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As a part of community screening, a 64-year-old man underwent gastric fluoroscopy, which revealed abnormalities indicative of a type 3 tumor. Contrast-enhanced abdominal computed tomography showed advanced gastric cancer with multiple regional lymph nodes and liver metastases. Chemotherapy was initiated, and after completion of 2 courses of capecitabine (Cape)and oxaliplatin(OHP)therapy, a distalgastrectomy was performed. The response to chemotherapy was Grade 2, and the lymph node status was pN1(1/17). The patient was strongly positive for HER2; thus, 4 courses of Cape, OHP, and trastuzumab(T-mab)therapy were administered for the metastatic liver lesions, and the liver metastases shrank markedly. S5 subsegmentectomy and S7 partial resection were performed subsequently, and pathological analysis showed completely necrotic tissue. Remarkable progress has been made in chemotherapy for gastric cancer, and the use of T-mab in combination is extremely effective for gastric cancer that is strongly positive for HER2. In our patient, we resected the primary lesion and liver metastatic lesions after neoadjuvant chemotherapy. The metastatic lesion showed complete response(CR). Metastases and recurrences can even occur in patients with primary and/or metastatic lesions who show a CR. Furthermore, whether cancers that are strongly positive for HER2 are recurrent remains unknown. The patient is alive and recurrence-free after having undergone a hepatectomy.

Diffusion-weighted whole-body imaging with background body signal suppression (DWIBS) images show significant contrast for cancer tissues against non-cancerous tissues. Fusion of a DWIBS and a T2-weighted image (DWIBS/T2) can be used to obtain functional, as well as anatomic, information. In the present study, the performance of DWIBS/T2 in the diagnosis of abdominal solid cancer was evaluated. The records of 14 patients were retrospectively analyzed [5 patients with hepatocellular carcinoma (HCC), 4 with metastatic liver cancer, 3 with pancreatic cancer, 1 with renal cellular carcinoma and 1 with malignant lymphoma of the para-aortic lymph node]. T1WI and T2WI scans did not detect pancreatic cancer in certain cases, whereas DWIs and DWIBS/T2 clearly demonstrated pancreatic cancer in all cases. In addition, metastatic liver cancer and HCC were successfully detected with abdominal US and CECT; however, US did not detect pancreatic cancer in 1 case, while CECT and DWIBS/T2 detected pancreatic cancer in all cases. In conclusion, the diagnostic performance of DWIBS/T2 was the same as that of abdominal US and CECT in detecting primary and metastatic liver cancer. DWIBS/T2 enabled the diagnosis of pancreatic cancer in cases where it was not detected with US, T1WI or T2WI.

Diffusion-weighted whole-body imaging with background body signal suppression (DWIBS) yields positive results for cancer against the surrounding tissues. The combination of DWIBS and T2-weighted images (DWIBS/T2) in the diagnosis of gastrointestinal tract cancers was retrospectively analyzed in the present study. Patients were subjected to magnetic resonance imaging after cancer was diagnosed through specimens obtained via biopsy or endoscopic mucosal resection. Sixteen patients were assessed between July, 2012 and June, 2013 and the correlation between detection with DWIBS/T2 and T staging was analyzed. Regarding patients who underwent surgery, the correlation between detection with DWIBS/T2 and the diameter or depth of invasion was analyzed. All cancers that had advanced to >T2 stage were detectable by DWIBS/T2, whereas all cancers staged as T2) or invading beyond the muscularis propria.

Gastric cancer is classified into two subtypes, diffuse and intestinal. The diffuse-type gastric cancer (DGC) has poorer prognosis, and the molecular pathology is not yet fully understood. The purpose of this study was to identify functional secreted molecules involved in DGC progression. We integrated the secretomics of six gastric cancer cell lines and gene expression analysis of gastric cancer tissues with publicly available microarray data. Hierarchical clustering revealed characteristic gene expression differences between diffuse- and intestinal-types. GDF15 was selected as a functional secreted molecule owing to high expression only in fetal tissues. Protein expression of GDF15 was higher in DGC cell lines and tissues. Serum levels of GDF15 were significant higher in DGC patients as compared with healthy individuals and chronic gastritis patients, and positively correlated with wall invasion and lymph node metastasis. In addition, the stimulation of GDF15 on NIH3T3 fibroblast enhanced proliferation and up-regulated expression of extracellular matrix genes, which were similar to TGF-β stimulation. These results indicate that GDF15 contributes to fibroblast activation. In conclusion, this study revealed that GDF15 may be a novel functional secreted molecule for DGC progression, possibly having important roles for cancer progression via the affecting fibroblast function, as well as TGF-β.

今回，我々は食道内分泌細胞癌術後の肝再発に対して外科的治療を行い，その後無再発生存中の1症例を経験したので報告する．症例は72歳の男性で，胸部中下部食道癌に対して右開胸開腹食道亜全摘術＋3領域郭清を施行．病理組織学的検査所見にて高分化型扁平上皮癌の診断であった（pT3N0M0，pStage II）．術後9か月の腹部CTにて単発性肝腫瘍を認めた．精査にて他部位に異常を認めず，食道癌術後肝再発の診断で切除術を施行した．病理組織学的検査所見にて内分泌細胞癌の診断であったため，先の食道癌手術標本に免疫染色検査を施行したところ一部に内分泌細胞成分を認めたことからの食道癌の内分泌細胞成分からの転移と判断した．

当科において過去19年間に経験した胃癌穿孔症例は24例でありうち23例に手術を施行した．同時期の胃癌手術症例の1.5％，胃穿孔の24.0％をしめる．20例が緊急手術例でありうち10例（50％）を術前に胃癌と診断したが，内7例は穿孔前に胃癌と診断されていた．手術23例中18例に切除術を施行しそのうち2例は2期的切除であった．Stage III:6，IV:7，根治度A:2，B:9，C:12と高度進行例が多い．根治度A症例は長期生存したが，Bには長期生存がなかった．根治度Cの予後は不良であり，手術関連死6例（26.1％）中5例が根治度Cであった．胃癌と確診され根治性のある症例は1期的に根治切除を考えるが穿孔時の診断は不確実でありその場合に穿孔部閉鎖を行い胃癌であれば2期的に根治術を行う方針は有用と考えられる．高度進行例で全身状態不良な症例も多くその場合は最低限の侵襲に留めるべきである．

肝細胞癌（HCC）の腫瘍マーカーとしてα-fetoprotein（AFP），AFPのレクチン分画（L3），protein induced by vitamin K absence or antagonist-II（PIVKA-II）が臨床で頻用されている．各々非担癌状態でも増加することは良く知られているが，非担癌状態でこの3者が同時高値をとることは極めて稀である．今回我々は，HCCで過去2回肝切除の患者の腫瘍マーカーが急上昇し，HCC再々発と誤診した症例を経験したので報告する．症例は67歳男性，平成13年12月，単発のHCCで肝右葉切除．平成15年1月，肝尾状葉に再発し，尾状葉切除．平成16年9月，各腫瘍マーカーの急上昇と共に肝S4切離面に画像状腫瘤像を認め，HCC再々発と診断，S4切除施行．切除標本の病理組織は黄色肉芽腫性腫瘤であった．3回目手術から約1年後，胆管気管支瘻による重症肺炎のため亡くなったが，剖検でもHCCの再発は認めなかった．

Background/Aims Liver failure associated with infections after hepatectomy remains a cause of mortality. It has recently been reported that toll-like receptor 4 (TLR4) is involved in recognizing lipopolysaccharides (LPS). The aim of this study was to investigate the role of TLR4 in endotoxin-induced liver injury after hepatectomy. Methods C3H/HeN and C3H/HeJ mice underwent 70% hepatectomy or sham surgery, and LPS was administered 48h after surgery. Expression of TLR4 mRNA, nuclear factor-κB (NF-κB) activation, tumor necrosis factor-α (TNF-α) and serum ALT levels, histological findings, and myeloperoxidase content were examined. Survival after LPS administration was also determined. Results Hepatic expression of TLR4 was significantly increased 6–72h after hepatectomy. In mice with endotoxemia after hepatectomy, hepatic NF-κB activation was greatly increased. Hepatic mRNA and serum levels of TNF-α, and ALT levels were significantly elevated compared with sham operated controls. Focal necrosis with neutrophil infiltration was apparent, which is consistent with increased myeloperoxidase contents in endotoxemia after hepatectomy in C3H/HeN mice. These were completely absent in C3H/HeJ mice. Survival of C3H/HeN mice with endotoxemia after hepatectomy was significantly lower than that of C3H/HeJ mice. Conclusions Upregulated TLR4 expression and function after hepatectomy plays a pivotal role in endotoxin-induced liver injury after hepatectomy.

Although extracellular heat-shock protein 70 (Hsp70) potentially mediates an inflammatory response, the association of circulating Hsp70 with complications after surgery is poorly understood.Perioperative plasma concentrations of Hsp70 and interleukin-6 were measured by immunoassays in 64 consecutive patients undergoing liver resection.Plasma concentrations of Hsp70 and interleukin-6 showed a striking increase immediately after surgery, and on postoperative day 1. The Hsp70 levels correlated significantly with operation time, hepatic ischemia time, postoperative alanine aminotransferase levels, and maximum interleukin-6 levels (P0.01). The Hsp70 and interleukin-6 concentrations were associated significantly with postoperative infection (P0.05); Hsp70 concentrations and blood loss but not interleukin-6 were associated significantly with postoperative organ dysfunction (P0.05) in multivariate analyses.These results suggest that circulating Hsp70 and IL-6 potentially play a pivotal role in pathophysiology of postoperative infection, and that circulating Hsp70 and blood loss may represent a prognostic marker for postoperative organ dysfunction.

OBJECTIVE. Splenectomy is the standard surgical treatment for hereditary spherocytosis, but partial splenic embolization is another potential option. We retrospectively studied the therapeutic effects of partial splenic embolization as a treatment for hereditary spherocytosis.CONCLUSION. Partial splenic embolization is a safe and effective alternative to splenectomy or partial splenectomy in the treatment of hereditary spherocytosis.

Background/Purpose. The aim of this report was to assess the outcome of aggressive surgical treatment for intrahepatic cholangiocarcinoma. Methods. From 1984 to 2001, we encountered 64 patients with intrahepatic cholangiocarcinoma. Of the 64 patients, 50 patients who underwent surgical resection with macroscopically curative objectives (78%) were reviewed for surgical procedures and outcomes. Results. Hemi- or more extensive hepatectomy was required for surgical resection in 40 patients (80%). Overall hospital morbidity and mortality rates were 50% and 8%, respectively. Curative resection with pathological free margins was achieved in 34 patients (68%). The 1-, 3-, and 5-year patient survival and tumor-free survival rates were 61.6%, 37.6%, and 22.5%; and 55%, 11%, and 11%, respectively. Among the macroscopic types, all 9 patients with intraductal growth type are alive 11–75 months after surgery. Survival rates among patients who had undergone curative resection were significantly better than those in patients who had undergone noncurative resection, even when patients with the intraductal growth type were excluded. Nodal status did not affect patient survival. Conclusions. Although the overall survival rate after surgical resection remains unsatisfactory, long-term survival is possible through extended surgical resection with pathological free margins. Patients with the intraductal growth type of intrahepatic cholangiocarcinoma might have the best chance of being cured by surgical treatment.

進行膵癌(Stage IVa)膵全摘術後,外来通院中, 9年を経て血清CA19-9値の上昇から両側の肺病変が判明し2度にわたり左右の肺切除を施行し病変を摘出しえた症例を経験した.肺病変摘出標本の病理像は粘液産生を伴う乳頭状腺癌を主体としたもので, 9年前に全摘術を施行した膵癌と酷似した病理像を示し,膵癌の肺転移と考えられた.腎癌など他臓器からの膵転移に対して膵切除がなされた報告は比較的多いが,進行膵癌の長期生存例自体少なく,まして膵癌の遠隔臓器転移に対し根治的手術が施行されたケースは,文献検索をした限り見いだしえなかった.長期生存を得ることの出来た症例では,例え膵癌であっても再切除あるいは転移巣切除可能な場合もあるので厳重な経過観察が必要と考えられた.

われわれは,胆管空腸吻合術後の吻合部狭窄に対してexpandable metallic stent (EMS)が留置され,その7年後のステント閉塞に対し,外科的治療を施行した1例を経験したので報告する.症例は48歳,女性.主訴は発熱,黄疸.前医にて先天性総胆管拡張症の診断にて胆管切除,胆管空腸吻合術を施行.その1年後に吻合部狭窄を発症し再吻合術を施行したが,術後再び狭窄をきたしたため, EMSを留置した.以後,胆管炎症状を繰り返していたが, EMS留置7年後に急性閉塞性化膿性胆管炎となりPTBD施行し,ステント部での胆管閉塞を認め当科紹介となった.当科にてPTCSにて癌合併なしを診断後,開腹にて胆管空腸吻合部を切開しEMSを除去,さらに吻合部とその肝側の肥厚した胆管を切除し,肝門部にて胆管空腸再吻合術を施行した. RTBDステントチューブは再狭窄予防の目的で術後6カ月で抜去した.術後17カ月現在経過良好である.

Although splenectomy is a standard surgical treatment for chronic idiopathic thrombocytopenic purpura, partial splenic embolization is another treatment option. We retrospectively studied the long-term results of initial and repeated partial splenic embolization.Thirty-nine patients, 15 men and 24 women, underwent initial embolization; 12 of the 39 underwent a repeated embolization. The therapeutic effects of the initial and repeated embolization were classified as a complete response if the patient's platelet count rose to more than 10 x 10(4)/ micro L without medication 1 year after the initial or repeated embolization, as a partial response if the platlet count reached 5-10 x 10(4)/ micro L under the same circumstances, or as no response.Twenty patients (51%) responded to the initial embolization (complete response in 11 and partial response in nine). No significant differences were found between those patients who responded to the treatment (responders) and those who did not respond to the treatment (nonresponders) in age, sex, lowest platelet counts, and steroid response before embolization. Peak platelet response was significantly higher in the responders (p = 0.029). One of the 11 complete responders and five of the nine partial responders relapsed after a median follow-up period of 34 months (range, 15-23 months) and underwent repeated embolization, resulting in complete response in one patient, partial response in the remaining four patients, and no response in one patient. However, in the six nonresponders (to the initial embolism), repeated embolization elicited a partial response in only one patient. The remission rate of 51% was maintained by means of repeated embolization for a median follow-up period of 76 months after the initial embolization.Partial splenic embolization combined with repeated embolization may be an effective alternative to splenectomy in the treatment of chronic idiopathic thrombocytopenic purpura.

Background: Poly-adenosine diphosphate (ADP)-ribosylation, catalysed by poly(ADP-ribose) polymerase (PARP), is a post-translational modification of nuclear proteins and is involved in a wide range of biological processes including DNA repair, cell proliferation and malignant transformation. Alteration of this reaction in human hepatocellular carcinoma (HCC) is of interest, but has not yet been explored. The aim of this study was to evaluate poly-ADP-ribosylation and to compare the expression of PARP in HCC and adjacent non-tumour tissues. Methods: Tumorous and adjacent non-tumorous tissues were obtained from five consecutive patients with HCC during surgery for tumour resection. Tissue homogenates were subjected to ADP-ribosylation with [32P]-nicotinamide adenine dinucleotide. The ADP-ribosylated proteins were separated by sodium dodecylsulfate–polyacrylamide gel electrophoresis, followed by autoradiography. Expression of PARP was also evaluated by western blotting. Results: Several proteins were ADP-ribosylated in human HCC tissues. Notably, the radiolabelling of a 116-kDa protein was remarkably greater than that in adjacent non-tumorous tissues (86.5 ± 35.2 arbitrary units by densitometry vs 12.2 ± 9.9, mean± SD, n = 5, P < 0.02). The radiolabelling of the 116-kDa protein was decreased in the presence of PARP inhibitors in a concentration-dependent manner. Immunoblot analyses revealed that the radiolabelled protein was PARP and that its expression was significantly greater in HCC than in adjacent non-tumorous tissues (333 ± 204% of non-tumorous tissue, P < 0.05). Conclusions: We found that poly-ADP-ribosylation and PARP expression were significantly increased in human HCC compared with those in adjacent non-tumorous tissues in surgically obtained specimens.

Activation of ADP-ribosylation factors (ARFs), approximately 20-kDa GTPases that are inactive in the GDP-bound form, depends on guanine nucleotide-exchange proteins (GEPs) to accelerate GTP binding. A novel ARF GEP, designated cytohesin-4, was cloned from a human brain cDNA library. Deduced amino acid sequence of the 47-kDa protein contains the same structural components present in cytohesin -1, -2, and -3, including an approximately 200-amino acid Sec7 domain with an approximately 100-residue pleckstrin homology domain near the C terminus. The Sec7 domain sequence is 77% identical to those of other cytohesins. Structures of the cytohesin-4 and cytohesin-1 genes were remarkably similar, except for an extra 3-base pair (GAG) exon present in cytohesin-1. Two mRNAs with and without the 3-base pair sequence were found in brain in different ratios for cytohesin-1, -2, and -3 but not cytohesin-4. Recombinant cytohesin-4 stimulated guanosine 5'-3-O-(thio)triphosphate binding by human ARF1 and ARF5 but not ARF6. Like other cytohesins and unlike the approximately 200-kDa ARF GEPs, it was not inhibited by brefeldin A. A cytohesin-4 mRNA of approximately 3.7 kilobases, abundant in leukocytes, was not detected in most tissues. Among separated populations of blood cells, approximately 90% of CD33(+) (monocytes), 80% of CD2(+) (NK/T), and 10-20% of CD19(+) (B) cells contained cytohesin-4 mRNA by in situ hybridization. Thus, in gene structure and brefeldin A-insensitive GEP activity, cytohesin-4 resembles other cytohesins, but its tissue distribution differs considerably, consistent with a different specific function.

胆嚢胆汁CEAが大腸癌の潜在性肝転移の予知に有用であると報告されているが, その追跡調査や胆汁CEA上昇の機序に関しては不明である.今回これらの点に注目して大腸癌症例における胆汁CEA測定の意義について検討した.大腸癌肝転移例の胆汁CEA値は1, 182.9±1,624.7ng/mlで, 肝転移のない症例34.8±69.9ng/mlに比べて有意に高値であった.肝転移のない症例の追跡調査の結果, 初回手術時の胆汁CEA値が60ng/ml以上の症例は肝転移再発が有意に高かった (42.9%vs8%, p

We experienced a case of Biloma which was formed by bile juice leakage into the subcapsular space of the liver due to incarcerated bile duct stone. An 80-year-old woman was admitted to the hospital because of fever and right hipochondralgia. Abdominal CT-scan and ultrasonography on admission demonstrated a stone, 1cm in diameter, in the dilated common bile duct and a giant cystic lesion in the subcapsular space of the right hepatic lobe. Under ultrasonographic guidance, the cystic lesion was percutaneously drained. The aspirated fluid revealed bile and she was diangosed as having a biloma accopanied with bile duct stone. The continuous drainage of the biloma brought about disappearance of cystic lesion 19 days after admission and the bile stone had pased through the papilla Vater. Bilomas are predominantly reported to develop traumatically or iatrogenically. In the Japanese literature, 21 cases of spontaneously developed biloma have been reported which were associated with hepatobiliary diseases. Fifteen of 21 cases had bile duct stones. In suspected patients of biloma, percutaneous drainage should be done to make the definitive diagnosis and to relief the symptoms by indwelling a catheter for continuous drainage.

This study was aimed to evaluate bow simultaneous resection of the bowel influences hepatic regeneration after partial hepatectomy (HTX). Two hundred and sixty-four rats underwent 70% partial HTX, ileocecal resection (ICR), transverse colon resection (TR), colon amputation and simulatenous resection of the liver and the bowel (HTX+ICR, HTX+TR). Hepatic DNA synthesis was remarkably suppressed by simultaneous resection compared with the 70% HTX group (p0.01). In simultaneous resection groups, delayed enhanced hepatic protein synthesis (HPS) was observed after the operation as compared with the 70% HTX group, which showed an early postoperative peak of HPS. Postoperative anastomosis leakage occurred more frequently and survival rates were significantly lower in simultaneous resection groups. Higher plasma endotoxin levels of the portal and the peripheral veins were found in simultaneous resection groups as compared with other groups (p0.01-0.001). This study suggested that simultaneous resection of the bowel with partial HTX might inhibit hepatic regeneration and result in the increased risk of anastomosis leakage and high surgical mortality rate by increased plasma endotoxin levels and delayed enhanced HPS.

肝細胞癌切除例15例におけるP-glycoproteinの発現をモノクローナル抗体C219を用いて免疫組織化学的に検討した.P-glycoproteinの局在は,正常肝細胞は毛細胆管側細胞膜,索状型肝細胞癌では細胞間腔,偽腺管型肝細胞癌では腺管内腔側細胞膜に発現しており,正常肝細胞との類似性を示していたが,充実型ではその発現は著しく低下していた.P-glycoproteinの組織内発現率はP-glycoprotein labeling index (P.L.I.)として表した.P.L.I.の組織学的構造別検討では正常肝細胞0.81±0.11 (M±SD),硬変肝細胞0.79±0.15,で発現率に差異は無く,索状型肝細胞癌0.47±0.14,偽腺管型肝細胞癌0.44±0.10,も同様の発現率であったが,正常および硬変肝細胞よりは有意に発現率が低下していた.また,充実型肝細胞癌では0.04±0.05と発現低下を示していた.P.L.I.を組織学的分化度別に検討すると,非癌肝細胞0.80±0.12,中分化型肝細胞癌0.46±0.13,低分化型肝細胞癌0.04±0.05と,分化度の低下にともなって,P-glycoproteinの発現率の低下が認められた.すなわち,正常肝細胞に発現しているP-glycoproteinは組織構造の違い,組織学的分化度の低下に伴って発現率が低下していた.以上より,肝細胞癌に対する癌化学療法を行う際には,P-glycoproteinを介した薬剤耐性機構の関与する可能性のあること,さらに,症例により,P-glycoproteinの発現に差異が見られることに注意すべきと思われた.

Serum biomarkers currently available for gastric cancers are not sufficiently sensitive and specific. We used matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MS) to generate comparative peptide profiles of serum samples obtained from gastric cancer patients (n = 81) and age- and sex-matched healthy controls (n = 66). Because of initial screening and further validation, we found that the intensities of a 2209 m/z MS peak were increased in the preoperative sera obtained from gastric cancer patients, and we identified this peak, a 2209 Da peptide, as a high molecular weight (HMW) kininogen fragment. Receiver operating characteristic analyses showed that the area under the curve (AUC) for the 2209 Da peptide (AUC = 0.715) was greater than those for conventional tumor markers (carcinoembryonic antigen AUC = 0.593, carbohydrate antigen 19-9 AUC = 0.527) used for the detection of stage I gastric cancers. Inverse correlations were observed between the levels of intact HMW kininogen and the 2209 Da peptide, suggesting that the upregulation of some protease activities is responsible for the overproduction of a kininogen fragment in gastric cancer patients. Serum levels of the 2209 Da peptide identified in this study have a greater diagnostic ability than those of conventional tumor markers used for the early detection of gastric cancer.

The patient was a 68-year-old man with melena. Endoscopic examination revealed a type 2 advanced tumor in the mid body and an elevated lesion in the upper body of the stomach. Biopsy specimens from both lesions were diagnosed histologically as squamous cell carcinoma. Abdominal CT showed thickening of the midbody in the greater curvature and bulky lymph nodes along the lesser curvature (No. 3), and the greater curvature(No. 4d). We diagnosed Stage IIIB (cP0, cH0, cT4, cN1, cM0) cancer, but we concluded radical resection would be difficult due to lymph node invasion to the diaphragm and mesocolon. DCF combination therapy (docetaxel 75 mg/m2 day 1, CDDP 75 mg/m2 day 1, 5-FU 750 mg/m2 day 1-5) was administered. After 3 courses of chemotherapy, endoscopic examination and abdominal CT findings showed remarkable reduction of the primary tumor and the lymph node metastasis, indicating a partial response (PR) to the chemotherapy. After consultation with the patient, total gastrectomy with lymph node dissection (D2) was performed. The pathological specimens showed no cancer cells in the gastric wall and lymph nodes, so the histological effect was judged as Grade 3. This case suggested that DCF combination chemotherapy may prove useful to treat patients with advanced squamous cell carcinoma of the stomach.

Primary malignant lymphoma of the breast is rare, and preoperative correct diagnosis is difficult to make. A case of primaly malignant lymphoma of the breast which was preoperatively detected by aspiration biopsy cytology is reported referring the literature.A 57-year-old woman was seen at the hospital because of an elastic hard and smooth tumor, 45×45 mm in size, the right breast. One right axillary lymphnode 20×15 mm was also palpable. The tumor was diagnosed as malignant lymphoma by aspiration biopsy cytology, and a standard radical mastectomy was performed. Histological diangosis was malignant lymphoma, diffuse medium cell type in LSG classification. Staging according to Ann-Arbor's classification was IIE. Eight courses of adjuvant chemotherapy (CHOP) were carried out postoperatively using human granulocyte colony-stimulating factor (G-CSF) due to granulocytopenia. No evidence of recurrence has been observed for nine months following the operation.

A case of retroperitoneal abscess due to a penetration of the duodenum by an ingested fish bone, in which emergency operation could saved the patient's life, is reported. This is the second case in Japan. A 65-year-old man was admitted to the hospital because of abdominal pain. There was a history of gastrectomy for gastric ulcer 16 years before. A abdominal plain X-ray photograph and abdominal CT revealed a retroperitoneal abscess due to the penetration of the duodenum by a foreign body. Laparotomy revealed the retroperitoneal abscess and the penetration of the posterior wall of the second portion of duodenum. The foreign body was recognized in the residual stomach by gastrofiberscope during operation and was taken out through gastrostomy. The foreign body was 58 mm in length, which was the longest ingested fish bone ever reported in Japan. In a review of 59 domestic cases of damaged gastrointestinal tract due to a fish bone, it is thought that the damaged portion and type of the lesion are not be able to be predicted by the length of the fish bone ingested by mistake.

症例は49歳男性.以前より肝硬変および脾腫を指摘され近医通院中であったが, 1987年3月左側胸部痛を訴え当院受診した.超音波検査, computed tomography検査, Gaシンチグラフィーなどにて, 脾原発悪性リンパ腫を疑い脾摘出術を行った.脾割面では充実性・弾性硬, 境界明瞭の最大7cm最小3cmの腫瘍を3個認めた.組織診断はmalignant lymphoma, diffuse large cell type (Bcell) であった.術後, CHOP療法を6クール施行し退院した.外来にて経過観察中, 2年1か月後肝細胞癌を指摘され, 経皮的エタノール注入療法を行った.脾摘後4年を経過した現在, 悪性リンパ腫は再発の徴候なく肝細胞癌は縮小している.

A 59-year-old man was diagnosed as having a pancreatic carcinoma with synchronous liver metastasis at initial surgery. After wedge resection of liver tumor for histopathological analysis and gastro-jejunostomy, he was treated with 3 cycles of combined systematic chemotherapy consisting of CDDP and CPT-11, because of histopathological diagnosis confirming a neuroendocrine carcinoma of the pancreas. After chemotherapy, there was no recurrence and the primary tumor was reduced in size. Therefore, pancreatico-duodenectomy was performed as a curative treatment in two stages. During the follow-up, the patient has been alive without any signs of recurrence for 20 months since the diagnosis. Recently, several consecutive chemotherapies have been an effective modality to improve a poor prognosis for unresectable neuroendocrine carcinoma.

A case of solitary tuberculoma of the liver is reported, together with a review of the literature.A 48-year-old female visited our hospital with the chief complaint of right lateroabdominal pain. Examinations on admission revealed a lack in inflammatory findings and all tumor markers in normal ranges. Abdominal ultrasonography and CT indicated an irregular tumorous lesion in the border region between S5 and S6 of right lobe of the liver. Ultrasonography-guided biopsy of the liver offered a suspision of liver cell carcinoma, and hepatectomy was carried out. Extirpated specimen was a well-defined and yellowish brown solid tumor, associating with a cavitation partially in the center. It was considered an inflammatory tumor. Pathohistologically almost of the tumor was consisted of coagulated necrosis surrounded by epitheloid cell layer containing Langhans giant cells in the outside of which infiltrated lymphocytes and plasma cells were seen. Ziehl-Neelsen staining resulted in negative, however, solitary tuberculoma was strongly suspected for its morphology. Postoperative course was uneventful. The patient is strictly followed without any antituberculosis treatments.

Early diagnosis of hepatocellular carcinoma (HCC) greatly improves its prognosis. However, the distinction between benign and malignant tumors is often difficult, and novel immunohistochemical markers are necessary. Using agarose two-dimensional fluorescence difference gel electrophoresis, we analyzed HCC tissues from 10 patients. The fluorescence volumes of 48 spots increased and 79 spots decreased in tumor tissues compared with adjacent nontumor tissue, and 83 proteins were identified by mass spectrometry. Immunoblot confirmed that the expression of clathrin heavy chain (CHC) and Ku86 significantly increased, whereas formiminotransferase cyclodeaminase (FTCD), rhodanese, and vinculin decreased in tumor. The protein expression in tumor and nontumor tissues was further evaluated by immunostaining. Interestingly, CHC and FTCD expression was strikingly different between tumor and nontumor tissues. The sensitivity and specificity of individual markers or a combination for the detection of HCC were 51.8% and 95.6% for CHC, 61.4% and 98.5% for FTCD, and 80.7% and 94.1% for CHC+FTCD, respectively. Strikingly, the sensitivity and specificity increased to 86.7% and 95.6% when glypican-3, another potential biomarker for HCC, was used with FTCD. Moreover, CHC and FTCD were useful to distinguish early HCC from benign tumors such as regenerative nodule or focal nodular hyperplasia, because the sensitivity and specificity of the markers are 41.2% and 77.8% for CHC, 44.4% and 80.0% for FTCD, which is comparable with those of glypican-3 (33.3% and 100%). The sensitivity significantly increased by combination of these markers, 72.2% for CHC+FTCD, and 61.1% for CHC+glypican-3 and FTCD+glypican-3, as 44.4% of glypican-3 negative early HCC were able to be detected by either CHC or FTCD staining. Conclusion: Immunostaining of CHC and FTCD could make substantial contributions to the early diagnosis of HCC. (HEPATOLOGY 2008.)

Persistent hyperbilirubinemia is a symptom of postoperative liver failure after hepatectomy. We examined the effectiveness of a herbal medicine, Inchin-Ko-To (ICKT), on postoperative serum bilirubin levels in patients undergoing liver resection.Patients were divided into two groups. ICKT group (n=50), 7.5g of ICKT was administered orally from three days before the operation and it continued after the operation. Control group (n=50), ICKT was not administered perioperatively.There was no significant difference between the two groups in postoperative serum total bilirubin levels, but in indirect bilirubin, the ICKT group showed significant decrease compared with the control group. Decreasing effect of postoperative serum bilirubin levels was much more conspicuous when a large amount of liver parenchyma was resected. In that subgroup of patients, serum all bilirubin subdivisions significantly decreased in the ICKT (n=12) group compared with controls (n=11).ICKT may be an effective and fresh agent in postoperative management of liver resection by its potent choleretic effect.

Gemcitabine has been shown to exhibit significant clinical activity against pancreatic cancer and has become a first-line chemotherapeutic for this disease in recent years. However, there are still many patients who do not respond to this treatment and it is expected to improve the clinical outcome if we can develop a method to predict the efficacy of gemcitabine before treatment. The purpose of this study was to determine novel factors that make pancreatic cancer resistant to gemcitabine. Using the high-resolution proteomic approach, agarose two-dimensional gel electrophoresis, we compared protein profiling of a gemcitabine-resistant pancreatic cancer cell line with its wild-type. We identified Annexin II as an up-regulated protein in the gemcitabine-resistant pancreatic cancer cell line. Immunohistochemistry demonstrated that Annexin II was mainly expressed at the cell surface of pancreatic cancer cells. Interestingly, Annexin II overexpression in cancer cells was significantly associated with rapid recurrence after gemcitabine adjuvant chemotherapy in postoperative patients (P = .0078), and its staining was also an independent prognostic indicator of recurrence in pancreatic cancer patients who underwent adjuvant gemcitabine treatment after curative surgery on multivariate analysis (P = .0047). In addition, inhibition of Annexin II expression by siRNA in pancreatic cancer cell lines increased the cytotoxic efficacy of gemcitabine. These results indicate that Annexin II overexpression may induce gemcitabine resistance in pancreatic cancer resulting in rapid recurrence. Analysis of Annexin II expression in cancer tissues may predict the clinical outcome of gemcitabine treatment, leading to the development of a new method for tailor-made treatment for this disease.

Liver resection for liver tumors located in deep positions in segment VIII remains a technical challenge. We successfully resected a hepatocellular carcinoma located in deep position in segment VIII and extended into the paracaval portion of the right caudate lobe, using an anterior transhepatic approach. The patient was a 73-year-old man with chronic hepatitis C. Preoperative ultrasonography and dynamic computed tomography revealed that the tumor was about 3.0 cm in diameter and close to the roots of the middle and right hepatic veins and the paramedian Glissonian pedicle. The right anterior artery was supplying the tumor. The liver was opened along the right side of the middle hepatic vein. The dorsal Glissonian pedicle of segment VIII was easily exposed, ligated, and divided. The dorsal part of segment VIII was removed, along with the paracaval portion of the right caudate lobe. The postoperative course was uneventful. The patient was disease-free 17 months after surgery. This anterior transhepatic approach provides a wide operating field and easy hemostasis, and could preserve the liver parenchyma as much as possible in a patient with liver dysfunction.

This study set out to evaluate, in patients with gemcitabine-resistant pancreatic cancer, the response rate and toxicity of S-1 plus cisplatin (CDDP).Seventeen patients with histologically diagnosed invasive ductal pancreatic cancer were enrolled in this study. All patients had growing recurrent pancreas cancer despite the administration of gemcitabine. Thirteen patients underwent pancreatectomy, and 2 underwent choledochojejunostomy and gastrojejunostomy without pancreatectomy. S-1 (80 mg/m(2) per day) was orally administered for 21 consecutive days, followed by a 14-day rest period. CDDP (40 mg/m(2)) in 500 ml saline was administered by intravenous drip on day 8. This schedule was repeated every 5 weeks until the occurrence of disease progression, unacceptable toxicities, or the patient's refusal to continue.Five (29.4%) patients achieved a partial response and 2 (11.8%) had stable disease. In 5 of 15 patients (33.3%) who had elevated serum carbohydrate antigen (CA)19-9 levels at the start of treatment the CA19-9 was reduced by more than 50%. The median survival time was 10 months (range, 20 months), with 63.7% and 31.9% of patients alive at 6 and 12 months, respectively. Major adverse reactions in the 15 patients included gastrointestinal toxicities of grade 1 or 2. Only one patient (5.9%) developed grade 3 leucopenia.S-1 with CDDP has a promising effect against gemcitabine-resistant pancreatic cancer, with easily manageable toxicities. Further investigation of this regimen is warranted in patients with pancreatic cancer, especially in comparison with gemcitabine.

To study the regulatory mechanisms of sinusoidal regeneration after partial hepatectomy.We investigated the expression of angiopoietin (Ang)-1, Ang-2, Tie-2, and vascular endothelial growth factor (VEGF) in regenerating liver tissue by quantitative reverse-transcription polymerase chain reaction (RT-PCR) using a LightCycler (Roche Diagnostics) and also immunohistochemical staining after 70% hepatectomy in rats. In the next step, we isolated liver cells (hepatocytes, sinusoidal endothelial cell (SEC), Kupffer cell, and hepatic stellate cells (HSC)) from regenerating liver tissue by in situ collagenase perfusion and counterflow elutriation, to determine potential cellular sources of these angiogenic factors after hepatectomy. Proliferation and apoptosis of SECs were also evaluated by proliferating cell nuclear antigen (PCNA) staining and the terminal deoxynucleotidyl transferase d-uridine triphosphate nick end labeling (TUNEL) assay, respectively.VEGF mRNA expression increased with a peak at 72 h after hepatectomy, decreasing thereafter. The expression of Ang-1 mRNA was present at detectable levels before hepatectomy and increased slowly with a peak at 96 h. Meanwhile, Ang-2 mRNA was hardly detected before hepatectomy, but was remarkably induced at 120 and 144 h. In isolated cells, VEGF mRNA expression was found mainly in the hepatocyte fraction. Meanwhile, mRNA for Ang-1 and Ang-2 was found in the SEC and HSC fractions, but was more prominent in the latter. The PCNA labeling index of SECs increased slowly, reaching a peak at 72 h, whereas apoptotic SECs were detected between 120 h and 144 h.Ang-Tie system, together with VEGF, plays a critical role in regulating balance between SEC proliferation and apoptosis during sinusoidal regeneration after hepatectomy. However, the VEGF system plays a more important role in the early phase of sinusoidal regeneration than angiopoietin/Tie system.

Depression of cell-mediated immunity frequently accompanies solid tumor malignancy, and appears to be worsened as the disease progresses. In this study, we investigated cell-mediated immune status in colorectal cancer patients.Interleukin-2 (IL-2) productivity by phytohemagglutinin (PHA)-stimulated non-adherent peripheral blood mononuclear cells (PBMC), and prostaglandin E2 (PGE2) productivity by LPS-stimulated adherent PBMC were investigated in colorectal cancer patients with hepatic metastasis (n=20) and without hepatic metastasis (n=20), and in non-malignant disease controls (n=20). Percentages of peripheral blood T-cell subsets and NK activity were also investigated.In the colorectal cancer patients with hepatic metastasis IL-2 productivity was significantly decreased, compared with the controls. However, the percentages of T-cell subsets and NK activity were not significantly different among the groups. Meanwhile, PGE2 productivity in the patients with hepatic metastasis was significantly increased, compared with the other groups, and was significantly correlated with the hepatic tumor load.Tumor-bearing state, especially metastasis to the liver, may influence immune status of the patient. For evaluating cellular immunity status, cytokine productivity by activated lymphocytes and monocytes may be a more sensitive marker rather than other conventional immunological parameters, and may also provide useful information for immune intervention in the treatment of patients from this point of view.

The precise mechanisms of pulmonary injury after liver transplantation, especially those associated with cold ischemia time, are not yet clear.We histologically evaluated the number of accumulated polymorphonuclear neutrophils (PMNs) in lungs, and pulmonary injury after liver transplantation with varying periods of cold ischemia (1, 6 and 24h in University of Wisconsin solution at 4 degrees C). Pulmonary expression of cytokine-induced neutrophil chemoattractant (CINC) and macrophage inflammatory protein-2 (MIP-2) mRNA were investigated by quantitative reverse-transcription polymerase chain reaction. The levels of tumor necrosis factor-alpha (TNFalpha), which stimulates these chemokine productions, were also monitored after liver transplantation.The accumulated PMN number, and lung edema, quantified by wet to dry weight ratio, significantly increased in the 24-hr cold-ischemia group after 3h of reperfusion, compared with the 1-hr and 6-hr cold-ischemia groups. Both pulmonary MIP-2 and CINC mRNA expression in the 24-hr group were remarkably upregulated at this time. According to the histological examination, pulmonary injury in the 24-hr group was prominent, characterized by interstitial edema, and alveolar hemorrhage. Furthermore, TNF in the hepatic vein was detected only in the 24-hr group.Cold ischemia time prolongation upregulates pulmonary MIP-2 and CINC expression via hepatic-derived TNFalpha, and promotes PMN accumulation, resulting in increased pulmonary injury after liver transplantation.

We present a case of long-term survival in a patient that involved intrahepatic cholangiocarcinoma that metastasized to the paraaortic lymph nodes. A 62-year-old man underwent extended left hepatic lobectomy with caudate lobe resection, extrahepatic bile duct resection, portal vein resection and reconstruction, and middle hepatic vein resection and reconstruction with lymph node dissection for a liver tumor that was located in the caudate lobe. Histological examination of the resected specimen revealed moderately differentiated adenocarcinoma compatible with cholangiocarcinoma, and lymph node metastases were found in the area of the hepatoduodenal ligament and the paraaortic region. After surgical resection, recurrence was detected twice in the lymph nodes at the site of the left supraclavicular region. These recurrent tumors were completely eliminated by systemic chemotherapy with cisplatin or mitomycin C. The patient is now doing well 6 years and 5 months after surgical treatment. In this case, there was only one tumor, and the preoperative serum carbohydrate antigen 19-9 level was normal. In addition, heterozygosity was retained at the loci on chromosome 8p. These findings suggested that tumor in the present case was less aggressive, despite the nodal spread. The extensive surgical approach may have contributed to the long-term survival of this patient, while the recurrent tumor was sensitive to antitumoral agents.

Surgical resection has been reported to be only hope for cure for the patients with hilar cholangiocarcinoma. Therefore, first of all, radical surgical resection should be considered to be a therapeutic option for hilar cholangiocarcinoma as much as possible. In preoperative staging for hilar cholangiocarcinoma, various extensive patterns of cancer such as the involvements of bile duct, portal vein, hepatic artery and lymph node etc, should be evaluated in each patient. As most patients are associated with obstructive jaundice at presentation, liver function has to be evaluated by appropriate tests for deciding the suitable surgical procedure. When the future remnant liver volume is less than 40% or severe liver functional damage exists or greater surgical stress is expected, preoperative portal vein embolization might have to be selected. On the other hand, if hilar cholangiocarcinoma involves limited region of the hilar bile duct confluence, parenchyma preserving hepatectomy such as S1 resection and S1 + S4 resection should be selected for avoiding the occurrence of liver failure. Combined portal vein resection should be done for the case of the cancer involvement of the portal vein without hesitation to improve the prognosis. However, hepatic artery resection and reconstruction in the involved case should be carefully performed only in severely selected cases. By using several useful pre-operative and intra-operative therapeutic modalities, hilar cholangiocarcinoma should be surgically resected with curative intent and without increasing surgical morbidity and mortality rates.

Hereditary hemorrhagic telangiectasia (Rendu-Osler-Weber disease) is clinically characterized by the triad of mucocutaneous telangiectasia, recurrent epistaxis, and a familial history. We describe a 68-year-old woman with hereditary hemorrhagic telangiectasia undergoing transduodenal papillectomy for ampullary submucosal bleeding-induced pancreatitis. When she was 63 years old, she presented with abdominal pain due to acute pancreatitis, and from the age of 68, frequency of the symptom increased a couple of times a month. Gastrofiberscopy showed enlarged ampulla of Vater. Doppler ultrasonography showed rich and tortuous signals of bloodstream at submucosal region of the ampulla. Arteriogram revealed that hypervascular staining was fed by the inferior pancreaticoduodenal artery. Microcoil embolization was attempted and hypervascular staining disappeared. However, one week later, endoscopic papillotomy was unable to be performed due to risk of uncontrollable bleeding since Doppler ultrasonography showed signals of bloodstream at submucosal region of the ampulla again. Finally, she underwent open transduodenal papillectomy. She had an uneventful postoperative course, and has been free of pancreatitis for 20 months after surgery. We also review the literature and discuss the surgical indication for gastrointestinal and hepato-biliary-pancreatic involvement with hereditary hemorrhagic telangiectasia. To our knowledge, this is the first reported case of successful surgical treatment for pancreatitis due to sequla of hereditary hemorrhagic telangiectasia.

It has been reported that contrast computed tomography (CT) provides a rapid and accurate diagnosis of acute appendicitis, and could potentially prevent adverse appendectomy. In the present study, we evaluated the diagnostic value of precontrast CT combined with that of serum C reactive protein (CRP) concentration for right lower quadrant inflammatory diseases.One hundred consecutive patients who had rebound tenderness and muscular rigidity or guarding on right lower quadrant underwent an emergency abdominal CT without contrast medium and laboratory tests. Based on the CT findings, 10 patients with peritonitis and 41 patients with definite acute appendicitis underwent emergency operations. Of 19 patients with negative CT findings, 11 patients who had positive CRP levels also underwent emergency appendectomies. The remaining patients, of whom 8 had negative CRP levels and 30 had CT findings of other inflammatory diseases, underwent conservative therapy and were examined again later on.The final diagnosis was acute appendicitis in 58 cases, other intestinal diseases in 21, gynecological disease in 6, urolithiasis in 1, and unknown in 14. Among 86 patients who underwent emergency operations and had a pathological diagnosis, CT had a sensitivity of 81% for the diagnosis of appendicitis, with a specificity of 89%, and an accuracy of 84%. CT combined with serum CRP concentration yielded a sensitivity of 100%, an accuracy of 97%, and a specificity of 89%. The adverse appendectomy rate was 3%. None of the patients underwent a delayed appendectomy. CT differentiated other inflammatory diseases from acute appendicitis in 23 patients.It may be concluded that precontrast CT scan combined with serum CRP can provide a rapid and accurate diagnosis of acute appendicitis and other right lower quadrant inflammatory diseases.

To avoid intraabdominal abscess and biliary fistula, which may lengthen hospital stay or result in lethal complications after major hepatic resection, it is important to control postoperative bleeding and bile leakage. We employed a technique for preventing postoperative bleeding and bile leakage, using omental packing with fibrin glue for the transected surface of the remnant liver after hepatic resection. This procedure was employed in 50 patients who underwent major hepatic resection. There was no postoperative bleeding or biliary fistula, and drain tubes were removed within 5 days in all patients. Omental packing with fibrin glue could be a very useful procedure of preventing postoperative biliary fistula, bleeding, and abscess after major hepatic resection.

Prognosis of pancreatic cancer is still remarkably poor, even if complete resection was performed by enlarged abscission. On the other hand, carbon-ion beam therapy is giving good results in some selected carcinoma such as small cell lung cancer, prostate cancer, uterus cancer, and soft tissue/bone tumor. In this report, we discuss four patients with pancreatic cancer treated by surgical pancreatectomy combined with preoperative carbon-ion beam irradiation. All patients were irradiated with 48 GyE carbon-iron beam by HIMAC (Heavy Ion Medical Accelerator in Chiba) to the pancreatic area including lymph nodes and nerve plexus. Severe cholangitis, as the postoperative complication, had occurred in one of the patients. However, there was no complication or disorder caused by carbon-iron radiation. All four patients are alive now, but two of them developed tumor recurrence, one with hepatic metastasis and the other with peritoneal dissemination. Surgical treatment for pancreatic cancer combined with preoperative carbon-ion irradiation is expected as a promising cure, but it is necessary to examine more cases in the future to evaluate the clinical outcome of this treatment.

When advanced hepatobiliary malignancy involves the major veins that are requisite for draining venous flow from the remnant liver after hepatectomy, it may be unresectable, unless the hepatic vein involved by the tumor can be reconstructed after combined resection with hepatectomy.Seven patients with hepatobiliary malignancy underwent hepatic vein resection and reconstruction using autologous vein grafts in our study. Five patients had patch repairs of the hepatic vein, with the gonadal vein used in 2 cases, the umbilical vein in 2, and the inferior mesenteric vein in 1. Two other patients underwent segmental reconstruction of the hepatic vein, using the inferior mesenteric vein for reconstruction of the middle hepatic vein, and the internal iliac vein for reconstruction of the right hepatic vein. Operative results and postoperative outcome, including liver function, patency, and survival, were evaluated. Literatures reporting hepatic vein reconstruction in hepatic resection, including this study, are also reviewed.In 6 of 7 patients, autologous vein grafts were obtained from the upper abdominal operative field without making an additional skin incision. The right internal iliac vein was used in segmental reconstruction of the right hepatic vein, and the inferior mesenteric vein was used in segmental reconstruction of the middle hepatic vein, based on caliber matching. Patch repairs of the right hepatic vein were successfully performed in 2 cases, the middle hepatic vein in 2, and the left hepatic in 1, using the umbilical vein, the gonadal vein and the inferior mesenteric vein. During hepatic vein reconstruction, total hepatic vascular exclusion was required in 2 cases, and Pringle's inflow clamp with selective clamp of reconstructed hepatic vein in 5, in order to avoid massive bleeding, congestion, and air embolism. Postoperatively, there were no remarkable complications of liver dysfunction or other organ damage encountered in any of the patients. Reconstructed hepatic veins were revealed to be patent postoperatively in all cases. Six patients survived for 60-1035 days after surgery, and 1 patient died of cancer recurrence 550 days after surgery.We conclude that hepatic vein reconstruction using an autologous vein graft can be safely and effectively performed with a suitable vascular control method for appropriately selected patients with advanced hepatobiliary cancer.

Background The incidence and mode of spread of carcinoma of the gallbladder into the hepatoduodenal ligament have not been well described pathologically for gallbladder carcinoma extending into the subserosa and beyond. Methods Between 1985 and 2002, 50 consecutive patients with gallbladder carcinoma extending into the subserosa or beyond underwent radical surgery, including extrahepatic bile duct resection. Serial sections of specimens of the resected extrahepatic bile ducts were examined to determine the incidence and the pattern of invasion of the hepatoduodenal ligament from the primary cancer. Results Invasion of the hepatoduodenal ligament was present in 30 of the 50 specimens. Of these, 9 showed direct extramural spread (type I), 4 showed continuous intramural spread (type II), 5 showed distant spread separated from the primary tumor (type III), and 4 showed spread of cancer cells from metastatic lymph nodes (type IV). The remaining 8 patients had more than 1 type: 1 patient had types I + III; 3 had types I + III+ IV; and 4 had types III + IV. Invasion of the hepatoduodenal ligament was present in 24 of 44 patients without preoperative obstructive jaundice and in 2 of 13 patients with stage IB disease. Patients with types II, III, and IV spread into the hepatoduodenal ligament had significantly better survival than those with type I spread. Conclusions Gallbladder carcinoma extending into the subserosa or beyond invades the hepatoduodenal ligament with relatively high frequency. Preoperative diagnosis of this invasion is difficult; therefore, strong consideration should be given to resection of the extrahepatic bile ducts and lymph nodes.

Combined resection of the inferior vena cava for hepatobiliary malignancies remains a technical challenge. We successfully resected an intrahepatic cholangiocarcinoma involving the retrohepatic vena cava, and reconstructed the caval defect using a left renal vein patch graft. The patient was a 79-year-old man. Preoperative ultrasonography and computed tomography revealed that the tumor was located in the right lobe of the liver and was about 6 cm in diameter. Arteriogram revealed encasement of the right arterial and portal branches. Magnetic resonance imaging scan revealed that the tumor involved the retrohepatic vena cava. The patient underwent a right hepatectomy combined with resection of the retrohepatic vena cava. The resected portion of the caval wall was 3.6 cm long and 2.7 cm wide. The caval defect was reconstructed using a left renal vein patch graft of a rhomboid shape, which was made by oblique incision of the vein graft. The postoperative course was uneventful. Postoperative cavogram showed adequate patency of the reconstructed retrohepatic vena cava. The patient was disease-free 22 months after surgery. In conclusion, major liver resection combined with caval resection and reconstruction can be performed safely. Furthermore, a left renal vein graft can provide a flexible patch according to the form and size of the caval defect.