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Laparoscopic surgery is performed worldwide and has clear economic and social benefits in terms of patient recovery time. It is used for most gastrointestinal surgical procedures, but laparoscopic surgery for more complex procedures in the esophageal, hepatobiliary, and pancreatic regions remains challenging. Minimally invasive surgery that results in accurate tumor dissection is vital in surgical oncology, and development of surgical systems and instruments plays a key role in assisting surgeons to achieve this. A notable advance in the latter half of the 1990s was the da Vinci Surgical System, which involves master-slave surgical support robots. Featuring high-resolution three-dimensional (3D) imaging with magnification capabilities and forceps with multi-joint function, anti-shake function, and motion scaling, the system compensates for the drawbacks of conventional laparoscopic surgery. It is expected to be particularly useful in the field of hepato-biliary-pancreatic surgery, which requires delicate reconstruction involving complex liver anatomy with diverse vascular and biliary systems and anastomosis of the biliary tract, pancreas, and intestines. The learning curve is said to be short, and it is hoped that robotic surgery will be standardized in the near future. There is also a need for a standardized robotic surgery training system for young surgeons that can later be adapted to a wider range of surgeries. This systematic review describes trends and future prospects for robotic surgery in the hepatobiliary-pancreatic region.

Juvenile polyposis syndrome (JPS) is an autosomal dominant, inherited disorder caused by pathogenic germline variants of mainly SMAD4 or BMPR1A genes. Some patients with JPS, especially with SMAD4 variants, also develop hereditary, hemorrhagic telangiectasia (HHT). HHT is also an autosomal dominant inherited disorder. Herein, we identified a novel germline pathogenic variant of the SMAD4 in a Japanese family with JPS and HHT. A six-base pair deletion in the SMAD4 gene (NM_005359.6:c.1495_1500delTGCATA) was identified in the patients. Two amino acids are deleted from SMAD4 protein (p.Cys499_Ile500del), which are located in MSH2 domain essential for the binding with SMAD3. This is a novel variant that has not been registered in any database surveyed. Amino acid structural analysis predicted significant changes in the secondary and three-dimensional structures in the vicinity of the two amino acids' deletion. The variant is classified as 'Likely Pathogenic' according to the American College of Medical Genetics and Genomics guidelines., (© The Author(s) 2022. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permission@oup.com.)

Development of surgical support robots began in the 1980s as a navigation and auxiliary device for endoscopic surgery. For remote surgery on the battlefield, a master-slave-type surgical support robot was developed, in which a console surgeon operates the robot at will. The da Vinci surgical system, which currently dominates the global robotic surgery market, received United States Food and Drug Administration and regulatory approval in Japan in 2000 and 2009 respectively. The latest, fourth generation, da Vinci Xi has a good field of view via a three-dimensional monitor, highly operable forceps, a motion scale function, and a tremor-filtered articulated function. Gastroenterological tract robotic surgery is safe and minimally invasive when accessing and operating on the esophagus, stomach, colon, and rectum. The learning curve is said to be short, and robotic surgery will likely be standardized soon. Therefore, robotic surgery training should be systematized for young surgeons so that it can be further standardized and later adapted to a wider range of surgeries. This article reviews current trends and potential developments in robotic surgery.

Although the incidence of gastric cancer has decreased because of the lower rate of Helicobacter pylori infection, it still accounts for a large number of deaths in Japan. Gastric cancer is mainly treated by resection, and the rate of radical resection is high in Japan because approximately 50% of cases are diagnosed at an early stage. Treatment advances have increased the number of endoscopic submucosal dissections, and development of laparoscopic surgery and robot-assisted surgery as minimally invasive approaches has yielded results similar to those of conventional surgeries, at least in the short term. Cases for which resection is contraindicated are treated with chemotherapy if performance status can be maintained. Although anticancer drugs are continuously under development, treatment outcomes remain unsatisfactory. As Japan becomes a super-aging society, the number of refractory cases is projected to increase. Therefore, evidence of any benefit for minimally invasive surgery and function-preserving surgery needs to be reported quickly. In this paper, we discuss gastric cancer treatment modalities recommended in the fifth edition of the gastric cancer treatment guidelines and describe recent research findings.

Chylous ascites associated with radical resection of gastric cancer is a serious clinical condition. Lymph node dissection is indispensable during gastrectomy for gastric cancer. However, postoperative chylous ascites prolongs the hospital stay and re-operation. There are few reports on this subject. Most cases of chylous ascites resolve without treatment, but the condition can result in substantial morbidity. The definition of chylous ascites is ambiguous and varies in the English literature. In this report, we discuss a case of chylous ascites in a 68-year-old man who underwent distal gastrectomy for early gastric cancer at our hospital. He was admitted 8 months after surgery with a main complaint of abdominal swelling. Abdominal puncture helped to diagnose chylous ascites with marked elevation of triglyceride level. The patient received a hypercaloric infusion through a central line, and octreotide acetate, but did not improve. After assessment of lymph outflow by lymph scintigraphy, surgical ligation of the lymph vessels was performed through laparotomy. The volume of milky-white ascites in the abdominal cavity was 3,000 mL. Macroscopically, the fluid was confirmed as flowing from behind the common hepatic artery. Thus, ligation was performed. Chylous ascites has not recurred at 12 months after the re-operation. In summary, a case of chylous ascites after radical gastrectomy for gastric cancer was successfully treated by surgery. We review and discuss the relevant literature.

Background: Ehlers-Danlos syndrome (EDS) is an inherited disorder that causes connective tissue fragility. The vascular type of EDS (vEDS) caused by defective collagen type III production accounts for 5%-10% of all EDS cases. Patients can develop gastrointestinal or arterial ruptures, which cause poor prognosis. We report a case of a patient who experienced colonic rupture, which was immediately followed by arterial rupture., Case Presentation: A 40-year-old man who had been genetically diagnosed with vEDS 6 years previously was admitted to our hospital with ischemic colitis. After 3 days of conservative treatment, his abdominal pain worsened, and computed tomography (CT) revealed free air in the abdominal cavity. Pan-peritonitis due to perforation of the sigmoid colon was diagnosed. Intraperitoneal lavage and drainage and Hartmann's operation were urgently performed. Because the patient had confirmed vEDS, we performed the surgery in a protective manner. The postoperative course was initially good, and he was transferred to the general ward 3 days after surgery. However, 5 days after surgery, massive intra-abdominal hemorrhage suddenly occurred, and contrast-enhanced CT showed an aneurysm in the common hepatic artery that had ruptured; this aneurysm was not present before surgery and was far from the surgical field. Although we considered an emergency operation, the patient suddenly experienced cardiac arrest and was unresponsive to resuscitation., Conclusions: In cases of vEDS, vascular rupture can occur immediately after surgery for intestinal rupture. We recommend paying special attention to vascular complications in patients in their forties, as such complications are the most common causes of death.

Background: Circulating tumor DNA (ctDNA) detected before surgery disappears after complete surgical resection of the cancer. Residual ctDNA indicates minimal residual disease (MRD), which is a cause of recurrence. The presence of long-fragment circulating cell-free DNA (cfDNA) or methylated cfDNA also implies the presence of cancer. In this study, we evaluated the prognostic value of cfDNA methylation and long-fragment cfDNA concentration in gastric cancer patients undergoing curative surgery METHODS: Ninety-nine gastric cancer patients were included. Peripheral blood samples were collected before and 1 month after surgery. In patients administered chemotherapy, samples were collected before starting chemotherapy. qPCR was performed to detect long- and short-fragment LINE-1. A plasma HELP (HpaII tiny fragment Enrichment by Ligation-mediated PCR) assay to determine the concentration of HpaII small fragments was performed using ligation-mediated PCR and HpaII was quantified as the HpaII:MspI ratio to detect methylation levels of cfDNA., Results: Overall survival (OS) of patients with low methylation levels before starting treatment was significantly worse than that of patients with high methylation levels (P = 0.006). In the 90 patients who underwent curative surgery, recurrence-free survival (RFS) and OS of patients with low methylation levels before surgery were worse than those with high methylation levels (P=0.08 and P = 0.11, respectively). RFS and OS of patients with high concentrations of long-fragment LINE-1 after surgery were significantly worse than those with low concentrations of long-fragment LINE-1 (P = 0.009, P = 0.04)., Conclusions: Pre-surgical low methylation levels of LINE-1 are a negative prognostic factor. Post-surgical high concentrations of long-fragment LINE-1 indicate MRD and a high risk of recurrence., (© 2021 The Authors. Cancer Medicine published by John Wiley & Sons Ltd.)

Background/aim: Skeletal muscle mass (SMM) is often depleted in patients with gastric cancer undergoing gastrectomy. Using a novel method, we evaluated the effect of SMM depletion after gastrectomy on disease prognosis., Patients and Methods: The maximum cross-sectional area of the psoas-muscle (MCA-PM) was measured before surgery and at 1 year after in 233 patients with gastric cancer who underwent radical gastrectomy to determine the ratio (MCA-PMR) as an indicator of SMM depletion., Results: The MCA-PMR cutoff value was set at 90%, and patients were divided into the groups with <90% and ≥90%. MCA-PMR <90% was an independent prognostic factor for all patients. In 88 patients who received adjuvant chemotherapy including S-1, the 5-year cancer-specific survival rate was significantly better for those with MCA-PMR ≥90% than for those with MCA-PMR <90% (84.1% vs. 59.1%; p=0.010; hazard ratio=2.974; 95% confidence interval=1.241-7.124)., Conclusion: SMM depletion after gastrectomy can be measured using the MCA-PMR. This novel measurement can be easily implemented in the clinical setting., (Copyright© 2020, International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Brain metastases originating from esophageal or gastric cancer are rare, accounting for 2.1-3.3% of all brain tumors registered in Japan. There are no established therapeutic measures for brain metastases, which accordingly have a poor prognosis. We present here a patient who survived for 5 years after surgery and gamma knife treatment of a cerebellar metastasis from esophagogastric adenocarcinoma. The primary gastric cancer was treated by laparotomy with total gastrectomy, splenectomy, and D2 lymphadenectomy. It was diagnosed as a esophagogastric junction Siewert type II tumor, type 3, tub1-2, pT3 (SS), pN1, and stage IIB on histopathological examination of the surgical specimen. Five months postoperatively, a solitary cerebellar metastasis was identified and surgically removed, followed by 20 Gy administered by gamma knife stereotactic radiosurgery; the patient received no subsequent treatment such as chemotherapy. Five years after the primary surgery, there have been no recurrences and the patient has a good quality of life. There are very few case reports of long-term survival after surgical treatment of cerebellar metastases from esophagogastric junction cancer. We report our experience and review published case reports of surgical treatment of brain metastases from gastric cancer., (Copyright© 2017, International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Aim: Cisplatin plus 5-fluorouracil (5-FU) or S-1 is a standard therapy for gastric cancer (GC). However, cisplatin is emetic and potentially nephrotoxic. Oxaliplatin may be less toxic, but few basic data are available for this setting. Here, we evaluated oxaliplatin for GC, by testing surgical specimens., Materials and Methods: We evaluated effects of oxaliplatin and 5-FU, alone and in combination, on surgical specimens from 11 patients with GC, using collagen gel droplet embedded culture drug tests., Results: Oxaliplatin was less efficacious than 5-FU, and its synergistic effect was less in tumors highly sensitive to 5-FU than in those with low sensitivity. Tumor differentiation and drug sensitivity were not correlated., Conclusion: Although oxaliplatin monotherapy had little effect on GC, we saw a limited synergistic effect of oxaliplatin with 5-FU in 5-FU-sensitive patients. Collagen gel droplet embedded culture drug tests may predict this synergistic effect, and help select candidates for this or other regimens., (Copyright© 2017, International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Background: Taxane-based chemotherapy is useful for peritoneal dissemination control in advanced/recurrent gastric cancer; however, insufficient relative dose intensity (RDI) may preclude disease control achievement. Nab-paclitaxel, with high tumour permeability, is a promising second- or later-line treatment., Patients and Methods: We retrospectively evaluated the clinical safety and efficacy of nab-paclitaxel for advanced/recurrent gastric cancer patients treated between April 2013 and December 2015. The response rate, RDI and survival outcomes were assessed., Results: Of 14 evaluated patients, 4 achieved partial response. Overall response and the disease control rates were 28.5% and 64.2%, respectively. Nine patients developed peritoneal metastasis; their overall response and disease control rate were 22.2% and 66.6%. Patients with high RDI (≥80%) showed longer progression-free and overall survival than those with low RDI (≤80%) (11.8 vs. 4.0 months, p=0.02; and 14.3 vs. 8.2 months, p=0.03, respectively)., Conclusion: Nab-paclitaxel, at an RDI ≥80%, was safe and beneficial for these patients., (Copyright© 2017, International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Background: Chylous ascites is an uncommon finding which is usually associated with recent abdominal/oncologic or retroperitoneal surgery. It is not usually seen in cases of acute obstruction., Case Presentation: A patient who had previously undergone a laparoscopy-assisted distal gastrectomy with Roux-en-Y reconstruction for early gastric cancer presented with acute abdominal pain and epigastric fullness. Computed tomography suggested small bowel obstruction due to volvulus. We were able to reduce the volvulus and close a Petersen's hernia without resecting the bowel; a large amount of chylous ascites was an incidental finding., Conclusions: We present a case of chylous ascites occurring in a setting of small bowel obstruction due to Petersen's hernia, 3 years after successful distal gastrectomy for early gastric cancer, with no evidence of tumor recurrence.

Background: When percutaneous endoscopic gastrostomy is not feasible, a gastrostomy tube may be inserted for enteral access by a laparoscopic or open technique. The aim of this study was to compare the postoperative pain of laparoscopic versus open gastrostomy in patients with complete obstruction caused by advanced esophageal cancer., Methods: Fifteen patients who had undergone either a reduced port access laparoscopic gastrostomy/jejunostomy (LGJ, n=7) or open gastrostomy/jejunostomy (OGJ, n=8) between July 2011 and December 2015 were retrospectively studied. Variables examined comprised age, sex, body mass index (BMI), operative time, blood loss volume, and American Society of Anesthesiologist physical status (ASA-PS) scores. The degree of postoperative pain was also assessed in both groups during the first seven postoperative days., Results: The patients in the two groups were comparable in age, sex, BMI, ASA-PS scores, intraoperative blood loss or postoperative complication rates. Operative time was shorter in the LGJ group than the OGJ group. No patients in the LGJ group required conversion to open laparotomy. Tube feedings were started on postoperative Day 1 in both groups; there were no postoperative complications. The duration of rescue nonopioid analgesic use was significantly shorter in the LGJ than the OGJ group (1.3 versus 3.5 days; P=0.0005). There was a significant difference in frequency of postoperative nonopioid analgesic use: 7.9 times in the LGJ group versus 17.9 times in the OGJ group (P=0.0219)., Conclusions: LGJ is associated with less postoperative pain than OGJ in patients with complete obstruction caused by advanced esophageal cancer.

We report the first documented case of pancreatic metastasis from a gastrointestinal stromal tumor of the stomach. A 42-year-old Japanese man presented with severe abdominal discomfort. Computed tomography of the abdomen showed a huge heterogeneous mass consisting of cystic and solid components in the left upper abdomen. (18)F-Fluorodeoxyglucose positron-emission tomography revealed high tracer uptake in the abdominal mass. After total gastrectomy with lymphnodectomy was performed, a hard mass was palpated in the pancreatic tail. The pancreatic tumor was also resected under the therapeutic strategy. Histological examinations of the resected gastric and pancreatic specimens revealed that both tumors consisted of uniform spindle cells with a fascicular growth pattern and were immunohistochemically positive for CD34 and CD117/KIT. Gene sequencing analysis of DNA from each tumor revealed an identical deletion of 21 nucleotides in exon 11 of the gene KIT. On the basis of these results, we concluded that the pancreatic tumor was a metastatic tumor from the gastrointestinal stromal tumor of the stomach.

We report a case of previously unreported metastasis to the spermatic cord from esophageal squamous cell carcinoma. A 63-year-old Japanese man underwent laparoscopy-assisted esophageal bypass surgery for an advanced esophageal cancer. An elastic hard tumor was found in the right lateral inguinal fossa on intraoperative laparoscopy, and laparoscopic enucleation was performed. Histological examination of the resected tumor revealed a moderately differentiated squamous cell carcinoma, compatible with metastasis from the esophageal cancer. Two months after the operation, computed tomography revealed a heterogeneously enhanced groin mass (20 mm in diameter) involving the right spermatic cord. To our knowledge, this is the first reported case of a solitary metastasis to the spermatic cord from esophageal squamous cell carcinoma.

Background: Refractory hepatic encephalopathy (HE) frequently develops in patients with cirrhosis and portal-systemic shunt. Recently, patients with refractory HE associated with portal-systemic shunt have been treated with interventional radiology. We describe a promising new treatment for portal-systemic shunt, ligation of the patent paraumbilical vein (PUV) after partial splenic embolization, in patients with refractory HE., Patients: Four patients with cirrhosis (3 women and 1 man; mean age, 56 years) and refractory HE due to a patent PUV were studied. Patency of the PUV had recurred in 1 patient after primary occlusion by interventional radiological procedures. The Child-Pugh class was B in 2 patients and C in 2. Before the present treatment, all patients had been hospitalized at least 3 times because of recurrent HE., Surgical Procedure: Partial splenic embolization was performed in all patients to decrease portal venous pressure before surgery. Surgical ligation of the patent PUV was performed under epidural anesthesia. The patent PUV was carefully skeletonized and doubly ligated. Esophageal varices were evaluated with upper gastrointestinal endoscopy before and after surgery., Result: The mean follow-up duration was 15.8 months. After ligation, there were no clinically significant complications. Esophageal varices were unchanged. The serum ammonia level was higher before surgery (162.3 +/- 56.4 mug/dL, mean +/- SD) than after surgery (41.8 +/- 20.2 mug/dL; p=0.0299). No patient had symptoms of HE., Conclusion: Ligation of the patent PUV is an effective treatment for patients with refractory HE.

We present a case report of a posttransplant patient who had hepatotoxicity due to both tacrolimus and cyclosporine and cholestatic jaundice due to tacrolimus. The patient did not show sustained improvement in enzyme and bilirubin abnormalities after an initial change from tacrolimus to cyclosporine or with a change back to tacrolimus, but he ultimately showed improvement when the blood concentration of tacrolimus was lowered. A 56-year-old man with subacute fulminant hepatitis induced by acarbose was admitted to our hospital for living donor liver transplantation. The liver graft consisted of the left lobe from his ABO-identical son. The early posttransplant course was uneventful. The serum levels of aspartate aminotransferase (AST), alanine aminotransferase (ALT), and total bilirubin improved initially, but the ALT and AST levels later increased. A liver biopsy suggested a presumptive diagnosis of drug reaction. All drugs were discontinued, the immunosuppressive agent was changed from tacrolimus to cyclosporine. After initial improvement, the ALT and AST levels increased again. Assuming a reaction to cyclosporine, we decreased the concentration of cyclosporine in the blood. The enzyme levels improved temporarily but again began to rise. We changed the immunosuppressive agent to tacrolimus, which resulted in improvements in the ALT and AST levels; however, the total bilirubin level increased. We interpreted this increase as tacrolimus-induced cholestasis; in response, we decreased the blood concentration of tacrolimus to between 3 and 5 ng/dL and added 1,000 mg of mycophenolate mofetil to the drug regimen. The patient recovered without further complications. Repeated liver biopsies throughout the hospital course suggested that the mild mononuclear cell infiltration observed in a few triads had not been caused by acute rejection but had possibly been drug-induced.

We describe a case of duodenal varices successfully treated with balloon-occluded retrograde transvenous obliteration (BRTO) alone. A 63-year-old man presented with tarry stools. Computed tomography demonstrated dilated varices around the duodenum. Emergency endoscopic examination revealed varices of the second portion of the duodenum without active bleeding. There was no evidence of bleeding in the esophagus or stomach. Colonoscopy revealed no bleeding sites in the colon. On the day after admission, a superior mesenteric arteriogram obtained in the venous phase demonstrated a collateral vein from the inferior pancreaticoduodenal vein to the inferior vena cava. Retrograde venography performed via the right femoral vein confirmed that the right inferior adrenal vein was the draining vein and that the collateral vein was occluded. There were no tarry stools after BRTO. The patient was discharged 7 days after BRTO. Two months after discharge, computed tomography showed no dilated varices around the duodenum. Three months after discharge, endoscopy confirmed the absence of varices. No bleeding has been detected as of 10 months after discharge. We conclude that BRTO is an effective treatment for duodenal varices.

Background: Malignant ascites may produce a cluster of symptoms that include abdominal distention, early satiety, respiratory embarrassment, impaired mobility, and lethargy, and relief of these symptoms is often difficult to achieve. We report on the placement of peritoneovenous shunts (PVSs) in a group of patients with malignant ascites, with particular reference to the effectiveness and complications of the procedure., Patients and Method: PVSs were inserted in 9 patients with malignant ascites after obtaining their informed consent. The patients were 6 men and 3 women with a median age of 59 years. All had previously been treated with vigorous diuretic therapy or repeated paracentesis or both. Shunt insertion was carried out via a percutaneous approach under local anesthesia., Results: The procedure was well tolerated by all patients. The abdominal distention resolved in all patients, and urine volume increased significantly, demonstrating that the PVS did not affect renal function. The platelet count was reduced, and prothrombin time was prolonged. Two patients had the complication of shunt occlusion, and both patients underwent shunt replacement. There were no lethal complications. Median survival time after PVS placement was 21 days (range, 10 approximately 90 days), and the shunt was functioning at the time of death with good control of ascites in all patients., Conclusions: Malignant ascites produces troublesome symptoms for patients, who may live for some time. Placement of a PVS is a well-tolerated, relatively minor surgical procedure that can provide excellent control of ascites in most patients selected. The selection of optimal patients requires further study.

A case of hepatocellular carcinoma (HCC) causing a major arterioportal (A-P) shunt is reported. The patient exhibited massive ascites and tested positive for hepatitis B surface antigen. An abdominal computed tomography (CT) examination showed a low-density lesion in the left lobe of the liver and an A-P shunt, but no tumor stain was visible. Upper gastrointestinal endoscopy revealed severe esophageal varices. Because the tumor marker level was abnormally high, an HCC causing an A-P shunt in a cirrhotic liver background with severe esophageal varices as a result of portal hypertension was diagnosed. We performed endoscopic variceal ligation to treat the severe esophageal varices and interventional radiology treatment for the A-P shunt and HCC, but the patients condition was unchanged. Because the patients liver function gradually improved, surgical treatment was selected. The patient underwent left hepatectomy. Pathological examination revealed a poorly differentiated HCC in a cirrhotic liver background. The postoperative course was uneventful, and the patient was discharged 2 weeks after the operation. The patient subsequently underwent transcatheter arterial embolization therapy for recurrent HCC in the right lobe of the liver, but the esophageal varices disappeared.

Background: The aim of this study was to investigate the advantages of laparoscopic hepatectomy over open surgery for liver tumors., Patients and Method: A retrospective study was performed of 10 patients with liver tumors (9 with hepatocellular carcinoma and 1 with focal nodular hyperplasia) at our hospital. Five patients who had received laparoscopic hepatectomy (Lap-Hx group) were compared with 5 patients who had undergone open hepatectomy (O-Hx group) in the same period. The operative procedure was partial hepatectomy and cholecystectomy in both groups. For liver excision, a microwave coagulation device and an ultrasonically activated scalpel were used., Results: Mean patient age was 55.6 +/- 13.9 years in the Lap-Hx group and 51.8 +/- 14.1 years in the O-Hx group. Four patients in the Lap-Hx group had hepatocellular carcinoma with liver cirrhosis and 1 patient had focal nodular hyperplasia. All patients in the O-Hx group had hepatocellular carcinoma and 4 patients had associated liver cirrhosis. The mean tumor size was 2.6 +/- 1.5 cm in the Lap-Hx group and 3.0 +/- 1.8 cm in the O-Hx group. The two groups did not thus differ significantly in the preoperative background factors. Blood loss and duration of the postoperative hospital stay were significantly less in the Lap-Hx than in the O-Hx groups(213 +/- 82 vs 247 +/- 97 min; 154 +/- 128 vs 648 +/- 468 ml, p=0.05: and 10.4 +/- 2.3 vs 18.0 +/- 5.1 days, p=0.017), but operating time did not differ significantly., Conclusions: Laparoscopic hepatectomy has the advantages of reducing the amount of operative blood loss because of the magnified view afforded by the laparoscope and shortening the hospital stay. The procedure is therefore recommended for patients with appropriate liver tumors, in particular, hepatocellular carcinoma in the cirrhotic liver.

We report a rare case of bleeding ileal varices successfully treated with emergency enterectomy. A 72-year old woman with hepatic cirrhosis due to hepatitis C was admitted to our hospital because of anemia and hematochezia. An endoscopic examination showed no evidence of bleeding in the upper and lower gastrointestinal tracts. Angiographic studies of portal hemodynamics revealed extravasation from the ileal varices and total occlusion of the portal vein due to portal thrombus. This made it difficult to remove the ileal varices using interventional radiology. Therefore, the patient underwent emergency enterectomy for the ileal varices. No further gastrointestinal bleeding occurred during the 1-year follow-up.

We report a case of hepatocellular carcinoma with situs inversus totalis treated by hepatectomy. A 70-year-old asymptomatic female with hepatocellular carcinomas in segments 5, 6 and 8 underwent transarterial embolization in the department of medicine. However, hepatocellular carcinoma in segment 8 relapsed, and she was referred to the department of surgery. Laboratory tests revealed elevation of serum PIVKA2 level (4,690 ng/mL). Angiography revealed tumor stain in segment 8, 3 cm in diameter. No aberrant vessels were detected on angiography. The operator stood on the patient's left, and partial hepatectomy could be performed safety after careful examination of the anatomy. Although aberrant vessels are detected in many patients with situs inversus totalis, operations can be performed safely on them with sufficient understanding of the anatomy.