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Background When monitoring patients with an intraductal papillary mucinous neoplasm (IPMN), it is important to consider both IPMN-derived carcinoma and concomitant ductal adenocarcinoma (PDAC). The latter is thought to have a poorer prognosis. We retrospectively analyzed the risk factors for concomitant PDAC in IPMN. Methods In total, 547 patients with pancreatic cysts, including IPMNs inappropriate for surgery on initial diagnosis, encountered from April 2005 to June 2019, were reviewed. We performed surveillance by imaging examination once or twice a year. Results Five IPMNs with high-grade dysplasia and one IPMN associated with invasive carcinoma were encountered. In comparison, 14 concomitant PDACs were encountered. The prognosis was very poor for concomitant PDACs. All 14 PDAC patients had IPMNs. In patients with IPMNs, long-standing diabetes mellitus was the only significant risk factor for concomitant PDAC in both univariate and multivariate analyses (P < 0.001 and P < 0.01, respectively). Furthermore, patients with IPMNs and diabetes mellitus had a high frequency of concomitant PDACs (9.5%, 9/95) in a median 48-month surveillance period. Conclusions When monitoring IPMNs, the development of not only IPMN-derived carcinomas but also concomitant PDACs should be considered. During this period, it may be prudent to concentrate on patients with other risk factors for PDAC, such as long-standing diabetes mellitus.

To clarify the usefulness of Onodera's prognostic nutritional index(OPNI)in adjuvant chemotherapy(AC)for older patients with colorectal cancer.This study included 39 patients aged over 70 years who underwent AC for colorectal cancer from August 2009 to February 2018. We evaluated the association of OPNI with AC toxicities and prognosis.OPNI was an independent predictor of toxicities of Grade 3 or higher(OR: 0.18, 95%CI: 0.043-0.75, p=0.019). The 3-year recurrence-free survival rate was significantly better in the higher OPNI group than in the lower OPNI group(89.9% and 66.7%, respectively; HR: 0.19, 95%CI: 0.04-0.92, p=0.038). There was a positive correlation with Spearman's rank correlation coefficient of 0.66 in OPNI before and after AC(p0.001).OPNI could be one of the valuable predictors of AC toxicities and the prognosis. There was a high correlation between OPNI before and after AC. These findings suggest the importance of early nutritional support for patients with lower OPNI.

BACKGROUND Situs inversus totalis (SIT) is a rare congenital anomaly in which the patient's internal organs are positioned in a mirror image of their normal locations. Laparoscopic surgery for a patient with SIT requires modification of the standard procedure. Several studies have recently reported surgical techniques for laparoscopic colectomy in patients with SIT. Herein, we present the case of a patient with congenital SIT who underwent laparoscopic colectomy for transverse colon cancer with intracorporeal anastomosis and discuss the usefulness of preoperative assessment. CASE REPORT A 63-year-old woman with SIT was referred to our department for surgical intervention following endoscopic submucosal dissection of transverse colon cancer. We performed a successful laparoscopic colectomy with intracorporeal anastomosis. Our team had no prior experience performing laparoscopic surgery on a patient with SIT; however, preoperative image training using a horizontally flipped video of a normal laparoscopic colectomy enabled the operation to be performed safely. Preoperative image training is very useful for gaining an understanding of images similar to the actual field of view before surgery. The patient was discharged without complications on the eighth postoperative day. CONCLUSIONS Careful preoperative assessment that takes into consideration the mirror-image anatomy and the contemplated laparoscopic procedure should allow patients with SIT to fully benefit from minimally invasive surgery.

Background: When monitoring patients with an intraductal mucinous neoplasm (IPMN), it is important to consider both IPMN-derived carcinoma and concomitant ductal adenocarcinoma (PDAC). The latter is thought to have a poorer prognosis. We retrospectively analyzed risk factors for concomitant PDAC in IPMN.Methods: In total, 547 patients with pancreatic cysts, including IPMN inappropriate for surgery on initial diagnosis, encountered from April 2005 to June 2019, were reviewed. We performed surveillance via imaging examination once or twice a year. Results: There were five intraductal papillary mucinous adenocarcinoma encountered. In comparison, there were 14 concomitant PDAC encountered. The prognosis was very poor in concomitant PDAC. All 14 PDAC patients had IPMN. In patients with IPMN, long-standing diabetes mellitus was the only significant risk factor for concomitant PDAC in both univariate and multivariate analysis ( P < 0.001 and P < 0.01, respectively). Further, patients with IPMN and diabetes mellitus had high frequency of concomitant PDAC (9.5%, 9/95) in a median 48-month surveillance period.Conclusions: When monitoring IPMN, concomitant PDAC should be considered, rather than IPMN-derived carcinoma. During this period, it may be prudent to concentrate on patients with other risk factors for PDAC, such as long-standing diabetes mellitus.

To investigate the efficacy and toxicity of adjuvant chemotherapy(AC)in elderly patients with Stage Ⅲ colorectal cancer(CRC).We performed a single-institutional retrospective analysis of 84 patients aged≥75 years with Stage Ⅲ CRC who underwent curative resection from August 2009 to February 2018.Thirty-seven(44.0%) patients received AC. Eleven(29.7%)patients required dose reduction at the start of AC. Twenty-three(62.2%)patients accomplished AC, and 13(35.1%)needed dose reduction during AC. Although toxicities of Grade 3 or higher occurred in 56.8% of patients, they were controllable. The 3-year recurrence-free survival rate was significantly better in the AC group than in the non-AC group(70.3% versus 50.5%, respectively; p=0.011). The prognosis tended to be worse in the group that started AC with dose reduction than in the group with the normal dose.AC is effective and well tolerated in elderly patients with Stage Ⅲ CRC. When reducing the initial dose, the need for dose reduction should be carefully considered.

BACKGROUND Socratic method, which is an educational method to promote critical thinking through a dialogue, has never been practiced in a large number of people at the academic societies. METHODS Modified Socratic method was performed for the first time as an educational seminar using an example case of moderate acute cholecystitis based on the evidence described in Tokyo Guidelines 2018. We adopted a method that Takada had been modifying for many years: the instructor first knows the degree of recognition of the audience, then the instructor gives a lecture in an easy-to-understand manner and receives questions from the audience, followed by repeated questions and answers toward a common recognition. RESULTS Using slides, video, and an answer pad, 281 participants including the audience, instructors and moderators came together to repeatedly ask and answer questions in the five sessions related to the case scenario. The recognition rate of the topic of Critical View of Safety increased significantly before vs after this method (53.0% vs 90.3%). The seminar had been successfully performed by receiving a lot of praise from the participants. CONCLUSION This educational method is considered to be adopted by many academic societies in the future as an effective educational method.

BACKGROUND Prevention of bile duct injury and vasculo-biliary injury while performing laparoscopic cholecystectomy (LC) is an unsolved problem. Clarifying the surgical difficulty using intraoperative findings can greatly contribute to the pursuit of best practices for acute cholecystitis. In this study, multiple evaluators assessed surgical difficulty items in unedited videos and then constructed a proposed surgical difficulty grading. METHODS We previously assembled a library of typical video clips of the intraoperative findings for all LC surgical difficulty items in acute cholecystitis. Fifty-one experts on LC assessed unedited surgical videos. Inter-rater agreement was assessed by Fleiss's κ and Gwet's agreement coefficient (AC). RESULTS Except for one item ("edematous change"), κ or AC exceeded 0.5, so the typical videos were judged to be applicable. The conceivable surgical difficulty gradings were analyzed. According to the assessment of difficulty factors, we created a surgical difficulty grading system (agreement probability = 0.923, κ = 0.712, 90% CI: 0.587-0.837; AC2 = 0.870, 90% CI: 0.768-0.972). CONCLUSION The previously published video clip library and our novel surgical difficulty grading system should serve as a universal objective tool to assess surgical difficulty in LC.

Recent advancements in surgical and anti-cancer therapies have provided significant hope of long survival in patients with pancreatic cancer (PC). To realize this hope, routine medical checkups of asymptomatic people should be performed to identify operable PCs. In this study, we evaluated the efficacy of medical checkups using abdominal ultrasonography (US). We retrospectively analyzed 374 patients with PC at our institute between 2010 and 2021. We divided these patients into several groups according to the diagnostic approach and compared their background and prognosis. These groups comprised PCs diagnosed through (a) symptoms, 242 cases; (b) US during medical checkup for asymptomatic individuals, 17; and other means. Of the 374 patients, 192 were men (51.3%), and the median age was 74 years (34–105). Tumors were located in the pancreatic tail in 67 patients (17.9%). Excision ratio and 5-year survival rate were significantly better in group (b) than in (a) (58.8% vs. 23.1%, p < 0.01 and 42.2% vs. 9.4%, p < 0.001, respectively). The prognosis of patients diagnosed using US during medical checkup was better than that of patients identified through symptomatic presentation of PC. US for asymptomatic individuals with PC might be one of the useful modalities for promoting better prognosis of PCs.

Primary mediastinal leiomyosarcoma is extremely rare, and few reports in the literature have described the clinical features of this malignancy. We report a case of a small anterior mediastinal leiomyosarcoma that showed rapid growth within a short period. An 85-year-old woman showed a small anterior mediastinal tumor on chest computed tomography (CT), three months prior to presentation. Contrast-enhanced chest CT revealed rapid tumor growth, and positron emission tomography/CT revealed significant 18-fluorodeoxyglucose uptake, suggestive of malignancy. Thoracoscopic tumor resection was performed via the left thoracic approach. In addition to the tumor and surrounding anterior mediastinal tissue, we resected an area of pericardial infiltration. The tumor was diagnosed as a primary mediastinal leiomyosarcoma based on histopathological and immunohistochemical findings.

PURPOSE To explore optimal diagnostic criteria for localizing insulinomas with the selective arterial calcium injection (SACI) test using decision tree analysis. MATERIALS AND METHODS A retrospective study included 86 vessels of 18 patients (5 men, 13 women; mean age 67 y; range, 49-73 y) with insulinomas who underwent SACI test between June 2007 and May 2016. Of 27 insulinomas, 7 were found in the head, 13 in the body, and 7 in the tail of the pancreas. Two patients had multiple tumors. To identify optimal diagnostic criteria, decision tree analysis was performed, and sensitivity, specificity, and accuracy of the conventional and the proposed new diagnostic criteria (plasma insulin concentration after calcium injection [ICpost] > 2.0 × plasma insulin concentration before calcium injection [ICpre]) were compared. RESULTS The proposed new diagnostic criteria for insulinoma obtained by decision tree analysis were (i) ICpost > 2.7 × ICpre and maximum insulin concentration > 60.3 μIU/mL or (ii) ICpost > 2.7 × ICpre and maximum insulin concentration < 60.3 μIU/mL with ICpre being ≥ 7.5 μIU/mL. Sensitivity, specificity, and accuracy of the new criteria for the SACI test were 100%, 91.4%, and 94.2; sensitivity, specificity, and accuracy of conventional criteria were 100%, 69.0%, and 79.1%. CONCLUSIONS New diagnostic criteria for localization of insulinomas with the SACI test yielded higher diagnostic performance than conventional criteria.

Rationale: Pancreatic cancer (PC) has the worst prognosis among all carcinomas. However, patients with carcinoma in situ (CIS) of the pancreas, usually, have a good prognosis. Many previous reports have mentioned the high frequency of fibrosis around CIS. In some cases, the fibrosis is detected on endoscopic ultrasonography (EUS), but there are few past reports of fibrosis detected on computed tomography (CT). Patient concerns: We encountered a case of fibrosis around CIS detected by CT. A 74-year-old man was being followed for chronic hepatitis C. On a contrast-enhanced CT (CE-CT), a space-occupied lesion (7 mm in size) in the pancreatic head was identified in the delayed phase. Diagnosis: It was shown to be a hypo echoic lesion in EUS, and EUS-fine-needle aspiration was performed. Cytological examination revealed abnormal cells suspicious for a neuroendocrine tumor. Interventions: Consequently, a pancreaticoduodenectomy was performed. Histopathological examination showed CIS in the branch duct with 10 mm of fibrosis around CIS. The fibrotic area corresponded to the mass detected by preoperative CE-CT. Outcomes: He had no relapse of PC but died 2 years later from another cause. Lessons: This case highlights the importance of identifying the enhanced area in the delayed phase on CE-CT, as this can be fibrosis around CIS.

Patient: Female, 74-year-old Final Diagnosis: Biloma Symptoms: Epigastralgia • fever • nausea Medication: — Clinical Procedure: — Specialty: Surgery Objective: Rare co-existance of disease or pathology Background: Spontaneous biloma is a rare non-traumatic disease in which an extrahepatic or intrahepatic bile duct perforates spontaneously with no discernable cause. We present the details of a patient with spontaneous biloma resulting from intrahepatic bile duct perforation with concurrent intrahepatic cholelithiasis and cholangiocarcinoma. Case Report: A 74-year-old woman was admitted to our hospital with symptoms of abrupt epigastralgia, nausea, and fever. Physical examination revealed epigastric tenderness, guarding, and rebound tenderness. Laboratory test results were normal, except for elevated leukocytes, and C-reactive protein, total bilirubin, and blood urea nitrogen concentrations. Carcinoembryonic antigen and carbohydrate antigen 19-9 concentrations were also elevated. Abdominal computed tomography revealed perihepatic fluid and ascites, with common bile duct dilatation and localized cholangiectasia of B2 with areas of slight high density, which indicated an intraabdominal abscess and intrahepatic cholelithiasis. Spontaneous intrahepatic bile duct perforation was subsequently diagnosed by cholangiography via endoscopic nasobiliary drainage. Left hepatic lobectomy was performed to treat the intrahepatic cholelithiasis and spontaneous biloma. Intraoperatively, a perforation was identified at the edge of the lateral segment of the left triangular ligament, through which bile had been leaking. Histopathology revealed intraductal cholangiocellular carcinoma with intrahepatic cholangiolithiasis. The patient’s postoperative course was excellent, and she was discharged on postoperative day 16. However, cancer dissemination to the peritoneum was identified 8 months after surgery. Conclusions: Treatment for patients with intrahepatic cholelithiasis should involve aggressive surgery because of the associated carcinogenicity. This approach reduces the risk of dissemination secondary to intrahepatic bile duct perforation.

Background Cone-beam computed tomography (CBCT) has been widely used during transcatheter arterial chemoembolization for hepatocellular carcinoma. Purpose To evaluate the sensitivity of CBCT for the detection of hepatocellular carcinomas and the tumor feeders by comparing celiac artery (CA) and common hepatic artery (CHA) injection. Material and methods We retrospectively enrolled 30 patients (52 hepatocellular carcinoma lesions) who had undergone CBCT-assisted transcatheter arterial chemoembolization. In 17 procedures (28 hepatocellular carcinomas) we acquired CBCT scans using CA injections (CBCT-CA) and in 18 (24 hepatocellular carcinomas) we used CHA injections (CBCT-CHA). Of the 30 patients, 5 underwent CBCT-CA and CBCT-CHA at different transcatheter arterial chemoembolization procedures. We performed inter-group comparisons of the detectability of hepatocellular carcinoma, the feeding artery, the intrahepatic artery branch order, and the tumor-to-liver contrast. Results CBCT-CA detected all 28 hepatocellular carcinomas and 27 of their feeders (96.4%); CBCT-CHA identified 22 of 24 hepatocellular carcinomas (91.7%) and 21 of their feeders (95.5%). There was no significant inter-group difference in the detectability of hepatocellular carcinoma lesions (p = 0.21) or feeding arteries (p = 0.69). CBCT-CHA was superior for the assessment of the tumor-to-liver contrast and the intrahepatic artery branch order (both: p Conclusion CBCT-CA and CBCT-CHA were equally useful for the detection of hepatocellular carcinoma and of the feeding artery, although CBCT-CHA yields better visualization of hepatocellular carcinoma and the hepatic artery. Thus CA injection seems sufficient for lesion and vessel detection when the insertion of an angiographic catheter into the CHA is difficult.

Background To explore best practices for acute cholecystitis, it is necessary to construct a system to assess the difficulty of laparoscopic cholecystectomy (LC) based on intraoperative findings. In this study, multiple evaluators assessed videos of LC to assemble a library of typical video clips for 25 intraoperative findings. Methods We have previously identified 25 items that contribute to surgical difficulty in LC. For each item, roughly 30-second video clips were submitted from videos of LC performed at member institutions. We then selected one typical video from the collected clips based on simple tabulation of the instances of agreement. Inter-rater agreement was assessed with Fleiss's κ and Gwet's agreement coefficient (AC). Results Except in the case of two assessment items ("edematous change" and "easy bleeding"), κ or AC significantly exceeded 0.5 and the typical videos were judged to be applicable. For the two remaining items, the evaluation was repeated after clarifying the definitions of positive and negative findings. Eventually, they were recognized as typical. The completed video clip library contains 31 clips and is divided into five categories (http://www.jshbps.jp/modules/project/index.php?content_id=13). Conclusions This clip library may be highly useful in clinical settings as a more objective standard for assessing surgical difficulty in LC.

Background Generally, surgeons’ perceptions of surgical safety are based on experience and institutional policy. Our recent pilot survey demonstrated that the acceptable duration of surgery and criteria for open conversion during laparoscopic cholecystectomy (LC) vary among workplaces. Methods A web-based survey was distributed to 554 expert LC surgeons in Japan, Korea, and Taiwan. The questionnaire covered LC experience, safety measures and recognition of landmarks, decision-making regarding conversion to open/partial cholecystectomy and the implications of this decision. Overall responses were compared among nations, and then stratified by LC experience level (lifetime cases 200–499, 500–999, and ≥1000). Results The response rate was 92.6% (513/554); 67 surgeons with ≤199 LCs were excluded, and responses from 446 surgeons were analyzed. We observed significant differences among nations on almost all questions. Differences that remained after stratification by LC experience were on questions related to acceptable duration of surgery, adoption rates of intraoperative cholangiography, the “critical view of safety” technique, identification of Rouviere's sulcus, recognition of the SS-Inner layer theory, and intraoperative judgment to abandon conventional LC. Conclusions Even among experts, surgeons’ perceptions during LC are workplace-dependent. A novel grading system of surgical difficulty and standardized LC procedures are paramount to generate high-level evidence. This article is protected by copyright. All rights reserved.

Background/Purpose Serious complications continue to occur in laparoscopic cholecystectomy (LC). The commonly used indicators of surgical difficulty such as the duration of surgery are insufficient because they are surgeon and institution dependent. We aimed to identify appropriate indicators of surgical difficulty during LC. Methods A total of 26 Japanese expert LC surgeons discussed using the nominal group technique (NGT) to generate a list of intraoperative findings that contribute to surgical difficulty. Thereafter, a survey was circulated to 61 experts in Japan, Korea, and Taiwan. The questionnaire addressed LC experience, surgical strategy, and perceptions of 30 intraoperative findings listed by the NGT. Results The response rate of the survey was 100%. There was a statistically significant difference among nations regarding the duration of surgery and adoption rate of safety measures and recognition of landmarks. The criteria for conversion to an open or subtotal cholecystectomy were at the discretion of each surgeon. In contrast, perceptions of the impact of 30 intraoperative findings on surgical difficulty (categorized by factors related to inflammation and additional findings of the gallbladder and other intra-abdominal factors) were consistent among surgeons. Conclusions Intraoperative findings are objective and considered to be appropriate indicators of surgical difficulty during LC.

Tubulocystic carcinoma of the kidney is rare and typically indolent. Our case involved an aggressive tubulocystic carcinoma as well as the radiological confirmation of its relation to papillary renal cell carcinoma. A 46-year-old male presented with renal multiloculated cysts with a solid part. On computed tomography and magnetic resonance imaging, the solid part showed the characteristics of papillary renal cell carcinoma. Contrast enhancement of the solid part was fluffy and sparse because of the coexistence of cysts. Perirenal fat invasion resulted in exophytic cysts, and renal-hilar cystic lymph node metastasis existed. The histopathological diagnosis was tubulocystic carcinoma associated with areas of papillary renal cell carcinoma and poorly differentiated carcinoma with metastasis. Our case suggests that the solid part enhancement of tubulocystic carcinoma tends to be fluffy and sparse, and exophytic cysts and cystic lymph nodes may show radiologically aggressive findings.

Background Pancreatic cancer often accompanies chronic obstructive pancreatitis (COP) due to obstruction of the main pancreatic duct, and the inflammatory environment may enhance cancer progression. The purpose of this study is to evaluate COP using the apparent diffusion coefficient (ADC) value measured by diffusion-weighted MR imaging (DWI), and to assess its prognostic significance in pancreatic cancer. Methods Twenty-eight patients (16 men, 12 women; mean age 67.1 years) with pancreatic cancers who underwent DWI followed by curative surgery were evaluated. The ADC value of pancreatic parenchyma upstream to the tumor (upstream pancreas) was measured and compared with the upstream pancreatic duct dilatation to assess whether DWI could reflect COP. The ADC values of tumor and upstream portion were compared with overall survival (OS) using Cox regression and Kaplan–Meier analysis. Results The ADC value of upstream pancreas was significantly lower in patients with greater dilated pancreatic duct than those with less (P = 0.03). In univariate Cox regression analysis, the ADC value of upstream pancreas showed a significant association with OS (P = 0.01), but that of tumor did not (P = 0.06). In Kaplan–Meier analysis, patients with lower ADC value of upstream pancreas ( −3 mm 2 /s) were significantly associated with poor OS (P = 0.0006). In multivariate analysis, the ADC value of upstream pancreas was identified as an independent prognostic factor (P = 0.01; hazards ratio, 0.05; 95% CI, 0.004–0.59). Conclusions The ADC value of upstream pancreas was an independent prognostic factor for OS in pancreatic cancer patients. Inflammatory environment may play an important role in pancreatic cancer progression.

OBJECTIVE The aim of this study was to evaluate the prevention of liver ischemic injury by preoperative coil embolization in patients with a replaced hepatic artery scheduled for pancreatectomy with splanchnic artery resection. METHODS Between July 2009 and May 2012, 4 patients with replaced hepatic artery underwent pancreatectomy plus splanchnic artery resection. The replaced right hepatic artery was preoperatively embolized in 2 patients. In the other 2 patients, the common hepatic artery was embolized preoperatively. We evaluated the complications encountered in the perioperative period. RESULTS There were no embolization-related complications. Although 2 patients presented with small liver infarcts, the aspartate aminotransferase and alanine aminotransferase levels did not exceed 1000 IU/L in any of the patients, and none experienced severe liver injury. CONCLUSIONS Coil embolization before pancreatectomy with splanchnic artery resection in patients with a replaced hepatic artery may help to prevent severe ischemic liver injury in the perioperative period.

Anatomical resections have been reported to achieve better long-term outcomes compared with partial resections for the treatment of hepatocellular carcinoma (HCC). Despite this, laparoscopic anatomical resections are very challenging operations, especially when approaching the posterosuperior segments of the liver (IVa, VII, and VIII). We report a full laparoscopic anatomical segment 8 resection focusing on the technical aspects of the Glissonian approach. A routine follow-up CT scan of an 80-year-old women affected by hepatitis C-related liver cirrhosis showed a 3-cm HCC in segment 8. Three-dimensional reconstruction was performed to evaluate the liver anatomy, the relationship of the lesion with major vessels, and the borders of segment 8. A true anatomical segmentectomy was performed by using selective occlusion of segment’s 8 Glissonian pedicle, which was identified from the liver hilum. Indocyanine green (ICG) dye demarcation was used as a guidance during parenchymal transection.1–4 Operative time was 420 min, and blood loss was 261 mL. The patient had an uneventful postoperative course and was discharged home after 8 days. Full laparoscopic anatomical segment 8 resection is a technically challenging operation. The use of the Glissonian approach and the aid of ICG dye could be of help, but advanced laparoscopic skills are necessary to complete such a difficult procedure safely.5–13

Background We previously identified 25 intraoperative findings during laparoscopic cholecystectomy (LC) as potential indicators of surgical difficulty per nominal group technique. This study aimed to build a consensus among expert LC surgeons on the impact of each item on surgical difficulty. Methods Surgeons from Japan, Korea, and Taiwan (n = 554) participated in a Delphi process and graded the 25 items on a seven-stage scale (range, 0–6). Consensus was defined as (1) the interquartile range (IQR) of overall responses ≤2 and (2) ≥66% of the responses concentrated within a median ± 1 after stratification by workplace and LC experience level. Results Response rates for the first and the second-round Delphi were 92.6% and 90.3%, respectively. Final consensus was reached for all the 25 items. ‘Diffuse scarring in the Calot's triangle area’ in the ‘Factors related to inflammation of the gallbladder’ category had the strongest impact on surgical difficulty (median, 5; IQR, 1). Surgeons agreed that the surgical difficulty increases as more fibrotic change and scarring develop. The median point for each item was set as the difficulty score. Conclusions A Delphi consensus was reached among expert LC surgeons on the impact of intraoperative findings on surgical difficulty.

Transcatheter arterial chemoembolization (TACE) is the interventional technique and mainstay of treatment for unresectable hepatocellular carcinoma (HCC). TACE is indicated mainly for unresectable HCC, cholangiocarcinoma, and hepatic metastases. In this method if used worldwide; however, many regimens, embolic materials, and techniques exist. The clinical results are also controversial. We present the history and the status of TACE for HCC.

To assess the adoptability of a new measuring method when true values are unknown, it is necessary to compare the proposed with the conventional method. Although Bland-Altman correlation analysis is widely accepted, it is occasionally misused or applied where it is inappropriate. We provide an overview of Bland-Altman analysis and teach its application and the interpretation of its results. We also comment briefly on regression analysis, another comparison method.

To investigate the diagnostic capability of multidetector computed tomography for detecting non-occlusive mesenteric ischemia (NOMI). We studied 11 NOMI patients and 44 controls. Radiologists evaluated the CT images for the presence of bowel ischemia and measured the diameters of the superior mesenteric artery and the superior mesenteric vein (D SMA and D SMV). We also performed linear discriminant analysis (LDA) using D SMA and D SMV. All NOMI patients presented with more than 2 CT findings of bowel ischemia. D SMA and D SMV were significantly smaller in NOMI patients than in the controls (p

We experienced a case of a subtype of spontaneous hemopneumothorax caused by external forces associated with a seat-belt injury. A female aged 39 years sustained a minor collision with an oncoming car while she was driving. Although pneumothorax was not detected, hemothorax and bleeding from the area surrounding the subclavian artery were observed on contrast-enhanced chest computed tomography (CT). After confirming continuous bleeding into the thoracic cavity after superselective arterial embolization, we performed emergency open surgery. We found a bulla in the apex of the lung, and the thoracic stump of the bulla was considered the source of bleeding. In this case, the direct cause of hemothorax was considered to be the external force associated with the seat-belt injury. When a bulla in the apex of the lung and continuous bleeding are both observed on CT, spontaneous hemopneumothorax should be suspected, necessitating open chest surgery in cases where pneumothorax is not observed.

A 40-year-old woman was noted to have clubbing of the nails during an outpatient service for smoking cessation. Chest computed tomography showed an aneurysm of an aberrant artery running from the descending aorta to the left lower lobe. Hence, we diagnosed anomalous systemic arterialization of the lung. The proximal part of the aberrant artery measured 13 mm in diameter;moreover, it had developed an aneurysm(17 mm in diameter) in the lung parenchyma. The aberrant artery was ligated with a covering material (absorbable felt) and cut via a small access thoracotomy by a cardiovascular surgeon;subsequently, left lower lobectomy was performed. Pathological examination revealed significant atherosclerosis in the aberrant artery, demonstrating its severe fragility. To apply appropriate safety procedures and approaches are recommended when treating an aberrant artery to the lung, especially in the presence of an aneurysm.

Serious complications continue to occur in laparoscopic cholecystectomy (LC). The commonly used indicators of surgical difficulty such as the duration of surgery are insufficient because they are surgeon and institution dependent. We aimed to identify appropriate indicators of surgical difficulty during LC.A total of 26 Japanese expert LC surgeons discussed using the nominal group technique (NGT) to generate a list of intraoperative findings that contribute to surgical difficulty. Thereafter, a survey was circulated to 61 experts in Japan, Korea, and Taiwan. The questionnaire addressed LC experience, surgical strategy, and perceptions of 30 intraoperative findings listed by the NGT.The response rate of the survey was 100%. There was a statistically significant difference among nations regarding the duration of surgery and adoption rate of safety measures and recognition of landmarks. The criteria for conversion to an open or subtotal cholecystectomy were at the discretion of each surgeon. In contrast, perceptions of the impact of 30 intraoperative findings on surgical difficulty (categorized by factors related to inflammation and additional findings of the gallbladder and other intra-abdominal factors) were consistent among surgeons.Intraoperative findings are objective and considered to be appropriate indicators of surgical difficulty during LC.

It is generally thought that an internal short stent placed across the pancreaticojejunostomy (PJ) following pancreatoduodenectomy (PD) usually passes spontaneously through the rectum thereafter; however, we experienced some patients who presented with pancreatitis and cholangitis owing to delayed defecation of the stent. The purpose of this study was to clarify when the stent eventually became detached from the PJ and how it passed through the body until it was finally defecated. In addition, we also investigated the factors that may prevent such detachment and defecation. This study retrospectively analyzed 57 patients who had had internal short stents placed across the PJ following PD. Defecation from the body, detachment from the PJ, and distal migration of the stent was confirmed by X-ray or computed tomography (CT) during the postoperative course. The cumulative rates of defecation and detachment of the stents, complications in relation to delayed defecation of the stents, and factors predictive of the delayed defecation, delayed detachment, and distal migration of the stents were analyzed. Defecation of the stent was confirmed in 35 patients. The median time to defecation after PD and the cumulative defecation rate at 1 year were 454 days and 41 %, respectively. Acute pancreatitis occurred in 2 patients with the stent remaining in the pancreatic duct. One patient experienced acute cholangitis owing to migration of the stent to the bile duct. Multivariate analysis showed that ≥5 stitches in the duct-to-mucosa anastomosis, stent size of ≥5 Fr, and pancreatic fistula classified as either Grade B or C were independent predictive factors for delayed defecation of the stent. Five or more stitches in the duct-to-mucosa anastomosis was an independent predictive factor for delayed detachment of the stent. A stent size of ≥5 Fr was a risk factor for distal migration of the stent. In more than half of the study patients, internal short stents were not defecated within 1 year. Retrieval of the stent should be considered following the migration of an internal short stent. A stent size of ≥5 Fr was an independent predictive factor for delayed defecation and distal migration of a stent. Five or more stitches in the duct-to-mucosa anastomosis was an independent predictive factor for delayed defecation and detachment of a stent.

Objectives To investigate the clinical significance of the "transitional phase" at gadoxetate disodium (Gd-EOB)-enhanced magnetic resonance imaging for diagnosing hepatocellular carcinoma (HCC). Methods We studied 54 patients with 70 histologically diagnosed HCC. Transitional- and hepatobiliary-phase (TP, HBP) images were acquired 3 and 20 minutes after Gd-EOB injection, respectively. Radiologists measured the size of the hepatic tumors on images and surgical specimens and qualitatively evaluated the signal intensity of the hepatic tumors during TP and HBP independently. Results In 4 patients with portal tumor embolism who had undergone percutaneous transhepatic portal embolization and who manifested arterioportal (AP) shunts, the low-intensity area was larger during HBP than TP. Of the 70 HCCs, 4 were of high signal intensity during HBP and 2 were of slightly low intensity during TP. Conclusion Tumor extension seen during TP rather than HBP more accurately reflected histological findings in patients with HCC with portal tumor thrombi, percutaneous transhepatic portal embolization, or AP shunt.

Postoperative hepatic infarction is rare; therefore, clinical characteristics and outcomes of postoperative hepatic infarction after pancreatobiliary surgery have not been obvious.Eleven patients encountered hepatic infarction after pancreato-biliary surgery. Management, clinical course, and outcome of these 11 patients were retrospectively analyzed.Possible causes of the hepatic infarction were inadvertent injury of the hepatic artery during lymph node dissection in five patients, right hepatic artery ligation in two patients, long-term clamp of the hepatic artery during hepatic arterial reconstruction in two patients, suturing for bleeding from the right hepatic artery in one patient, and celiac axis compression syndrome in one patient. Five of the 17 infarcts extended for one whole section of the liver, and distribution of the other 12 was less than one section. Ten patients discharged from hospital; however, one patient died of sepsis of unknown origin.Attention should be paid to inadvertent injury of hepatic artery to prevent hepatic infarction. Hepatic infarctions after pancreato-biliary surgery seldom extend to the entire liver and most of them are able to be treated without intervention.

We often encounter unresectable pancreatic cancer due to invasions of the major vessels. Vascular resection for locally advanced pancreatic cancers has an advantage in en block local resection. There are potential cases in which good outcomes can be achieved by arterial resection. Pancreatectomy (including total pancreatectomy in 15 cases, pancreatoduodenectomy in 7 cases and distal pancreatectomy in one case) was performed in 23 cases of invasive ductal carcinoma of the pancreas, in combination with resection and reconstruction of the hepatic artery in 15 cases, the superior mesenteric artery in 12 cases (there are overlaps) and the portal vein in 20 cases. The median operating time was 686 min (416–1,190 min) and the median blood loss was 2,830 ml (440–19,800 ml). This shows that the surgery was highly-invasive. The operative mortality rate was 4.3%. On the basis of the UICC classification, there were 2 cases of Stage IIa, 4 cases of Stage IIb, 9 cases of Stage III, 8 cases of Stage IV, while there were 18 cases (78.3%) of R0 resection. On the other hand, the final histological findings showed that there were 8 cases (34.8%) of M1 (liver and non-regional lymph node metastases), so it is thought that decisions on operative indications should be not be made slightly. As for the overall survival rate, the 1-year survival rate was 51.2% and the 3-year survival rate was 23.1% while the median survival time (MST) was 12 months. As for 15 cases of M0, the 1-year survival rate was 61.9% and the 4-year survival rate was 38.7% while the MST was 16 months. On the other hand, the MST was poor (10 months) in 8 cases of M1, showing that a statistically significant difference was observed depending upon the degree of metastasis (log-rank P = 0.0409). In 18 cases of R0, the 1-year survival rate was 67.2%, the 4-year survival rate 30.2% and the MST 13 months, respectively, while in 5 cases of R1 and R2, the MST was 6 months, showing that there was a statistically significant difference between R0 cases and R1, R2 cases (log-rank P = 0.0002). Further discussion is required concerning surgical indications and significance. However, it is thought that resection is useful only when surgery of R0 has taken place for selected locally advanced pancreatic cancer (M0).

Purpose To examine the effectiveness of concomitant intra-arterial infusion chemotherapy (IAIC) using cisplatin (CDDP) with radiotherapy for Stage III squamous cell carcinoma of the cervix. Materials and Methods We analyzed 29 cases of Stage III squamous cell carcinoma of the uterine cervix treated with radiotherapy and IAIC of CDDP from 1991 to 2006. External-beam therapy was given to the whole pelvis using four opposing parallel fields with an 18-MV linear accelerator unit. A central shield was used after 30–40 Gy with external whole-pelvic irradiation, and the total dose was 50 Gy. High-dose-rate brachytherapy was given with 192Ir microSelectron. The dose at Point A was 6 Gy per fraction, 2 fractions per week, and the total number of fractions was either 3 or 4. Two or three courses of IAIC were given concomitantly with CDDP 120 mg or carboplatin 300 mg. Results We confirmed excellent medicine distribution directly by using computed tomographic angiography. The 5-year overall survival rate for Stage III patients was 62%, the cause-specific survival rate was 70%, and the local relapse-free survival rate was 89%. Local recurrence, distant metastasis, and occurrences of both were 7%, 38%, and 3%, respectively. The incidence of severe acute hematologic adverse reactions (Grade ≥3) was 27% for all patients; however, all recovered without interruption of radiotherapy. Severe nonhematologic effects (Grade ≥3) were 3%, including nausea and ileus. Only 1 patient's radiotherapy was interrupted for a period of 1 week because of ileus. Severe late complication rates (Grade ≥3) for the bladder, rectum, and intestine were 3%, 3%, and 10%, respectively. Conclusion A combination of IAIC and systemic chemotherapy should be considered to improve the prognosis of patients with Stage III squamous cell carcinoma of the cervix.

We evaluate the long-term prognosis and prognostic factors in patients treated with transarterial infusion chemotherapy using cisplatin-lipiodol (CDDP/LPD) suspension with or without embolization for unresectable hepatocellular carcinoma (HCC). Study subjects were 107 patients with HCC treated with repeated transarterial infusion chemotherapy alone using CDDP/LPD (adjusted as CDDP 10mg/LPD 1ml). The median number of transarterial infusion procedures was two (range, one to nine), the mean dose of CDDP per transarterial infusion chemotherapy session was 30 mg (range, 5.0–67.5 mg), and the median total dose of transarterial infusion chemotherapy per patient was 60 mg (range, 10–390 mg). Survival rates were 86-0x1.fc400000008p+0t 1 year, 40 0x1.c617665206557p+855t 3 years, 20 0x1.5687420657461p-505t 5 years, and 16 0x1.5742d676e6f6cp+807t 7 years. For patients with >90% PD accumulation after the first transarterial infusion chemotherapy, rates were 98 0x1.e676f7270206dp+759t 1 year, 60 0x1.46e6120736973p-505t 3 years, and 22 0x1.36f6e676f727p+840t 5 years. Multivariate analysis identified >90% PD accumulation after the first transarterial infusion chemotherapy (p = 0.001), absence of portal vein tumor thrombosis (PVTT; p < 0.001), and Child-Pugh class A (p = 0.012) as independent determinants of survival. Anaphylactic shock was observed in two patients, at the fifth transarterial infusion chemotherapy session in one and the ninth in the other. In conclusion, transarterial infusion chemotherapy with CDDP/LPD appears to be a useful treatment option for patients with unresectable HCC without PVTT and in Child-Pugh class A. LPD accumulation after the first transarterial infusion chemotherapy is an important prognostic factor. Careful consideration should be given to the possibility of anaphylactic shock upon repeat infusion with CDDP/LPD.

The purpose of our study was to assess the relationship between hemodynamic changes in portosystemic collaterals and the prognosis of patients with esophageal varices after endoscopic injection sclerotherapy using multiplanar reconstruction (MPR) MDCT images.The subjects of this prospective study were 53 patients who underwent endoscopic injection sclerotherapy for esophageal varices. We evaluated the reconstructed MPR images of portosystemic collaterals before and after endoscopic injection sclerotherapy. Patients were divided into three groups based on the rate of change in the diameter of the feeding vessel into complete eradication (group A), narrowing (group B), and no change (group C). We analyzed the relationship between hemodynamic change in portosystemic collaterals and prognosis.The left gastric vein, posterior gastric vein, and left gastric vein plus posterior gastric vein were the main feeding vessels (n=44 [83%] of patients, n=5 [9%], and n=4 [8%], respectively). The proportions of patients of groups A, B, and C were 19% (n=10), 24% (n=13), and 57% (n=30), respectively. The relapse-free rates at 2 years after endoscopic injection sclerotherapy were 100%, 65%, and 52% in groups A, B, and C, respectively (p0.05). For group C, the relapse-free rate at 2 years after endoscopic injection sclerotherapy of patients with a large-diameter paraesophageal vein (or= 3 mm, 63%) was significantly higher than in those with a small-diameter paraesophageal vein (3 mm, 36%; p0.05). However, there were no significant differences in the survival rate among the three groups.MPR MDCT images on portosystemic collaterals can accurately predict relapse of esophageal varices after endoscopic injection sclerotherapy.

Intra-abdominal arterial hemorrhage is still one of the most serious complications after pancreato-biliary surgery. We retrospectively analyzed our experiences with 15 patients in order to establish a therapeutic strategy for postoperative arterial hemorrhage following pancreato-biliary surgery. Between August 1981 and November 2007, 15 patients developed massive intra-abdominal arterial bleeding after pancreato-biliary surgery. The initial surgery of these 15 patients were pylorus-preserving pancreatoduodenectomy (PPPD) (7 patients), hemihepatectomy and caudate lobectomy with extrahepatic bile duct resection or PPPD (4 patients), Whipple’s pancreatoduodenectomy (PD) (3 patients), and total pancreatectomy (1 patient). Twelve patients were managed by transcatheter arterial embolization and three patients underwent re-laparotomy. Patients were divided into two groups according to the site of bleeding: SMA group, superior mesenteric artery (4 patients); HA group, stump of gastroduodenal artery, right hepatic artery, common hepatic artery, or proper hepatic artery (11 patients). In the SMA group, re-laparotomy and coil embolization for pseudoaneurysm were performed in three and one patients, respectively, but none of the patients survived. In the HA group, all 11 patients were managed by transcatheter arterial embolization. None of four patients who had major hepatectomy with extrahepatic bile duct resection survived. Six of seven patients (85.7%) who had pancreatectomy survived, although hepatic infarction occurred in four. Management of postoperative arterial hemorrhage after pancreato-biliary surgery should be done according to the site of bleeding and the initial operative procedure. Careful consideration is required for indication of interventional radiology for bleeding from SMA after pancreatectomy and hepatic artery after major hepatectomy with bilioenteric anastomosis.

A 50-year-old male patient with a 15-year history of hypertension was referred to our hospital for evaluation of bilateral adrenal tumors. No Cushingoid features were observed. Computed tomographic scan showed 10-mm masses in each adrenal gland. Preoperative endocrinological examinations revealed autonomous cortisol and aldosterone secretion in this patient. The results of a subsequent adrenal venous catheterization study were consistent with the presence of a left cortisol-producing tumor and a right aldosterone-producing tumor. A left partial adrenalectomy was performed initially, but cortisol and aldosterone over-secretion persisted. Accordingly, the patient underwent a right adrenalectomy. Pathological examination of the resected specimens, including immunohistochemical analysis, demonstrated that both adenomas possibly produced cortisol and aldosterone. This is an extremely rare case of bilateral adrenal tumors, in which the left adrenocortical tumor produced and secreted cortisol or both cortisol and aldosterone and the right one produced and secreted both aldosterone and cortisol, as confirmed by clinical findings and pathological studies using immunohistochemical analysis.

The purpose of this study was to retrospectively analyze the frequency and anatomical pattern of the anterior branch of the left inferior phrenic artery (LIPA) arising from the right inferior phrenic artery (RIPA). Angiography of the RIPA for patients (n = 140) with hepatic malignancy was retrospectively reviewed. The frequency at which the anterior branch of the LIPA arose from the RIPA was 14.3% (20 of 140 patients [pts]). Among the three branches that may arise from the RIPA in these cases (the anterior branch of the LIPA and the anterior and posterior branches of the RIPA), the anterior branch of the LIPA was the first branch of the RIPA in 9 of 20 pts (45%), and the posterior branch of the RIPA in 11 of 20 pts (55%). The anterior branch of the LIPA ran along the ventral side of the esophagus or stomach and supplied the esophagogastric region and dome of the left diaphragm in all cases. In conclusion, the anterior branch of the LIPA arises from the RIPA at a comparatively high frequency. In embolization of the RIPA, to effectively treat and avoid possible complications, interventionalists should be aware of this potential variant anatomy.

Splenic artery steal syndrome (SASS) has only recently been recognized as a potential threat to transplanted livers. We report a case of SASS with progressive liver dysfunction that developed after living donor right lobe liver transplantation. SASS suspected by serial pre- and postoperative computed tomographic (CT) scans was diagnosed by celiac trunk angiography. It was successfully salvaged by splenic artery embolization. In this case, serial examinations of CT scans were useful to diagnose SASS. This case showed that portal hyperperfusion injury is a cause of liver graft dysfunction in SASS. The splenic artery embolization technique is a safe procedure that can be applied to treat such injury.

The purpose of our study was to evaluate the long-term outcome and complications of balloon-occluded retrograde transvenous obliteration (B-RTO) in patients with hemorrhage from gastric fundal varices.Thirty-four consecutive patients with bleeding from gastric varices who were treated with B-RTO were enrolled in this study between December 1994 and September 2005 (urgent cases, n = 12; elective cases, n = 22). The long-term outcome, complications, and various liver functions were evaluated.Complete obliteration was achieved in 31 of 34 (91%) patients with an acute bleeding episode. In one of the remaining patients, there was a technical failure, and the other two had only partial obliteration. The two patients with partial obliteration did not obtain hemostasis. Thus, the rate of hemostasis was 94% (31/33). Gastric varices disappeared in all patients with complete obliteration during the treatment. The rate of gastric variceal eradication was 91%. Variceal rebleeding from esophageal varices occurred in three patients. The rate of rebleeding was 10% (3/31). Rebleeding from gastric varices was not observed after complete obliteration. None of the patients showed worsening of their Child-Pugh score. Although the 5-year cumulative worsening rate of esophageal varices was 52%, neither portal hypertensive gastropathy nor ectopic varices were observed. The patients with worsening esophageal varices were successfully treated with an endoscopic procedure. The 5-year survival rate was 68%.B-RTO is useful for treatment of bleeding gastric varices, achieving high eradication of gastric varices, a low rebleeding rate, and a fairly good prognosis with improved hepatic function.

We report a rare case of mesenteric bleeding following blunt abdominal trauma successfully treated solely with transcatheter arterial embolization (TAE) of the right colic marginal artery. A 56-year-old woman presented with mesenteric bleeding after being involved in a car accident. Computed tomography (CT) showed a large mesenteric hematoma and hemoperitoneum with no associated major injuries to other organs. There was a pseudoaneurysm with extravasation inside the hematoma. TAE was attempted to control bleeding during the preparation for surgical laparotomy. A superior mesenteric angiogram revealed a right colic marginal artery pseudoaneurysm. After successful TAE with microcoils, the affected colon perfusion was preserved via collateral circulation from the ileocolic artery. No ischemic gastrointestinal complications have occurred, and laparotomy has not been necessary during the 6 months after TAE. In isolated mesenteric injury cases, TAE may be a reasonable alternative to emergency laparotomy.

When pancreatic duct dilatation is found in the patient having undergone pancreatoduodenectomy (PD), observation is chosen in most cases. Similarly, recurrent tumor in the remnant pancreas of invasive ductal carcinoma (IDC) of the pancreas is seldom indicated for resection. We have aggressively performed repeated pancreatectomy for these cases and obtained good results. Repeated pancreatectomy after PD was performed for three types of circumstances: (1) pancreatodigestive anastomotic stricture; (2) neoplasm after intraductal papillary mucinous neoplasm (IPMN); and (3) recurrence of IDC of the pancreas. Resection of anastomosis and reanastomosis was performed for pancreatodigestive stricture in four patients. Symptoms derived from pancreatitis in three patients resolved by the second operation and did not recur during follow-up. None of the four patients required pancreatic enzyme substitution because of clinically overt malabsorption, and the defecation frequency of the four patients was within twice a day. Mild diabetes mellitus has been identified in only one patient who had diabetes mellitus before the second surgery. Completion pancreatectomy and pancreatic tail resection was performed for recurrence in two patients and IDC in one patient, respectively, after PD for IPMN. Intrapancreatic recurrences of IPMN in two patients existed in the main pancreatic ducts. As CT revealed pancreatic duct dilatation but not intraductal tumors, recurrences were not correctly diagnosed before the second operation. Completion pancreatectomy was performed for recurrence of IDC in two patients. One patient who underwent completion pancreatectomy for recurrence of IDC survived 66/44 months after the first/second operation. Repeated pancreatectomy should be performed for patients with pancreatodigestive anastomotic stricture to preserve remnant pancreatic function and for patients with neoplasm or pancreatic duct dilatation after PD for IPMN, and repeated pancreatectomy for recurrence of IDC might be indicated for selected patients.