A case of severe bilateral empyema due to Streptococcus pyogenes.

Bilateral empyema is a rare and severe condition and deciding on a treatment is quite difficult. Additionally, infections caused by group A Streptococcus (GAS [Streptococcus pyogenes]) are known to be invasive. We successfully treated without surgery a previously healthy 59-year-old woman with bilateral empyema due to GAS, with repeated drainages, antibiotics, and fibrinolytic therapy. To our knowledge, there have not been any published reports on cases of bilateral empyema due to GAS infection. In rare, severe cases of bilateral empyema caused by organisms such as GAS, physicians managing the condition should consider the overall condition of the patient.

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.

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.

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.

Characteristics of ectopic pancreas in dynamic gadolinium-enhanced MRI.

The characteristics of jejunal ectopic pancreas in dynamic gadolinium-enhanced magnetic resonance imaging are described in a 40-year-old man with bowel obstruction. The pre-contrast signal intensity and post-contrast enhancement pattern of ectopic pancreas are the same as those of the pancreas.

Prognostic significance of peritoneal washing cytology in patients with potentially resectable gastric cancer.

BACKGROUND/AIMS: The prognostic value of cytological examination of intraoperative washings in potentially resectable gastric cancer is controversial. METHODOLOGY: Between February 1993 and August 2001, clinicopathological features and surgical outcome of 26 consecutive patients with gastric cancer with positive cytological findings of peritoneal washings without peritoneal dissemination were retrospectively analyzed. RESULTS: The overall 1, 2, 3-year survival rates for 26 patients were 69%, 35%, and 0%, respectively. The median survival was 17.5 months. The median survival of patients with curative resection (n=16) and non-curative resection (n=10) was 19 months and 12.5 months, respectively. There was no significant difference in survival between curative resection and non-curative resection (p=0.10). Recurrent disease frequently occurred as peritoneal dissemination (69%). No patient survived for more than 34 months. CONCLUSIONS: Aggressive surgical resections do not provide any survival benefit for gastric cancer with positive cytological findings of peritoneal washings even in the absence of peritoneal dissemination.

Imaging modality of three-dimensional CT in caudate cholangioma: assessment for resectability.

Conventional preoperative imaging has limited modality and accuracy in primary intrahepatic cholangiocellular carcinoma (ICC) in the caudate lobe (CL). Furthermore, estimating resectability and tumor extension from preoperative imaging is inaccurate. A 60-year-old patient with ICC administrated in our institution requested a second opinion. His lesion was judged unresectable hilar cholangiocellular carcinoma because it had spread widely to the bilateral lobe of the liver as shown by preoperative imaging studies. The irregular shaped mass was located in the para-caval portion of the CL and the size as shown by computed tomography (CT) was 40mm in diameter. The tumor extended close to the common hepatic artery and the right portal branch was involved. The left lobe showed marked atrophy and intrahepatic biliary duct (IHBD) dilatation of the whole liver was observed. The tumor was mainly located in the proximal side of the left lobe and every IHBD were interrupted in the porta hepatis by magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiography. However, the resectability of this tumor could not be determined from these imaging studies. Three-dimensional imaging by multidetector CT (3D-CT) revealed that the tumor involved the left hepatic artery and portal branch whereas the right hepatic artery was intact. The patient was successfully treated in surgery by extending the left lobectomy with en bloc caudate lobectomy. The 3D-CT imaging study was helpful in assessing the resectability in ICC of CL.

Triple cancer in liver, esophagus and urinary bladder: indications and problems of hepatectomy.

In patients with multiple cancers and chronic liver damage, it is difficult to decide on the operative procedures. We describe a 70-year-old man with triple cancer: liver, esophageal and urinary bladder. The patient had the complication of chronic hepatitis C and mild liver damage. He received curative resections of all cancers. In patients with multiple cancers, including hepatocellular carcinoma accompanied by liver damage, the treatment strategy should be decided after clarifying the relationship between the staging of multiple cancers and liver function.

A case of anaplastic ductal carcinoma of the pancreas with production of granulocyte-colony stimulating factor.

We report a case of anaplastic ductal carcinoma of the pancreas with production of granulocytecolony stimulating factor in a 46-year-old man. He underwent distal pancreatectomy, total gastrectomy with Roux-en-Y reconstruction and splenectomy. He recovered uneventfully postoperatively and was discharged from hospital on the 22nd postoperative day. Histological examination showed anaplastic ductal carcinoma (giant cell type) of the pancreas. However, three months after the operation, multiple liver metastases were demonstrated by CT scan and the peripheral leukocyte count rose to 81,800/microL. Serum granulocyte-colony stimulating factor concentration was 155pg/mL (normal 5.78-27.5 pg/mL). Therefore, we diagnosed granulocyte-colony stimulating factor-producing pancreatic cancer. Anaplastic ductal carcinoma of the pancreas with production of granulocyte-colony stimulating factor is very rare. Tumors with production of granulocyte-colony stimulating factor are highly malignant, and this patient died of hepatic failure four months after the operation.

Aggressive multimodal treatment for peritoneal dissemination and needle tract implantation of hepatocellular carcinoma: a case report.

We encountered a patient with hepatocellular carcinoma (HCC) with peritoneal dissemination and needle tract implantation, both of which were strongly suspected to have been caused by percutaneous needle biopsy. The patient was a 65-year-old man. Partial hepatectomy of subsegment VI had been performed following the diagnosis of HCC by percutaneous needle biopsy in February 1997. After this first surgery, the patient additionally underwent five further surgeries for the treatment of intrahepatic recurrences, peritoneal recurrences and needle tract implantation caused by the percutaneous needle biopsy. The intrahepatic and peritoneal recurrences were surgically controlled for 3 years after the fifth operation. The needle tract implantation was first resected in February 2001. Since then, treatment by surgery and radiotherapy has been administered twice for local recurrences forming tumor thrombosis of the abdominal wall. Now, 7 years after the first surgery, the patient remains alive without any evidence of recurrence. This case report serves to emphasize that needle tract implantation and peritoneal seeding caused by percutaneous needle biopsy are rare but possible complications. When such iatrogenic spreading of malignant cells occurs, aggressive multimodal treatment is well worth considering. Wide resection of the tumor including the adjacent soft tissues should be performed in these cases, considering that the tumor spreads along the subcutaneous veins in needle tract implantation of HCC and repeated aggressive surgeries could provide good local control.

Inferior head resection of the pancreas and cyst resection for choledochal cyst with chronic calcifying pancreatitis.

We report inferior head resection of the pancreas and cyst resection for congenital choledochal cyst with an anomalous arrangement of pancreaticobiliary duct and chronic calcifying pancreatitis. A 42-year-old man was admitted to the National Cancer Center Hospital East complaining of back pain. Contrast-enhanced computed tomography showed marked dilatation of the bile duct and multiple pancreatic stones in the main pancreatic duct. Endoscopic retrograde cholangiopancreatography demonstrated pancreatic stones in the dilated main pancreatic duct. The patient underwent cyst excision, inferior head resection of the pancreas, hepaticojejunostomy and lateral pancreaticojejunostomy. The postoperative course was uneventful. This procedure relieved the back pain. Choledochal cyst with anomalous arrangement of the pancreaticobiliary duct is frequently associated with acute pancreatitis. Inferior head resection of the pancreas removed the common channel which could be the cause of relapsing pancreatitis. Thus, inferior head resection can play a role in the management of choledochal cyst with chronic pancreatitis.

Invasive carcinoma derived from intraductal papillary mucinous carcinoma of the pancreas.

BACKGROUND/AIMS: Most patients with intraductal papillary mucinous tumors of the pancreas have a favorable prognosis after surgical treatment. However, recurrent disease frequently occurs in patients with invasive carcinoma derived from intraductal papillary mucinous carcinoma. The objective of this study was to clarify the clinicopathological features of invasive carcinoma derived from intraductal papillary mucinous carcinoma. METHODOLOGY: We performed a retrospective review of the 29 patients with intraductal papillary mucinous tumor including 10 patients with invasive carcinoma who underwent pancreatic resection between June 1995 and December 2001 at the National Cancer Center Hospital East. RESULTS: Of 10 patients with invasive carcinoma derived from intraductal papillary mucinous carcinoma, 7 patients had lymph node involvement and 8 patients had retroperitoneal invasion. The overall 1-, 2-, 4-year actuarial survival rate for invasive carcinoma derived from intraductal papillary mucinous carcinoma was 39%, 26%, 13%. Recurrence occurred as liver metastasis in 3 patients, carcinomatous peritonitis in 3, local recurrence in 3, and lung metastasis in 1. All patients with adenoma, non-invasive carcinoma, and minimally invasive carcinoma are alive without recurrent disease after pancreatic resection. CONCLUSIONS: Patients with invasive carcinoma derived from intraductal papillary mucinous carcinoma had a worse prognosis. Margin-negative pancreatic resection is essential for treating this disease.