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 ß-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).

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.

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.

[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.

[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).

[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.

[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.

[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.

[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.

[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.

[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.