Search

The mesentery of the jejunum (MJ) of the Roux limb is conventionally divided when Roux-en-Y reconstruction is performed after total gastrectomy for gastric cancer (GC). However, the impact of dividing or preserving the MJ on anastomotic leakage (AL) at the esophagojejunostomy (EJS) site after minimally invasive total gastrectomy for GC is unclear.This retrospective cohort study enrolled 226 patients with GC who underwent EJS after laparoscopic or robotic total gastrectomy, including preservation of the MJ (n = 87) and division of the MJ (n = 137). The prevalence of anastomotic complications at the EJS and short-term outcomes were compared between groups using propensity score (PS) matching.After PS matching, 69 patients were selected for the preserving and dividing MJ groups. There were no significant intergroup differences in patient backgrounds, including oncological stage, body mass index, and gender ratio. After PS matching, overall and severe complications after surgery were compared between the preserving and dividing MJ groups (21.7% vs. 27.5%, p = 0.554 and 8.7% vs. 13.8%, p = 0.137, respectively). However, the rate of AL at the EJS was significantly lower in the preserving than that in the dividing MJ group (1.4% vs. 13.0%, p = 0.017). In addition, the median postoperative hospital stay was significantly shorter in the preserving than that in the dividing MJ group (13.0 days vs. 16.0 days, p = 0.005).Preserving the MJ significantly reduced AL at the EJS after minimally invasive total gastrectomy for GC.

Few studies compared the oncological and biological characteristics between ampullary carcinoma (AC) and cancer of the second portion of the duodenum (DC-II), although both tumors arise from anatomically close locations.To elucidate differences in clinicopathological characteristics, especially the patterns of lymph node metastasis (LNM), between AC and DC-II.This was a retrospective cohort study of 80 patients with AC and 27 patients with DC-II who underwent pancreaticoduodenectomy between January 1998 and December 2018 in two institutions. Clinicopathological factors, LNM patterns, and prognosis were compared between the two groups.The patients with AC and DC-II did not exhibit significant differences in 5-year overall survival (66.0% and 67.1%, respectively) and 5-year relapse-free survival (63.5% and 62.2%, respectively). Compared to the patients with DC-II, the rate of preoperative biliary drainage was higher (Although there were no significant differences in the prognosis and recurrence rates between the two groups, metastases to N-He and N-Py were more frequent in patients with DC-II than in those with AC.

A 76-year-old male was diagnosed as locally advanced pancreatic cancer because abdominal CT scan revealed a pancreatic head tumor with involvement of the proper hepatic artery. Gemcitabine plus nab-paclitaxel was initiated, but was discontinued because interstitial pneumonia was occurred. The treatment was switched to S-1 therapy and achieved stable disease for 22 months. Therefore, conversion surgery was scheduled. Because stenosis of the celiac artery origin due to median arcuate ligament(MAL)compression and dilatation of pancreatoduodenal artery arcade were observed, laparoscopic MAL section was performed. The patient was discharged on postoperative day 5 without complications. Postoperative CT scan revealed no stenosis of the celiac artery origin and disappearance of dilatation of pancreatoduodenal artery arcade. On postoperative day 14, subtotal stomach-preserving pancreaticoduodenectomy(PD)with portal vein resection was performed. The patient was discharged on postoperative day 19 without complications. Two-staged PD after MAL section make possible to evaluate blood flow accurately and select an appropriate operative method. Laparoscopic MAL section is minimally invasive and may be useful for two-staged PD in patients with celiac axis stenosis.

This study aimed to assess short-term and long-term outcomes and to identify the factors that affect outcomes for patients with colorectal cancer aged 80 years or older. Two hundred patients with colorectal cancer who were underwent resection of the primary tumor between January 2013 and December 2018 were enrolled. Short-term outcomes of elderly patients with poor PS and of those who take antithrombotic agents and of those who were underwent open surgery were poor. Long-term outcomes of elderly patients with high GNRI and of those who were underwent D3 lymph nodes dissection were better. Laparoscopic surgery with D3 lymph nodes dissection for elderly patients who were more than 80 years old should be useful to improve short- and long-term outcomes. GNRI might be a prognostic predictive factor for patients with colorectal cancer aged 80 years or older.

We examined 14 cases who underwent robotic rectal resection with neoadjuvant chemotherapy(NAC)or neoadjuvant chemoradiation therapy(NACRT)for local advanced rectal cancer in our hospital from 2018 June to 2020 December. Two patients underwent NACRT, 12 patients underwent NAC. Sex was 10 males and 4 females. The median age was 66. The surgical procedure was ISR 2 cases, LAR 8 cases, APR 4 cases. The median operation time was 397 minutes and the median blood loss was 73 mL. The histological response grade were Grade 3: 1 case, 2: 7 cases, 1b: 3 cases, and 1a: 3 cases. Surgical margin was negative in all cases. Postoperative complications(≥Clavien-Dindo Grade Ⅲ)required reoperation due to intestinal obstruction in 1 case. Urinary dysfunction was nothing in all cases. Although long-term results such as prognosis and function preservation need to be examined, short-term results of robot-assisted rectal resection after NAC or NACRT were generally good.

The effectiveness and extent of regional lymph node dissection in primary duodenal cancer (DC) remains unclear. This study aimed to analyze the prognostic factors and lymph node metastasis (LNM) patterns in DC. Fifty-three patients who underwent surgical resection for DC between January 1998 and December 2018 at two institutions were retrospectively analyzed. Univariate and multivariate analyses were performed on the prognostic factors of resected DC. Moreover, the relationships between depth of tumor invasion and incidence of LNM and between tumor location and LNM stations were analyzed. The five-year survival rate of the study population was 68.9%. Multivariate survival analysis demonstrated that histologic grade G2–G4, presence of LNM, pT3–4, and elevated preoperative CA19-9 were the independent poor prognostic factors. No patient with pTis–T2 had LNM. On the other hand, LNM was found in 70% of patients with pT3–4. Among 36 patients who underwent pancreaticoduodenectomy (PD), LNM around the pancreatic head was observed, regardless of the duodenal cancer site, including the duodenal bulb and the third to the fourth portion. Histologic grade G2–G4, presence of LNM, pT3–T4, and elevated preoperative CA19-9 were the independent poor prognostic factors in patients with resected DC. Our results suggested that lymph node dissection could be omitted for DC Tis–T1a. Moreover, based on the high frequency of LNM in T3–4 cases, PD with lymph node dissection in the pancreatic head region was considered necessary for T3–4 DC at any site.

Introduction This study aimed to investigate the predictive factors and classifications for difficulty of laparoscopic repeated liver resection (LRLR) in patients with recurrent hepatocellular carcinoma. Methods Sixty patients who underwent LRLR were included. Potential predictive factors for difficult LRLR included the approach of the previous liver resection (laparoscopic or open), the number of previous liver resections, a history of cholecystectomy in previous liver resection, the operative procedure of previous liver resection, whether the tumor was near the resected site of the previous liver resection, non-surgical treatments before the present surgery, and the difficulty scoring system for laparoscopic liver resection. The relationship between these factors and perioperative outcomes were evaluated to investigate the predictive factor for difficult LRLR. Results Univariate and multivariate analyses demonstrated that an open approach during previous liver resection, two or more previous liver resections, a history of previous liver resection with not less than sectionectomy, tumor near the resected site of the previous liver resection, and intermediate or high difficulty in the difficulty scoring system were independent risk factors for prolonged operative time and/or severe adhesion of LRLR. Three difficulty classifications were then suggested based on the number of these five predictive factors. The difficulty classification reflected operative time, intraoperative blood loss, and incidence of postoperative complication. Conclusion The difficulty of LRLR may be predicted by three difficulty classifications using five preoperative predictive factors.

Introduction We investigated the indications for laparoscopic liver resection (LLR) of mass-forming intrahepatic cholangiocarcinoma (MF-ICC), including the need for lymph node dissection for improved postoperative prognosis. Methods This study involved 36 patients who underwent surgery for solitary peripheral MF-ICC. Fifteen patients underwent LLR, and 21 underwent open liver resection (OLR). Surgical outcomes and prognostic factors were investigated to determine the indications for LLR. Results No significant differences were observed in perioperative outcomes between patients who underwent LLR and OLR. A significantly worse disease-free survival (DFS) rate was observed in patients who preoperatively had a tumor diameter ≥3 cm, vascular invasion on diagnostic imaging, and elevated serum carbohydrate antigen (CA) 19-9 and carcinoembryonic antigen (CEA) levels. A significantly worse overall survival (OS) rate was observed in patients with a tumor diameter ≥3 cm, vascular invasion on diagnostic imaging, and elevated serum CA19-9 levels. Therefore, a tumor diameter ≥3 cm, vascular invasion on diagnostic imaging, and elevated serum CA19-9 and CEA levels were determined to be preoperative prognostic factors. DFS and OS rates were significantly better in patients without these factors. Moreover, in six patients without these factors who underwent LLR, neither lymph node metastasis nor postoperative recurrence was observed. Conclusion A tumor diameter ≥3 cm, vascular invasion on diagnostic imaging, and elevated serum CA19-9 and CEA levels are preoperative prognostic factors for peripheral MF-ICC. LLR is indicated for patients without these factors.

A 66‒year‒old man was admitted to our hospital because of anemia and a positive fecal occult blood test in the medical examination. Colonoscopy revealed a type 2 advanced sigmoid colon cancer with circular stenosis. Computed tomography (CT)colonography was performed to examine the oral colon. The apple core signs were found both in the sigmoid and transverse colon. We diagnosed a double colon cancer and performed a laparoscopic left hemicolectomy and sigmoidectomy. The tumor was histopathologically diagnosed as a multiple cancer including a transverse and a sigmoid colon cancer. Although evaluations of the intestine for colon cancer with stenosis are performed by enema examination or endoscopic examination after colon stent placement, both examinations are invasive. CT colonography is considered to be a minimally invasive and an effective preoperative examination for colorectal cancer with stenosis.

We examined 22 cases who underwent preoperative chemotherapy in our hospital from 2013 April to 2018 December. Seven patients were treated as neoadjuvant chemotherapy(NAC). Out of 15 patients with unresectable diseases before chemotherapy, 6 patients were able to R0 resection after chemotherapy(conversion). Although only one patients was underwent RM1 resection, the other patients were underwent RM0 resection. The median overall survival was 42 months in NAC group, 28 months in conversion group, and 17 months in palliative resection group, respectively. Recurrence was observed in 1 patient in NAC group, however, all patients had recurrent disease in conversion group. In this study, although further examination should be done according to the clinical significance of preoperative chemotherapy, preoperative chemotherapy may be carried out without severe adverse event and severe postoperative complication.

A 82-year-old female had received radiofrequency ablation for hepatocellular carcinoma(HCC)in segment 2 30 months before surgery. One month before surgery, enhanced CT showed enhanced lesion about 20 mm in diameter in the abdominal wall along the needle-tract. There was no other recurrent lesion including liver. We diagnosed the lesion as needle-tract implantation and she underwent surgical resection of the abdominal rectus muscle and sheath including needle-tract. The pathological findings revealed well differentiated HCC. After the surgery, she underwent transcatheter arterial embolization for the recurrent HCC in segment 3 and segment 4. Twenty one months after the surgery, she has been alive without recurrence. Our case demonstrated that surgical resection of the needle-tract implantation of the HCC is one of the useful therapeutic options for the selected patients.

A 66-year-old female with upper abdominal pain was diagnosed the pancreatic tail cancer infiltrating into the stomach and transverse colon by computed tomography(CT). Umbilical metastasis(so called Sister Mary Joseph's nodule)and peritoneal metastases in pouch of Douglas were detected by FDG-PET. The patient was diagnosed as unresectable pancreatic cancer with distant metastases. Thus, she received FOLFIRINOX therapy. After 9 courses of FOLFIRINOX therapy and 15 courses of FOLFIRI therapy, the pancreatic tumor shrunk on CT. In addition, umbilical metastasis and peritoneal metastases disappeared on FDG-PET. Therefore, conversion surgery was scheduled. Fourteen months after the initial treatment, we performed distal pancreatectomy with left adrenalectomy partial gastrectomy, transverse colectomy, and umbilical resection. The patient was discharged 15 days after the operation without serious complications. Histopathological findings revealed the presence of adenocarcinoma infiltrating into the preperitoneal adipose tissue in the umbilicus. Histological therapeutic effect was Grade Ⅰb according to the 7th Edition of the General Rules for the Study of Pancreatic Cancer. Seven months after the operation, local recurrence was showed. The patient is still alive 2 years and 5 months since the initial treatment.

A 42-year-old man, after remission of MALT lymphoma of the small intestine, was repeatedly hospitalized because of abdominal pain and severe dehydration caused by frequent vomiting and watery diarrhea. His symptoms would improve quickly every time when he was fasted and inserted a nasogastric tube. We were unable to find abnormalities on endoscopic examination and computed tomography. He was suspected to have gastrinoma because of active bleeding from a duodenal ulcer. High-level serum gastrin, endoscopic ultrasound, somatostatin receptor scintigraphy, and selective arterial calcium injection test were done. He was diagnosed with pancreatic gastrinoma in the pancreatic head by endoscopic ultrasound fine needle aspiration and subsequently underwent pancreatoduodenectomy. Histopathologic findings showed a 3-mm neuroendocrine tumor located in the duodenal submucosal layer. The presence of metastasis was confirmed in one of the peripancreatic lymph nodes. The pancreatic gastrinoma in the pancreatic head that we initially diagnosed was a lymph node metastasis behind the pancreas. Because additional resection was performed on the duodenum, we were able obtain a diagnosis of duodenal gastrinoma.

A 67-year-old woman was diagnosed with borderline resectable pancreatic cancer and obstructive jaundice. A covered self-expandable metallic stent(SEMS)was placed endoscopically. Neoadjuvant chemotherapy with gemcitabine plus nabpaclitaxel was provided. Forty-seven days after the SEMS placement, she presented with hematemesis. Computed tomography revealed migration of SEMS into the small bowel. No pseudoaneurysms were detected. Upper digestive endoscopy demonstrated hemobilia without obvious causes of bleeding in the stomach or duodenum. As hemorrhage recurrence was confirmed in the bile duct, we performed pancreaticoduodenectomy. Thus, bile duct hemorrhage can occur in patients with pancreatic cancer after SEMS placement.

The patient was an 81-year-old woman. She had undergone extended cholecystectomy with lymph node dissection for primary gallbladder cancer. The pathological diagnosis was moderately differentiated tubular adenocarcinoma(pT2, N0, M0, pStage Ⅱ). Eleven months after the initial surgery, dynamic CT revealed a solitary low-enhanced tumor in S5 ofthe liver. As the tumor was detected with abnormal FDG uptake by PET-CT, we diagnosed the patient with a metastatic liver tumor from gallbladder cancer. Although chemotherapy was considered, conservative treatment was selected as the patient did not want to undergo chemotherapy. Therefore, laparoscopic partial liver resection was performed 15 months after the initial surgery with the consideration that no other distant metastasis was found, and tumor markers were within normal ranges. The postoperative course was uneventful, and the patient was discharged 13 days after liver resection without any morbidities. The resected tumor was pathologically diagnosed as a metastatic liver tumor from gallbladder cancer. She has achieved 18 months recurrence free survival after the liver resection without adjuvant chemotherapy. Although liver resection for a metastatic liver tumor from gallbladder cancer is not a standardized treatment, it may be a therapeutic option in cases of limited metastasis.

A 76-year-old man was referred to our hospital for advanced hepatocellular carcinoma(HCC)with chronic hepatitis type B. Although he underwent right anterior sectionectomy and S3 segmentectomy, multiple recurrences were found in the hepatic remnant after 2 months. Transcatheter arterial chemoembolization(TACE)and transcatheter arterial infusion (TAI)were performed separately. One and a half month after the last TAI, AFP and PIVKA-Ⅱ levels markedly elevated, and multiple early enhancing nodules with portal vein tumor thrombosis were detected on CT. A half dose of sorafenib(400mg/ day)was administered to the patient who was refractory to TACE. Sorafenib was discontinued after 4 weeks because the patient developed general fatigue and anorexia(Grade 3). Furthermore, these adverse events became worse, and ascites appeared. He was hospitalized in the palliative care unit for best supportive care for 3 weeks and also received outpatient treatment for more than 14 months. Fifteen months after discontinuing sorafenib administration, his condition improved dramatically, and CT revealed that the multiple HCC had reduced in size. Moreover, the portal vein tumor thrombosis disappeared. As his performance status and liver function were well preserved, he underwent partial hepatectomy for residual HCC. The patient remains alive without recurrence at 18 months, despite no administration of sorafenib.This case demonstrates that sorafenib administration combined with surgical treatment could possibly cure advanced HCC refractory to TACE.

A 74-year-old woman presented with epigastric pain. Imaging revealed a tumor measuring 80 mm, with internal necrosis, originating from the gallbladder and invading the liver. We performed extended anterior segmentectomy of the liver and lymph node resection following a preoperative diagnosis of gallbladder cancer. Histologically, the tumor was diagnosed as an undifferentiated carcinoma of the gallbladder. Although curative resection was performed, the patient developed recurrence with liver metastasis and peritoneal dissemination after 6 postoperative weeks and died after 10 postoperative weeks.

In June 2018, a 75-year-old woman was admitted for right upper quadrant pain. She had a history of radical mastectomy for left breast cancer in April 2009. The axillary lymph node, bone, gastric, and pleural metastases had been treated with hormonal therapy for 2 years from April 2016. Based on the examination findings, we diagnosed her with acute calculous cholecystitis and performed emergency percutaneous transhepatic gallbladder drainage(PTGBD). Eleven days after PTGBD, we performed laparoscopic cholecystectomy. Pathological examination revealed a metastatic tumor from breast cancer in her gallbladder. Although her postoperative course was uneventful, the patient died of progression of the other organ metastasis 7 months after cholecystectomy. Gallbladder metastasis should be considered in patients with advanced breast cancer who present symptoms of cholecystitis.

Background Prospective studies are needed to understand the safety and feasibility of laparoscopic pancreatectomy. The aim of the present study was to describe laparoscopic pancreatectomy currently undertaken in Japan, using a prospective registration system. Methods Patient characteristics and planned operations were registered preoperatively, and then the performed operation and outcomes were reported using an online system. Collected data were also compared between institutions based on their level of experience. This study was registered with UMIN000022836. Results Available data were obtained from 1,429 patients at 100 Japanese institutions, including 1,197 laparoscopic distal pancreatectomies (LDPs) and 232 laparoscopic pancreatoduodenectomies (LPDs). The rates of completion for planned operations were 92% for LDP and 91% for LPD. Postoperative complication rates after LDP and LPD were 17% and 30%, and 90-day mortality rates were 0.3% and 0.4%, respectively. Shorter operation time, less blood loss, and lower incidence of pancreatic fistula were observed in institutions experienced in LDP. A higher rate of pure laparoscopic procedure and shorter operation time were noted in institutions experienced with LPD. Conclusion LDPs and LPDs are performed safely in Japan, especially in experienced institutions. Our data could support the next challenges in the field of laparoscopic pancreatectomy.

In Japan, the Southampton method for dopamine transporter (DAT) SPECT is widely used to quantitatively evaluate striatal radioactivity. The specific binding ratio (SBR) is the ratio of specific to non-specific binding observed after placing pentagonal striatal voxels of interest (VOIs) as references. Although the method can reduce the partial volume effect, the SBR may fluctuate due to the presence of low-count areas of cerebrospinal fluid (CSF), caused by brain atrophy, in the striatal VOIs. We examined the effect of the exclusion of low-count VOIs on SBR measurement. We retrospectively reviewed DAT imaging of 36 patients with parkinsonian syndromes performed after injection of 123I-FP-CIT. SPECT data were reconstructed using three conditions. We defined the CSF area in each SPECT image after segmenting the brain tissues. A merged image of gray and white matter images was constructed from each patient’s magnetic resonance imaging (MRI) to create an idealized brain image that excluded the CSF fraction (MRI-mask method). We calculated the SBR and asymmetric index (AI) in the MRI-mask method for each reconstruction condition. We then calculated the mean and standard deviation (SD) of voxel RI counts in the reference VOI without the striatal VOIs in each image, and determined the SBR by excluding the low-count pixels (threshold method) using five thresholds: mean-0.0SD, mean-0.5SD, mean-1.0SD, mean-1.5SD, and mean-2.0SD. We also calculated the AIs from the SBRs measured using the threshold method. We examined the correlation among the SBRs of the threshold method, between the uncorrected SBRs and the SBRs of the MRI-mask method, and between the uncorrected AIs and the AIs of the MRI-mask method. The intraclass correlation coefficient indicated an extremely high correlation among the SBRs and among the AIs of the MRI-mask and threshold methods at thresholds between mean-2.0D and mean-1.0SD, regardless of the reconstruction correction. The differences among the SBRs and the AIs of the two methods were smallest at thresholds between man-2.0SD and mean-1.0SD. The SBR calculated using the threshold method was highly correlated with the MRI–SBR. These results suggest that the CSF correction of the threshold method is effective for the calculation of idealized SBR and AI values.

To evaluate the image quality and lesion visibility of virtual monoenergetic images (VMIs) reconstructed using a new monoenergetic reconstruction algorithm (nMERA) for evaluation of breast cancer. Forty-two patients with 46 breast cancers who underwent 4-phasic breast contrast-enhanced computed tomography (CT) using dual-energy CT (DECT) were enrolled. We selected the peak enhancement phase of the lesion in each patient. The selected phase images were generated by 120-kVp-equivalent linear blended (M120) and monoenergetic reconstructions from 40 to 80 keV using the standard reconstruction algorithm (sMERA: 40, 50, 60, 70, 80) and nMERA (40 +, 50 +, 60 +, 70 +, 80 +). The contrast-to-noise ratio (CNR) was calculated and objectively analyzed. Two independent readers subjectively scored tumor visibility and image quality each on a 5-point scale. The CNR at 40 + and tumor visibility scores at 40 + and 50 + were significantly higher than those on M120. The CNR at 50 + was not significantly different from that on M120. However, the overall image quality score at 40 + was significantly lower than that at 50 + and on M120 (40 + vs M120, P

An 82-year-old female underwent contrast computed tomography (CT) that revealed multiple ring-like enhanced masses in the pancreatic tail. Additionally, the inside of the masses showed enhancement on contrast endoscopic ultrasound (EUS). She was diagnosed with a pancreatic neuroendocrine tumor on histopathological examination after EUS-guided fine-needle aspiration, and distal pancreatectomy and splenectomy were performed. In the resected specimen, toward the tumor center, tumor cells with lipid droplets and fibrosis were remarkably observed. These rare histopathological features well reflected the image findings of contrast CT and contrast EUS.

This paper proposes the information sharing algorithm for preventing propagation of wrong information in the agent-based network such as SNS, and aims at investigating the effectiveness of the proposed algorithm through the complex network such as a small world network. Towards practical applications, this paper extends the conventional opinion sharing model (OSM) to cope with the multi-value opinion from the binary opinion, and proposes the new algorithm for preventing propagation of wrong information to cope with the multi-value opinion. The intensive simulations of three types of the complex network have revealed that the accuracy of the correct opinion of agents in the proposed algorithm (called Self-information Weight Tuning (SWT)) reaches around 80% which is not affected by the number of opinion states in the multi-value opinions, while that of the conventional algorithm (called Autonomous Adaptive Tuning (AAT)) is lower than the proposed algorithm and decreases as the number of opinion states increases.

A 70's man underwent subtotal stomach preserving pancreatoduodenectomy(SSPPD)for pancreatic head cancer. The pathological diagnosis was adenosquamous carcinoma(ASC)of the pancreas. Two months after surgery, a recurrent tumor in the remnant pancreas was confirmed with a CT scan and suspected to be ASC by endoscopic ultrasound-guided fine needle aspiration(EUS-FNA). As the recurrent lesion was limited in the pancreas, total remnant pancreatectomy(TP)was performed 4 months after SSPPD. The final pathological diagnosis was ASC. Two months after TP, liver and para-aortic lymph node metastases were revealed. The patient has been alive for 14 months after SSPPD with chemotherapy. Because of its rarity, it is difficult to implement treatment plans for recurrent ASC in the remnant pancreas.

A 58-year-old man complaining of dysphagia was admitted to our hospital and diagnosed with esophageal cancer.He underwent thoracoscopic subtotal esophagectomy with 3-field lymph node dissection and reconstruction with a gastric tube created by hand-assisted laparoscopy.The pathological diagnosis was classified as AeLtG, pT3N2M0, pStage III .He was subsequently treated with systemic chemotherapy with 5-fluorouracil and cisplatin.After 2 courses, a single liver metastatic tumor appeared at segment 5.As chemotherapy against the recurrence, weekly-paclitaxel was administered.After 2 courses, the metastatic liver tumor reduced in size.Subsequently, laparoscopic partial liver resection was performed 11 months after first surgery.The pathological finding was negative for malignancy(pathological complete response).

This chapter covers a range of important topics of laparoscopic hepatectomy as a novel approach toward treatment of liver cancer. Although laparoscopic hepatectomy was performed in a limited number of centers in the 1990s, technological innovations, improvements in surgical techniques and accumulation of experience by surgeons have led to more rapid progress in laparoscopic hepatectomy in the late 2000s for minimally invasive hepatic surgery. Currently, laparoscopic hepatectomy can be performed for all tumor locations and several diseases via several approaches. The laparoscopic approach can be applied to several types of resection, not only for tumors but also for liver transplantation, with equivalent or better results compared with those obtained with open surgery. Therefore, laparoscopic hepatectomy will become a standard procedure for treatment of liver cancer in the near future.

A bifunctional aminoboronic acid has been used to facilitate for the first time the intramolecular aza- and oxa-Michael reactions of α,β-unsaturated carboxylic acids. The combination of an arylboronic acid with a chiral aminothiourea allowed for these reactions to proceed successfully in an enantioselective manner to afford the desired heterocycles in high yields and ee's (up to 96% ee). The overall utility of this dual catalytic system was demonstrated by a one-pot enantioselective synthesis of (+)-erythrococcamide B, which proceeded via sequential Michael and amidation reactions.

Background Anaplastic pancreatic cancer (APC) cell lines have been scarcely established. Methods The morphology, gene expressions, karyotyping and epithelial-mesenchymal transition markers of newly established APC cell lines OCUP-A1 and OCUP-A2 were analyzed. Their abilities of proliferation under normoxia and hypoxia, migration and invasion were compared to 4 commercially available pancreatic ductal adenocarcinoma (PDA) cell lines. Their induction of angiogenesis, stem-like cell population and subcutaneous tumor growth in nude mice were estimated, comparing 2 PDA cell lines examined here. Results OCUP-A1 and OCUP-A2 cells continuously grew with spindle and polygonal shapes, respectively. Gene analysis revealed 9 gene mutations including KRAS and TP53. Karyotyping clarified numerical structural abnormalities in both cells. Loss of E-cadherin and expression of vimentin in both cell lines were observed. The doubling time of both cell lines was approximately 20 h. Proliferation, migration and invasion abilities were not notable compared to other PDA cell lines. However stem-like cell population of both cell lines was superior to a part of PDA cell lines. Moreover OCUP-A1 showed stronger hypoxia tolerance and induction of angiogenesis than other PDA cell lines. The tumorigenicity in vivo of OCUP-A2 was stronger than conventional PDA cell lines. Conclusions The OCUP-A1 and OCUP-A2 cell lines of rare malignancies might be useful for investigating the biology of pancreatic cancer.

The prognosis of HCC with vascular invasion is dismal, but surgery is elected when the hepatic reserve is adequate. The case involved a 68-year-old male HCV carrier. A 10 cm diameter tumor occupying the central 2 segments of the liver and liver metastasis in the left lobe were detected. The patient was diagnosed with multiple HCC with severe vascular invasion of Vp2 and Vv3. The tumor shrunk dramatically after starting HAIC therapy with cisplatin and oral administration of sorafenib. A laparoscopic partial hepatectomy was performed for the viable lesion. The tumor showed almost complete coagulative necrosis. Multiple hepatic metastases were found 4 months after surgery, but the tumor was under control at 25 months after the first HAIC due to HAIC, oral administration of sorafenib, and RFA. An improved prognosis for multiple HCC with severe vascular invasion can be expected by performing multidisciplinary treatments including surgery.

Sorafenib has been a standard therapy for advanced hepatocellular carcinoma (HCC) with portal vein thrombosis. Hepatic arterial infusion chemotherapy (HAIC) is still preferably performed in Japan because of its relatively good tumor-shrinking effect. We report a case of advanced multiple HCC with portal thrombus that responded to combination chemotherapy with sorafenib and repeat hepatic arterial infusion with a fine-powder formulation of cisplatin (IA-call®). A 57-year-old man presented for the treatment of HCC with alcoholic cirrhosis. Multiple HCC were found to be rapidly progressing with portal thrombosis. HAIC with IA-call® was performed, but the tumors progressed. TAE was performed 3 times thereafter and the main tumor shrunk to some extent. A month after the last TAE, the HCC was found to progress again, and oral sorafenib was administered. A reservoir and catheter were placed and HAIC with low-dose 5-fluorouracil and cisplatin was performed for 3 cycles following 1 HAIC cycle with epirubicin and mitomycin C, which was not effective. For 10 months after initial therapy, HAIC using IA-call® has been performed once for 6 weeks. After performing HAIC with IA-call® 5 times, the serum levels of HCC tumor markers AFP and PIVKA-Ⅱdecreased, and the tumors continued to shrink and were not stained on enhanced CT scan. The patient has been alive for 23 months after the initial therapy and has maintained stable disease.

A multi-purpose seismic experiment named the 2002 integrated seismic experiment Southwest Japan was conducted in 2002 along a more-than-240-km-long line across southwest Japan from the Pacific coast to the Japan Sea coast. Its profile provides the first crustal-scale cross section across the Japanese island arc, which highlights a number of significant points related to the structural development of the arc. Major outstanding points are that the Japanese island arc is composed of two completely different crusts juxtaposed by the Median Tectonic Line (MTL), and that the MTL started its activity associated with lower crustal thinning and formation of an upper crustal-scale half-graben in Late Cretaceous.

Cataclastic rocks found in the Disaster Prevention Research Institute, Kyoto University (DPRI) 500 m drill core and outcrops along the Nojima Fault zone on Awaji Island, southwest Japan, were examined at mesoscopic and microscopic scales. The damaged zone of this fault in granitic rocks, observed on the southeast side of the fault, is 50–60 m wide and is composed of fractured host rocks and cataclastic rocks including cataclasite, fault breccia, and fault gouge. The fault breccia and gouge of small scales are scattered in the damaged zone. Fault core (zone of extremely concentrated shearing deformation along a fault) consists of fault gouge measuring several tens to approximately 150 mm in width, as recognized both in the drill core and at outcrops of the Nojima Fault along which surface ruptures formed during the 1995 Kobe earthquake. Fault breccia, measuring a few meters wide, has developed pervasively in the damaged zone, just next to the fault core. Pseudotachylyte has been found interlayered with fault gouge within the fault core only at outcrops at Hirabarashi, not in the DPRI 500 m core. Petrological studies and powder X-ray diffraction analysis show that the pseudotachylyte and fault gouge are composed mainly of fine-grained angular clasts of the host granitic rocks, suggesting the pseudotachylyte is of ‘crush origin’. Foliated cataclasite is characterized by the preferred orientation of elongated biotite clasts and granular aggregates of quartz and feldspar clasts, and by the development of cataclastic shear bands. Unlike cataclastically deformed quartz and feldspar in the cataclasite, biotite in the foliated cataclasite shows combinations of brittle and plastic deformation, such as biotite ‘fish’, cleavage steps, bending and kinking. These textures suggest that the foliated cataclasite formed at a deeper level than the cataclasite, fault breccia and gouge, possibly before the Quaternary period during which the Nojima Fault has moved as a dextral strike–slip fault with some reverse movement resulting in the uplifting of Awaji Island. Examination of fault rocks from surface outcrops can yield similar results to those obtained from drill cores with regard to the internal structures of a fault zone.

This paper describes the results of petrographical and meso- to microstructural observations of brittle fault rocks in cores obtained by drilling through the Nojima Fault at a drilling depth of 389.52 m. The zonation of deformation and alteration in the central zone of the fault is clearly seen in cores of granite from the hanging wall, in the following order: (i) host rock, which is characterized by some intragranular microcracks and in situ alteration of mafic minerals and feldspars; (ii) weakly deformed and altered rocks, which are characterized by transgranular cracks and the dissolution of mafic minerals, and by the precipitation of zeolites and iron hydroxide materials; (iii) random fabric fault breccia, which is characterized by fragmentation, by anastomosing networks of transgranular cracks, and by the precipitation of zeolites and iron hydroxide materials; and (iv) fault gouge, which is characterized by the precipitation of smectite and localized cataclastic flow. This zonation implies that the fault has been weakened gradually by fluid-related fracturing over time. In the footwall, a gouge layer measuring only 15 mm thick is present just below the surface of the Nojima Fault. These observations are the basis for a model of fluid behavior along the Nojima Fault. The model invokes the percolation of meteoric fluids through cracks in the hanging wall fault zone during interseismic periods, resulting in chemical reactions in the fault gouge layer to form smectite. The low permeability clay-rich gouge layer sealed the footwall. The fault gouge was brecciated during coseismic or postseismic periods, breaking the seal and allowing fluids to readily flow into the footwall, thus causing a slight alteration. Chemical reactions between fluids and the fault breccia and gouge generated new fault gouge, which resealed the footwall, resulting in a low fluid condition in the footwall during interseismic periods.

Drilling was carried out to penetrate the Nojima Fault where the surface rupture occurred associated with the 1995 Hyogo-ken Nanbu earthquake. Two 500 m boreholes were successfully drilled through the fault zone at a depth of 389.4 m. The drilling data show that the relative uplift of the south-east side of the Nojima Fault (south-west segment) was approximately 230 m. The Nojima branch fault, which branches from the Nojima Fault, is inferred to extend to the Asano Fault. From the structural contour map of basal unconformity of the Kobe Group, the vertical component of displacement of the Nojima branch–Asano Fault is estimated to be 260–310 m. Because the vertical component of displacement on the Nojima Fault of the north-east segment is a total of those of the Nojima Fault of the south-west segment and of the Nojima branch–Asano Fault, it is estimated to total to 490–540 m. From this, the average vertical component of the slip rate on the Nojima Fault is estimated to be 0.4–0.45 m/103 years for the past 1.2 million years.

To clarify the movement of the standing up assistance chair and correspondence with the sense side of the user in this research, it considered it based on the result of the senses examination experiment. As a result, in the superiority or inferiority judgment of the influence that the movement pattern on the seat with the difference exerted on the person, there was a common criterion to the person, and it was guessed that it was an anxiety. Next, to examine the relation between the movement orbit on the seat and the user's posture change, the operation measurement experiment was done. Based on those results, the relation with rise on the seat and user's psychological senses was considered. Result, to decrease the anxiety according to the movement on the seat, the suggestion that it was important to reduce the change of the angle of the knee, and to reduce the spine curve angle change, and to support the body by the area with a wide seat, and to support a lot of weight by the seat, and to slow down the movement of the seat load center was obtained.

症例は67歳の男性で, 10年前よりC型慢性肝炎にて通院中, 2003年8月腰背部痛が出現したため当院を受診した. AFPが60ng/mlと高値で, 腹部USにて肝S5に4cm大の高エコー腫瘍を認めた. 造影CTでは辺縁のみ造影され, 総肝動脈, 下大静脈周囲リンパ節腫大もみられた.上部・下部消化管に癌病変なく, 肺・縦隔にも異常所見はなかった. 腹部血管造影検査でS5に腫瘍濃染像がみられ, CT-APにてperfusion defectを呈し肝細胞癌と診断, TAEを施行した. しかし, 壊死効果不十分であったため, 開腹下にマイクロ波凝固療法およびリンパ節摘出術を行った. 肝腫瘍は生検にて低分化型肝細胞癌と診断され, 摘出したリンパ節に類上皮細胞肉芽腫と転移巣が混在して認められた. 術後約2年健存中である. 悪性腫瘍の数%にサルコイド反応がみられ本邦では胃癌, 肺癌に多いとされているが, 肝細胞癌に伴った報告は自験例を含め5例とまれであり文献的考察を加えて報告する.

A soft-coagulation system (SCS) was introduced as an effective device to reduce blood loss in hepatectomy. Here we evaluated the efficacy of a two-surgeon technique using precoagulation by an SCS and the Cavitron Ultrasonic Surgical Aspirator (CUSA) for liver transection.The 163 patients with liver tumors were divided into two groups (conventional group and two-surgeon group). Liver transection was conducted using saline-coupled bipolar electrocautery and CUSA in 102 patients (conventional group). In 61 patients (the two-surgeon group), a two-surgeon technique using precoagulation by an SCS and CUSA for liver resection was performed.The median blood loss was significantly less in the two-surgeon group compared to the conventional group (354.8 mL vs. 557.8 mL, respec tively: p = 0.0011). The postoperative hospital stay was significantly shorter in the two-surgeon group compared to the conventional group (12.7 days vs. 15.5 days, p = 0.0035).The two-surgeon technique using precoagulation by an SCS and CUSA was significantly reduced blood loss during liver transection, and associated with low morbidity and mortality. This technique may be useful for many hepatobiliary surgeons.

For the first time aminoboronic acids (such as BNP) are used as efficient catalysts for the direct intramolecular hetero-Michael addition to α,β-unsaturated carboxylic acids to give a wide variety of O- and N-containing heterocycles.

Study Background: In the International Consensus Guidelines 2012 for intraductal papillary mucinous neoplasm (IPMN), 'high-risk stigmata' (HRS) were described as indications for resection. The purpose of this study was to evaluate the prognostic meaning of HRS in the 2012 guidelines. Method: Clinical and pathological data from 98 patients who underwent pancreatic resection for IPMN at our institution between 1994 and 2014 were retrospectively analyzed. Results: The 98 resected IPMNs were categorized as demonstrating no criteria (NC) (n=18), worrisome features (WF) (n=39), or HRS (n=46) according to the guidelines. By multivariate analysis, positive lymph node metastasis and HRS were significantly identified as independent prognostic factors. Five-year disease-specific survival rates for NC and WF were both 100%, whereas that for HRS was significantly poorer at 49.5% (p

症例は66歳, 男性. 全身倦怠感, 黄疸を主訴に受診. 血液検査では肝胆道系酵素の上昇と高γグロブリン血症, 高IgG血症を認めた. 画像検査にて膵頭部腫大と主膵管の狭細化, 膵内胆管の狭窄を認め, また膵尾部から脾周囲に線維化様陰影もみられた. 膵頭部の針生検にて自己免疫性膵炎と判断し, ステロイド療法を行った. その結果, 膵頭部腫大は改善したが, 膵尾部周囲の線維化陰影は不変であった. 3年後, 新たに腹部大動脈周囲に線維化陰影が出現したが, 膵頭部病変の再燃はみられず経過観察中である. 後腹膜線維症を合併した自己免疫性膵炎の報告は稀であり, さらにステロイド療法後に興味深い経過をたどった貴重な症例と考えられたので報告する.