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Highlights • We presented a patient with gastric tube cancer who successfully underwent subtotal gastrectomy with intraoperative ICG fluorescence. • ICG fluorescence is useful for evaluating the flow of the gastric tube and helping to determine the operating method., Introduction Currently, the frequency of evaluating the flow of a reconstructed gastric tube using indocyanine green (ICG) fluorescence has been increasing. However, it has been difficult to decide on the operation method for patients with gastric tube cancer (GTC). We herein report a case in which ICG was effective in a patient with resection of GTC. Presentation of case An 83-year-old man underwent subtotal esophagectomy with gastric tube reconstruction via the retrosternal route for esophageal cancer and right hemicolectomy for ascending colon cancer 16 years earlier. Postoperatively, the proximal part of the gastric tube had poor blood flow. Therefore, the patient underwent proximal-side resection of the gastric tube. Thereafter, free jejunal graft reconstruction was performed. The patient had not developed recurrence at that point. Recently, the patient visited the hospital complaining of nausea and chest discomfort. Upper gastrointestinal endoscopy revealed a type 0-IIa + IIc lesion located around the pylorus. A biopsy showed adenocarcinoma. Based on these findings, the patient was diagnosed with gastric tube cancer (cT1bN0M0StageI). The invasion depth of the cancer was predicted to be widespread submucosal invasion. Therefore, the patient underwent surgery. Intraoperatively, we evaluated the flow of the gastric tube after clamping the right gastroepiploic artery using ICG fluorescence. As a result, the flow of the gastric tube was deemed insufficient. Consequently, subtotal gastrectomy was performed with preservation of the right gastroepiploic artery via Roux-en-Y reconstruction. Discussion ICG fluorescence is useful for evaluating the flow of the gastric tube helping to decide the operating method. Conclusion We herein report a case of subtotal gastrectomy for GTC using intraoperative ICG fluorescence.

We present a 46-year-old female patient who underwent resection of a retroperitoneal tumor, which was found by medical check-up. The tumor which was elastic hard and had good mobility displaced the duodenum to her abdominal wall. Since her right ovarian vein adhered to the tumor, we removed the tumor with the ligated vein. Pathological findings showed the tumor consisted of spindle-shaped cells with pleomorphic nucleus and it presented the fascicular growth pattern. Additional immunostaining showed positive for HHF35, h-caldesmon. Because the leiomyosarcoma connected with the smooth muscle of the right ovarian vein, we considered the vascular smooth muscle was the origin of the tumor. It is 2 years after the operation, there has been no local recurrence or metastasis.

An 80-year-old woman who visited our hospital with chief complaints of decreased appetite and diarrhea. Lower gastrointestinal endoscopy showed a type 2 tumor in the rectal Ra, and biopsy revealed a well-differentiated adenocarcinoma. The patient had locally advanced rectal cancer with widespread contact with the sacrum, and preoperative radiochemotherapy (S-1 100 mg/day plus radiotherapy 50 Gy/25 Fr)was performed. After the treatment was completed, the tumor was remarkably reduced, but the surgery was strongly rejected, and therefore chemotherapy became the policy. XELOX plus bevacizumab therapy was started, but in the second course was performed, obstructive symptoms appeared, so a semi-urgent lower anterior resection and ileostomy were performed. Postoperative pathological findings showed only a small amount of tumor cells in the mucosa, suggesting that preoperative treatment was effective.

A63 -year-old man complaining of anal pain visited our hospital. Three years 6 months previously, the patient underwent endoscopic submucosal dissection(ESD)for early-stage rectal cancer. Based on the pathological findings, adenocarcinoma with invasion to the submucosal layer(2,000 mm)and lymphovascular invasion were diagnosed. Abdominal computed tomography( CT)revealed a solid tumor 50mm in diameter and hematoma measuring approximately 90mm in length adjoining the tumor in the mesorectum. We performed exploratory laparoscopy. Ahematoma was confirmed in the mesentery from the sigmoid colon and rectum. After the surgery, endoscopic ultrasound-guided fine needle aspiration(EUS-FNA)revealed well-differentiated adenocarcinoma. We diagnosed a hematoma associated with mesenteric recurrence following ESD for rectal cancer. The patient received chemotherapy first because of the large size of the recurrent cancer. Four courses of mFOLFOX6(5-FU: bolus 400mg/m / / / 2,2,400mg/m2,oxaliplatin 85 mg/m2) and panitumumab(6 mg/kg)were administered. Based on the CT findings following chemotherapy, the hematoma had disappeared, and the size of the recurrent cancer in the mesorectum reduced to 28 mm. The patient underwent laparoscopic lower anterior resection with D3 lymph node dissection and ileostomy. The postoperative course was uneventful. Currently, the patient has no recurrence.

A 55-year-old man was admitted to our hospital for jaundice. Magnetic resonance cholangiopancreatography showed a mass in the pancreatic head as well as biliary obstruction. We strongly suspected invasive ductal carcinoma of the pancreas. We performed pancreaticoduodenectomy with partial resection of the portal vein. The histopathological diagnosis was small cell carcinoma of the pancreas. We detected metastasis of the right hilar lymph node in PET-CT scan performed 2 months after the surgery and started chemotherapy with cisplatin(CDDP)plus irinotecan(CPT-11). However, we observed recurrent metastasis of the right hilar lymph node 12 months after the surgery. We started second-line chemotherapy with amrubicin( AMR)and radiotherapy. Unfortunately, the patient died from multiple metastases of the left adrenal gland and brain 26 months after the surgery. The prognosis of small cell carcinoma of the pancreas is extremely poor. Multimodal treatment such as chemotherapy, radiotherapy, and curative operation are required for long-term survival.

Objective: The aim of the present study was to evaluate the value of anatomical resection for HCC with micro-portal vascular invasion (vp1) between 2000 and 2010. Summary of Background: Vascular invasion has been reported as a prognostic factor of liver resection for hepatocellular carcinoma (HCC). Anatomical resection for HCC has resulted in optimum outcomes of eradicating intrahepatic micrometastases through the portal vein, but opposite results have also been reported. Methods: A clinical chart review was performed for 546 HCC patients with vp1. We retrospectively evaluated the recurrence-free survival (RFS) between anatomical (AR)and non-anatomical resection (NAR). The site of recurrence was also compared between these groups. The influence of AR on the overall survival (OS) and RFS rates was analyzed in patients selected by propensity score matching, and the prognostic factors were identified. Results: A total of 546 patients were enrolled, including 422 in the AR group and 124 in the NAR group. There was no difference in the 5-year OS and RFS rates between the two groups. Local recurrence was significantly more frequent in the NAR group than in the AR group. In a multivariate analysis, hepatitis C (HCV), PIVKAII ?380 mAU/ml, tumor diameter ?5 cm and ?70 years of age were significant predictors of a poor RFS after liver resection. There were no significant differences in the OS or RFS between the AR and NAR groups by a propensity score-matched analysis. Conclusion: Although local recurrence around the resection site was suppressed by AR, AR for HCC with vp1 did not influence the RFS or OS rates after hepatectomy in the modern era., Annals of Surgery, 271(2), pp.339-346; 2020

A 49-year-old woman who was asymptomatic was found to have a small liver tumor on abdominal ultrasonography (US) at her annual health checkup. US revealed a hypoechoic, solid, mass measuring 17-mm in size in segment 6. The tumor markers associated with liver malignancy were negative. An infectious disease screen was negative for hepatitis B surface antigen, but positive for antibody to hepatitis B core antigen. Imaging studies using computed tomography (CT), magnetic resonance imaging (MRI), and CT angiography suggested a malignant liver tumor, such as hepatocellular carcinoma. Partial hepatic resection of the posterior segment was performed. The pathological diagnosis was pseudolymphoma of the liver.

Objectives of the present study were to identify predictors of the recurrence of intrahepatic cholangiocarcinoma (ICC), and to evaluate the survival benefit of adjuvant chemotherapy and surgical treatment for ICC recurrence. A multi‐institutional retrospective study was carried out in 356 patients with ICC who underwent curative surgery at one of 14 institutions belonging to the Kyushu Study Group of Liver Surgery. A total of 214 patients (60%) had recurrence. Predictors of ICC recurrence were as follows: positive for pathological intrahepatic metastasis (im), positive for lymph node metastasis (n), positive for pathological lymphatic infiltration (ly), pathological bile duct invasion (b), and tumor size ≥4.4 cm. Adjuvant chemotherapy was given to 120 patients (34%) and, in the patients with im or tumor size ≥4.4 cm, adjuvant chemotherapy showed a survival benefit. Only 37 patients (17%) underwent surgical treatment for ICC recurrence. The surgical treatment resulted in a good 5‐year survival rate (44%), which is similar to the rate obtained by the first operation for primary ICC. Prognosis of patients with primary im after the second operation was significantly worse (5‐year survival 18%) compared to patients without primary im. Primary im+ should be considered a contraindication for surgical treatment for ICC recurrence.

Superficial surgical site infections (S-SSIs), which prolonged hospital stay and increased costs, are a critical problem. The aim of the present study was to clarify the risk factors for S-SSIs after urgent gastroenterologic surgery and what surgeons can do to reduce their incidence and to shorten the hospital stay. A total of 275 patients who underwent urgent gastroenterologic surgery were enrolled in the present study. The correlations between the incidence of S-SSIs and clinicopathologic factors were retrospectively analyzed using propensity score matching. Of 275 cases, 43 (15.6%) patients had an S-SSI. On univariate analysis, the following factors were associated with a significantly higher incidence of S-SSI: American Society of Anesthesiologists score (P = 0.043); wound classification (P = 0.0005); peritonitis (P = 0.019); prolonged operation time (P = 0.0001); increased blood loss (P = 0.019); transfusion (P = 0.0047); and abdominal closure without triclosan-coated polydioxanone sutures (P = 0.042). However, a propensity score–matching analysis showed that abdominal closure using triclosan-coated polydioxanone sutures did not reduce the incidence of S-SSIs in patients who underwent urgent gastroenterologic surgery (P = 0.20), but it tended to be associated with a shorter hospital stay (P = 0.082). To reduce morbidity after urgent gastroenterologic surgery, surgeons should shorten the operation time and decrease the blood loss. In addition, abdominal closure using triclosan-coated polydioxanone sutures alone could not reduce the incidence of S-SSIs but might shorten the hospital stay after urgent gastroenterologic surgery by inhibiting bacterial activity and preventing prolongation of the infections.

A 79-year-old man was diagnosed with Stage ⅢB(T4N2M0)adenocarcinoma of the lung, administered. He suddenly developed abdominal pain with muscle guarding and rebound tenderness. An abdominal computed tomography scan revealed a thickened small bowel wall and mesenteric mass, as well as massive ascites and free air. He underwent an emergency laparotomy following a diagnosis of pan-peritonitis due to intestinalperforation. A partialresection of the smallintestine and abdominal drainage were performed. The resected specimen included an ulcerative lesion on the mucosal surface. The pathological diagnosis was a metastasis of lung cancer. The patient died in hospice 29 days postoperatively. In the present case, however, surgery improved the patient's quality of life. Although lung cancer metastasis to the small bowel is associated with a poor prognosis, palliative surgery is indicated in otherwise fatal circumstances.

A 73 -year-old man was found to have a mesenteric tumor on abdominal ultrasonography and computed tomography (CT). Single-port laparoscopic surgery using an umbilical ZigZag incision was performed. Operative findings revealed that the tumor involved the mesentery. The tumor and a section of small intestines were resected. Pathological examination diagnosed follicular lymphoma. Single-port laparoscopic surgery using an umbilical ZigZag incision is superior for manipulation of forceps and evisceration. This operative method may be useful for resection or biopsy of mesenteric tumors.

Background We aimed to clarify the appropriate timing for performing percutaneous transhepatic gallbladder drainage (PTGBD) and cholecystectomy, and the effect of PTGBD on surgical difficulty in acute cholecystitis patients. Methods We retrospectively examined 46 patients who underwent laparoscopic cholecystectomy (LC) after PTGBD for acute cholecystitis. We evaluated the duration from acute cholecystitis onset to PTGBD and the appropriate interval from PTGBD to elective LC. Intraoperative blood loss, operating time, rate of conversion to open surgery, and rate of severe adhesion were the objective and subjective measures. Results Based on the cut-off value calculated using the Youden index, the group with a duration from acute cholecystitis onset to PTGBD of ≤73.5 h had a significantly shorter operating time (127.5 min vs. 180.0 min, P = 0.007), lower rate of severe adhesion (3/20 vs. 14/26, P = 0.007), and lower rate of conversion to open surgery (2/20 vs. 13/26, P = 0.004); moreover, the interval from PTGBD to elective LC did not significantly differ between these groups. Conclusion The most important predictor of successful LC following PTGBD for acute cholecystitis was a duration from acute cholecystitis onset to PTGBD of ≤73.5 h. Hence, PTGBD should be performed immediately in cases where early cholecystectomy is not indicated.

A 73-year-old female with hepatocellular carcinoma (HCC) received percutaneous transhepatic portal vein embolization (PTPE) before extensive right lobe hepatectomy. Serum levels of des-gamma-carboxy-prothrombin (DCP) were increased and remained at a high level until hepatectomy. Immunohistochemical examination revealed that an increased expression of DCP was demonstrated not only in HCC tissues, but also in the non-cancerous liver of the right lobe, where portal blood flow was blocked off as a result of PTPE. The serum level of DCP is known to be greatly increased in patients with HCC accompanied by portal vein invasion. We speculate that this increased DCP level is caused by both increased DCP production in HCC tissue and the surrounding non-cancerous liver, where portal flow is blocked off as a result of portal invasion by HCC.

A 69-year-old man, who had undergone distal gastrectomy for duodenal ulcer, was diagnosed with remnant gastric cancer and jejunal mesenteric lymph node metastasis. To improve curability, we planned 2 courses of S-1 and cisplatin therapy. After chemotherapy, primary lesion and lymph node metastases reduced in size drastically. Completion gastrectomy and lymph node dissection were performed with curative intent. The tumor was found to have a pathological complete response(pCR) to chemotherapy on histological examination.

Background: While the safety of pancreaticoduodenectomy (PD) has improved, the high level of difficulty associated with this operation means that the procedure carries a high mortality rate compared to other gastrointestinal operations. Various trials have been implemented in efforts to reduce the incidence of complications after PD. In particular, a large amount of intraoperative bleeding and the use of red blood cell transfusions are reportedly risk factors for postoperative complications after PD. Aim: In an attempt to reduce the amount of intraoperative bleeding during PD, consideration was given to the anatomical characteristics of the region of the pancreatic head, and the gastroduodenal artery (GDA) and inferior pancreaticoduodenal artery (IPDA) were ligated in advance of separating the head from the portal vein. We herein report the use of ultrasonography during PD to facilitate the early identification and ligation of the IPDA. Case Presentation: A 72-year-old female was diagnosed with pancreatic cancer and underwent pylorus-preserving pancreatoduodenectomy. We used ultrasonography during the operation to initially identify the IPDA and then ligate it in advance, after which the GDA was ligated before separating the pancreatic head from the superior mesenteric artery and portal vein. Identification of the IPDA was performed with the SMA as a guide using ultrasonography in Doppler mode. The amount of intraoperative bleeding was 235 ml. The patient left the hospital without any postoperative complications and has since demonstrated a good postoperative course, with no evidence of recurrent disease. Conclusions: Early ligation of the IPDA using intraoperative US is non-invasive and makes it simple to identify the IPDA. This method may be a useful technique for reducing intraoperative bleeding during the normal course of PD procedures.

Background It is important to identify biomarkers for sepsis and organ damage in acute cholangitis patients. We investigated the usefulness of procalcitonin (PCT) as a biomarker of inflammation based on the Tokyo Guidelines 2013 (TG13). Methods A total of 110 acute cholangitis patients were categorized based on TG13, and the PCT levels and common laboratory inflammatory markers were measured. The cases undergoing hemoculture (n = 72) at the time of diagnosis also correlated with the PCT levels. Results The PCT and C-reactive protein levels were significantly higher in grade III cases versus grade I. The mean PCT levels for positive hemoculture cases (8.6 ng/ml) were significantly higher than those for negative cases (0.7 ng/ml). In hemoculture positive cases or when purulent bile was obtained from the duodenal papilla, i.e., cases clearly requiring emergency biliary drainage and necessitating categorization as grade III, three cases were categorized as grade I and 13 as grade II. Only PCT showed statistically significant increases in severe cases underestimated as grade I or II despite them being fundamentally grade III cases. Conclusions Acute cholangitis with high PCT levels can signify the need to perform emergency biliary drainage and institute intensive care even if categorized by TG13 as not being severe cases.

A 59-year-old male with hepatocellular carcinoma (HCC) due to liver cirrhosis caused by the hepatitis C virus underwent cadaveric whole liver transplantation. Two years later, he had a metastatic HCC in the superior mediastinum. Over the following postoperative year, he underwent transcatheter arterial chemoembolization (TACE) for 4 tumors in the implanted liver. In the third post-TACE month, he was emergently hospitalized due to intracerebral hematoma with a tumor invading the bone in the medial frontal segment. He underwent emergency intracranial tumorectomy and hemorrhage removal. The histopathologic diagnosis was metastatic HCC. He regained consciousness as well as the ability to speak and to feed himself, resulting in an improved quality of life. The incidence of HCC recurrence after liver transplantation is observed in approximately 8% to 11% of selected cases, with frequent relapses observed in the implanted liver, bones, adrenal glands, and lungs. Mediastinal and intracranial metastases from HCC post-liver transplantation are very rare.

It has been reported that many colorectal cancer (CRC) patients with synchronous or metachronous liver metastases underwent surgery subsequent to neoadjuvant combination chemotherapy with folinic acid, fluorouracil, and oxaliplatin (FOLFOX), folinic acid, fluorouracil, and irinotecan (FOLFIRI), or capecitabine and oxaliplatin (XELOX). However, there are very few reports of the use of capecitabine and irinotecan (XELIRI). We herein report a successfully resected case of recurrent lung and liver metastases of rectal cancer treated with combination chemotherapy with XELIRI + bevacizumab (BV) therapy. A 63-year-old male developed recurrence of a solitary nodule in the right lower lobe of the lung and multiple liver metastases after low anterior resection for rectal cancer 1 year previously. Partial resection of the right lower lobe of the lung was performed and treatment with XELIRI + BV was initiated. A computed tomography scan revealed a reduction in tumor size without any new lesions after four cycles of XELIRI + BV therapy. Partial hepatectomy of S1, S5, and S7 was safely performed. The patient is now undergoing adjuvant chemotherapy and has been free from recurrence for 18 months following surgery. There are only few studies with relatively low patient numbers reporting on the outcome after resection of both pulmonary and hepatic metastases of CRC. We therefore report a patient who underwent sequential resection of pulmonary and hepatic metastases with XELIRI + BV therapy.

Background This multi-institutional study aimed to assess the benefits of anterior approach for right hepatectomy with hanging maneuver (ARH-HM) for hepatocellular carcinoma (HCC) compared with conventional right hepatectomy (CRH). Methods From January 2000 to December 2012, 306 patients with HCC ≥5 cm were divided into two groups: ARH-HM (n = 104) and CRH (n = 202). Results After one-to-one propensity score-matched analysis, 72 ARH-HM and 72 CRH patients presented comparable background factors. Patients in the ARH-HM group demonstrated significantly less intraoperative blood loss (480 vs. 1,242 g, P

We report a case of locally far-advanced colon cancer resected by laparoscopic surgery after colonic stent insertion and neoadjuvant chemotherapy. A 71-year-old man with obstructive symptoms was admitted to our hospital in July 2015. CT revealed a sigmoid colon tumor infiltrating the retroperitoneum and small intestine. Lower gastrointestinal endoscopy showed a sigmoid colon cancer. Self-expandable metallic stent insertion for obstructive colon cancer alleviated the patient's symptoms quickly. Four courses of neoadjuvant chemotherapy(XELOX)reduced the primary tumor in size, allowing for laparoscopic surgical resection. Combination therapy with colonic stenting and neoadjuvant chemotherapy can be an effective treatment for obstructive colon cancer. However, further studies and additional cases are needed to assess the safety and efficacy of this combination therapy.

Aim: The diagnosis of Wilson disease is based on the results of several clinical and biochemical tests. This study aimed to clarify the clinical features and spectrum of Wilson disease, including severe Wilson disease. Methods: Between 1985 and 2009, 10 patients with clinical, biochemical or histological evidence of Wilson disease were either diagnosed or had a previously established diagnosis confirmed at Fukuoka University Hospital. Severe Wilson disease was defined by a serum prothrombin time ratio of more than 1.5 or serum prothrombin activity of less than 50%. The 10 Wilson disease patients were divided into two groups, one containing three non-severe patients and the other containing seven severe patients, and the biochemical features of the patients in these two groups were compared. Results: The mean age at diagnosis was 21.5 ± 11.7 years (range, 7–39). Decreased serum ceruloplasmin, enhanced 24-h urinary copper excretion, presence of Kayser–Fleischer rings and histological signs of chronic liver damage were confirmed in 100%, 100%, 66.7% and 100% of patients, respectively. Severe Wilson disease patients had higher levels of serum ceruloplasmin and serum copper (P

Background: It is not clear if more intense surveillance is associated with improved survival after curative resection for gastric cancer. Patients and Methods: A prospectively maintained gastric c

OBJECTIVE: The characteristic differences between patients with lung or liver metastases from colorectal carcinoma (CRC) have not yet been clarified. A small group of these patients demonstrate a better prognosis, and the selection criteria for resection of liver and/or lung metastasis are not well defined. It is important to compare and analyze the most common metastatic sites, which include liver metastases and lung metastases. The objective of this study was to compare the characteristics of the two groups in order to identify patients who benefitted from surgical resection of CRC. METHODS: We retrospectively reviewed the medical charts of 80 patients who had undergone resection for liver or lung metastasis from CRC in Fukuoka University Hospital between June 1991 and December 2004. These patients were grouped according to surgical therapy received for the metastases, and separated into two groups, as follows: LUM, lung metastases resection; LIM, liver metastases resection. We evaluated these groups for a set of several factors. RESULTS: The characteristic factors between the two groups (LUM vs. LIM) demonstrated significant differences according to histological differentiation, venous invasion, and lymphatic permeation. There was a statistical difference in the disease-free interval (DFI) between the two groups (947.06 +/- 840.39 days in LUM vs. 246.03 +/- 229.26 days in LIM). Although serum CEA levels at resection of metastasis showed significant differences between the groups (LUM, 13.25 +/- 31.55 ng/ml; LIM, 55.21 +/- 99.52 ng/ml), the primary serum CEA levels were not significantly different. Overall survival rates at 5 years were 37.0 % for LUM and 42.8 % for LIM. There was no significant difference in the survival rate of the LUM vs. the LIM group after resection of metastasis. The Cox proportional hazards regression model was used to determine serum CEA status at the time of the metastases and showed a significant difference indicating poor prognosis for patients with LUM, but the results were not significant for LIM cases. CONCLUSIONS: Candidates for surgical treatment for lung or liver metastases from CRC may be an acceptable for the same valuable approach, even if characteristic differences were observed in each group.

Background: Dye-enhanced laser ablation (DLA) using a low-power diode laser for indocyanine green (ICG)-stained tissue has proven its effectiveness in dye-enhanced laser photocoagulation of retinal vessels or endoscopic surgical mucosectomy. We have applied DLA in hepatectomy and described its histological distinction in comparison with the cavitron ultrasonic surgical aspirator (CUSA). Methods: A diode laser (UDL-60 Laser unit, Olympus, Tokyo, Japan) with 810 ± 20 nm wavelength was employed for this study. The ICG dye (Diagnogreen®, Daiichi Pharmaceutical, Tokyo, Japan) with a peak absorption wavelength at 800–810 nm was injected topically into the resection plane of the liver. The liver tissue was divided by touching the tip of the diode laser. Three different concentrations of ICG solution such as 2.0, 1.0 and 0.5 mg/ml were tested in the preliminary animal experiment. The use of a low-power diode laser at 10 W with an ICG concentration of 0.5 mg/ml was the appropriate combination for liver resection. In the clinical series, 27 hepatectomies were performed by DLA, and 10 with CUSA. Results: DLA demonstrated smooth cutting and good hemostasis in liver resection. Among the hepatectomy cases given DLA, no postoperative hemorrhage or bile leakage was noted. The postoperative hospital stay was significantly shorter in the DLA than the CUSA group. The cut surface of the liver was sealed microscopically with a layer of protein coagulum. Conclusions: A layer of protein sealant on the cut surface of the liver contributes to the short postoperative hospital stay when using DLA.

Although lymph node metastasis (LNM) has been considered an important prognostic factor for intrahepatic cholangiocarcinoma (ICC), the impact of lymph node enlargement on the prognosis of ICC, and the accuracy of diagnosis of LNM, have not been fully clarified. Using a chart review of 225 patients with ICC, we compared survival times between patients with and without lymph node enlargement, and we evaluated the accuracy of diagnosis of LNM. We also performed a multivariate analysis to determine the variables affecting overall survival in the study population. The survival time of patients without lymph node enlargement was significantly longer than that of patients with lymph node enlargement (median survival time [MST] 43.7 vs. 20.1 months; p = 0.007). However, in the group with enlarged lymph nodes, survival time was prolonged as a result of hepatectomy (MST 20.1 vs. 7.6 months; p

A 67-year-old woman was referred with an abnormal finding on an abdominal echogram but presented with no symptoms; a pancreatic tail tumor was detected by ultrasonography. Biochemical examinations showed slight elevation of serum carcinoembryonic antigen level. The lesion was resected by tail and body pancreatectomy and her postoperative course was uneventful. Seven years and 4 months after the initial operation, however, her serum level of carbohydrate antigen 19-9 was found to be elevated, and a recurrence of pancreatic cancer was suspected. Examinations revealed a mass in the head of the remnant pancreas. The lesion was radically resected by total remnant pancreatectomy. Histological examinations showed that the initial tumor was a well differentiated tubular adenocarcinoma, while the second tumor was characterized as a moderately differentiated tubular adenocarcinoma. The surgical margins of the distal pancreatectomy specimen were free of atypical cells. Therefore, the position of the second lesion diminished the likelihood that it had developed by intrapancreatic metastasis. This suggests that the second carcinoma in the head of the pancreas may have been a second primary lesion.

We encountered a rare case of adeno-endocrine cell carcinoma of the gallbladder in an 81-year-old woman. Imaging study revealed a common bile duct stone. Endoscopic sphincterotomy was performed, and the stone was extracted successfully. Thereafter, cholecystectomy was performed. A papillary tumor was found in the neck of the gallbladder. Histologically, the tumor consisted of two components, well differentiated adenocarcinoma and endocrine cell carcinoma. However, no clinical signs of tumor hormonal activity were observed. The tumor cells in the area of the endocrine cell carcinoma were small and round. Histochemical studies of these tumor cells were positive for chromogranin A and Grimelius silver impregnation. The tumor cells in the area of the adenocarcinoma were well differentiated adenocarcinoma and included goblet-type cells with a tubular structure or solid growth pattern. These adenocarcinoma cells stained positively for Alcian blue and periodic acid-Schiff, and both types of tumor cells stained positively for carbohydrate antigen and carcinoembryonic antigen. It was suggested that the histogenesis of the endocrine cell carcinoma of the gallbladder was closely related to that of the adenocarcinoma.

切除不能な肝腫瘍に対し新しい装置を用いたRF波組織熱焼灼療法を行い,その有効性と安全性にっき検討した.肝細胞癌13例,転移性肝癌27例の40例で,腫瘍個数は136個,腫瘍径は5mm～126mmであった.周波数460kHzのRF波による熱焼灼装置を使用し, USガイド下に焼灼範囲を確認しつつ80°C～120°Cに温度制御し焼灼した.腫瘍の壊死効果判定には,手術前後のCTスキャンならびに腫瘍マーカーを用いた.平均観察期間は8.5カ月であった.病変への穿刺アプローチは18例は経皮的, 4例は腹腔鏡下, 18例は開腹下であった.腫瘍の完全壊死効果は腫瘍136個中127個(93.3%)に認められた.重篤な合併症はなく,対極板による熱傷が1例,胸水3例,腹水4例,軽度心不全1例であった.生存率は20カ月の観察期間で肝細胞癌および転移性肝癌でそれぞれ85.7%と88.2%であった.(結語) RF波熱焼灼療法は腫瘍壊死効果が大きく,低侵襲で合併症が少なく,肝腫瘍の局所コントロールに有用であると思われた.

Axillary lymph node status is an important factor for staging and treatment planning in breast cancer. Our study was performed in vitro on a node-by-node basis to evaluate the ability of B-mode ultrasonographic images to distinguish metastatic from nonmetastatic nodes. Immediately prior to histologic examination, individual dissected axillary nodes were scanned in a water bath using a 10 MHz B-mode ultrasonographic transducer. Four B-mode features (size, circularity, border demarcation, and internal echo) were evaluated for their ability to distinguish metastatic from nonmetastatic lymph nodes. Lymph node metastasis was indicated by (1) a large size (i.e., a length of the longest axis of 10 mm or greater); (2) a circular shape (i.e., the ratio of the shortest axis to the longest axis between 0.5 and 1.0); (3) a sharply demarcated border compared with surrounding fatty tissue; and (4) a hypoechoic internal echo, with obliteration of the fatty hilum. The sensitivity and specificity were compared for all combinations of features. We examined 84 histologically characterized axillary nodes from 27 breast cancer patients, including 64 nonmetastatic and 20 metastatic nodes. Of the criteria cited, circular shape was the best single feature for distinguishing metastatic from nonmetastatic nodes (sensitivity, 65%; specificity, 73%). The best combination of sensitivity (85%) and specificity (73%) was obtained using the criterion that a lymph node contained cancer when at least three positive features were present. The present in vitro study demonstrated that the sensitivity and specificity of B-mode ultrasonography for diagnosing lymph node metastasis were lower than 90%. Therefore, B-mode ultrasonography may not be an optimal noninvasive screening method for diagnosing axillary lymph node metastasis in breast cancer patients, particularly under in vivo clinical conditions.

Bronchogenic cysts usually develop in the intrathoracic or intramediastinal area, but those originating in retroperitoneal cavity are extremely rare. Eight cases of abdominal bronchogenic cyst have been reported in Japan (five cases of retroperitoneal cyst and three cases of intraperitoneal cyst). A 26-year-old male was admitted to the hospital because of a left lateral abdominal pain. Upper gastro-intestinal series, Ultrasonography, Computed tomography and Magnetic resonance imaging revealed an adrenal tumor or retroperitoneal hematoma. A operation was performed, because a possible malignancy could not be ruled out. The tumor was adjacent to the surface of the left kidney and left adrenal gland, and a 5.5×4.0×4.0 cm elastic soft multicystic tumor with smooth surface. The pathological diagnosis was bronchogenic cyst, because it was approved mucosal epithelium, smooth muscle fibers and cartilage tissue. The disease presents very difficulty in preoperative diagnosis. It appears in a low frequency, but we should entertain it as a probable differential diagnosis. We describe the present case with discussion of eight cases reported in Japan.

To reduce bacterial adherence to surgical sutures, triclosan-coated polyglactin 910 suture materials with antiseptic activity were developed. The aim of this study was to evaluate whether the incidence of surgical site infections can be reduced when triclosan-coated sutures are used. Until December 2009, we used conventional polyglactin 910 sutures (VICRYL, Ethicon) for the closure of the fascia in digestive tract surgery. Therefore, for the control group we retrospectively collected surveillance data for 1.5 years. In the control group, 611 patients underwent digestive tract surgery with VICRYL sutures. Beginning in July 2010, we used triclosan-coated polyglactin 910 sutures (VICRYL Plus, Ethicon, Tokyo, Japan) for the closure of the fascia in all digestive surgeries. So, we collected data for the study group from July 2010 until June 2011. In the study group, 467 patients underwent digestive tract surgery with triclosan-coated VICRYL Plus sutures. In the control group, 75 patients (12.2%) developed wound infections. In the study group, 31 patients (6.6%) developed wound infections, which was significantly lower. Emergency cases; laparoscopic cases, including some cholecystectomy and colectomy cases; American Society of Anesthesiologists classification; the use of immunosuppressive therapy; colostomy cases; wound classification; and suture material were identified as the risk factors for wound infections. In both groups, as the wound classification worsened, the wound infection rate increased. Triclosan-coated polyglactin 910 antimicrobial sutures lead to a significant decrease in the incidence of surgical site infections, especially in clean/contaminated cases.

Portal vein embolization (PVE) is useful to expand the indications of major hepatectomy; however, its oncologic effects are not fully understood. This study aimed to confirm the efficacy of preoperative PVE for hepatocellular carcinoma patients.Between 2000 and 2012, five hundred and ten patients with hepatocellular carcinoma undergoing right-side hemihepatectomy were enrolled (PVE group, n = 162 and non-PVE group, n = 348). To equalize background factors, one-to-one propensity case-matched analysis and multivariate analysis were performed. Short- and long-term outcomes were evaluated.Propensity score-matched patients, 148 in each group, were selected. The percentage of resected liver volume on admission was significantly greater in the PVE group (60.5% vs 48.3%; p0.001), but decreased considerably after PVE, from 60.5% to 50.3% (p 0.001). The 5-year cumulative recurrence-free survival (36.4% vs 35.3%) and overall survival (58.6% vs 52.8%) rates were comparable. Extrahepatic recurrences were less common in the PVE group (18.1% vs 38.8%; p = 0.004). Independent prognostic factors for recurrence-free survival were morbidity (hazard ratio [HR] = 1.56), multiple tumors (HR = 1.97), red cell concentrate administration (HR = 1.57), older age (HR = 2.09), and massive portal invasion (HR = 2.33); and those for overall survival were morbidity (HR = 2.37), multiple tumors (HR = 1.71), and massive hepatic venous invasion (HR = 3.49).Even though hepatocellular carcinoma patients who underwent preoperative PVE and right-side hemihepatectomy had a significantly larger resected liver volume on admission, they have a comparable long-term prognosis as patients with up front hepatectomy. In addition, PVE might decrease extrahepatic recurrences.

Fundamental treatment for acute cholecystitis is cholecystectomy. However, the adoption of a treatment is dependend on degree of a severity of acute cholecystitis in each patient because its degree is influenced by factors such as duration from the onset of symptoms to medical examination. Early laparoscopic cholecystectomy is the preferred procedure for mild acute cholecystitis. Early cholecystectomy is also performed for moderately acute cholecystitis. However, if patients have severe local inflammation (gangrenous and purulent cholecystitis) early gallbladder drainage or open cholecystectomy is indicated. Emergency operation under adequate medical treatment is indicated for a patient with severe local inflammation of the gallbladder, torsion of the gallbladder, emphysematous cholecystitis, gangrenous cholecystitis, and purulent cholecystitis. Pericholecystic abscess, necrosis of the gallbladder wall, and perforation of the gallbladder can be diagnosed accurately by use of imaging diagnosis. The optimal surgical treatment for acute cholecystitis according to grade of severity should be performed referring to imaging findings.

Prospective studies in the gastroenterological surgery literature have shown fewer wound related complications with a closed-suction drainage than with an open passive drainage. This study compared the SSI and cost of closed-suction drainage and open passive drainage in a randomized trial.This study involved 112 patients undergoing colectomy from December, 2003 through April, 2007. A closed-suction or an open (Penrose) drainage was used based on the surgeon's preference. The cost and the incidence of complications including SSI was compared in the two drain types.The SSI rate was 13/112 cases 11.6%, but there was no significant difference between the drain groups. In addition, 18 laparoscopic surgery cases did not show any wound infection or drain infections. The closed-suction drain was not expensive regarding personnel expenses and the cost of changing the dressings.No statistically significant postoperative differences were observed between a closed-suction drain or an open drain after a colectomy. However, a closed-suction drain management is useful for the reduction of a cost, labor saving, and the decrease of medical waste.

The diagnosis of Wilson disease is based on the results of several clinical and biochemical tests. This study aimed to clarify the clinical features and spectrum of Wilson disease, including severe Wilson disease. Between 1985 and 2009, 10 patients with clinical, biochemical or histological evidence of Wilson disease were either diagnosed or had a previously established diagnosis confirmed at Fukuoka University Hospital. Severe Wilson disease was defined by a serum prothrombin time ratio of more than 1.5 or serum prothrombin activity of less than 50%. The 10 Wilson disease patients were divided into two groups, one containing three non-severe patients and the other containing seven severe patients, and the biochemical features of the patients in these two groups were compared. The mean age at diagnosis was 21.5 ± 11.7 years (range, 7-39). Decreased serum ceruloplasmin, enhanced 24-h urinary copper excretion, presence of Kayser-Fleischer rings and histological signs of chronic liver damage were confirmed in 100%, 100%, 66.7% and 100% of patients, respectively. Severe Wilson disease patients had higher levels of serum ceruloplasmin and serum copper (P 0.05, P 0.05, respectively) than non-severe patients. In severe Wilson disease patients, the serum ceruloplasmin and serum copper levels were higher than those in non-severe Wilson disease patients.

We describe the innovative techniques with single orifice vein reconstruction for the complete venous drainage in the left liver plus caudate lobe graft.Eight left liver plus caudate lobe grafts used for living donor adult liver transplantation were reviewed. A wide and single venous orifice was created by gathering the left, middle or its tributaries, and/or short hepatic vein using a patch vein graft or a conduit vein graft. This single, newly-created orifice was then anastomosed to the common trunk created in the recipient's hepatic veins.Of 8 liver grafts, six included the middle hepatic vein trunk. Another two included only the middle hepatic vein tributaries. Significantly-sized short hepatic veins were preserved in 4 grafts and were connected with the major hepatic veins or tributaries of the middle hepatic vein to make a single orifice using a conduit vein graft. For remaining 4 grafts without significantly-sized short hepatic veins, two adjacent hepatic vein trunks (left and middle hepatic veins) were simply connected together. To enlarge the common orifice of the hepatic veins, the patch vein grafts were further attached. Hepatic vein waveforms of all grafts showed the biphasic or triphasic pattern and the graft congestion was not observed immediately after venoplasty. No graft was lost due to hepatic venous outflow block with the mean follow-up of 15 months.The short-term results of our technique were satisfactory. The present technique can simplify graft-to-recipient hepatic vein reconstruction without unfavorable tension on the anastomosis.

Although several prognostic factors for gastric cancer have been shown, the predictive factors of early recurrent death remain to be elucidated. This study included 402 patients who underwent a curative resection for gastric cancer. Fifty-six patients died of recurrence. A multivariate analysis was performed to determine the independent factors correlated with survival time. The patients with an elevation of tumor markers, tumors in the upper one third of the stomach, deep wall invasion (T3, T4), extended lymph node metastases (N2, N3), an advanced stage (stages III and IV), and operation (total gastrectomy) showed a significantly different survival time. According to a multivariate analysis, the survival time was independently associated with tumor location, tumor markers, and lymph node metastases. The patients with tumors in the upper one third of the stomach, elevated tumor markers, and extended lymph node metastases can not be controlled by surgery alone.

This study was undertaken to evaluate the correlation between tumor occupation rate and stage in rectal cancer patients. 210 patients with histologically confirmed adenocarcinoma of the rectum were evaluated. Retrospectively, we divided the subjects' pathological specimens into four groups: group A, tumor occupied less than one fourth of the colic lumen; group B, tumor occupied one fourth to one half of the colic lumen; group C, tumor occupied one half to three quarters of the colic lumen; group D, tumor occupied more than three quarters of the colic lumen. As the tumor occupation rate increased, more invasive cases were observed. Patients of group A had significantly longer survival than those of the other groups. Tumor occupation rates correlated significantly with the Dukes classification (r = 0.546, P0.0001). Tumor occupation rate is a primitive method but an easy and inexpensive technique for judging tumor stage. This method can assist in preoperative evaluation, thereby reducing the need for other redundant methods.

Right lateral sector (RLS, segments VI and VII according to Couinaud's nomenclature for liver segmentation) graft was introduced as an alternative liver graft. The authors report their surgical techniques for bile duct division in RLS graft harvest.Between January 2000 and December 2001, 11 donors provided their RLS. Intraoperative cholangiography was performed and the anatomy of the upper biliary confluence was confirmed. When the right lateral duct entered the common bile duct (caudal right lateral duct), the duct was divided at its root in situ. In other situations, the right portal branch was first dissected and taped. With the right portal branch pulled cranially, the right lateral duct was dissected from surrounding connective tissues and divided as long as possible.Cholangiography revealed various right lateral duct anatomies, such as entering the right duct (n=6), the left and right bifurcation (n=2), the common bile duct (n=2) and the left duct (n=1). The postoperative course was uneventful in all donors. All of the patients survived the operation.Careful attention should be paid to bile duct division in donor hepatectomy. The present technique can ensure a safe harvest of RLS graft with a long right lateral duct.

There are few reports of central pontine myelinolysis after living donor liver transplantation. A 59-year-old male received a right liver graft from his daughter for hepatitis B-related liver cirrhosis. Methylprednisolone and tracrolimus were used for immunosuppression. Dysarthria and dysphasia were noted on the second postoperative day. Brain magnetic resonance image taken on the 9th postoperative day revealed a hyperintense area at the center of his pons in T2-weighted images. The symptoms improved spontaneously 1 month after the operation. Central pontine myelinolysis should be included in the differential diagnosis when neurologic manifestations are observed after living donor liver transplantation.

Hepatic allograft rejection after liver transplantation remains an important problem. We report a case of corticosteroid and anti-T cell monoclonal antibody-resistant acute cellular rejection in living related liver transplantation. A 57-year-old female received a right liver graft from her daughter for hepatitis C-related liver cirrhosis. Methylprednisolone and tracrolimus were used for immunosuppression. The patient experienced acute rejection 10 days after the operation. Rescue therapy was attempted using high doses of methylprednisolone and then monoclonal antibodies. Deterioration of graft function, however, was not prevented, resulting in graft and patient loss. Graft lost due to refractory acute rejection could also occur in living related liver transplantation, although it should be rare.