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Background: The prognosis of hepatocellular carcinoma (HCC) with vascular invasion is extremely poor, especially in patients with tumor thrombus (TT) of the inferior vena cava (IVC), which is an oncological emergency with a high risk of sudden death due to TT extension or migration. Herein, we describe a case of HCC with TT of the IVC that rapidly extended into the right atrium (RA), in which right hepatectomy was performed under cardiopulmonary bypass. Case presentation: A 64-year-old man was diagnosed with HCC with IVC TT, and right hepatic lobectomy was scheduled. While awaiting surgery, he complained of respiratory distress and rushed to the emergency room. The TT had reached the RA, and the patient was in a state of oncologic emergency. We requested the cooperation of the cardiovascular surgery department, and under artificial cardiopulmonary support, the right atrium was incised, and a part of the TT was removed. The IVC was clamped to prevent tumor dispersal, and right hepatic lobectomy was performed. The remaining thrombus was excised along with the right lobe of the liver by incising the IVC. There were no serious postoperative complications, and the patient is alive 1 year and 5 months postoperatively. Conclusion: Hepatic resection with cardiopulmonary bypass could be an option for HCC with TT reaching the RA. [ABSTRACT FROM AUTHOR]

Background: The surgical strategy for thoracic esophageal cancer that invades the lungs is controversial. In particular, invasion of the pulmonary vein is often regarded unresectable. We successfully applied bilateral video-assisted thoracic surgery (VATS) in esophagectomy for esophageal cancer with left inferior pulmonary vein invasion following induction chemoradiotherapy (CRT), with a favorable response. Case presentation: A 64-year-old woman was diagnosed with squamous cell carcinoma of the lower third of the esophagus. Computed tomography (CT) revealed that the tumor was suspected to be invading the main trunk of the left lower pulmonary vein and left lower lung. We initiated induction CRT comprising 5-fluorouracil, cisplatin, and concurrent radiotherapy at 50.4 Gy/28Fr. CT revealed shrinkage of the tumor, and the main trunk of the left inferior pulmonary vein was released from the tumor invasion. We considered the tumor to be completely resectable. VATS esophagectomy is usually performed using a right-sided approach. However, the right-sided approach is inappropriate for evaluating tumors around the left inferior pulmonary vein. We started with left-sided VATS to determine tumor resectability and dissected between the esophagus and the main trunk of the left inferior pulmonary vein. We only needed to perform partial resection of the left lower lobe. We then performed a right-sided VATS esophagectomy and lymphadenectomy with partial en bloc resection of the left lower lobe. Following this, we performed hand-assisted laparoscopic proximal gastrectomy and reconstruction using the gastric remnant. The postoperative course was uneventful. The patient was discharged on postoperative day 14. Histopathological examination of the surgical specimen revealed a complete pathological response without any remnant tumor or lymph node metastasis. There were no signs of recurrence or metastasis at the 1-year follow-up. Conclusions: Curative resection for thoracic esophageal cancer that invades the pulmonary vein could be possible via the bilateral VATS approach following induction CRT with a favorable response. [ABSTRACT FROM AUTHOR]

Background: After esophagectomy for esophageal and esophagogastric cancer, more than half of patients have lost > 10% of their body weight at 12 months. In most cases, the gastric remnant is used for reconstruction after esophagectomy. One of the most serious nutritional complications of this technique is delayed gastric emptying caused by gastric remnant mobilization and denervation of the vagus nerve. The aim of the PYloroplasty versus No Intervention in GAstric REmnant REconstruction after Oesophagectomy (PYNI-GAREREO) trial is to analyze the clinical outcome of modified Horsley pyloroplasty (mH-P) as a method of preventing delayed gastric emptying. Methods: The PYNI-GAREREO trial is designed as an open randomized, single-center superiority trial. Patients will be randomly allocated to undergo gastric remnant reconstruction with mH-P (intervention group) or no intervention (control group) in parallel groups. All patients with esophageal cancer or esophagogastric cancer planning to undergo curative minimally invasive esophagectomy will be considered for inclusion. A total of 140 patients will be included in the study and randomized between the groups in a 1:1 ratio. The primary outcome is the body weight change at 6 months postoperatively, and the secondary outcomes are the nutritional status, postoperative complications, functional outcome, and quality of life until 1 year postoperatively. Discussion: We hypothesize that mH-P after minimally invasive esophagectomy more effectively maintains patients' nutritional status than no pyloroplasty. Trial registration: UMIN Clinical Trials Registry UMIN000045104. Registered on 25 August 2021. https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000051346. [ABSTRACT FROM AUTHOR]

Background: Spontaneous retroperitoneal hematoma is defined as bleeding in the retroperitoneal space without any triggers such as trauma, invasive procedures, and abdominal aortic aneurysm. Case presentation: A 48-year-old Japanese man who experienced sudden abdominal pain, severe hypotension, and decreased hemoglobin was diagnosed with spontaneous retroperitoneal hematoma. Contrast-enhanced computed tomography revealed massive left retroperitoneal hematoma; however, neither extravasation nor causative aneurysm was noted. Through conservative management with close monitoring, he was treated and discharged on the tenth hospital day without any morbidity. Conclusions: Spontaneous retroperitoneal hematoma treatment comprises conservative management, transcatheter arterial embolization, and surgical intervention. The mortality rate of spontaneous retroperitoneal hematoma is so high that the optimal treatment timing needs to be carefully judged on the basis of detailed evaluation, and management algorithm with clear criteria. [ABSTRACT FROM AUTHOR]

Transanal total mesorectal excision is a relatively new approach for treating lower rectal cancer. Carbon dioxide embolism is a critical complication of this procedure. We report the case of a 69‐year‐old man with lower rectal cancer who underwent transanal total mesorectal excision followed by laparoscopic low anterior resection. He had a sudden intraoperative carbon dioxide embolism during the transanal mesorectal excision. During the ventral dissection of the rectum, end‐tidal carbon dioxide and blood oxygen saturation suddenly decreased. We stopped the insufflation of carbon dioxide and suspended the procedure. There was no circulatory collapse, and the vital signs gradually recovered; therefore, we resumed the surgery approximately 30 minutes later and completed it without additional complications. Upon reviewing the video, we found a small injured vein that would aspirate carbon dioxide. These findings suggested that careful hemostasis is essential to prevent carbon dioxide embolus during transanal total mesorectal excision. [ABSTRACT FROM AUTHOR]

Background: Replaced right hepatic artery (rRHA) is a common vascular variation, and combined resection of this vessel is sometimes needed for the curative resection of pancreatic head malignancy. Safe surgical management has not been established, and there is a small number of reported cases. Here, we reported five cases, wherein preoperative embolization of rRHA was performed for combined resection. Case presentation: All patients had pancreatic head malignancies that were in contact with rRHA. We performed a preoperative embolization of the rRHA before the scheduled pancreaticoduodenectomy for the combined resection. Arterial embolization was safely accomplished, and the communicating arcade from the left hepatic artery via the hilar plate was clearly revealed in all cases. Four patients underwent the operative procedure, except for one patient who had liver metastasis at laparotomy. No patient suffered from a severe abnormal liver function during the management; however, one patient had multiple liver infarctions during the postoperative course. Conclusions: Preoperative embolization for the combined resection of rRHA in pancreaticoduodenectomy can be a management option for the precise evaluation of hemodynamics after sacrificing rRHA. In our cases, arterial flow to the right liver lobe was supplied by the left hepatic artery via the bypass route, including the communicating arcade of the hilar plate. [ABSTRACT FROM AUTHOR]

Background: The depth of invasion determines the surgical method for treating gallbladder cancer (GBC). However, the preoperative correct diagnosis of invasion depth, especially discrimination of T1 lesions among sessile elevated GBCs, is difficult. We investigated the utility of preoperative endoscopic ultrasound (EUS) findings for diagnosing the invasion depth. Methods: We studied a sessile elevated GBC specimen diagnosed as a T1 lesion before developing our study protocol. EUS evidenced an intact boundary between the tumor and the inner hypoechoic layer (the intact boundary sign). To evaluate the potential of using this sign to diagnose T1 GBC as a primary outcome indicator, we retrospectively analyzed patients who underwent surgical resection of sessile elevated GBCs between April 2009 and March 2020. Results: Of the 26 surgically resected sessile elevated GBC specimens, 20 were included and six were excluded due to difficulty in evaluating the overall tumor or layer structure. The Kappa coefficient for interobserver agreement regarding the intact boundary sign was 0.733. The sensitivity and specificity of the sign for diagnosing T1 lesions were 0.857 and 1.000, respectively. Conclusion: This new EUS finding could guide the accurate diagnosis of T1 lesions in patients with sessile elevated GBC. [ABSTRACT FROM AUTHOR]

Aim and Background: TJ-100 is a traditional Japanese medicine that affects inflammation and gastrointestinal motility, and is used as a preventive and treatment for paralytic ileus. This study aims at determining the effect of TJ-100 on the peritoneal levels of IFN-γ/IL-9, cytokines related to ileus, after pancreaticoduodenectomy (PD) in a clinical setting. Methods: This was a subsidiary study of the clinical trial investigating the effect of TJ-100 on postoperative bowel function. Ascites was collected from 180 patients using an abdominal drainage tube on postoperative day 1 and 3 after PD (POD 1 or POD 3) and used to measure 27 cytokines. We performed univariate and multivariate analyses using several perioperative variables and administration of TJ-100/placebo to determine the effect of TJ-100 on the levels of IFN-γ and IL-9. Results: Peritoneal levels of IL-9 and IFN-γ decreased between POD 1 and 3 (Wilcoxon signed-rank test p< 0.001). Multivariate analysis was performed after univariate analysis to select the variables and patients with a body mass index of ≥ 22 kg/m2, older age, use of epidural anesthesia, and longer surgery correlated with the levels of IL-9 and IFN-γ. However, we could not detect a correlation between the use of TJ-100 and cytokine levels in ascites either on POD 1 or 3. Conclusion: TJ-100 did not affect peritoneal IL-9 and IFN-γ levels after PD. This was in accordance with published clinical findings showing no improvement in bowel function after PD and TJ-100 treatment. [ABSTRACT FROM AUTHOR]

A 69‐year‐old woman was referred to our department with complaints of abdominal discomfort in the standing position. She had undergone robot‐assisted radical cystectomy and ileal conduit urinary diversion for bladder cancer 10 months earlier. Abdominal CT revealed a parastomal hernia. Laparoscopic parastomal hernia repair using the Pauli technique was performed successfully with no recurrence after a 4‐month follow‐up. Although there are concerns about potential mesh‐related complications and long‐term results, this novel approach can be a successful option for parastomal hernia repair. As far as we know, this is the first English‐language report on the application of Pauli parastomal hernia repair combined with a pure laparoscopic approach. [ABSTRACT FROM AUTHOR]

Our previous study aimed to examine the effect of TJ-100, a widely used herbal medicine, on intestinal function following pancreaticoduodenectomy (PD) in a multicenter, randomized, double-blinded, placebo-controlled manner (JAPAN-PD study). This concomitant study investigated the effect of TJ-100 on serum cytokine levels in patients who underwent PD. Due to the fact that several clinical variables can affect the absolute values of baseline serum cytokine levels, the ratios of the cytokine levels on postoperative day (POD)3 to those on POD1 were also used for analysis. The present study enrolled 180/224 randomized patients, of whom 91 received TJ-100 and 89 received placebo. As the main findings of the analysis, Wilcoxon signed-rank test revealed no significant difference in the levels of serum cytokines between the groups; however, patients in the TJ-100 group without severe inflammatory complications exhibited significantly higher ratios of interleukin (IL)-4 (n=123), IL-9 (n=72), IL-10 (n=97), PDGF-BB (n=143) and tumor necrosis factor-α (n=135), compared with patients in the Placebo Group (P<0.05). According to the results of the present study, TJ-100 has an effect on the change in serum cytokine levels from POD1 to POD3 following PD. However, the role of different transition pattern of cytokines in postoperative recovery following PD has to be investigated by further mechanical studies focusing on these extracted cytokines (ClinicalTrials.gov ; no. NCT01607307; May 30, 2012). [ABSTRACT FROM AUTHOR]

Purpose: To minimize the parietal trauma associated with multiple surgical access sites, single-incision laparoscopic surgery for colectomy has been emerging with the improvements in instrumentation and surgical techniques. The purpose of this study was to compare the clinicopathological outcomes between single-incision laparoscopic right colectomy (SILC) and multiport laparoscopic right colectomy (MLC) for right colon cancer. Methods: Thirty-five consecutive patients undergoing SILC from a prospective single-institution database were case matched according to demographic data to an equivalent number of patients who underwent MLC. Results: The SILC patients had decreased scores for maximal pain assessed by a visual analog scale on postoperative days 1 and 3, and used fewer postoperative systemic narcotics. The median length of the hospital stay for the SILC patients was significantly shorter compared with the MLC patients. The postoperative morbidity rates were similar between the groups. The oncological findings were not significantly different between the groups. Conclusion: SILC is a feasible and safe alternative to conventional MLC for patients with right colon cancer. [ABSTRACT FROM AUTHOR]

We herein report a rare case of a patient who developed a spindle cell tumor at the inferior mesenteric artery clipping site. A 58-year-old man underwent laparoscopy-assisted sigmoid colectomy for sigmoid colon cancer. As follow-up, CT scans were performed every 6 months after the primary surgery. At the 1-year CT, an nodular soft tissue density mass measuring 54 mm in diameter was found in the mesentery. Although we initially suspected locoregional recurrence of the colon cancer resected 1 year earlier, PET-CT showed that the tumor was unrelated to the previous cancer. During the subsequent laparotomy, the mass appeared to originate from the inferior mesenteric artery clipping site, and it adhered to the jejunum and the left ureter. We completely resected the tumor and part of the jejunum, which we separated from the abdominal aorta and left ureter. The tumor was histologically diagnosed of a spindle cell tumor. The patient has been free from recurrence since the surgery more than 4.5 years ago. Preoperative PET-CT was helpful in ruling out local recurrence of colon cancer, which might have made palliative care a better option than surgical resection. [ABSTRACT FROM AUTHOR]

Background: One of the most common morbidities of pancreaticoduodenectomies is delayed gastric emptying (DGE). The recent advent of subtotal stomach-preserving pancreaticoduodenectomy (SSPPD) attempts to lessen this troublesome complication; however, the incidence of DGE still remains to be 4.5-20 %. This study aims to evaluate whether the incidence of DGE can be reduced by the side-to-side gastric greater curvature-to-jejunal anastomosis in comparison with the gastric stump-to-jejunal end-to-side anastomosis in SSPPD. Methods: Between October 2007 and September 2012, a total of 160 consecutive patients who had undergone SSPPD were analyzed retrospectively. In the first period (October 2007-March 2010), gastrojejunostomy was performed with end-to-side anastomosis in 80 patients (SSPPD-ETS group). In the second period (April 2010-September 2012), gastrojejunostomy was performed with the greater curvature side-to-jejunal side anastomosis in 80 patients (SSPPD-STS group). The postoperative data were collected prospectively in a database and reviewed retrospectively. Results: The incidence of DGE was 21.3 % in the SSPPD-ETS group and 2.5 % in the SSPPD-STS group ( P = 0.0002). According to the classification of the International Study Group of Pancreatic Surgery (ISGPS), the incidence of DGE of grades A, B, and C were 5, 5, and 7 in the SSPPD-ETS group and 0, 2, and 0 in the SSPPD-STS group, respectively. The overall morbidity and postoperative hospital stay of the two groups were not significantly different. Conclusions: The greater curvature side-to-side anastomosis of gastrojejunostomy is associated with a reduced incidence of DGE after SSPPD. [ABSTRACT FROM AUTHOR]

Background: Women undergoing surgery for primary breast cancer routinely have suction drains inserted deep to the wounds. A lack of data exists in relating how long suction drains should stay in situ after major breast surgery. Purpose: This study evaluates the appropriate timing of drain removal by comparing the 5-day-long postoperative drainage or drain removal when less than 50 mL/24 h to conventional drain removal. Methods: This controlled clinical trial was undertaken between February 1997 and May 2012 with a total of 214 consecutive patients who underwent elective total or partial mastectomy with level II axillary lymph node dissection. The main outcome measures included the length of hospital stay, and surgical morbidity, especially seroma formation. Results: In the study group, the age and operation time were significantly increased compared to the conventional group whereas the median hospital stay was significantly shorter in the study group than the control group (7 days vs. 9 days; p < 0.05). The incidence of seroma was 42.8 % in the study group and 31.6 % in the control group ( p = 0.14). The mean number of outpatient visits for seroma was 3.6 in the study group and 1.5 in the control group ( p < 0.05). Drainage volume of more than 150 mL/24 h all resulted in seroma formation. Conclusions: The new criteria for early drain removal are safe and acceptable despite the slightly increased chance of seroma formation. [ABSTRACT FROM AUTHOR]

Background: The risk factors predisposing to bile duct injury or postoperative bile leakage associated with laparoscopic cholecystectomy (LC) include the presence of an accessory hepatic duct, the anomalous cystic duct confluence, and duct of Luschka. One method to prevent bile duct injury is preoperative placement of an endoscopic nasobiliary drainage tube (ENBD assisted LC). The aims of this investigation are first, to report the incidence of bile duct anomalies according to the classification system proposed by Wakayama Medical University and second, to evaluate the efficacy of ENBD assisted LC with regard to prevention of intraoperative bile duct injury and postoperative bile duct injury or leakage. Methods: A total of 1,835 consecutive LCs performed at our institution during a recent 10-year period were reviewed. Results: Anomalous cystic duct confluence was detected in 11 cases and an accessory hepatic duct was detected in 37 cases. These anomalies were risk factors for bile duct injury in our series. However, there was no significant difference in the length of surgery, conversion rate to laparotomy, or frequency of bile duct injury or leakage between the standard LC group and ENBD assisted LC group. Conclusion: A bile duct anomaly was seen in 2.6% of LC cases. Placement of an ENBD tube prior to LC in predictably complicating bile duct anomalies may have successfully decreased the incidence of complications. [ABSTRACT FROM AUTHOR]

We report a male patient aged 45 years, who in 1993 had been diagnosed as having middle bile duct cancer and had received a pancreatoduodenectomy. Histopathology showed a nodular tumor with the main lesion in the middle bile duct and superficial spreading in both proximal and distal directions (which was not observed macroscopically), and residual tumor in the epithelium of the cut edge near the liver. The patient underwent follow-up without postoperative adjuvant therapy. In 2002, 9 years after the operation, the patient developed jaundice and was diagnosed with recurrence of bile duct cancer in the anastomotic site, based on cholangiographic results. He underwent resection of the right hepatic and caudate lobes and the anastomotic region of the bile duct and jejunum. Pathological findings showed an invasive tumor in the anastomotic region, with continuous intraepithelial spread in the direction of the bile duct, which suggested that the residual tumor in the epithelium had grown to become an invasive cancer. In this patient, the recurrence required 9 years after resection. This case provides evidence for the clinical course that might be anticipated for a patient with a residual tumor in the epithelium of the bile duct stump and subsequent superficial spreading bile duct cancer. [ABSTRACT FROM AUTHOR]

Background. The extent of paraaortic lymph node (PAN) metastasis parellels that of distant metastases in patients with biliary carcinoma. Accurate preoperative assessment of PAN metastasis has a crucial impact on surgical indications. In this retrospective study, we evaluated whether computed tomography (CT) scans were useful for diagnosing PAN metastases and excluding patients with PAN metastases from an indication for surgery. Methods. Between March 1999 and November 2003, 57 patients with biliary carcinoma underwent radical lymphadenectomy or surgical biopsy of PANs. Nine of these patients were diagnosed as having PAN metastasis microscopically. All patients had undergone abdominal CT scans before surgery. To diagnose PAN metastases, we used the following diagnostic criteria. (1) Size; when lymph nodes were greater than 12mm, 10mm, 8mm, or 6mm in longo or short-axis diameter, the nodes were considered metastatic. (2) Shape and size; when the axial ratio of a lymph node was greater than 0.5, 0.7, 1.0, and the maximum diameter of the long or short axis was greater than 12 mm, 10mm, 8mm, or 6mm, the node was considered metastatic. (3) Internal structure; if the internal structure of a PAN was heterogeneous, the node was considered metastatic. A positive predictive value was calculated for each included criterion when patients numbered ten or more. Results. Positive predictive values using the above criteria ranged from 13% to 36%. Only one patient had PANs with heterogeneous internal structures. conclusions. We were unable to determine surgical indications based on the morphological criteria revealed by a CT scan. [ABSTRACT FROM AUTHOR]

Almost all reported cases of intraductal papillary-mucinous tumors of the pancreas (IPMTs) originate from Wirsung’s duct (WD), the main pancreatic duct, or their branches. IPMTs arising from Santorini’s duct (SD) and its branches have rarely been reported. This article presents the clinicopathologic features of IPMTs originating in SD and its branches. Of 36 IPMTs resected in our institution, 5 originated in the region of SD: 3 in SD and 2 from its branches. Both SD and WD were dilated in all cases on radiographic and ultrasonographic studies. The maximum diameter of SD, determined by computed tomography or ultrasonography, was larger than that of WD in all cases. Seven reports of IPMT arising from SD have been published. Four lesions originated from SD and the others from its branches. Overall, 9 of 12 lesions (75%) were considered malignant. In conclusion, the coexistence of an IPMT and a dilated SD suggests an origin in the SD. These tumors have a high malignant potential and should be excised. [ABSTRACT FROM AUTHOR]

Cholangiocarcinoma of a raised, elevated type, not an infiltrative type, may be accompanied with superficial spread in the continguous mucosa. We report a case of an extrahepatic cholangiocarcinoma that showed a specific cholangiographic finding of extensive superficial spread. The patient was a 62-yr-old man. Cholangiography revealed an elevated lesion in the middle of the bile duct, which was surrounded by irregularity of the bile duct wall extensively. We accurately diagnosed the tumor extent by percutaneous transhepatic cholangioscopy and achieved radical resection without hepatic resection. The margins were tumor-negative by microscopy. In conclusions, it is important to accurately diagnose the extent of superficial spread preoperatively by cholangioscopy and biopsy, and decide the resecting lines to make margins tumor-negative. [ABSTRACT FROM AUTHOR]

Carcinoma of the cystic duct remnant is extremely rare, and only five cases have been reported previously in the English literature. We present another case of carcinoma of the cystic duct remnant and review the literature. A 62-yr-old woman was diagnosed as having hilar cholangiocarcinoma and transverse colon cancer. However, at laparotomy, the center of the tumor mass was in the cystic duct remnant with contiguous colonic invasion. The pathology of the surgical specimen confirmed carcinoma of the cystic duct remnant. The diagnosis of carcinoma of the cystic duct remnant was made using Ozden’s new criteria. [ABSTRACT FROM AUTHOR]

Background. The caudate lobe of the liver is divided into three subsegments based on the portal blood supply: the Spiegel lobe, the paracaval portion (S1r), and the caudate process. An isolated paracaval (S1r) subsegmentectomy is indicated for a small hepatocellular carcinoma localized within S1r. Because this challenging procedure has not been described, we report the details of successful surgical technique. Methods. The portal pedicle isolation technique provides easy access to the S1r portal pedicle. A tape is passed along the midline of the anterior surface of the vena cava and its lower end is passed through the caudate parenchyma dorsoventrally to establish a landmark for the left border of S1r. A liver-splitting anterior approach is used to open the interlobar plane widely to the precaval tape. As exposing the vena cava and the root of the right hepatic vein, parenchymal dissection is advanced to the right and then, upward. Results. The procedure was performed successfully in a 51-year-old man with hepatitis B who had a 2-cm hepatocellular carcinoma in S1r. Blood loss was 645 ml. Conclusions. An isolated paracaval subsegmentectomy of the caudate lobe can be performed successfully, although it is likely to remain an uncommonly used procedure. [ABSTRACT FROM AUTHOR]

A 65-yr-old man who underwent pancreaticoduodenectomy with portal vein resection for pancreatic cancer is alive 8 yr after surgery. Originally, computed tomography (CT) revealed an 8-cm tumor in the pancreatic head. The tumor had infiltrated the portal vein, but grew expansively, so there was neither biliary obstruction nor jaundice. Pancreaticoduodenectomy with resection of the portal vein was performed for pancreatic cancer. Many tumor-infiltrating lymphocytes were seen within cancer cell nests on routine histopathology. We performed immunostaining for CD8, and found that a large number of the lymphocytes were CD8+ T cells. The patient’s prognosis was considered poor because the tumor was large and had infiltrated the portal vein. We suspect that long-term survival may be related to the response of CD8+ T cells to the cancer. [ABSTRACT FROM AUTHOR]

Background. Locally advanced cancer of the pancreatic body involving the celiac and/or common hepatic arteries is often considered unresectable. Radical distal pancreatectomy with en bloc resection of these arteries without reconstruction was recently introduced to treat these tumors. However, experience is still limited. This study reviewed the safety and utility of the operation. Patients and methods. We retrospectively studied the charts of 13 patients who underwent radical distal pancreatectomy. Results. Unplanned arterial reconstruction was required in three patients due to accidental injury. The postoperative mortality rate was 0% despite a morbidity rate of 62%. Patient's intractable abdominal and/or back pain was completely relieved immediately after surgery. Contrary to expectations, postoperative diarrhea was mild. The surgical margins, including the retroperitoneum, were clear histologically (R0 resection) in all patients. The 1- and 2-year survival rates were 51% and 14%, respectively, and median survival was 12.2 months. The site of recurrence was the liver in six patients and retroperitoneum in one. Conclusions. Distal pancreatectomy with en bloc resection of the celiac artery is feasible and safe, offers a high resectability rate, and has dramatic analgesic effect. Local control of disease is excellent despite frequent hepatic recurrence. [ABSTRACT FROM AUTHOR]

Background/Purpose: We report our experience performing wedge resection of the portal bifurcation and transverse suture closure in patients undergoing left hepatectomy and caudate lobectomy plus biliary reconstruction for hepatobiliary cancer. Methods: The procedure was performed in three patients with hilar or intrahepatic cholangiocarcinoma. After confirming that tumor invasion of the portal bifurcation was not circumferential, the portal trunk and the right posterior and right anterior portal branches were isolated and clamped. Wedge resection of the portal bifurcation was performed, taking care to secure a clear surgical margin. The edges of the portal vein were approximated, using guy-sutures in the dorsal and ventral edges and a temporary central guy-suture, and portal reconstruction was carried out using a continuous transverse suture. After unclamping, good portal flow was confirmed by color Doppler ultrasonography. Results: The procedure was completed successfully in all three patients; the average time of portal vein occlusion was 15 min. Two patients had postoperative complications: bile leakage and wound infection, but no patient developed postoperative hepatic failure or died. The three patients are alive without recurrence at 2, 11, and 22 months after the operation. Conclusions: Wedge resection of the portal bifurcation is easier and simpler than using a venous patch or performing segmental resection. [ABSTRACT FROM AUTHOR]

We report the successful treatment of Budd-Chiari syndrome (BCS) due to an obstruction of the hepatic veins. A 19-year-old man developed bleeding esophageal and gastric varices, and a large amount of ascites was thus caused by portal hypertension. BCS complicated by an obstruction of the major hepatic veins was diagnosed after examinations. We performed percutaneous transluminal angioplasty (PTA). This resulted in a great improvement of BCS, a marked decrease in the pressure of the hepatic veins, and the disappearance of ascites. Restenosis occurred at 1 year and 5 years after the initial angioplasty, for which PTA was repeatedly performed. Nine years after the initial treatment, no stenosis has been observed and the patient has shown a favorable outcome. [ABSTRACT FROM AUTHOR]

Background: Solitary true cyst of the pancreas is rare in adults, and the differential diagnosis of cystic lesions of the pancreas is challenging. Aim of the Study: To describe a solitary true cyst of the pancreas in an adult and discuss the differential diagnosis. Methods: A 50 yr old woman presented with a mass lesion in the right upper quadrant of the abdomen. Abdominal computed tomography showed a cystic lesion, with a maximum diameter of 12 cm, between the inferior surface of the liver and the ascending colon. The cyst was homogenous and had smooth edges. On magnetic resonance imaging, a unilocular cyst was seen that was low intensity on T1-weighted images and very high intensity on T2-weighted images. No connection between the cyst and the pancreatic ductal system was demonstrated on endoscopic retrograde cholangiopancreatography. Laparotmy was performed with a presumptive diagnosis of cystic tumor of the pancreas. Results: On pathologic examination, the cyst was serous and was lined with a single layer of normal cuboidal epithelium that was periodic acid Schiff stain negative. Meticulous examination failed to identify honeycomb-like microcysts characteristic of serous cystadenoma. The final diagnosis was a solitary true cyst of the pancreas. Conclusion: The differential diagnosis of solitary true cyst from other cystic lesion of the pancreas usually is based on histology. Particular care must be taken to distinguish this lesion from macrocystic serous cystadenoma. [ABSTRACT FROM AUTHOR]

We present two patients who underwent a portal stent placement for bleeding jejunal varices of the afferent loop caused by extrahepatic portal venous stenosis. Case 1 involved a 66-year-old woman who developed bleeding jejunal varices due to extrahepatic portal venous stenosis 1 year after a pancreaticoduodenectomy with intraoperative radiation therapy. Percutaneous transhepatic balloon dilatation and stent placement were performed. Since undergoing the procedure, no bleeding has occurred. Case 2 concerned a 44-year-old woman who had a rupture and bleeding of jejunal varices 16 years after a choledocojejunostomy. Stenosis was observed from the right and left branches of the portal vein to its intrahepatic branches. Both balloon dilatation and stent placement were attempted. However, the stent could not be fully inserted into the intrahepatic portal vein. Portal stent placement is less invasive and radical, and therefore should be attempted for the treatment of extrahepatic portal venous stenosis. However, there are limits to its application if the stenosis extends to the intrahepatic branches of the portal vein. [ABSTRACT FROM AUTHOR]

Spindle cell carcinoma of the breast was formerly called carcinosarcoma, and is relatively rare. We report a case of spindle cell carcinoma of the breast. The patient was treated with multiple surgeries and achieved long-term survival. The patient was a 52-year-old woman, in whom small induration developed at the areola of the nipple of the right breast. The lesion was resected, and benign tumor was diagnosed pathologically. Four years later, she had recurrence at the scar, and a typical mastectomy was performed. A tumor developed again 5 years later; the lesional focus was at the scar of the right chest wall and invasion of the ribs and the sternum was noted. The sternum and the right costal cartilage of ribs 3–9 were dissected together. The right chest wall was reconstructed and adjuvant radiation therapy performed. Four years after this operation, tumor recurred near the scar and chest wall resection including part of the pericardial cavity and the left lung was performed. However, 6 months later, invasion of the mediastinum, heart and lung were noted. The patient died 16 years after the first surgery. Dermatofibrosarcoma protuberance of the breast was diagnosed at the second operation. However, the diagnosis was changed to spindle cell carcinoma of the breast following immunohistochemical studies. Spindle cell carcinoma of the breast is rare, and definitive histopathological diagnosis is often difficult. When spindle cell carcinoma is suspected, comprehensive diagnostic studies including immunohistochemical examinations should be performed. Even in case with multiple recurrences correctly performed operations may contribute to prolongation of survival. [ABSTRACT FROM AUTHOR]

We report a case of nonfunctioning endocrine tumor of the pancreas with extrapancreatic growth and cyst formation. A 48-year-old woman was admitted to our hospital with an upper abdominal mass, which was detected during a routine medical checkup. The preoperative diagnosis was a solid cystic tumor of the pancreas. The tumor, which measured about 7 cm in diameter, arose from the head of the pancreas and had a thin stalk, measuring about 1 cm in diameter. The histopathological diagnosis was a malignant nonfunctioning endocrine tumor of the pancreas. Cyst formation occurred in 67% of the reported cases with extrapancreatic growth in Japan. It is speculated that the cyst formation in this disease is related to the large size of the tumor and to the extrapancreatic growth. [ABSTRACT FROM AUTHOR]

Presents a correction to the article "Results of Radical Distal Pancreatectomy With en bloc Resection of the Celiac Artery for Locally Advanced Cancer of the Pancreatic Body," published in previous issue.