[Regimen Selection by Narrative Approach in Patients with Advanced Gastric Cancer-Paclitaxel or Nab-Paclitaxel?]

BACKGROUND

According to the sixth Gastric Cancer Treatment Guideline, the regimen included nab-paclitaxel(nab-PTX) is a conditional recommendation as second-line treatment for advanced gastric cancer. However, the selection criteria of nab-PTX is not clear.

METHOD

Questionnaire survey as narrative approach on the problems of paclitaxel premedication, the symptoms due to paclitaxel containing alcohol, and infusion time was conducted for patients who had been treated with paclitaxel.

RESULTS

Thirty-six patients answered the questionnaire. Nonelderly patients(<65 years)or patients without comorbid medications complained of dissatisfaction with the inconvenience due to premedication significantly more than elderly patients(≥65 years)or patients with comorbid medications. Females or nonelderly patients were significantly more troubled by sleepiness due to premedication than males or elderly patients. Eight out of 11 patients who had visited hospital by driving a car for first-line treatment were troubled by prohibition of driving on the day of treatment. Thirty out of 36 patients answered that they would feel benefits from 30-minutes shortening of infusion time.

CONCLUSION

Questionnaire survey suggests that we may select the patients for nab-PTX properly by clarifying the inconvenience of daily life associated with premedication, the way of transportation for visiting hospital, and the benefits by shortening of infusion time.

[Questionnaire Survey on Oral Care and Oral Troubles for Patients with Gastric Cancer Received Chemotherapy]

BACKGROUND

The actual situation of oral care and oral troubles for patients with gastric cancer received chemotherapy is not clear.

METHODS

Questionnaire survey in the form of oral questions was performed for patients with gastric cancer who received chemotherapy from December 2021 to February 2022. The relevance between the survey results and background factors was examined using the χ2 test.

RESULTS

We performed the questionnaire survey for 36 patients. Of the 36 patients, 29 patients received dental check-up before starting chemotherapy. Fourteen of the 29 patients(48%)continued the dental check-up. Of 14 patients who continued the dental check-up, 9 patients were 65 years or older, while 14 of 15 patients who discontinued the dental check-up were 65 years or older. Continuity of dental check-up was low among the elderly patients. The rate of dysgeusia were 78 vs 30% in the patients who adopted and who did not adopt oral care other than toothbrushing(p=0.01). The frequency of oral troubles was dysgeusia(47%), stomatitis(42%), and dry mouth(36%). The severity of the oral troubles was, in order, dysgeusia, dry mouth, and pain. The most common side effect due to chemotherapy causing decreased food intake was dysgeusia.

CONCLUSIONS

Dysgeusia was the most frequent and severe oral trouble.

[A Case of 30s Female with Advanced Anal Canal Adenocarcinoma Managed with Adolescent-And-Young-Adult Team]

A 30s female complaining of anal pain and melena was referred to our hospital. The support by adolescent-and-young- adult(AYA)team was initiated after the first encounter. Colonoscopic examination revealed an ulcerated tumor on the anterior wall of anal canal with its anal margin on anal verge and the tumor was diagnosed as an adenocarcinoma. Contrast- enhanced CT and MRI revealed adjacency of tumor and vagina, enlarged lymph nodes and multiple pulmonary nodules. 18F-fluorodeoxyglucose(FDG)-positron emission tomography(PET)additionally revealed tracer accumulation in left sciatica, which led us to the diagnosis of advanced anal cancer. We planned and safely performed concomitant partial vaginal resection in robot-assisted laparoscopic abdominoperineal resection for the palliative purpose after discussion on physical and psychosocial issues including stoma and fertility with the patient, her family and AYA members. The pathological diagnosis was pT4b(vagina)N1aM1b, pStage ⅣB, and the local margin was pathologically negative. The postoperative course was smooth and she was discharged on postoperative day 16. Fifty one days after operation, she started systemic chemotherapy after decision on not to take ovarian samples and continues systemic chemotherapy as of writing. Support by AYA team was effective to facilitate the patient's decision-making and the communication between the patient and the medical team.

[A Case of Diffuse Large B-Cell Lymphoma Which Was Diagnosed during the Best Supportive Care of Recurrent Ascending Colon Cancer]

A 70s male, who had undergone single-incision laparoscopic ileocecal resection for ascending colon cancer with pathological diagnosis of T3N3M0, Stage Ⅲc(without adjuvant chemotherapy), had enhanced-computed tomography(CT)for 3-month follow-up and a hepatic low-density area, an newly emergent nodule behind inferior vena cava and distal ileal tumor were found. Three months later, enhanced CT showed that the distal ileal tumor got exponentially larger and the diagnosis of"malignant lymphoma"was suspected. The patient became sepsis, so we planned and safely performed partial resection of the tumor. The pathological diagnosis was diffuse large B-cell lymphoma. Postoperative course was smooth except for the Clostridium difficile colitis and he was discharged on postoperative day 19. Although the regrowth of the remnant tumor was observed soon after surgery, partial response was confirmed after introduction of systemic chemotherapy. When we cope with malignant lymphoma of small intestine, we need to keep it in mind that surgery is an option for the prevention of perforation and bacterial translocation.

[A Case of Fibromatosis-Like Tumor Which Was Difficult to Differentiate from Local Recurrence of Ascending Colon Cancer]

A 60s female, who had undergone single-incision laparoscopic ileocecal resection for ascending colon cancer with pathological diagnosis of T3N1bM0, Stage Ⅲb, followed by adjuvant therapy with 8 courses CAPOX 2 years ago, had enhanced- computed tomography(CT)for follow-up and a 15-mm nodule near anastomotic site was found. 18F-fluorodeoxyglucose (FDG)-positron emission tomography(PET)CT revealed abnormal accumulation of 18F-FDG only to the lesion and diagnosis of"anastomotic recurrence"was made. We planned and safely performed resection of the anastomotic site and the nodule. The pathological diagnosis was fibromatosis-like tumor without evidence of recurrence, and margin was negative. Postoperative course was smooth and she was discharged on postoperative day 9. When we diagnose local recurrence, we need to keep it in mind that fibromatosis is one of the differential diagnoses, although its incidence rate is low.

[A Case of Peritoneal Recurrence from Ascending Colon Cancer Successfully Treated with Laparoscopic Concomitant Right Seminal Vesiculectomy in Low Anterior Resection]

A 60s male, who had laparoscopic ileocecal resection for ascending colon cancer 2 years ago, had enhanced computed tomography(CT)for follow-up and a 12-mm nodule in Douglas' pouch adjacent to right seminal vesicle and rectum was found. 18F-fluorodeoxyglucose(FDG)-positron emission tomography CT revealed abnormal accumulation of 18F-FDG only to the lesion(standardized uptake value max 2.60)and the diagnosis of peritoneal recurrence of ascending colon cancer was made. We planned and safely performed laparoscopic concomitant right seminal vesiculectomy in low anterior resection. The pathological diagnosis was peritoneal dissemination of colon cancer and the margin was pathologically negative. The postoperative course was smooth except for temporary dysuria and he was discharged on postoperative day 17. As of writing 1 year after surgery, the patient continues to do well with no sign of recurrence. Laparoscopic concomitant seminal vesiculectomy in low anterior resection can be a good option for the curative resection of peritoneal recurrence.

Robot-assisted laparoscopic surgery with a fluorescent near-infrared ray ureteral catheter for a rectal cancer patient with pelvic kidney: A case report

An 85-year-old woman presented with a stomachache after a meal and was admitted to the previous clinic. Multi-detector computed tomography (CT) of the abdomen showed wall thickening in the rectum and right ectopic pelvic kidney. Colonoscopy revealed a mass at the rectum, and a biopsy showed adenocarcinoma. CT showed no lymphadenopathy or distant metastasis. Hartmann's procedure with fluorescent near-infrared ray ureteral catheters was used to avoid causing urinary injury. Robotic surgery was performed while checking the route of the ureter in near-infrared mode. The patient was discharged on postoperative day 14 without specific complications. This case appears to be the first of robot-assisted laparoscopic surgery for a rectal cancer patient with pelvic kidney.

Higher Body Mass Index Is a Simple Favorable Non-cancer Prognostic Marker for Japanese Elderly Colorectal Cancer Patients after Curative Resection

Objectives:

In elderly colorectal cancer (CRC) patients, preoperative surgical indications can be controversial in some cases depending on the patient's physical condition. In comparison with younger patients, both cancer-specific survival (CSS) and non-CCS (NCSS) have an impact on the prognosis and both CSS and NCSS should be considered in the preoperative assessment. We aimed to investigate the impact of body mass index (BMI) on CSS and NCSS in Japanese elderly CRC patients.

Methods:

We retrospectively collected data from 471 Japanese elderly patients (≥80 years) with stage I-III CRC who underwent curative surgery from 1998 to 2017. A Kaplan-Meier survival analysis with propensity score matching (PSM) and a multivariate Cox regression analysis were performed.

Results:

After PSM, 123 higher BMI (≥23) and 123 lower BMI (<23) cases were matched. The higher BMI group had significantly better survival than the lower BMI group regarding NCSS and overall survival (OS; P < .001 and P < .001, respectively). The multivariate survival analysis further confirmed that the higher BMI group had significantly better survival than the lower BMI group regarding CSS, NCSS, and OS (P = .027, P < .001, and P < .001, respectively).

Conclusions:

In Japanese elderly patients with stage I-III CRC who underwent curative surgery, preoperative higher BMI was a significant and simple favorable prognostic predictor, especially for NCSS and OS.

Left paraduodenal hernia treated by single-incision laparoscopic surgery: a case report

Background

Paraduodenal hernia is a rare internal hernia which accounts for only 1% of all intestinal hernias. There have been limited reported cases of paraduodenal hernia treated by laparoscopic surgery. We report a case of left paraduodenal hernia that was successfully treated by single-incision laparoscopic surgery (SILS).

Case presentation

A 17-year-old woman presented with left upper abdominal pain. An abdominal enhanced multi-detector computed tomography demonstrated encapsulated cluster of small bowel loops in the left upper quadrant which passed through the dorsal side of the inferior mesenteric vein, and showed that blood flow of the prolapsed small bowel was preserved. We preoperatively diagnosed left paraduodenal hernia without ischemia or necrosis. We performed elective SILS because she was a young actress training school student and cosmetic benefit was thought to be important. We pulled out the protruded small bowel and closed a defect with a running suture by SILS. The patient was discharged 3 days after the surgery with no complications.

Conclusions

We reported the case of left paraduodenal hernia successfully diagnosed and treated by SILS.

Efficacy of pleural coverage with polyglycolic acid sheet after bullectomy for postoperative recurrence of spontaneous pneumothorax in young patients: a multi-institutional cohort study

OBJECTIVE

Various surgical procedures have been performed to decrease the recurrence of primary spontaneous pneumothorax after video-assisted thoracic surgery. This study aimed to examine the efficiency of pleural coverage for the prevention of postoperative recurrence in relatively young patients.

METHODS

Between January 2008 and December 2012, a total of 357 cases of 345 patients (age 15-29 years) with primary spontaneous pneumothorax who underwent bullectomy at 13 institutions were enrolled in this multi-institutional retrospective cohort study. A concurrent bilateral operation was counted as two cases. Polyglycolic acid sheets were used in 238 cases, and oxidized regenerated cellulose sheets were used in 37 cases to cover the visceral pleura, with no pleural coverage in 82 cases. The average observation period was 4.2 ± 2.0 years.

RESULTS

Postoperative recurrence was observed in 50 cases (14.0%) after video-assisted thoracic surgery. Twenty-six cases (10.9%) in the polyglycolic acid group, eight (21.6%) in the oxidized regenerated cellulose group, and sixteen (19.5%) in the non-coverage group experienced postoperative recurrence. Kaplan-Meier analysis revealed that the rate of freedom from postoperative recurrence in the polyglycolic acid group was significantly higher than that in the non-coverage group. Multivariate analysis showed that age ≥ 20 years and coverage with polyglycolic acid sheets were associated with reduced risk factors for postoperative recurrence.

CONCLUSION

Pleural coverage with a polyglycolic acid sheet is suggested to be effective in preventing postoperative recurrence of pneumothorax compared with non-coverage in relatively young patients.

[A Case of Anastomotic Recurrent Descending Colon Cancer Successfully Treated with Single-Incision Laparoscopic Partial Colectomy with Intracorporeal Anastomosis]

A 60s-year-old male, who had laparoscopic partial colectomy with resection of left colic artery for descending colon cancer 8 years ago and completed 5-year-follow-up without the evidence of recurrence, was diagnosed as anastomotic recurrence of descending colon cancer, and referred to our hospital. We planned and safely performed single-incision laparoscopic colectomy(SILC)with intracorporeal anastomosis(ICA)(operation time of 390 min and estimated blood loss of 60 g). Following the adhesiolysis, the intracorporeal resection of the lesion was performed with automatic stapling device preserving middle colic and inferior mesenteric arteries and veins. Then, after the recovery of the specimen, ICA was performed as follows; after making a small hole just below the staple line at the opposite side of mesenteric attachment, the oral and the anal stump of colon was pulled-up and placed side-by-side with temporary strings and automatic suturing device was inserted into the holes and fired to form a side-to-side anastomosis, then the common stab incision was pulled- up with 3 temporary strings and closed with a stapler. The postoperative course was smooth and discharged on postoperative day 8. The ICA can be a good option for SILC when colonic and vascular tension would be the limiting factor of anastomosis.

[A Case of Locally Advanced Rectal Cancer with Multiple Liver Metastases Could Be Resected after Triplet Chemotherapy]

The patient was a 60's man, whose chief complaints were melena and weight loss. He visited our hospital, and further evaluation revealed rectal cancer(Ra)invading the abdominal wall with multiple liver metastases. The clinical diagnosis was cT4b(abdominal wall)N2bM1a(H1), cStage Ⅳ. We performed a transverse colostomy on the day prior to chemotherapy administration. He was administered 8 courses of FOLFOXIRI plus bevacizumab. After the chemotherapy, the primary tumor and liver metastases showed PR, with a diagnosis of ycT3N1bM1a(H1), Stage Ⅳ. We performed a robot-assisted laparoscopic low anterior resection for the primary tumor. Two months later, the partial resection of liver S6 and S8 was performed. The patient has been cancer-free for 6 months now.

[Long-Term Survival in a Case of Colon Cancer with Peritoneal Dissemination and Ovarian Metastasis after Multimodality Therapy]

A 70-year-old woman underwent treatment for cecal cancer(pT4bN1M0, Stage Ⅲb)in 2010. Four years and 2 months after the first surgery, she underwent ileum resection for stenosis due to perineal dissemination(P3). Two years after this recurrence, during which time she had completed 26 courses of FOLFIRI plus bevacizumab(Bmab), 9 courses of capecitabine plus oxaliplatin(CapeOX)plus Bmab, and 3 courses of Cape, no peritoneal dissemination was detected by computed tomography( CT). Thereafter, an additional 19 courses of Cape plus Bmab were introduced, but CEA continued to increase. Right ovarian metastasis was suspected based on CT and FDG-PET/CT examination. Four years and 1 month after the initial recurrence of perineal dissemination, the patient underwent bilateral ovarian resection, during which the lack of peritoneal dissemination was confirmed. Pathologically, right ovarian metastasis was diagnosed. The patient is still alive 4 years and 6 months after the first operation.

[A Resected Case of Hemorrhagic Hepatic Cyst Difficult to Differentiate from Mucinous Cystic Neoplasm of the Liver]

CASE

A 77-year-old woman was referred to our hospital for detailed examination of a cystic liver tumor. Contrast-enhanced CT and MRIshowed a cystic liver tumor with an enhanced mural nodule in S6 of the liver. Under a preoperative diagnosis of hemorrhagic hepatic cyst and mucinous cystic neoplasm(MCN)of the liver, extended posterior segmentectomy was performed. Histological examination of the tumor revealed no neoplastic cells, and the tumor was finally diagnosed as a hemorrhagic hepatic cyst of the liver.

CONCLUSION

Similar to previous reports of hemorrhagic hepatic cysts, preoperative differential diagnosis from MCN of the liver was difficult in this case. Hemorrhagic hepatic cysts are rare and are sometimes confused with MCN of the liver, especially when an enhanced mural nodule is found in the cyst. The possibility of hemorrhagic hepatic cysts should be considered during diagnosis of liver cystic tumors.

[A Case of Resection of a Metastatic Tumor Combined with the Spleen, Preserving the Remnant Stomach, for Recurrent Gastric Cancer of the Splenic Hilar Region after Distal Gastrectomy]

We describe a case of residual stomach preserving surgery performed under evaluation of residual gastric blood flow with indocyanine green(ICG)fluorography, for gastric cancer with recurrence of splenic lymph node metastasis after distal gastrectomy( DG)in a 65-year-old man. After 4 courses of S-1 plus CDDP(SP)therapy for advanced gastric cancer with ascites, DG, D2 dissection, and Billroth Ⅰ reconstruction were performed and radical resection was obtained(L, Type 3, pap/tub, ypT3N1H0P0CY0M0, ypStage ⅡB). Three years and 6 months after the surgery, a mass 4 cm in diameter was found in the splenic hilum, and a pancreatosplenial resection was performed to remove the tumor for diagnosis and treatment purposes. We confirmed that there was no problem with blood flow, and we were able to preserve the stomach. Intraoperative ICG fluorescence imaging was considered a promising method for evaluating residual gastric blood flow.

[Gastric Gastrointestinal Stromal Tumor Appearing Nine Years after Resection of a Duodenal Gastrointestinal Stromal Tumor-A Case Report]

Multiple sporadic gastrointestinal stromal tumor(GIST)are rare, except for those restricted to von Recklinghausen disease or hereditary conditions.We reported a case of a gastric GIST resected 9 years after the resection of a duodenal GIST.The patient was a 58-year-old male who had been followed-up with computed tomography scans after pancreatoduodenectomy for a duodenal GIST when he was 49-years-old.The patient was admitted to our hospital for anemia examination.A CT scan detected a tumor in the stomach, with a diameter of over 10 cm, and necrosis.Esophagogastroduodenoscopy revealed the presence of a delle on the gastric SMT.Due to suspected invasion of the spleen and left diaphragm by the tumor, we performed subtotal gastrectomy with splenectomy and left diaphragm segmental resection.In the pathological diagnosis, the tumor was diagnosed as a gastric GIST, because the cell type of the tumor was spindle and tested positive for c-kit.Based on the tumor size and mitotic count, the patient was diagnosed with high-risk GIST by the modified-Fletcher classification, and imatinib 400mg/day was administered.There have been no signs of recurrence for 2 years since the operation.

Significance of fistulography findings to the healing time of postoperative pancreatic fistula after pancreaticoduodenectomy

PURPOSE

Pancreatic fistula (PF) is a common and serious complications after pancreaticoduodenectomy (PD). However, few studies have discussed the time required for PF healing in patients with this complication. This study investigates the PF healing time (PF-HT) and its association with findings of postoperative fistulography performed via the drainage tubes.

METHODS

The subjects of this study were 35 patients with PF among a total of 144 patients who underwent PD for periampullary diseases in our hospital. PF-HT, which was defined as the duration from the first postoperative fistulography to removal of the drainage tubes, was assessed in the enrolled patients. Fistulography findings were classified into four types based on fluid collection and communication with the jejunal loop. We investigated the factors affecting the PF-HT, including the fistulography findings.

RESULTS

The average PF-HT was 22 ± 20 days. Multivariate analysis revealed that the fistulography type was the only independent factor that affected PF-HT significantly. The PF-HT was significantly shorter in patients without fluid collection than in those with fluid collection. Moreover, those patients with fluid collection and a communication had a significantly shorter PF-HT than those without a communication.

CONCLUSIONS

We found that fistulography findings were significantly associated with the PF-HT. This suggests that fistulography findings could help to predict the time needed for PF healing.

[Long-Term Survival after Surgical Treatment of Neuroendocrine Carcinoma of the Ampulla of Vater-A Case Report]

A 60s man underwent upper gastrointestinal endoscopy at a regular medical check-up without symptoms, which showed an ulcerative region in the duodenal ampulla, measuring 3 cm in diameter. He was diagnosed with poorly differentiated adenocarcinoma on biopsy and referred to our hospital. Abdominal contrast-enhanced CT scan revealed an enhanced-ulcerative tumor, measuring 3 cm, at the duodenal ampulla. After the preoperative diagnosis of adenocarcinoma of the duodenal ampulla, subtotal stomach-preserving pancreatoduodenectomy with regional lymph node dissection was performed. The final diagnosis was neuroendocrine carcinoma(NEC)of the duodenal ampulla. He has been alive for 9 years with no recurrences. NEC of the duodenal ampulla is rare, and its prognosis is poor. We report a case of long-term survival after resection of NEC of the duodenal ampulla.

[Surgical Outcomes of Laparoscopic Repeat Hepatectomy at Our Institution]

Laparoscopic hepatectomy has gained popularity owing to its merits, such as low invasiveness and reduced bleeding. However, the efficacy of laparoscopic repeat hepatectomy(LRH)has not been confirmed. The aim of this study was to evaluate the feasibility and efficacy of LRH compared to that of open repeat hepatectomy(ORH). We performed 60 repeat hepatectomies from January 2011 to March 2019, of which 19 were LRH(Lap group)and 41 were ORH(Open group). This study retrospectively compared the patient characteristics and short-term outcomes of repeat hepatectomy between the Lap and Open groups. There were no significant differences in patient characteristics, except for the type of approach in the previous hepatectomy(p<0.01). The Lap group had lesser blood loss(median: 150 mL vs 355 mL, p<0.01)and shorter postoperative hospital stays(median: 8 days vs 11 days, p<0.01). There were no differences in operation time or severe postoperative complications. LRH is feasible and useful, providing good short-term outcomes.

[Pulmonary Metastases of Hepatocellular Carcinoma Treated with Repeated Pulmonary Resection-A Case Report]

A 65-year-old man visited our hospital for hepatocellular carcinoma(HCC)and underwent extended posterior sectionectomy. Eight months after the hepatic resection, follow-up computed tomography(CT)revealed a solitary, recurrent tumor in S4 of the liver, and transcatheter arterial chemoembolization and radiofrequency ablation were performed for the intrahepatic recurrence. After 12 postoperative months, follow-up CT demonstrated pulmonary metastases in S5 of the right lung and S10 of the left lung. Since there were no other metastases, the 2 metastatic lesions were resected using video-assisted thoracoscopic surgery(VATS). The resected tumors were histologically diagnosed as pulmonary metastases of HCC. Three years after the pulmonary resection, 3 additional pulmonary metastases were detected on CT in S3 and S10 of the right lung and S4 of the left lung. No other metastases were found. Bilateral VATSmetastasectomy was performed for the metastases. The tumors were diagnosed as pulmonary metastases of HCC on histological examination. One year and 8 months after the surgery, he was alive in a good condition, with no recurrences. The present case suggested that some patients with pulmonary metastasis of HCC can have long-term survival with surgical resection of the metastasis. Therefore, while systemic chemotherapy is generally considered the standard treatment for extrahepatic metastasis of HCC, surgical resection might be an option.

[Intraoperative Assessment of Blood Flow in the Remnant Stomach Using Indocyanine Green and Regional Oxygen Saturation Monitoring at Distal Pancreatectomy Following Gastrectomy]

A92 -year-old man was diagnosed with pancreatic cancer 14 years after undergoing distal gastrectomy for gastric cancer. His remnant stomach was fed by the cardiac branch of the left inferior phrenic artery, short gastric artery, and posterior gastric artery. We planned distal pancreatectomy(DP). Intraoperative indocyanine green(ICG)fluorography showed that the remnant stomach was perfused under the clamp of the splenic artery. We also confirmed that regional oxygen saturation (rSO2)of the remnant stomach was not decreased by the clamp. Based on the findings, we judged that blood flow in the remnant stomach was preserved at the clamp. We then performed DP with preservation of the remnant stomach. Postoperative complications associated with the remnant stomach were not observed. The patient is alive without any postoperative recurrences of pancreatic cancer or trouble associated with the remnant stomach 22 months after the surgery. This case suggested that ICG fluorography and rSO2 monitoring are useful to evaluate blood flow in the remnant stomach.

[A Case of Resected Primary Hepatic Neuroendocrine Tumor]

A 70s man presented with a solitary liver tumor measuring 4.5 cm on CT. On contrast-enhanced CT, the tumor appeared partly well-enhanced in the late phase, and the remaining part was enhanced in the early phase and washed out in the late phase. Contrast-enhanced MRIshowed fused multiple nodules, and the enhancement/washout pattern was clearer than that of the contrast-enhanced CT. The tumor showed a defective image in the hepatobiliary phase and a high signal on diffusionweighted imaging. Then, the tumor was diagnosed as hepatocellular carcinoma, and thus, left liver lobectomy was performed. On histological examination of the resected specimen, the tumor was found to be composed of uniform and small tumor cells with solid or trabecular growth fashion. On immunohistochemical staining, synaptophysin and chromogranin A positivity was noted, and the Ki-67 index was 14%. Finally, the tumor was diagnosed as a NET G2. Postoperatively, somatostatin receptor scintigraphy was performed to identify the primary site; however, no obvious primary site could not be identified, and thus a diagnosis of primary hepatic NET was made. Eighteen months postoperatively, the patient is alive without relapse. Preoperative diagnosis of primary hepatic NETs is difficult because NETs present various imaging findings and are rare. Moreover, no accurate preoperative diagnosis was reached in our case, suggesting the difficulty in the preoperative diagnosis of NETs.

[A Case with Three Resections of the Pulmonary Metastases of a Distal Bile Duct Carcinoma]

A 68-year-old man underwent a subtotal stomach-preserving pancreatoduodenectomy(SSPPD)for a distal bile duct carcinoma(BDC)pT3aN1M0, pStage ⅡB and adjuvant chemotherapy with gemcitabine. One year 7 months after the initial surgery, CT revealed a nodule with an increasing tendency in the left lung. As it was difficult to distinguish primary lung cancer from BDC lung metastasis, we performed a thoracoscopic left wedge resection. The histopathology of the resected specimen was BDC lung metastasis. In the follow-up with adjuvant chemotherapy with S-1 for 10 months, 2 nodules were found in the right lung, and we performed thoracoscopic right S6 segmentectomy. Eight months later, another nodule was found in the left lung, and we performed thoracoscopic left wedge resection. The histopathology was BDC lung metastasis for all the resected specimens. The patient is alive with no evidence of recurrence after 9 months of the latest surgery(4 years 11 months after the initial surgery). Although the standard treatment for metastatic recurrence of BDC is systemic chemotherapy, some cases treated with surgical resection had relatively good prognosis, such as the present case. Surgical resection might be feasible as a treatment option for metastatic recurrence of BDC.

Outcomes of laparoscopic cholecystectomy for xanthogranulomatous cholecystitis

Xanthogranulomatous cholecystitis (XGC) is a rare inflammatory disease of the gallbladder with distinct histopathological characteristics. Laparoscopic cholecystectomy (LC) is currently the standard treatment for gallbladder disease. However, the outcomes of LC for XGC have not been completely investigated, due to the rarity of XGC. The present study aimed to assess the surgical outcomes of LC for XGC. Among 3,037 patients undergoing cholecystectomy between 2005 and 2017 at our institution, 58 patients (1.9%) were diagnosed with XGC based on histopathology. Of the patients, LC was performed in 38 (65.5%), and they were enrolled in the present study. The outcome of LC for XGC in the cases was assessed, and was compared with outcomes of LC for other diseases. The average operation time was 109±36 min, and average intraoperative blood loss was 58±85 ml. LC was converted to open cholecystectomy in 6 (15.8%) of the 38 cases. No operative mortality occurred. One patient developed postoperative complications greater than grade II in the Clavien-Dindo classification, and the mean postoperative hospital stay was 6.1±5.8 days. Based on previous reports and the nature of XGC itself, the outcomes reported herein of LC for XGC seemed acceptable. It should be also noted that LC for XGC exhibited a higher conversion rate compared with LC than other benign gallbladder diseases, implying that LC for XGC remains challenging.

Surgical outcomes of laparoscopic cholecystectomy for acute cholecystitis in elderly patients

INTRODUCTION

The clinical significance of laparoscopic cholecystectomy (LC) for acute cholecystitis in elderly patients aged 80 years or older has not been determined. This study aimed to investigate surgical outcomes of LC for acute cholecystitis in elderly patients compared to non-elderly patients.

METHODS

Patients who underwent urgent LC for acute cholecystitis were enrolled. Older (≥80 years) and younger patients (<80 years) were compared for perioperative factors to assess surgical outcomes of LC.

RESULTS

A total of 351 patients were included; 52 (14.8%) and 299 (85.2%) were categorized as older and younger, respectively. The older group had a significantly higher proportion of patients with concomitant physiological diseases than the younger group and a significantly higher ASA classification. No significant differences between the two groups were found in operation time, intraoperative blood loss, or conversion rate to open surgery. Incidence of postoperative complications and duration of postoperative hospital stay also were not significantly different between the two groups.

CONCLUSION

Surgical outcomes of LC for acute cholecystitis in older patients are comparable to those in younger patients, which confirms the feasibility of LC for acute cholecystitis in elderly patients.

[A Rare Case of Adenosquamous Carcinoma in the Liver with Hepatolithiasis]

This report describes a case of primary adenosquamous carcinoma of the liver with hepatolithiasis. A 70's man was followed up at a clinic for hepatolithiasis, gallbladder stone, and dilatation of the intrahepatic duct. He visited our hospital for computed tomography(CT)examination. CT showed a 30mm diameter low-density mass in the S2 liver and dilatation of the intrahe- patic duct filled with hepatolithiasis. Blood examination showed elevated levels of tumor markers(CEA 8.0 ng/mL, CA19-9 19,196 U/mL). We diagnosed the tumor as cholangiocellular carcinoma(cT2N1M0, cStage ⅣA)with hepatolithiasis and performed left hepatectomy and lymphadenectomy. In the specimen, a 39×22mm diameter solid tumor was detected and the intrahepatic duct was filled with haptolithiasis. Pathologically, a mixture of adenocarcinoma and squamous cell carcinoma was observed adjacent to the bile duct. Accordingly, a diagnosis of adenosquamous carcinoma was made(pT3N0M0, pStage Ⅲ). Multiple liver metastases were detected 8 months after the operation, and chemotherapy was started. He remains alive 11 months after the operation. We experienced a rare case of adenosquamous carcinoma in the liver with hepatolithiasis.

[A Resected Case of Reactive Lymphoid Hyperplasia of the Liver Preoperatively Diagnosed as Hepatocellular Carcinoma]

A60s woman was followed-up regularly for primary biliary cholangitis and a solitary enlarging hepatic mass in the S6 segment of her liver was discovered by ultrasonography. We diagnosed the mass as hepatocellular carcinoma by contrast ultrasonography, contrast computed tomography, and ethoxbenzyl magnetic resonance imaging and laparoscopic partial hepatectomy of S6 segment was performed. The resected specimen was histopathologicaly diagnosed as liver-reactive lymphoid hyperplasia(RLH). The patient is alive without recurrence 17 months after the surgery. Although liver RLH is a rare disease, it should be considered in the differential diagnosis of small liver tumors.

Factors affecting healing time of postoperative pancreatic fistula in patients undergoing pancreaticoduodenectomy

Clinically-relevant postoperative pancreatic fistula (CR-POPF) is one of the most serious complications following pancreaticoduodenectomy. While many investigators have studied risk factors for the development of CR-POPF, few studies have focused on time needed for CR-POPF healing in patients who develop this complication. The present study enrolled 38 cases in whom CR-POPF developed following pancreaticoduodenectomy (24.1%) out of 158 cases receiving treatment with pancreaticoduodenectomy between 2009 and 2017 for periampullary diseases. CR-POPF healing time, was defined as the length of time from the day of pancreaticoduodenectomy to the day when intraabdominal drainage tubes used for CR-POPF treatment were removed, were assessed and factors affecting the healing time were investigated. The mean CR-POPF healing time was 40.2±21.7 days (median; 35 days, range; 10-110 days). Univariate analysis demonstrated a significant relationship between CP-POPE healing time and sex, intraoperative blood loss, and type of pancreaticojejunostomy procedure. Multivariate Cox regression analysis using these factors revealed that intraoperative blood loss and type of pancreaticojejunostomy procedure were significant independent factors for the length of CR-POPF healing time. CR-POPF healing time following pancreaticoduodenectomy was 40.2±21.7 days on average (median, 35 days; range 10-110 days). Intraoperative blood loss and type of pancreaticojejunostomy procedure were identified as significant independent factors associated with the healing time. These results will help with earlier recovery from CR-POPF.

[Clinicopathological Study of 15 Cases of Primary Duodenal Cancer]

There have been few reports discussing treatments for primary duodenal cancer. In this study, 15 cases of primary duodenal cancer that were treated by curative resection in our hospital between April 2005 and December 2017 were analyzed to study appropriate operative procedures. Prognostic analysis revealed that the median of relapse-free survival and overall survival were 49 months and 74 months, respectively. The 5-year survival rate was 47%. On univariate analysis of relapse-free survival, lymph node metastasis(p<0.01)and post-operative adjuvant therapy(p=0.02)were significant independent prognostic factors. Analysis of the relationship between lymph node metastasis and the depth or location of tumors suggested that pancreaticoduodenectomy with lymph node dissection should be performed to achieve radical resection, since there were some cases that involved lymph node metastasis around the pancreatic head or hepatoduodenal ligament.

[A Resected Case of Gallbladder Cancer Concomitant with Xanthogranulomatous Cholecystitis with Difficulty in Preoperative Diagnosis]

A 78-year-oldman was referredto our hospital for right abdominal pain. The patient was diagnosedwith xanthogranulomatous cholecystitis(XGC)at the gallbladder fundus and adenomyomatosis(ADM)at the gallbladder neck. Because malignancy was undeniable, laparotomy was performed. Frozen section examination of the excised whole-layer gallbladder revealed cancer cells at the gallbladder neck and cystic duct. Therefore, additional gallbladder bed resection, extrahepatic bile duct resection, and lymphadenectomy were performed. The final diagnosis, based on the histopathological examination of all resected specimens, was gallbladder adenocarcinoma(T3aN0M0, Stage ⅢA). ADM was not observedat the same sites as the adenocarcinoma. The fundus lesion was diagnosed as XGC. Here, we report our rare case of XGC coexisting with gallbladder cancer.

[A Case of Resection of a Mucinous Cystic Neoplasm of the Liver]

A 55 -year-old woman presented at our hospital in 2017. In 2014, a large cyst had been detected in her liver by ultrasonography, and she was followed up at a clinic. Abdominal computed tomography(CT)revealed a large multilocular cystic tumor measuring 12 cm in diameter in the left lobe of the liver. Although no solid component was identified in the tumor, the cystic tumor was increasing in size, and the serum level of CA19-9 was elevated. Under a preoperative diagnosis of mucinous cystic neoplasm(MCN)of the liver, we performed extended left liver lobectomy. There were no postoperative complications. Histopathological examination of the resected specimen revealed low-grade intraepithelial neoplasia, and the epithelium covered an ovarian-type stroma. The ovarian-type stromal cells were immunoreactive for estrogen receptor and progesterone receptor. The definitive diagnosis of the tumor was MCN of the liver with low-grade intraepithelial neoplasia. Eight months after the surgery, the patient remains alive without any recurrence.

[A Case of Successful Control of Advanced Duodenal Cancer with Liver Metastasis Receiving Paclitaxel Chemotherapy and Potential Radical Resection]

We report a case of successful control of advanced duodenal cancer with paclitaxel chemotherapy. A woman in her 70s with epigastralgia was diagnosed with hemorrhagic duodenal ulcer upon upper gastrointestinal endoscopy. A type 3 tumor was found in the duodenal bulb upon upper gastrointestinal endoscopy and biopsy at our hospital. By contrast CT, we found wall hypertrophy of the duodenal bulb, lymph node metastasis, and liver metastasis and started chemotherapy. Four courses of SOX therapy were first administered. The wall hypertrophy of the duodenal bulb worsened, and new lesions appeared in the liver, so we diagnosed progressive disease. Next, 4 courses of wPTX therapy were administered. The wall hypertrophy of the duodenal bulb improved, and all liver metastatic lesions shrunk and became obscure. The reduction rate was 75%, so we diagnosed partial response. Accumulation in the primary tumor was observed on PET-CT, and the lymph node and liver metastases disappeared, so we considered radical curative resection. The patient underwent subtotal stomach preserving pancreatoduodenectomy, D2 lymph node dissection, reconstruction of the digestive tract by the modified CHILD method, partial hepatectomy, and Brawn's anastomosis. No cancer cells were found in the hepatectomized area. Paclitaxel chemotherapy may be useful for advanced duodenal cancer.

[A Resected Case of Lymph Node Metastasis at the Splenic Hilum from Lung Cancer Invading the Pancreas and Spleen]

A 72-year-old man received chemoradiotherapy for lung squamous cell carcinoma(T4N2M0, Stage Ⅲb). Nine months after the start of chemoradiotherapy, a 60 mm sized mass was identified in the spleen on abdominal CT. FDG-PET/CT examination revealed abnormal FDG accumulation in the tumor, and no obvious accumulation was observed in other sites. By endoscopic ultrasound-guided fine needle aspiration cytology, the tumor was diagnosed as splenic metastasis from lung cancer. Since the primary lung tumor was well controlled by the chemoradiotherapy and no metastatic lesions were found except in the spleen, laparoscopic excision of the splenic metastasis was planned. Since the tumor was suspected to have infiltrated the tail of the pancreas, laparoscopic distal pancreatectomy and splenectomy were performed. There were no severe postoperative complications. The resected tumor was histopathologically diagnosed as not splenic metastasis, but lymph node metastasis at the splenic hilum from lung cancer invading the pancreas and spleen. Brain metastasis and bone metastasis were observed 3 months postoperatively. He did not undergo any treatments for the metastatic lesions, and he died because of the cancer 11 months after the operation. This case suggests the clinical significance of surgical treatment for distant metastatic lesions from lung cancer.

[A Case of Intrahepatic Cholangiocarcinoma with Tumor Thrombus in the Left Portal Branch]

A 63-year-old man was referred to our hospital for detailed examinations and treatment of a hepatic tumor. Abdominal contrast-enhanced CT examination showed a huge mass measuring 12 cm in diameter with ring enhancement in the left liver lobe. The liver tumor was accompanied by a macroscopic tumor thrombus in the left portal branch. Under preoperative diagnosis of intrahepatic cholangiocarcinoma with portal vein tumor thrombus, left liver lobectomy, removal of the tumor thrombus, extrahepatic bile duct excision, and lymph node dissection were performed. Histopathological examination of the resected specimens revealed moderately differentiated adenocarcinoma concomitant with tumor thrombus in the left portal branch. Adjuvant chemotherapy with S-1 was administered. However, 3 months after the surgery, CT examination revealed postoperative recurrences in the liver, lung, and bone. Systemic chemotherapy with gemcitabine and cisplatin was administered with radiotherapy for the bone metastasis. However, the chemotherapy was not effective, and 6 months after surgery, he died of the cancer. There have been few reports of cases with ICC accompanied by a macroscopic portal vein tumor thrombus. Based on the reported cases and the present case, prognosis of the disease seems very poor.

Is Intraoperative Blood Loss Underestimated in Patients Undergoing Laparoscopic Hepatectomy?

BACKGROUND

Less intraoperative blood loss is frequently reported as an advantage of laparoscopic hepatectomy (LH) over open hepatectomy (OH). However, the small work space during laparoscopic surgery could lead to insufficient blood suction from the abdominal cavity, with possible underestimation of intraoperative blood loss. This study compared estimated blood loss (E-BL) with intraoperatively counted blood loss (IC-BL) in patients undergoing LH.

METHODS

This study included 110 consecutive patients undergoing partial hepatectomy for solitary liver tumors (59 had OH and 51 had LH). IC-BL and E-BL were determined, and the difference between them was calculated based on the surgical approach. Factors affecting the difference were investigated. IC-BL was quantified from the suction fluid volume and weight of surgical gauzes used for blood and fluid collection. E-BL was calculated with the total blood volume and change in hematocrit.

RESULTS

Although there were no significant differences between IC-BL and E-BL in the OH group (292 ± 198 vs. 259 ± 167 mL, p = 0.1239), E-BL was significantly greater than IC-BL in the LH group (273 ± 166 vs. 128 ± 177 mL, p < 0.0001). Percentage of patients with E-BL > IC-BL in the LH group was significantly greater than in the OH group (86.3 vs. 42.4%, p < 0.0001). The surgical approach (OH/LH) was the only significant independent factor determining E-BL > IC-BL status.

CONCLUSIONS

E-BL was significantly greater than IC-BL only in patients undergoing LH, and the surgical approach (OH/LH) was the only factor affecting E-BL > IC-BL status. These results suggest that intraoperative blood loss may be underestimated during LH.

Extracranial meningiomas concurrently found in the lung and vertebral bone: a case report

Background

Primary pulmonary meningiomas are very rare, and primary intraosseous meningiomas outside the head and neck region have not yet been reported. We report an extremely unusual case of concurrent meningiomas arising in the pulmonary parenchyma and vertebral bone.

Case presentation

A 40-year-old Asian woman presented with a destructive lesion of the lumbar vertebral bone and a small nodule in the right lung. Five years later, both lesions slightly increased in size. To evaluate both the pulmonary and vertebral lesions, video-assisted thoracic surgery and curettage of the lytic lesion were performed. Both lesions showed similar histopathological findings corresponding to an intracranial meningioma of World Health Organization grade 1. The patient made good postoperative progress and remained free from disease at 41 months after the operation.

Conclusions

Our patient presented with almost synchronous pulmonary and lumbar vertebral intraosseous meningiomas. Regarding the relationship between the two lesions, there are two possibilities: Independent tumors occurred coincidentally or the primary pulmonary meningioma metastasized to the vertebral bone despite its bland morphology. It is important to keep in mind the exceptionally rare condition of extracranial meningioma.

A case of intraductal papillary-mucinous neoplasm of the pancreas penetrating into the stomach and spleen successfully treated by total pancreatectomy

Background

Intraductal papillary-mucinous neoplasms (IPMNs) are potentially malignant intraductal epithelial neoplasms that sometimes penetrate into other organs. To the best of our knowledge, no report has yet described a case with penetration into the spleen. We recently encountered a case of IPMN with penetration of the stomach and spleen that was successfully treated by total pancreatectomy.

Case presentation

A 70-year-old female visited our hospital with a complaint of fever and abdominal pain. Contrast-enhanced computed tomography (CT) revealed dilatation of the main pancreatic duct in the entire pancreas and penetration into the stomach and spleen. Upper gastrointestinal endoscopy revealed mucin extruding from four openings of the fistula in the stomach. No malignancy was detected based on cytology of the mucin. Inflammation markers and tumor markers (CEA, CA19–9) were elevated in the blood. The pre-operative diagnosis was IPMN of main pancreatic duct type penetrating into the stomach and spleen. A total pancreatectomy and splenectomy were performed, combined with distal gastrectomy including resection of the fistulas between the pancreas and stomach. No postoperative complications were noted. Histopathological examination of the resected specimen revealed atrophy of the pancreatic parenchyma, and the main duct of the pancreas was filled with mucin. Mucin-producing malignant tumor cells were detected in the epithelium of the main pancreatic duct with no signs of invasion. No malignancy was found at the fistulas between the pancreas and stomach or spleen. The patient was finally diagnosed with non-invasive intraductal papillary-mucinous carcinoma (IPMC) of main pancreatic duct type. Mechanical penetration was suspected as a mechanism of the penetration. The patient remained disease-free without evidence of recurrence more than 15 months after the operation.

Conclusion

Though IPMNs sometimes penetrate into other adjacent organs, penetration into two organs, including the spleen, is rare. The rare case of IPMC penetrating into the stomach and spleen presented here was treated successfully by total pancreatectomy.

[A Case Report of SOX Treatment for Primary Duodenal Carcinoma with Liver Metastasis]

We report a case of effective S-1 plus oxaliplatin (SOX) treatment for duodenal cancer with liver metastases. The patient was a 70-year-old female diagnosed with duodenal carcinoma that was unresectable because of liver metastasis(cT4N1M1, cStage IV in UICC 7th). She received SOX treatment(100mg/m / 2 of oxaliplatin on day 1 combined with 40 mg/day of S-1 twice daily on days 1-14, was repeated every 3 weeks). After 4 courses, a partial response was confirmed by computed tomography and no severe adverse events were observed. However, during the 5th courses, several new liver metastases were observed, so we changed to weekly paclitaxel treatment. This case suggests that SOX treatment may be an effective chemotherapy for advanced primary duodenal carcinoma.

Ruptured Cystic Artery Pseudoaneurysm Successfully Treated with Urgent Cholecystectomy: A Case Report and Literature Review

Patient: Male, 90

Final Diagnosis: Ruptured cystic artery pseudoaneurysm

Symptoms: Epigastric pain • Fever

Medication: —

Clinical Procedure: Open cholecystectomy

Specialty: Gastroenterology and Hepatology

[A Case of Small-Sized Acinar Cell Carcinoma of the Pancreas Resected by Laparoscopic Distal Pancreatectomy]

A 81-year-old woman was referred to our hospital for a stomach pain. Abdominal enhanced CT scan showed a pancreatic hypovascular tumor 10mm in size. Abnormal FDG uptake was found on the tumor at FDG/PET-CT examination. The tumor was identified also at endoscopic ultrasonography, and the endoscopic ultrasound-guided fine needle aspiration biopsy of this tumor gave the diagnosis of pancreatic adenocarcinoma. Under the preoperative diagnosis, laparoscopic distal pancreatectomy was performed. There were no postoperative complications. Histopathological examination of the resected tumor revealed acinar cell carcinoma of the pancreas, not pancreatic adenocarcinoma. The patient is alive without any postoperative recurrences 1 year after the pancreatectomy.

[A Case in Which S-1/Oxaliplatin(SOX)/Trastuzumab Therapy Was Effective for Unresectable HER2 Positive Advanced Gastric Cancer and Radical Resection Could Be Performed]

The case was a 70s-year-old man. In July 2016, he was admitted to our hospital with a complaint of epigastralgia. Upper gastrointestinal endoscopy revealed type 3 advanced gastric cancer in the vestibule, directly infiltrating the pancreas and the left lobe of the liver to form an abscess, and swelling of the aortic lymph node and multiple liver metastases were observed. The cancer was diagnosed as cT4b(liver/pancreas), N2M1(H1P0CYX), cStage IV and diagnosed it as a chemotherapy policy. We initiated SOX plus trastuzumab therapy from August 2016. After 4 courses, the primary tumor shrunk significantly and invasion to the pancreas/liver had disappeared. Furthermore, the periarterial lymph node and multiple liver metastases were obscured(chemotherapy effect judgment: PR). With a diagnosis of ycT4aN1MX(HXP0CYX), in December 2016, we performed a pyloric side gastrectomy D2(+No.16)dissection and partial resection of the liver(S3, S4, S6), liver RFA(S4, S6, S7). Due to recent progress in chemotherapy and multidisciplinary therapy, there is a possibility that radical resection may be carried out for advanced gastric cancer, which was previously unresectable, by performing a treatment with surgery in mind.

[A Case of a Hepatic Inflammatory Pseudotumor Difficult to Distinguish from Metastatic Liver Cancer and Potentially Caused by Colon Diverticula]

This report describes the case of an 85-year-old man who underwent left hemicolectomy for descending colon cancer and hepatic segmentectomy for metastatic liver cancer. Seven years after the liver surgery, an abdominal CT scan revealed a tumor in the remnant liver. He also presented with colon diverticula in the ascending colon, which was located close to the liver tumor. With a preoperative diagnosis of metastatic liver cancer, the tumor was resected with S8 segmentectomy. Histopathological examination of the resected tumor revealed a hepatic inflammatory pseudotumor, not metastatic liver cancer. The present case showed the difficulty of preoperatively diagnosing inflammatory pseudotumors. Furthermore, it is noted in the case that since the liver tumor was located close to the colon diverticula in the ascending colon, the diverticula was potentially associated with the formation of hepatic inflammatory pseudotumor.

Feasibility of laparoscopic cholecystectomy in patients with cerebrospinal fluid shunt

INTRODUCTION

Previous reports of laparoscopic surgery in patients with cerebrospinal fluid (CSF) shunts for intracranial hypertension described shunt-related complications. Thus, the shunts have been considered a contraindication for laparoscopic procedures. However, with the implementation of recent improvements in surgical techniques, perioperative management, and shunt technology, laparoscopic surgery may now be safe in cases with shunts. The aim of the present study was to examine the safety of such procedures based on our own experiences with laparoscopic surgery in patients with CSF shunts.

METHODS

A total of 582 patients underwent laparoscopic cholecystectomy for gallbladder disease at our institute during the study period. Among these patients, four (0.7%) had a CSF shunt at the time of laparoscopic cholecystectomy. We retrospectively investigated the clinical characteristics of these four cases.

RESULTS

Two patients had ventriculoperitoneal shunts, and two patients had lumboperitoneal shunts. Based on the advice of consulted neurosurgeons, the shunt catheter was clamped during pneumoperitoneum in three of the four cases, and the catheter was left unclamped in the remaining case because it was judged to be occluded. Laparoscopic cholecystectomy was performed under pneumoperitoneum pressure of 8 mmHg. All four cases experienced an uneventful postoperative course, with no shunt-associated complications.

CONCLUSION

Analysis of our current cases suggests the safety of laparoscopic cholecystectomy in cases with CSF shunts.

[Case of Adenocarcinoma with Neuroendocrine Carcinoma Component in the Gallbladder]

A 73-year-old man visited our hospital complaining of abdominal pain. An abdominal CT scan revealed diffuse wall thickening of the gallbladder with a gallstone. Urgent laparoscopic cholecystectomy was performed with the diagnosis of acute cholecystitis. Histopathological examination indicated adenocarcinoma with a small neuroendocrine carcinoma component invading the subserous layer. Additional gallbladder bed resection and lymphadenectomy were performed. The final pathological diagnosis was adenocarcinoma with NEC, pT2N0M0, pStage II . The patient is alive without any recurrence 7 months after the last surgery.

Pancreatic intraductal tubulopapillary neoplasm with associated invasive cancer successfully treated by total pancreatectomy: A case report

A 74-year-old male was admitted to Departments of Surgery, Toyonaka Municipal Hospital (Osaka, Japan) for treatment of a pancreatic tumor. Contrast enhanced computed tomography (CT) revealed a mass with small cystic lesions in the pancreatic head and body. Fluorodeoxyglucose-positron emission tomography/CT revealed an abnormal uptake of fluorodeoxyglucose, corresponding to the mass lesions. Upper gastrointestinal endoscopy revealed rough mucosa near the opening of the accessory pancreatic duct, and the mucosa biopsy exhibited adenocarcinoma with no mucin observed. The preoperative diagnosis was pancreatic intraductal tubulopapillary neoplasm (ITPN) with cancerous lesions, and a total pancreatectomy with splenectomy was performed. The resected tissue specimen revealed a solid tumor occupying the entire pancreas with intraductal growth into the main pancreatic duct. Histological examination revealed high-grade dysplastic cells in a tubulopapillary growth pattern without overt mucin production beyond the pancreatic duct. Immunohistochemical staining analysis of the tumor was positive for cytokeratin (CK)7, CK19 and mucin (MUC)1, and negative for MUC2, MUC5AC, MUC6 and caudal type homeobox 2. The tumor was finally diagnosed as pancreatic ITPN with associated invasive cancer. The patient remains well without evident recurrence nine months post-surgery. ITPN is a rare type of epithelial neoplasm of the pancreas, and is characterized by intraductal tubulo-papillary growth, ductal differentiation, limited intracellular mucin production, and cellular dysplasia. The present case report may contribute to improved understanding of how to effectively treat patients with ITPN.

[A Resected Case of Intraductal Pupillary Mucinous Neoplasm of the Pancreas Characterized by Recurrence in the Remnant Pancreas and Multiple Malignant Neoplasms in Other Organs]

A 74-year-old man underwent pancreaticoduodenectomy for intraductal pupillary mucinous neoplasm(IPMN)of the pancreatic head. Histopathological examination of the specimen revealed non-invasive intraductal papillary mucinous carcinoma( IPMC). Two years after surgery, recurrent IPMN developed in the remnant pancreas, and a liver tumor was identified in S8 of the liver. The patient underwent total pancreatectomy of the remnant pancreas and partial resection of S8. These tumors were histopathologically diagnosed as invasive IPMC and hepatocellular carcinoma, respectively. Five years after the resec- tions, another liver tumor was identified in S4/3 of the liver, and partial resection of S4/3 was performed. The tumor was histopathologically identified as cholangiocellular carcinoma. Seven months after the last surgery, the patient remains in good health without any recurrences. IPMN is characterized by IPMN recurrence in the remnant pancreas and malignant neoplasms in other organs, and the present case showed both characteristics. The case suggested the importance of postoperative follow-up of IPMN patents with regard to the characteristics of IPMN.

[Afferent Loop Syndrome after Hepatobiliary and Pancreatic Surgery Successfully Treated with Percutaneous Drainage]

We report 2 cases where afferent loop syndrome after hepatobiliary and pancreatic surgery was successfully treated with percutaneous drainage. Case 1: A 74-year-old man who had undergone pancreaticoduodenectomy for pancreatic cancer presented with cholangitis, obstructive jaundice, and dilatation of the elevated jejunum. These conditions were attributed to obstruction of the elevated jejunum on the anal side due to peritoneal dissemination. Subsequently, percutaneous transhepatic biliary drainage was performed, and the dilated jejunum was drained through the approach route. Case 2: A 71-year-old woman who had undergone left hepatectomy for hilar bile duct cancer presented with peritoneal dissemination. Owing to the dissemination, the elevated jejunum was obstructed, resulting in its dilatation on the oral side. Percutaneous drainage of the dilated jejunum was directly performed. Percutaneous drainage was effective in both the abovementioned cases, and no symptoms related to the obstruction were observed until the death of the patients because of primary cancer. This suggested that percutaneous drainage may be an effective treatment option for afferent loop syndrome after hepatobiliary and pancreatic surgery.

[Resection of Hepatocellular Carcinoma with Synchronous Bilateral Adrenal Metastases]

A 59-year-old man was admitted to our hospital with liver dysfunction. Examinations revealed a huge liver tumor in the right hepatic lobe and a mass in each adrenal gland. The preoperative diagnosis was hepatocellular carcinoma(HCC)with synchronous bilateral adrenal metastases. The patient underwent right hepatic lobectomy, cholecystectomy, and bilateral adrenalectomy. Histopathological examination of the specimens confirmed the diagnosis of HCC with synchronous bilateral adrenal metastases. After surgery, he received steroid replacement therapy and had a favorable clinical course without complications. Six months after surgery, the patient has experienced no recurrence and is being followed up on an outpatient basis. Although further postoperative follow-up is necessary, the findings of this case suggested a positive oncological impact of surgical resection for HCC and synchronous bilateral adrenal metastases.

[A Case of Adenocarcinoma of the Vater Papilla Treated with Pancreatoduodenectomy after Hepaticojejunostomy for Prior Adenocarcinoma of the Gallbladder]

A 77-year-old man was diagnosed with acute cholecystitis and underwent laparoscopic cholecystectomy. Since adenocarcinoma in the gallbladder was detected by histopathological examination, he received additional resection for the carcinoma: partial hepatectomy(S4a, S5), extrahepatic bile duct resection, and hepaticojejunostomy. Five years after the surgery, he was diagnosed with adenocarcinoma of the Vater papilla. Pancreatoduodenectomy was performed. During the surgery, the prior hepaticojejunostomy and jejunojejunostomy were preserved, and the gastrointestinal tract was cut at the stomach and jejunum 5 cm from the Treitz ligament. A postoperative pancreatic fistula developed, but it resolved. The method of reconstruction in this case has the advantage of not only a smaller number of resections and anastomoses of the gastrointestinal tract but also a better preservation of blood flow in the jejunum compared to other methods reported in previous studies.