The proportion of male patients (p < 0.001) and patients with drinking habits (p = 0.020) were significantly higher in the right‐ than left‐sided colon cohort. By contrast, the mean age (p = 0.002) was significantly higher in the left‐ than right‐sided colon cohort, and the proportion of patients with a performance status score of ≥ 2 tended to be higher in the left‐ than right‐sided colon cohort (p = 0.052). There were no significant differences in smoking proportions, comorbidities, or vital signs at hospital admission between the right‐ and left‐sided colon cohorts. However, the proportion of patients taking corticosteroids was markedly higher in the left‐ than right‐sided colon cohort (p = 0.047). Regarding the blood test results at hospital admission, hemoglobin levels (p = 0.044) and serum albumin concentrations (p = 0.010) were significantly lower in the left‐sided colon cohort, whereas blood urea nitrogen (p = 0.001) and serum creatinine levels (p = 0.046) were significantly higher in the left‐ than right‐sided colon cohort. In terms of surgical procedures, endoscopy‐assisted surgery was significantly more common in the right‐sided colon cohort (p = 0.041), whereas colostomy was significantly more frequent in the left‐sided colon cohort (p < 0.001). Clinically, postoperative complications (p = 0.010) and the highest postoperative CRP values (p = 0.004) were significantly higher in the left‐sided colon cohort. The mean length of intensive care unit stay was also significantly longer in the left‐ than right‐sided colon cohort (p < 0.001), as was the overall hospital stay (p < 0.001). While the time from hospital admission to surgery did not differ significantly between the cohorts (p = 0.126), the duration from surgery to discharge was significantly longer in the left‐sided colon cohort (p < 0.001). However, the postoperative in‐hospital mortality rate showed no significant difference between the two groups (p = 0.896). The hospitalization cost analysis was performed using data from July 2017 to December 2021 because earlier records were unavailable in the electronic medical records. The mean hospitalization cost was considerably higher in the left‐sided colon cohort (n = 50) than in the right‐sided colon cohort (n = 5) (20 363.0 ± 13 815.8 vs. 10 160.9 ± 3873.0 USD; p = 0.001) (Figure 4).
TABLE 2.
Demographic data of the right‐sided (n = 20) and left‐sided (n = 118) colon cohorts.
| Right‐sided colon cohort | Left‐sided colon cohort | p | |
|---|---|---|---|
| Male, n (%) | 18 (90.0) | 57 (48.3) | < 0.001 |
| Age, mean ± SD (year) | 62.4 ± 18.9 | 71.5 ± 15.1 | 0.002 |
| Performance status of ≥ 2, n (%) | 3 (15.0) | 44 (37.2) | 0.052 |
| Body mass index, mean ± SD | 20.4 ± 5.6 | 21.9 ± 4.4 | 0.266 |
| Smoking habit (%) | 11 (55.0) | 41 (34.7) | 0.084 |
| Drinking habit (%) | 10 (50.0) | 29 (24.6) | 0.020 |
| Comorbidities, n (%) | |||
| Hypertension | 4 (20.0) | 48 (40.7) | 0.078 |
| Hyperlipidemia | 4 (20.0) | 26 (22.0) | 0.838 |
| Malignant tumor | 2 (10.0) | 19 (16.1) | 0.482 |
| Cardiovascular disease | 3 (15.0) | 16 (13.6) | 0.863 |
| Dementia | 1 (5.0) | 15 (12.7) | 0.319 |
| Cerebrovascular disease | 1 (5.0) | 12 (10.2) | 0.464 |
| Diabetes | 3 (15.0) | 12 (10.2) | 0.521 |
| CKD under hemodialysis | 0 (0.0) | 12 (10.2) | 0.136 |
| Collagen diseases | 0 (0.0) | 11 (9.3) | 0.155 |
| Liver cirrhosis | 1 (5.0) | 4 (3.4) | 0.722 |
| Non | 7 (35.0) | 20 (16.9) | 0.060 |
| Medication, n (%) | |||
| NSAIDs | 0 (0.0) | 8 (6.8) | 0.724 |
| Corticosteroids | 0 (0.0) | 20 (16.9) | 0.047 |
| Antithrombotic agents | 4 (20.0) | 20 (16.9) | 0.740 |
| Antiplatelets | 1 (5.0) | 10 (8.5) | |
| Anticoagulants | 3 (15.0) | 7 (5.9) | |
| Antiplatelets and anticoagulants | 0 (0.0) | 3 (2.5) | |
| Anti‐acids | 6 (30.0) | 38 (32.2) | 0.697 |
| Vital signs at hospital admission, mean ± SD | |||
| Systolic blood pressure (mmHg) | 105.2 ± 35.0 | 101.5 ± 32.2 | 0.319 |
| Pulse rate (beats/min) | 95.5 ± 21.4 | 93.1 ± 21.2 | 0.291 |
| Body temperature (°C) | 37.3 ± 1.0 | 37.3 ± 1.0 | 0.753 |
| Blood test at hospital admission, mean ± SD | |||
| White blood cell count (/μL) | 12 653.0 ± 5237.1 | 10 517.5 ± 5592.8 | 0.107 |
| Hemoglobin (g/dL) | 13.6 ± 2.1 | 12.5 ± 2.4 | 0.044 |
| Serum albumin (g/dL) | 3.6 ± 0.7 | 3.2 ± 0.7 | 0.010 |
| Blood urea nitrogen (mg/dL) | 16.6 ± 6.9 | 23.8 ± 14.8 | 0.001 |
| Serum creatinine (mg/dL) | 1.0 ± 0.5 | 1.5 ± 2.1 | 0.046 |
| CRP (mg/dL) | 13.0 ± 9.6 | 11.1 ± 10.6 | 0.442 |
| Surgical procedures, n (%) | |||
| Endoscopy‐assisted surgery a | 2 (10.0) | 2 (1.7) | 0.041 |
| Colostomy | 5 (25.0) | 111 (94.1) | < 0.001 |
| Postoperative clinical course | |||
| Postoperative complications, n (%) | 1 (5.0) | 35 (29.7) | 0.010 |
| Abdominal abscess | 5 (14.3) | ||
| Wound dehiscence | 5 (14.3) | ||
| Cardiovascular complications | 1 (100) | 4 (11.4) | |
| Anastomotic leak | 3 (8.6) | ||
| Respiratory infection | 3 (8.6) | ||
| Cerebrovascular complications | 3 (8.6) | ||
| Pseudomembranous colitis | 3 (8.6) | ||
| Wound infection | 2 (5.7) | ||
| Others | 7 (20.0) | ||
| Highest postoperative CRP value (mg/dL), mean ± SD | 16.7 ± 7.3 | 22.4 ± 9.1 | 0.004 |
| Mean length of intensive care unit stay (day), mean ± SD | 1.1 ± 1.5 | 4.0 ± 4.7 | < 0.001 |
| Mean length of overall hospital stay (day), mean ± SD | 17.5 ± 9.2 | 35.6 ± 28.9 | < 0.001 |
| Mean length from hospital admission to surgery (day), mean ± SD | 1.1 ± 1.8 | 2.0 ± 5.2 | 0.126 |
| Mean length from surgery to discharge (day), mean ± SD | 16.4 ± 9.4 | 33.6 ± 28.2 | < 0.001 |
| Postoperative in‐hospital mortality, n (%) | 1 (5.0) | 7 (5.9) | 0.869 |
Note: Bold values indicate p < 0.05.
Abbreviations: CKD, chronic kidney disease; CRP, C‐reactive protein; NSAIDs, nonsteroidal anti‐inflammatory drugs; SD, standard deviation.
All other cases underwent laparotomy.
FIGURE 4.
Comparison of hospitalization costs in patients with colonic diverticular perforation between right‐ and left‐sided colon cohorts. The hospitalization cost analysis was performed using data from July 2017 to December 2021. USD, United States dollars.
The median length of hospital stay in the left‐sided colon cohort was 27 days, and the median hospitalization cost was 16 217.7 USD. The associations of a prolonged hospital stay (> 27 days) (Table S1) and high hospitalization costs (> 16 500.0 USD) (Table S2) with various factors at hospital admission were analyzed. In the multivariate analyses, an age of ≥ 75 years was significantly associated with a prolonged hospital stay in the left‐sided colon cohort (adjusted odds ratio: 2.572; 95% confidence interval: 1.148–5.763; p = 0.022). However, no significant associations were found between high hospitalization costs and factors at hospital admission (Figure 5).
FIGURE 5.
Association between economic factors and various factors at hospital admission in patients with left‐sided colonic diverticular perforation in multivariate analysis. (a) Association between prolonged hospital stay (> 27 days) and factors at hospital admission. (b) Association between high hospitalization costs (> 16 500 USD) and factors at hospital admission. Bold values indicate p < 0.05. The hospitalization cost analysis was conducted using data from July 2017 to December 2021 (n = 50). CI, confidence interval; OR, odds ratio; USD, United States dollars.
4. Discussion
We analyzed the current status of patients who underwent surgery for colorectal perforation. Study 1 demonstrated that colonic diverticulum was the most common cause of colonic perforation, with the sigmoid colon being the most frequently affected site in the diverticulum cohort. Study 2 revealed that the number of patients with colonic diverticular perforation increased with age, and the proportion of the left‐sided colon cohort tended to rise with advancing age. Furthermore, patients in the left‐sided colon cohort presented with poorer clinical conditions, experienced longer hospital stays, and incurred higher hospitalization costs than those in the right‐sided colon cohort. These results align with a previous report on acute colonic diverticulitis, which found that the left‐sided colon cohort had a significantly higher number of patients with Hinchey classification stage ≥ II and required longer hospital stays than the right‐sided colon cohort [24].
Colonic diverticulitis often leads to colonic diverticular perforation. However, the exact onset mechanism of diverticulitis remains unclear. Previous studies have hypothesized that diverticulitis results from inspissated stool eroding through the diverticular wall, compromising peri‐diverticular submucosal blood vessels, and causing local ischemia and inflammation. Consequently, the fundus of the diverticulum, which has only a serosal covering, may become distended to the point of micro‐perforation [25]. Chronic constipation is more prevalent at older ages, and its incidence increases with age [26]. In our study, the incidence of colonic diverticular perforation also increased with age, particularly in the left‐sided colon cohort. Chronic constipation may contribute to the rising incidence of colonic diverticular perforation.
As shown in Table 2, the mean age, performance status of ≥ 2, hemoglobin, serum albumin, blood urea nitrogen, and serum creatinine levels tended to be higher in the left‐ than right‐sided colon cohort. The mean length of overall hospital stay and hospitalization costs were also significantly higher in the left‐ than right‐sided colon cohort. However, no significant differences were observed in the mean time from hospital admission to surgery between the two cohorts. These findings suggest that prolonged hospital stays and high hospitalization costs in the left‐sided colon cohort were influenced by surgical costs and the postoperative clinical course. The proportion of patients who underwent laparotomy and colostomy was significantly higher in the left‐sided colon cohort, likely contributing to increased surgical costs. Additionally, postoperative complications and the highest postoperative CRP values were significantly more frequent in the left‐sided colon cohort. Furthermore, the mean length of intensive care unit stay during hospitalization was significantly longer in the left‐sided colon cohort. These disparities may be attributed to the more severe condition of patients at hospital admission in the left‐sided colon cohort. The left‐sided colon, particularly the sigmoid colon, which is often located in the pelvis, is situated deeper in the abdominal cavity than the right‐sided colon [27]. As a result, left‐sided colonic diverticulitis tends to present as a more complicated condition and is more challenging to diagnose promptly [19, 28]. Furthermore, surgical procedures have become more complicated, increasing the risk of postoperative complications. Manabe et al. [19] reported that left‐sided colonic diverticulum and older age are risk factors for complicated colonic diverticulitis. In our study, an age of ≥ 75 years in the left‐sided colon cohort was significantly associated with prolonged hospital stays (p = 0.020) and tended to be associated with high hospitalization costs (p = 0.075). These factors likely contribute to the prolonged hospital stays and increased hospitalization costs observed in the left‐sided colon cohort. It is necessary to confirm these findings with a larger sample size in further studies.
In Study 2, the proportion of patients taking corticosteroids was markedly higher in the left‐ than right‐sided colon cohort, and no patients in the right‐sided colon cohort had collagen disease. A previous study reported that corticosteroid use in patients with rheumatoid arthritis was strongly associated with sigmoid colon diverticular perforation [29]. In our study, the left‐sided colon cohort included 11 patients with collagen disease. Among these, 8 patients (72.7%) had rheumatoid arthritis, and all 11 patients (100%) had sigmoid colon diverticular perforation (data not shown). Other studies have also highlighted the association between corticosteroid use and an increased risk of colonic diverticular perforation [30, 31]. Weiner et al. [32] reported that neurosurgical patients receiving corticosteroids are more likely to develop diverticular perforation of the sigmoid colon. Although the precise mechanism underlying the association between corticosteroid use and diverticular perforation remains unclear, corticosteroids may impair immune resistance in the colon. Patients taking corticosteroids with sigmoid colonic diverticulum should be closely monitored for the potential development of perforation.
Although our study is the largest to date evaluating the characteristics of colonic diverticular perforation requiring surgery, it has several limitations. First, the distribution and extent of the colonic diverticulum were not determined. Second, the difference in the proportion of cases in which diverticulitis was treated conservatively between the right‐ and left‐sided colon cohorts remains unclear. Third, treatment strategies varied as the attending surgeons decided the treatment plans. Fourth, the study's observational retrospective design may limit the generalizability of the findings.
5. Conclusions
Our study identified left‐sided colonic diverticulum, advanced age, and corticosteroid use as potential risk factors for colonic diverticular perforation. As patients age, those with left‐sided colonic diverticulum should be closely monitored for the potential development of perforation. In particular, patients aged ≥ 75 years with a perforated left‐sided colonic diverticulum may experience prolonged hospital stays. Developing risk models to predict colonic diverticular perforation requiring surgery is crucial for improving prevention and management strategies. Therefore, further research is needed to validate these findings through prospective multicenter studies with larger sample sizes, including cases of colonic diverticular perforation managed conservatively.
Author Contributions
Minoru Fujita: conceptualization, formal analysis, investigation, methodology, project administration, visualization, writing – original draft. Noriaki Manabe: conceptualization, data curation, methodology, supervision, validation, writing – review and editing. Munenori Takaoka: data curation. Masaharu Higashida: data curation. Hideo Matsumoto: data curation. Atsushi Urakami: data curation. Tomoki Yamatsuji: data curation, supervision. Tomio Ueno: data curation, supervision. Jiro Hata: data curation, supervision. Ken Haruma: conceptualization, data curation, methodology, supervision, writing – review and editing.
Ethics Statement
The protocol for this research project has been approved by a suitably constituted Ethics Committee of the institution and it conforms to the provisions of the Declaration of Helsinki. Committee of Kawasaki Medical School Hospital, Approval No. 5980‐1. The research ethics committee of Kawasaki Medical School Hospital waived the need for consent for this retrospective analysis of data from January 2011 to December 2021. All efforts were made to ensure data confidentiality.
Conflicts of Interest
The authors declare no conflicts of interest.
Supporting information
Table S1.
Table S2.
Acknowledgments
The authors thank all staff members of the Department of Gastroenterology and Hepatology, the Department of Clinical Pathology and Laboratory Medicine, and the Department of Digestive Surgery at Kawasaki Medical School Hospital, as well as those of the Department of General Internal Medicine 2 and the Department of General Surgery at Kawasaki Medical School General Medical Center. We also thank Edanz (https://jp.edanz.com/ac) for editing a draft of this manuscript.
Funding: The authors received no specific funding for this work.
Collaborators: Hisako Kubota (Department of Digestive Surgery, Kawasaki Medical School Hospital, Kurashiki, Japan; Department of Surgery, Okayama Central Hospital, Okayama, Japan), Jiro Hayashi (Department of General Surgery, Kawasaki Medical School General Medical Center, Okayama, Japan; Department of Digestive Surgery, Kawasaki Medical School Hospital, Kurashiki, Japan), Masaki Matsubara (Department of General Surgery, Kawasaki Medical School General Medical Center, Okayama, Japan), Takako Konishi (Division of Endoscopy and Ultrasonography, Department of Clinical Pathology and Laboratory Medicine, Kawasaki Medical School General Medical Center, Okayama, Japan; Department of General Surgery, Kawasaki Medical School General Medical Center, Okayama, Japan), Emiko Bukeo (Division of Endoscopy and Ultrasonography, Department of Clinical Pathology and Laboratory Medicine, Kawasaki Medical School General Medical Center, Okayama, Japan; Division of Gastroenterology, Department of Gastroenterology and Hepatology, Kawasaki Medical School Hospital, Kurashiki, Japan), Tomohiro Tanikawa (Department of General Internal Medicine 2, Kawasaki Medical School General Medical Center, Okayama, Japan), Jun Nakamura (Division of Endoscopy and Ultrasonography, Department of Clinical Pathology and Laboratory Medicine, Kawasaki Medical School General Medical Center, Okayama, Japan; Department of General Internal Medicine 2, Kawasaki Medical School General Medical Center, Okayama, Japan), Mitsuhiko Suehiro (Department of General Internal Medicine 2, Kawasaki Medical School General Medical Center, Okayama, Japan), Maki Ayaki (Division of Endoscopy and Ultrasonography, Department of Clinical Pathology and Laboratory Medicine, Kawasaki Medical School General Medical Center, Okayama, Japan; Department of Gastroenterology and Hepatology, HITO Medical Center, Shikokuchuo, Japan), Takahisa Murao (Division of Gastroenterology, Department of Gastroenterology and Hepatology, Kawasaki Medical School Hospital, Kurashiki, Japan; Department of Health Care Medicine, Kawasaki Medical School General Medical Center, Okayama, Japan), Kazuhiro Yoshida (Department of General Surgery, Kawasaki Medical School General Medical Center, Okayama, Japan; Department of Digestive Surgery, Kawasaki Medical School Hospital, Kurashiki, Japan), Takashi Akiyama (Department of Pathology, Kawasaki Medical School General Medical Center, Okayama, Japan; Department of Pathology, Kawasaki Medical School Hospital, Kurashiki, Japan), Katsuya Kato (Department of Diagnostic and Therapeutic Radiology, Kawasaki Medical School General Medical Center, Okayama, Japan), Hirofumi Kawamoto (Department of General Internal Medicine 2, Kawasaki Medical School General Medical Center, Okayama, Japan), Tomoari Kamada (Division of Gastroenterology, Department of Gastroenterology and Hepatology, Kawasaki Medical School Hospital, Kurashiki, Japan; Department of Health Care Medicine, Kawasaki Medical School General Medical Center, Okayama, Japan), Akiko Shiotani (Division of Gastroenterology, Department of Gastroenterology and Hepatology, Kawasaki Medical School Hospital, Kurashiki, Japan), Minoru Haisa (Department of General Surgery, Kawasaki Medical School General Medical Center, Okayama, Japan), Yoshio Naomoto (Department of General Surgery, Kawasaki Medical School General Medical Center, Okayama, Japan), Toshihiro Hirai (Department of Digestive Surgery, Kawasaki Medical School Hospital, Kurashiki, Japan; Department of Surgery, Mitsugi General Hospital, Onomichi, Japan).
Contributor Information
Minoru Fujita, Email: minorufu@med.kawasaki-m.ac.jp.
Collaborators:
Hisako Kubota, Jiro Hayashi, Masaki Matsubara, Takako Konishi, Emiko Bukeo, Tomohiro Tanikawa, Jun Nakamura, Mitsuhiko Suehiro, Maki Ayaki, Takahisa Murao, Kazuhiro Yoshida, Takashi Akiyama, Katsuya Kato, Hirofumi Kawamoto, Tomoari Kamada, Akiko Shiotani, Minoru Haisa, Yoshio Naomoto, and Toshihiro Hirai
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Supplementary Materials
Table S1.
Table S2.