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Subjects: We first reviewed surgical outcomes and pathological findings of 32 patients(laparoscopic group: LDP n=11, open group: ODP n=21)who underwent distal pancreatectomy for pancreatic cancer from January 2018 to October 2022. Then we reviewed long-term outcomes, and recurrence type for 20 patients(LDP: n=5, ODP: n=15)from January 2018 to February 2021., Results: LDP group had significantly longer operation time and less blood loss. There was no difference in length of hospital stay, postoperative complications, number of dissected lymph nodes, positive lymph node metastasis rate, and adjuvant chemotherapy rate. Because of high rate of pancreatic stump closure by hand sewing in ODP, postoperative pancreatic fistula rate was higher in ODP than in LDP. The 2-year relapse-free survival rate was 60% in LDP, 33% in ODP, and the 2-year overall survival rate was 60% in LDP, 71% in ODP, and there were no significant differences. As for the type of recurrence, in LDP group, 2 cases of distant metastases and no local recurrence was observed, and in ODP group, 6 cases each of local recurrences and distant metastases were observed., Conclusion: LDP was not inferior to ODP in short and long- term outcomes, safety, curability, and local control ability.

A 69-year-old woman underwent a pancreaticoduodenectomy at the age of 41 years for a submucosal tumor of duodenum, which was diagnosed as leiomyoma at that time. Twenty eight years later, a liver tumor, which is 10 cm in a diameter, was identified on an abdominal ultrasonography. The left hepatectomy was undertaken. Immunohistochemical examination indicated that the tumor was positive for c-kit and diagnosed as a gastrointestinal stromal tumor(GIST). The pathological reexamination revealed the primary tumor was also positive for c-kit and diagnosed as GIST. Therefore, the liver tumor was considered as a metastasis of the duodenal GIST, which was resected 28 years earlier.

Among gastric submucosal tumors, neurogenic tumors are considered to be rare diseases. We experienced a case of laparoscopic local gastrectomy of gastric schwannoma coexisting with extramurally developed gastric GIST found accidentally during surgery. A 61-year-old man was pointed out a gastric submucosal tumor with a diameter of 15 mm in a medical checkup. Endoscopic ultrasound-guided fine needle aspiration(EUS-FNA)was performed, and immunostaining showed that c-kit(-), CD34(-), S-100(+), SMA(-), MIB-1<2%. Diagnosis was gastric schwannoma. We performed laparoscopic local gastrectomy. During the surgery another extramural nodule was accidentally found with a diameter of 8 mm at the anterior wall of the gastric body near lesser curvature. Immunostaining showed c-kit(+), CD34(+)and was diagnosed GIST. Because a gastric schwannoma coexisting with GIST is a rare case, we decided to report it by adding discussion with some literatures.

A 60-year-old woman was referred to our hospital due to pancreatic head cancer with right ureter invasion. We considered that it was difficult to achieve R0 resection for the patient by operation because of a wide range of retroperitoneal invasions involving the right ureter. She was treated with chemotherapy(gemcitabine plus nab-paclitaxel: GnP). GnP therapy was administered 3-weeks on/1-week off for 1 course. After 3 courses, we performed pancreaticoduodenectomy, right nephrectomy and partial transverse colectomy. We achieved R0 resection and considered the GnP therapy to be effective.

Introduction: Primary small-cell carcinomas occur commonly in the lungs but rarely in the other organs. We studied the treatment outcomes in 6 cases of primary small-cell carcinoma of the digestive tract at our hospital., Patients: Six patients were diagnosed with small-cell carcinoma of the digestive tract histopathologically and treated at our hospital from September 2000 to December 2018., Results: The average age of the patients was 61.5 years(range: 40-80 years). Patients were 3 men and 3 women. The occurrence sites were the esophagus, stomach, and colon in 1, 2, and 3 patients, respectively. The patient with esophageal cancer underwent chemoradiotherapy without surgery. Other patients, except for 1 patient with colon cancer, underwent adjuvant chemotherapy after the surgery. Two of the 6 patients survived for over 5 years., Discussion: For small-cell carcinomas of the digestive tract with poor prognosis, long-term survival can be expected using multidisciplinary treatments depending on the case.

A 50-year-old man underwent low anterior resection for rectal cancer. The final diagnosis was rectal cancer of pT3N0M0, fStage Ⅱ. CT performed for examination of obstructive jaundice at 17 months after surgery revealed metastatic lesions of the pancreatic head and right lung. By core needle biopsies, the lesions were pathologically diagnosed as metachronous metastases of rectal cancer. Chemotherapy was carried out but was discontinued at 5 courses due to severe side effects. The pancreatic metastasis disappeared after 11 months. As the lung metastasis remained, a right upper lobectomy was performed 1 month later. The patient remains alive without recurrence 6 months after the partial lung resection.

Were port a caseof an 82-year-old man who presented with vomiting. Computed tomography(CT)revealed a jejunum tumor and small bowel obstruction. Enteroscopy revealed a protruded lesion and biopsy indicated adenocarcinoma. PET-CT revealed nothing without jejunal tumor. Therefore, with a preoperative diagnosis of primary small bowel cancer, we performed operation. Surgery indicated peritoneal disseminations and a jejunal tumor 40 cm distal from the ligament of Treitz, and we performed small bowel partial resection. Pathological examination revealed adenocarcinoma originating from a Heinrich type I ectopic pancreas in the jejunum. Ectopic pancreatic cancer in the jejunum is rare, and we review case reports in the literature.

A 58-year-old woman was referred to our hospital with high fever and right upper abdominal pain. Abdominal computed tomography (CT) revealed a bulky tumor of the gallbladder with liver invasion, metastases to para-aortic lymph nodes, and extensive infiltration to Glisson's sheath. The tumor was initially considered to be unresectable locally advanced gallbladder carcinoma with inflammation, and she received 6 courses of chemotherapy with gemcitabine plus cisplatin. Subsequently, the inflammation was extinguished, and CT showed the main tumor shrunk and the Glisson's sheath infiltration disappeared; however, a liver metastasis existed in segment 5. Thus, S4a plus S5 hepatic segmentectomy with extrahepatic bile duct resection and regional and para-aortic lymphadenectomy was performed. The pathological diagnosis was pT3a, pN1, pM1 (Hep, LYM), fStage ⅣB. Curative resection was then performed. If selected according to their response to downsizing chemotherapy, conversion therapy might therefore be an effective multidisciplinary treatment for patients with initially unresectable locally advanced gallbladder carcinoma.

Distal anterior choroidal artery aneurysms are quite rare, and appropriate treatment timing and methods remain unclear. Direct surgery of these aneurysms is difficult due to their deep location, small size, and angioarchitecture;however, pseudoaneurysms might disappear spontaneously with conservative treatment. A 65-year-old man with a history of hypertension was admitted to our hospital with a 5-day history of sudden headache and nausea. Computed tomography revealed an intraventricular hematoma located mainly in the right lateral ventricle. Cerebral angiography 7 days after onset revealed a right distal anterior choroidal artery aneurysm and proximal right middle cerebral artery occlusion caused by atherosclerotic changes. Endovascular coil embolization was performed under general anesthesia 14 days after onset. Preoperative angiography demonstrated definite enlargement of the aneurysm and stasis of the contrast agent in the aneurysm in the venous phase. Detachable platinum coils were delivered into the aneurysm and parent artery. The patient was discharged neurologically intact after the procedure. Follow-up angiography 3 months after coil embolization showed complete occlusion of the aneurysm. In recent years, endovascular surgery has emerged as a less invasive treatment option. Early treatment should be considered for patients with ruptured distal anterior choroidal artery aneurysm because these aneurysms might grow and re-rupture in the short term.

A 67-year-old woman was referred to our hospital because of a gallbladder mass. Abdominal computed tomography revealed a protruding mass 34 mm in diameter in the body of the gallbladder with wall thickening and enhancement. Advanced gallbladder carcinoma was diagnosed by image analysis, with liver metastasis in segment 5 and lymph node metastasis in the hepatoduodenal ligament. Subsequently, S4a+S5 hepatic segmentectomy was performed with extrahepatic bile duct resection and regional lymphadenectomy. The final pathological diagnosis was pT2 pN1 pM1, Stage IV,according to the International Union against Cancer classification system. Curative resection was then performed. In addition, we performed adjuvant chemotherapy with 15 courses of 1,000 mg/m2 gemcitabine on days 1, 8, and 15 at every 28 days. At 5 years after the operation, the patient was alive and free of disease. Therefore, in cases of limited liver metastasis (within segments 4a and 5), aggressive surgery should be considered even for Stage IV gallbladder carcinoma. In such cases, long-term patient survival may be expected only when curative resection is achieved.

A 59-year-old woman with upper abdominal pain was diagnosed as having an advanced-stage gallbladder carcinoma with significant metastases in the para-aortic lymph nodes to the more distant right external iliac nodes by imaging studies. These findings suggested that the tumor was unresectable, and therefore, palliative cholecystectomy with lymph node biopsy was performed. Furthermore, we initiated chemoradiotherapy with linac radiotherapy( 50 Gy) and weekly gemcitabine (GEM 300 mg/body) for 6 weeks. Partial response (PR) was achieved after chemoradiotherapy. Subsequently, we initiated chemotherapy with GEM alone (1,000 mg/m2) on days 1, 8, and 15, every 28 days for 15 courses. Following disease progression, we initiated chemotherapy with S-1 alone( 80 mg/m2/day) on days 1-14, every 21 days for 9 courses, as second-line treatment. Two years later, following re-progression of the disease, we performed best supportive care with retrograde ureteral stenting for hydronephrosis and retrograde biliary stenting for obstructive jaundice. The patient survived for 35 months after palliative surgery. Moreover, she remained well and performed normal activities for 34 months. This experience indicates that, in patients with unresectable gallbladder carcinoma, multidisciplinary treatment could extend survival and improve the quality of life.

A 72-year-old man presented with grade III dyspnea according to the Hugh-Jones scale in February, 2007, and he was referred to our department. Massive fibrosis of upper lung field dominance and bilateral pleural effusion were observed on chest X-ray films and CT. A respiratory function test revealed mixed ventilatory disturbance. Thereafter, left-sided pneumothorax developed in February 2008, followed by right-sided pneumothorax. He recovered once; however, respiratory failure progressed. He was re-hospitalized due to pneumonia and CO2 narcosis. Respiratory failure could not be prevented, and he died in September 2008. Macroscopic autopsy findings included fibrous adhesion of the pleura and fibrous consolidation of lung parenchyma which was most dominant in the bilateral apices. These were accompanied by bronchiectasis and brochiolectasis. Microscopically, the core pathology was organizing bronchiolitis and organizing pneumonia. Reported cases of diffuse lung lesions complicated with von Recklinghausen disease mostly comprise fibrosis and emphysematous changes. The unique pathological findings in this case seemed unrelated to any known disease entity.

The patient was a 68-year-old man with melena. Endoscopic examination revealed a type 2 advanced tumor in the mid body and an elevated lesion in the upper body of the stomach. Biopsy specimens from both lesions were diagnosed histologically as squamous cell carcinoma. Abdominal CT showed thickening of the midbody in the greater curvature and bulky lymph nodes along the lesser curvature (No. 3), and the greater curvature(No. 4d). We diagnosed Stage IIIB (cP0, cH0, cT4, cN1, cM0) cancer, but we concluded radical resection would be difficult due to lymph node invasion to the diaphragm and mesocolon. DCF combination therapy (docetaxel 75 mg/m2 day 1, CDDP 75 mg/m2 day 1, 5-FU 750 mg/m2 day 1-5) was administered. After 3 courses of chemotherapy, endoscopic examination and abdominal CT findings showed remarkable reduction of the primary tumor and the lymph node metastasis, indicating a partial response (PR) to the chemotherapy. After consultation with the patient, total gastrectomy with lymph node dissection (D2) was performed. The pathological specimens showed no cancer cells in the gastric wall and lymph nodes, so the histological effect was judged as Grade 3. This case suggested that DCF combination chemotherapy may prove useful to treat patients with advanced squamous cell carcinoma of the stomach.

A 59-year-old man was diagnosed as having a pancreatic carcinoma with synchronous liver metastasis at initial surgery. After wedge resection of liver tumor for histopathological analysis and gastro-jejunostomy, he was treated with 3 cycles of combined systematic chemotherapy consisting of CDDP and CPT-11, because of histopathological diagnosis confirming a neuroendocrine carcinoma of the pancreas. After chemotherapy, there was no recurrence and the primary tumor was reduced in size. Therefore, pancreatico-duodenectomy was performed as a curative treatment in two stages. During the follow-up, the patient has been alive without any signs of recurrence for 20 months since the diagnosis. Recently, several consecutive chemotherapies have been an effective modality to improve a poor prognosis for unresectable neuroendocrine carcinoma.