Keiichi Fujino

Insulin Treatment Directly Restores Neutrophil Phagocytosis and Bactericidal Activity in Diabetic Mice and Thereby Improves Surgical Site Staphylococcus aureus Infection

ABSTRACT Bacterial infections, including surgical site infections (SSI), are a common and serious complication of diabetes. Staphylococcus aureus, which is eliminated mainly by neutrophils, is a major cause of SSI in diabetic patients. However, the precise mechanisms by which diabetes predisposes to staphylococcal infection are not fully elucidated. The effect of insulin on this infection is also not well understood. We therefore investigated the effect of insulin treatment on SSI and neutrophil function in diabetic mice. S. aureus was inoculated into the abdominal muscle in diabetic db/db and high-fat-diet (HFD)-fed mice with or without insulin treatment. Although the diabetic db/db mice developed SSI, insulin treatment ameliorated the infection. db/db mice had neutrophil dysfunction, such as decreased phagocytosis, superoxide production, and killing activity of S. aureus; however, insulin treatment restored these functions. Ex vivo treatment (coincubation) of neutrophils with insulin and euglycemic control by phlorizin suggest that insulin may directly activate neutrophil phagocytic and bactericidal activity independently of its euglycemic effect. However, insulin may indirectly restore superoxide production by neutrophils through its euglycemic effect. HFD-fed mice with mild hyperglycemia also developed more severe SSI by S. aureus than control mice and had impaired neutrophil phagocytic and bactericidal activity, which was improved by insulin treatment. Unlike db/db mice, in HFD mice, superoxide production was increased in neutrophils and subsequently suppressed by insulin treatment. Glycemic control by insulin also normalized the neutrophil superoxide-producing capability in HFD mice. Thus, insulin may restore neutrophil phagocytosis and bactericidal activity, thereby ameliorating SSI.

Intrapulmonary cystic lymphangioma: Report of a case

We describe herein the case of a 52-year-old man found to have a solitary pulmonary lymphangioma. Computed tomography (CT) scan demonstrated a nodule with homogeneous density and a well-defined border in the lower lobe of the right lung. T2-Weighted magnetic resonance imaging (MRI) revealed a nodule with homogeneously high signal intensity. The tumor was removed by partial resection, and pathologic examination confirmed a diagnosis of primary lymphangioma of the lung.

Proposal of a risk score for recurrence in patients with curatively resected gastric cancer

In this study, 168 patients who underwent curative resection for gastric cancer with prognostic serosal invasion [ps(+)] and 150 without prognostic serosal invasion [ps(−)] were analyzed separately to determine the prognostic importance of clinicopathological factors, and identify which patients were at high risk of recurrence. A multivariate analysis of survival time using Coxs proportional hazard model revealed the important prognostic factors to be: Lymph node involvement, the classification of gross appearance, macroscopic serosal invasion, and interstitial connective tissue in the ps(+) group; and lymph node involvement, macroscopic serosal invasion, and venous invasion in the ps(−) group. We proposed a risk score of recurrence based on the results of a further multivariate analysis called Hayashis Quantification Analysis II, in which recurrence was chosen as an objective variable and the above prognostic factors were chosen as explanatory variables. Eighty-four percent of the patients with a score of 0 or higher in the ps(+) group and 83% of those with a score of +6 or higher in the ps(−) group showed recurrence. Thus, we believe that this score is useful for identifying those patients at high risk of recurrence, who should receive intensive chemotherapy even after curative resection.

Treatment of Chilaiditi syndrome using laparoscopic surgery

Chilaiditi syndrome is defined as the interposition of the bowel between the liver and right diaphragm. It is a rare disease and may be difficult to diagnose and manage. Treatment for asymptomatic patients with Chilaiditi is usually conservative and does not require surgical intervention, but surgery may be necessary if conservative treatment fails. This report describes a rare case of Chilaiditi syndrome causing small bowel obstruction and corrected using laparoscopic surgery.

Postpancreatectomy Hemorrhage After Pancreatic Surgery in Patients Receiving Anticoagulation or Antiplatelet Agents

Background. Postpancreatectomy hemorrhage (PPH) is a serious complication after pancreatic surgery. In this study, we evaluated PPH and thromboembolic complications after pancreatic surgery in patients with perioperative antithrombotic treatment. Methods. Medical records of patients undergoing pancreatic surgery were reviewed retrospectively. Patients receiving thromboprophylaxis were given either bridging therapy with unfractionated heparin or continued on aspirin as perioperative antithrombotic treatment according to clinical indications and published recommendations. The International Study Group of Pancreatic Surgery definition of PPH was used. Risk factors associated with PPH were assessed by multivariate analysis. Results. Thirty-four of 158 patients received perioperative antithrombotic treatment; this group had a significantly higher PPH rate (29.4% vs 6.5%, P = .001) and mortality (11.8% vs 2.4%, P = .039) than patients not receiving thromboprophylaxis. Multivariate analysis revealed that perioperative antithrombotic treatment was the only independent risk factor for PPH after pancreatic surgery (odds ratio 4.77; 95% CI 1.61-14.15; P = .005). Conclusions. Perioperative antithrombotic treatment is an independent risk factor for PPH in patients undergoing pancreatic surgery, although this treatment effectively prevents postoperative thromboembolic events.

Association between antithrombotic therapy and risk of postoperative complications among patients undergoing endovenous laser ablation

BACKGROUND The aim of the study was to evaluate the clinical results and postoperative complications, especially recanalization or bleeding complications, in patients with saphenous varicose veins undergoing endovenous laser ablation (EVLA) while receiving antithrombotic therapy (ATT). METHODS This retrospective cohort study included 1136 Japanese patients undergoing EVLA with a 980-nm diode laser between January 2012 and November 2015 at our institution. The patients were divided into two groups: ATT users (ATT group) and nonusers (control group). The ATT group was further divided into two subgroups according to whether the patients received antiplatelet or anticoagulant therapy. Clinical outcomes and postoperative complications among these patients were assessed. RESULTS Approximately 20% of the patients undergoing surgery for saphenous varicose veins at our institution received ATT. Of these, 141 (12.4%) received antiplatelet therapy and 95 (8.4%) received anticoagulant therapy. Successful occlusion of the full length of the treated vein was achieved in 99.9% of the patients; there were no severe perioperative complications. Endovenous heat-induced thrombosis occurred in 2.4% of patients, whereas postoperative complications developed in 1.2% of patients. One patient experienced recanalization (0.08%). There were no significant between-group differences in the incidence of recanalization and postoperative complications on univariate analysis. CONCLUSIONS The clinical outcomes and postoperative complications of EVLA in the ATT group were equivalent to those in the control group, indicating that EVLA can be safely performed in patients receiving ATT.

Immunoglobulin G4-related sclerosing cholecystitis presenting as gallbladder cancer: a case report.

Immunoglobulin G4 (IgG4)-related sclerosing disease is a systemic inflammatory syndrome, and an understanding of its characteristics is currently evolving. IgG4-related cholecystitis is a manifestation of IgG4-related sclerosing disease in the gallbladder. This case report describes the clinical, radiographic, and histopathological findings in a young male patient who presented with a synchronous mass in the gallbladder. Serum levels of IgG4 and the IgG4/IgG ratio were normal, and there was no associated autoimmune pancreatitis. Therefore, establishing a preoperative diagnosis of IgG4-related cholecystitis was very difficult, and a differential diagnosis of gallbladder cancer infiltrating the liver was suggested. Postoperative histopathological examination established a diagnosis of IgG4-related cholecystitis definitively. A preoperative diagnosis of IgG4-related cholecystitis, although possible, would have been highly challenging in this case. It is difficult to establish whether surgical intervention is necessary in IgG4-related cholecystitis. Because malignant tumors are frequently suspected with this clinical presentation, surgical intervention should be undertaken only after due deliberation.

A Case of Esophageal Carcinoma with Hyperamylasemia after Recurrence in Postoperative Course

術後再発を契機に高アミラーゼ血症を伴い, 免疫組織学的検査にて再発部位での腫瘍細胞のアミラーゼ産生を認めた食道癌の1例を経験した.症例は49 歳の男性で, 嚥下困難と心窩部痛を主訴に来院した.精査の結果, 下部食道領域の低分化扁平上皮癌と診断し, 術前化学療法施行後, 右開胸開腹胸部食道全摘を行った.術後3か月目に右鎖骨上リンパ節転移を認めたため, 右鎖骨上リンパ節郭清を行った.術後8か月目に多発肝転移と血清アミラーゼ値が1,447U/Lと上昇を認め, 分画では唾液腺由来が優位であった.以後, 血清アミラーゼ値はさらに上昇し, 全身化学療法を行うも, 肝不全のため死亡した.抗α-amylase抗体を用いた免疫組織学的検索では, 原発巣は陰性であったが, 転移右鎖骨上リンパ節内の腫瘍細胞の胞体が明瞭に染色され, 食道癌によるアミラーゼ産生が示唆された.アミラーゼ産生食道癌の報告は過去になく, 最初の症例であると考えられた.

Effect of Blood Transfusions on Survival after Curative Resection for Advanced Gastric Cancer.

手術前後の輸血が胃癌切除後の予後と関連するか否かを検討した.教室における初発進行胃癌治癒切除症例を入院中の輸血たついて非輸血群144例,輸血量1,000ml未満の少量輸血群72例,1,000ml以上の大量輸血群69例に分けて比較すると,大量輸血群の生存率は非輸血群に比べ有意に低かった.両群間に進行程度の差がみられたため因子別に検討すると,深達度漿膜下層(ss)以上の症例およびリンパ節転移がないか1群までの症例で大量輸血群の生存率が非輸血群に比べ低かった.ss以上の症例では両群間に深達度,リンパ節転移の差はなかった.さらにss以上の症例について生存率に関与しうる11の臨床病理学的因子を選びCoxの比例ハザードモデルによる解析を行うと,周術期の輸血はリンパ節転移,腫瘍最大径,静脈侵襲とならんで有意に予後と関連していた.以上より進行胃癌治癒切除例,特に深達度ss以上の症例では周術期における輸血が切除後の生存率を悪くする可能性が示唆された.