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Our aim was to determine the utility of Tc-99m-diethylenetriaminepentaacetic acid-galactosyl human serum albumin single-photon-emission computed tomography (99mTc-GSA SPECT/CT) fusion imaging for detecting incomplete portal vein embolization (PVE). Fifty-five candidates underwent PVE. Among them, five underwent second PVE. Detectability of first inadequate PVE using CT and 99mTc-GSA SPECT/CT fusion imaging was analyzed. Cases of inadequate PVE were detected in three patients using CT and in five using 99mTc-GSA SPECT/CT fusion imaging. Fusion imaging detected two cases of insufficient PVE in which portal branches were apparently well embolized on CT. Median value for volumetric rate in the embolized liver was 63.3% after the first PVE and 54.7% after the second (P more...

Among elderly patients with severe trauma, the sites of massive hemorrhage and their clinical characteristics are not well understood. Therefore, we investigated the sites of massive hemorrhage in patients with severe trauma, and compared the results for younger and elderly patients.A cohort of severe trauma patients (Injury Severity Score ≥16) admitted from March 2007 to December 2014 was reviewed retrospectively. The inclusion criterion was massive bleeding, which was defined as bleeding that required the transfusion of ≥10 red cell concentrate units within 24 hours of admission, or as cases of early death that occurred despite continuous blood transfusion and before the patient could receive ≥10 red cell concentrate units within the first 24 hours after their admission.Eighty-four patients met our inclusion criterion. The younger group (65 years old) included 40 patients (48%), whereas the older group (≥65 years old) included 44 patients (52%). The percentage of nondiagnosable cases at the primary survey (massive bleeding due to multisite damage caused by a bone fracture or contusion, retroperitoneal hematoma without a pelvic ring fracture and with stable pelvic ring fracture) was 14% in the younger group and 40% in the older group (odds ratio, 3.92; 95% confidence interval, 1.37-11.27, P = .017).Even if no abnormalities are observed at the primary survey of elderly patients with severe trauma, physicians should consider the possibility of massive bleeding. more...

There are no accepted surgical strategies for the treatment of pancreatic cancer recurrence in the remnant pancreas after initial resection. We retrospectively analyzed our experiences with patients undergoing completion pancreatectomy for recurrent pancreatic cancer in the remnant pancreas.Six patients with recurrent pancreatic cancer in the remnant pancreas underwent completion pancreatectomy between March 2005 and December 2012. Operative, postoperative, and pathological data and long-term outcomes for these six patients were analyzed retrospectively.There was no operative morbidity or mortality associated with completion pancreatectomy. The median survival times were 49.0 and 27.5 months after initial resection and second pancreatectomy, respectively. However, all six patients died during follow-up. Five patients had recurrent pancreatic cancer at the time of death. One patient had no recurrence but had poor blood sugar control and eventually died after repeated bouts of cholangitis.Completion pancreatectomy is a safe and effective option in select patients with local pancreatic cancer recurrence in the remnant pancreas after initial pancreatectomy. It is essential to select patients who have a good performance status and can tolerate major surgery and the resultant apancreatic state. more...

Some clinicians have argued that combining pancreatic and portomesenteric venous resection could improve the rates of long-term survival. However, whether resection of the portosplenomesenteric vein could provide an acceptable survival benefit to patients with pancreatic cancer involving the portosplenomesenteric system remains controversial. The purpose of this study was to determine the significance of pathological portosplenomesenteric venous invasion on survival in patients who underwent surgical management for pancreatic adenocarcinoma. Patients who underwent curative surgical treatment were divided into two subgroups: those with pathological invasion to the portosplenomesenteric vein (PV-positive group) and those without invasion (PV-negative group). Of 160 studied patients, the median overall survival was 48.0 months after pancreatic surgery in the PV-negative group and 18.0 months in the PV-positive group. The incidence of postoperative peritoneal dissemination was significantly lower in the PV-negative group than in the PV-positive group. Accordingly, patients in the PV-negative group showed a cumulative rate of pancreatic cancer recurrence at 2 years after pancreatic surgery of 54.4 %, while this rate was 89.4 % in the PV-positive group. Finally, an elevated presurgical serum CA19-9 level (>700 IU/mL) was found to be significantly associated with a poor outcome after surgery in pancreatic cancer patients with pathological portosplenomesenteric venous invasion. Pancreatic cancer carries a high risk of recurrence even if surgical resection is technically possible. The current study suggested that portosplenomesenteric involvement and preoperative high serum CA19-9 are poor prognostic indications; however, the findings provided little insight into the role of neoadjuvant therapy in such patients. more...

The treatment of locally advanced unresectable pancreatic cancer remains extremely challenging, particularly as the efficacy of concurrent chemoradiotherapy (CRT) remains unclear.We studied 93 patients (8.0%) with locally advanced unresectable pancreatic cancer without distant metastases from among a total group of 1168 patients who were diagnosed with pancreatic cancer from March 2005 to November 2015 at the Kochi Health Sciences Center, Kochi, Japan. We therefore evaluated the clinical efficacy of CRT in patients with locally advanced unresectable pancreatic cancer.Of the 93 patients with locally advanced unresectable pancreatic cancer, 35 patients (37.6%) were subsequently classified as having resectable disease following CRT. The median overall survival of patients who received CRT alone for locally advanced unresectable pancreatic cancer was 8.0 months, and all died within 3 years. On the other hand, the overall 1-, 3- and 5-year survival rates in patients who were reclassified as having resectable tumour after CRT were 71.3%, 39.2% and 23.5%, respectively. Our pathological assessments after surgical resection suggested that CRT might be associated with a significant reduction in the risk of lymph node metastases in patients with locally advanced unresectable pancreatic cancer.The results of this study suggested that CRT is clinically effective in improving survival, particularly in association with the resultant possibility of curative resection. Advances in knowledge: The best treatment strategy for patients with locally advanced unresectable pancreatic cancer is the subject of considerable debate, and CRT is only recommended if cancer has only grown around the pancreas without any distant metastases. more...

Complete surgical resection remains the only curative treatment option for pancreatic neuroendocrine tumor (PNET). However, the proper management of PNET with liver metastasis remains debatable. We describe two patients with PNET and multiple liver metastases that were treated with aggressive surgical resection. In one case, a 45-year-old man with non-functional PNET with unresectable liver metastases received cytoreductive operation for both primary PNET and liver metastatic lesions. Thereafter, he received somatostatin analog after transcatheter arterial chemoembolization for residual liver metastases. In the other case, a 70-year-old man with functional PNET, gastrinoma, and resectable liver metastases underwent surgical resection with intent-tocure. Post-operatively, everolimus was administered as an adjuvant treatment. These patients survived after surgical management. These cases suggest that aggressive surgical management with multimodal therapy for PNET with metastases may be effective in achieving long-term survival. more...

The objective of this study was to determine the utility of Tc-99m-diethylenetriamine-penta-acetic acid-galactosyl human serum albumin ((99m)Tc-GSA) single-photon emission computed tomography (SPECT)/CT fusion imaging for posthepatectomy remnant liver function assessment in hilar bile duct cancer patients.Thirty hilar bile duct cancer patients who underwent major hepatectomy with extrahepatic bile duct resection were retrospectively analyzed. Indocyanine green plasma clearance rate (KICG) value and estimated KICG by (99m)Tc-GSA scintigraphy (KGSA) and volumetric and functional rates of future remnant liver by (99m)Tc-GSA SPECT/CT fusion imaging were used to evaluate preoperative whole liver function and posthepatectomy remnant liver function, respectively. Remnant (rem) KICG (= KICG × volumetric rate) and remKGSA (= KGSA × functional rate) were used to predict future remnant liver function; major hepatectomy was considered unsafe for values0.05. The correlation of remKICG and remKGSA with posthepatectomy mortality and morbidity was determined.Although remKICG and remKGSA were not significantly different (median value: 0.071 vs 0.075), functional rates of future remnant liver were significantly higher than volumetric rates (median: 0.54 vs 0.46; P .001). Hepatectomy was considered unsafe in 17% and 0% of patients using remKICG and remKGSA, respectively. Postoperative liver failure and mortality did not occur in the patients for whom hepatectomy was considered unsafe based on remKICG. remKGSA showed a stronger correlation with postoperative prothrombin time activity than remKICG.(99m)Tc-GSA SPECT/CT fusion imaging enables accurate assessment of future remnant liver function and suitability for hepatectomy in hilar bile duct cancer patients. more...

52歳の女性で, 平成13年6月頃昼頃突然左側腹部から背部痛出現し近医を受診した. CTおよび腹部超音波検査にて膵尾部に4cm大の膵嚢胞を認め当院消化器科に紹介された. 上腹部造影CT検査で, 脾上極の梗塞とそれに連続して膵尾部から脾門部にかけて辺縁に造影効果のある嚢胞性腫瘤を認め, 膵尾部腫瘍による脾梗塞と診断し手術を施行した. 開腹所見は膵尾部から脾門部において硬い腫瘤を触知した. 脾上極は嚢胞を形成し腫瘤と一塊となっていたため, 膵尾部脾合併切除を行った. 病理検査は膵尾部の嚢胞性膵癌で, 脾動脈分枝内に腫瘍浸潤を認めた. またその末梢で脾は虚血性変化を示しており, 嚢胞性膵癌による脾梗塞と診断された. 膵疾患による脾合併症は比較的まれであり, 脾梗塞を合併する事は極めてまれである.今回我々は脾梗塞を合併した浸潤性粘液性膵嚢胞腺癌の1例を経験したので報告した. more...

Acute coagulopathy of trauma has been much discussed recently. However, the changes in coagulation markers after trauma in the elderly are unknown. Furthermore, the baseline fibrinogen level is high in elderly patients, and the question remains as to whether fibrinogen levels also decrease early and the degree of decrease in elderly trauma patients. The purpose of this study was to compare coagulation markers including the fibrinogen level on admission in younger and elderly severe trauma patients.A cohort of severe trauma patients (Injury Severity Score (ISS) ≥16), admitted from January 2011 to June 2014, with coagulation markers including the fibrinogen level on admission available, was reviewed retrospectively. The patients were divided into a younger (16-64 years old) and an older (≥65 years old) group based upon their age at presentation. Activated partial thromboplastin time (aPTT), international normalized ratio (INR), fibrinogen, and D-dimer were compared between the younger and older groups.There were 251 patients who met the inclusion criteria for this analysis. The younger group included 117 patients and the older group included 134 patients. The median aPTT (26.3 vs 27.5s, P=0.001) and median D-dimer levels (18.8 vs 40.2 μg/dL, P=0.006) were significantly higher in the older group. However, the fibrinogen level (205 vs 248 mg/dL, P0.001) was significantly higher in the older group. The regression lines of fibrinogen and age in non-massive transfusion and massive transfusion cases are given by Y=1.03 X+185 (r=0.24, r(2)=0.06, P0.001) and Y=0.86 X+134 (r=0.25, r(2)=0.06, P=0.09) respectively, and the fibrinogen levels tended to increase with older age in severe trauma patients.The fibrinogen level did not show a low value as it can in younger patients in elderly patients. Therefore, the fibrinogen level is difficult to use as an early indicator of acute blood loss with haemorrhage in elderly severe trauma patients, as it can be used in younger patients. Thus, it is necessary to keep in mind that the fibrinogen level increases by approximately 1mg/dL when the age increases by 1 year and to carefully observe the fibrinogen level even if the admission level is not low. more...

Xanthogranulomatous changes in the pancreas are extremely rare. A 66-year-old man presented with a 2-year history of epigastralgia. Computed tomography scan revealed a 4-cm low-density area around the body of the pancreas. Magnetic resonance imaging demonstrated that the mass appeared hyperintense on a T2-weighted image and isointense on a T1-weighted image. Based on a diagnosis of invasive ductal carcinoma of the pancreas, distal pancreatectomy and splenectomy were performed. Sections examined from the mass showed an aggregation of many foamy histiocytes, lymphocytes, and plasma cells. The surrounding pancreatic tissue showed fibrosis and chronic inflammation. These findings suggested a xanthogranulomatous inflammation, and resulted in a diagnosis of xanthogranulomatous pancreatitis. more...

Current case is the third report of S-1 chemotherapy against acinar cell carcinoma (ACC) of pancreas, and our patient has achieved the longest reported recurrence-free survival, longer than 6 years, despite the presence of disseminated nodules at laparotomy. A 77-year-old man presented with abdominal discomfort. Computed tomography showed a low-density tumor in the pancreas tail and the patient was referred for surgery. A 3-cm sized pancreatic tumor, with localized disseminated nodules, was detected on laparotomy. Distal pancreatectomy with concomitant resection of disseminated nodules was performed, and histopathological examination revealed an ACC. Oral S-1 chemotherapy was administered postsurgery, and the patient showed no sign of recurrence during 73 months of follow-up. This is the first report of long-term survivor of pancreatic ACC with peritoneal dissemination, following pancreatectomy and S-1 chemotherapy. Current case suggests a beneficial effect of S-1 chemotherapy in cases of ACC. more...