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We present a rare case of concurrent resection of pancreatic and gastric cancer in which indocyanine green (ICG) fluorescence was used to evaluate the remnant stomach. An 80-year-old man was referred with a tumor in the distal pancreas. Computed tomography showed a 25-mm mass in the pancreatic tail; endoscopic ultrasound-guided fine-needle aspiration revealed adenocarcinoma. Upper gastrointestinal endoscopy and subsequent upper gastrointestinal series revealed advanced gastric cancer in the mid-stomach. Concurrent resection of the pancreatic and gastric tumors was performed. After distal pancreatectomy and distal gastrectomy, ICG evaluation of the stomach showed fluorescence extending only 3 cm distal from the cardia. To avoid ischemic change at the remnant stomach, total gastrectomy was performed. Since remnant gastric necrosis and anastomotic leak following ischemia can lead to fatal outcomes, the use of ICG to evaluate blood supply at anastomotic sites can help determine the extent of safe resection in such cases.

A 68-year-old man was followed up with chronic kidney disease. Follow-up CT incidentally detected a tumor at the left kidney and multiple small nodular shadows in the lungs bilaterally. The patient underwent needle biopsy and was diagnosed with Xp11.2 translocation renal cell carcinoma (RCC) pathologically. Hence, laparoscopic nephrectomy was performed. Fluorescence in situ hybridization analysis revealed a break-apart of the transcription factor E3 (TFE3) genes in the left tumor. After 2 months postoperatively, nivolumab and ipilimumab were administered thrice intravenously, considering the intermediate risk by the IMDC risk classification. However, pleural effusion occurred but was removed adequately. Lung metastasis decreased, but new metastasis occurred at the left iliopsoas muscle. Target therapy was performed with axitinib. Unfortunately, he died 6 months later postoperatively. These tumors commonly occur in children than in adults, and very rare in elderly patients. Xp11.2 translocation RCC in the elderly has a poorer prognosis than that in children. To date, no effective treatment for Xp11.2 translocation RCC has been established.

We report a case of ureteral stump carcinoma following a radical nephrectomy for renal cell carcinoma. A 76-year-old man was diagnosed as having ascending colon cancer and a right renal carcinoma. He was treated with partial colon resection and radical nephrectomy without lymphadenectomy. The histology was renal cell carcinoma. Three years after that surgery, he complained of intermittent macrohematuria. Abdominal computed tomography (CT) suggested a solid mass in the pelvis. We then performed a biopsy with CT guidance. An epithelial tumor was suspected by immunohistochemistry. A total excision of ureter was then performed. The histology showed the features of urothelial carcinoma, G3, v(+), pT3. He received adjuvant chemotherapy with gemcitabine and cisplatin. He was free of disease for the following 11 months.

To determine whether preoperative white blood cell (WBC) counts reflect risk of anastomotic leak (AL) for patients with colorectal cancer (CRC), we retrospectively examined data from records of 208 consecutive patients who had undergone resections for left-sided CRC, including their clinicopathological parameters and preoperative laboratory data. The diagnostic value of WBC count for AL was evaluated and compared with those of neutrophil-lymphocyte ratio, platelet-lymphocyte ratio, lymphocyte-monocyte ratio and platelet count × C-reactive protein level multiplier (P-CRP) value; optimal cut-off values were derived from receiver operating characteristic curves. AL was observed in 11 of the 208 patients (5.3%). Compared with the no-AL group, the AL group had a significantly higher mean WBC count and smoking rate. In multivariate analysis, WBC count and smoking were independent risk factors for AL. Compared with the other tested inflammatory indicators, the cut-off value for WBC (6,200/μL) had the highest sensitivity (81.8%) and negative predictive value (98.4%), as well as the lowest likelihood ratio (0.289). Preoperative WBC count could therefore be a convenient predictor of AL in patients with left-sided CRC.

We report a case of tacrolimus vascular toxicity found on a protocol biopsy shortly after a deceased donor renal transplantation. The patient was immunologically high-risk and acute antibody-mediated rejection during post-transplant dialysis phase was suspected on the protocol biopsy. Although the patient was stable after treatment of rejection, a further examination showed a very rare but specific side-effect of tacrolimus. It is sometimes difficult to make a differential diagnosis during postoperative dialysis period among AMR, primary non-functioning, drug toxicity, infection or just prolonged recovery from the damage of a long agonal phase on the non-heart beating donor. Although the possibilities of coexistence of rejection or other causes such as infection have not been completely excluded, it is important to be aware of this unusual side effect of tacrolimus.

TPS474 Background: Adjuvant chemotherapy with S-1 in patients with resected pancreatic ductal adenocarcinoma (PDAC) improved the 5-year survival rate to 44.1% and therefore has been a standard of care in Japan. Recent epidemiologic data has revealed possibility of metformin (a drug for type II diabetes) improving the prognosis of PDAC. In this context, we compare the efficacy and safety of S-1 plus metformin with S-1 alone as adjuvant chemotherapy in patients with resected PDAC. Methods: This multicenter-randomized-phase II study is conducted at 29 institutions in Japan (Registry Number; UMIN000020681). Key eligibility criteria are age 20 years or more with good performance status; histologically proven PDAC of stage I-II without macroscopic residual tumor. Patients receiving preoperative treatment for PDAC and previously treated with DPP-4 inhibitor, GLP-1, and metformin are excluded. After giving written consent to the study, patients are randomly assigned either study group (S-1 plus metformin) or control group (S-1 alone), balancing residual tumor status, nodal status, and institutions. S-1 is given orally for 2 weeks in a 3-week cycle. Cycles are lasted for 6 months. In the study group, metformin is administrated together with S-1 for 2 years. The treatment would be discontinued when the patient has either recurrence or unacceptable toxicity. The primary endpoint is 2-year OS, and the secondary endpoints are relapse-free survival and incidence rate of adverse events. Sample size was calculated based on the data in previous trials, with an expected 2-year survival rate in the control group of 65%. An improvement in 2-year-survival rate from 65% in the control group to 78% in the study group, yielding a hazard ratio of 0.58, is considered clinically relevant in this population. A total of 73 events in each group were required for a power of 80% at a two-sided alpha 20% to detect a difference in OS using an unstratified log-rank test. A total of 160 patients (80 per group) were estimated to achieve the specified number of events in the scheduled follow-up. Duration of this study would be 5 years and it has been started from January 2018. Until September 2018, 17 patients have been enrolled. Clinical trial information: UMIN000020681.

症例は19歳の男性で,腹部USで偶然に右肝静脈根部S7領域に直径2cmの腫瘤が発見された.血液検査ではHCV抗体, HBs抗原は陰性, AFP, PIVKA-II, 肝機能は正常であった. CT, MRI, 血管造影では全体に明瞭な造影効果を認めたが,中心性瘢痕やspoke wheel appearanceは描出されなかった.画像所見からは肝細胞腺腫や肝細胞癌との鑑別は困難であり,外科的に腫瘍を切除した.腫瘍は直径27mmの被膜を有さない単結節型であった.組織学的には中心性瘢痕は認められなかったが,異型に乏しい肝細胞の増生と,グリソン鞘では線維化と胆管の増生を認め,肝限局性結節性過形成 (FNH) と診断した.中心性瘢痕, spoke wheel appearance, Kupffer細胞の存在はFNHに特徴的な所見ではあるが,典型的な所見を呈する症例は少なく,肝細胞癌との鑑別は困難である.また右斜め胴切り開胸開腹法は,右肝静脈根部近傍を安全に操作するのに適したアプローチと思われた.

原発性直腸癌様所見を呈した胃癌術後直腸転移の1例を経験したので報告する.症例は58歳,女性. 1999年5月,胃癌の診断にて胃全摘術を施行した.病理組織学的所見はpor, se, INFγ, ly1, v0, n2 (+), stage IIIB,根治度Bであった.術後外来にてfollow中, 2001年12月,便秘症状がしだいにひどくなったため精査を施行した.注腸造影では直腸Raに比較的境界明瞭な約5cm大の全周性の狭窄を,また腹部CTでは直腸に全周性の壁肥厚を認め,直腸癌の診断にて低位前方切除術を施行した.病理組織学的には,胃癌と同等な低分化型腺癌が粘膜下層を中心に増殖しており,胃癌の直腸転移と診断した.胃癌の大腸転移は稀な疾患であり切除可能な症例は極めて少ない.中には原発性大腸癌との鑑別が困難な症例も散見される.注腸X線検査の詳細な検討による診断と治療方針の決定が必要とされる.

We report herein the case of a 70-year-old woman found to have a gastrointestinal stromal tumor (GIST) of the stomach. Preoperative X-ray and endoscopic examination revealed a hemispheric submucosal tumor with central depression in the anterior wall of the gastric fornix. The tumor, which was 3 cm in diameter, was resected by a laparoscopy-assisted procedure. Histologic examination revealed that it was composed of spindle-shaped cells with elongated nuclei, and few mitoses. Most of the tumor cells showed immunoreactivity for vimentin and CD34, but not for alpha-smooth muscle actin, desmin, or S-100 protein. The PCNA index was 40.5%. Thus, the GIST did not show differentiation toward smooth muscle or neural cells. A gastrectomy was not performed because the small size of the tumor, and the paucity of the mitoses indicated that it was benign. Nevertheless, careful and long-term follow-up is needed to monitor for signs of possible local recurrence or distant metastases.

A 48-year-old man was admitted to the hospital because of fresh anal bleeding and pyrosis.Preoperative examination revealed advanced esophageal cancer (Im, 3'type) and rectal cancer (Rb, 2'type). Under a diagnosis of synchronous double primary cancer of the esophagus and rectum, an operation was performed on one-step approach. A subtotal esophagectomy with lymph node dissection and reconstruction of esophagus by gastric roll was performed, followed by a low anterior resection for the rectal cancer. Postoperative course was uneventful, but pharyngeal, tongue and mediastinal lymph nodes metastases of the esophageal cancer occurred. Radiation and chemotherapy were added, but the patient died 2 years after the operation. Pre-operative laboratory data showed a slight immunodeficient tendency and postoperative immunohistochemical examination revealed genetic arrangement of p 53 cancer suppressed gene in both the esophageal and rectal cancers. It was suggested that carcinogenesis might correlate with immunodeficiency and genetic alteration in synchronous multiple cancer.

Using desensitization protocol, we performed a secondary donor specific antibody (DSA) positive and ABO incompatible kidney transplantation. One-hour biopsy showed no C4d deposition. The protocol biopsy after 2 weeks showed diffuse C4d deposition with peritubulitis. After 12 weeks, however, the protocol biopsy showed disappearance of tubulitis in spite of remaining C4d deposition. The recipient was in stable condition with excellent graft function despite high titer of the DSA. Monitoring of protocol biopsy is critical while antibody titer and the interpretation of the histological findings correlating with clinical markers must be considered.

We report the response of two patients with advanced nonfunctioning islet cell carcinoma of the pancreas with liver metastases treated with a combination of surgi-cal resection and transarterial embolization (TAE), using Lipiodol with epirubicin. After pretreatment evaluation, the two patients were diagnosed with nonfunctioning islet cell carcinoma of the pancreas with liver metastases. Preoperatively, in both patients, TAE was performed through the hepatic arteries, using Lipiodol and sponzel plus epirubicin. Surgical resection of the primary tumor (radical distal pancreatectomy and pancreaticoduodenectomy) was performed. After surgical resection and evaluation of the malignant histopathological features of the neoplasms, chemotherapy, which included oral 5-fluorouracil (FU), and transarterial infusion therapy, using Lipiodol with epirubicin, was administered to the patients. Follow-up evaluation of the two patients by computerized tomography (CT) scan showed a reduction in the size of the metastatic hepatic masses after several chemoembolizations through the hepatic arteries. This combined treatment modality may be an effective therapeutic strategy for improved management of patients with advanced nonfunctioning islet cell carcinoma of the pancreas with liver metastases.

肝内胆管B7に限局した原発性硬化性胆管炎 (PSC) の1例を経験したので報告する.症例は71歳の男性. 胃検診で異常を指摘され精査目的で当院を受診した. 胃内視鏡検査にて胃癌 (0'IIc, T1 (M), tub1) と診断され, 同時に施行した腹部US, CT検査にて肝内胆管B7の限局性の拡張が認められ, 精査目的で入院した. MRI, ERC, PTCの検査を施行し, 肝内結石症あるいは肝内胆管癌の疑い, および胃癌の診断にて, 肝後区域切除術, 胃切除術を施行した. 肝内胆管B7は著明に拡張しており, その起始部は狭窄していたが, 結石, 腫瘍は認めなかった. 病理組織像では, 胆管壁の著明な線維性肥厚像と強い炎症性細胞浸潤がみられ, 肝内限局型PSCと診断した. 限局型PSCの中でも肝亜区域に限局したものは過去に報告のないまれな疾患である. 限局型PSCは診断が困難であるが, 進行性の疾患であること, 胆管癌の合併がみられることから, 切除術を考慮すべきである.

Postoperative delirium is a common complication which can interfere with the surgical treatment and recovery of elderly patients, and is likely to prolong their hospitalization. Unfortunately, there is as yet no completely effective pre- and/or post operative technique of patient care to reduce or prevent postoperative delirium. In this study, 36 patients aged over 70 years undergoing gastrointestinal operations were assessed to examine the relationships between the preoperative cognitive state, the postoperative sleep cycle, and the occurrence of postoperative delirium. All patients were evaluated preoperatively using the revised version of Hasegawa's dementia scale (HDS-R). We correlated those test results and assessed the sleep-wakefulness disturbance postoperatively, to obtain a clinical DMS-III diagnosis of postoperative delirium. The incidence of postoperative delirium was 17% (6/36). The patients who developed postoperative delirium demonstrated preoperative cognitive impairment, and had a short sleep period during the night and a long sleep period during the day. Postoperatively, these results suggest that HDS-R is a useful method of evaluating preoperative cognition in elderly patients. Considering that sleep deficiency is likely to predispose elderly patients to postoperative delirium, techniques to prevent sleep deprivation may be of considerable value in minimizing the incidence of postoperative delirium.

A 69-year-old man was admitted to the department for operation with a diagnosis of early esophageal cancer and adenoma of the ampulla of Vater that was revealed by upper GI series with biopsies at medical checkup. The tumor of the ampulla of Vater was diagnosed with adenoma and no remnant tumor in the resected stumps was confirmed by intraoperative frozen section diagnosis, the operative procedures comprised local resection of the ampulla of Vater, sphincteroplasty and nonthorocotomic esophagectomy. Histopathologically, the resected specimen of the papilla showed adenoma with moderately-severe atypia and just partially disclosed carcinoid (2mm) in adenoma. Cancer change of adenomas of the ampulla of Vater occurs in a high frequenty and we have difficulty in the treatment. Previous cases of cancer in adenoma of the ampulla of Vater have been performed pancreatoduodenectomy (PD) and no local lymph node involvement has been reported in all cases. So, it is thought that local resection can be indicated, if no remnant tumor in the resected stumps is confirmed by intraoperative frozen section diagnosis.

Hepatocellular carcinoma (HCC) is one of the most common human malignancies in the world and it is especially prevalent in Asia and Africa (1). Some tumors are suitable for resection, however, there is a very high rate of recurrence (2). Infection with hepatitis B or C virus, alcoholic cirrhosis, and ingestion of aflatoxin B1-contaminated food are important risk factors for HCC (3,4), but the exact molecular mechanism of tumorigenesis is still unclear.