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There are two techniques for a spleen-preserving distal pancreatectomy (SPDP): SPDP with splenic vessel preservation, and SPDP with splenic vessel resection. In some cases, although the splenic artery (SpA) can be preserved, the splenic vein (SpV) must be resected. We report the short- and long-term outcomes of three patients who underwent a new technique of laparoscopic SPDP with SpA preservation and SpV resection (SPDP-VRes). A grade B pancreatic fistula, which occurred in two patients, was successfully treated with drainage tube management. In all cases, the omental branches of the left gastroepiploic vein functioned as a drainage vein, and there was no splenomegaly, thrombocytopenia, or varix formation during the follow-up period (19 months to 5 years). Patients undergoing laparoscopic SPDP-VRes had no severe complications during the follow-up period; preserving the left omental branch is a key to this procedure. Laparoscopic SPDP-VRes might be a useful treatment option for patients undergoing SPDP.

The purpose of this study is to clarify the survival benefit and acceptable extent of surgery for very elderly patients with pancreatic cancer. Patients (n=55) ≥80 years with resectable pancreatic cancer were studied. 29 underwent pancreatectomy, 16 underwent chemotherapy, and 10 received best supportive care. Uni and multivariate analysis were performed to explore predictive factors for overall survival (OS) with surgery and chemotherapy (n=45). Postoperative survival of PD (pancreatoduodenectomy) and DP (distal pancreatectomy) and of PD-PVR (PD with portal vein resection) and PD were compared. OS was equivalent with surgery and chemotherapy (median survival time [MST]; 685 vs. 626 days, respectively; p=0.057); 6 patients surivived ≥3 years after surgery. Pancreatectomy was not a prognostic factor. Survival was significantly worse with PD-PVR than with PD, but equivalent with PD and DP. Within 2 years after PD-PVR, 8 patients have died. Surgery was not a positive prognostic factor for very elderly patients with pancreatic cancer, but was the sole chance for survival ≥3 years. Indication for PD-PVR for very elderly patients should be determined more cautiously compared with that for non-elderly patients.

Background Postoperative bleeding originating from pseudoaneurysms after radical gastrectomy is not common, but it can be fatal. In particular, delayed bleeding that occurs after the seventh postoperative day is rare. Case presentation A 54-year-old man underwent laparoscopic distal gastrectomy, D2 lymph node dissection, and Roux en-Y reconstruction for duodenal neuroendocrine tumors. Drainage was performed for a postoperative pancreatic fistula and abdominal abscess. On the 28th postoperative day, he passed a large amount of bloody stool; therefore, emergency esophagogastroduodenoscopy (EGD) and angiography were performed. However, neither examination demonstrated any bleeding foci or pseudoaneurysm. He was conservatively observed and discharged on the 50th postoperative day. Approximately 1 year after the surgery, he passed a bloody stool and experienced hemorrhagic shock. An EGD revealed exposed blood vessels at the duodenal blind end. His condition was diagnosed as a pseudoaneurysm arising from gastroduodenal artery, which ruptured into the duodenum, based on abdominal contrast-enhanced computed tomography findings. Emergency angiography was performed, and the pseudoaneurysm and artery were successfully embolized. Conclusions This case illustrates that there is a possibility of delayed bleeding even 1 year after gastrectomy. Such cases may be serious and require immediate and careful management.

There have been no reports of ruptured solid pseudopapillary neoplasm (SPN) into adjacent organs. A 22-year-old female was referred to our hospital for treatment of a pancreatic head tumor. Computed tomography (CT) examination at our hospital showed a 5-cm tumor containing air, although CT at a previous hospital revealed an 8-cm tumor without air. Thus, a spontaneous rupture of the tumor into the duodenum was suspected. Subtotal stomach preserving pancreaticoduodenectomy with combined resection of the portal vein was performed. Contrast radiography of resected specimen showed the medium injected into the tumor leaking out from the 2nd portion of the duodenum. Histologically, the patient was diagnosed as SPN. Microscopic invasion to the portal vein and duodenum were also confirmed. She did not experience any postoperative complications and has remained well without any signs of recurrence during 2 years of follow-up. Although there have been 14 studies reporting ruptured SPN, this is the first report of SPN that spontaneously ruptured into the duodenum. An extremely rare case of SPN of the pancreatic head that spontaneously ruptured into the duodenum was reported.

Introduction An Amplatzer Vascular Plug (AVP), which was designed as a permanent occluding device derived from the Amplatzer Septal Occluder and Amplatzer Duct Occluder, is a useful embolic device that can be precisely deployed in medium to large vessels with high resistance to migration. However, migration of these Amplatzer devices has been reported as a relatively rare but major complication. Case report A 59-year-old woman was referred for the treatment of advanced pancreatic body cancer; after systemic chemotherapy, distal pancreatectomy with en bloc celiac axis resection (DP-CAR) was planned as curative treatment. Therefore, preoperative embolisation of the common hepatic artery (CHA) for arterial redistribution was performed. Although a 6-mm AVP II was deployed at the mid-portion of the CHA, the AVP migrated to the proper hepatic artery. Although migrated AVP retrieval using a goose neck snare was attempted, it was impossible to retrieve it into the 5-F guiding sheath. Therefore, the AVP was delivered to the splenic artery, which was planned to be resected in DP-CAR. Finally, a 10-mm AVP II was redeployed at the proximal portion of the CHA, and complete occlusion was achieved. Conclusions When AVP retrieval is not possible, delivery to the other arteries having lesser influence might be an alternate technique.

Background The postoperative pancreatic fistula (POPF) rate for duct-to-mucosa and invagination anastomosis after pancreatoduodenectomy is still debated. The aim of this RCT was to investigate the POPF rate for duct-to-mucosa versus invagination pancreaticojejunostomy. Methods Patients were stratified by pancreatic texture and diameter of the main pancreatic duct and randomized to the duct-to-mucosa or invagination group. The primary endpoint was the rate of clinically relevant POPF (defined as grade B or C). Secondary endpoints were suture material cost for pancreaticojejunostomy, drain insertion duration and duration of postoperative hospital stay. Results Some 120 patients undergoing pancreatoduodenectomy were included following consent. Clinically relevant POPF developed in six of 59 patients (10 per cent) in the invagination group and in 14 of 61 patients (23 per cent) in the duct-to-mucosa group (P = 0·077). Duration of drain insertion (6 versus 7 days respectively; P = 0·027) and postoperative hospital stay (19 versus 24 days; P = 0·015) were shorter in the invagination group. Subgroup analysis for 61 patients with a soft pancreas revealed a lower rate of clinically relevant POPF in the invagination group (10 per cent versus 42 per cent in the duct-to-mucosa group; P = 0·010). Among 20 patients with a clinically relevant POPF, the six patients in the invagination group had a shorter duration of drain insertion (38·5 days versus 49 days for 14 patients in the duct-to-mucosa group; P = 0·028) and postoperative hospital stay (42 versus 54·5 days respectively; P = 0·028). Conclusion This study did not demonstrate a superiority of invagination over duct-to-mucosa pancreaticojejunostomy in the risk of POPF. However, in high-risk patients with a soft pancreas, invagination may reduce the risk of clinically relevant POPF compared with duct-to-mucosa. Registration number: UMIN000005890 (http://www.umin.ac.jp).

Herein, we describe the operative procedure for combined resection of re-recurrent lateral lymph nodes and the external iliac vein. There is no consensus on the clinical implications of resection of locally re-recurrent colorectal tumors, as the operative procedure is extremely difficult. We present the case of a 52-year-old woman who underwent abdominoperineal resection. About one year later, we excised a recurrent lymph node in the left lateral obturator area through an extraperitoneal approach. About 18 months later, lymph node re-recurrence in the left external iliac area was observed. Re-recurrent lymph nodes directly invade the left external iliac vein. We removed the re-recurrent lymph node with combined, radical segmental resection of the left external iliac vein, left obturator artery and vein, and left obturator nerve. J. Med. Invest. 65:136-138, February, 2018.

Background/aim The reported incidence of rectovaginal fistula is very low. Although some case reports have described surgical procedures, no systematic approach to the treatment of rectovaginal fistula according to diagnostic image and colonoscopy findings has been proposed. We present a comprehensive surgical strategy for rectovaginal fistula after colorectal anastomosis according to diagnostic image and colonoscopy findings. Patients and methods This retrospective study included 11 patients who developed rectovaginal fistula after colorectal anastomosis. Rectovaginal fistula was classified into 4 types according to contrast enema images and colonoscopy findings, i.e., "Alone type", "Dead space type", "Anastomotic stricture type", and "Dead space and Anastomotic stricture type". The surgical strategies were "Diversion (Stoma)", "Percutaneous drainage", "Anastomotic stricture type", "Endoscopic balloon dilation", "Curettage of foreign bodies", "Simple full-thickness closure", "Split-thickness closure", "Pedicled flaps packing", and "Reanastomosis". The surgical strategy appropriate for each rectovaginal fistula type was investigated. Results Among "Alone type" cases, 5 (71.4%) healed with "only Diversion (Stoma)". "Alone type" cases (n=11) and all other cases (n=4) healed with "only Diversion (Stoma)" (n=5) or any other method (n=6) (p=0.022). Conclusion For treatment of rectovaginal fistula after colorectal anastomosis, less invasive treatment approaches should be attempted first.

Non-ampullary duodenal adenocarcinoma (NADC) is extremely rare. Little is known about its clinicopathological and molecular features or its management. Herein we retrospectively analyzed the cases of 32 NADC patients, focusing on microsatellite instability (MSI), genetic mutations, CpG island methylator phenotype (CIMP), and immunostaining including mucin phenotype and PD-L1 expression. The incidence of MSI, KRAS/BRAF/GNAS mutations and CIMP was 51.6%, 34.4%/3.1%/6.5% and 28.1%, respectively. PD-L1 expression was seen in 34.4% of patients. No significant associations between clinicopathological features and KRAS/BRAF/GNAS genetic mutations or CIMP were found. Histologically non-well-differentiated-type NADCs and those in the 1st portion of the duodenum were significantly associated with later stages (stages III–IV) (P = 0.006 and P = 0.003, respectively). Gastric-phenotype NADCs were frequently observed in the 1st portion and in late-stage patients; their cancer cells more frequently expressed PD-L1. Histologically, the non-well-differentiated type was an independent predictor of PD-L1 expression in cancer cells (OR 25.05, P = 0.04) and immune cells (OR 44.14, P = 0.02). Only late-stage disease (HR 12.23, P = 0.01) was a prognostic factor for worse overall survival in a Cox proportional hazards regression model. Our observation of high proportions of MSI and PD-L1 expression may prompt the consideration of immune checkpoint inhibitors as a new treatment option for NADCs.

A germ cell tumor is the most common form of malignancy in early male life, and can be classified as either seminomatous or nonseminomatous. Choriocarcinoma, comprised of nonseminomatous germ cells, is the most aggressive type of germ cell tumor and characteristically metastasizes to the retroperitoneal lymph nodes and less frequently to the lungs, liver, bone or brain [Shibuya et al., 2009;48: 551–554]. A 56-year-old man was admitted to another hospital complaining of abdominal distension. Symptoms included anorexia, vomiting, and diarrhea. The patient was diagnosed with an extragonadal germ cell tumor and referred to our hospital to receive chemotherapy. The day after admission, the patient’s abdominal distension gradually worsened. An emergency operation revealed venous hemorrhage from the surface of a metastatic extragonadal germ cell tumor between the ligament of Treitz and the inferior mesenteric vein in a horizontal position. Hemostatic treatment was performed with 4-0 proline thread attached to a medicated cotton sponge, rather than using a simple proline thread, and the closure area was manually compressed. Chemotherapy was initiated on postoperative day 10. A metastatic extragonadal germ cell tumor that causes massive hemorrhage and gastrointestinal hemorrhage is very rare, and represents a life-threatening emergency. If the patient’s condition carries a substantial risk of bleeding to death, it may be worthwhile to attempt abdominal operations.

A 77-year-old Japanese female underwent laparoscopic ileocecal resection and lymph node dissection for cecal cancer by a previous doctor. Two years and 9 months after previous operation, contrast-enhanced computed tomography and magnetic resonance imaging with gadolinium ethoxybenzyl-L-diethylenetriamine pentaacetic acid revealed an intraperitoneal tumor at the right subphrenic fossa. 18F-fluorodeoxyglucose position emission tomography showed fluorodeoxyglucose accumulation in the tumor, and we suspected the tumor to be solitary distant peritoneal metastasis of the previous cecal cancer to the right diaphragm. We performed partial diaphragmectomy and direct closure, and pathological examination revealed moderately differentiated tubular adenocarcinoma resembling the previous cecal cancer, which seemed to be disseminated metastasis in the pathological features. Based on the intraoperative findings, we assumed the tumor to be solitary distant peritoneal metastasis caused by procedures during the previous laparoscopic operation. The present report suggests the importance of paying close attention to procedures during laparoscopic colorectal resection to prevent peritoneal seeding. J. Med. Invest. 64: 288-290, August, 2017.

The aim of the present study was to examine the utility of convex endoscopic ultrasonography (EUS) for the preoperative vascular evaluation of malignant biliary tract neoplasm, by comparing EUS findings with histological findings from resected specimens. Between January 2008 and January 2016, the present study retrospectively retrieved 82 cases diagnosed with malignant biliary tract neoplasm to compare findings from convex EUS with histological findings from resected specimens. A total of four groups were defined according to the results of EUS of the hepatic artery (HA) and portal vein (PV): Group 1, hyperechoic tissue between tumor and vessel; group 2, close proximity between tumor and vessel without loss of hyperechoic tissue; group 3, tumor and vessel contiguity, with loss of hyperechoic tissue; and group 4, encasement >180°. Regarding the HA, all 17 cases in groups 2 and 3 in which the tumor was close to the HA however no obvious encasement was evident, demonstrated no histological invasion, or the HA could be separated from the tumor intraoperatively. However, this was not the case for the portal vein. Of the six cases in group 3, 4 cases (66.7%) demonstrated PV invasion. Overall, convex EUS is useful for the preoperative evaluation of malignant biliary tract neoplasms, and surgery may be considered when the tumor is close to the HA on computed tomography scans, however there is no obvious encasement visualized by convex EUS.

We report the case of a 60-year-old male who was diagnosed with gastric cancer. Upper gastrointestinal endoscopy indicated advanced cancer in the posterior wall of the gastric body. Biopsy revealed poorly differentiated adenocarcinoma. Abdominal computed tomography demonstrated thickening of the gastric wall and enlargement of the regional lymph nodes and of the para-aortic lymph nodes (PAN). The involvement of the PAN extended from the celiac axis to the caudal area of the inferior mesenteric artery [cT3N3aH0P0M1(LYM), stage IV]. Systemic chemotherapy was initiated. After 3 courses of S-1 plus cisplatin combination chemotherapy, the primary lesion and the enlarged lymph nodes revealed marked regression except for a minute residual lesion in the lymph nodes. Upon obtaining informed consent, open distal gastrectomy, D2 lymphadenectomy with PAN dissection, and Roux-en-Y reconstruction were performed. The patient was discharged from the hospital 35 days after the operation. Histopathological examination of the resected samples revealed malignant cells only in the PAN, not in the stomach or in the regional lymph nodes [ypT0N0M1(LYM), stage IV]. Currently, the patient is undergoing postoperative adjuvant chemotherapy with S-1 and has remained well without any recurrence after 6 months following surgery.

This study aimed to assess the pathogenic causes, clinical conditions, surgical procedures, in-hospital mortality, and operative death associated with emergency operations at a high-volume cancer center. Although many reports have described the contents, operative procedures, and prognosis of elective surgeries in high-volume cancer centers, emergency operations have not been studied in sufficient detail. We retrospectively enrolled 28 consecutive patients who underwent emergency surgery. Cases involving operative complications were excluded. The following surgical procedures were performed during emergency operations: closure in 3 cases (10.7%), diversion in 22 cases (78.6%), ileus treatment in 2 cases (7.1%), and hemostasis in 1 case (3.6%). Closure alone was performed only once for peritonitis. Diversion was performed in 17 cases (77.3%) of peritonitis, 4 cases (18.2%) of stenosis of the gastrointestinal tract, and 1 case (4.5%) of bleeding. There was a significant overall difference (P = 0.001). The frequency of emergency operations was very low at a high-volume cancer center. However, the recent shift in treatment approaches toward nonoperative techniques may enhance the status of emergency surgical procedures. The results presented in this study will help prepare for emergency situations and resolve them as quickly and efficiently as possible.

Herein, we report coincident recurrences at the port site and functional end-to-end anastomosis after laparoscopic right hemicolectomy for cancer of the ascending colon. The patient was an 83-year-old man who had undergone the aforementioned procedure (Stage IIA) in the referral hospital. At the 10-month follow-up, computed tomography showed two tumours around 3 cm in diameter: one on the right-flank abdominal wall - the surgical port-site - and the other at the functional end-to-end anastomosis. Likewise, a positron emission tomography scan was positive for two tumours. Endoscopic examination showed an ulcerated tumour with a clear margin, and a biopsy confirmed moderately differentiated tubular adenocarcinoma. The patient was diagnosed with coincident recurrences at the port site and functional end-to-end anastomosis after laparoscopic right hemicolectomy for cancer of the ascending colon. We re-operated in March 2016. The tumours at the functional end-to-end anastomosisand functional end-to-end anastomosiswere resected. After 7 months, no recurrence was detected. J. Med. Invest. 64: 177-180, February, 2017.

We report a long-term survivor of colorectal cancer who underwent aggressive, frequent resection for peritoneal recurrences. A 58-year-old woman was diagnosed with descending colon cancer. Resection of the descending colon along with lymph node dissection was performed in September 2006. The pathological findings revealed Stage IIA colorectal cancer. The following peritoneal recurrences were removed: two in July 2007, two in the omental fat and two in the pouch of Douglas in June 2008 resected by low anterior resection of the rectum, one in the uterus and right ovarian recurrence resected via bilateral adnexectomy and Hartmann’s procedure in May 2011, and one in the ascending colon by partial resection of the colon wall in December 2011. Postoperative adjuvant chemotherapy (uracil and tegafur/leucovorin, fluorouracil/levofolinate/oxaliplatin/bevacizumab, 5-fluorouracil/leucovorin/bevacizumab, irinotecan/bevacizumab, and irinotecan/panitumumab) was administered. The patient did not desire postoperative adjuvant chemotherapy after the fourth operation. The long-term survival was 6 years and 7 months.

We retrospectively evaluated rectal cancer surgery cases in which resection had been performed for invasion of other organs in terms of pathologic findings from the viewpoint of sex differences. We enrolled 61 consecutive patients with rectal cancer who had undergone curative surgery with resection of invaded adjacent organs. We investigated invasion of adjacent organs in terms of pathologic findings according to sex differences. Among males, 4 cases (13.8%) had received combined radical resections of more than 2 organs, while the number of such female cases was 15 (46.9%). The difference between males and females was statistically significant (P = 0.006). Among male cases, histopathologic invasion was present in 4 (13.8%), while 9 female cases (28.1%) showed this feature. Nevertheless, there was not a statistically significant difference between males and females (P = 0.08); the rate in females was roughly twice that in males. No significant difference was recognized in the overall survival rates between males and females, but more females than males experienced local recurrence. In cases with rectal cancer invading neighboring organs, the effect of the invasion must be carefully determined, and the most appropriate operative approach selected accordingly.

A sufficient surgical margin is critical for preventing re-recurrence and achieving R0 status after resection of a local recurrence of rectal cancer (LRRC).Re-recurrence-free survival was analyzed in 110 cases of LRRC according to histological type of primary lesion. The circumferential resection margin (CRM) was classified as 'R1' (x=0 μm), 'R0 shortness' (0 μmx2,000 μm), or 'R0 longness' (x≥2,000 μm). The histological change from the primary lesion to the recurrent lesion was classified as 'No change pattern', from well- to moderately-differentiated (W/M) to an expanding lesion; as 'Change pattern', from W/M to an infiltrating lesion.Re-recurrence-free survival was better in 'R0 longness' than 'R0 shortness' groups and showed that 'No change pattern' cases had considerably better prognosis than 'Change pattern' cases.Ensuring a CRM2,000 μm during resection of LRRC is more likely to prevent re-recurrence. Cases with poorly differentiated carcinoma from the primary lesion to the recurrent lesion tend to have poor prognoses.

Pathological complete response to systemic chemotherapy is associated with more favorable survival in patients with colorectal cancer liver metastases. We present a case of a 63-year-old man with multiple liver metastases from descending colon cancer. Following surgical resection of the primary tumor, the patient received systemic chemotherapy with S-1 and oxaliplatin in combination with bevacizumab. On achievement of a markedly favorable response to chemotherapy, surgical treatment of liver metastases was performed, and the liver tumors were successfully resected without any macroscopic residue. Histopathological analyses showed necrotic tissue in the complete absence of residual viable tumor cells. This is the first reported case of a patient with multiple liver metastases from descending colorectal cancer to achieve a pathological complete response following systemic chemotherapy with S-1 and oxaliplatin in combination with bevacizumab. This regimen is a systemic chemotherapy option to 'cure' liver metastasis from colorectal cancer.

症例は87歳の女性で，72歳時，直腸癌で内視鏡的粘膜下層剥離術を受け，深達度smであった．84歳時，下行結腸癌で下行結腸切除術を受けた．85歳時，直腸傍リンパ節の再発巣が膣へ浸潤し穿孔したため，後方骨盤内臓全摘術を受けた．2007年4月（86歳），大腸癌の異時性多発肝転移（左外側区域，右後下区域（S6），右前上区域（S8））と診断した．左外側区域の腫瘍には門脈内腫瘍栓を認めた．同年6月（87歳），肝左葉切除，左尾状葉切除，肝S6，S8部分切除，肝外胆管を温存した総肝動脈周囲および肝十二指腸間膜内リンパ節郭清を施行した．摘出標本では，左外側区域の腫瘍は門脈内腫瘍栓の他に胆管内腫瘍栓も伴っていた．病理組織学的には腺癌であり，大腸癌肝転移，門脈内および胆管内腫瘍栓として矛盾なく，傍胆管リンパ節に転移を認めた．術後経過は良好で，術後第15病日に退院した．術後1年1か月間，無再発生存中で，まれな進展形式をとった肝転移と考えられた．

Rectourethral fistula is one of the complications that can occur after prostatectomy in the urologic discipline. However, a delayed-onset rectourethral fistula after intersphincteric resection (ISR) for low rectal cancer is extremely rare. Here, we report one such case in a 57-year-old man. After ISR for low rectal cancer with a diverting stoma (DS), the DS was closed. After approximately 1 year, frequent pneumaturia and right orchitis were observed. Results of contrast enemas and abdominal computed tomography examinations revealed a rectourethral fistula from an anastomosis to the urethra. The colonoscopic appearance revealed a pinhole fistula on the anastomotic line, with thick pus. We performed a transverse colostomy, and the pneumaturia and right orchitis were no longer observed. Two months later, colonoscopy, contrast enemas, and cystoscopy revealed no rectourethral fistula. To the best of our knowledge, our case is the first report of a delayed-onset rectourethral fistula after ISR.

A resected case of hepatocellular carcinoma which extended into the right atrium after treatment with hepatic arterial infusion chemotherapy (HAIC) is described. An 81-year-old man presented with right hypochondralgia. CT demonstrated a hypervascular tumor 11.5 cm in diameter extending into the right atrium through the right hepatic vein. The patient underwent HAIC with 100 mg of cisplatin (CDDP IA-call®) particles three times every month. The tumor showed a marked shrinkage and an involution of the venous thrombus around the orifice of the right hepatic vein. Right hemihepatectomy with tumor thrombectomy was performed as a salvage surgery using a total hepatic vascular exclusion technique. Histologically, the tumor turned into diffuse necrosis and fibrosis, so viable tumor cells were encountered neither in the main tumor nor venous thrombus. The therapeutic effect of HAIC was pathological complete remission. The patient has been doing well for 6 years after the surgery without evidence of tumor recurrence. The salvage operation was safely achievable for the initially unresectable advanced hepatocellular carcinoma extending into the right atrium.

症例は48歳,男性.平成5年に胃平滑筋肉腫(体上部小彎,直径4cm)のため胃全摘術を当科で施行し,病理ではlow grade malignancyと診断された.その後再発を認めなかったが平成12年8月,腹部腫瘤を主訴に受診した.精査の結果肝左葉全体を占める巨大な胃平滑筋肉腫の肝転移と診断.平成12年9月12日肝左葉切除術を施行した.病理検査の結果,胃平滑筋肉腫の肝転移と診断,原発巣より悪性度を増していた. 3カ月後残肝に再発し,肝動注療法を行ったが手術から13カ月後に死亡した.胃平滑筋肉腫は肝転移の頻度が多いと報告されているが肝切除施行例の報告は少なく,検索しえた限りでは自験例を含み28例であった.また7年後に発見され切除しえたものは稀であった.自験例のように原発巣が比較的小さく,病理検査でlow grade malignancyと診断されたにもかかわらず,術後7年を経過して再発をきたすものもあり,長期間の慎重なfollow upが必要であると思われた.

OBJECTIVE To retrospectively evaluate relative enhancement (RE) in the hepatobiliary phase of gadoxetic acid disodium-enhanced magnetic resonance (MR) imaging as a preoperative estimation of future remnant liver (FRL) function in a patients who underwent portal vein embolization (PVE). MATERIALS AND METHODS In 53 patients, the correlation between the indocyanine green clearance (ICG-K) and RE imaging was analyzed before hepatectomy (first analysis). Twenty-three of the 53 patients underwent PVE followed by a repeat RE imaging and ICG test before an extended hepatectomy and their results were further analyzed (second analysis). Whole liver function and FRL function were calculated on the MR imaging as follows: RE x total liver volume (RE Index) and FRL-RE x FRL volume (Rem RE Index), respectively. Regarding clinical outcome, posthepatectomy liver failure (PHLF) was evaluated in patients undergoing PVE. RESULTS Indocyanine green clearance correlated with the RE Index (r = 0.365, p = 0.007), and ICG-K of FRL (ICG-Krem) strongly correlated with the Rem RE Index (r = 0.738, p < 0.001) in the first analysis. Both the ICG-Krem and the Rem RE Index were significantly correlated after PVE (r = 0.508, p = 0.013) at the second analysis. The rate of improvement of the Rem RE Index from before PVE to after PVE was significantly higher than that of ICG-Krem (p = 0.014). Patients with PHLF had a significantly lower Rem RE Index than patients without PHLF (p = 0.023). CONCLUSION Relative enhancement imaging can be used to estimate FRL function after PVE.

腹腔鏡下総胆管切開切石術の利点,欠点を明らかにし,今後の標準術式となり得るかを検討した.(方法) 1995年1月から2000年3月までに当科で手術治療を受けた総胆管結石症例97例のうち開腹症例43例と,腹腔鏡症例54例から開腹移行例,経胆嚢管切石例を除く44例の間で比較検討を行った.(結果)手術時間は腹腔鏡症例で有意に長かった(196分vs. 259分, P

SUMMARY Assessment of surgical resectability in cholangiocarcinoma is more complicated than other gastrointestinal malignancies and remains unestablished. According to the primary origin and tumor extent, the applied surgical procedure varies from extrahepatic bile duct resection to right or left trisectionectomy concomitant with pancreatoduodenectomy. Portal vein resection and reconstruction during hepatectomy has been feasible. Thanks to the availability of new microscopic surgical techniques, hepatic arterial resection and reconstruction have also come to be applied for locally advanced cholangiocarcinoma cases. These vascular surgical techniques can expand surgical indications for advanced cholangiocarcinoma. On the other hand, determination of the tumor extent or staging still remains difficult and imprecise. The endoscopic approach has come to play significant roles both for preoperative biliary drainage and tumor staging. Estimation of the functional reserve of future remnant liver in cholestatic patients still remains unresolved. Hepatobiliary surgeons should carefully estimate the safety of the surgical procedure in each individual patient requiring extensive hepatobiliary resection. Early establishment of the measurement methods of the functional capacity of future remnant liver is an important and urgent issue for assessing safer surgical resectablity of cholangiocarcinoma.

A 16-year-old man was seen at the hospital because of upper abdominal pain, and admitted with adiagnosis of intestinal obstruction. On the second day after admission, the abdominal pain intensified and ascites appeared. Laparotomy was carried out with the diagnosis of strangulation ileus. The intestinal loop was strangul ated by a cord. The necrosed intestine and the cord were resected. The cord appered to be vitellin cyst. In this case, there was no inflamation, any cord reaching to the abdominal wall, nor inhasion in the vitellin cyst itself, but the vitellin cyst winded itself round the small intestine forming a knot to strangulate it. It presented an extremely specific morphology. Such cases are so rare. As for even Meckel's diverticulum which is representative vitellin duct rest, so far only six foreign cases and two domestic cases have been seen. No cases of strunglation ileus due to vitellincyt like in this case have been reported as far as we could review.

A 37-year-old man was seen at the hospital because of right lower abdominal pain. Abdominal ultra-sonography (US) visualized a tumor on the right side of the umbilicus. The CT scan visualized an elliptical stratified structure extending from the middle upper to the right lower abdomen. Laparotomy was carried out. Laparotomy findings disclosed that the tumor was in the greater omentum with necrosis and 3 clockwise rotations. The greater omentum was resected at the normal site. It is said that preoperative diagnosis of omental torsion is difficult because this condition is a relatively rare and lacks specific clinical symptoms. There are a few reports that CT scan or US was carried out before an operation because these case are treated as acute abdomen. In this paper a case of the disease is reported with a review of the US and CT scan findings. The specific findings of this disease is a tumor under the abdominal wall in US, and a whorl-like or stratified structure in CT scan. These findings seem to make it possible to diagnose this disease preopera-tively.

We report a patient with stage IV mucinous carcinoma of the colon who is surviving for 7 years after the initial operation with resection of metastatic foci 4 times. The patient was a 47-year-old man. In October, 1990, he underwent a laparotomy for a cancer of the transverse colon adhered to the jejunum, when peritoneal dissemination was noted in the greater omentum and resections of the transverse colon, jejunum and omentum with colostomy were performed. Pathological report was mucinous carcinoma, H0, P1 and stage IV. Another peritoneal dissemination involved the descending colon and ileum appeared and was resected in November 1993. A recurrence of the abdominal wall incision appeared and was resected in February, 1996. Peritoneal dissemination involved the ileum and left ureter appeared which was resected in May, 1997 and metastasis to the left external iliac lymph node was resected in March, 1998. In spite of 4 times of operations for metastasis, the patient is doing well as of 7 years after the initial operation. It is thought that we were able to resect lesions because no synchronous multiple metastasis had occurred. The positive additional resection for metastasis is useful for long term survival if the lesion is solitary.

We experienced 47 cases of common bile duct stone, which were treated under laparoscopy. Procedures included choledocholithotomy in 34 cases and trans-cystic choledocholithotomy in 13 cases. For 30 cases of choledochotomy, we performed primary closure. Operating time were between 90 minutes and 622 minutes. In choledochotomy cases mean operating time was 249 minutes and in trans-cysticduct cases 282 minutes. As to 15 cases treated recently, a mean operating time was remarkably shortened to 194 minutes. We experienced no morbid complications. Bile leakage occured in 7 of 30 chledochotomy cases, but stopped in several days. Mean hospital stay was 10.8 days in choledochotomy cases and 8.2 days in trans-cystic duct cases. In conclusion, laparoscopic treatment for common bile duct stone is safe and useful method, which can reduce the wound pain and shorten the hospital stay. In the near future, it will become the standard treatment of common bile duct stone.

To examine the usefulness of the histopathological finding of tumor necrosis for stratifying TNM stage IV colorectal cancer in R0 status.We enrolled 98 patients with stage IV colorectal cancer, without residual disease after resection. The extent of necrosis was assessed using published thresholds, the extent was graded as "absent", "moderate" (30% of tumor area), or "severe" (≥30%) in each section.In multivariate analysis, the only significant difference in the disease-free survival rate was related to tumor necrosis (p=0.01) and the significant differences in the overall survival rates were related to the maximum tumor size and the degree of tumor necrosis (p=0.02 and p=0.001, respectively).Tumor necrosis is associated with a poor prognosis in colorectal cancer and may allow the stratification of TNM stage IV patients without residual disease after surgery.

We aimed to clarify the clinicopathological features of poorly differentiated colorectal adenocarcinomas and to define two subtypes of these adenocarcinomas.We enrolled 78 patients, who had undergone surgery for poorly differentiated colorectal adenocarcinoma. On the basis of the microscopy results, the Por1 type is characterized by cancer cells with solid growth and little stroma; most cells contained round-shaped nuclei. The Por2 type is characterized by cancer cells with a predominantly trabecular structure; these tumors are rich in fibrous stroma. The two groups were compared for clinicopathological factors.The frequency of metastasis of the lymph node, liver, lung, and peritoneum in the Por2 group was significantly higher than that in the Por1 group. The survival rate in the Por2 group was lower than that in the Por1 group.The classification system described in this study is a simple and easy method for predicting poorly differentiated colorectal adenocarcinomas, and the prognosis of patients with Por2 tended to be unfavorable than that of Por1.

BackgroundPerihilar cholangiocarcinoma (PHCCA) remains a surgical challenge for which few large Western series have been reported. The aims of this study were to investigate the results of surgical resection for PHCCA and assess how practice has evolved over the past 15 years.MethodsA prospectively maintained database was interrogated to identify all resections. Clinicopathological data were analysed for impact on survival. Subsequently, data for resections carried out during the periods 1994–1998, 1999–2003 and 2004–2008 were compared.ResultsEighty-three patients underwent resection. Trisectionectomy was required in 67% of resections. Overall survival was 70%, 36% and 20% at 1, 3 and 5 years, respectively. Size of tumour, margin (R0) status, lymph node status, distant metastasis, tumour grade, portal vein resection, microscopic direct vascular invasion, T-stage and blood transfusion requirement significantly affected outcome on univariate analysis. Distant metastasis (P= 0.040), percutaneous biliary drainage (P= 0.015) and blood transfusion requirement (P= 0.026) were significant factors on multivariate analysis. Survival outcomes improved and blood transfusion requirement was significantly reduced in the most recent time period.DiscussionBlood transfusion requirement and preoperative percutaneous biliary drainage were identified as independent indicators of a poor prognosis following resection of PHCCA. Longterm survival can be achieved following the aggressive surgical resection of this tumour, but the emergence of a clear learning curve in our analyses indicates that these patients should be managed in high-volume centres in order to achieve improved outcomes.

症例は50歳代，女性．糖尿病と体重減少で2007年9月に前医を受診，膵尾部に嚢胞性腫瘍を指摘され精査加療目的で当院紹介．US，CT，EUSで膵尾部から腹側に突出する径8cm，比較的厚い被膜を有する嚢胞を認めた．嚢胞と膵の境界部には2cm大の充実性腫瘤が存在し，脾静脈は閉塞し，膵後面結合織への浸潤が疑われた．以上の所見から，浸潤性粘液性嚢胞腺癌を第一に考え，10月膵体尾部·脾切除，横行結腸切除，左腎部分切除を施行した．切除割面で嚢胞は単房性で，嚢胞壁に連続して3.5cmの結節が存在した．病理所見では充実性部分は管状腺癌の所見で，癌は3/4周にわたり嚢胞壁に沿って浸潤，また脾静脈，横行結腸，腎被膜にも浸潤していた．嚢胞上皮は腺腫∼癌の所見を認めたがovarian-like stromaは認めなかった．本例の病態としては浸潤性粘液性嚢胞腺癌，膵管内腫瘍由来浸潤癌，通常型膵癌+貯留嚢胞の可能性が考えられたが，いずれかに決定できる所見は得られなかった．

With advances in surgical procedures and perioperative management, hepato-biliary-pancreatic surgery, including hepatectomy and pancreaticoduodenectomy, has been employed for recurrent colon cancer. However, no report has described a case of major hepatectomy with the combined resection of hepaticojejunostomy following pancreaticoduodenectomy for locoregionally recurrent colon cancer. Here, such a case is reported. The patient, a 37-year-old woman, had undergone pancreaticoduodenectomy for lymph node recurrence along the extrahepatic bile duct from cecal cancer. Thirteen months later, a biliary stricture was found at the hepaticojejunostomy site and right hepatectomy was performed. The resected specimen showed a papillary tumor at the hepaticojejunostomy. Based on its histological features, the pathogenesis of this tumor was considered to be intramural recurrence via lymphatic vessels. Although she underwent resection of a lymph node recurrence at her mesentery 12 months later, she has remained well thereafter, without any sign of further recurrence during 5 years of follow-up after hepatectomy.