Publications by authors named "Yasushi Harihara"

46 Publications

Change in antimicrobial susceptibility of pathogens isolated from surgical site infections over the past decade in Japanese nation-wide surveillance study.

J Infect Chemother 2021 Jul 29;27(7):931-939. Epub 2021 Mar 29.

Department of Infection Control and Prevention, Kagoshima University Hospital, Kagoshima, Japan.

Inappropriate antimicrobial therapy for surgical site infections (SSIs) can lead to poor outcomes and an increased risk of antibiotic resistance. A nationwide survey was conducted in Japan from 2018 to 2019 to investigate the antimicrobial susceptibility of pathogens isolated from SSIs. The data were compared with those obtained in 2010 and 2014-2015 surveillance studies. Although the rate of detection of extended-spectrum β-lactamase producing strains of Escherichia coli was increased from 9.5% in 2010 to 23% in 2014-2015, the incidence decreased to 8.7% in 2018-2019. Although high susceptibility rates were detected to piperacillin/tazobactam (TAZ), the geometric mean MICs were substantially higher than to meropenem (2.67 vs 0.08 μg/mL). By contrast, relatively low geometric mean MICs (0.397 μg/mL) were demonstrated for ceftolozane/TAZ. Although the MRSA incidence rate decreased from 72% in the first surveillance to 53% in the second, no further decrease was detected in 2018-2019. For the Bacteroides fragilis group species, low levels of susceptibility were observed for moxifloxacin (65.3%), cefoxitin (65.3%), and clindamycin (CLDM) (38.9%). In particular, low susceptibility against cefoxitin was demonstrated in non-fragilis Bacteroides, especially B. thetaiotaomicron. By contrast, low susceptibility rates against CLDM were demonstrated in both B. fragilis and non-fragilis Bacteroides species, and a steady decrease in susceptibility throughout was observed (59.3% in 2010, 46.9% in 2014-2015, and 38.9% in 2018-2019). In conclusion, Japanese surveillance data revealed no significant lowering of antibiotic susceptibility over the past decade in organisms commonly associated from SSIs, with the exception of the B. fragilis group.
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http://dx.doi.org/10.1016/j.jiac.2021.03.010DOI Listing
July 2021

Long-term survival after pancreatic metastasis resection from breast cancer: a systematic literature review.

Surg Case Rep 2021 Feb 3;7(1):39. Epub 2021 Feb 3.

Department of Surgery, NTT Medical Center Tokyo, 5-9-22, Higashi-Gotanda, Shinagawa-ku, Tokyo, 141-8625, Japan.

Background: Patients with advanced-stage breast cancer often demonstrate pancreatic metastases. However, pancreatic metastases resection from breast cancer has been rarely performed, with only 20 cases having been reported to date.

Case Presentation: A 49-year-old woman presented to our hospital in September 2003 with complaints of uncontrollable oozing from her left breast tumor. Computed tomography revealed a left breast tumor approximately 9.3 cm in diameter as well as heterogeneously enhanced solid mass lesions with necrotic foci in the pancreatic tail and body, up to 6.2 cm, which were radiologically diagnosed as pancreatic metastases from breast cancer. An emergent left simple mastectomy was performed to control bleeding. After epirubicin and cyclophosphamide hydrate treatment failed to improve her condition, the pancreatic metastases responded to weekly paclitaxel treatment, but eventually regrew. The patient underwent distal pancreatectomy with splenectomy, left adrenalectomy, partial stomach resection, and paraaortic lymph nodes excision in December 2004 after no other metastasis was confirmed. Furthermore, she received radiation therapy for left parasternal lymph node metastasis 6 months later. The patient recovered well. Consequently, she has no evidence of disease > 15 years after pancreatectomy.

Conclusions: This is the first reported case of pancreatectomy for pancreatic metastases from breast cancer, which was simultaneously diagnosed. Patients with no metastasis other than resectable pancreatic metastases and breast cancer and who possess some sensitivity for chemotherapy may benefit from pancreatectomy.
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http://dx.doi.org/10.1186/s40792-021-01124-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7859131PMC
February 2021

A placebo-controlled, double-blind, randomized study of recombinant thrombomodulin (ART-123) to prevent oxaliplatin-induced peripheral neuropathy.

Cancer Chemother Pharmacol 2020 11 23;86(5):607-618. Epub 2020 Sep 23.

Division of Gastroenterology, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8577, Japan.

Purpose: The purpose of this clinical study was to be the first to explore whether ART-123, a recombinant human soluble thrombomodulin, prevents oxaliplatin-induced peripheral neuropathy (OIPN).

Methods: This randomized, phase IIa trial enrolled stage II/III colon cancer patients who received adjuvant mFOLFOX6 chemotherapy. Participants were randomly allocated to 3 arms in a double-blind manner: placebo (placebo: days 1-3); 1-day ART (ART-123: day 1, placebo: days 2-3); and 3-day ART (ART-123: days 1-3). ART-123 (380 U/kg/day) or placebo was infused intravenously before each 2-week cycle of mFOLFOX6. OIPN was assessed with the Functional Assessment of Cancer Therapy/Gynecological Oncology Group-Neurotoxicity-12 (FACT/GOG-Ntx-12) score by participants and the NCI Common Terminology Criteria for Adverse Events (NCI-CTCAE) by investigators.

Results: Seventy-nine participants (placebo n = 28, 1-day ART n = 27, 3-day ART n = 24) received study drugs. The least-squares mean FACT/GOG-Ntx-12 scores at cycle 12 from the mixed effect model for repeated measures were 28.9 with placebo, 36.3 with 1-day ART (vs. placebo: 7.3 [95% CI 1.9 to12.8, p = 0.009]), and 32.3 with 3-day ART (vs. placebo: 3.4 [95% CI -.1 to 9.0, p = 0.222]). The cumulative incidence of NCI-CTCAE grade ≥ 2 sensory neuropathy at cycle 12 was 64.3% with placebo, 40.7% with 1-day ART (vs. placebo: -23.5 [95% CI -48.4 to 4.0], p = 0.108), and 45.8% with 3-day ART (vs. placebo: -18.5 [95% CI -44.2 to 9.4], p = 0.264). Common adverse events were consistent with those reported with mFOLFOX6; no severe bleeding adverse events occurred.

Conclusion: ART-123 showed a potential preventive effect against OIPN with good tolerability. A larger study with 1-day ART is warranted. NCT02792842, registration date: June 8, 2016.
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http://dx.doi.org/10.1007/s00280-020-04135-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7561567PMC
November 2020

A Novel Role of Interleukin 13 Receptor alpha2 in Perineural Invasion and its Association with Poor Prognosis of Patients with Pancreatic Ductal Adenocarcinoma.

Cancers (Basel) 2020 May 20;12(5). Epub 2020 May 20.

Tumor Vaccines and Biotechnology Branch, Division of Cellular and Gene Therapies, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring, MD 20993, USA.

Perineural invasion (PNI) is one of the major pathological characteristics of pancreatic ductal adeno-carcinoma (PDAC), which is mediated by invading cancer cells into nerve cells. Herein, we identify the overexpression of Interleukin-13 Receptor alpha2 (IL-13Rα2) in the PNI from 236 PDAC samples by studying its expression at the protein levels by immunohistochemistry (IHC) and the RNA level by in situ hybridization (ISH). We observe that ≥75% samples overexpressed IL-13Rα2 by IHC and ISH in grade 2 and 3 tumors, while ≥64% stage II and III tumors overexpressed IL-13Rα2 (≥2+). Interestingly, ≥36 % peripancreatic neural plexus (PL) and ≥70% nerve endings (Ne) among PNI in PDAC samples showed higher levels of IL-13Rα2 (≥2+). IL-13Rα2 +ve PL and Ne subjects survived significantly less than IL-13Rα2 -ve subjects, suggesting that IL-13Rα2 may have a unique role as a biomarker of PNI-aggressiveness. Importantly, IL-13Rα2 may be a therapeutic target for intervention, which might not only prolong patient survival but also help alleviate pain attributed to perineural invasion. Our study uncovers a novel role of IL-13Rα2 in PNI as a key factor of the disease severity, thus revealing a therapeutically targetable option for PDAC and to facilitate PNI-associated pain management.
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http://dx.doi.org/10.3390/cancers12051294DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7281570PMC
May 2020

[A Surgical Case of Desmoid Tumor in the Transverse Mesocolon with Pancreatic Invasion].

Gan To Kagaku Ryoho 2020 Jan;47(1):71-75

Dept. of Surgery, NTT Medical Center Tokyo.

A 40-year-old man with no previous history of abdominal surgery or noteworthy family history presented to our hospital because of a palpable abdominal mass. Abdominal CT revealed a 9 cm diameter mass in the mesocolon. The differential diagnosis included desmoid tumor, and right hemicolectomy with partial resection of the pancreas head and duodenum was performed. Pathologically, the tumor cells were negative for S-100, c-kit, CD34, and desmin but partially positive for a-SMA and slightly for b-catenin. From these findings, desmoid tumor of the mesocolon was diagnosed. Invasion of the pancreas was also found. Desmoid tumor is pathologically benign, but because of its malignant-like characteristics, such as direct invasion and local recurrence, it is treated as a malignant tumor. Desmoid tumors are associated with familial adenomatous polyposis coli and Gardner syndrome, or they arise in patients who have a history of laparotomy or antecedent trauma. In this paper, we report a rare case of resected sporadic desmoid tumor in the mesocolon with pancreatic invasion, together with a review of the literature.
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January 2020

Colonic Neurogenic Lesion: An Admixture of Mucosal Neurofibromatous Lesion and Submucosal Ganglioneuromatous Lesion With Transition.

Int J Surg Pathol 2020 Aug 6;28(5):563-568. Epub 2020 Feb 6.

NTT Medical Center Tokyo, Tokyo, Japan.

Benign neural tumors or tumor-like lesions are rarely detected in the gastrointestinal tract. In this article, we present the case of a neural lesion of the sigmoid colon, which was incidentally detected in a 68-year-old man treated with laparoscopic low anterior resection for an advanced carcinoma of the rectosigmoid junction. Within the resected specimen, a submucosal tumor-like protruding lesion was found in the sigmoid colon. Histologically, the growth was composed of mucosal neurofibromatous and submucosal ganglioneuromatous lesions, between which there was transition. Immunohistochemical analysis revealed a rupture of the perineurium in the area of transition, along with a proliferation of Schwann cells and supporting cells extending into the deep mucosa. This transition indicated that the mucosal and submucosal lesions comprised a single lesion, and that a diagnosis of neurofibroma or ganglioneuroma would be inadequate in this case. Because we could not classify it as an established single entity, we diagnosed the mass as an unclassifiable colonic neurogenic lesion. In summary, we report the case of an extremely rare occurrence of an unclassifiable colonic neurogenic lesion comprising an admixture of transitioning mucosal neurofibromatous and submucosal ganglioneuromatous lesions.
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http://dx.doi.org/10.1177/1066896920904158DOI Listing
August 2020

Intrahepatic Carcinosarcoma With Cholangiocarcinoma Elements and Prominent Bile Duct Spread.

Int J Surg Pathol 2019 Dec 17;27(8):900-906. Epub 2019 Jun 17.

NTT Medical Center Tokyo, Tokyo, Japan.

Carcinosarcomas with elements of cholangiocarcinoma and sarcoma are rare and have a poor prognosis. The spreading pattern and radiological findings of these lesions remain unclear. A 74-year-old man presented with a high γ-glutamyl transferase level. Magnetic resonance imaging revealed dilation of the right intrahepatic and common bile ducts, consistent with an intraductal papillary neoplasm of the bile duct (IPNB), and diffusion-weighted imaging (DWI) indicated an area of high signal intensity in the intrahepatic bile duct. Bile duct biopsy yielded a small amount of atypical spindle cells, and the patient underwent a right hepatectomy. Microscopically, the tumor contained cholangiocarcinoma and sarcomatous components, including osteosarcoma and leiomyosarcoma, leading to a diagnosis of intrahepatic carcinosarcoma. The tumor spread primarily through the intrahepatic bile duct. An accurate radiological diagnosis of carcinosarcoma was challenging, given the apparent similarities with IPNB. The findings from DWI and pathology of a bile duct biopsy may assist with preoperative diagnosis.
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http://dx.doi.org/10.1177/1066896919855766DOI Listing
December 2019

Enterocolic lymphocytic phlebitis with marked myointimal hyperplasia and perivenous concentric fibrosis.

Cardiovasc Pathol 2019 May - Jun;40:68-71. Epub 2019 Mar 6.

Department of Diagnostic Pathology, NTT Medical Center Tokyo, Tokyo, Japan; Faculty of Healthcare, Tokyo Healthcare University, Tokyo, Japan.

Enterocolic lymphocytic phlebitis (ELP) is a rare enteropathy characterized by lymphocytic phlebitis of the mesenteric veins without arteritis. Idiopathic myointimal hyperplasia of mesenteric veins (IMHMV) is a rare disease similar to ELP, characterized by myointimal hyperplasia that constricts the lumen of veins, causing mucosal injury. A 62-year-old man with chief complaint of abdominal pain was treated by partial resection of the ileum after 3 months of conservative therapy. The pathologic diagnosis was ELP with prominent myointimal hyperplasia. Histologically, the lesion consisted of lymphocytic infiltration into the vein accompanied by prominent myointimal hyperplasia and perivenous concentric fibrosis, which are characteristics shared by ELP and IMHMV. The observations in this case suggest that some of ELP and IMHMV may belong to the same disease spectrum. Furthermore, perivascular concentric fibrosis was a remarkable observation that may contribute to differential diagnosis between ELP and "true" IMHMV.
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http://dx.doi.org/10.1016/j.carpath.2019.02.006DOI Listing
July 2019

Intramucosal colorectal carcinoma with lymphovascular invasion: clinicopathological characteristics of nine cases.

Histopathology 2019 Jun;74(7):1055-1066

Department of Diagnostic Pathology, NTT Medical Center Tokyo, Tokyo, Japan.

Aims: Recent studies have provided the concept of invasive intramucosal colorectal carcinoma (CRC), and a case of intramucosal CRC with lymphatic invasion has been reported; however, the characteristics of such cases and the risk of lymph node metastasis have never been investigated. Therefore, we aimed to assess the pathological characteristics of intramucosal CRCs with lymphovascular invasion as well as the possibility of lymph node metastasis as an indication for additional surgery.

Methods And Results: To delineate the histological features of intramucosal CRCs with lymphovascular invasion, we analysed several histological features and compared their incidence among nine such cases, as well as 20 other cases of intramucosal CRCs without lymphovascular invasion. High-grade tumour budding and a pattern of 'eosinophilic cytoplasm and round nuclei with inflammatory reaction (ERI)' were morphological characteristics of intramucosal CRCs with lymphovascular invasion, compared with those without lymphovascular invasion (both P < 0.05). Among the seven lymph node-dissected cases of intramucosal CRCs with lymphovascular invasion, none showed lymph node metastasis.

Conclusions: In intramucosal CRCs with lymphovascular invasion, high-grade tumour budding and the 'ERI' pattern are morphological characteristics that are distinct from those of non-invasive CRC, which is synonymous with high-grade dysplasia. Further studies using a larger number of cases by focusing on the above-mentioned histological pattern are expected to clarify the potential of lymph node metastasis of such cases.
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http://dx.doi.org/10.1111/his.13826DOI Listing
June 2019

Colon Metastasis From Microscopic Serous Carcinoma of the Fallopian Tube Fimbria Mimicking a Primary Colon Cancer.

Int J Surg Pathol 2019 Jun 20;27(4):390-395. Epub 2019 Jan 20.

1 NTT Medical Center Tokyo, Tokyo, Japan.

Metastatic diseases rarely develop in the colorectum, and diagnosing colorectal metastasis by biopsy without history of a malignant tumor or clinical information of a primary tumor is challenging. A 65-year-old woman with a 6-month history of constipation and diarrhea was admitted to our hospital and diagnosed with rectosigmoid colonic micropapillary carcinoma. Low anterior resection was performed after neoadjuvant chemotherapy. Because the lipoleiomyoma in the uterus obstructed the operator's vision, total hysterectomy and bilateral salpingo-oophorectomy were performed. Examination of the colon and adnexa, together with immunohistochemical studies, revealed that the colonic tumor was actually serous carcinoma that had metastasized from the left fimbria of the fallopian tube. Retrospective immunohistochemical examination of the colon biopsy specimen suggested carcinoma with a Müllerian immunophenotype. When a colon biopsy reveals carcinoma with an invasive micropapillary pattern without a component of conventional tubular adenocarcinoma, immunohistochemical examination should be performed to rule out the possibility of metastasis.
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http://dx.doi.org/10.1177/1066896918824028DOI Listing
June 2019

An estrogen receptor-positive locally aggressive smooth muscle neoplasm of the transverse colon: A case report.

Medicine (Baltimore) 2018 Nov;97(46):e13250

Department of Diagnostic Pathology, NTT Medical Center Tokyo.

Rationale: Extrauterine leiomyomas (LMs) in women are often positive for the estrogen receptor (ER); however, almost all extrauterine leiomyosarcomas (LMSs) are negative for ER. Invasive smooth muscle neoplasms (SMNs) of the gastrointestinal tract walls are very rare and those ER statuses have not been well studied.

Patient Concerns: A 48-year-old woman presented to our hospital with a 10 years history of recurrent severe abdominal pain and diarrhea lasting about an hour, with frequency of about twice per year. She was clinically diagnosed with a submucosal tumor (SMT) of the transverse colon and underwent a partial transverse colectomy.

Diagnosis: A colonoscopy revealed a 30-mm SMT in the transverse colon. A contrast abdominal computed tomography detected a 21-mm mass with significant late phase enhancement in the transverse colon and the lesion was clinically diagnosed as an SMT. Post-operative pathology confirmed a diagnosis of ER-positive locally aggressive SMN.

Interventions: The patient underwent laparoscopic partial transverse colectomy.

Outcomes: The patient received no adjuvant therapy postoperatively. The patient has remained disease-free without recurrence 13 months after the surgery.

Lessons: This is the first case of an ER-positive invasive SMN in the gastrointestinal tract. It highlights the difficulty in classifying some gastrointestinal SMNs as either LMs or LMSs and the importance of ER status in SMNs.
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http://dx.doi.org/10.1097/MD.0000000000013250DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6257419PMC
November 2018

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

Pancreatology 2018 Dec 10;18(8):1005-1011. Epub 2018 Sep 10.

Department of Surgery, Dokkyo Medical University Saitama Medical Center, Saitama, Japan.

Background/objectives: To demonstrate the utility of portal encasement as a criterion for early diagnosis of local recurrence (LR) after pancreaticoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDAC).

Methods: A 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.

Results: Benign 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.

Conclusions: Portal encasement should be considered as a promising diagnostic criterion for earlier diagnosis of LR after PD for PDAC.
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http://dx.doi.org/10.1016/j.pan.2018.09.002DOI Listing
December 2018

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

Surg Radiol Anat 2018 Jul 12;40(7):749-756. Epub 2018 Apr 12.

Department of Surgery, NTT Medical Center Tokyo, 5-9-22 Higashi-Gotanda, Shinagawa-Ku, Tokyo, 141-8625, Japan.

Purpose: The 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.

Methods: We retrospectively enrolled 176 consecutive patients who underwent esophagectomy with gastric tube reconstruction. They were classified into the ALHA (N = 16, 9.1%) and non-ALHA (N = 160, 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.

Results: The 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 (36 IU/L, 14-515; 32 IU/L, 13-295) than in the non-ALHA group (24 IU/L, 8-163; 19 IU/L, 6-180), respectively (p = 0.0055; p = 0.0073). Overall survival was not statistically different between the two groups (p = 0.26).

Conclusions: Severe 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.
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http://dx.doi.org/10.1007/s00276-018-2022-4DOI Listing
July 2018

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

J Infect Chemother 2018 May 16;24(5):330-340. Epub 2018 Mar 16.

Department of Surgery, Osaka Rosai Hospital, Osaka, 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. coli, 24.1% of strains produced extended-spectrum β-lactamase (ESBL). Carbapenems, piperacillin/tazobactam, cephamycins/oxacephem, aminoglycosides, and tigecycline had high activity against E. coli, including ESBL-producing isolates. Among E. cloacae, low susceptibility rates to ceftazidime were demonstrated, whereas cefepime retained its activity. P. aeruginosa revealed high susceptibility rates to all antimicrobials tested except for imipenem. Among B. fragilis 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. faecalis. Imipenem had the highest activity against E. faecalis 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.
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http://dx.doi.org/10.1016/j.jiac.2018.02.011DOI Listing
May 2018

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

Surg Case Rep 2018 Feb 16;4(1):17. Epub 2018 Feb 16.

Department of Surgery, NTT Medical Center Tokyo, 5-9-22 Higashi-Gotanda, Shinagawa-Ku, Tokyo, 141-8625, Japan.

Background: Aggressive 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 Presentation: A 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 354 ml, 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 1242 ml, 78.5% of the total liver volume. Therefore, the patient underwent left hemihepatectomy 58 days 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 5 months after the second hepatectomy.

Conclusions: Our TSH strategy helped avoid POLF by waiting for the development of intrahepatic venous collaterals.
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http://dx.doi.org/10.1186/s40792-018-0424-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5815977PMC
February 2018

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

J Infect Chemother 2017 Jun 5;23(6):339-348. Epub 2017 Apr 5.

Department of Surgery, Mazda Hospital, Mazda Motor Corporation, Hiroshima, Japan.

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 (p < 0.001). MRSA isolates with a vancomycin minimum inhibitory concentration (MIC) of 2 μg/mL accounted for 1.2% of all MRSA isolates, which was significantly lower than in 2010 (9.7%, p = 0.029). 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 (p = 0.011). The geometric mean MICs for ESBL-producing isolates were 0.07 μg/mL for meropenem, 9.51 μg/mL for tazobactam/piperacillin, 0.15 μg/mL for flomoxef, and 1.56 μg/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%, p = 0.007). More than 90% of isolates belonging to the B. fragilis 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. fragilis. Overall, the surveillance data clarified trends in antimicrobial susceptibility for organisms commonly associated with SSI.
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http://dx.doi.org/10.1016/j.jiac.2017.03.010DOI Listing
June 2017

Real-time confocal laser endomicroscopic evaluation of primary liver cancer based on human liver autofluorescence.

J Surg Oncol 2017 Feb 4;115(2):151-157. Epub 2016 Nov 4.

Hepato-Biliary-Pancreatic Surgery Division, and Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan.

Background: 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.

Methods: A probe-based CLE system (Cellvizio 100, Mauna Kea Technologies, Paris, France) was used. The subjects comprised seven specimens obtained from six patients with primary liver cancer in November 2015. The probe was manually attached to the surfaces of specimens, and images were collected without external fluorophores. CLE images were compared with hematoxylin and eosin-stained slides. Fluorescence intensity (FI) values of the CLE images were assessed using luminance-analyzing software.

Results: CLE examination visualized non-cancerous regions in the background liver as regular structures with high fluorescence because of human liver autofluorescence. Conversely, hepatocellular carcinoma and intrahepatic cholangiocarcinoma were depicted as irregular structures with low fluorescence. The median FI values of the non-cancerous regions and the cancerous regions were 104 (79.8-156) and 74.9 (60.6-106), respectively, and were significantly different (P = 0.031).

Conclusions: The probe-based CLE enables real-time differentiation of cancerous regions from non-cancerous tissues in surgical specimens because of human liver autofluorescence. CLE can be used to confirm negative surgical margins in the operating room. J. Surg. Oncol. 2017;115:151-157. © 2016 Wiley Periodicals, Inc.
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http://dx.doi.org/10.1002/jso.24491DOI Listing
February 2017

Pancreatic paraganglioma with draining vessels.

World J Gastroenterol 2015 Aug;21(31):9442-7

Yoshitsugu Misumi, Toshio Fujisawa, Koichi Kagawa, Nobuyuki Matsuhashi, Department of Gastroenterology, NTT Medical Center Tokyo, Tokyo 141-8625, Japan.

A pancreatic paraganglioma is a rare neoplasm that is difficult to distinguish from a pancreatic neuroendocrine tumour. Here we present a case of pancreatic paraganglioma that was surgically resected following preoperative diagnosis of a pancreatic neuroendocrine tumour. Careful evaluation of the endoscopic ultrasonography findings revealed abundant draining vessels, which could have led to a correct preoperative diagnosis of pancreatic paraganglioma.
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http://dx.doi.org/10.3748/wjg.v21.i31.9442DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4541398PMC
August 2015

Laparoscopic versus open adrenalectomy for adrenal myelolipoma.

Ann Med Surg (Lond) 2014 Jun 16;3(2):34-8. Epub 2014 Apr 16.

Department of Surgery, NTT Medical Center Tokyo, Higashi-Gotanda 5-9-22, Shinagawa-ku, Tokyo 141-8625, Japan.

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.
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http://dx.doi.org/10.1016/j.amsu.2014.04.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4268474PMC
June 2014

Development of a new compact intraoperative magnetic resonance imaging system: concept and initial experience.

Neurosurgery 2014 Jun;10 Suppl 2:220-9; discussion 229-30

*Department of Neurological Surgery, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan; ‡Department of Neurosurgery, Hamamatsu University Hospital; §Department of Neurosurgery, Tokyo Metropolitan Police Hospital, Tokyo, Japan; ¶Departments of Neurosurgery, ‖Radiology, #Operative Medicine, and **Anesthesiology, NTT Medical Center Tokyo, Tokyo, Japan; ‡‡Department of Electronics Engineering and Computer Science, Peking University, Beijing, China; §§Cross Tech Corporation, Tokyo, Japan.

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.
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http://dx.doi.org/10.1227/NEU.0000000000000304DOI Listing
June 2014

[Coproductive teamwork in surgical cancer treatment].

Gan To Kagaku Ryoho 2013 Apr;40(4):430-4

Department of Surgery, NTT Medical Cancer Tokyo, 5-9-22 Higashigotanda, Shinagawa-ku, Tokyo 141-8625, Japan.

With regard to surgical treatment of cancer, there is a strong demand for safe treatment with few errors: treatment must be based on transparency, understandability, and rationality. There is also demand for treatment which is quick, efficient and not wasteful. Rather than maintaining our current pyramidal system which has doctors standing as authorities at the top, there is a need for a flat, non-authoritarian system at every level and section of the hospital. As we change methodology, electronic medical records and clinical pathways will be important tools. Among the surgical department's treatment team in our hospital, there are many branches at work on peri-operative management aside from operations; There are teams for infection control (ICT), nutrition support (NST), decubitus and stoma management, rehabilitaion, and chemotherapy, and team cooperation after discharge from hospital. In addition, the collaborative and coproductive team focusing on pain releif and palliative care in terminal phase (PCT) is important. Having introduced each of the parts of team treatment within the setting of the surgical department, the need now for strong leadership from young and brightful surgeons is also emphasized.
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April 2013

[II. Stomach 2. Community networks for treatment of stomach cancer].

Gan To Kagaku Ryoho 2012 Sep;39(9):1350-5

Department of Surgery, Kanto Medical Center NTT EC NTT, Tokyo, Japan.

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September 2012

Utility of preoperative small-bowel endoscopy for hemorrhagic lesions in the small intestine.

Surg Today 2012 Jun 27;42(6):536-41. Epub 2011 Dec 27.

Department of Surgery, Kanto Medical Center NTT EC, Higashi-Gotanda 5-9-22, Shinagawa-ku, Tokyo, Japan.

Purpose: We evaluated a small group of patients with hemorrhagic lesions in the small intestine diagnosed preoperatively by video capsule endoscopy (VCE) and/or double-balloon endoscopy (DBE), who underwent surgery in our hospital.

Methods: The subjects were 20 patients with hemorrhagic lesions in the small intestine diagnosed preoperatively by VCE and/or DBE, who underwent surgery between April 2004 and December 2008.

Results: VCE, DBE, and computed tomography were performed in 12, 17, and 20 patients, respectively. Eleven patients also had a biopsy taken during DBE, resulting in a definitive diagnosis in eight. Because of the risk of hemorrhage during DBE in five patients, a biopsy was not taken and the sites of the lesion were marked in these patients. Twenty patients underwent surgery, and the diagnoses were small-intestinal cancer in eight, gastrointestinal stromal tumor in seven, arteriovenous malformation in two, and Crohn's disease, angioectasia, and leiomyoma in one each. The interval between the onset of symptoms and surgery was less than 50 days for six patients, 50-100 days for two, 100-200 days for five, and more than 200 days for seven.

Conclusion: Preoperative small-bowel endoscopy proved useful for diagnosing the cause of hemorrhagic lesions in the small intestine.
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http://dx.doi.org/10.1007/s00595-011-0109-1DOI Listing
June 2012

Fat replacement of the distal pancreas in a case of advanced gastric cancer.

Int Surg 2010 Jul-Sep;95(3):261-4

Department of Surgery, Kanto Medical Center NTT EC, Tokyo, Japan.

Preoperative computed tomography in a 67-year-old man admitted with type 2 advanced gastric cancer involving the upper body of the stomach revealed marked atrophy of the left lobe of the liver and atrophy of the distal pancreas. Total gastrectomy with D2 lymph node dissection was planned; however, additional distal pancreatectomy with splenectomy was also performed during the operation because of direct invasion of the pancreas by the gastric cancer. Histopathologic examination of the resected pancreas revealed the absence of lobules, acini, conduits, and pancreatic ducts, with only islets of Langerhans found scattered in the adipose tissue. The findings revealed that the gastric cancer had directly invaded the fat, replacing the distal pancreas. In patients with fat-replaced pancreas, preoperative evaluation of direct invasion of adjacent organs/tissues by gastric cancer is difficult.
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December 2010

[Risk management and postoperative infection control].

Nihon Geka Gakkai Zasshi 2010 May;111(3):143-8

Department of Surgery, NTT Medical Center, Tokyo.

Review of nine cases of judicial precedent on the issue of the postoperative infection in Japan indicates the following issues: indication of surgery; violation of informed consent; preventive measures against nosocomial infection during the preoperative period; cleanliness control during surgery; and treatment of postoperative infection. The most important yardstick for judgment is whether the provided treatment is conformed to the level of standard medical treatment available at the time. Therefore, we should be well versed in the standard postoperative infection treatment, particularly infection surveillance data and CDC standard precautions and related guidelines. Moreover, in each hospital, an infection control team should play an important role in infection control and prevention through preparing manuals and clinical paths incorporating precautions to ensure that the whole staff comply with the prescribed procedures.
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May 2010

[Effectiveness of antimicrobial prophylaxis in prevention of surgical site infections].

Masui 2010 May;59(5):589-96

Kanto Medical Center NTT EC, Tokyo 141-8625.

Preventing surgical site infection (SSI) is important in providing safe and high-quality surgical care. Antimicrobial prophylaxis is given to prevent SSI. Many reports revealed that antimicrobial prophylaxis is effective to reduce SSI rates, when its initial dose is given at proper timing and additional dose is properly given in longer operations. Initial dose of antimicrobial prophylaxis is recommended to be administered within one hour before starting operation. Additional dose is recommended to be administered each two to three hours in longer operations. Antimicrobial prophylaxis should be given according to pharmacokinetics/pharmacodynamics (PK/PD). Beta-lactam drugs are recommended to be administered three or four times a day to obtain longer time above MIC and effective antimicrobial activity. In United States, Surgical Care Improvement Project (SCIP) is ongoing to reduce complications after surgery. Proper usage of antimicrobial prophylaxis is strongly recommended to reduce SSI in this project. Surgical team hopes to reduce SSI by proper administration of antimicrobial prophylaxis with the cooperatiing of anesthesiologists and operating room staffs.
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May 2010

Maximal sterile barrier precautions do not reduce catheter-related bloodstream infections in general surgery units: a multi-institutional randomized controlled trial.

Ann Surg 2010 Apr;251(4):620-3

Department of Surgery, Nippon Medical School, Tokyo, Japan.

Objective: To investigate whether maximal sterile barrier precautions (MSBPs) during central venous catheter (CVC) insertion are truly effective in preventing catheter-related bloodstream infections (CRBSIs) in patients in general surgical units.

Summary Background Data: The reported effectiveness of MSBPs was based on the results of a single-center randomized controlled trial by Raad et al and the majority of the patients (99%) in the study were chemotherapy outpatients.

Methods: Between March 14, 2004 and December 28, 2006, the patients scheduled for CVC insertion in surgical units at 9 medical centers in Japan were randomly assigned to either an MSBP group (n = 211) or a standard sterile barrier precaution (SSBP) group (n = 213). This study was registered in the UMIN Clinical Trials Registry (registration ID number: UMIN000001400).

Results: The median (range) duration of catheterization was 14 days (0-92 days) in the MSBP group and 14 days (0-112 days) in the SSBP group. There were 5 cases (2.4%) of CRBSI in the MSBP group and 6 cases (2.8%) in the SSBP group (relative risk, 0.84; 95% confidence interval, 0.26-2.7; P = 0.77). The rate of CRBSIs per 1000 catheter days was 1.5 in the MSBP group and 1.6 in the SSBP group. There were 8 cases (3.8%) of catheter-related infections in the MSBP group and 7 cases (3.3%) in the SSBP group (relative risk, 1.2; 95% confidence interval, 0.43-3.1; P = 0.78). The rate of catheter-related infection per 1000 catheter days was 2.4 in the MSBP group and 1.9 in the SSBP group.

Conclusions: This study is larger in sample size than the one performed by Raad et al and could not demonstrate better prevention of CRBSIs by MSBP compared with SSBP. A large randomized controlled trial or at least a meta-analysis of any other studies in the literature is necessary to reach to a conclusion on this issue.
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http://dx.doi.org/10.1097/SLA.0b013e3181d48a6aDOI Listing
April 2010