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We report the long-term survival of a patient with metastatic breast cancer treated with trastuzumab and chemoendocrine therapy. The patient was a 60-year-old female. She underwent right mastectomy with axillary lymphadenectomy I c for advanced right breast cancer in 1999. In 2007, she consulted our hospital for treatment of recurrent giant liver metastasis. A giant liver metastasis up to 15 cm in diameter was detected by CT upon arrival. After 4 years of trastuzumab and chemoendocrine therapy, she was diagnosed as in progressive remission with good quality of life. Breast cancer with liver metastasis often can be life-threatening. Therefore, an optimal chemotherapy should be applied as soon as possible. Trastuzumab and chemoendocrine therapy showed efficacy for the treatment of a HER2-positive breast cancer with recurrent giant liver metastasis.

To clarify the clinical features of acute acalculous cholecystitis (AAC), we reviewed 113 cases of AAC experienced from January, 2000 to December, 2007 in regard to patient background, etiology, imaging diagnosis, treatment, and outcomes. Functional bile stasis caused AAC in 34 of 113 cases (30.1%), and 28 of those developed in a nosocomial manner (82.4%). On the contrary, mechanical bile stasis caused 37 cases (32.7%), and all but one case developed in a community-acquired manner. mechanical bile stasis included 9 cases of biliary tract neoplasm (5, cystic duct cancer; 3, gallbladder cancer; 1, papillary adenoma). Since considerable cases of AAC were caused by biliary tract neoplasm, we have to pay attention to their existences.

We report a case of multiple sequential celiacsplenic aneurysms which we removed completely without arterial reconstruction. The patient was a 67-year-old man. During work-up for hypertension and diabetes, a splenic artery aneurysm was identified on abdominal ultrasonography. Follow-up examination 1 year and 3 months later showed enlargement of the aneurysm. The patient was referred to our Radiology Department for treatment. Abdominal computed tomography and angiography of the celiac trunk showed that the celiac artery was narrowed and then dilated to form a fusiform aneurysm. Splenic artery aneurysms were identified immediately distal to the bifurcation with the common hepatic artery, measuring about 5 cm and 3 cm. These findings ruled out treatment by interventional radiology, and surgery was performed. At laparotomy, a white, 5-cm aneurysm was densely adherent to the pancreas, and separation was impossible. We performed en bloc resection of the pancreatic body and tail, spleen, celiac artery, and common hepatic artery. Since pulsation in the replaced right hepatic artery and the color of the stomach were good, we did not perform an arterial reconstruction. Although the surgical treatment of aneurysms generally consists of resection and arterial reconstruction, we resected the lesion safely and completely without arterial reconstruction.

Background/aims: The differences in long-term results of distal splenorenal shunt with splenopancreatic and gastric disconnection (DSRS with SPGD) for portal hypertension of different etiologies including non-cirrhotic portal hypertension have yet to be reported. The data are important to determine the indications and contraindications for this procedure., Methodology: Records of 54 patients of esophagogastric varices who survived 3 years or longer after DSRS with SPGD operation were reviewed. Patients were divided into three groups based on underlying liver disease; posthepatitic cirrhosis (HC) group, alcoholic cirrhosis (AC) group, and idiopathic portal hypertension (IPH) group., Results: The only serious long-term complication of DSRS with SPGD was portal thrombosis in two patients in the IPH group. Postoperative bleeding occurred in two cases of each group; one in IPH group was the only variceal bleeding and others were bleeding from portal hypertensive gastropathy. Hepatocellular carcinoma (HCC) was developed in 28.6% patients in both the HC group and AC group. In all the cases, treatment for HCC was accomplished without aggravation of the varices. The cumulative survival rate was similar in the three groups, and no patient died of gastrointestinal bleeding., Conclusions: A favorable outcome was achieved by DSRS with SPGD operation both in the patients with cirrhosis or IPH. Underlying liver disease is not a factor when considering DSRS with SPGD for portal hypertension.

Pancreatoduodenectomy is not optimal for organ preservation in patients with mucosal carcinoma of the choledochus. When the lesion spreads near the papilla of Vater, pancreas-preserving biliary amputation may be indicated to achieve complete resection of the biliary system. The first successful case is reported here with technical considerations. First, the pancreatic neck was divided and a tube was inserted into the main pancreatic duct beyond the papilla. The choledochus was dissected downward with division of the posterior pancreatoduodenal vessels. The main pancreatic duct was isolated with the aid of palpation of the tube, and was then ligated and divided. Subsequent dissection was performed to the level of the duodenal mucosa, which was incised circularly. The duodenal defect was then closed. The elevated jejunum was interposed between the pancreatic stumps and bilateral pancreaticojejunostomies were created. The procedure was successfully performed in a patient with superficially spreading cholangiocarcinoma. Postoperative bile leak and pancreatic fistula were controlled with medical management. The patient is currently well without tumor recurrence 19 months after surgery. Her glucose tolerance, which was moderately impaired preoperatively, has been maintained. Pancreas-preserving biliary amputation has been developed as an organ-preserving procedure alternative to pancreatoduodenectomy. Indications, methods of pancreatic reconstruction, and long-term results require further study.

Selective hepatectomy under the guidance of hepatic venous drainage has not yet been developed because hepatic venous occlusion alone produces no visible congested area. Now that this area can be identified by simultaneous occlusion of the hepatic vein and artery, venous-drainage-guided selective hepatectomy is considered feasible. Because the congested area becomes dysfunctional or atrophic due to the absence of portal blood supply, it can be regarded as a first candidate for preventive resection in livers that may bear latent tumors. We report here a novel approach to selective hepatectomy. Segment 4 hepatectomy and ventral hemisectorectomy of segments 5+8, with middle hepatic vein resection, was undertaken in a patient with hepatocellular carcinoma. After hepatic dissection between segments 2+3 and 4, the root of the middle hepatic vein was isolated. Test clamping of the middle hepatic vein and proper hepatic artery demonstrated a discolored area. Hepatic dissection was performed along the discolored border towards the hepatic hilum, exposing the right anterior portal pedicle with division of the ventral branches. The middle hepatic vein was finally divided. Selective hepatectomy was successfully performed without transfusion or complications. Venous-drainage-guided selective hepatectomy is feasible with acceptable perioperative results.

Background/aims: Radical distal pancreatectomy with en-bloc resection of the common hepatic, celiac, and left gastric arteries for pancreatic body cancer that involves these arteries does not routinely require arterial reconstruction because the collateral pathways via the pancreatoduodenal arcades from the superior mesenteric artery are recruited immediately. However, accidental injury to the pancreatoduodenal artery compromises collateral blood flow and may lead to fatal complications. This article describes the middle colic artery-gastroepiploic artery bypass as an emergent salvage procedure for restoring collateral flow., Methodology: The inferior pancreatoduodenal artery was accidentally injured in 2 of 9 patients who underwent the radical procedure between 1997 and 2001. Microvascular anastomosis between the left branch of the middle colic artery and the gastroepiploic artery in an end-to-side fashion was employed., Results: The pulsation of the gastroepiploic artery and the color of the stomach recovered immediately after completion of the middle colic artery-gastroepiploic artery bypass. No ischemia-related complication developed postoperatively. Postoperative angiography showed the middle colic artery-gastroepiploic artery bypass supplying arterial flow to the liver, stomach, duodenum, and pancreas., Conclusions: The middle colic artery-gastroepiploic artery bypass is an excellent alternative restoring compromised collateral flow via the pancreatoduodenal arcades when microsurgical technique is available.

We present 2 cases of primary sclerosing cholangitis complicated with autoimmune pancreatitis with narrowing of the pancreatic duct. In both cases, endoscopic retrograde cholangiography showed the characteristic findings of primary sclerosing cholangitis. In addition, positivity for autoantibody, hypergamma-globulinemia and narrowing of the pancreatic duct shown on endoscopic retrograde pancreatography were noticed in both. They were thu diagnosed as autoimmune pancreatitis. Whereas it is well known that primary sclerosing cholangitis is often complicated with chronic pancreatitis, it has rarely been studied whether the chronic pancreatitis is autoimmune pancreatitis or not. In English literature, possibly 7 equivalent cases have been reported so far. In those cases, the onset was in the post-prime of life, and the disease was frequently accompanied with Sjögren's syndrome, but not with ulcerative colitis; frankly the nature of the disease was slightly different from what has traditionally been thought as a typical primary sclerosing cholangitis. In primary sclerosing cholangitis complicated with autoimmune pancreatitis, the autoimmune mechanism seems to be much involved, and thus steroid therapy might be effective as in Case 2 in our series.

Background/aims: While hemostasis by transcatheter arterial embolization is often the first choice in the initial treatment of ruptured hepatocellular carcinoma, post-transcatheter arterial embolization treatment has not fully been established. We studied the prognoses of ruptured hepatocellular carcinoma cases where hepatectomy was possible after transcatheter arterial embolization., Methodology: We retrospectively reviewed 10 cases of ruptured hepatocellular carcinoma which had been treated in our institution between 1989 and 1998. In all the 10 cases, emergency transcatheter arterial embolization was performed, which successfully achieved hemostasis., Results: Following the achievement of hemostasis by transcatheter arterial embolization, hepatectomy was carried out in 5 cases after evaluation of general condition, functional liver reserve and extent of tumor spread. There was neither operative nor hospital death. One-year and 3-year survival rates were 100% and 40%, respectively, and 50% survival time was 36 months. In the other 5 patients, hepatectomy was decided to be impossible after evaluation of general condition, functional liver reserve and extent of tumor spread; all of them died within 0.5-10 months after transcatheter arterial embolization., Conclusions: Among the patients with ruptured hepatocellular carcinoma, those in which hepatectomy was decided to be possible after evaluation of general condition, functional liver reserve and extent of tumor spread, following successful hemostasis by transcatheter arterial embolization, had fairly good prognoses.