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Disseminated intravascular coagulation(DIC)has a poor prognosis in gastric cancer. The patient was a 78-year-old man. He had been diagnosed with Stage Ⅳ gastric cancer. Before chemotherapy, thrombocytopenia and elevated D-dimer occurred, and we diagnosed DIC. We started SOX therapy to treat gastric cancer with DIC. DIC improved on the 10th day after the onset of DIC. But developed DIC again on the 21st day. We started SOX therapy again. However, the DIC did not improve. The patient died 32 days after the initial DIC. Oxaliplatin regimen may be a potential treatment for DIC.

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.

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.

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 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.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.

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.

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.

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 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.

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.

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 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.

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(p0.01). The Lap group had lesser blood loss(median: 150 mL vs 355 mL, p0.01)and shorter postoperative hospital stays(median: 8 days vs 11 days, p0.01). There were no differences in operation time or severe postoperative complications. LRH is feasible and useful, providing good short-term outcomes.

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.

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(p0.01)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.

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.

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 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 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 70-year-old woman presented to our hospital because of stomach pain. She was diagnosed as having clinical Stage ⅢC gastric cancer with invasion into the pancreas and treated with S-1+oxaliplatin(SOX)as neoadjuvant therapy, after palliative radiotherapy for tumor bleeding. After 4 courses of SOX therapy and 7 courses of S-1 therapy, the tumor size reduce and the invasion into the pancreas disappeared. Subsequently, she underwent distal gastrectomy. The pathological diagnosis was ypStage ⅢB, with no findings of tumor invasion into the pancreas. As of 1 year 9 months after the surgery, no metastasis or recurrence was observed.

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.

A 69-year-old man was administered S-1/oxaliplatin/trastuzumab as induction chemotherapy for advanced gastric cancer (cT4b[liver, pancreas], N2M1(H1P0CYX), cStage IV). After 4 courses, because contrast-enhanced computed tomography showed remarkable reduction of the tumor, distal gastrectomy, partial hepatectomy, and radiofrequency ablation for the liver metastasis were performed. The patient was histopathologically diagnosed with gastric neuroendocrine carcinoma(NEC). S- 1/oxaliplatin/trastuzumab was continued after surgery; however, recurrence in the remnant liver was observed after 4 cours- es. For recurrence, cisplatin/irinotecan as first-line and paclitaxel/ramucirumab as second-line treatment were administered, but progression of liver metastasis and ascites due to peritoneal dissemination were observed. As third-line treatment, nivolumab was initiated. Ascites decreased after 3 courses, but after 2 more courses, progression of ascites, liver recurrence, and multiple metastasis in the lumbar vertebra were observed.

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.

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 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.

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.

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.

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.

The aim of this study was to clarify the clinicopathological characteristics of incidental gallbladder cancer(iGBC)diagnosed after laparoscopic cholecystectomy. A total of 33 patients diagnosed with iGBC were enrolled in this study, and their clinicopathological characteristics were investigated. Preoperative diagnoses were as follows: cholelithiasis in 16 patients, polypoid lesions in 8, cholecystitis in 7, and adenomyomatosis in 2. Depth of mural invasion of iGBC was M in 14 cases, MP in 3, SS in 12, and deeper than SS in 4. M/MP cases with negative margins were followed up, and cases with SS/deeper than SS underwent additional resection. Prognosis of these patients with iGBC was not significantly different from that of non-iGBC (niGBC)patients. There was no significant difference in R2 resection rate between iGBC and niGBC with SS/deeper than SS. Intriguingly, peritoneal dissemination was identified on additional resection in 1 case that had intraoperative bile leakage at the prior laparoscopic cholecystectomy. Port-site recurrence was found in 2 iGBC cases. These results suggested that the treatment strategy for iGBC is acceptable. However, considering the existence of cases with peritoneal dissemination or portsite recurrence, the possible presence of iGBC should be kept in mind at the initial laparoscopic cholecystectomy.

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.

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.

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 56-year-old woman was referred to our hospital because of epigastric discomfort and jaundice. Contrast-enhanced computed tomography and gastrointestinal endoscopy revealed an ampullary tumor. A biopsy specimen showed adenocarcinoma of the ampulla of Vater. The carbohydrate antigen (CA19-9) level was elevated, but insulin and glucagon levels were in the normal range. Based on a diagnosis of adenocarcinoma of the ampulla of Vater, we performed subtotal stomach-preserving pancreatoduodenectomy with regional lymph node dissection. Postoperative histopathological examinations indicated both neuroendocrine carcinoma (40%) and adenocarcinoma (60%) components in the ampulla of Vater and regional lymph node metastasis. According to the 2010 WHO Classification of Tumours of the Digestive System, the diagnosis of mixed adenoneuroendocrine carcinoma (MANEC) of the ampulla of Vater was confirmed. The patient was treated for 6 months with oral administration of TS-1 as adjuvant chemotherapy. Currently, the patient is alive without recurrence 8 months after surgery. MANEC of the ampulla of Vater is rare. It is a highly malignant tumor, and the standardization of its treatment, including surgery, chemotherapy, and radiotherapy requires further study.

An 83-year-old man underwent extended cholecystectomy for gallbladder cancer. On postoperative day 13, he developed fever and computed tomography (CT) revealed fluid collection at the cut surface of the liver. Ultrasound-guided fluid drainage was conducted, and he was diagnosed with biliary leakage. Radiological examination using a contrast agent revealed that the anterior branch of the bile duct (B5) was completely interrupted. Simple drainage and ethanol injections into the bile duct proved ineffective. Thus, we performed transcatheter arterial embolization (TAE) in the anterior segmental artery (A5) to stop the production of bile in the injured part of anterior segment. The treatment was effective, and he was discharged 15 days after TAE. TAE might be a useful method for treating intractable interrupted-type bile leakage.

A 60-year-old male patient underwent curative surgical resection for gastric cancer. After the surgery, the patient was diagnosed with T4b, N3b, ly3, v2, CY0, fStageⅢc gastric cancer, and adjuvant systemic chemotherapy using S-1 and CDDP was administered. However, follow-up computed tomography (CT) scan examination taken 2 months after surgery revealed a pancreatic fistula and retroperitoneal abscess, and percutaneous drainage was performed. After 1 month, the enhanced CT scan detected liver metastasis measuring 25 mm in diameter at segment 7. The CT-guided percutaneous radiofrequency ablation (RFA) combined with transcatheter arterial chemoembolization (TACE) procedure was performed on the liver metastasis using degradable starch microspheres (DSM). Two months after the RFA, a follow-up CT scan revealed local recurrence of the lesion in the medial side of the ablated area in segment 7. A second CT-guided RFA, which was combined with DSM-TACE, was performed on the recurrent lesion. The patient has since survived more than 2 years after the second treatment without any further recurrences. This case report suggests that RFA treatment combined with DSM-TACE might be a safe and feasible treatment for liver metastasis from gastric cancer.

To examine the effect of S-1 adjuvant chemotherapy on muscle volume after curative gastrectomy in gastric cancer patients.Forty-eight gastric cancer patients (31 men and 17 women) who underwent curative gastrectomy (distal gastrectomy: n=37, and total gastrectomy: n=11) between April 2010 and July 2011 were enrolled in this study. Sixteen patients underwent S-1 adjuvant chemotherapy (S-1 group) for 1 year after the operation, and 32 patients did not (NT group).The psoas muscle areas were measured at the fourth lumbar vertebrae on CT images obtained before the operation, and at 6, 12, and 24 months after the operation. Muscle areas was statistically examined by comparing the preoperative and postoperative ratios.The muscle areas 12 months after the operation decreased to 0.86 ± 0.11 in the S-1 group and to 0.96 ± 0.08 in the NT group (p0.05), and the significant difference disappeared at 24 months (0.93 ± 0.10 vs. 0.93 ± 0.11, NS). In the patients who underwent distal gastrectomy, the muscle areas decreased to 0.90 ± 0.05 in the S-1 group and to 0.96 ± 0.09 in the NT group at 12 months (p0.05). Meanwhile, in those who underwent total gastrectomy, the muscle areas decreased to 0.80 ± 0.15 and 0.93 ± 0.03, respectively (NS).S-1 adjuvant chemotherapy affected muscle volume loss after gastrectomy in the gastric cancer patients, but the patients recovered from the adverse effect by 12 months after chemotherapy.

A 74-year-old man with chronic hepatitis C was diagnosed with liver tumors. Contrast-enhanced computed tomography (CT) and ethoxybenzyl diethylenetriamine pentaacetic acid-enhanced magnetic resonance imaging (EOB-MRI) revealed hepatocellular carcinomas(HCC) in segments 8 (S8)and 5/8 (S5/8), and detected a lymph node (LN) swelling of 75 mm diameter in the posterior aspect of the pancreatic head. Fluorine-18-fluorodeoxyglucose positron emission tomography (FDG-PET) was positive for the swollen LN (SUVmax 12.3), but negative for the intrahepatic HCCs. The alpha-fetoprotein (AFP) and protein induced by vitamin K absence or antagonist-II (PIVKA-II) values were elevated, and soluble interleukin- 2 receptor levels were also increased (1,440 U/mL). Based on a diagnosis of HCCs with either LN metastasis, or with malignant lymphoma, partial hepatectomy (S8 and S5/8), lymphadenectomy (#13LN), and cholecystectomy were performed. Histopathological examination indicated well differentiated HCC in S5/8, and moderately to poorly differentiated HCC in S8, while poorly differentiated HCC was detected in the LN. Therefore, the final diagnosis was HCCs with metastasis to #13LN originating from the HCC in S8. At present, the patient is alive without further extrahepatic recurrence. The extent of FDG accumulation is related to the degree of differentiation of the HCC; furthermore, there are discrepancies between the FDG uptake in intrahepatic and extrahepatic lesions.

The patient was a 73-year-old male with advanced gastric cancer in the lesser curvature of the antrum.Abdominal computed tomography revealed multiple liver metastases(S5, S8).He was diagnosed with clinical Stage IV gastric cancer (cT3N0M1H1).He received 3 courses of combined neoadjuvant chemotherapy with capecitabine, cisplatin, and trastuzumab because immunostaining indicated the tumor was human epidermal growth factor receptor 2(HER2)-positive.The therapeutic response, as assessed by imaging studies, was partial for the primary lesions and stable for liver metastases.Distal gastrectomy, D2 lymph node dissection, and S5 extended subsegmentectomy of the liver were performed.Histopathological findings indicated that both the primary tumor and liver metastases were neuroendocrine carcinoma.The patient declined post-operative adjuvant chemotherapy and he is alive 6 months after the surgery with no evidence of recurrence.Surgery with neoadjuvant chemotherapy appears to be a promising option for advanced gastric cancer with liver metastases.

We report a case of long-term survival of a patient who underwent hepatic resection for metastatic gastric cancer. The patient was a 75-year-old man who underwent distal gastrectomy for gastric cancer in 2004. On pathological examination, the tumor was diagnosed as T4a (SE) N0M0, stage IIB. A metastatic lesion was detected in segment 6 of the liver at 2 years after gastrectomy. With regard to radiological findings, a single metastatic lesion and no lymph node metastasis or peritoneal recurrence was observed. The hepatic lesion was curatively resected. Another metachronous liver metastasis was identified in segment 7 of the liver at 3 years after gastrectomy. We resected the remnant liver metastasis, after which the patient has not exhibited any evidence of tumor recurrence for more than 5 years. This case suggests that patients could survive for a long period after undergoing resection of hepatic metastasis because no lymph node metastasis was observed during the operation of the primary gastric cancer, only a single hepatic metastasis without any metastasis to other organs was observed, and the metastatic lesion of the liver could be curatively resected.

We report a case of a patient in whom a giant mucinous cystadenocarcinoma was treated with distal pancreatectomy. A 37-year-old woman was admitted to the hospital complaining of intermittent epigastric pain. The laboratory data revealed a marked increase in serum levels of carcinoembryonic antigen( CEA 22 ng/mL), cancer antigen( CA) 19-9( 258,129 U/ mL), and CA125 (53 U/mL). A computed tomography (CT) scan revealed a cystic tumor, 15 cm in diameter, in the body of the pancreas. The tumor presented as a multilocular cyst with enhanced nodules. On positron emission tomography (PET)-CT,[ 18F] fluorodeoxyglucose uptake by the nodules of the cyst was noted. Under the diagnosis of malignant mucinous cystic neoplasm, we performed distal pancreatectomy, splenectomy, partial gastrectomy, and left adrenalectomy because the tumor was suspected to be invading the stomach and left adrenal gland. The tumor was histologically diagnosed as invasive mucinous cystadenocarcinoma with ovarian-like stroma. The patient survived for 14 months after surgery without tumor recurrence. Invasive mucinous cystadenocarcinoma of the pancreas has high rates of lymph node metastasis and early recurrence after surgery. We believe that we would have had to perform complete tumor resection equivalent to that of invasive ductal carcinoma of the pancreas if the mucinous cystic neoplasm was found to be malignant preoperatively.

A 49-year-old man was admitted to our hospital with back pain, appetite loss, and body weight loss in January 2009. Gastroduodenal endoscopy, abdominal computed tomography( CT), and magnetic resonance imaging( MRI) revealed type 4 advanced gastric cancer( signet-ring cell carcinoma) with multiple lymph node( No. 16 LNs), right adrenal gland, and multiple bone metastases. Between February 2009 and April 2011, 20 courses of S-1( 80 mg/m2) plus CDDP( 60 mg/m2) and zoledronic acid hydrate (4 mg/body) were administrated. Since May 2011, S-1 (70 mg/m2) and zoledronic acid hydrate( 4 mg/body) have been continued. The lymph node and adrenal gland metastases showed a complete response( CR), and the gastric tumor showed a partial response; however, the bone metastases did not show CR or progressive disease (PD) for 4 years after initiation of therapy. Chemotherapy with zoledronic acid hydrate is considered as a useful therapeutic option for advanced unresectable gastric cancer with multiple bone metastases.

Hand-foot syndrome( HFS) has been reported to be the most common adverse effect of capecitabine, with an incidence of more than 50%. AboundTM, containing β-hydroxy-β-methyl butyric acid( HMB), L-glutamine, and L-arginine is effective in the treatment of decubitus ulcers and in wound healing; however, whether AboundTM is efficacious for HFS caused by capecitabine is not clear. This study aimed at evaluating the effectiveness of AboundTM in the recovery from HFS caused by capecitabine. Capecitabine administration was discontinued in 6 patients with more than grade 2 HFS, and AboundTM was administered. The time to recovery was examined. The median time to recovery to less than grade 1 HFS was 10 days( range, 4-14 days). The grade of HFS decreased following the administration of AboundTM. The findings of this study suggest that AboundTM is effective against HFS caused by capecitabine.

A 55-year-old man with a positive fecal occult blood test visited our department, and after a thorough medical evaluation, was diagnosed with Stage IV Rs rectal cancer with marked para-aortic lymph node metastasis. In December 2007, the patient underwent low anterior rectal resection with D3 lymph node dissection, but the para-aortic lymph nodes were left. The metastatic lymph nodes showed a complete response(CR)to post-operative chemotherapy with FOLFOX, FOLFIRI, IRIS, and irinotecan+cetuximab, and the complete response was sustained for 18 months after surgery. Later, he developed Virchow's lymph node metastasis, which was also resected. At present, 5 years after the first surgery, the patient, whose chemotherapy has been discontinued, is alive without recurrence. It appears that using key drugs, such as 5-fluorouracil, leukovorin, oxaliplatin, irinotecan, and cetuximab, and performing aggressive salvage surgery for Virchow's lymph node recurrence, led to long-term recurrence-free survival.

We retrospectively examined the feasibility and outcome of S-1 adjuvant chemotherapy for 18 patients with gastric cancer treated based on the liaison-clinical pathway (liaison group), and compared them with those of 26 patients treated before the induction of the liaison-clinical pathway (non-liaison group). The persistent rate of S-1 adjuvant chemotherapy for one year except for recurrence, the relative performance (RP) value of cases who had received S-1 for one year, and Grade 3/4 adverse events in non-liaison group/liaison group, were 88.5/87.5% (p = 0.93), 87.0/92.9% (p = 0.56), and 26.9/5.6% (p = 0.07), respectively. This did not show a significant difference. The rate of patients administered medication for coexistent diseases in our hospital in the non-liaison group/liaison group was 53.8/0% (p = 0.0002), which reflected the accomplishment of the transfer of medical care for coexistent disease from a hospital to a clinic on the liaison-clinical pathway. Furthermore, a neighboring clinic could be arranged to accommodate 9 (64.3%) of 14 patients living quite far from the hospital in the liaison group. In conclusion, S-1 adjuvant chemotherapy for patients with gastric cancer treated based on the liaison-clinical pathway was feasible, led to the effective practice of sharing between hospital and clinic, and the shorter trip for treatment at a neighboring clinic by patients living far from a hospital.

We report a case of methicillin-resistant Staphylococcus aureus(MRSA) surgical site infection successfully treated with linezolid. A 66-year-old man had undergone total gastrectomy for gastric cancer after neoadjuvant chemotherapy. Three days after the operation, he was diagnosed with deep incisional surgical site infection due to MRSA, and wound care was started. After discharge, he received adjuvant chemotherapy and wound care, but the wound had not healed in 10 months. We started treatment with oral linezolid and nutritional support, and the wound was fully healed 12 months after the operation. Antibiotic treatment with oral linezolid may be effective for refractory deep incisional surgical site infection due to MRSA in outpatients.

S-1/cisplatin(CDDP) combination therapy(SP therapy)(S-1: 80 mg/m2/day, day 1-21, CDDP: 60 mg/m2, day 8, q35 days) is a standard regimen for advanced gastric cancer in Japan. Hydration under hospitalization is necessary for CDDP administration to prevent renal toxicity; nevertheless, ambulatory chemotherapy has recently become commonly used. Therefore CDDP administration using a short hydration regimen for gastric cancer outpatients undergoing SP therapy has been performed in our institute. Between August 2009 and November 2011, 23 patients who were treated with SP therapy as a first line therapy and began CDDP treatment in the outpatient setting were examined, and monitored for adverse events, response rate[best objective response rate(ORR)], time to treatment failure(TTF) and overall survival. A short hydration regimen means 2,550 mL of fluid in 4 h and 55 min, and the necessity of an oral intake of more than 1,000 mL liquid per day on day 7 to 9 was explained to the patients. Grade 1/2 serum creatinine elevation occurred in 5 patients (22%), but there were no incidences of grade 3/4 serum creatinine elevation or heart failure. The best ORR was 69%, median time to treatment failure(mTTF) was 11.5 months, the 1-year survival rate was 77.8%, and the 2-year survival rate was 44.7%.CDDP administration using a short hydration regimen for gastric cancer outpatients undergoing SP therapy was considered to be feasible.

S-1+cisplatin (CDDP) combination therapy is a standard regimen for advanced gastric cancer and is usually administered within the hospital environment. Recently, ambulatory chemotherapy has been applied to treat various cancers. For the realization of outpatient treatment, it is necessary to strengthen supportive therapy. We developed a comprehensive and supportive care clinical pathway. The use of this pathway in combination with the expertise of pharmacists has resulted in enhanced supportive therapy, reduced side effects, and increased treatment intensity.

A man is his 50s experienced epigastric discomfort and body weight loss from 60 to 56 kg over 3 months. A lesion was diagnosed as type 3 advanced gastric cancer (group 5, tub2) with para-aortic lymph node and multiple liver metastases. Pretreatment hemoglobin(Hb), albumin(Alb), and C-reactive protein(CRP) levels were 11.0 mg/dL, 3.0 g/dL, and 2.40 mg/dL, respectively. S-1+cisplatin (CDDP) combined chemotherapy (S-1 120 mg/day, day 1-21, CDDP 60 mg/ m2, day 8, q35 days) with nutritional supportive care using enteral nutrition (EN) agent (Prosure) enriched with eicosapentaenoic acid (EPA) was initiated. After 6 weeks, body weight, Hb, Alb, and CRP improved to 60 kg, 13.6 mg/dL, 4.6 g /dL, and 0.14 mg/dL, respectively. Moreover, a marked reduction in para-aortic lymph node and multiple liver metastases was seen on computed tomography (CT) scans 12 weeks after treatment initiation. Accordingly, nutritional supportive care using EN agent enriched with EPA during chemotherapy might be an effective treatment for patients with gastric cancer who show increased CRP and decreased albumin levels.