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We monitored serum p53 antibody (s-p53-Ab) titers in a 76-year-old man with esophageal adenocarcinoma, clinical stage III (T2N2M0), for over 4 years, including during the perioperative period and throughout follow-up after surgery. Screening tests for CA19-9 (205 IU/ml) and s-p53-Abs (381 U/ml) were positive before treatment. After neoadjuvant chemotherapy with 5-FU and cisplatin, CA19-9 decreased to the normal range, but the s-p53-Ab titer remained positive (224 U/ml). Pathological findings of surgically resected specimens showed stage T1b disease and no lymph node metastases. After surgery, s-p53-Ab titers consistently decreased, with no disease recurrence. Although the s-p53-Ab titer remained positive even after 4 years, it decreased to 8.66, 3.59, 2.38, and 1.92 U/ml, 1, 2, 3, and 4 years after surgery, respectively. Thus, monitoring perioperative changes in s-p53-Ab titers proved useful for detecting the presence of residual cancer cells in a patient with superficial esophageal adenocarcinoma.

Although recent technological developments and improved endoscopic procedures have further spread the application of laparoscopic pancreatic resection, laparoscopic pancreaticoduodenectomy still presents major technical difficulties, such as when performing pancreatic–enteric anastomosis. Laparoscopic dunking pancreaticojejunostomy using mattress sutures was performed in 15 consecutive patients with a soft pancreas and a nondilated pancreatic duct between October 2011 and December 2012. According to the International Study Group on Pancreatic Fistula criteria, 3 patients developed PF (grade A), whereas the remaining 12 patients did not. Dunking pancreaticojejunostomy using mattress sutures is considered to be a feasible and safe method for performing pure laparoscopic pancreaticoduodenectomy.

We report a case of anal canal cancer with inguinal lymph node metastasis treated with laparoscopic abdominoperineal resection combined with inguinal lymph node dissection. A 52-year-old woman was diagnosed with anal squamous carcinoma after excision of an anal canal tumor. Further examination revealed right inguinal lymph node metastasis. Chemoradiotherapy was administered but was discontinued because of serious adverse events. We therefore performed laparoscopic abdominoperineal resection combined with inguinal lymph node dissection. The pathological findings revealed residual squamous cell carcinoma at the lymphatic vessels in the rectal wall and lymph nodes, including the right inguinal region. Therapeutic effect of Grade 1a was achieved in spite of interruption of the chemoradiotherapy. She was discharged 17 days after the operation, and no recurrence was observed for 11 months. Radical resection was performed for the anal canal squamous cell carcinoma with the metastasis to the right inguinal lymph node, even after interruption of the chemoradiotherapy.

Introduction Laparoscopic hemihepatectomy has not yet become widely accepted because of the technical difficulties in controlling each Glissonean pedicle laparoscopically. Materials and Surgical Technique The subjects in the present study included 12 patients who underwent laparoscopic left hemihepatectomy between August 2007 and June 2011. Arantius' ligament was divided. Retracting the caudal stump of the ligament revealed a space between the left Glissonean pedicle and the liver parenchyma. The left Glissonean pedicle could be easily encircled by using an Endo Retract Maxi. No Glissonean injuries, including bleeding or biliary leakage, occurred in any of the 12 patients. Discussion Therefore, the Arantius' ligament approach for the left extrahepatic Glissonean pedicle appears to be feasible and safe for successfully performing pure laparoscopic left hemihepatectomy.

Although recent technological developments and improved endoscopic procedures have further spread the application of laparoscopic liver resection, laparoscopic major liver resection remains a highly specialized field because there are major technical difficulties, such as hilar dissection and pedicle control. The entire length of the primary branches of the Glissonean pedicle and the origin of the secondary branches are located outside the liver. In contrast, the trunks of the secondary branches and more peripheral branches run inside the liver. The right, left, anterior, or posterior Glissonean pedicle can thus be tied and divided en bloc extrahepatically during open anatomical liver resection. Each Glissonean pedicle can be easily and safely encircled and divided en bloc extrahepatically during laparoscopic anatomical liver resection using an Endo Retract Maxi or Endo Mini-Retract. This report describes a novel technique by which the extrahepatic Glissonean approach appears to be both feasible and safe for the performance of laparoscopic major liver resection.

Pancreas-sparing duodenectomy (PSD) is a practical surgical procedure for patients with duodenal adenoma, which is difficult to resect endoscopically. We describe how we performed a totally laparoscopic PSD to resect a duodenal adenoma in a 64-year-old woman, who had been referred for treatment of a 50-mm villous polypoid mass in the second portion of the duodenum. We performed end-to-side anastomosis between the common duct of the bile and pancreatic ducts and the jejunal limb intracorporeally following the duodenal resection. A biliary leak developed, but resolved spontaneously and the patient was discharged on postoperative day (POD) 32. The surgical margin was free of neoplastic change. Although there is limited experience and appropriate indications must await future studies, this case demonstrates that laparoscopic PSD is feasible, safe, and effective for selected patients.

症例は65歳，女性．主訴は上腹部痛，嘔気．平成15年12月S状結腸癌で腹腔鏡補助下S状結腸切除を他院で施行され経過観察されていた．平成17年8月CT，上部消化管内視鏡検査にて4cm大の十二指腸壁外腫瘍を認めたが，手術を拒否していた．平成20年10月主訴出現しCTにて腫瘍は8cmに増大し，腫瘍内出血を認めた．保存的加療で症状消失し，手術目的で当院紹介された．平成20年11月CTで腫瘍は4cmに縮小し，上部消化管内視鏡検査では十二指腸粘膜に変化はなかった．超音波内視鏡ガイド下穿刺細胞診でカルチノイドが疑われた．十二指腸カルチノイドの術前診断にて平成20年12月膵頭十二指腸切除術を施行した．病理組織診断では，術前には確認されなかった7mm，5mm大の十二指腸球部粘膜下腫瘍がカルチノイドであり，4×3×2.5cm大の十二指腸壁外腫瘍は転移リンパ節と診断された．今回，微小カルチノイドのリンパ節転移が孤立性に4年間経過観察された稀な1例を経験したので報告する．

A 56-year-old man was referred with lower rectal cancer showing anal canal invasion and liver metastasis. He underwent an abdominoperineal resection and a partial hepatectomy. Adjuvant therapy with tegafur-uracil and leucovorin was administered postoperatively. Lung metastasis was detected 2 years later and was resected. Right mandibular metastasis was diagnosed 2 months after the resection of the lung metastasis. A partial mandibular resection was performed after chemoradiotherapy, followed by reconstruction with a titanium frame and oral cavity reconstruction with a greater pectoral musculocutaneous flap. The pathological diagnosis was metastatic rectal cancer, and the therapeutic effect chemoradiotherapy was Grade 2. He is presently alive without any evidence of cancer, and has maintained a good quality of life 3 years after the mandibular resection and more than 5 years after his first operation. Mandibular metastasis from rectal cancer is very rare and the prognosis is poor according to the literature, so this case is considered to be very unusual.

症例は58歳女性．心窩部痛・発熱を主訴に近医受診．当初腫瘍随伴性膵炎として治療開始されたが症状のコントロール困難で当院紹介された．好中球数の増多を伴う膵腫瘍との診断で精査加療目的入院．血清中G-CSF高値を示し，超音波内視鏡下生検の病理診断では低分化型腺癌であり，免疫組織学的にG-CSF産生膵癌と診断した．CT上根治手術困難な状態であったため，全身化学療法を開始し，同時にステロイドの投与を行った．治療開始1ヶ月後に好中球はほぼ正常化し退院したが，その後すぐに好中球は再上昇し入院．治療開始2ヶ月後に永眠した．G-CSF産生膵癌の報告は散見されるが，病態にいまだ不明な点も多いため若干の文献的考察を加えて報告する．

Although laparoscopic colorectal or gastric surgery has become widely accepted as a superior alternative to conventional open surgery, the surgical management of hepato-biliary-pancreatic disease has traditionally involved open surgery. Recently, many reports have described laparoscopic partial liver resection, lateral segmentectomy, and distal pancreatectomy. However, laparoscopic major hepato-biliary-pancreatic surgery, such as hepatic lobectomy and pancreaticoduodenectomy, has not been widely developed because of technical difficulties. We describe our experience with laparoscopic major hepato-biliary-pancreatic surgery, including right hepatectomy using hilar Glissonean pedicle transaction, and pylorus-preserving pancreaticoduodenectomy. Although our experience is limited, and randomized study is necessary to elucidate the appropriate indications for and effects of the present procedures, we believe that laparoscopic major hepato-biliary-pancreatic surgery can be feasible, safe, and effective in highly selected patients, and that it will be one of the standard therapeutic options for carefully selected patients with hepato-biliary-pancreatic disease.

To study the relationship of anomalous right-sided round ligament with respect to branches of the portal vein. We studied four patients of right-sided round ligament diagnosed radiologically in the last 5 years. 3-D volume rendered CECT abdominal images were analyzed for attachment of the round ligament in the liver in relation to portal venous anatomy and position of gallbladder. In all cases, a trifurcate pattern of portal venous branching was observed. Right-sided round ligament was attached at the point of divergence of the right anterior portal vein. The region to the left of the point of its attachment drained into the middle hepatic vein while the region to the right of the point of attachment drained into the right hepatic vein. The left portal vein branched into posterior and paramedian branches. Right, middle, and left hepatic veins were visualized having normal course in all cases. In all, the gallbladder was present to the left of the round ligament. Trifurcate pattern of portal vein branching in all four cases. Right-sided round ligament was attached to the bifurcation of the right anterior portal vein in all the cases. The left portal vein branched into posterior and paramedian branches.

症例は71歳，女性．32歳時に右乳癌に対してHalsted手術を施行され，術後に局所の放射線治療を受けている．2008年1月に，胸部上部食道癌の診断で当科入院した．入院時，右前胸部に皮膚腫瘍を認めた．開胸困難症例であったため，非開胸食道抜去術を施行し，術後19日目に軽快退院となった．病理所見は，T2N0M0（stageII）であった．術後79日目に皮膚腫瘍切除術を施行し，基底細胞癌と診断された．乳癌術後放射線治療の照射野に一致して，皮膚および食道に癌を認めたことから，2次性発癌と判断した．欧米においては，乳癌に対する放射線治療の既往のある女性では，食道扁平上皮癌発症の危険性が高いとされており，本邦でも放射線治療に起因する2次性の食道扁平上皮癌が増加する可能性があると考えられた．

Patients with carcinoma of the gallbladder that is preoperatively diagnosed by radiology do not undergo laparoscopic resection, because such surgery is thought to worsen the prognosis of gallbladder carcinoma. However, the prognosis for patients with incidental T2 gallbladder carcinoma who are treated laparoscopically is reportedly no worse than that for patients undergoing conventional surgery. We successfully performed total laparoscopic resection of the gallbladder together with the gallbladder bed without any complications. We believe that this procedure represents a valid therapeutic option for carefully selected patients with T2 carcinoma of the gallbladder.

今回われわれは肝膿瘍を契機に発見された混合型肝癌の1例を経験した．稀な症例と考え報告する．症例:64歳，男性．主訴:上腹部痛，発熱．現病歴:2003年6月主訴出現し，当院受診した．初診時体温38.8度．血液検査所見:白血球10700/μl，CRP 20.5mg/dl．CEA 5.5ng/ml，AFP 215ng/ml，PIVKA II 777mAU/ml．造影CT:肝内側区域に長径7cmの腫瘤を認めた．一部膿瘍形成を認めた．門脈左枝に腫瘍栓を認めた．血液培養でKlebsiella. pneumoniaeを検出した．肝膿瘍を合併した肝細胞癌と診断．抗生剤による感染症治療の後，拡大肝左葉切除+リンパ節郭清術を施行した．病理組織学的検査所見:混合型肝癌．T4N1M0stageIVA．治癒度C．術後4カ月目に癌の残肝再発．肝膿瘍再発．抗生物質と肝動注化学療法により一時軽快するも術後7カ月目に肝膿瘍再燃して死亡した．

Sarcomatous hepatocellular carcinoma is a rare neoplasm of the liver. A 79-year-old man with a liver tumor was admitted to our hospital. Enhanced computed tomography and magnetic resonance imaging revealed a cystlike lesion, whereas abdominal ultrasonography revealed a solid tumor. The patient underwent medial segmentectomy of the liver for the presumptive diagnosis of atypical hepatocellular carcinoma. Microscopically, the tumor was diagnosed as hepatocellular carcinoma with sarcomatous change. Although anticancer therapy is presumed to be a cause of sarcomatous change in hepatocellular carcinoma, some cases in which patients had not previously undergone anticancer therapy have been reported. Here we report a case of sarcomatous hepatocellular carcinoma without previous anticancer therapy and present a review of the literature.

ガーゼ遺残を防ぐためにはガーゼを使わないことが一つの解決策であり, 小ガーゼを使わず大ガーゼと吸引のみで行う手術 (小ガーゼ不使用群 : n=50) と小ガーゼ, 大ガーゼ, 吸引の全てを使う手術 (従来法群 : n=50) をprospectiveに比較検討した. 原疾患によらず出血量, 手術時間は両群間に差を認めなかった. ガーゼカウント回数は従来法群3.8回, 小ガーゼ不使用群2.4回と小ガーゼ不使用群で有意に少なかった. 数え間違いも含めたガーゼカウントの不一致は従来法群で12例 (24%) にみられたのに対し, 小ガーゼ不使用群では1例も認めなかった. 従来法群のガーゼカウントの不一致は, 出血量およびガーゼ使用枚数が多い症例に多かった. 看護師のアンケートでは小ガーゼを使わない手術はガーゼカウントが簡便, 出血量の把握が容易, 血液への暴露が少ない, ガーゼ遺残のリスクが減少と好評であった. 小ガーゼを使わなくても従来と変わらない手術が可能であり, 医療安全および業務の簡素化の面からも本法は推奨される.

Background The aim of this multi-institutional study was to assess the feasibility and the efficacy of gemcitabine plus cisplatin (CDDP) combination therapy (GC therapy) for biliary tract cancer (BTC) in the adjuvant setting. Methods Eligible patients identified between January 2008 and January 2013 were enrolled. GC therapy at 1,000 mg/m2 of gemcitabine and 25 mg/m2 of CDDP on days 1 and 8 repeated every 3 weeks was performed for 6 months. The primary endpoint was the feasibility and the adverse events, and the secondary endpoint was recurrence-free survival (RFS) and overall survival (OS). Results Among 29 evaluable patients, the protocol was completed in 21 (72%) patients. Relative dose intensity (RDI) of gemcitabine and CDDP was 77% and 81%, respectively. There was no difference in the completion rate and the RDI between patients who underwent resection with vs. without major hepatectomy. Grade 3–4 toxicities included leukopenia (14%) and neutropenia (27%). Two-year RFS and 2-year OS was 59% and 90%, respectively. Conclusions Standard dose of GC therapy is tolerable in patients with BTC who underwent curative resection either with or without major hepatectomy. The survival effect of this regimen is promising, but further comparative study is needed.

We evaluated the efficacy of intraperitoneal chemotherapy with cisplatin (CDDP) for peritoneal recurrent gastric cancer following surgical intervention. Twelve patients were enrolled. The combination systemic chemotherapy was S-1 or S-1 plus paclitaxel (S-1+PTX). PTX was administered intravenously at 80 mg/m² on day S-1 and 15. S-1 was administered at 80 mg/ m²/ day for 7 consecutive days, followed by 7 days of rest, and the cycle was repeated. CDDP was administered intraperitoneally at 40 mg/body on day 8. This treatment was repeated every 4 weeks until disease progression was diagnosed. The survival time(ST)and time to treatment failure(TTF)were estimated. The surgical interventions were gastrectomy in 3 patients, colostomy in 8 patients, and enterostomy in 1 patient. Overall, the median TTF and ST were 294 days and 455 days, respectively. When stratified by surgical method and combination chemotherapy, the median TTF and ST were not statistically significant. However, when stratified by performance status (PS), the median TTF was 352 days for patients with PS 0 and 218 days for those with PS 1, 2 (p=0.0029), whereas the median ST was 553 days for patients with PS 0 and 331 days for those with PS 1, 2 (p=0.0198). In conclusion, the data suggest that intraperitoneal CDDP chemotherapy with systemic chemotherapy is effective for the treatment of extensive peritoneal recurrent gastric cancer, especially in patients with good PS.

We report a case of gastrointestinal stromal tumor (GIST) locally resected after long-term chemotherapy with imatinib mesylate. A 78-year-old woman was diagnosed with GIST in the lower rectum on screening colonoscopy for anemia. The tumor was 7 cm in diameter, and the anal sphincter was considered to be difficult to preserve due to the extent of the tumor. The patient refused surgery, so she was administered imatinib mesylate chemotherapy. The medication was continued for 5 years without any major adverse events, and the status of the tumor was stable. Five years later, she underwent transanal local resection for anal prolapse and incarceration of the tumor. Pathological findings revealed a 7 cm sized high-risk GIST. The long-term stable status of the tumor was maintained, and the anal function was preserved by the local resection.

There are two intensive modalities for the treatment of resectable esophageal carcinoma: esophagectomy and definitive chemoradiotherapy (CRT). Esophagectomy with preoperative CRT was retrospectively compared with CRT alone in resectable stage II/III esophageal squamous cell carcinoma. Seventy-four patients with resectable stage II/III (T1-3N0, 1M0) esophageal squamous cell carcinoma were treated with preoperative CRT by 5-fluorouracil (5-FU) 700 mg/m2 on days 1 to 5, nedaplatin 80 mg/m2 on day 1, and concurrent radiation for a total of 30 Gy in 3 weeks. If patients decided to undergo surgery, esophagectomy from the thoracoabdominal approach was carried out 6 weeks after the completion of CRT (CRT + Surg group, n = 51). If patients decided not to undergo surgery, they were treated with one more course of CRT (CRT-alone group, n = 23). There was no significant difference in overall survival between the two groups (P = 0.1006), whereas the disease-free survival in the CRT + Surg group was improved compared with the CRT-alone group (P = 0.0186). In the patients with clinical stage III carcinoma or with regional lymph node metastasis, the overall survival rate was significantly improved in the CRT + Surg group compared with the CRT-alone group. The rate of local failures in the CRT + Surg group was significantly lower compared with the CRT-alone group (P = 0.0011). Preoperative CRT followed by esophagectomy provides better local control, but does not prolong overall survival, compared with definitive CRT. However, in clinical stage III or N1, esophagectomy with preoperative CRT could contribute to the improvement of survival in esophageal squamous cell carcinoma.

Background There is an increasing demand for living donor liver transplants. However, the biliary complication rates are still high. Methods The anatomy of the communicating arcade (CA) between the right and left livers and its relevance to the blood supply of the hilar bile duct was evaluated using adult cadaveric livers and cast specimens. Results In all specimens that were of sufficient quality for evaluation, th CA was found to be located extrahepatically in the hilar plate with thin tributaries branching to the hilar bile duct. On the left side, 55% of the CA originated from a segment IV artery. On the right side, 73% of the CA originated from the right anterior hepatic artery. Conclusions To maintain an adequate blood supply for the hilar bile duct of the donor graft during living donor liver transplantation, the branching point of the CA should be preserved.

To evaluate prospectively the relationship between the arterial collateral system at the hepatic hilum and the blood supply to the hilar bile duct by using computed tomography (CT) and angiography during temporary balloon occlusion of the right or left hepatic artery.Institutional review board approval and informed consent were obtained. The study included 13 patients with no lesions at the hepatic hilum (eight men and five women; age range, 41-78 years; mean, 65.8 years). After serial angiographic studies were performed for preoperative evaluation or transcatheter arterial chemoembolization, a 5.5-F catheter with an occlusion balloon was positioned in the right or left hepatic artery. Eleven patients underwent angiography of the left hepatic artery with temporary occlusion of the right hepatic artery, and two patients underwent angiography of the right hepatic artery with temporary occlusion of the left hepatic artery. In addition, 11 patients underwent single-level dynamic CT during hepatic arteriography (CTHA) with temporary occlusion of the right or left hepatic artery. The images from angiography and CTHA were interpreted by two authors who assessed the existence of the arterial communication and its branching points, location, and relationship to the hilar bile duct and caudate lobe.During temporary occlusion of the right or left hepatic artery, the communicating arcade (CA) between the right and left hepatic arteries was immediately evident in all patients. On the left side, the CA originated from the segment IV artery in eight patients (62%) and from the left hepatic artery in five (38%). On the right side, the CA originated from the right anterior hepatic artery in six patients (46%), the right hepatic artery in two (15%), and both arteries in five (38%). The CA was extrahepatically located close to the hilar bile duct and forked into a few branches to the caudate lobe.The CA may play an important role not only in the interlobar arterial collateral system but also in the blood supplies to the caudate lobe and hilar bile duct.

Background Portal branching patterns that differ from those previously described are occasionally encountered during liver surgery. Methods A total of 60 patients with normal intrahepatic venous anatomy underwent helical computed tomography during arterial portography (CTAP). Next, 3 dimensional portograms were reconstructed to verify the locations of the portal veins. Portal branching patterns in the right hemiliver were assessed. Results In all 60 patients examined, the right anterior portal vein bifurcated into the ventral and dorsal branches. In 42 (70%) of 60 patients, some branches arose from the right posterior portal trunk. Between 1 and 3 branches (mean 2.3 branches per patient) coursed cranially, between 2 and 5 branches (mean 3.2 branches per patient) coursed caudally, and between 1 and 2 branches (mean 1.3 branches per patient) coursed laterally. Conclusions We propose that the right liver should be divided into 3 segments, which are designated as the right anterior, middle, and posterior segments.

Although the anterior segment of the liver has been divided into segments 8 and 5, we have, during surgical or interventional procedures, occasionally encountered patients in whom the right anterior portal vein does not bifurcate into the superior and inferior branches. Thus, the in vivo anatomy of the right liver was reevaluated to clarify the segmental anatomy.We evaluated the hepatic venous and portal ramification patterns, using three-dimensional images reconstructed from computed tomography. In addition, liver volumetry was performed.All branches arising from the anterior trunk were divided into two groups: the right ventral portal branches (RVP) and the right dorsal portal branches (RDP), and the anterior fissure vein crossed between the RVP and RDP. The ventral and dorsal regions of the anterior segment were approximately equal from a volumetric point of view.The anterior segment seems to be divided into the ventral and dorsal segments by the anterior fissure, and we propose a reclassification of the right liver that divides the right liver into three segments. Dissection of the parenchyma along the anterior fissure makes the third door of the liver open, resulting in the exposing of all Glissonian pedicles of the right liver. The introduction of our segmental anatomy and surgical procedure will allow more systematic and limited liver resections.

We report a case of a ruptured aneurysm in the anterior superior pancreaticoduodenal artery (PDA) with hypovolemic shock managed successfully by superselective transcatheter arterial embolization of the aneurysm. A 75-year-old male presented to our hospital with hematemesis and melena. On admission, he was in shock. Angiography showed an aneurysm about 1 cm in diameter in the anterior superior PDA. However, extravasation of contrast medium was not seen owing to hypovolemic shock. A catheter was inserted into the aneurysm, and superselective microcoil embolization of the PDA aneurysm was successfully achieved. After the microcoil was inserted into the aneurysm itself, it was observed that duodenal vascularity and pancreaticoduodenal arcades were preserved and aneurysm was not present. There was no complication such as necrosis or abscess formation in the pancreas. The patient recovered and is doing well after 18 months of follow-up. Superselective transcatheter arterial embolization should be considered as the initial treatment of choice for all peripancreatic aneurysms.

A 50-year-old man with extrahepatically growing hepatocellular carcinoma (HCC) associated with direct duodenal invasion underwent a right posterior segmentectomy associated with pancreas-sparing duodenectomy. Neither periduodenal lymph-node metastasis nor pancreatic invasion was detected, thus we separated the supra-ampullary duodenum from the pancreatic head and performed pancreas-sparing supra-ampullary duodenectomy. The resected specimen was observed to be a centrally necrotic tumor that had infiltrated the duodenal wall, resulting in exposure of the lumen. Pathology examination revealed that the tumor consisted of poorly differentiated HCC, which had extensively infiltrated the mucosa of the duodenum. Gastrointestinal tract involvement in patients with HCC is rare, and pancreas-sparing duodenectomy is a safe and effective treatment for patients with HCC associated with direct duodenal invasion.

Serous cystic neoplasms (SCN) of the pancreas are typically honeycombed microcystic masses, which are believed to be benign entity. This report describes a case of a 69-year-old man with a rare solid type of serous cystadenocarcinoma of the pancreas with liver metastases. A 6-cm well enhanced pancreatic tumor and multiple liver nodules were depicted with contrast medium on computed tomography scan. Distal pancreatectomy was performed at first operation. The cut surface of the tumor was solid and glossy appearance. Second operation of liver resection for all metastatic nodules was performed 27 months after the initial operation. The tumor cells in both the pancreas and the liver had cytoplasmic periodic acid-Schiff positive granules, which were completely digested by diastase. Eleven cases of serous cystadenocarcinoma of the pancreas have been reported in the literature. To our knowledge, this is the first case of a solid type serous cystadenocarcinoma.

In previous reports of laparoscopic pancreaticoduodenectomy, the Kocher maneuver with a wide mobilization of the right colonic flexure is carried out in the early phase, and dissection of the superior mesenteric artery is performed in the last phase of resection. This report describes laparoscopic superior mesenteric artery first approach, in which the superior mesenteric artery is dissected in the early phase of resection. Through the ligament of Treitz, the retroperitoneum is widely opened and the superior mesenteric artery is isolated just superior to the left renal vein. The periarterial connective tissue and nerve plexuses surrounding the superior mesenteric artery are dissected longitudinally to identify the inferior pancreaticoduodenal artery, which is then tied and divided. The superior mesenteric artery first approach and early ligation of the inferior pancreaticoduodenal artery is considered to be a feasible, safe, and effective method for performing pure laparoscopic pancreaticoduodenectomy.

To evaluate the segmental anatomy of the right anterosuperior area (segment 8) of the liver by using helical computed tomography during arterial portography (CTAP).Twenty-seven patients without lesions at segment 8 underwent helical CTAP. Three-dimensional portograms were reconstructed to verify the course of the portal veins. The number of subsegmental branches, in addition to the branching point and the distribution in segment 8, was assessed.In 25 (93%) patients, the dorsal branch of segment 8 gave rise to dorsally directed branches posterior to the right hepatic vein. In only four (25%) of 16 patients in whom the medial branch of segment 8 arose near the porta hepatis, the long paracaval portal branch of the caudate lobe extended upward above the interval between the middle and right hepatic veins.In most of the patients, the dorsal branches of segment 8 supplied the dorsocranial area of the right lobe posterior to the right hepatic vein. The paracaval portion of the caudate lobe was limited to below the interval between the middle and right hepatic veins in the majority of patients who showed medial branches of segment 8 arising near the porta hepatis. Recognition of this vascular anatomy is clinically important for preoperative evaluation of hepatic tumors in segment 8 because it may contribute to a safer surgical approach.

A major challenge in laparoscopic liver resection to avoid massive hemorrhage from the transection plane.This study investigated 32 consecutive patients who underwent laparoscopic or laparoscopically assisted hepatic resection and had the hepatoduodenal ligament encircled by vessel tape using an Endo Retract Maxi as a tourniquet for complete interruption of blood inflow to the liver.Laparoscopic encircling of the hepatoduodenal ligament was performed in a few minutes without any complications for any of the 32 patients.Laparoscopic Pringle's maneuver using an Endo Retract Maxi can be performed easily for all patients undergoing laparoscopic liver resection.

From 1992 to 1995, we treated 25 patients who had unresectable pancreatic cancer with a stomach-preserving gastric bypass (SPGB). After as much of the stomach as possible was preserved, it was bypassed to the jejunum by end-to-side anastomosis. During the same period, five patients underwent other types of bypasses while 47 similar patients did not undergo gastric bypass. Although the mean operative time for SPGB was significantly longer than for other types of bypass, the mean intraoperative blood loss was similar. Operative morbidity with SPGB was 28%, and there were no operative deaths. In patients undergoing SPGB, the incidence of delayed gastric emptying was high (24%), but the comfort index (ratio of duration of good palliation to duration of survival) exceeded 50% when metastases were either regional or systemic but limited. The comfort index of patients undergoing other types of bypass or not undergoing bypass was less than 40%. However, the patients with extensive systemic metastases survived less than 100 days and the comfort index was less than 30% for all treatment groups. Our results thus suggest that SPGB is safe and effective for patients with either regional metastases or limited systemic metastases.

Introduction: Hepatopancreaticoduodenectomy (HPD) has been offered as a surgical option for selected patients with cholangiocarcinoma showing widespread infiltration.1 Although the applications of laparoscopic liver or pancreatic resection have been greatly expanded,2 there have been a few reports on a laparoscopic HPD. Materials and Methods: An 80-year-old woman with cholangiocarcinoma showing widespread infiltration underwent a pure laparoscopic HPD, including left hepatectomy, caudate lobectomy, and pylorus-preserving pancreaticoduodenectomy. First, a pylorus-preserving pancreaticoduodenectomy was performed as previously described.3 The common bile duct was lifted in the cranioventral direction, and skeletonization of the hepatic artery and portal vein was advanced up to the hepatic hilum, and then the left hepatic artery and portal vein were divided. The left liver was mobilized, and the caudate lobe was fully separated from the inferior vena cava (IVC). Liver parenchymal transection began fr...

Laparoscopic hemihepatectomy has not yet become widely accepted because of the technical difficulties in controlling each Glissonean pedicle laparoscopically.The subjects in the present study included 12 patients who underwent laparoscopic left hemihepatectomy between August 2007 and June 2011. Arantius' ligament was divided. Retracting the caudal stump of the ligament revealed a space between the left Glissonean pedicle and the liver parenchyma. The left Glissonean pedicle could be easily encircled by using an Endo Retract Maxi. No Glissonean injuries, including bleeding or biliary leakage, occurred in any of the 12 patients.Therefore, the Arantius' ligament approach for the left extrahepatic Glissonean pedicle appears to be feasible and safe for successfully performing pure laparoscopic left hemihepatectomy.

We report a case of early duodenal cancer (2.5 cm in diameter, located in the proximal part) in a 65-year-old female whom segmental resection was performed and a 7- year disease-free survival was achieved. The surgical specimen, showed and a 2.5 × 1.5 × 1.0cm exophytic lesion histopathological examination revealed highly differentiated intramucosal adenocarcinoma. We also report or our review of 122 cases of early duodenal cancer reported in Japan. Intramucosal carcinoma was found in 66%, and submucosal carcinoma in 34% of the patients. The location of the lesion was bulbar in 73 patients (60%), supraampullary in 33 (27%), periamupllary in 5 (4%), and infraampullary in 11 (9%). Distal gastrectomy, including the bulb, was performed in 46 patients, pancreatoduodenectomy in 23, partial resection in 24, endoscopic polypectomy in 25, and segmental resection in 4, including our patient. The frequency of lymph node metastasis is low in early duodenal cancer, so that segmental resection appears to be a reasonable treatment method.

Laparoscopy for liver resection is a highly specialized field, as laparoscopic liver surgery presents severe technical difficulties. However, the recent rapid development of technological innovations, improvements in surgical skills and the accumulation of extensive experience by surgeons have improved the feasibility and safety of a laparoscopic approach for properly selected patients [1]. Since the first report of laparoscopic anatomical left lateral sectionectomy in 1996 [2], increasing numbers of laparoscopic anatomical liver resections have been reported [3-6]. However, laparoscopic anatomical resection has not been widely accepted because major technical difficulties remain, such as hilar dissection and pedicle control. During open anatomical liver resections, each Glissonean pedicle is often ligated and divided en bloc extrahepatically [7, 8]. Using the same concept, we describe herein a novel technique by which each Glissonean pedicle can be easily and safely encircled and divided en bloc extrahepatically during laparoscopic anatomical liver resection.

Background: Recent technological developments and improved endoscopic procedures have greatly enlarged the applications of laparoscopic pancreatic resection. Patient and Methods: A 77-year-old female with invasive ductal cancer of the pancreatic body touching the common hepatic and splenic arteries underwent a pure laparoscopic distal pancreatectomy with en bloc celiac axis resection (DP-CAR). The celiac axis, the celiac plexus and ganglions, the left gastric artery, the Gerota fascia, the left adrenal gland, and the retroperitoneal fat tissues above the left renal vein were removed en bloc. Results: The procedure took 245 minutes and there was minimal blood loss. The postoperative course was uneventful and the patient was discharged on the seventh postoperative day. The surgical margins were histologically clear (R0 resection). Conclusion: Pure laparoscopic DP-CAR is minimally invasive, safe and feasible, and can achieve R0 resection in selected patients with pancreatic invasive ductal adenocarc...

Laparoscopic pancreatic resection of pancreatic cancer is still not universally accepted as an alternative approach to open surgery because of technical difficulties and a lack of consensus regarding the adequacy of this approach for malignancy. Ten patients with pancreatic cancer underwent laparoscopic pancreatic resection, including pancreaticoduodenectomy and distal pancreatectomy in our institution. Eight of the 10 patients recovered without any complications and were discharged on the 10-29th postoperative day. The remaining 2 patients developed pancreatic fistula and were discharged on the 46 and 60th postoperative day, respectively. All lesions were well clear of surgical margins in 6 patients (R0). In the remaining 4 patients, microscopic neoplastic change was found at the surgical margin (R1). Those 4 patients developed tumor recurrence, including liver metastases or peritoneal dissemination, and 3 of the 4 died of the primary disease. Although experience is limited, laparoscopic pancreatic resection of pancreatic cancer can be feasible, safe, and effective in carefully selected patients. However, the benefit of this procedure has yet to be confirmed. Not only adequate experience in pancreatic surgery but also expertise in laparoscopy is mandatory, and careful selection of patients is essential for successful application of this procedure.

Although recent technological developments and improved endoscopic procedures have further spread the application of laparoscopic liver resection, laparoscopic anatomical liver resection still presents major technical difficulties, such as pedicle control. Subjects comprised 27 patients who underwent laparoscopic anatomical liver resection using an extrahepatic Glissonean pedicle transaction between August 2005 and February 2010. A total of 61 Glissonean pedicles could be encircled en bloc extrahepatically, as planned. No serious complications, including major bleeding or injury of the portal triad, were encountered during procedures. Extrahepatic Glissonean access seems to be feasible and safe for laparoscopic anatomical resection of the liver.