[A Case of Sigmoid Colon Cancer with Intussusception Prolapsing through the Anus].

A 76-year-old woman presented to the hospital with the colon prolapsing through the anus. The enhanced abdominal computed tomography(CT)showed intussusception of the sigmoid colon due to sigmoid colon cancer. It was difficult to reduce the intussusception, and we did not recognize the ileus and ischemic change of the colon. Therefore, we performed an elective surgery. Hartmann's procedure and lymph node dissection were performed 8 days after the hospitalization. The postoperative course was uneventful. We report a case of sigmoid colon cancer with intussusception prolapsing through the anus.

A case of intraductal papillary neoplasm of the bile duct accompanied by intraductal papillary mucinous neoplasm of the pancreas and hepatocellular carcinoma.

A 73-year-old man with mixed-type intraductal papillary mucinous neoplasm of the pancreas body was followed up for 14 years. Based on imaging findings, the intraductal papillary mucinous neoplasm of the pancreas met the high-risk stigmata, and new hepatic masses were suspected to be intraductal papillary neoplasms of the bile duct. With a diagnosis of intraductal papillary mucinous neoplasm of the pancreas and intraductal papillary neoplasm of the bile duct, the patient had undergone left lateral hepatectomy and distal pancreatectomy. Based on pathology, the pancreatic specimen was diagnosed as a high-grade intraductal papillary mucinous neoplasm of the pancreas, and the hepatic specimen was diagnosed as an intraductal papillary neoplasm of the bile duct and hepatocellular carcinoma. The intraductal papillary neoplasms of the bile duct and hepatocellular carcinoma were adjacent to each other. Fifteen months after surgery, recurrence in the remnant pancreas was detected. The patient had undergone residual total pancreatectomy, with no recurrence thirty months after the second resection. This case demonstrates that second surgery for metachronous high-risk lesions in the remnant pancreas of patients with intraductal papillary mucinous neoplasm of the pancreas and intraductal papillary neoplasm of the bile duct may also be considered to improve survival.

[A Case of Complete Resection Using the Liver-First Approach after Systemic Chemotherapy in a Patient with Synchronous Colorectal Liver and Lung Metastases].

Conversion surgery for patients with initially unresectable colorectal liver metastases is increasingly being performed because of effective systemic chemotherapy. Additionally, many studies have reported the benefit of the liver-first approach for advanced liver metastasis. We report a case of an initially unresectable advanced colon cancer with multiple liver and lung metastases that was successfully treated with the liver-first approach following chemotherapy. The patient was a 36-year- old woman who was diagnosed with advanced rectal cancer, cT4aN2aM1b, cStage Ⅳb. After a temporary transverse colostomy, she was administered systemic chemotherapy for 9 months. The primary tumor and liver metastases showed partial response while the lung metastases showed complete response. Since it was considered that liver metastases were the main prognostic factors, we performed a right hemihepatectomy plus S3 partial hepatectomy, followed by laparoscopic high anterior resection. A partial pneumonectomy was also performed because of the regrowth of the lung metastases, and we succeeded in complete resection. The liver-first approach was a beneficial treatment option for this patient with unresectable colorectal liver metastases.

Hepatocellular carcinoma recurrence in the extrahepatic bile duct wall: A case report.

We should know that hepatocellular carcinoma can progress as if it replaces the bile duct wall itself.

A case of laparoscopic anterior resection for rectal cancer with duplication of the inferior vena cava using preoperative 3D computed tomography angiography.

We report the case of a patient with duplication of the inferior vena cava (DIVC) who underwent anterior laparoscopic resection for rectal cancer. A 66-year-old woman presented with abnormal lung shadows on a chest x-ray during a routine health checkup. She was diagnosed with rectal cancer and lung metastasis using colonoscopy and thoracoabdominal computed tomography (CT). In addition, a 3D CT angiography revealed double inferior vena cava, one on either side of the aorta. The preoperative diagnosis was rectal cancer cT3N0M1a(Lung) cStage IVA with DIVC, and a two-stage surgery was planned. The first stage was high anterior laparoscopic resection. This was safely performed because the pre-hypogastric nerve fascia was preserved and the left inferior vena cava was not visualized during the surgery. During the second stage of the surgery, video-assisted thoracoscopic left lower lobectomy was performed and no recurrence was observed for >6 months after the second surgery.

Laparoscopic hepatectomy for liver metastasis of lung large-cell neuroendocrine carcinoma: A case report.

INTRODUCTION: Lung large-cell neuroendocrine carcinoma (LCNEC) is an aggressive and a rare type of lung cancer, and the prognosis of LCNEC with distant metastasis is extremely poor, with a five-year survival rate of 0%. Here, we report a case of laparoscopic hepatectomy for liver metastasis of lung LCNEC. PRESENTATION OF CASE: A 63-year-old man received a routine physical examination, and abnormal chest radiographic findings were observed; chest computed tomography (CT) in our hospital revealed that the patient had left pneumothorax and a lesion measuring 18 mm in the inferior lingular segment of the lung. The patient underwent thoracoscopic lobectomy, and the final pathological diagnosis was lung LCNEC. Four years after surgery, abdominal CT revealed a mass measuring 27 mm in the liver. The patient underwent laparoscopic partial hepatectomy, and postoperative pathological examination showed liver metastasis of LCNEC. There was no sign of recurrence 6 months after hepatectomy. DISCUSSION: LCNEC with distant metastasis has a poor response to systemic chemotherapy, and the median survival time of patients with distant metastasis is estimated to be approximately 6 months, with a five-year survival rate of 0%. Although the common site of metastasis from LCNEC is the liver, there are no previous reports of hepatectomy for liver metastasis of LCNEC. CONCLUSION: We report a case of laparoscopic hepatectomy for liver metastasis of lung LCNEC. It is suggested that surgical resection for solitary distant metastasis of LCNEC may improve prognosis.

Laparoscopic anatomical segment 3 segmentectomy for hepatocellular carcinoma accompanied by hypoplasia of the right hepatic lobe.

We report a case of laparoscopic anatomical segment 3 segmentectomy for hepatocellular carcinoma (HCC) accompanied by hypoplasia of the right hepatic lobe. An 80-year-old man was admitted with a suspicion of HCC diagnosed by computed tomography during follow-up for thyroid cancer. Dynamic computed tomography showed 40-mm HCC in segment 3 and hypoplasia of the right hepatic lobe with the Chilaiditi sign. We performed laparoscopic anatomical segment 3 segmentectomy. There were no postoperative complications, and the patient was discharged 6 days postoperatively. This procedure can be performed safely and is technically feasible, but special attention should be paid to anatomical alterations to avoid fatal surgical complications.

Preoperative Cholangitis Affects Survival Outcome in Patients with Extrahepatic Bile Duct Cancer.

BACKGROUND: It remains controversial whether preoperative cholangitis affects long-term outcomes after resection in patients with extrahepatic bile duct cancer. METHODS: A total of 107 patients with extrahepatic bile duct cancer who underwent resection with curative intent from 2008 to 2014 were retrospectively reviewed. Patients were categorized into two groups according to the presence or absence of preoperative cholangitis. Clinicopathological variables and long-term outcomes were compared in the two groups. RESULTS: In the preoperative cholangitis group, the rate of preoperative biliary drainage, the number of tube changes and/or additions, and the rate of lymph node metastasis were higher compared to the no-cholangitis group. Overall survival and disease-free survival were significantly worse in the cholangitis group compared to the no-cholangitis group (p = 0.022, p = 0.007). A poorer prognosis was not observed with an increasing grade of cholangitis in Tokyo Guidelines 2013 (p = 0.09). A multivariate logistic regression analysis revealed that the preoperative cholangitis was an independent prognostic factor for extrahepatic bile duct cancer. CONCLUSION: Preoperative cholangitis is an independent prognostic factor in patients with extrahepatic bile duct cancer regardless of the severity of the cholangitis.

Normal viscous force of pendular liquid bridge between two relatively moving particles.

In this work, Direct Numerical Simulations (DNS) of a pendular liquid bridge formed between two relatively moving particles are performed to evaluate the normal component of the viscous force exerted on the particles. The viscous force obtained are non-dimensionalised in order to clarify the parameters which can affect the dimensionless force. The DNS results are compared with the viscous force models in literature which are commonly used in DEM simulations. It is found that these models cannot be used with large inter-particle separation distance. A new and more accurate viscous force model is proposed from the DNS results which can be directly implemented in the DEM framework.

Preoperative neutrophil-to-lymphocyte ratio as a predictor of survival after reductive surgery plus percutaneous isolated hepatic perfusion for hepatocellular carcinoma: a retrospective analysis.

PURPOSE: We assessed the predictive value of the preoperative neutrophil-to-lymphocyte ratio (NLR) in patients who underwent a two-stage treatment combining reductive surgery and percutaneous isolated hepatic perfusion for multiple hepatocellular carcinoma (HCC) with portal vein tumor thrombus (PVTT). METHODS: Forty-two patients underwent the two-stage treatment between January 2000 and December 2014 at Kobe University Hospital (Hyogo, Japan). The NLR was calculated from lymphocyte and neutrophil counts in the preoperative routine blood test. Clinical data and overall survival were compared statistically and multivariate analysis was done to identify prognostic factors. RESULTS: The median survival of patients with a preoperative NLR > 2.3 was 14.9 months (n = 13), whereas that of patients with a preoperative NLR ≤ 2.3 was 26.1 months (n = 29; P = 0.022). A preoperative NLR > 2.3 was an independent prognostic factor in patients with multiple HCC with PVTT [hazard ratio (HR) 2.329; 95 % confidence interval (CI) 1.058-5.667; P = 0.036]. CONCLUSION: Based on the results of this study, an elevated preoperative NLR is an independent predictive risk factor for patients undergoing two-stage treatment for multiple HCC with PVTT.

Pathological complete response after percutaneous isolated hepatic perfusion in hepatocellular carcinoma with portal vein tumor thrombosis: a case report.

BACKGROUND: Although the effectiveness of perioperative adjuvant therapy in the treatment of hepatocellular carcinoma (HCC) has been investigated, the efficacy of preoperative therapy is unclear. Herein, we report a case of pathological complete response after percutaneous isolated hepatic perfusion (PIHP) for HCC involving portal vein tumor thrombosis (PVTT). CASE PRESENTATION: A 77-year-old woman was referred to our institute with a liver mass detected on a routine health screening. Computed tomography revealed a 28 × 25 mm HCC in the left lobe of the liver and a tumor thrombus in the left and right portal branches (T4N0M0, stage IVA). The patient received a single dose of preoperative PIHP with doxorubicin plus mitomycin C, without severe toxicity. After the chemotherapy, she underwent extended left hepatic lobectomy and thrombectomy of the PVTT. No cancer cells were detected during histopathological analysis, indicating pathological complete response. She remained relapse-free 12 months after the surgery. CONCLUSIONS: We experienced a case of pathological complete response after preoperative PIHP with doxorubicin plus mitomycin C for HCC involving PVTT.

[A Case of Recurrent Ovarian Fibrosarcoma Resected by Pancreaticoduodenectomy].

A 66-year-old woman presented to the Department of Gynecology in our institution in 2005 with peritoneal recurrence of ovarian fibrosarcoma. Originally, combined modality therapy including repeated surgical resection and somatic chemotherapy was performed. A peritoneal recurrence was found near the pancreatic head. She was referred to our department in October 2015, and underwent pancreaticoduodenectomy. The tumor was severely adhesive to the portal vein and combined portal venous resection was performed. Histological examination of tumor specimens revealed tumor invasion to the adjacent pancreatic parenchyma and portal vein. No evidence of recurrence was detected after a follow-up of 8 months. We suggest that in cases with peritoneal recurrence of ovarian tumors, radical resection might be considered, taking into account the biologic behavior of the tumor.

[A Case of Pancreatic Metastasis of Osteosarcoma Resected Using Laparoscopic Spleen Preserving Distal Pancreatectomy].

A 44-year-old woman underwent surgical resection and received preoperative and postoperative chemotherapy for conventional osteosarcoma in the right fibular head. Three years later, follow-up PET-CT revealed accumulation ofFDG in the tail ofthe pancreas. Contrast-enhanced computed tomography showed a 13mm well-circumscribed hypovascular tumor. EUS showed a heterogeneous solid tumor, which was diagnosed as metastasis ofosteosarcoma to the pancreas. Laparoscopic spleen preserving distal pancreatectomy(LAP-SPDP)was performed. Pathologically, the tumor was diagnosed as metastasis ofconventional osteosarcoma to the pancreas. Cells from pancreas islet tissue were detected in the tumor, suggesting invasion ofthe tumor into the pancreatic body and surrounding adipose tissue. Although postoperative chemotherapy was administered, lung metastasis was detected 1.1 years after surgery. Laparoscopic partial resection of the lung metastasis was performed, and the patient is still alive. Metastasis ofosteosarcoma to the pancreas is rare, and there is no report oflaparoscopic approach as a treatment. Herein, we report a case with several references.

Simultaneous quantitative analysis of 12 methoxyflavones with melanogenesis inhibitory activity from the rhizomes of Kaempferia parviflora.

A methanol extract from the rhizomes of Kaempferia parviflora Wall. ex Baker (Zingiberaceae) has shown inhibitory effects against melanogenesis in theophylline-stimulated murine B16 melanoma 4A5 cells (IC50 = 9.6 µg/mL). Among 25 flavonoids and three acetophenones isolated previously (1-28), several constituents including 5-hydroxy-7,3',4'-trimethoxyflavone (6, IC50 = 8.8 µM), 5,7,3',4'-tetramethoxyflavone (7, 8.6 µM), 5,3'-dihydroxy-3,7,4'-trimethoxyflavone (12, 2.9 µM), and 5-hydroxy-3,7,3',4'-tetramethoxyflavone (13, 3.5 µM) showed inhibitory effects without notable cytotoxicity at the effective concentrations. Compounds 6, 7, 12, and 13 inhibited the expression of tyrosinase, tyrosine-related protein (TRP)-1, and TRP-2 mRNA, which could be the mechanism of their melanogenesis inhibitory activity. In addition, a quantitative analytical method for 12 methoxyflavones (1, 2, 4-11, 13, and 14) in the extract was developed using HPLC. The optimal condition for separation and detection of these constituents were achieved on an ODS column (3 µm particle size, 2.1 mm i.d. × 100 mm) with MeOH-0.1 % aqueous acetic acid solvent systems as the mobile phase, and the detection and quantitation limits of the method were estimated to be 0.08-0.66 ng and 0.22-2.00ng, respectively. The relative standard deviation values of intra- and interday precision were lower than 0.95 and 1.08 %, respectively, overall mean recoveries of all flavonoids were 97.9-102.9 %, and the correlation coefficients of all the calibration curves showed good linearity within the test ranges. For validation of the protocol, extracts of three kinds of the plant's rhizomes collected from different regions in Thailand (Leoi, Phetchabun, and Chiang Mai provinces) were evaluated. The results indicated that the assay was reproducible, precise, and could be readily utilized for the quality evaluation of the plant materials.

Anatomical variations of liver blood supply in patients with pancreaticobiliary maljunction.

PURPOSE: Pancreaticobiliary maljunction (PBM) arises from a developmental abnormality during the embryonic period; thus, these patients may have anatomical variations of the liver blood supply, including aberrant vessels and unusual locations. METHODS: We reviewed retrospectively the vascular anatomy of 52 patients with PBM, who were seen between 1998 and 2013. RESULTS: There were 11 male patients and 41 female patients. Sixteen patients had bile duct type (C-P type) PBM, 35 had pancreatic duct type (P-C type) PBM, and one had complex type PBM. Thirty-three patients had biliary dilatation. Nine (17.3 %) patients had an aberrant (replaced or accessory) hepatic artery and 2 (3.8 %) had an aberrant portal vein. Among 39 patients evaluated by contrast-enhanced computed tomography, 8 (20.5 %) had their right hepatic artery positioned on the ventral side of the common bile duct. The presence of aberrant hepatic vessels was not related to the type of confluence, biliary dilatation, type of Todani classification, or associated biliary malignancies. CONCLUSIONS: The incidence of the right hepatic artery being located on the ventral side of the common bile duct may be higher in patients with PBM than the naturally occurring incidence of about 10 % in the general Japanese population.

Ice Plant (Mesembryanthemum crystallinum) Extract Promotes Lipolysis in Mouse 3T3-L1 Adipocytes Through Extracellular Signal-Regulated Kinase Activation.

The antiobesity effect of ice plant (IP) (Mesembryanthemum crystallinum), a salt-resistant African plant, has recently attracted increased attention. IP is rich in pinitol, which lowers blood sugar, and myo-inositol, which prevents fatty liver disease. Furthermore, IP can potentially prevent or reduce the symptoms of metabolic syndrome. However, the details of the physiological mechanisms and mechanisms of action of IP are unclear. A previous study by our group demonstrated the capability of IP extract to prevent adipogenesis in 3T3-L1 preadipocytes. In this study, we analyzed the physiological function of IP extract on lipolysis in 3T3-L1 cells and the underlying mechanisms of this process. We found that the release of glycerol from cells treated with IP extract increased in an IP dose-dependent manner. IP extract exhibited cytotoxic activity at concentrations above 4 mg/mL. Real-time polymerase chain reaction and western blotting showed that IP extract downregulated peroxisome proliferator-activated receptor (PPAR-)γ, hormone-sensitive lipase (HSL), and adipose triglyceride lipase (ATGL) in a concentration-dependent manner, but did not affect HSL-Ser563, HSL-Ser660, or perilipin phosphorylation. Although the cAMP-dependent protein kinase A (PKA)-specific inhibitor H89 did not affect IP extract-induced lipolysis, the extracellular signal-regulated kinase (ERK1/2) inhibitor U0126 significantly abrogated IP extract-activated glycerol release. Furthermore, IP extract strongly enhanced ERK1/2 phosphorylation at the concentrations used in the study. These results suggest that IP extract augments lipolysis by enhancing ERK phosphorylation.

Clinical significance of bile reflux into the pancreatic duct without pancreaticobiliary maljunction assessed by intraoperative cholangiography.

INTRODUCTION: Bile reflux into the pancreatic duct (BRPD) is sometimes demonstrated during intraoperative cholangiography (IOC) even in patients without pancreaticobiliary maljunction. However, the clinical significance of this finding in laparoscopic and open cholecystectomy is unclear. METHODS: Among 484 patients who underwent cholecystectomy (372 laparoscopic, 112 open), patients whose pancreatic duct was depicted in IOC were selected. The value of pancreatic amylase (p-amylase) of the gallbladder bile, histological changes, and the immunohistochemical expression of proliferating cell nuclear antigen (PCNA) in the gallbladder mucosa were analyzed in patients with BRPD. The data were then compared to those in patients without BRPD whose gallbladder bile p-amylase was measured (control group, n = 20). RESULTS: The success rate of IOC was 93.6%. The rate of BRPD in laparoscopic and open cholecystectomy was 5.2% and 5.7%, respectively. The value of gallbladder bile p-amylase in patients with BRPD was significantly higher than in the control group (790.5 vs 14.0 IU/L, P = 0.034). The value of the PCNA labeling index in patients with BRPD was significantly higher than that of the control group (15.4% vs 4.1%, P = 0.0026). Among the 24 patients with BRPD, pathological changes in the gallbladder mucosa were detected in five (two hyperplasia, three metaplasia), but there was no correlation between the presence of pathological change and PCNA labeling index or gallbladder bile p-amylase. CONCLUSIONS: IOC could detect BRPD both in laparoscopic and open cholecystectomy at a similar rate. Patients with BRPD had high levels of gallbladder bile p-amylase and PCNA labeling index, findings similar to those in patients with pancreaticobiliary maljunction.

[Resection of Initially Unresectable Gallbladder Cancer with Multiple Liver Metastases after Chemotherapy with Gemcitabine plus Cisplatin].

A 61-year-old woman was referred to our hospital for surgery for gallstones. She was diagnosed as having gallbladder cancer after a detailed radiologic examination. At the first laparotomy, gallbladder cancer with bulky invasion to the liver and multiple liver metastases were observed. Gemcitabine plus cisplatin (GC) administration was chosen. After 7 administration of GC, we changed GC to gemcitabine alone due to blood toxicity. After 7 months of chemotherapy, although CT findings showed regression of the liver invasion and the liver metastases, the serum CA19-9 level gradually increased. Because there were no obvious distant metastases on detailed radiologic examination, we performed surgery for the primary lesion after obtaining informed consent. Pathological examination demonstrated fibrosis without viable cancer cells in the metastatic liver tumor. Gemcitabine was administered as post-operative adjuvant chemotherapy. Twelve months after surgery, there was no sign of recurrence.

[A Case of Invasive Intraductal Papillary Mucinous Carcinoma, Penetrating the Stomach, Colon, and Jejunum].

A 69-year-old woman was admitted to a nearby clinic complaining of abdominal pain. Abdominal CT showed a 10 cm diameter huge cystic lesion in the body and tail of the pancreas. The patient was referred to our institution for treatment. Endoscopic ultrasonography (EUS) revealed a cystic mass with a solid lesion. Endoscopic retrograde pancreatography(ERP) demonstrated mucous at the opening of the papilla of Vater and dilatation of the pancreatic duct with a solid nodule. Contrast radiography revealed a fistula from the tumor to the jejunum. A biopsy specimen from the lesion showed adenocarcinoma. Intraoperative findings showed a tumor occupying the pancreas body and tail with suspected invasion to the stomach, jejunum, and transverse colon. We performed distal pancreatectomy with partial resection of stomach, jejunum, and colon. Pathological findings showed an invasive type of IPMC, with invasion to the subserosal layer of the stomach and colon and the mucous layer of the jejunum. While IPMC is recognized as a slow growing malignancy, some cases of invasive carcinoma with fistulation into adjacent organs have been reported. To our knowledge, a case of IPMC penetrating to 3 adjacent organs is rare.

Preoperative bile replacement improves immune function for jaundiced patients treated with external biliary drainage.

BACKGROUND: Although preoperative biliary drainage in jaundiced patients is controversial, external biliary drainage (EBD) is beneficial for infection control in patients with biliary cancers. When EBD is performed, additional bile replacement (BR) has the benefit of improving impaired intestinal barrier function, but the detailed mechanism remains unknown. We examined the effect of bile replacement on immune functions over the duration of BR in jaundiced patients. METHODS: Fifteen patients were enrolled into this prospective study. BR was started soon after the total serum bilirubin concentration reached 5.0 mg/dl and was continued for 14 days. Drained bile was given two times orally (2 × 100 ml/day). Concanavalin A (Con A)- and phytohemagglutinin (PHA)-stimulated lymphocyte proliferation and serum diamine oxidase (DAO) activity were measured before starting and during BR. Twenty patients with EBD and no BR were analyzed as a control group. RESULTS: Serum liver enzymes, prothrombin time-international normalized ratio (PT-INR), and responses to Con A and PHA gradually improved over the 14 days of BR, but percentages of lymphocytes and DAO levels did not. PT-INR, and Con A and PHA responses did not improve during EBD in the control group. PT-INR significantly decreased in patients with a greater fraction of their drained bile replaced. CONCLUSIONS: Our results indicate that preoperative BR using as large a quantity of bile as possible is useful for improving blood coagulability and cellular immunity in patients with EBD.