Randomized clinical trial of 24 versus 72 h antimicrobial prophylaxis in patients undergoing open total gastrectomy for gastric cancer

BACKGROUND

Open total gastrectomy carries a high risk of surgical-site infection (SSI). This study evaluated the non-inferiority of antimicrobial prophylaxis for 24 compared with 72 h after open total gastrectomy.

METHODS

An open-label, randomized, non-inferiority study was conducted at 57 institutions in Japan. Eligible patients were those who underwent open total gastrectomy for gastric cancer. Patients were assigned randomly to continued use of β-lactamase inhibitor for either 24 or 72 h after surgery. The primary endpoint was the incidence of SSI, with non-inferiority based on a margin of 9 percentage points and a 90 per cent c.i. The secondary endpoint was the incidence of remote infection.

RESULTS

A total of 464 patients (24 h prophylaxis, 228; 72 h prophylaxis, 236) were analysed. SSI occurred in 20 patients (8·8 per cent) in the 24-h prophylaxis group and 26 (11·0 per cent) in the 72-h group (absolute difference -2·2 (90 per cent c.i. -6·8 to 2·4) per cent; P < 0·001 for non-inferiority). However, the incidence of remote infection was significantly higher in the 24-h prophylaxis group.

CONCLUSION

Antimicrobial prophylaxis for 24 h after total gastrectomy is not inferior to 72 h prophylaxis for prevention of SSI. Shortened antimicrobial prophylaxis might increase the incidence of remote infection. Registration number: UMIN000001062 ( http://www.umin.ac.jp).

Linezolid versus vancomycin for the treatment of infections caused by methicillin-resistant Staphylococcus aureus in Japan

OBJECTIVES

To compare the efficacy and safety of linezolid and vancomycin for the treatment of methicillin-resistant Staphylococcus aureus (MRSA) infections in Japan.

METHODS

Patients with nosocomial pneumonia, complicated skin and soft-tissue infections or sepsis caused by MRSA were randomized to receive linezolid (600 mg every 12 h) or vancomycin (1 g every 12 h).

RESULTS

One hundred patients received linezolid and 51 received vancomycin with outcomes evaluated at the end of therapy (EOT) and at the follow-up (FU), 7-14 days later. At EOT, clinical success rates in the MRSA microbiologically evaluable population were 62.9% and 50.0% for the linezolid and vancomycin groups, respectively; and microbiological eradication rates were 79.0% and 30.0% in the two groups, respectively (P < 0.0001). At FU, the clinical success rates were 36.7% for both groups and the microbiological eradication rates were 46.8% and 36.7%, respectively. Reversible anaemia (13%) and thrombocytopenia (19%) were reported more frequently in linezolid patients; laboratory analysis showed mild decrease in platelet counts with full recovery by FU. The mean platelet count in linezolid patients with thrombocytopenia was 101,000/mm(3). Significantly low platelet counts (<50,000/mm(3)) were observed more frequently in patients receiving vancomycin than in linezolid patients (6% versus 3%). Mean changes in haemoglobin levels between the two groups were not different.

CONCLUSIONS

Linezolid is as effective as vancomycin for the treatment of MRSA infections and may be more effective than vancomycin in achieving microbiological eradication. Haematological adverse events were reported more frequently in linezolid-treated patients; analysis of laboratory data showed a mild reversible trend towards lower platelet counts.

Omental cyst: report of a case

We report the case of an omental cyst, a rare type of abdominal cystic lesion that is difficult to diagnose preoperatively. A 43-year-old man with no clinical symptoms was admitted to our hospital for investigation of an abdominal cyst detected by ultrasonography (US). We performed diagnostic examinations including US, computed tomography, and magnetic resonance imaging. An omental cyst was diagnosed because of its position and connection to the surrounding tissues. Pathological examination of the surgical specimen revealed endothelial cells on its internal wall and colonies of lymphocytes, confirming a diagnosis of lymphangioma, which is the most common type of omental cyst.

[Guidelines for perioperative antibiotic use in digestive tract surgery]

Guidelines for the use of antibiotics in postoperative infections after digestive tract surgery have been under discussion in Japan since the mid-1980s, when the number of infections with methicillin-resistant Staphylococcus aureus began to increase. It is important to make a distinction between prophylactic and therapeutic antibacterial administration in the perioperative period. Prophylactic antibacterial administration to prevent postoperative infection is necessary to prevent surgical site infection and remote infection from invading the surgical site. Because the type of bacterial contamination of the surgical site differs with the organ undergoing surgery, the type of antibiotic selected also differs. Antibiotic administration to prevent postoperative infection after surgery requiring a short time to perform may be started preoperatively. In patients undergoing prolonged surgery, antibiotics are administered every 3 hours. If an antibacterial agent is administered for 3-4 days, there is a risk of the development of resistance and therefore administration should not exceed 3-4 days, including the day of surgery. However, during surgery in which bacterial contamination is already evident, the therapeutic use of antibiotics should be initiated at diagnosis. For example, toxinemia is common in many cases of colon rupture and the administration of powerful antibiotics is necessary to save patients' lives.

A case of adenoid cystic carcinoma (ACC) of the breast and review of the utility of preoperative imaging diagnose

A case of adenoid cystic carcinoma (ACC) of the breast in a 66-year-old woman is reported herein. ACC accounts for about 0.1% of all breast cancers. Our patient presented with a small, elastic and hard mass, measuring 2.0x2.0 cm, between both outer quadrants of the right breast. Although physical examination, ultrasonography and magnetic resonance (MR) mammography suggested a benign tumor, aspiration biopsy cytology (ABC) was performed twice, and the second ABC specimen was evaluated as suspicious for breast carcinoma. Breast conserving surgery with a level II lymph node dissection was subsequently performed. There was no lymph node metastases and estrogen receptor (ER) status was negative. Light microscopy revealed various growth patterns, with the cells showing biphasic cellularity. According to immunohistochemical analyses, CEA, actin and vimentin were positive, S-100 protein was negative, and the cytokeratin reaction was partially positive. Therefore, ACC of the breast was diagnosed. Although ACC of the breast is a rare neoplasm, it should be considered in the differential diagnosis even if various diagnostic imaging studies suggest a benign tumor of the breast. Awareness of this tumor will help prevent misdiagnosis.

Herniation through both Winslow's foramen and a lesser omental defect: report of a case

The herniation of small bowel through Winslow's foramen is a rare type of internal hernia which can cause ileus; however, a hernia traversing the lesser sac is even more unusual. To the best of our knowledge, only 25 cases of herniation through Winslow's foramen and 10 cases of lesser sac hernia have been reported in the Japanese literature. We describe herein the case of a 33-year-old man who presented to our hospital complaining of abdominal pain in whom a plain abdominal radiograph revealed small bowel gas with air-fluid levels, suggesting ileus. Following admission, an ileus tube was inserted, but the intestinal shadow did not improve and surgery was performed based on suspicion of an internal hernia. Approximately 100 cm of ileum was found to have herniated through a defect in the lesser omentum after passing through Winslow's foramen. Since the herniated bowel was viable, manual reduction without resection was performed. The patient had a satisfactory postoperative course, and was discharged on postoperative day 11. There are many unknown aspects surrounding the etiology of Winslow's foramen hernia and lesser sac hernia, and although internal hernia is a rare cause of ileus, its possibility should be kept in mind.

[Photodynamic diagnosis and photodynamic therapy for experimental hepatoma with ME 2906]

We studied the effects of photodynamic diagnosis (PDD) and photodynamic therapy (PDT) in confirming the existence of hepatoma, using the new photosensitizer mono-L-aspartyl chlorine 6. Japanese white rabbits were selected for abdominal incision under intravenous anesthesia, and VX 2 tumor cells were transplanted into the left liver lobe to create a hepatoma model. In the experiment, hepatoma of 1 cm in diameter (at one week after transplantation) was radiated with a semiconducter laser (664 nm, 200 J/cm2) for treatment.

Clinical and analytical evaluation of the simultaneous HPLC assay of retinol and alpha-tocopherol

We describe a method for the simultaneous assay of retinol and alpha-tocopherol using normal-phase, high-performance liquid chromatography (HPLC). Our normal-phase HPLC method gave better resolution (Rs) of retinol (Rs= 1.58) and alpha-tocopherol (Rs = 1.40) when compared with the Rs values for a-tocopherol and retinol from literature. Also, the alpha-tocopherol concentrations obtained by our method agreed well with another normal-phase HPLC method that used fluorometric detection (r = 0.951, p<0.001. Sy.x=0.58 mg/L). The concentrations of retinol in our method agreed well with those determined by a reversed-phase HPLC procedure, although the correlation (r=0.646, p<.001, Sy.x=62 microg/L) was not as good as the method proposed. Our procedure gave acceptable precision: the within-run CV was 7.7% for alpha-tocopherol and 5.9% for retinol. The between-day CV was 9.0% for alpha-tocopherol and 6.8% for retinol. The mean recoveries were 97% for alpha-tocopherol and 107% for retinol. Our assays were linear for alpha-tocopherol concentrations from 0.1 to 30 mg/L and for retinol concentrations from 20 to 2,000 microg/L. In children ages 7 to 12 y, and in adolescents ages 14 to 16 y, the alpha-tocopherol and retinol concentrations in the blood were significantly lower than the concentrations in normal adults. Individuals over 70 y old also showed alpha-tocopherol and retinol values that were lower than those of normal adults between ages 30 and 40 y. In female university students, the inter-individual variation of alpha-tocopherol was reduced by dividing the alpha-tocopherol results by their total cholesterol or total lipid concentrations; however, this was not obtained for retinol. In cancer patients undergoing surgery, the ratio of retinol to retinol-binding protein (RBP) remained fairly constant, although the concentrations of both retinol and RBP decreased to about one-half the preoperative values after surgery. We conclude that our normal-phase HPLC method is a stable and reproducible method for alpha-tocopherol and retinol, and is an easy-to-use analytical tool.

[Treatment policy for colon cancer liver metastases]

Hepatectomy provides the highest rates of cure among the methods for treating colon cancer liver metastases, but it cannot be performed in many cases. Hepatectomy is the treatment of choice for colon cancer liver metastases in our department, but we conduct transcatheter arterial embolization alone or in combination with MCT on patients in whom hepatectomy cannot be performed or those with residual tumor following hepatectomy. Transcatheter arterial embolization is conducted on patients shown to have tumor vessels, following a single intra-arterial shot of an anticancer drug. MCT is performed under general anesthetic percutaneously or by abdominal section in patients who have not responded well to transcatheter arterial embolization, in order to improve the effectiveness of treatment on the tumor overall. We consider the combination of transcatheter arterial embolization and MCT to be an effective treatment for patients with a colon cancer liver metastasis who present with tumor vessels.

New methods of control against postoperative methicillin-resistant Staphylococcus aureus infection

The incidence of postoperative infections caused by methicillin-resistant Staphylococcus aureus (MRSA) in Japan has been increasing dramatically. In March 1990, we assigned special doctors in infection control (infection control doctor, ICD), and defined comprehensive controls against MRSA infection. A total of 3536 cases of digestive tract surgery performed at our department were studied during the period between September 1987 and August 1997. We changed the use of antibiotics to prevent postoperative infection. Cefazolin (CEZ) was employed for surgery of the upper digestive tract, including esophagus, stomach, duodenum, and gallbladder. Cefotiam (CTM) was employed for surgery of the lower digestive tract, liver, and pancreas. In esophageal resection, the tracheal tube was extracted during the early postoperative period, and for cervical esophagogastroanastomosis, the autosuture was changed to layer-to-layer anastomosis. We have achieved successful control of postoperative MRSA infection, the incidence having decreased to 0.3% (9/2703). In conclusion, our methods of control against postoperative MRSA infection implies that comprehensive measures of prevention, including the reviewed specification and usage of antibiotics and operation management, have been well implemented. This value is the lowest and the first of any domestic hospital or institute in Japan, suggesting a continued and significant decrease.

[A basic study of photodynamic therapy of experimental hepatoma with ME 2906]

We have studied effects of photodynamic diagnosis (PDD) and photodynamic therapy (PDT) in hepatoma as confirmed by the existence of hepatoma when using a new photosensitizer mono-L-aspartyl chlorin e6. Japanese white rabbits were selected to perform abdominal incision under intravenous anesthesia and transplant VX2 tumor cells into the liver left lobe for the hepatoma model. Hepatoma of 1 cm in diameter (at one week after transplantation) was used experimentally to radiate a semiconductor laser (664 nm, 200 J/cm2) for treatment.

Altered N-glycosylation of glucose transporter-1 associated with radiation-induced tumorigenesis of human cell hybrids

Studies on human cell hybrids between a cervical carcinoma cell line, HeLa, and normal fibroblasts have indicated that their tumorigenicity is under the control of a putative tumor suppressor on chromosome 11. We have previously demonstrated that a tumorigenic cell hybrid CGL4 expresses a larger glucose transporter, GLUT1, due to altered glycosylation when compared to the nontumorigenic counterpart CGL1. In this study, we demonstrated this glycosylation change in GLUT1 in gamma-ray-induced tumorigenic mutants (GIMs) isolated from CGL1 cells as expressing a tumor-associated surface antigen, intestinal alkaline phosphatase. In contrast, GLUT1 in the gamma-irradiated nontumorigenic control cells (CONs) did not show this alteration. In accordance with this glycosylation change, affinity to 2-deoxyglucose in these GIM clones was increased by about twofold when compared to the nontumorigenic CONs. These results suggest a close correlation between the glycosylation change in GLUT1 with increased affinity to D-glucose and tumorigenicity of these human cell hybrids.

Stent endoprosthesis for obstructing colorectal cancers

PURPOSE

Purpose of this study was to assess stent endoprosthesis for colorectal cancer (SECC) as an adjuvant to operative preparation in patients with obstructing colorectal cancers.

METHODS

A self-expanding stainless steel stent was inserted in 15 patients with obstructing colorectal cancers under colonoscopic observation and fluoroscopic control. Following successful SECC, the colon was mechanically prepared using polyethylene glycol. Definitive surgical treatment then was undertaken.

RESULTS

All 12 patients in whom the stent had been successfully placed recovered intestinal transit and tolerated mechanical preparation. A satisfactory preparation was confirmed during the operation. Two perforations and one dislocation were encountered.

CONCLUSION

SECC is a new method for operative preparation of patients with obstructing colorectal cancers, which may reduce morbidity and mortality associated with this difficult problem.

[Traditional open cholecystectomy]

During the past 5 years, traditional open cholecystectomy was performed on 344 patients with gallbladder stones at our hospital. Using the data obtained, we studied the indications and results of traditional open cholecystectomy. In the cases of gallbladder stones with a history of cholecystitis, cholecystectomy was performed as a rule by laparoscopic cholecystectomy. However, traditional open cholecystectomy was chosen in cases which were complicated by perforation, pericholecystic abscess, internal biliary fistra, cirrhosis, or suspicious carcinoma of gallbladder. Investigation of the time of operation revealed that early operation tended to be performed easily. However, cases with gallbladder stones were often complicated with carcinoma of alimentary tracts, therefore before operation we must examine the alimentary tract. Cases in which gallbladder could not be visualized under ERCP, and those accompanied by pericholecystic abscess under US were difficult to operate on by laparoscopic cholecystectomy. Thus many cases required laparotomy. Postoperative complications of open cholecystectomy were rare, it was concluded that traditional cholecystectomy is one of the most valuable procedures for the treatment of gallbladder stones.

[The treatment of thymoma with myasthenia gravis: report of 20 cases]

Sixty-eight patients with myasthenia gravis underwent thymic surgery in our department. Among of 68 cases, twenty patients with thymoma were followed and their prognosis were investigated. Sixteen cases received a extended thymectomy with thymomectomy, six cases received local irradiation, and 16 cases received a chemotherapy. Among of 16 cases, 13 cases received corticosteroid only, and 3 cases received CHOP (CPA+ADM+VCR+PSL). Survival rates for thymoma of 20 cases were 94.7%, 88.9%, 78.6%, and 54.5% at 1, 3, 5 and 7 years, respectively. Survival rates for thymoma at 5 years were 83.3%, 50.0%, 100%, and 100% in stage I (complete encapsulation of 8), II (invasion into pericapsular fatty tissue of 7), III (invasion into surrounding organ of 3), and IV a (pleural dissemination of 2), respectively. Survival rate for extended thymectomy with thymomectomy of 16 cases was 81.8% at 5 years. Among of 18 total resection cases of thymoma, a recurrence occurred (5.6%). Causes of 6 death after surgery were crises of myasthenia gravis (3), other diseases (2), and recurrence of thymoma (1).

[Distribution of thymic tissue in the mediastinal adipose tissue removed at the thymectomy in 47 patients with myasthenia gravis]

In this report, the distribution of thymic tissue in the mediastinal adipose tissue was examined histologically in 54 patients with myasthenia gravis underwent extended thymectomy. In fourty-seven of 54 patients, the mediastinal adipose tissues were removed from 6 different parts adjacent to the thymus, i.e., right upper, right middle, right lower, left upper, left middle, and left lower, respectively. Upper area means of around the upper pole of thymus, middle area means of around hilum and lower area means of around from lower pole of thymus to diaphragma. In the mediastinal adipose tissue, thymic tissue was found outside the thymus lobes in 41 (75.9%) of 54 patients. The each prevalence (percent of occurrence) of 6 areas were as follows: 15.0% in the right upper area, 21.4% in the right middle area, 19.0% in the right lower area, 17.5% in the left upper area, 66.7% in the left middle area and 33.3% in the left lower area. There was significant differences in the prevalence of the left middle area according to the other 5 areas (p < 0.01). There were no significant differences in the prevalences among sex, Osserman type, duration of the disease, pre-operative treatment and histological findings or removal thymus. There were significant differences in the prevalence of all according to the proportion of thymic tissue in the thymus (0.01 < P < 0.05). In conclusion, it is suggested that for the removal of all thymic tissue, the sufficient procedure required utmost care especially to the left middle area around thymus.(ABSTRACT TRUNCATED AT 250 WORDS)

[Managements of hospital MRSA infections in digestive tract surgery]

1444 cases if digestive tract surgery in our department were studied for the prevention of postoperative MRSA infections, during the period from September 1987 to February 1992. They were divided into nine stages each six months. There were no significant differences in incidence of postoperative MRSA infections, after some managements for hospital infection among each stage. We used the antibiotics as follows; the first generation of cefem families was used for the upper digestive tract operations and the second generation of cefem families was used for the lower digestive tract operation, and the incidence of postoperative MRSA infections were diminished significantly. This study showed that managements for hospital infections and appropriate selection of antibiotics for the purpose of postoperative prophylactic use are effective for the prevention of MRSA infections.

[The prediction of the need for postoperative mechanical ventilation in patients with myasthenia gravis undergoing transsternal thymectomy]

During a sixteen-year period, 51 patients with myasthenia gravis underwent trans-sternal thymectomy including extended resection of the adipose tissue around thymus. Using the criteria of risk factors described by Leventhal and Kimura, a predictive score was assessed for our 51 patients. Leventhal's scoring system achieved an accuracy of 54.3%, a sensitivity of 20.0% and a specificity of 63.9%. And, Kimura's scoring system achieved an accuracy of 75.0%, a sensitivity of 81.8% and a specificity of 73.0%. From this study it was concluded that Kimura's scoring system is statistically more adaptive for Japanese than Leventhal's scoring system, and the Leventhal's accuracy may have increased by adding "bulbar symptoms" and "preoperative crisis" as other risk factors and by decreasing "points" for "duration of myasthenia" and "pyridoxamine dosage", and the "Kimura's " accuracy may have increased by decreasing "7 points" for preoperative crisis. Consequently, patients who received postoperative ventilation were compared with the group who did not, with respect to the 19 factors. Evidence is that Osserman's type, bulbar symptoms, preoperative crisis and preoperative % VC were influenced to require the postoperative ventilation, but sex, age, thymic histology, duration of myasthenia and pyridoxamine dosage were not any influenced to require the postoperative ventilation.

[Clinical studies on cefoxitin in the field of gastro-surgery (author's transl)]

Cefoxitin (CFX) was administered to the total of 21 hospitalized patients at a daily dose of 1 to 6 g for the duration of 6 to 23 days and the following results were obtained. 1) Clinical results of the 10 patients with surgical infections were excellent in 3 patients, good in 5, fair in 1 and poor in 1, with the efficacy rate of 90%. 2) CFX was also administered to 11 cases for prophylaxis of postoperative infections and the clinical efficacy rate was 100%. 3) Susceptibility tests showed all clinical isolates such as E. coli, Klebsiella and Gram-negative anaerobes were highly susceptibility to CFX except for Pseudomonas. 4) There were no subjective nor objective side effects related to CFX. The above results indicate that CFX is exceedingly useful for the treatment of infections in the field of gastro-surgery.