Perioperative anaphylaxis in Japan: Epidemiology, diagnosis, and challenges

Perioperative anaphylaxis (POA) is one of the most critical acute complications in anesthesia practice, characterized by rapid onset, diagnostic complexity, and potentially fatal outcomes. Despite global improvements in anesthesia safety, the unpredictable nature of anaphylaxis continues to challenge clinicians. The Japanese Epidemiologic Study for Perioperative Anaphylaxis (JESPA) established the first nationwide, prospective surveillance system for POA, providing valuable insights into the epidemiology and mechanisms of POA in Japan. Large-scale studies from multiple countries, including the United Kingdom's National Audit Project 6 (NAP6) and France's Groupe d'Étude des Réactions Anaphylactiques Périopératoires (GERAP), have reported similar incidence rates, at approximately 1 in 5000 to 10,000 general anesthesia cases, indicating that POA is a rare but consistently serious global event. In Japan, JESPA confirmed a comparable frequency, identifying neuromuscular blocking agents (NMBAs), antibiotics, and sugammadex as major culprits causing anaphylaxis. Notably, the frequency of sugammadex-induced anaphylaxis is higher in Japan, likely reflecting its extensive clinical use. POA involves both immunologic and non-immunologic pathways, culminating in mast cell activation and mediator release. Its presentation, primarily hypotension and bronchospasm, is often masked under anesthesia, complicating its recognition. Diagnosis requires integrating clinical findings, measuring tryptase using the European Academy of Allergy and Clinical Immunology (EAACI) consensus formula (1.2 × baseline + 2 ng/mL), and identifying causative drugs via skin testing, basophil activation tests (BATs), or drug provocation tests (DPTs). Future priorities include expanding access to tryptase testing, strengthening multidisciplinary collaboration, and promoting anesthesiologist-led allergy investigations to enhance diagnostic precision and patient safety in perioperative care.