Acute peripheral facial paralysis caused by tegmental pontine infarction.

Facial paralysis presents as unilateral mouth drooping and lagophthalmos. The main causes of peripheral facial paralysis are Bell's palsy and Ramsay-Hunt syndrome. However, rarely occurring pontine infarctions of the facial nucleus also manifest a lower motor neuron pattern of facial paralysis. We report a case of a man in his 50s who presented to the emergency department with unilateral peripheral facial paralysis. The initial diffusion-weighted images were unremarkable, and the patient was managed as per guidelines for hypertensive encephalopathy or Bell's palsy. On the 3rd day after admission, he was diagnosed with left pontine infarction and suspected infarction of the left anterior inferior cerebellar artery. We propose that in similar cases, re-examination of imaging results should be considered, as diffusion-weighted imaging is characteristically prone to generate false-negative results in patients with early onset or posterior circulation infarction.

Eosinophilic Gastroenteritis Following Covid-19 MRNA Vaccination.

Introduction: Large-scale clinical studies for COVID-19 vaccines have shown the infection-preventing effect and short-term adverse effects. Some rare illnesses such as eosinophilia can develop following COVID-19 vaccinations. Case description: We report a case of 65-year-old man with unexplained abdominal pain that developed 2 weeks after COVID-19 mRNA vaccination. The patient had received a second dose of COVID-19 mRNA vaccine and revealed eosinophilia at the first visit to our hospital. Eosinophil infiltration was observed in the lamina propria of the duodenum by a step biopsy. Montelukast 10 mg was administered as the initial treatment of eosinophilic gastroenteritis (EGE), and the abdominal pain was improved. Discussion: The strong influence of COVID-19 vaccination on the development of EGE remains unproven. Reports of eosinophilia following COVID-19 vaccination have discussed that COVID-19 mRNA vaccination triggered an eosinophilic response. Conclusion: This case presented EGE that developed following COVID-19 mRNA vaccination, which would be a rare adverse event. LEARNING POINTS: Eosinophilia can develop following COVID-19 mRNA vaccination.To evaluate the relationships of these illnesses with vaccination, clinicians should collect information on vaccinations history and vaccination dates through interviews.It is clinically practical to know the differential diseases that may develop after a new vaccination.

A case of laparoscopic sigmoidectomy using thermography for colonic blood flow assessment.

BACKGROUND: Indocyanine green (ICG) fluorescence imaging is widely used in gastrointestinal surgery and is considered useful for reducing anastomotic leakage; however, because ICG remains in the tissue for a certain amount of time, we occasionally must re-evaluate colonic blood flow over a short time period during surgery. Herein, we verify the usefulness of thermography (TG) for evaluating colonic blood flow in a patient who underwent a laparoscopic sigmoidectomy for sigmoid colon cancer. CASE PRESENTATION: The patient is 43-year-old man who underwent laparoscopic resection of the sigmoid colon for colon cancer. After vascular treatment of the colonic mesentery, ICG/TG identified the boundary between ischemic and non-ischemic colon tissues. An additional 2 cm of colonic mesentery was resected because of the presence of a diverticulum noted at the intended site of oral anastomosis when attaching the anvil head. After additional vascular treatment of the colonic mesentery and administration of ICG, fluorescence was observed in the colon; however, TG identified the zone of the temperature transition on the surface of the colonic mesentery, even after additional colonic mesentery resection in the same region as previously observed. This zone was used as the cut-off line. There were no complications, such as anastomotic leakage, after the surgery. CONCLUSION: Although accumulation of similar cases is necessary, TG has the potential for use as an auxiliary diagnostic tool in clinical practice. TG can depict the presence or absence of blood flow based on surface temperature without the use of imaging agents, and is inexpensive and easy to perform.

[A Case Report of Hepatic Angiosarcoma Developed against the Background of Hepatic Hemochromatosis].

A 35-year-old man who had fever and stomachache was referred to our hospital. He underwent surgery and chemoradiotherapy for neuroblastoma as a child and subsequently developed leukemia. Frequent blood transfusions and bone marrow transplants were performed due to anemia. Abdominal contrast CT scan and contrast MRI showed tumorous lesions with a diameter of 60×42 mm in liver S6, and a tendency to increase in a short term. There was also hemochromatosis in the liver. We considered it a malignant tumor and performed a right lobectomy. Pathological examination diagnosed the tumor hepatic angiosarcoma. The postoperative course was fine and he was discharged without complications. But multiple liver metastases appeared 6 months after surgery. We performed chemotherapy but he passed away 10 months after surgery. Hepatic angiosarcoma is a rare disease among liver malignancies and has a very poor prognosis. As for the cause of hepatic angiosarcoma, many of them are unknown, but chronic exposures such as vinyl monomers have been reported in some cases. Hemochromatosis has been reported as a background factor for malignant tumors such as hepatocellular carcinoma. In this case it is possible that it contributed to the development of hepatic angiosarcoma.

Percutaneous Decannulation for Venoarterial Extracorporeal Membrane Oxygenation Using a Perclose ProGlide Closure Device and a Balloon Catheter Without On-Site Cardiac Surgical Backup.

Surgical decannulation for venoarterial extracorporeal membrane oxygenation (VA-ECMO) is recommended as a standard weaning strategy considering large-sized cannulas (14-22 French) are inserted in VA-ECMO. However, we should be aware of complications such as bleeding and infection when removing an arterial cannula, especially in facilities without on-site cardiac surgical backup. Percutaneous closure devices for femoral arterial access sites are currently approved for the decannulation of a 10-French or smaller sheath. We reported a case of successful weaning off from ECMO using a combination method of a balloon catheter and a Perclose ProGlide closure device. We successfully removed the arterial cannula using this technique for four ECMO-treated patients without vascular complications or blood transfusion. Percutaneous decannulation by this method could reduce the procedural time and adverse events and be safely performed even in facilities without on-site cardiac surgical backup.

Peritonsillar abscess caused by Prevotella bivia during home quarantine for coronavirus disease 2019: Case report.

RATIONALE: Since late 2019, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) had rapidly spread worldwide, resulting in a pandemic. Patients with coronavirus disease 2019 (COVID-19) have difficulty in visiting clinics in person during pandemic because they might be encouraged to quarantine at home with supportive care. Peritonsillar abscess rarely coexists with COVID-19; however, patients with SARS-CoV-2 infection could get co-infections or become superinfected with other microorganisms which could cause peritonsillar abscess. We herein describe a case of peritonsillar abscess caused by Prevotella bivia that occurred as a co-infection with COVID-19 during home quarantine. PATIENT CONCERNS: A 32-year-old Asian woman who was diagnosed with COVID-19 was instructed to stay home for quarantine. Her pharyngeal discomfort worsened, and she experienced trismus and dysphagia. An emergent visiting doctor referred her to our hospital. Contrast-enhanced computed tomography showed peritonsillar abscess findings, following which we referred her to an ear, nose, throat specialist. Prevotella bivia was identified on needle aspiration pus culture; however, two sets of blood and throat cultures were negative. DIAGNOSIS: A definitive diagnosis of acute COVID-19 and peritonsillar abscess due to Prevotella bivia was made. INTERVENTIONS: An antibiotic drug, antiviral drug, and adjunctive steroid were administered intravenously. OUTCOMES: Her symptoms improved without the need for incision and drainage, and she was discharged on day 7. CONCLUSION: Patients with suspected peritonsillar abscess should be triaged and referred to ear, nose, throat specialists appropriately. Scoring systems, such as modified Liverpool peritonsillar abscess score or the guidelines criteria might be useful tools to triage patients. During the early phase of SARS-CoV-2 infection, administration of corticosteroids is not recommended. When adjunctive steroids are considered for peritonsillar abscess, prior to or simultaneous use of the antiviral agent remdesivir for COVID-19 might be recommended.

10Z­Hymenialdisine inhibits angiogenesis by suppressing NF­κB activation in pancreatic cancer cell lines.

10Z­Hymenialdisine is a natural product derived from the marine sponge Axinella carteri. 10Z­Hymenialdisine has anti­inflammatory effects exerted through NF­κB; however, it is unclear whether 10Z­Hymenialdisine has anti­angiogenic effects in cancer cells. In the present study, both the anti­angiogenic and antimetastatic effects of this compound in pancreatic cancer were investigated. It was initially confirmed that 10Z­Hymenialdisine significantly inhibited the proliferation of pancreatic cancer cells. Next, using both reverse transcription­quantitative PCR and ELISA, it was demonstrated that 10Z­Hymenialdisine significantly suppressed the expression of VEGF and IL­8 mRNAs and proteins in pancreatic cancer. Immunohistochemical analysis revealed that 10Z­Hymenialdisine inhibited NF­κB activity in pancreatic cancer cell lines. It was also identified that 10Z­Hymenialdisine inhibited tube formation in EA.hy926 cells. In vivo, 10Z­Hymenialdisine significantly inhibited the growth of BxPC­3 pancreatic cancer cells that were subcutaneously injected into model mice. In conclusion, the present study demonstrated that 10Z­Hymenialdisine exerted anti­angiogenic effects by suppressing NF­κB activity and angiogenic factors, such as VEGF and IL­8, in pancreatic cancer cell lines. 10Z­Hymenialdisine has potential applications as a novel therapeutic agent for the treatment of pancreatic cancer.

Escin inhibits angiogenesis by suppressing interleukin­8 and vascular endothelial growth factor production by blocking nuclear factor­κB activation in pancreatic cancer cell lines.

Pancreatic cancer (PaCa) is one of the most aggressive types of cancer. Thus, the development of new and more effective therapies is urgently required. Escin, a pentacyclic triterpenoid from the horse chestnut, has been reported to exhibit antitumor potential by reducing cell proliferation and blocking the nuclear factor­κB (NF­κB) signaling pathway in several types of cancer. Our previous study reported that NF­κB enhanced the secretion of interleukin (IL)­8 and vascular endothelial growth factor (VEGF), thereby inducing angiogenesis in PaCa cell lines. In the present study, it was examined whether escin inhibited angiogenesis by blocking NF­κB activation in PaCa. It was initially confirmed that escin, at concentrations >10 µM, significantly inhibited the proliferation of several PaCa cell lines. Next, using immunocytochemical staining, it was found that escin inhibited the nuclear translocation of NF­κB. Furthermore, ELISA confirmed that NF­κB activity in the escin­treated PaCa cells was significantly inhibited and reverse transcription­quantitative PCR showed that the mRNA expression levels of tumor necrosis factor­α­induced IL­8 and VEGF were significantly suppressed following escin treatment in the PaCa cell lines. ELISA also showed that escin decreased the secretion of IL­8 and VEGF from the PaCa cells. Furthermore, tube formation in immortalized human endothelial cells was inhibited following incubation with the supernatants from escin­treated PaCa cells. These results indicated that escin inhibited angiogenesis by reducing the secretion of IL­8 and VEGF by blocking NF­κB activity in PaCa. In conclusion, escin could be used as a novel molecular therapy for PaCa.

Effectiveness of endoscopic hemostasis in preventing diverticular bleeding with extravasation detected by contrast-enhanced computed tomography: A single-center retrospective cohort study.

ABSTRACT: In diverticular bleeding, extravasation detected by computed tomography indicates active bleeding. It is unclear whether an endoscopic procedure is the best method of hemostasis for diverticular bleeding. This retrospective study was conducted to examine the effectiveness of endoscopic hemostasis in preventing diverticular rebleeding with extravasation visualized by contrast-enhanced computed tomography.This single-center, retrospective, the observational study utilized data from an endoscopic database. Adult patients admitted to our hospital due to diverticular bleeding diagnosed by colonoscopy were included. We compared the data between the extravasation-positive and extravasation-negative groups. The primary outcome was the proportion of successful hemostasis without rebleeding within 1 month after the first endoscopic procedure. Altogether, 69 patients were included in the study (n = 17, extravasation-positive group; n = 52, extravasation-negative group). The overall rebleeding rate was 30.4% (21/69). The rebleeding rate was higher in the extravasation-positive group than in the extravasation-negative group, although without a statistically significant difference. However, among the patients who underwent endoscopic hemostasis, the rebleeding rate was significantly higher in the extravasation-positive group than in the extravasation-negative group (50% [8/16] vs 10.5% [2/19], p = .022). In the extravasation-positive group, all 8 patients with rebleeding underwent repeat colonoscopy. Of these, 5 patients required additional clips; bleeding was controlled in 3 patients, while arterial embolization or surgery was required for hemostasis in 2 patients. None of the remaining 3 patients with rebleeding in the extravasation-positive group required clipping; thus, their conditions were only observed.Many patients with diverticular bleeding who exhibited extravasation on computed tomography experienced rebleeding after endoscopic hemostasis. However, bleeding in more than half of these patients could be stopped by 2 endoscopic procedures, without performing transcatheter arterial embolization or surgery even if rebleeding occurred. Some serious major complications due to such invasive interventions are reported in the literature, but colonoscopic complications did not occur in our patients. Endoscopic hemostasis may be the preferred and effective first-line therapy for patients with diverticular bleeding who have extravasation, as visualized by contrast-enhanced computed tomography.

A hybrid approach for chronic pancreatitis: combination of laparoscopic assisted distal pancreatectomy and open Frey procedure.

BACKGROUND: The treatment of chronic pancreatitis requires a surgical approach in patients who are refractory to medical therapy. During surgical treatment, ductal decompression is required, but a pancreatectomy is necessary for some patients, such as those with severe stenosis of the pancreatic duct. Indeed, suboptimal procedures lead to recurrent pancreatitis. We used a laparoscopic hybrid approach for patients with severe stenosis of the pancreatic duct. In this report, we present the feasibility and outcomes of our approach. METHODS: We selected a laparoscopic approach for the distal pancreatectomy, which is relatively safe and the effect of reducing the length of the wound is substantial. We selected an open approach for the Frey procedure because complete ductal compression has a high risk for injury to the vessels posterior to the pancreas. We recorded the operative outcomes, postoperative complications, and recurrence of pancreatitis. RESULTS: We performed the laparoscopic hybrid approach on 3patients between January and December 2018. There were no major intraoperative complications (Clavien-Dindo classification IIIa or more) and the postoperative course was uneventful in all patients. There were no recurrences of pancreatitis and no postoperative pain in all patients in > 2 years of follow-up. CONCLUSION: Our hybrid method with a focus on complete ductal compression with safety and minimal invasiveness might be the optimal approach for the surgical treatment of chronic pancreatitis that requires a pancreatectomy with the Frey procedure.

[A Case of Solitary Liver Metastasis from Renal Cell Carcinoma That Was Difficult to Distinguish from Hepatocellular Carcinoma and Underwent Laparoscopic Resection].

We experienced a case of solitary liver tumor that developed after renal cancer surgery. Before the surgery, the tumor was suspected to be hepatocellular carcinoma and was subsequently diagnosed as renal cancer liver metastasis. An 81-year-old man underwent retroperitoneal laparoscopic nephrectomy for left renal cancer in January 2017. After that, the cancer had not recurred, but a follow-up CT examination 1 year after the operation revealed a 42 mm-sized tumor in the liver S6. Liver biopsy was performed for diagnosis, but in histopathological findings, the diagnosis was difficult to make. Eventually, the preoperative final diagnosis was hepatocellular carcinoma. Laparoscopic partial hepatectomy was performed in June 2018, and in the histopathological findings of the resected specimen, the final diagnosis was the liver metastasis from renal cancer. Generally, the prognosis of renal cancer with liver metastasis is poor, but if complete resection is possible, it is recommended in the Clinical Practical Guideline for Renal Cancer. In recent years, the number of minimally invasive laparoscopic surgeries for hepatectomy has increased, and its safety has also improved. Therefore, resection is diagnostic treatment for cases where, like this case, preoperative diagnosis for solitary liver tumor is difficult. Laparoscopic hepatectomy could be one of the effective treatment strategies.

Early Detection of High-grade Biliary Intraepithelial Neoplasia (BilIN-3) in the Cystic Duct Visualized by SpyGlass DS Cholangioscopy.

An 84-year-old man was admitted with epigastralgia. Computed tomography showed contrast-enhanced wall thickness in the cystic duct. An endoscopic examination revealed short irregular stricture in the cystic duct, and per-oral cholangioscopy revealed a reddish papillary tumor at the stricture site. Surgical resection revealed high-grade biliary intraepithelial neoplasia (BilIN) at the stricture site of the cystic duct. To our knowledge, this is the first case of a solitary high-grade BilIN epithelium in the cystic duct detected by per-oral cholangioscopy.

Epithelial cyst arising in an intrapancreatic accessory spleen: a case report of robotic surgery and review of minimally invasive treatment.

BACKGROUND: An epithelial cyst in an intrapancreatic accessory spleen (ECIPAS) is rare. We report a case of ECIPAS that was treated with robot-assisted distal pancreatectomy with splenectomy. CASE PRESENTATION: The case was a 59-year-old woman who was referred to our hospital after a pancreatic tail tumor was found on computed tomography prior to surgery for small bowel obstruction at another hospital. A cystic lesion in the pancreatic tail was discovered and evaluated by magnetic resonance imaging and endoscopic ultrasonography. Based on clinical and radiological features, mucinous cystic neoplasm was included in the differential diagnosis. The patient underwent robot-assisted distal pancreatectomy with splenectomy. The postoperative course was uneventful. Pathological evaluation revealed a 20-mm ECIPAS in the pancreatic tail. CONCLUSIONS: If a pancreatic tail tumor is present, ECIPAS should be included in the differential diagnosis. However, preoperative diagnosis is difficult, and a definitive diagnosis is often not obtained until after surgery. Surgery should be minimally invasive. Laparoscopic distal pancreatectomy has become a standard surgical procedure because it is minimally invasive. Robot-assisted surgery is not only minimally invasive, but also advantageous, because it has a stereoscopic magnifying effect and allows the forceps to move smoothly. Robot-assisted distal pancreatectomy may be a good option, when performing surgery for a pancreatic tail tumor.

[A Case of Unresectable Hilar Cholangiocarcinoma Resected Curatively Through Effective Response to Neoadjuvant Chemotherapy].

A 60's man came to our hospital for jaundice. Contrast-enhanced CT showed irregular thickening of the hilar bile duct, and the lymph nodes(LN)were swollen from the hilar to the abdominal aorta. These LNs showed similar findings in endoscopic ultrasonography(EUS), and fine needle aspiration cytology(FNA)was performed on the enlarged No.13LN to diagnose LN metastasis of hilar cholangiocarcinoma. Since the peri-aortic LN was also markedly enlarged, it was considered to be metastasis, and was diagnosed as unresectable hilar cholangiocarcinoma with distant LN metastasis. When gemcitabine/cisplatin therapy(GC therapy)was started, tumor markers normalized and LN decreased in 4 months. We performed GC therapy for a total of 12 cycles and did not re-exacerbate. Cholangioscopy revealed that bile duct stenosis at the hilar portion had improved. We have determined that curative resection is possible and performed surgery. We confirmed that No.16b1LN was negative by pathological diagnosis during surgery and performed left hepatic caudate lobectomy, extrahepatic cholangectomy, and biliary reconstruction. Diagnosis was pT2aN1(n8a)M0, fStage ⅢB, and pR0. After surgery, adjuvant chemotherapy with S-1 was continued.

[A Case Report of Lymph Node Metastasis of Hepatocellular Carcinoma Resected by Laparoscopic Surgery].

The case presented is a 72-year-old male with no history of hepatitis B or C. Dynamic CT revealed a 2 cm mass in the liver (S8), with arterial phase hyperenhancement and delayed phase washout. The patient underwent an open S8 subsegmentectomy. The mass was pathologically diagnosed as well-to-moderately differentiated hepatocellular carcinoma(T2N0M0, Stage Ⅱ). At 2 years 10 months postoperatively, MRI showed a 4 cm mass in contact with the pancreatic head, inferior vena cava, and duodenum. The mass had moderate FDG uptake on PET scan, and early phase hyperenhancement and delayed phase washout on dynamic CT. We performed laparoscopic mass resection, suspecting lymph node metastasis of the hepatocellular carcinoma, which was confirmed by the pathological diagnosis. The patient has survived for 1 year without recurrence. Lymph node metastasis of hepatocellular carcinoma is rare. It is unclear whether surgical resection is feasible in such cases. Here, we report a case of lymph node metastasis of hepatocellular carcinoma resected by laparoscopic surgery.

[A Case of Gallbladder Cancer with Para-Aortic Lymph Node Metastasis Successfully Treated by Gemcitabine plus Cisplatin Combination Chemotherapy and Conversion Surgery].

The case is a 59-year-old woman. A medical examination revealed a high CA19-9, she visited a nearby hospital. Abdominal echo showed thickening of the gallbladder wall, and she was referred to our hospital for further examination. EUS-FNA was performed and a biopsy of #12 lymph node revealed undifferentiated cancer, which was diagnosed as gallbladder cancer. FDG-PET showed accumulation of FDG in the gallbladder lumen and swollen lymph nodes around the aorta. Therefore, the cancer was considered unresectable and chemotherapy was performed. FDG-PET was re-examined after 4 courses of gemcitabine plus cisplatin combination chemotherapy. As a result, the lymph node swelling contracted, the accumulation of FDG disappeared, and surgery was scheduled. Extended cholecystectomy and extrahepatic bile duct resection were performed. She was discharged 22 days after the surgery without complications. Histopathological examination showed fibrotic tissue at the gallbladder and lymph nodes, but no residual tumor cells. There are no recurrences 11 months after surgery. Although the prognosis of gallbladder cancer with para-aortic lymph node metastasis is generally poor, it is suggested that conversion surgery with multimodality treatment including preoperative chemotherapy may be a useful therapeutic strategy.

Serum levels of the chemokine CCL2 are elevated in malignant pleural mesothelioma patients.

BACKGROUND: Malignant pleural mesothelioma (MPM) is a debilitating disease of the pleural cavity. It is primarily associated with previous inhalation of asbestos fibers. These fibers initiate an oxidant coupled inflammatory response. Repeated exposure to asbestos fibers results in a prolonged inflammatory response and cycles of tissue damage and repair. The inflammation-associated cycles of tissue damage and repair are intimately involved in the development of asbestos-associated cancers. Macrophages are a key component of asbestos-associated inflammation and play essential roles in the etiology of a variety of cancers. Macrophages are also a source of C-C motif chemokine ligand 2 (CCL2), and a variety of tumor-types express CCL2. High levels of CCL2 are present in the pleural effusions of mesothelioma patients, however, CCL2 has not been examined in the serum of mesothelioma patients. METHODS: The present study was carried out with 50 MPM patients and 356 subjects who were possibly exposed to asbestos but did not have disease symptoms and 41 healthy volunteers without a history of exposure to asbestos. The levels of CCL2 in the serum of the study participants was determined using ELISA. RESULTS: Levels of CCL2 were significantly elevated in the serum of patients with advanced MPM. CONCLUSIONS: Our findings are consistent with the premise that the CCL2/CCR2 axis and myeloid-derived cells play an important role in MPM and disease progression. Therapies are being developed that target CCL2/CCR2 and tumor resident myeloid cells, and clinical trials are being pursued that use these therapies as part of the treatment regimen. The results of trials with patients with a similar serum CCL2 pattern as MPM patients will have important implications for the treatment of MPM.

Acquisition of gemcitabine resistance enhances angiogenesis via upregulation of IL­8 production in pancreatic cancer.

Gemcitabine (Gem) is widely used as chemotherapy for pancreatic cancer (PaCa), but its effect is not fully satisfactory. One of the reasons for this is the acquisition of Gem resistance (Gem­R). To elucidate the mechanism of Gem­R, two Gem­R PaCa cell lines were established from AsPC­1 and MIA PaCa­2 cells. It was demonstrated that expression of interleukin­8 (IL­8) mRNA was significantly upregulated in Gem­R PaCa cells by cDNA microarray and RT­qPCR analyses. Increased IL­8 secretion by Gem­R cells was confirmed by cytokine array and enzyme­linked immunosorbent assay. Moreover, we found that co­culture with Gem­R PaCa cells significantly enhanced tube formation of human umbilical vein endothelial cells, and treatment with an anti­CXCR2 (main receptor for IL­8) antibody significantly prevented this effect. We previously reported that a chemokine network centered on the IL­8/CXCR2 axis plays an important role in PaCa angiogenesis, and suppression of this axis has an antitumor effect. Since acquisition of Gem­R increased IL­8 production and consequently increased tumor angiogenesis, the IL­8/CXCR2 axis may be a potential novel therapeutic target for PaCa after acquiring Gem­R.

[A Case with Long Survival after Total Remnant Pancreatectomy for Recurrence of Pancreatic Body Cancer].

A 56-year-old man underwent distal pancreatectomy due to pancreatic body carcinoma in 2009, at the age of 46. There had been no sign of metastasis and recurrence until levels of tumor markers began to increase in January 2014. PET scan, CT scan, and other examinations showed a possible carcinoma in the pancreas head. The patient underwent total remnant pancreatectomy. The tumor was located in the uncinate process of the pancreas with infiltration of the portal vein. The pathological diagnosis of the tumor was moderately differentiated adenocarcinoma. The ductal lumen structure was relatively maintained and the cytoplasm was comparatively clear. Since its pathological findings were similar to those observed in 2009, the tumor appeared to be a recurrence of the tumor resected at that time. The patient had received postoperative chemotherapy and remains alive in 2019 without recurrence. While there is evidence that surgical resection for the recurrence of other cancers such as colon cancer may improve patient survival, it remains unclear if surgical resection of recurrence in the remnant pancreas after pancreatectomy of pancreatic cancer is feasible. We report a case with long survival after surgical resection of a pancreatic carcinoma recurrence in the remnant pancreas.

[A Case of Conversion Surgery for an Initially Locally Advanced Unresectable Pancreatic Cancer after S-1 Chemotherapy].

We report a case of conversion surgery for a locally advanced unresectable(UR-LA)pancreatic cancer that was radically resected after S-1 therapy. A 65-year-old man visited a referral physician because of fatigue and liver dysfunction. A CT scan revealed a mass in the pancreatic uncinate process that was suspected to be superior mesenteric artery(SMA)infiltration and was diagnosed as UR-LA pancreatic cancer. GEM nab-PTX therapy was initiated but was discontinued after 2 courses because of adverse events. The treatment was switched to S-1 monochemotherapy. After that, the tumor did not progress for around 1.5 years, and the patient was referred to our hospital for surgical treatment. As the contact between the tumor and the SMA was considered to be less than half-round, we made a diagnosis of borderline resectable(BR-A)pancreatic cancer. Subsequently, we performed a pancreaticoduodenectomy with partial resection of the portal vein and achieved R0 resection. The patient received adjuvant chemotherapy with S-1 and showed no signs of recurrence for 10 months after surgery.