Venous reconstruction based on virtual liver resection to avoid congestion in the liver remnant.

BACKGROUND: Hepatic vein (HV) reconstruction may prevent venous congestion following resection of liver tumours that encroach on major HVs. This study aimed to identify criteria for venous reconstruction based on preoperative evaluation of venous congestion. METHODS: A volumetric analysis using image-processing software was performed in selected patients with liver tumours suspected on preoperative imaging of major HV invasion. The size of the non-congested liver remnant (NCLR) was calculated by subtracting the congested area from the liver remnant. Venous reconstruction was scheduled in patients who met the following criteria: normal liver function (indocyanine green retention rate at 15 min (ICGR(15) ) of less than 10 per cent) with a NCLR smaller than 40 per cent of total liver volume (TLV), or liver dysfunction (ICGR(15) 10-20 per cent) with a NCLR smaller than 50 per cent of TLV. Surgical outcomes and liver regeneration were investigated. RESULTS: A total of 55 patients with suspected HV invasion were enrolled. Sacrifice of one or more HVs was deemed possible in 37 patients. Venous reconstruction was scheduled in 18 patients. At operation, there was seen to be no venous involvement in 11 patients. The HV was sacrificed in 29 patients, and preserved or reconstructed in 24. Volume restoration ratios at 3 months were similar in the sacrifice (88 per cent) and preserve (87 per cent) groups. Operating time was shorter (465 min) and blood loss was lower (580 ml) in the sacrifice than in the preserve group (523 min and 815 ml respectively). CONCLUSION: The HV can be sacrificed safely according to the proposed criteria, reducing surgical invasiveness without influencing the postoperative course.

[Single-stage operation for synchronous bilateral multiple lung cancer through median sternotomy].

An asymptomatic 65-year-old woman was incidentally found to have abnormal shadows on a chest X-ray during a medical examination. A chest computed tomography (CT) scan showed a pulmonary nodule in both right and left lung. Those were diagnosed as synchronous cStage IA bilateral lung cancer, and right upper lobectomy and segmentectomy of the left lung with lymphoadenectomy were sequentially performed through median sternotomy. The patient showed a favorable course after surgery, and was discharged on postoperative day 12. The pathological diagnosis was synchronous lung cancer and both were adenocarcinoma. The pathological stage was IA on the right side and IB on the left. A single-stage operation through median sternotomy was a useful surgical procedure for treating this case of synchronous bilateral lung cancer.

[Resected case of pulmonary arteriovenous malformation diagnosed with a brain abscess as a clinical manifestation; report of a case].

A 63-year-old female with Rendu-Osler-Weber disease had general fatigue and right hemiparesis. A computed tomography (CT) scan of her head demonstrated an enhancing cystic mass in the left frontal lobe, and it was diagnosed as a brain abscess and then drainaged. Thereafter, a pulmonary arteriovenous malformation (PAVM) identified in the left lingular segment by chest CT scan and the PAVM was resected by partial resection of the lung.

Three-dimensional computed tomography for planning donor hepatectomy.

BACKGROUND: An accurate estimation of preoperative volumetric measurements of the donor liver is essential in living donor liver transplantation. METHODS: Three-dimensional (3-D) computed tomography (CT) was applied to 56 living donors. 3-D images of the liver were constructed using the region-growing method and the volume of each sector was measured. RESULTS: The median volume ratios of the left liver, caudate lobe, right paramedian, and lateral sectors were 34%, 4%, 38%, and 25% of the total liver volume, respectively. The shape of the congestive area in the right paramedian sector was properly demonstrated by 3-D CT. The volume of the region corresponded to 32% of the right liver. The actual volume of the graft correlated well with the estimated graft volume (n = .86). CONCLUSIONS: The region-growing method was useful for graft selection and for determining the indication of middle hepatic vein reconstruction in right liver grafts.

Preoperative estimation of right lateral sector graft by three-dimensional computed tomography.

The right lateral sector is an alternative graft for living donor liver transplantation. Three-dimensional image reconstruction of right lateral sector grafts was performed to reveal vascular anatomy and volume using three-dimensional computed tomography software in three donors. There was a correlation between actual and estimated volume (r=.93), although actual graft volume tended to be larger than the preoperative estimated volume. In one donor, a portal branch of the right lateral sector was independently ramified. The branch was sacrificed in the operation because its territory volume was only 44 cm3. Three-dimensional images matched the shape of the right lateral sector graft. Three-dimensional computed tomography might be useful before donor hepatectomy, providing important information for decisions regarding the operative procedure.

[Sternal metastasis of breast cancer; report of a case].

A 51-year-old woman presented with a painful sternal lump. Nine years earlier she had undergone right modified mastectomy for breast cancer, followed by chemotherapy. Computed tomography and bone scintigraphy demonstrated a solitary sternal bone metastasis. The patient was treated by partial sternectomy. Thereafter, the sternal defect was reconstructed with Marlex mesh and rectus abdominis myocutaneous flap. The postoperative course was uneventful. The patient subsequently developed brain metastasis and died within 52 months after sternal resection. The stability of the chest wall was well preserved for the duration of follow-up.

[Pyogenic sacroiliitis in pregnancy].

Pyogenic sacroiliitis is an extremely rare disease in the field of obstetrics and gynecology, and especially for the cases discovered and treated during pregnancy, only five cases can be found in literature. We experienced one case of the disease in which the patient needed urgent hospitalization due to dysbasia caused by fever and pain at the left hip at the 27th week of her pregnancy. The patient was a 31-year-old primipara presenting typical clinical symptoms of pyogenic sacroiliitis along with evidence of severe infection as represented by fever of 39.7 degrees C and CRP of 12.6 mg/dl. She showed a good response to meropenem (MEPM) at 1 g twice a day for 8 days and then at 0.5 g twice a day for 2 days, followed by faropenem (FRPM) at 200 mg three times a day for 12 days, which successfully improved her subjective and objective findings as well as her laboratory test values, resulting in a complete cure. The definitive diagnosis of the disease in the patient was made on the basis of MRI findings, but no pathogen was identified. The patient was found to have marginal placenta previa as a complication, but she had an uneventful trans-vaginal delivery at the 37th week of her pregnancy and left hospital after both she and her baby showed favorable post-delivery progress. The case reported here is the first case of pyogenic sacroiliitis that has ever been discovered and treated during pregnancy in Japan.

[Retrospective evaluation of PSA density for selection of biopsy candidates with prostate specific antigen in the gray zone].

PURPOSE: We examined the usefulness of prostate specific antigen density (PSAD) for selection of biopsy candidate with prostate specific antigen levels between 4.1 and 10.0 ng./ml. in prostate cancer screening retrospectively. MATERIALS AND METHODS: The screening was conducted on male candidates in Natori city, aged 55 years or older, for 6 years from 1994 through 1999. We could analyze serum PSA levels and PSA density in 118 men with PSA levels between 4.1 and 10.0 ng./ml. All of 118 men underwent ultrasound guided systematic prostate biopsy regardless of findings of digital rectal examination and transrectal ultrasound. Prostate volume was estimated by transrectal ultrasound measurements using the prolate ellipse formula (pi/6 x length x width x height). PSAD was calculated by dividing serum PSA level by prostate volume. Serum PSA levels were determined by Tandem-R assay. RESULTS: In 118 men, twenty-five men had prostate cancer. There was no significant difference in mean PSA between those with prostate cancer and those without prostate cancer, but the difference was significant in the mean PSA density (mean 0.26 and 0.16, respectively, p < 0.0001). Receiver operating characteristic curves for PSA and PSAD demonstrated superior benefit for PSAD in 118 men. A sensitivity, a specificity, a positive predictive value and a negative predictive value of PSAD cut-off of 0.15 were 88%, 52.7%, 33.3% and 94.2%. PSAD cut-off of 0.18 showed the highest sum of sensitivity and specificity, which gave a sensitivity of 80%, a specificity of 72%, a positive predictive value of 43.5% and a negative predictive value of 93.1%. PSAD cut-off of 0.15 would seem to be preferable to cut-off of 0.18 because of less cancer missing. CONCLUSIONS: Although further studies are needed to determine optimal cut-off value to be used in clinical practice, PASD seems to be useful for the selection of biopsy candidates with PSA levels of 4.1 to 10.0 ng./ml. in the prostate cancer screening.

[Chronic cough caused by gastroesophageal reflux].

We reported a case of chronic cough due to gastroesophageal reflux (GER). The patient was a 29-year-old woman who had suffered from persistent chronic cough for more than 3 years. She had been treated with high doses of inhaled steroids, oral bronchodilators, and oral corticosteroids on a presumed diagnosis of asthma. However, her cough was not alleviated by these treatments, and the patient was referred to our hospital. She did not exhibit typical GER symptoms except for belch. Although esophagoscopy did not disclose reflux esophagitis, esophageal pH monitoring revealed acid reflux 7 to 8 times higher than the reference value. The patient was treated with a proton-pump inhibitor, which markedly alleviated her cough. Chronic cough due to GER was diagnosed. Although the incidence of chronic cough due to GER was thought to be rare in Japan, the findings in our case report underscored the importance of this association to the differential diagnosis of chronic cough.

[Changes in the antibacterial activity of chemotherapeutic agents (especially carbapenems) for 10 species of clinical isolates between 1994 and 1996. Surveillance group of the sensitivities of clinical isolates to antibacterial agents].

During October and December of each year of from 1994 to 1996, 3,849 strains of 10 species of bacteria were isolated from clinical materials in 21 institutions nationwide. The minimum inhibitory concentrations (MICs) for these bacteria of four carbapenems (imipenem [IPM], panipenem [PAPM], meropenem [MEPM], and biapenem [BIPM]) and other representative antibacterial agents were measured to investigate annual changes in antibacterial activity. Carbapenems showed potent activity against methicillin-sensitive S. aureus (MSSA), S. pneumoniae, E. faecalis, H. influenzae, E. coli, K. pneumoniae, E. cloacae, S. marcescens, and the B. fragilis group, with the activity being stable. However, these drugs showed weak activity against methicillin-resistant S. aureus (MRSA) and P. aeruginosa. The antibacterial activity (MIC90) against the tested organisms generally remained stable. Particularly, there was annual improvement of the MIC90 values of IPM and BIPM for S. pneumoniae, as well as the values of IPM and PAPM for H. influenzae, and those of IPM, PAPM, and BIPM for S. marcescens. On the other hand, the activity of carbapenems (including IPM) against MRSA was not necessarily strong, but there was annual improvement of MIC90 values.

[Survey of the sensitivities of clinical isolates to antibacterial agents (annual report)].

Research groups were formed in 21 institutions nationwide to investigate carbapenem resistance. The activities of various antibacterial agents, principally carbapenems, were tested against clinical isolates collected from these institutions. The broth microdilution method was used to determine the minimum inhibitory concentrations (MIC) of 17 antibacterial agents for 1,241 strains of 11 bacterial species isolated at all institutions between October and December 1996. The results were as follows: Carbapenems exhibited strong antibacterial activities against MSSA and Streptococcus pneumoniae and showed low activities against MRSA. Their activities against Enterococcus faecalis were comparable to that of ampicillin and piperacillin. The carbapenems showed high activities against Haemophilis influenzae, Escherichia coli, Klebsiella pneumoniae. Enterobacter cloacae. Serratia marcescens and Bacteroides fragilis group. Their activities were greater than that exhibited by other beta-lactam antibacterial agents, but some resistant strains of Serratia marcescens were detected. The antibacterial activity of carbapenems against Pseudomonas aeruginosa was comparable to that of CAZ, and there were some resistant strains.

[Survey of the sensitivities of clinical isolates to antibacterial agents (annual report)].

Research groups were formed in 21 institutions nationwide to investigate carbapenem resistance. The activities of various antibacterial agents, principally carbapenems were tested against clinical isolates collected from these institutions. The broth microdilution method was used to determine the minimum inhibitory concentrations (MIC) of 17 antibacterial agents for 1,282 strains of 11 bacterial species isolated at all institutions between October and December 1995. The results were as follows: 1. Carbapenems exhibited strong antibacterial activities against MSSA and Streptococcus pneumoniae. Their activities against Enterococcus faecalis were comparable to that of ABPC. Carbapenems showed low activities against MRSA. 2. OFLX exhibited the greatest antibacterial activity against Haemophilus influenzae, followed by MEPM. The antibacterial activities of the other carbapenems were comparable to those of FMOX and CTM. 3. The carbapenems showed high activities against Escherichia coli, Klebsiella pneumoniae, Enterobacter cloacae, and Bacteroides fragilis group. Their activities were greater than that exhibited by other beta-lactam antibacterial agents. The carbapenems also exhibited greater antibacterial activities against Serratia marcescens than the other beta-lactam antibacterial agents, but some resistant strains were detected. 4. The antibacterial activities of carbapenems against Pseudomonas aeruginosa were comparable to those of CAZ, AZT, AMK.

Phenotypical heterogeneity of CD4+CD8+ double-positive chronic T lymphoid leukemia.

Chronic T lymphoid leukemias are defined as leukemias of post-thymic T cells. The CD4+CD8+ double-positive (DP) phenotype is seen in a few cases. Since DP generally occurs in thymic T cells, whether the DP T leukemia cells represent thymic or peripheral T cells has been a matter of controversy. To address this issue, we studied phenotypical features in eight cases of DP T cell leukemia. Thymic DP T cells and peripheral CD8+ T cells have CD8 of alphabeta subunit, while CD8alphaalpha is induced in CD4+ T cells on activation with IL-4. We found that two patients with DP T large granular lymphocyte leukemia (LGLL) showed dim expression of CD8alphaalpha, identical to the phenotype on IL-4-activated DP-T cells. The leukemic cells of these patients expressed IL-4 mRNA and produced high levels of IL-4. These findings suggest that they may be derived from peripheral CD4+ T cells. Three patients with adult T cell leukemia/lymphoma (ATLL) showed CD8alphaalpha, suggestive of an activated peripheral T cell origin. One case expressed CD8alphaalpha dim and IL-4 mRNA, while the other two cases expressed no IL-4 mRNA and showed CD8alphaalpha bright phenotype, features not found in normal T cell populations. Three patients with T-prolymphocytic leukemia (T-PLL) expressed CD8alphabeta. The DP phenotype is relatively common in T-PLL, and CD4+CD8alphabeta+ is characteristic of thymic T cells. The DP T-PLL cells did not express TdT,CD1 or recombination activating gene-1 (RAG-1), which is down-regulated at the late stage of thymic T cell development. On the basis of these findings, we propose a late thymic origin for DP T-PLL. The phenotype of DP T cells differed for each entity and appeared to correlate with minor normal DP T cell population.

[Survey of sensitivities of clinical isolates to antibacterial agents (annual report)].

Research groups were formed in 20 institutions nationwide to investigate carbapenem resistance of clinical isolates. Activities of various antibacterial agents, principally carbapenems, were tested against clinical isolates collected from these institutions. The broth microdilution method was used to determine the minimum inhibitory concentrations (MICs) of 17 antibacterial agents for 1,326 strains of 11 bacterial species isolated at the institutions between October and December 1994. The results are as follows: 1. Carbapenems exhibited strong antibacterial activities against MSSA and Streptococcus pneumoniae. Their activities against Enterococcus faecalis were comparable to that of ABPC. Carbapenems showed low activities against MRSA. 2. OFLX exhibited the greatest antibacterial activity against Haemophilus influenzae, followed by MEPM. Antibacterial activities of the other carbapenems were comparable to those of FMOX, CTM, and ABPC. 3. The carbapenems showed high activities against Escherichia coli, Klebsiella pneumoniae, Enterobacter cloacae, and Bacteroides fragilis group. Their activities were greater than those exhibited by other beta-lactam antibacterial agents. The carbapenems also exhibited stronger antibacterial activities against Serratia marcescens than the other beta-lactam antibacterial agents, but some resistant strains were detected. 4. The antibacterial activities of carbapenems against Pseudomonas aeruginosa were comparable to those of CAZ, AZT, AMK.

[CT findings of pulmonary inflammatory pseudotumors (plasma cell granulomas)].

Pulmonary inflammatory pseudotumor (plasma cell granuloma) is not a true neoplastic lesion, but is composed of a variety of inflammatory cells, predominantly plasma cells. The chest X-ray features resemble those of malignant lung tumors; therefore, CT is often necessary for further evaluation. We report the CT features of five cases with histologically proved pulmonary inflammatory pseudotumor, which can be summarized as follows: a solitary round or oval parenchymal mass with regular or irregular margin, and with or without calcifications. The calcifications are useful for differential diagnosis if present, but they are usually non-specific in shape and configuration. The mean CT attenuation value of the major portion of the mass was increased from 41 HU to 78 HU by the injection of contrast material. In one case, a linear extension of the lesion was seen from the mass to the lung hilum. In three cases, satellite lung nodules were seen. One of these nodules was also proved histopathologically to be inflammatory pseudotumor. The biopsy specimens obtained by using a 20 gauge cutting-needle and an automated biopsy gun were satisfactory for histopathological diagnosis.

[Clinical study of 8 cases of spontaneous esophageal rupture].

Among 8 patients with spontaneous esophageal rupture, mean age was 46.5 years, and there was only one female. Vomiting after drinking was the main cause of onset. In 4 patients who underwent drainage of the thoracic cavity or initial treatment by surgery within 24 hrs after onset, closure after layer-layer suture of the site of rupture was made in two patients in whom definitive diagnosis was obtained at the first medical examination and early discharge was possible. A definitive diagnosis was obtained after drainage of the thoracic cavity in the other two patients, and esophagectomy without thoracotomy was performed on the 55th day after onset in one and the other patient received only conservative treatment without surgery, both patients were discharged. Of 4 patients who underwent treatment after 24 hrs, two patients who recovered included one who received only conservative treatment and another who underwent closure by suture of the site of rupture and covering with a pedicled omental flap 12 days after onset. The other two patients died of MOF after operation. We propose the following guidelines for treatment of this condition; In patients in whom surgical treatment is possible within 24 hrs after onset, closure by layer-layer suture of the site of rupture may be indicated. In cases in which more than 24 hrs has elapsed after rupture spontaneous closure sometimes can be expected in patients with a rupture would less than 2 cm. In patients accompanied with progressing mediastinitis or pyothorax with drainage procedure surgical treatment is indicated.(ABSTRACT TRUNCATED AT 250 WORDS)