Yukinari Ohmori

Operative Morbidity Associated with Groin Dissections

Purpose.Groin dissection remains the treatment of choice for malignant neoplasms of the skin in the lower extremities and perineum. We sought to quantify the hospital complications after groin dissection, and to identify the patient- and procedure-related factors affecting these complications.Methods.We reviewed 20 consecutive patients who underwent a collective 25 groin dissections for malignant neoplasms of the skin between 1996 and 2002 to determine the incidence and degree of morbidity, and to analyze the clinical factors associated with morbidity. An S-shaped incision was used for the first 8 procedures, whereas a straight incision was used for the next 17.Results.The overall incidences of complications were 24% for wound infection, 52% for skin flap problems, 32% for seromas, 40% for edema, and 4% for hemorrhage, whereas the incidences of moderate to severe complications were 16% for wound infection, 16% for skin flap problems, 12% for seromas, 4% for edema, and 4% for hemorrhage. The incidence of wound infection tended to be higher after S-shaped incisions than after straight incisions (P = 0.059), and the incidence of leg edema was significantly higher after S-shaped incisions than after straight incisions (P = 0.028).Conclusion.S-shaped incisions more often resulted in lymphatic collection and stagnation, with a higher incidence of wound infections and leg edema than straight incisions. Therefore, we now perform straight incisions to minimize the risk of wound infections and leg edema.

Laparoscopic Lymphatic Mapping and Sentinel Node Biopsies for Early-stage Gastric Cancer: The Cause of False Negativity

Sentinel node (SN) biopsies might be useful for performing minimally invasive surgery without interrupting surgical curability. This study examined the cause of false negativity during laparoscopic lymphatic mapping and SN biopsies for early-stage gastric cancer. Thirty-seven patients with gastric cancer (preoperative stage T1-2 or N0) who underwent laparoscopic lymph node mapping and SN biopsies between March 2001 and June 2004 were enrolled in this study. The tracer, patent blue and technecium-99m-labeled tin colloid, was injected endoscopically. Blue-stained or radioactive nodes were defined as SNs. Gastrectomy with lymphadenectomy was performed then the results of the SN biopsies were compared with the final diagnosis of the removed lymph nodes in permanent sections. Sentinel nodes were successfully identified in 35 patients (94.6%), and they were positive in 3 of 4 patients with metastatic lymph nodes; sensitivity was 75% and specificity was 100%. Sentinel node status could therefore be used to diagnose lymph node status with 97.1% accuracy. Of 6 SNs with metastasis, 5 showed radioactivity, and only 2 were blue stained. In the false negative case, a radioactive SN with metastasis in the right paracardial region was missed during laparoscopic mapping. An error in laparoscopic intracorporeal detection of the radioactive node with metastasis occurred because we could not eliminate the shine-through effect. We found that during laparoscopic SN mapping there is a high risk of false negativity with SNs located in the right paracardial region. To apply laparoscopic SN mapping to early-stage gastric cancer patients, the shine-through effect must be eliminated because radiotracers are essential for this method.

Lymphatic Mapping and Sentinel Node Biopsy during Laparoscopic Gastrectomy for Early Cancer

Background/Aims: Intraoperative lymphatic mapping and sentinel node (SN) biopsy can potentially be combined with minimally invasive surgery, but there are few reports of laparoscopic lymphatic mapping for gastrointestinal cancer. We examined the feasibility and accuracy of laparoscopic lymphatic mapping in predicting lymph node status in patients with gastric cancer. Methods: Seventeen patients with gastric cancer invading the mucosal or submucosal layers (T1) underwent laparoscopic gastrectomy with lymphatic mapping between March 2001 and May 2002. The day before surgery, a technetium-99m-labelled tin colloid solution was injected endoscopically around the tumor. Immediately after the pneumoperitoneum, patent blue was injected. Gastrectomy was performed in all patients, and blue-stained or radioactive nodes were defined as SNs. Fresh SNs were immediately processed for frozen-section examination by hematoxylin-eosin (H&E) and immunohistochemical (IHC) staining. All non-SNs harvested from resected specimens were subjected to histological examination with H&E. Results: SNs were detected in all patients by combination of the two kinds of tracers. Three patients had lymph node metastases in their final examination, and SNs in these 3 were operatively diagnosed as positive by H&E or IHC staining. Lymphatic mapping and SN biopsy under laparoscopic surgery were performed with 100% accuracy. Conclusion: Our preliminary study shows the feasibility of intraoperative lymphatic mapping in laparoscopic gastrectomy for T1 gastric cancer.

Factors predicting postoperative infectious complications and early induction of inflammatory mediators in ulcerative colitis patients.

BackgroundPositive outcomes after restorative proctocolectomy are compromised by a number of specific septic complications. However, there is no useful perioperative marker predicting postoperative infectious complications (PICs) in steroid overdosed patients with ulcerative colitis (UC).MethodsTo determine factors associated with PICs and their relation to circulating levels of pro- and anti-inflammatory cytokines and neutrophil elastase (NE), we obtained perioperative blood samples from 60 UC patients.ResultsPostoperative infectious complications were identified in 47% of cases. Patients who developed PICs had significantly longer disease duration, had been administered a greater total preoperative dosage of prednisolone, and had a higher body mass index. Logistic regression analysis showed that the total preoperative dosage of prednisolone was independently associated with the development of PICs. These patients showed suppressed systemic inflammation and pro- and anti-inflammatory cytokine induction. An early increase in the NE level was found to be predictive of PICs in the high-dose group, whereas there was no significant difference in neutrophil counts between the high- and low-dose groups.ConclusionsCirculating NE levels in the early postoperative period might be a useful predictor of PICs in immune-controlled UC patients who received high doses of steroids.

Successful treatment of refractory hepatic lymphorrhea after gastrectomy for early gastric cancer, using surgical ligation and subsequent OK-432 (Picibanil) sclerotherapy.

Postoperative hepatic lymphorrhea is a very rare complication after abdominal surgery. Hepatic lymphorrhea, not containing chyle, involves an internal lymph fistula between the lymphatic channels toward the cisterna chyli and the peritoneal cavity. Over the past 20 years, 17 cases have been reported in Japan. Here, we report a further case, of a patient with successfully treated intractable hepatic lymphorrhea following gastrectomy for early gastric cancer. We review 18 cases, including the present case, with respect to the management of postoperative lymphorrhea refractory to conventional medical treatment.

Serum monocyte chemoattractant protein-1 in patients with postoperative infectious complications from gastrointestinal surgery for cancer

We examined the kinetics of serum monocyte chemoattractant protein-1 (MCP-1) perioperatively and clarified its significance regarding the development of infectious complications. We studied 94 patients who underwent gastrointestinal surgery for gastric or colorectal cancer at Mie University Hospital from 1996 to 2000. Serum concentrations of MCP-1 and interleukin-6 (IL-6) were measured perioperatively. The number of circulating lymphocytes and neutrophils were counted to assess the apoptotic rate of neutrophils. Patients were divided into two groups at the median preoperative MCP-1 level obtained from 40 gender-and agematched healthy volunteers. The rate of developing infectious complications was significantly higher and tumor size was significantly larger in the low MCP-1 group than in the high MCP-1 group. The increasing IL-6 ratio (postoperative/preoperative IL-6 level) in the low MCP-1 group was about twofold greater than that in the high MCP-1 group. The neutrophil level calculated for the low MCP-1 group was significantly higher than that in the high MCP-1 group on postoperative day 3. We concluded that a decreased level of serum MCP-1 reflected tumorrelated immunosuppression. Low MCP-1 levels were associated with an exaggerated postoperative IL-6 response and delayed neutrophil apoptosis, which affected the incidence of postoperative infectious complications developing in patients with gastrointestinal malignancies.RésuméNous avons examiné la cinétique périopératoire de la protéine monocytaire chimiosensible 1 (MCP-1) et avons clarifié sa signification dans le développement de complications infectieuses. Quatrevingt quatorze patients opérés entre 1996 et 2000 pour cancer gastrique ou colorectal à l’hôpital universitaire Mie ont été étudiés. Les concentrations sériques de MCP-1 et de l’interleukine (IL)-6 ont été dosées en périopératoire. Pour l’évaluation du taux de l’apoptose des neutrophiles, le nombre de lymphocytes circulants et de neutrophiles a été compté. Les patients ont été divisés en deux groupes selon la value médiane des taux de MCP-1, obtenue à partir de 40 volontaires appariés pour le sexe et pour l’âge. Le taux de complications infectieuses a été significativement plus élevé, et la taille tumorale significativement plus importante dans le groupe de MCP-1 en dessous de la valeur médiane (MCP-1 inf) par rapport au groupe de MCP-1 au-dessus (MCP-1 sup). Le rapport (taux d’IL-6 postopératoire/taux d’IL-6 préopératoire) dans le groupe de MCP-1 inf était approximativement deux fois ceux du groupe MCP-1 sup. Le taux de neutrophiles calculé dans le groupe MCP-1 inf a été significativement plus élevé que le group MCP-1 sup au troisième jour postopératoire. En conclusion, nous considérons que le taux diminué de MCP-1 sérique témoigne d’une immunodépression tumorale. Un taux de CP-1 plus bas était associé à une réponse IL-6 postopératoire exagérée et un retard de l’apoptose neutrophile, ce qui a influencé l’incidence des complications postopératoires infectieuses chez le patient porteur de maladie maligne gastro-intestinale.ResumenCon objeto de aclarar la trascendencia que tiene en el desarrollo de complicaciones infecciosas estudiamos, la cinética durante el perioperatorio del factor quimiotáctico proteina-1 monocitario (MCP-1). Se estudiaron 94 pacientes sometidos a cirugía gastrointestinal por cáncer gástrico o colorrectal entre los años 1996–2000 en el Hospital Universitario de Mie. Se determinaron en el perioperatorio las concentraciones séricas de MCP-1 e interleucina (IL-6). Se realizó un recuento del número de linfocitos y neutrófilos circulantes con objeto de averiguar la tasa de apoptosis de los neutrófilos. En concordancia con los niveles preoperatorios de MCP-1 y tomando como referenda los valores medios obtenidos en 40 voluntaries sanos comparables tanto por lo que al sexo como por lo que a la edad se refiere, los pacientes se dividieron en 2 grupos. En el grupo con bajos niveles de MCP-1 el porcentaje de complicaciones infecciosas fue significativamente mayor al igual que el tamaño de los tumores, que en el grupo con niveles de MCP-1 elevados. En el grupo con niveles bajos de MCP-1 el incremento del cociente IL-6 (nivel de IL-6 postoperatorio/nivel de IL-6 preoperatorio) duplicó al del grupo con niveles de MCP-1 elevados. En POD3, el valor de los neutrófilos, calculado para el grupo con niveles bajos de MCP-1 fue significativamente mayor que en el grupo con niveles de MCP-1 elevados. En conclusión, consideramos que el descenso del nivel sérico de MCP-1 refleja un estado de inmunosupresión propiciado por el tumor. Niveles bajos de MCP-1 se acompañaron de una hiperrespuesta postoperatoria de la IL-6 así como de un retraso en la apoptosis de los neutrófilos, lo que se relaciona con la incidencia de las complicaciones infecciosas desarrolladas en pacientes con neoplasias malignos gastrointestinales.

Evaluation of tap water for surgical handwashing

PurposeIn Japan, sterile water is used for rinsing in surgical handwashing, whereas in Western countries tap water is generally used. We conducted this study to examine the conditions and the equipment that affect bacterial contamination in tap water and to determine whether the tap water in our institute is suitable for surgical handwashing.MethodsFirst, we examined the water pipes and measured the free chlorine content in the tap water in the operating room. Next, we recruited 40 volunteers and conducted preliminary tests with sterile water. Thirty of these subjects participated in a handwashing test using tap water.ResultsThe mean free chlorine levels in the tap water and the sterile water were 0.30 ± 0.05 and 0.07 ± 0.03 mg/l, respectively. The handwashing test using tap water showed immediate, persistent, and cumulative bacteria activity within the minimum limits set by the Food and Drug Administration (FDA).ConclusionThe free chlorine levels in the tap water in our institute satisfied Japanese health regulations. Moreover, the handwashing test met the criteria of the FDA. Thus, we conclude that this tap water is safe to use for rinsing in surgical handwashing.

Cardiac tamponade as a postoperative complication of spontaneous esophageal rupture

We report a case of Boerhaaves syndrome developing cardiac tamponade caused by an esophageal leak after primary repair, despite a normal postoperative contrast study. A 65-year-old man underwent emergency surgery for spontaneous esophageal rupture leading to septic shock. He recovered from the septic condition within 2 weeks. Oral intake was started on the 17th postoperative day with no evidence of esophageal leak. Hypotension, tachycardia, and low urine output gradually developed, although he was not in a septic condition. Chest computed tomography demonstrated a large pericardial effusion with a floating heart, consistent with cardiac tamponade. On the 26th postoperative day, pericardiocentesis resulted in symptomatic and hemodynamic improvement. Because of an increase in leukocyte count and C-reactive protein after oral intake, esophageal leak was suspected as the possible cause of effusive pericarditis leading to cardiac tamponade. Water-soluble contrast examination revealed a small esophageal leak at the repaired site on the 27th postoperative day. Cardiac tamponade is a rare complication of Boerhaaves syndrome. Cardiac tamponade caused by esophageal leak may occur after primary repair of the tear in a patient with Boerhaaves syndrome and should be considered as a cause of hypotension, tachycardia, and low urine output during the postoperative course.

Modified pharmacokinetic modulating chemotherapy using 5-fluorouracil, UFT, and taxotere (docetaxel) for advanced gastric cancer

The efficacy of neoadjuvant chemotherapy for advanced gastric carcinoma is controversial. Moreover, a standard regimen for such chemotherapy has not been clearly established. Pharmacokinetic modulating chemotherapy (PMC), a combination of infused 5-fluorouracil and oral uracil-tegafur, has been proven to be highly effective for the treatment of colorectal carcinoma. We report two patients with advanced gastric carcinoma successfully treated with PMC and infused taxotere (TXT; docetaxel). Preoperative treatment with PMC and TXT significantly decreased the depth of wall penetration of the tumor in one patient and reduced the size of the tumor in the other patient. In both patients, there were significant chemotherapeutic effects on the primary tumor and on regional lymph nodes pathologically. Preoperative PMC plus TXT produced primary tumor downstaging, leading to improved resectability. The responsiveness of metastatic cancer cells in the regional lymph nodes suggested the possibility of nodal downstaging by this regimen.