Risk factors for incisional surgical site infections in elective surgery for colorectal cancer: focus on intraoperative meticulous wound management.

PURPOSE: An incisional surgical site infection (I-SSI) is a frequently observed complication following colorectal surgery. Intraoperative wound management is one of the most important factors that determine the incidence of postoperative I-SSI. The purpose of this study was to assess the impact of the methods used for intraoperative wound management on the incidence of I-SSI following elective surgery for colorectal cancer. METHODS: Between November 2009 and February 2011, the data of 1,980 consecutive patients who underwent elective colorectal resection for colorectal cancer were prospectively collected from 19 affiliated hospitals. The incidence of and risk factors for I-SSI were investigated. RESULTS: Overall, 233 I-SSIs were identified (11.7 %). Forty-two possible risk factors were analyzed. Using a multivariate analysis, the independent risk factors for I-SSI were identified to be a high body mass index, previous laparotomy, chronic liver disease, wound length, contaminated wound class, creation or closure of an ostomy, right hemicolectomy procedure, the suture material used for fascial closure and the incidence of organ/space SSI. CONCLUSION: To prevent I-SSI following elective colorectal surgery, it is crucial to avoid making large incisions and reduce fecal contamination whenever possible. A high quality randomized control trial is necessary to confirm the definitive intraoperative procedure(s) that can minimize the incidence of I-SSI.

[A case of peritoneal dissemination from mucinous carcinoma of the duodenum, which was associated with tumor thrombosis in the accessory pancreatic duct and successfully treated by chemotherapy].

A 72-year-old woman was admitted with an abdominal tumor, which had been detected by computed tomography scanning. Endoscopic examination of the upper gastrointestinal tract revealed a type 3 tumor in the descending limb of the duodenum. A diagnosis of adenocarcinoma was made on the basis of the histological analysis of the biopsy sample. Pancreatoduodenectomy was performed, and peritoneal dissemination was confirmed at surgery. The pathological findings indicated primary duodenal cancer (mucinous carcinoma) associated with tumor thrombosis in the accessory pancreatic duct. Postoperative chemotherapy was performed. Carcinomatous peritonitis was controlled and the patient showed long-term survival.

Left atrial myxosarcoma with previously detected intestinal metastasis.

Primary cardiac myxosarcoma is a rare disease; it is exceedingly rare for symptoms of systemic metastasis to precede diagnosis of the primary cardiac tumor. We describe the case of a previously healthy 60-year-old man with left atrial myxosarcoma, who had first presented with jejunal intussusception due to intestinal polyposis. Three months after resection of the jejunum, the patient experienced cerebral infarction and pulmonary edema. Further physical evaluation, which included echocardiography for the 1st time, revealed a mass in the left atrium that protruded through the mitral valve into the left ventricle. At emergency cardiac surgery, we found that the tumor involved multiple sites of the left atrium, the pulmonary veins, and the mitral anterior leaflet. Two months after surgery, the patient died of massive cerebral hemorrhage. Necropsy disclosed multiple recurrences of the cardiac myxosarcoma and widespread metastatic lesions. The intestinal polyps that had been resected originally were diagnosed, on retrospective histopathologic examination, as metastases of the myxosarcoma. In this unusual case, the metastatic lesions were the 1st clinical manifestations of a malignant cardiac tumor.

Computed tomographic demonstration of a fish bone in abdominal actinomycosis: report of a case.

A 53-year-old man who had the habit of consuming fish bones was referred to our clinic because of a suspected malignant abdominal wall tumor. Computed tomography (CT) showed a mass (10 x 5 cm) in continuity with the transverse abdominal muscle, containing a small calcification. A laparotomy was performed with a preoperative diagnosis of an inflammatory mass due to fish bone penetration from the sigmoid colon. A fish bone, measuring 2.3 cm in length, was detected within the tumor by specimen radiography. The pathological findings demonstrated actinomycotic colonies. We herein present the first case of a CT demonstration showing a fish bone in an abdominal mass which was pathologically confirmed to be actinomycosis. Evidence of the presence of a foreign body is valuable for diagnosing inflammatory nodules such as actinomycosis and differentiation from malignancies.

Bile duct carcinoma arising in metaplastic biliary epithelium of the intestinal type: a case report.

We report herein a case of distal bile duct carcinoma showing intestinal differentiation diagnosed 3 years after endoscopic sphincterotomy for choledocholithiasis. The diagnostic problem in this case was that the granular mucosa, which is a typical finding of superficial mucosal extension of bile duct carcinoma in general, was interpreted as hyperplasia accompanying metaplasia in cholangioscopic biopsy. Discrimination of superficial mucosal cancer extension from hyperplastic mucosa with metaplastic changes was impossible using cholangioscopic examination. In our case, reflux and stasis of the duodenal and pancreatic juice into the biliary tract might have occurred because of abnormal function of the papilla of Vater following endoscopic sphincterotomy. It might be suggested that endoscopic sphincterotomy contributed to the metaplastic changes in the bile duct mucosa in our case.

Hepatectomy for proximal bile duct carcinoma in a patient with situs inversus; a case report.

Situs inversus is a rare condition which mandates a full understanding of all anatomic relationships prior to invasive procedures. A 76-year-old woman with situs inversus presented with fever and rigors. She had previously undergone endoscopic sphincterotomy and lithotomy for choledocholithiasis, and laparoscopic cholecystectomy for cholecystolithiasis. Laboratory examination revealed hyperbilirubinemia and transaminasimia. Percutaneous transhepatic biliary drainage, percutaneous transhepatic cholangioscopy, percutaneous transhepatic portography, percutaneous transhepatic portal embolization, and visceral angiography were performed without complications. She underwent right hepatic lobectomy, caudate lobectomy and extrahepatic bile duct resection for papillary adenocarcinoma of the proximal bile duct. Full investigation of the anatomical relationships between the biliary tree and the vascular system in the hepatic hilus enabled safe hepatectomy in a patient with situs inversus.

Adenosquamous carcinoma of the jejunum.

Primary adenosquamous carcinomas of the intestine are rare, particularly in the small intestine. One case, in the jejunum of an adult female, is described here. The patient was a 70-year-old Japanese woman presenting with upper abdominal pain. Computed tomography of the abdomen showed a mass in the small intestine, measuring 86 x 44 mm, and a double-contrast barium study revealed a filling defect in the upper jejunum. The patient was diagnosed as suffering from upper small-intestinal cancer, and surgical excision was performed. Histological examination, including immunohistochemistry and electron microscopy, revealed the tumor to have both malignant glandular and squamous components. A review of the literature regarding this type of lesion is presented.

Most informative projection for portography: quantitative analysis of 47 percutaneous transhepatic portograms.

The goal of this study was to determine which projection for percutaneous transhepatic portography best depicts the anatomy of the proximal portal vein. Portograms ( n = 47) obtained in the anteroposterior, right anterior oblique, and right anterior caudal oblique projections were analyzed retrospectively. Lengths of the right portal trunk, the transverse portion of the left portal vein, and the right anterior and posterior portal branches, as well as angles between the right portal trunk and the transverse portion of the left portal vein and between the right anterior and posterior portal branches were measured in the various projections. Differences were evaluated using analysis of variance with Scheffe's method. The transverse portion of the left portal vein and the right anterior and posterior portal branches appeared longer on the right anterior caudal oblique views than on the anteroposterior ( p < 0.0001, < 0.0001, < 0.0001) or right anterior oblique ( p < 0.0001, = 0.001, < 0.0001) views. The angle between the right portal trunk and the transverse portion of the left portal vein was wider on the right anterior oblique views than on the anteroposterior ( p < 0.0001) or right anterior caudal oblique ( p = 0.007) views. The angle between the right anterior and posterior portal branches was wider on the right anterior caudal oblique views than on the anteroposterior ( p < 0.0001) or right anterior oblique ( p = 0.030) views. The right anterior caudal oblique projection provides the best image of the proximal portal vein, and therefore should be obtained whenever possible in preoperative staging of hepatobiliary cancer.

Factors influencing postoperative hospital mortality and long-term survival after radical resection for stage IV gallbladder carcinoma.

Factors influencing postoperative hospital mortality and long-term survival after radical resection of stage IV gallbladder carcinoma remain unclear. The objective of this study was to identify characteristics of patients who are good candidates in terms of surgical risk and long-term survival for radical resection of stage IV gallbladder carcinoma. A retrospective study was made of attempted surgical cure in 72 patients with stage IV gallbladder carcinoma. There were 14 postoperative hospital deaths (19%). Eleven (19%) of the 58 patients discharged from hospital survived for more than 3 years. Multivariate analysis indicated male gender, extended right hepatic lobectomy in a cholestatic liver, and portal vein resection as independent risk factors that correlated with hospital death. Distant metastasis was the sole independent factor that related negatively with long-term survival by multivariate analysis. Subset analysis was performed with combinations of the four independent factors obtained by multivariate analyses. The hospital mortality rate and the 3-year survival rate in the 44 patients without portal vein involvement were 9% and 28%, respectively, and were 3% and 27%, for the 31 women in this group. The highest 3-year survival rate (39%) was observed in the 26 patients without distant metastasis and portal vein involvement, despite a hospital mortality rate of 12%. Better patient selection may improve the outcome of radical surgery for stage IV gallbladder carcinoma. These data may be useful in designing future trials of the surgical treatment of advanced gallbladder carcinoma.

Mode of tumor spread and surgical strategy in gallbladder carcinoma.

BACKGROUND AND AIMS: The mode and degree of tumor spread in gallbladder carcinoma is poorly documented. The present study classifies the patterns of dissemination of this tumor with a focus on surgical strategy. PATIENTS AND METHODS: Surgical specimens from 112 patients who underwent curative resection were reviewed. There were stage I, II, III, and IV in 9, 11, 14, and 78 patients, respectively. RESULTS: Six types of spread were identified. In the hepatic bed type ( n=20) a large mass in the fundus and body penetrated into the liver through the gallbladder bed with or without contiguous spread to the gastrointestinal tract. The extent of hepatectomy was individualized from wedge resection to extended right hepatectomy based on the clinical findings. In the hepatic hilum type ( n=26) a relatively small tumor in the neck infiltrated the hepatic hilum causing obstructive jaundice. Extended right hepatectomy plus bile duct resection with or without portal vein resection was necessary for curative resection because the tumor had extended into the right portal pedicle, and postoperative hepatic failure was common. In the bed and hilum type ( n=18) a huge mass occupying the entire gallbladder involved both the gallbladder bed and the hepatic hilum. Extended right hepatectomy with combined resection of contiguous spread was necessary for curative resection. In the lymph node type ( n=15) enlarged metastatic lymph nodes were the most prominent feature, and the primary tumor remains limited to the gallbladder in most cases. Extended lymphadenectomy with combined individualized resection was performed. In the cystic duct type ( n=9) a small mass arising from the cystic duct involved the common bile duct. This type presented at an earlier stage than the first four types. In the localized type ( n=24) tumor spread is localized to the gallbladder and presented at the earliest stage of any type. Simple cholecystectomy with or without wedge hepatic resection and regional lymphadenectomy resulted in a satisfactory outcome. Prognosis depends on the stage rather than on the mode of tumor spread. Even in the advanced types favorable results may be obtained in selected patients undergoing radical resection for M0 tumors without portal vein invasion. Success also was achieved in the rare patients with para-aortic lymph node metastases that were not infiltrative. CONCLUSIONS: These six types of gallbladder cancer can be diagnosed preoperatively by clinical and radiological examination. This information should assist the surgeon in the choice of operation and predict outcome.

[Surgical treatment for advanced gallbladder cancer: indications and limitations].

We have aggressively performed extensive surgery including major liver resection for advanced gallbladder cancer since 1979. The 5-year survival rates for stage IVa and IVb patients after curative resection were 19% and 6%, respectively. Seven patients in the stage IVa group (n = 69) and one in stage IVb (n = 16) have survived for more than 5 years. The hospital mortality rate including all deaths within and over 30 days of curative operation for stage IV gallbladder cancer was 19%. Although radical resection is the only treatment of choice for advanced gallbladder cancer to obtain long-term survival, there are serious problems in extensive surgery. The most important issue is reduction of the hospital mortality rate. Elucidation of the clinical and molecular characteristics leading to potential long-term survival and development of new strategies for the treatment of recurrent tumors are also important issues.

Bacteremia after hepatectomy: an analysis of a single-center, 10-year experience with 407 patients.

BACKGROUND AND AIMS: Septic complications after hepatectomy remain a difficult problem. Intra-abdominal sources of postoperative infections are well described in the literature. However, no studies have examined the cause and outcome of bacteremia after hepatectomy. This study evaluated the incidence and outcome of bloodstream infections, bacteremia, after hepatectomy and determined the risk factors associated with the development of this serious complication. PATIENTS AND METHODS: Records were retrospectively reviewed of 407 patients who underwent an elective first hepatectomy at Nagoya University Hospital between January 1990 and December 1999. The incidence, cause, outcome, and possible risk factors for bacteremia were examined. RESULTS: A total of 403 blood cultures were performed after hepatectomy in 188 patients (46%), and bacteremia was confirmed in 46 (11%). The incidence was significantly different between patients with obstructive jaundice and those without (24% vs. 4%). Multivariate analysis identified four significant independent variables: operative time, age, obstructive jaundice, and large-scale hepatectomy. The most common bacteria isolated were Staphylococci, followed by Enterococci, Klebsiella pneumoniae, and Enterobacter. A probable source of bacteremia was identified in 21 (46%) of the 46 patients. Patients with bacteremia had higher morbidity and mortality rates than patients without bacteremia, and the incidence of organ failure was five to ten times that of patients without bacteremia; the mortality rate was 43% (20/46). CONCLUSIONS: Postoperative bacteremia is a common complication of hepatectomy to resect biliary tract carcinoma, especially in older patients with obstructive jaundice undergoing major hepatectomy. In addition, for more than half of patients with bacteremia, no clear source of the infection is identified. Thus blood cultures are mandatory in high-risk patients who spike a fever after hepatectomy to identify the correct pathogen and its antibiotic susceptibility.

Hepaticojejunostomy using a Roux-en-Y jejunal limb via the retrocolic-retrogastric route.

BACKGROUND: Hepaticojejunostomy following hepatobiliary resection has been performed using a Roux-en-Y jejunal limb via the antecolic or the retrocolic-anteduodenal route. However, in morbidly obese patients difficulty arises from the thickened, foreshortened mesentery of the jejunum and from limited mobility due to intra-abdominal fat deposition. METHODS: We developed new placement of Roux-en-Y jejunal limb in which the limb is placed via the retrocolic-retrogastric route. Hepaticojejunostomy via this route was performed in 133 obese and nonobese patients with biliary cancer. RESULTS: Tension-free anastomosis was successfully performed in all patients. Neither early nor late complications directly related to this new reconstruction route occurred. CONCLUSIONS: The retrocolic-retrogastric route is simple and an alternative to the standard methods of biliary reconstruction following hepatobiliary resection. This new placement may circumvent the obesity-related problem.