Yasushi Harihara

Laparoscopic versus open adrenalectomy for adrenal myelolipoma.

Introduction Earlier reports of laparoscopic adrenalectomy (LA) for adrenal myelolipoma are limited. Presentation of case Between June 2000 and September 2012, we performed right adrenal resections using LA and open adrenalectomy (OA) in patients with myelolipoma (n = 3 and n = 3, respectively). Then, we evaluated patients background characteristics and short- and long-term outcomes for both groups. The median maximum diameters of tumors were 3.5 (3.0–4.4) cm and 7.1 (7.0–9.5) cm for the LA and OA groups, respectively. The median durations of the operation were 152 (117–188) min and 218 (153–230) min, and the median blood loss volumes were 50 (20–160) mL and 290 (62–1237) mL in the LA and OA groups, respectively. The median postoperative lengths of hospital stay were 4 (4–4) days and 11 (11–13) days for the LA and OA groups, respectively. Conversion from LA to an open approach during surgery was not necessary in any of the cases. Additionally, perioperative morbidity and mortality were not observed. Discussion The limitation of this study is its methodological design; it is a case series and not a matched-control study, which would be difficult to conduct owing to the rare nature of adrenal myelolipoma. However, we esteem that LA will become widespread in the future because it is feasible, cosmetic, and less invasive. Conclusion LA was a safe, feasible, and effective approach to adrenal myelolipoma, assisted by advancement in preoperative imaging diagnostic techniques.

Antimicrobial susceptibility of pathogens isolated from surgical site infections in Japan: Comparison of data from nationwide surveillance studies conducted in 2010 and 2014–2015

A nationwide survey was conducted in Japan from 2014 to 2015 to investigate the antimicrobial susceptibility of pathogens isolated from surgical site infections (SSI). The resulting data were compared with that obtained in an earlier survey, conducted in 2010. Seven main organisms were collected, and 883 isolates were studied. A significant reduction in methicillin resistance was observed among Staphylococcus aureus isolates, dropping from 72.5% in 2010 to 53.8% in 2014-2015 (pxa0<xa00.001). MRSA isolates with a vancomycin minimum inhibitory concentration (MIC) of 2xa0μg/mL accounted for 1.2% of all MRSA isolates, which was significantly lower than in 2010 (9.7%, pxa0=xa00.029). Of the Escherichia coli isolates, 23.0% produced an extended spectrum β-lactamase (ESBL) in the 2014-2015 survey, which was a significant increase from 9.5% in 2010 (pxa0=xa00.011). The geometric mean MICs for ESBL-producing isolates were 0.07xa0μg/mL for meropenem, 9.51xa0μg/mL for tazobactam/piperacillin, 0.15xa0μg/mL for flomoxef, and 1.56xa0μg/mL for gentamycin. There was a significant increase in the isolation rate of non-fragilis Bacteroides among Bacteroides fragilis group species between the two study periods (35.2% vs. 53.1%, pxa0=xa00.007). More than 90% of isolates belonging to the B.xa0fragilis group remained susceptible to tazobactam/piperacillin, meropenem, and metronidazole. In contrast, lower levels of susceptibility were observed for cefmetazole (49.6%), moxifloxacin (61.9%), and clindamycin (46.9%). Non-fragilis Bacteroides isolates had lower rates of antibiotic susceptibility compared with B.xa0fragilis. Overall, the surveillance data clarified trends in antimicrobial susceptibility for organisms commonly associated with SSI.

Real-time confocal laser endomicroscopic evaluation of primary liver cancer based on human liver autofluorescence: Endomicroscopy of Primary Liver Cancer

Confocal laser endomicroscopy (CLE) is available for real‐time microscopic examination. This study aims to evaluate the usefulness of intraoperative CLE examination as a modality to evaluate surgical margins in surgery for primary liver cancer.

Clinical evaluation of the aberrant left hepatic artery arising from the left gastric artery in esophagectomy

PurposeThe left gastric artery (LGA) is commonly severed when the gastric tube is made for esophageal reconstruction. Sacrifice of the LGA can cause liver ischemic necrosis in patients with an aberrant left hepatic artery (ALHA) arising from the LGA. We experienced a case of life-threatening hepatic abscess after severing the ALHA. Therefore, the purpose of this study is to evaluate clinical outcomes of severing the ALHA.MethodsWe retrospectively enrolled 176 consecutive patients who underwent esophagectomy with gastric tube reconstruction. They were classified into the ALHA (Nu2009=u200916, 9.1%) and non-ALHA (Nu2009=u2009160, 90.9%) groups. Univariate analysis was performed to compare the clinicopathological variables. Long-term survival was analyzed using the Kaplan–Meier method in matched pair case–control analysis.ResultsThe postoperative morbidities were not statistically different between the two groups, although serum alanine aminotransferase levels on postoperative days 1 and 3 were significantly higher in the ALHA group (36xa0IU/L, 14–515; 32xa0IU/L, 13–295) than in the non-ALHA group (24xa0IU/L, 8–163; 19xa0IU/L, 6–180), respectively (pu2009=u20090.0055; pu2009=u20090.0073). Overall survival was not statistically different between the two groups (pu2009=u20090.26).ConclusionsSevere hepatic abscess occurred in 6.3% of the patients with the ALHA after esophagectomy, even though the results presented here found no statistical differences in morbidity or mortality with or without the ALHA. Surgeons should probably attempt to preserve the ALHA especially in patients with altered liver function while making a gastric tube for esophageal reconstruction.

Two-stage hepatectomy aiming for the development of intrahepatic venous collaterals for multiple colorectal liver metastases

BackgroundAggressive hepatectomy with venous resection has a higher risk of postoperative liver failure (POLF) than hepatectomy without venous reconstruction; however, venous reconstruction is technically demanding. We performed a novel two-stage hepatectomy (TSH) without venous reconstruction in a patient with bilobar multiple colorectal liver metastases located near the caval confluence, waiting for the development of intrahepatic venous collaterals between procedures.Case presentationA 60-year-old man was referred to our hospital with sigmoid colon cancer accompanied by intraabdominal abscess and two synchronous liver metastases. One of the liver tumors (tumor 1) was located in segment 8 near the caval confluence and was attached to both the right hepatic vein (RHV) and middle hepatic vein (MHV). The other tumor (tumor 2) in the left lobe invaded the umbilical portion of the portal vein. Both liver metastases decreased in size after four cycles of panitumumab/5-fluorouracil, leucovorin, and oxaliplatin (FOLFOX) therapy. Radical liver resection was planned because tumor 1 had not invaded the MHV. However, three-dimensional volumetric software showed that the non-congested volume of the future liver remnant was estimated at 354xa0ml, which corresponded to 26.3% of the total liver volume. TSH was scheduled to avoid POLF. We first performed limited resection of segment 8 with resection of the RHV root. After the first hepatectomy, the development of intrahepatic venous collaterals between the RHV and MHV was seen on computed tomography and magnetic resonance imaging. The estimated non-congested future liver remnant was 1242xa0ml, 78.5% of the total liver volume. Therefore, the patient underwent left hemihepatectomy 58xa0days after the first hepatectomy. We saw no adhesions around the porta hepatis, and the left hepatic artery and left branch of the portal vein were safely exposed and divided. Intraoperative Doppler ultrasonography revealed intrahepatic venous collaterals arising from RHV to MHV. The patient’s postoperative course was uneventful, and he underwent eight cycles of panitumumab/FOLFOX therapy for 5xa0months after the second hepatectomy.ConclusionsOur TSH strategy helped avoid POLF by waiting for the development of intrahepatic venous collaterals.

Portal encasement: Significant CT findings to diagnose local recurrence after pancreaticoduodenectomy for pancreatic cancer

BACKGROUND/OBJECTIVESnTo demonstrate the utility of portal encasement as a criterion for early diagnosis of local recurrence (LR) after pancreaticoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDAC).nnnMETHODSnA total of 61 patients who underwent PD for PDAC were included in this retrospective study. Portal stenosis was evaluated by sequential postoperative computed tomography (CT) scans and correlated with disease recurrence. In addition to the conventional LR diagnostic criterion of a growing soft tissue mass, LR was evaluated using portal encasement as an additional diagnostic criterion. Portal encasement was defined as progressive stenosis of the portal system accompanied by a soft tissue mass, notwithstanding the enlargement of the mass.nnnRESULTSnBenign portal stenosis was found on the first postoperative CT imaging in 16 patients. However, stenosis resolved a median of 81 days later in all but one patient whose stenosis was due to portal reconstruction during PD. Portal encasement could be distinguished from benign portal stenosis based on the timing of emergence of the portal stenosis. Portal encasement developed in 13 of the 19 patients with LR, including 6 patients in whom the finding of portal encasement led to the diagnosis of LR a median of 147 days earlier with our diagnostic criterion compared with the conventional diagnostic criteria.nnnCONCLUSIONSnPortal encasement should be considered as a promising diagnostic criterion for earlier diagnosis of LR after PD for PDAC.

Corrigendum to “Antimicrobial susceptibility of common pathogens isolated from postoperative intra-abdominal infections in Japan” [J Infect Chemother 24 (2018) 330–340]

Yoshio Takesue a, w, , Shinya Kusachi a, , Hiroshige Mikamo a, , Junko Sato , Akira Watanabe , Hiroshi Kiyota , Satoshi Iwata , Mitsuo Kaku , Hideaki Hanaki , Yoshinobu Sumiyama c, , Yuko Kitagawa c, , Kazuhiko Nakajima , Takashi Ueda , Motoi Uchino , Toru Mizuguchi , Yoshiyasu Ambo , Masafumi Konosu , Keiichiro Ishibashi , Akihisa Matsuda , Kazuo Hase , Yasushi Harihara , Koji Okabayashi , Shiko Seki , Takuo Hara , Koshi Matsui , Yoichi Matsuo , Minako Kobayashi , Shoji Kubo , Kazuhisa Uchiyama , Junzo Shimizu , Ryohei Kawabata , Hiroki Ohge , Shinji Akagi , Masaaki Oka , Toshiro Wakatsuki , Katsunori Suzuki , Kohji Okamoto , Katsunori Yanagihara ae

Antimicrobial susceptibility of common pathogens isolated from postoperative intra-abdominal infections in Japan

The principle of empirical therapy for patients with intra-abdominal infections (IAI) should include antibiotics with activity against Enterobacteriaceae and Bacteroides fragilis group species. Coverage of Pseudomonas aeruginosa, Enterobacter cloacae, and Enterococcus faecalis is also recommended for hospital-associated IAI. A nationwide survey was conducted to investigate the antimicrobial susceptibility of pathogens isolated from postoperative IAI. All 504 isolates were collected at 26 institutions and referred to a central laboratory for susceptibility testing. Lower susceptibility rates to ciprofloxacin and cefepime were demonstrated in Escherichia coli. Among E.xa0coli, 24.1% of strains produced extended-spectrum β-lactamase (ESBL). Carbapenems, piperacillin/tazobactam, cephamycins/oxacephem, aminoglycosides, and tigecycline had high activity against E.xa0coli, including ESBL-producing isolates. Among E.xa0cloacae, low susceptibility rates to ceftazidime were demonstrated, whereas cefepime retained its activity. P.xa0aeruginosa revealed high susceptibility rates to all antimicrobials tested except for imipenem. Among B.xa0fragilis group species, low levels of susceptibility were observed for cefoxitin, moxifloxacin, and clindamycin, and high susceptibility rates were observed for piperacillin/tazobactam, meropenem, and metronidazole. Ampicillin, piperacillin, and glycopeptides had good activity against E.xa0faecalis. Imipenem had the highest activity against E.xa0faecalis among carbapenems. In conclusion, we suggested the empirical use of antimicrobials with the specific intent of covering the main organisms isolated from postoperative IAI. Piperacillin/tazobactam, meropenem, or doripenem, are appropriate in critically ill patients. Combination therapy of cefepime (aztreonam in patients with β-lactam allergy) plus metronidazole plus glycopeptides, imipenem/cilastatin or cephamycins/oxacephem plus ciprofloxacin plus metronidazole are potential therapeutic options.

1012The Effect of Modification of Operative Procedure Category in the Surgical Site Infections Surveillance in Japan: Toward the Better Stratification

Surgical Site Infections Surveillance in Japan: Toward the Better Stratification Keita Morikane, MD, PhD; Akihiro Sawa, PharmD; Junzo Shimizu, MD, PhD; Hisami Tanimura, RN, CNIC; Yasushi Harihara, MD, PhD; Infection Control, Yamagata University Hospital, Yamagata, Japan; Hiroshima International University, Kure, Japan; Osaka Rosai Hospital, Sakai, Japan; NTT Kanto Hospital, Tokyo, Japan; Surgery, NTT Kanto Hospital, Tokyo, Japan

Development of a New Compact Intraoperative Magnetic Resonance Imaging System: Concept and Initial Experience

BACKGROUND: Magnetic resonance imaging (MRI) during surgery has been shown to improve surgical outcomes, but the current intraoperative MRI systems are too large to install in standard operating suites. Although 1 compact system is available, its imaging quality is not ideal. OBJECTIVE: We developed a new compact intraoperative MRI system and evaluated its use for safety and efficacy. METHODS: This new system has a magnetic gantry: a permanent magnet of 0.23 T and an interpolar distance of 32 cm. The gantry system weighs 2.8 tons and the 5-G line is within the circle of 2.6 m. We created a new field-of-view head coil and a canopy-style radiofrequency shield for this system. A clinical trial was initiated, and the system has been used in 44 patients. RESULTS: This system is significantly smaller than previous intraoperative MRI systems. High-quality T2 images could discriminate tumor from normal brain tissue and identify anatomic landmarks for accurate surgery. The average imaging time was 45.5 minutes, and no clinical complications or MRI system failures occurred. Floating organisms or particles were minimal (1/200 L maximum). CONCLUSION: This intraoperative, compact, low-magnetic-field MRI system can be installed in standard operating suites to provide relatively high-quality images without sacrificing safety. We believe that such a system facilitates the introduction of the intraoperative MRI. ABBREVIATIONS: FLAIR, fluid-attenuated inversion recovery FOV, field of view RF, radiofrequency