Restoration of clean water supply and toilet hygiene reduces infectious diseases in post-disaster evacuation shelters: A multicenter observational study.

After a massive disaster, many residents in affected areas are forced to temporarily stay in evacuation shelters. The exact impact of the state of resource supply and infrastructure in evacuation shelters on the health status of evacuees has not been sufficiently studied. Two weeks after the 2011 Great East Japan Earthquake (GEJE), comprehensive surveillance related to the health status and hygiene level was performed for all evacuation shelters (328 shelters with 46,480 evacuees at the peak) in one of the most devastating medical zones after the tsunami hit the area (Ishinomaki City). The joint relief team regularly visited all evacuation shelters across the area to assess the situation of resource supply levels, infrastructural damage, rapid need of resources, and the health status of the evacuees. In this cross-sectional observational study, we evaluated the relationship between the resource supply levels and health status among evacuees in two time periods (days 14-19 and 20-25). Among the evaluated vital resources, clean tap water supply was among the most disrupted by the disaster, and was not fully restored in most shelters during the assessment period. The cross-sectional relationship between resource supplies and morbidity was inconsistent between the two assessment periods, reflecting the multifactorial nature of health status in evacuation shelters. The clean tap water supply level at the first assessment showed a strong negative correlation with the subsequent prevalence of respiratory or gastrointestinal infectious conditions at the second assessment. Restorations in the clean tap water supply and toilet hygiene correlated each other, and both correlated with a decrease in the prevalence of gastrointestinal infectious conditions. In conclusion, disrupted clean tap water supply and inadequate toilet hygiene after a massive disaster would jointly harm the health status of those in shelters. Prompt assessments using quick visual assessment and restorations of these key resources have validity with suppressed environmental health risks among evacuees.

Repeat Hepatectomy After Major Hepatectomy for Colorectal Liver Metastases.

OBJECTIVE: This study assessed predictors of survival after repeat hepatectomy and the feasibility of a repeat hepatectomy after a major hepatectomy in the patients with colorectal liver metastases (CLM). BACKGROUND: More than half of all patients who receive a curative initial hepatectomy for CLM develop hepatic recurrence, and aggressive indications for a repeat hepatectomy can improve the outcome in selected patients. However, the feasibility of repeat hepatectomy after major hepatectomy remains uncertain, and optimal selection criteria for repeat hepatectomy have not yet been established. METHODS: Data were collected retrospectively on 296 CLM patients who underwent an initial curative hepatectomy between 2007 and 2017 at our institution. The postoperative outcomes of patients undergoing a repeat hepatectomy after major hepatectomy were assessed, and independent predictors of survival were investigated. RESULTS: After a median follow-up period of 32 months, 247 patients (83%) developed disease recurrence and 122 patients (49%) underwent repeat hepatectomy. The 5-year overall survival (OS) was significantly higher in patients who underwent a repeat hepatectomy than in those who did not receive repeat hepatectomy (51% vs. 19%, respectively; P < 0.001). In a multivariate analysis, an extrahepatic lesion at the time of the repeat hepatectomy (HR, 2.49; P = 0.001) and 5 or more liver tumors at the time of recurrence (HR, 1.88; P = 0.04) remained as independent factors negatively affecting OS after repeat hepatectomy. The type of operative procedure and the intraoperative and postoperative factors at the time of the initial hepatectomy did not have any significant influence on the OS after repeat hepatectomy. No significant difference in OS was found between patients who received repeat hepatectomy after major hepatectomy (n = 43) and those after non-major hepatectomy (n = 79). CONCLUSIONS: The operative procedure and the liver tumor status at the time of the initial hepatectomy have little impact on the indications for a repeat hepatectomy for recurrent CLM. Repeat hepatectomy is feasible even if major hepatectomy was initially performed.

Practical Contribution of Virtual Hepatectomy for Colorectal Liver Metastases: a Propensity-Matched Analysis of Clinical Outcome.

BACKGROUND: Recent improvements in imaging technologies have enabled surgeons to perform precise planning using virtual hepatectomy (VH). However, the practical and clinical benefits of VH remain unclear. This study sought to assess how three-dimensional analysis using a VH contributed to preoperative planning and postoperative outcome in patients undergoing liver surgery for the treatment of colorectal liver metastases (CRLM). METHODS: From 2007 to 2017, a total of 473 CRLM patients who received curative hepatectomy were retrospectively assessed. A 1:1 matched propensity analysis was performed between patients who did not receive a VH (without 3D group: n = 188) and received a VH (3D(+) group: n = 285). RESULT: The rate of VH increased over the study period (P < 0.001). After propensity score matching (n = 150 for each group), no significant differences were observed in the intraoperative and postoperative outcome, including liver transection time, blood loss, or morbidity between the groups. More patients received a small anatomical resection (plus limited resections) in the 3D(+) group (25 vs 11%, [P = 0.03]). A submillimeter margin was less frequent in the 3D(+) group. No significant differences in the 5-year overall survival and disease-free survival rates were seen between the without 3D group and the 3D(+) group (38.0 vs. 45.9% [P = 0.99], 11.1 vs. 21.7%, respectively [P = 0.109]). CONCLUSION: Although VH did not significantly influenced on the long-term outcome after hepatectomy, a more parenchymal-sparing operative procedure (anatomical resections, plus limited resections) was selected and the risk of a submillimeter surgical margin was reduced after introduction of VH.

Surgical Strategy Based on Indocyanine Green Test for Chemotherapy-Associated Liver Injury and Long-Term Outcome in Colorectal Liver Metastases.

BACKGROUND: It remains unclear whether the presence of chemotherapy-induced liver injury (CALI) or impaired liver functional reserve affects the long-term outcome. This study assessed the applicability and long-term effects of using criteria based on the indocyanine green (ICG) test results in selecting the operative procedure among patients with colorectal liver metastases (CRLM) who had a risk of CALI. STUDY DESIGN: CRLM patients who received preoperative chemotherapy including oxaliplatin and/or irinotecan prior to a curative hepatectomy between 2007 and 2017 were included. For each case, the minimum required future remnant liver volume and operative procedure were decided based on the ICG retention rate at 15 min (ICG R15). Patients with an ICG R15 > 10% and who had undergone a major hepatectomy were categorized in a marginal liver functional reserve (MHML) group. RESULTS: Overall, 161 patients were included; 77 of them had an ICG R15 > 10%, and 57 had pathological liver injury (PLI). After the median follow-up time of 30.9 months, the 5-year overall survival rate was 36.1%. The presence of an impaired ICG test result or CALI did not negatively impact the overall and recurrence-free survival outcomes. A multivariate analysis revealed that the presence of four or more nodules of liver metastases was the only independent predictor of a poor overall survival. A significantly larger proportion of patients in the MHML group (n = 37) had a 25% or larger increase in splenic volume (30 vs. 13%; P = 0.024). CONCLUSION: The presence of an impaired ICG test result or PLI did not affect the long-term outcome after individually selected operative procedure. However, patients undergoing MHML had a higher possibility of developing a > 25% splenic volume increase after hepatectomy.

Two-dimensional assessment of submillimeter cancer-free margin area in colorectal liver metastases.

The aim of the study is to evaluate the prognostic impact of the extent of submillimeter or zero surgical margin (SubMM) area among the patients who underwent liver resection for colorectal liver metastases (CRLM).The influence of suboptimal margin width of <1 mm on long-term outcome is unclear.A total of 423 liver resections for CRLM were performed at Japanese Red Cross Medical Center between 2007 and 2015. Among them, we identified 235 patients who underwent curative initial liver resection and classified them into 2 groups: R0 (margin: ≥1 mm) and R1 (SubMM). The R1 group was further divided into 2 groups by the extent of SubMM area: small SubMM area (≤4 cm) and broad SubMM area (>4 cm).The median tumor number was 4 (range 1-97), 23% had solitary and 37% had 8 or more number of metastases. With a median follow-up period of 30 months, the overall 1-, 3-, 5-year survival for R0 (n = 72) versus R1 (n = 163) groups were 98.4% vs 87.5%, 75.5% versus 57.1%, and 50.1% versus 36.6%, respectively (P = 0.004). After propensity score analysis allowing for matching the tumor number (<8 vs 8 or more), tumor size, and serum carcinoembryonic antigen level, the DFS and OS were significantly higher in the small SubMM area group (P = 0.024, P = 0.049), respectively.Although wide margins >1 mm should be attempted whenever possible, reducing the extent of SubMM area (≤4 cm) can contribute to better long-term outcome when wide margin is not practicable.

Dynamic assessment of carcinoembryonic antigen in the first month after liver resection for colorectal liver metastases as a rapid-recurrence predictor.

BACKGROUND: Carcinoembryonic antigen (CEA) is a tumor marker used widely for detecting the recurrence and predicting the prognosis of colorectal cancer. This study investigates the possibility of serial measurement of serum CEA in several weeks after liver resection for colorectal liver metastases (CRLM) in detecting earlier detection of recurrence. METHODS: From 2007 to 2014, CEA levels were assessed at 1 week and at 2-3 weeks after curative-intent liver resection among a total of 240 patients with CRLM. The CEA half-life was calculated and patients were divided into two groups: those with a CEA half-life ≤10 days or normalized (Group S), and those with a CEA half-life >10 days or rising (Group L). RESULTS: The 1-, 3-, and 5-year overall survival rates in Group S versus Group L were 91.3% versus 83.3%, 64.0% versus 41.3%, and 44.2% versus 29.3%, respectively (P = 0.0079). Multivariate analysis revealed that resection of extrahepatic lesions, four or more lesions of liver metastases, and categorization in Group L were independent factors of rapid recurrence within 100 days. CONCLUSION: A CEA half-life >10 days or rising 1 month after curative-intent liver resection was associated with rapid recurrence of CRLM within 100 days. J. Surg. Oncol. 2016;113:463-468. © 2016 Wiley Periodicals, Inc.

Living donor liver transplantation using a graft with periportal fibrosis.

A 57-year-old woman with familial amyloid polyneuropathy (FAP) was scheduled to undergo living donor liver transplantation (LDLT), but the operation was cancelled because the only potential donor had chronic alcohol-related liver disease. One year later, FAP-related neurological symptoms progressed rapidly, and emergency LDLT was planned. The donor's hepatic function had returned to normal range after 1 year of abstinence. The left liver graft volume was equivalent to 37.7% of the standard liver volume (SLV) of the recipient. However, a liver biopsy revealed mild fibrosis (score, F1). LDLT was successfully performed without any complications. The recipient's neurological findings returned to normal. One year after LDLT, the liver graft volume was equivalent to approximately 90% of the SLV, and the fibrosis had improved. LDLT using a graft with a fibrosis score of up to F1 may be an acceptable alternative for recipients with normal hepatic function.

Applicability of enhanced recovery program for advanced liver surgery.

BACKGROUND: Enhanced recovery programs (ERPs) have been developed in various surgical fields and have been shown to accelerate postoperative recovery without increasing the incidence of adverse events. Whether ERP can be safely applied to patients undergoing complex liver surgery with a risk of liver failure remains unclear. METHODS: We created an ERP by rearranging our conventional postoperative treatments and applied this program to patients undergoing major hepatectomy between 2008 and 2013. The ERP elements included greater perioperative education, individualized postoperative fluid therapy, and early mobilization. The success of the ERP was evaluated on postoperative day (POD) 6 based on the criterion of independence from continuous medical intervention with the exception of an abdominal drainage tube. Adherence to each item in the ERP was evaluated, and risk factors for delayed accomplishment were analyzed. RESULTS: Altogether, 200 patients were included, and 165 patients (82.5 %) completed the ERP. Multivariate analyses showed that (1) an age of 65 years or older and (2) a red blood cell transfusion were independent risk factors for delayed accomplishment. The performance of thoracotomy or choledocojejunostomy did not significantly affect accomplishment of the ERP. Oral intake starting on POD 1 was achieved in 179 patients (89.5 %), and termination of intravenous drip infusions on POD 5 was feasible in 72.5 %. CONCLUSIONS: An ERP for major hepatectomy was completed in more than 80 % of the patients. Earlier bowel movement can be challenged. The liquid in-out balance should be adjusted on an individual basis, rather than uniformly, especially for patients over 65 years of age or who required a red blood cell transfusion.

[A case of mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes (MELAS) with treatment-resistant status epilepticus that was effectively treated with lamotrigine].

A 16-year-old woman with MELAS developed fever and myoclonic epilepsy which improved with conventional anti-epileptic drugs. Since seizures recurred one month after successful treatment, the doses of phenobarbital, clonazepan, and valproate were increased. However, there was no improvement and status epilepticus continued. The addition of lamotrigine resulted in a decreased frequency and good control of seizures. This case is important, showing satisfactory results from the addition of lamotrigine for treatment-resistant status epilepticus.

Planning of anatomical liver segmentectomy and subsegmentectomy with 3-dimensional simulation software.

BACKGROUND: The aim of this study was to evaluate whether 3-dimensional (3D) simulation software is applicable to and useful for anatomic liver segmentectomy and subsegmentectomy. METHODS: A prospective study of 83 consecutive patients who underwent anatomic segmentectomy or subsegmentectomy using the puncture method was performed. All patients underwent 3D simulation analysis (SA) preoperatively for planning operative procedures. The clinical information acquired by 3D SA and the consistency of virtual and real hepatectomy were evaluated. RESULTS: The time needed for completing 3D SA was 18.3 ± .7 minutes. Three-dimensional SA proposed resection of multiple segments or subsegments in 29 patients (35%). It also helped complement the resection line in 26 patients (31%) who lacked a bold staining area on the liver surface. The volume of segment or subsegment calculated by 3D SA was correlated with the actual resected specimen (R(2) = .9942, P < .01). The bordering hepatic veins were clearly exposed in 71 patients (86%), in accordance with completed drawings by 3D SA. CONCLUSIONS: Three-dimensional SA showed accurate completed drawings and assisted liver surgeons in planning and executing anatomic segmentectomy and subsegmentectomy.

[Anti-aquaporin-4 antibody autoimmune syndrome with disturbance of consciousness, respiratory failure, and ophthalmoplegia associated with extensive brain stem involvement with intractable hiccup and nausea as an initial manifestation. A case report].

A 45-year-old female was positive for anti-aquaporin-4 antibody with disturbance of consciousness, respiratory failure, and ophthalmoplegia associated with extensive brain stem involvement with intractable hiccup and nausea as an initial manifestation. Her level of consciousness and state of respiration worsened approximately one month later. There was no abnormality in the cerebrospinal fluid examination. A lesion was found in the medullary tegmentum on brain MRI. The patient received steroid pulse therapy and her level of consciousness improved the next day. However, her state of respiration worsened, and she had extensively clinical involvement of the brain stem. Her symptoms gradually improved with intravenous administration of prednisolone and intravenous immunoglobulin therapy (IVIg). The patient had almost completely recovered, but she relapsed with cervical myelitis extending over 3 vertebral segments approximately 10 months later. She underwent steroid pulse therapy, oral prednisolone, and IVIg again and improved.

Recovery of liver function after the cessation of preoperative chemotherapy for colorectal liver metastasis.

BACKGROUND: Preoperative chemotherapy containing oxaliplatin (FOLFOX) or irinotecan (FOLFIRI) causes histological liver injury and increases postoperative morbidity and mortality in patients with colorectal liver metastasis (CRLM). However, information on the aggravation of liver function and its reversibility is scarce. METHODS: A total of 55 patients who underwent a hepatectomy after receiving FOLFOX and/or FOLFIRI were included in the present study. Indocyanine green tests were repeatedly performed before hepatectomy for monitoring the change of hepatic functional reserve. RESULTS: A significant decrement in the ICG R15 value was observed at 2-4 weeks (12.9%, P = .04), 4-8 weeks (11.4%, P = .01), and 8 or more weeks (11.1%, P = .006) after the last chemotherapy, compared with results documented within 2 weeks (16.8%). However, no significant change was observed among the values obtained at 2-4 weeks, 4-8 weeks, and 8 or more weeks. The individual ICG R15 values at the beginning and end of the cessation period also improved from 17.7% to 11.6% (P = .001). Histological liver injury was associated with larger amounts of operative blood loss but not with morbidity. Neither liver failure nor mortality occurred in the present series. CONCLUSIONS: The hepatic functional reserve, represented by the ICG R15 value, improves during the period after chemotherapy cessation. The present study suggests that chemotherapy cessation for at least 2-4 weeks enables an improvement in the hepatic functional reserve, especially among patients with an abnormal ICG R15 value (> 10%) who have received 6 or more cycles of FOLFOX and/or FOLFIRI.

A case of mixed connective tissue disease complicated with thymic carcinoma and Hashimoto's thyroiditis.

We report the case of a 63-year-old woman who suffered from mixed connective tissue disease (MCTD) complicated with thymic carcinoma and Hashimoto's thyroiditis. Although many systemic syndromes associated with thymoma and thymic carcinoma, i.e., myasthenia gravis, pure red cell aplasia, hypogammaglobulinemia, and Hashimoto's thyroiditis, are known, this is the first report of MCTD complicated with thymic carcinoma. It was suggested that MCTD may be a paraneoplastic syndrome associated with thymic carcinoma.

[A case of brainstem encephalitis caused by herpes simplex virus type 1 with possible infection via trigeminal nerve].

A 24-year-old man was admitted to our hospital because of consciousness disturbance, a stiff neck and various brainstem symptoms including a right one-and-a-half syndrome and right peripheral facial palsy a week after an episode of pharyngitis and right facial herpes simplex. Magnetic resonance imaging of the brain on admission showed high-signal intensities in the right pontine tegmentum, right cerebellar peduncle and vermis on fluid-attenuated inversion recovery imaging. Examination of cerebrospinal fluid yielded mononuclear pleocytosis, elevated protein and increased IgM antibodies to herpes simplex virus (HSV) by enzyme immunoassay. HSV-1 specific antibodies also were detected in serum by neutralization test. We gave a diagnosis of brainstem encephalitis caused by HSV-1. The patient was successfully treated with high dose of acyclovir, steroid and intravenous immunoglobulin. He was discharged without any neurologic sequelae. We herein presented a case of atypical encephalitis due to HSV-1 involving mainly the brainstem with possible infection via right trigeminal nerve and summarized recent 35 cases with herpetic brainstem encephalitis since 1990.