Shigetomi Iwai

ORAL VANCOMYCIN HYDROCHLORIDE THERAPY FOR POSTOPERATIVE METHICILLIN-CEPHEM-RESISTANT STAPHYLOCOCCUS AUREUS ENTERITIS

The postoperative development of methicillincephem-resistantStaphylococcus aureus (MRSA) enteritis can be fatal unless it is detected at an early stage and treated with effective antibacterial agents. We report herein a Japanese multicenter collaborative clinical study on the efficacy and safety of oral vancomycin hydrochloride (VCM) in the treatment of MRSA enteritis. A total of 49 patients who had been diagnosed as having, or were strongly suspected of having, MRSA enteritis during the early postoperative period, were given oral VCM as four standard doses of 0.5g per day. The VCM concentrations in the blood, urine, and feces were then measured. No side effects were observed and the clinical efficacy of oral VCM in the 31 evaluable patients was excellent. There was a 100% clinical response rate and a 95.8% bacterial elimination rate in the feces. The clinical complete response (CR) rate to oral VCM differed significantly between patients in whom MRSA was detected only in the feces (100%) and those in whom MRSA was isolated from an additional source (57%) (P<0.01). Although VCM concentrations in the stools were extremely high, the levels in the blood and urine were very low. These results demonstrate that oral VCM should be the treatment of choice for postoperative MRSA enteritis due to its safety and efficacy.

Abnormal nucleotide repeat sequence in the TGF-βRII gene in hepatocellular carcinoma and in uninvolved liver tissue

Replication error (RER)‐related genetic alterations are associated with a subset of hepatocellular carcinomas (HCCs) with multiple primary cancers. This study investigated whether mutations in the nucleotide repeats of three putative target genes of RER are associated with hepatocarcinogenesis. The genes examined were those encoding transforming growth factor β type II receptor (TGF‐βRII), BCL‐2‐associated X protein (BAX), and insulin‐like growth factor II receptor (IGF‐IIR). Tumour and non‐tumour hepatic tissues were examined in 48 HCC patients, 34 with solitary HCC and 14 who had double cancer with gastric cancer. Four double‐cancer cases showed an abnormal signal in the single nucleotide repeat (A)10 of the TGF‐βRII gene. These four were among the six RER‐positive cases in this series. The genotypes of the poly A tract of the TGF‐βRII gene in the liver tumour tissue of the four cases with an abnormal signal were (A)9/10, (A)9/10, (A)9/10, and (A)9/9. Five uninvolved liver tissue specimens from these four patients showed (A)9/10 and (A)9/9, (A)9/10, (A)10/10 and (A)9/9, respectively. The genotype in the stomach cancer specimens of these four patients was (A)10/10, indicating no germline mutation of the TGF‐βRII gene. There were no mutations in the nucleotide repeats of the BAX and IGF‐IIR genes in any of the liver tissue specimens. Abnormality of the nucleotide repeat in the TGF‐βRII gene occurred in the uninvolved liver tissue as well as the HCC tissue in some HCC patients. Such genetic instability may be gene‐specific and tissue‐specific in carcinogenesis. Copyright

[1-13C]Galactose Breath Test for Quantitative Measurement of Liver Function in a Short Period

Background: Using a rat model of hepatectomy, we investigated whether the severity of hepatopathy could be quantitatively measured from changes in expiratory ¹³CO₂ levels after intravenous administration of [1-¹³C]galactose. Materials and Methods: Under nembutal anesthesia, 100 mg/kg [1-¹³C]galactose was administered to rats via the femoral vein, and expiratory ¹³CO₂ levels were measured for 60 min. Then, 30, 70 or 90% hepatectomy was performed. In the control group, simple laparotomy was performed. Breath test was conducted 20 min after laparotomy. We examined the correlation of total ¹³CO₂ output (S) or single point ¹³CO₂ level (SP) every 5 min until 30 min, and at 45 and 60 min with liver weight/body weight (LW/BW) (%). Results: In the control group, the breath test graph reached a plateau level, but in all groups undergoing hepatectomy a plateau level was not reached during measurement. The correlation coefficient between S³⁰ after [1-¹³C]galactose administration and LW/BW was 0.889 (p < 0.0001). The correlation coefficient between SP²⁵ after [1-¹³C]galactose administration and LW/BW was highest, 0.923 (p < 0.0001). Conclusion: In the breath test with intravenously administered [1-¹³C]galactose, hepatopathy could be evaluated by measuring S³⁰ and hepatopathy could be more accurately quantitatively evaluated by measuring SP²⁵ over a short period.

Pheochromocytoma presenting as an abdominal emergency: association with perforation of the colon.

A pheochromocytoma is a rare tumor derived from the adrenal medulla (or from chromaffin cells of sympathetic ganglia). Its symptoms derive mostly from the excessive release of catecholamines (adrenaline and noradrenaline). Hypertension is the most recognized feature of this disease, but gastrointestinal manifestations can on rare occasions be just as serious and life threatening. This report describes a rare case of a 70-year-old woman with pheochromocytoma who developed an acute abdominal emergency with shock and panperitonitis as a result of perforation of the descending colon which was effectively treated by surgical removal of the tumor and the perforated colon. There have been 2 such cases in the English literature in whom a pheochromocytoma was associated with perforation of the colon. Successful surgical removal of such a pheochromocytoma has been not reported previously. Our case demonstrates the importance of recognizing that a pheochromocytoma presents with a wide spectrum of manifestations, and rapid treatment brings improvement to the patient.

Guidelines for the Assessment of the Therapeutic Efficacy of Antibiotics for Postoperative Infections in Japan (1997)

7Second Department of Surgery, Wakayama Medical School, Wakayama 2Digestive Center, Matsunami General Hospital, Gifu 3Department of Obstetrics and Gynecology, Kohtoh Hospital, Tokyo 4Department of Urology, National Hospital Kyushu Medical Center, Fukuoka SGeneral Surgery, Saitama National Hospital, Saitama 6Department of Mathematics, Kansai Medical University, Moriguchi ZDepartment of Clinical Pathology, School of Medicine, Juntendo University, Tokyo 8Third Department of Surgery, School of Medicine, Nihon University, Tokyo 9Institute of Medical Science, School of Medicine, St. Marianna University, Kawasaki 1~ of Surgery, Tokyo Dental College, Ichikawa General Hospital, Ichikawa ~Nagoya Municipal Kosei Hospital, Nagoya ~2Second Department of Surgery, Medical School, Osaka City University, Osaka 73Department of General Medicine, School of Medicine, Hiroshima University, Hiroshima, Japan

Radical surgery for Budd-Chiari syndrome. Direct Excision and repair for obstruction of the Vena Cava (Budd-Chiari syndrome) under hepatic vascular exclusion using a centrifugal pump

OBJECTIVE To attempt to reduce the incidence of hepatic and cardiac failure after radical surgery for the Budd-Chiari syndrome. DESIGN Retrospective case study. SETTING University hospital, Japan SUBJECTS Three patients with obstruction of the vena cava (Budd-Chiari syndrome) by a thick membrane, thrombus, and a long stenosis, respectively. INTERVENTION Direct excision and repair by patch dilatation under hepatic vascular exclusion using a Biomedicus centrifugal pump. RESULTS Hepatic vascular exclusion provides good visibility and enables accurate assessment of the obstruction, proper treatment, and relatively little blood loss. There were no complications, particularly liver failure or heart failure, and the inferior vena cava stayed patent in all cases. Liver function was improved in all three patients. CONCLUSION This technique is safe and reliable for removal of obstruction of the inferior vena cava (Budd-Chiari syndrome).

A questionnaire survey on the theory of postoperative infection prophylaxis in gynecology

A questionnaire survey on the theory of postoperative infection prophylaxis was conducted to obtain the consensus on perioperative antimicrobial use among gynecologists in Japan in the period from April to July 2000. Fifty-six of the 83 gynecologists replied, and the following consensus was obtained. An antimicrobial prophylaxis (AMP) agent should be chosen based on their efficacy against the pathogens expected to be contaminants, such as Staphylococcus spp., Escherichia coli and Bacteroides fragilis group. Use an AMP agent that archives a bactericidal concentrations in both the serum and operating site. Use an AMP agent that has little unfavourable side effects. The newer agents should be considered as a therapeutics for postoperative infections. The therapeutic antimicrobial agents having no cross-resistance to the AMP agents should be used, if postoperative infection is suspected or developed. The most commonly used agent for clean operations are cefazolin (CEZ), followed by cefotiam (CTM) and cefmetazole (CMZ). The most commonly used agent for clean-contaminated operations where low grade level of bacterial invasion expected is CTM, followed by CEZ and CMZ, where as operations where mild grade level of bacterial invasion expected is flomxef (FMOX), followed by CTM and other cephalosporins.