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Delta-shaped anastomosis is an established procedure for intracorporeal Billroth-I reconstruction (B-I). However, this procedure has several technical and economic problems. The aim of the current study was to present the technique of B-I using an overlap method (overlap B-I), which is a side-to-side intracorporeal gastroduodenostomy in laparoscopic distal gastrectomy (LDG), and to evaluate the short- and long-term outcomes of this overlap B-I procedure. We retrospectively reviewed the medical records of 533 patients who underwent LDG with overlap B-I (n = 247) or Roux-en-Y reconstruction (R-Y) (n = 286). Patients with overlap B-I were propensity score matched to patients with R-Y in a 1:1 ratio. Short- and long-term outcomes of the two procedures were compared after matching. In the total cohort, anastomosis-related complications occurred in 2.4% of patients with overlap B-I, and 3.2% of those with R-Y (P = 0.794). Morbidity rate, including anastomosis-related complications, and postoperative course were comparable after overlap B-I performed by qualified versus general surgeons. Of 247 patients with overlap B-I, 169 could be matched. After matching, morbidity rate and postoperative course were comparable between the two procedures. Median operation time was significantly shorter for overlap B-I (205 min) than R-Y (252 min; P

Background Wernicke’s encephalopathy (WE) is an acute neuropsychiatric disorder resulting from thiamine (vitamin B1) deficiency, frequently associated with chronic alcoholism and total parenteral nutrition without thiamine. However, only a few reports have focused on the relationship between WE and subtotal stomach-preserving pancreatoduodenectomy (SSPPD). Case presentation A 71-year-old woman underwent SSPPD for an adenocarcinoma of the ampulla of Vater. Although there had been no evidence of recurrence, the patient was treated with antibiotics for cholangitis at 12 and 31 months, respectively, post-surgery. Thereafter, the patient presented with vomiting and disorientation 33 months after surgery. Although she was admitted and underwent closer inspection by a neurologist and a psychiatrist, the exact cause of these syndromes remained unknown. The psychiatrist measured thiamine concentration to examine the cause of disorientation. After 6 days, her level of consciousness worsened. Magnetic resonance imaging of the head showed symmetrically multiple abnormal hyperintense signals on fluid-attenuated inversion-recovery and diffusion weighted image, compatible with WE. An administration of intravenous thiamine was immediately initiated. After 8 days of the measurement of the thiamine level, the patient’s serum thiamine level was found to be 6 µg/mL (reference range, 24–66 µg/mL). Accordingly, the patient was diagnosed with WE. Shortly after starting the treatment, blood thiamine value reached above normal range with significant improvement of her confusional state. However, short-term memory and ataxia remained. Conclusions Development of WE after SSPPD is uncommon. However, to prevent an after-effect, the possibility of development of WE after SSPPD should be recognized.

Background Pancreatic ductal adenocarcinoma (PDAC) is among the most aggressive malignancies. The prognosis for recurrence after surgery is extremely unfavorable, and liver metastasis of PDAC confers poor prognosis despite resection. Case presentation A 51-year-old man was admitted to our hospital for further examination and treatment, including surgery for a pancreatic tumor. On close inspection, he was suspected to have pancreatic head cancer without enlarged lymph nodes or distant metastasis, and pancreatoduodenectomy with D2 lymph node dissection was performed. A postoperative pathological examination revealed well-differentiated invasive ductal adenocarcinoma with lymph node metastasis (stage IIB; pT2N1M0). Postoperatively, he received adjuvant chemotherapy containing gemcitabine for 1 year. Eight years after the radical surgery, his serum carbohydrate antigen 19-9 level was elevated, and computed tomography (CT) and magnetic resonance imaging revealed a well-circumscribed 10-mm mass in liver segment 5. Positron emission tomography/CT also revealed high fluorine-18-fluorodeoxyglucose uptake only in this hepatic tumor. Accordingly, the patient was diagnosed with a solitary liver metastasis of PDAC. As the liver metastasis was isolated and identified long after the initial surgery, we decided to resect it using laparoscopic partial hepatectomy of segment 5. Histopathological examination confirmed liver metastasis of PDAC and the patient received adjuvant chemotherapy containing S-1. No evidence of recurrence has been seen for 11 years since the pancreatoduodenectomy and 3 years since the hepatic resection. Conclusions Cases of metachronous liver metastasis of PDAC after radical surgery, in which patients exhibit long-term survival without recurrence after hepatectomy, are extremely rare. Hepatectomy may confer long-term survival, and the time to postoperative recurrence and the number of liver metastases may be useful criteria for deciding whether to perform hepatic resection.

This study was performed to evaluate the surgical indication for intraductal papillary mucinous neoplasm (IPMN) advocated by the 2017 revised International Association of Pancreatology consensus guidelines (IAPCG2017). The medical records of 63 patients who underwent pancreatectomy for IPMN were retrospectively reviewed. Thirteen patients had main-duct IPMN, 25 had mixed IPMN, and 25 had branch-duct IPMN with frequencies of high-grade dysplasia or invasive carcinoma of 62, 24, and 28%, respectively. The sensitivity and specificity of high-risk stigmata for high-grade dysplasia or invasive carcinoma advocated by the IAPCG2017 were 90 and 67%, respectively. Of 17 patients with invasive carcinoma, all patients had high-risk stigmata, and 16 had an enhanced mural nodule (MN) of ≥ 5 mm. The sensitivity and specificity of a ≥ 5-mm enhanced MN for predicting invasive carcinoma were 94% and 87%, respectively. Introducing a size threshold for enhanced MNs into the assessment of high-risk stigmata increases the specificity without jeopardizing the sensitivity. The surgical indication for any type of IPMN may be determined using only a ≥ 5-mm enhanced MN. When the type of IPMN is classified strictly, about half of IPMNs are mixed type, and most are benign. The surgical indication for mixed IPMN should be reconsidered.

The benefit of pancreatectomy for elderly patients with pancreatic ductal adenocarcinoma (PDAC) remains controversial. Moreover, adjuvant chemotherapy (AC) for elderly patients has not been fully evaluated. We investigated the long-term outcomes after pancreatectomy for PDAC in elderly patients with special reference to AC. The medical records of 123 patients who underwent pancreatectomy for PDAC from 2007 to 2016 were retrospectively reviewed. The patients were divided into two groups: young (

This study aimed to evaluate the surgical outcomes and clinical safety of laparoscopic distal gastrectomy (LDG) when performed by trainee surgeons with little prior experience in performing open gastrectomy, under the guidance of trainer surgeons. From January 2008 until March 2015, 17 trainee surgeons and 5 trainer surgeons performed LDGs to treat 371 patients with clinical stage T1–T3 gastric cancer. Of these patients, 140 and 231 underwent LDG performed by trainee surgeons and trainer surgeons, respectively. We retrospectively analyzed the surgical outcomes of the two groups. Trainee surgeons required significantly longer operation times than the trainer surgeons, with respective mean operation times of 262 and 223 min (p

The aim of this study was to investigate the validity of the management strategy for intraductal papillary mucinous neoplasms (IPMNs) advocated by the international consensus guidelines 2012 (ICG2012). The medical records of 49 patients who underwent pancreatectomy for IPMN were retrospectively reviewed. According to preoperative imaging, 10 patients (20 %) had main-duct IPMNs, 20 (41 %) had mixed IPMNs, and 19 (39 %) had branch-duct IPMNs, with malignancy frequencies of 80, 15, and 37 %, respectively. Twenty-seven patients had high-risk stigmata and 21 had worrisome features, with malignancy frequencies of 59 and 10 %, respectively. The sensitivity, specificity, and positive and negative predictive values of high-risk stigmata for malignancy were 88, 65, 59, and 91 %, respectively. Lesions were malignant in 88 % of patients with an enhanced solid component, which was significantly correlated with the prevalence of malignancy (P

The therapeutic advances in breast cancer have improved the survival of patients with early disease; however, survival improvement of patients with recurrent disease remains ambiguous. In this retrospective study, we examined whether disparities in survival improvement exist in patients with recurrent breast cancer with distant metastasis.The survival time of 126 patients who experienced recurrence at distant sites from 1990 through 1996 was compared to that of 195 patients who did from 1997 through 2003.A significant survival improvement was observed in the patients who experienced recurrence in the period of 1997-2003 in comparison to the other period in the subsets with estrogen receptor (ER)-positive disease, those who received adjuvant hormonal therapy, and those with a disease-free interval (DFI) of 24 months or more. However, no significant survival improvement was observed in each counterpart. The median survival time (MST) from the first relapse of patients with ER-positive disease in the recurrence period of 1997-2003 was 18.8 months longer than that in the recurrence period of 1990-1996 (46.6 months vs. 27.8 months). The MST of patients with a DFI of 24 months or more in 1997-2003 was 20.3 months longer than that in the other time period (47.2 months vs. 26.9 months).The survival of recurrent breast cancer has improved with disparities. The ER status and the DFI are associated with a survival improvement of women with recurrent breast cancer with distant metastases.

The purpose of this study was to determine the most appropriate tests and procedures to detect disease progression effectively during the postoperative follow-up of patients with early breast cancer. We reevaluated our current surveillance protocol which involves the intensive follow-up of 643 patients with stage I disease. With the exception of one case of bone metastasis, all cases of recurrence (97%) were suspected from abnormal results detected during surveillance involving physical examination, serial determination of tumor markers, and chest roentgenography. Among 15 patients with asymptomatic distant metastasis, disease recurrence was suspected in 12 (80%) because of increased levels of serum tumor markers. No disease recurrence was detected by routine complete blood counts or automated chemistry studies alone. Our experience indicates that an effective follow-up regimen for patients with early breast cancer may include careful history-taking, physical examination, and the determination of serum tumor markers every 3-6 months for the first 3 years, then less frequently thereafter, and chest roentgenography every 6 months for 5 years, in addition to annual mammography. Serial determination of the tumor markers tumor polypeptide antigen, NCC-ST-439, and either carcinoembryonic antigen or carbohydrate antigen 15-3, seems to be of value for the selection of patients who should undergo radiologic exploration. The health benefits and cost-effectiveness of a follow-up focused on the measurement of serum tumor markers need to be evaluated in large prospective randomized trials.

The occurrence of a collision tumor in the stomach, consisting of adenocarcinoma and malignant lymphoma, is extremely rare. We report herein the case of a patient who had undergone a pancreatoduodenectomy for bile duct cancer 5 year earlier, in whom an ulcerating tumor of the remnant stomach developed and grew rapidly within 5 months. Surgical exploration revealed a tumor in the remnant stomach, multiple liver metastases, and multiple lymph node metastases. Total resection of the remnant stomach was performed, and pathological examination revealed a collision tumor consisting of adenocarcinoma and malignant lymphoma. The patient died of liver metastases and lymph node metastases 7 months after his second operation. The coexistence of both adenocarcinoma and malignant lymphoma of the remnant stomach and the etiology of this unusual combination, never previously reported, is discussed.

We reviewed the clinical and pathologic features of pure tubular carcinoma of the breast with particular emphasis on the reported risk factors associated with local recurrences and survival following breast-conserving therapy. Of 1653 cases of invasive breast cancer, 12 (0.7%) were identified as pure tubular carcinoma. Clinical/pathologic features of pure tubular carcinoma were compared with those of T1 invasive carcinoma of all other histologic types (T1 IC). Of the 12 patients with pure tubular carcinoma (median tumor diameter 1.4 cm; range 0.5-3.0 cm), a multicentric association was identified in one patient while a multifocal association was seen in two. One patient had nodal metastatic disease out of the ten who underwent axillary dissection. No lymphatic vessel invasion was identified in any tumors (P < 0.1 vs T1 IC). In addition, extensive intraductal spread was not present in any tumors (P < 0.05 vs T1 IC). This study shows that patients with pure tubular carcinoma are appropriate candidates for breast-conserving therapy based on the clinical/ pathologic features. When a multifocal association is suspected preoperatively, either a wide local excision or a quadrantectomy which includes other lesions is thus recommended.

BACKGROUND: A tumor 30 mm or less in diameter is a standard candidate for breast conserving surgery (BCS) in Japan. Axillary lymph node metastases (ALNM) is the most important prognostic factor for survival in patients with breast cancer, but the role of axillary node dissection has been controversial. Histopathological predictive factors of axillary lymph node involvement have not been established. The purpose of this study was to determine the association between the incidence of ALNM and histopathological factors by univariate and multivariate analysis METHODS: Sixty-five patients with noninvasive ductal carcinoma, and 993 patients with tumors 30 mm or less in diameter who underwent axillary dissection between 1988 and 1997 at our institute were reviewed. The association between ALNM and 13 histopathological factors (size, age, histological subtype, histological invasiveness, lymphatic invasion, vascular invasion, macroscopic classification, histological daughter mass, ductal spread, ER, PgR, p-53, and c-erbB-2) were analyzed by univariate and, when significant, by multivariate analysis. RESULTS: Only one patient with noninvasive ductal carcinoma had ALNM, and 33.1% of 993 patients with a tumor 30 mm or less in size had ALNM. Multivariate analysis identified six factors as independent predictors for ALNM: lymphatic invasion, size, histological invasiveness, macroscopic classification, age and histological daughter mass. CONCLUSION: Axillary lymph node dissection can be omitted in patients with noninvasive ductal carcinoma. Histopathological features of tumors 30 mm or less in diameter can be used to estimate the risk of ALNM, and routine axillary node dissection might be spared in selected patients at minimal risk of ALNM, if the treatment decision is not influenced by lymph node status, such as in elderly patients.

We report herein an unusual case of a composite glandular-neuroendocrine carcinoma of the hilar bile duct. A 71-year-old Japanese woman was admitted to our hospital suffering from general fatigue, progressive jaundice, and a high fever. Computed tomography and angiography findings revealed a solid hypervascular mass in the hepatic hilus. Thus, a subsegmentectomy of the liver (S4, S5) and bile duct resection with lymph node dissection were performed. A tumor measuring 6.0 x 3.0 cm was found to be located in the bile duct of the hepatic hilus. Histologically, the tumor was composed of well-differentiated adenocarcinoma and small cell neuroendocrine carcinoma cells, with a histological transition between the two components. Grimelius' method revealed the presence of diffuse positive tumor cells in neuroendocrine carcinoma. The neuroendocrine tumor cells were also diffusely immunoreactive to chromogranin A. To the best of our knowledge, only 22 previous cases of composite glandular-neuroendocrine carcinoma in the biliary tract have been reported; however, this is the first case report of a clearly composite tumor of the hilar bile duct.

Papillary cystic tumour (PCT) is a rare, low-grade malignant pancreatic neoplasm, in which the histological criteria for malignancy are still uncertain. We performed a histological examination of 3 metastasizing PCTs, while comparing them with 18 non-metastasizing PCTs, using a computed image analyser. The mean maximum nuclear diameter, the mean standard deviation (SD) of the nuclear diameter, the mean nuclear area and the nuclear-nonnuclear (N/NN) ratio obtained by the image analyser of the metastasizing PCTs (7.23 microns, 2.21 microns, 30.45 microns2, 36.41%) were all significantly larger than those of the non-metastasizing PCT (6.34 microns, 1.59 microns, 23.66 microns2, 23.74%; P0.005, P0.005, P0.005, P0.001 respectively). However, there were no statistical differences in either the nuclear ellipsoidity or nuclear regularity. These results suggested that nuclear morphometry might be a useful parameter to define metastatic potential, in addition to histological variables such as venous invasion, nuclear grade and mitotic rate.