Rectal neuroendocrine tumor developing lateral lymph node metastasis after curative resection: a case report.

BACKGROUND: Among gastrointestinal neuroendocrine tumors (NETs), rectal NETs account for about one-third of all tumors. Despite the occasional observation of lateral lymph node metastasis in patients with rectal NETs, lateral lymph node recurrence is rare. We present a rare case of lateral lymph node recurrence after curative resection of a rectal NET. CASE PRESENTATION: A 55-year-old man presented with fecal occult blood and colonoscopy revealed a mass in the distal rectum. Systematic computed tomography scan showed no evidence of regional lymph node or distant metastasis. The patient underwent laparoscopic intersphincteric resection and D2 lymph node dissection with diverting stoma. Diverting stoma closure was performed 6 months after the initial operation. Pathological diagnosis was NET of the rectum, grade 2, T1b, N0, Stage I without lymphovascular invasion. At 54 months after the surgery, recurrence in a left lateral lymph node was suspected and lymph node dissection was performed. The pathological diagnosis of the specimen was consistent with lateral lymph node metastasis of a recurrent rectal NET. To our best knowledge, there are no case reports in English of lateral lymph node recurrence after curative resection of a rectal NET, grade 2, T1b, N0, Stage I without lymphovascular invasion. CONCLUSION: Considering that patients with lateral lymph node metastasis have worse survival than those without metastasis in rectal cancer, if complete resection of the tumor can be achieved for lateral lymph node recurrence, surgery may be an important option in the strategy to treat this condition.

GelPOINT single-port laparoscopy-assisted transanal minimum invasive surgery for low rectal cancer: a preliminary report on the use of the GOD VISION wireless smart glass-shaped monitor.

BACKGROUND: The GOD VISION wireless smart glass-shaped monitor (INBYTE) was used in the treatment of an elderly patient with mixed breathing disorder undergoing transanal minimally invasive surgery (TAMIS) for low rectal cancer under lumbar anesthesia. METHOD: After wearing the GOD VISION wireless smart glass-shaped monitor, we attached it to the Gel POINT Path® (Applied Medical). The tumor was surgically removed from all layers of the rectum using an ENDOPATH Electrosurgery PROBE PLUS II System® (a spatula-type electric scalpel) and the site was closed after sufficient washing. RESULTS: The total operation time was 93 min, and the estimated blood loss was 6 mL. The patient was discharged without complications on postoperative day 14. No local recurrence or distant metastasis in the 7 months after the operation. The patient remained in a good condition with the preservation of the anal function. CONCLUSIONS: It is necessary to accumulate cases and to perform long-term follow-up. In addition, the anal side operators are able to operate without discomfort. In the present case, the GOD VISION wireless smart glass-shaped monitor allowed the TAMIS operation to be performed more comfortably.

Risk and early predictive factors of anastomotic leakage in laparoscopic low anterior resection for rectal cancer.

BACKGROUND: In recent years, laparoscopic surgery has been widely used for rectal cancer. In laparoscopic rectal surgery, a double-stapling technique (DST) anastomosis using a stapling device is considered a relatively difficult procedure. Postoperative anastomotic leakage (AL) is a major complication related to patients' quality of life and prognosis. METHODS: This study was a retrospective, single-institution study of 101 rectal cancer patients who underwent laparoscopic low anterior resection (LAR) with DST anastomosis (excluding simultaneous resection of other organs and construction of protective diverting stoma) between February 2008 and November 2017 at the Gifu University Graduate School of Medicine. This study aimed to identify risk and early predictive factors of AL. RESULTS: Among 101 patients, symptomatic AL occurred in 13 patients (12.9%), of whom 10 were male and 3 were female. Their median BMI was 22.7 kg/m2 (range, 17.9-26.4 kg/m2). Among the pre- and intraoperative factors, AL was significantly associated with tumor location (lower rectum), distance from the anal verge (< 6 cm), intraoperative blood loss (≥ 50 ml), and the number of linear staples (≥ 2) in univariate analysis. In multivariate analysis, only intraoperative blood loss (≥ 50 ml, odds ratio [OR] 4.59; 95% confidence interval [CI] 1.04-19.52; p = 0.045) was identified as an independent risk factor for AL. Among the postoperative factors, AL was significantly associated with tachycardia-POD1 (≥ 100 bpm), CRP-POD3 (≥ 15 mg/dl), fever on postoperative day (fever-POD) 3 (≥ 38 °C), and first defecation day after surgery (< POD3) in univariate analysis. In multivariate analysis, fever-POD3 (≥ 38 °C, OR 30.97; 95% CI 4.68-311.22; p = 0.0003) and first defecation day after surgery (< POD3, OR 5.82; 95% CI 1.34-31.30; p = 0.019) were identified as early predictive factors for AL. CONCLUSION: In this study, intraoperative blood loss was an indicator of difficulty in a transection and anastomosing procedure, and fever-POD3 and early first defecation day after surgery were independent early predictive factors for AL. Careful surgery using an appropriate technique and standardized procedures with minimal bleeding and careful postoperative management paying attention to fever and defecation may prevent the onset and severity of AL.

[A Case of Metastatic Colorectal Cancer with Brain Metastasis Treated with Combined TFTD and Bevacizumab Therapy].

A woman in her 70s was confirmed as presenting with multiple liver and lung metastases from transverse colon cancer. After undergoing resection of the primary lesion, partial response(PR)was achieved after undergoing the first regimen (sLV5FU2 and bevacizumab[Bmab]); therefore, partial hepatectomy was performed. Adjuvant chemotherapy was administered for 7 months, but liver metastasis recurrence, multiple lung metastases, and brain metastasis were confirmed. As the brain metastasis was a single lesion and was accompanied by symptoms, resection of the lesion was performed. Treatment with regorafenib was initiated, but Grade 3 severe erythema multiforme was detected, and the treatment had to be discontinued. Therefore, combined TFTD and Bmab therapy was initiated as the third regimen. Liver and lung metastases were maintained as stable disease(SD), and the treatment was continued for approximately 1 year together with stereotaxic radiation therapy for the newbrain metastatic lesion. The utility of combined TFTD and Bmab therapy has been reported in a phase II trial, and it has also been indicated that Bmab is effective for reducing brain edema. As this treatment was effective in this case, we will report on it together with a discussion of the literature.

[Experience with Nivolumab in the Treatment of Metastatic Gastric Cancer].

Immunological checkpoint inhibitors have effects on various advancedcancers. Nivolumab was approvedfor advanced gastric cancer after third-line treatment in 2017. In our hospital, 10 patients were treatedwith nivolumab from October 2017 to March 2018. Thus, we retrospectively examinedthe clinical background, treatment outcomes, andad verse events of those patients. The median age was 70 years; male-to-female ratio was 6:4; recurrence sites were peritoneal dissemination, liver, lymph nodes, brain, ovaries, and bone(8, 2, 2, 1, 1, and1 , respectively); andtreatment lines were third, fourth, andfifth(in 6, 3, and1 patients, respectively). The minimum number of cycles was 1 course, while the maximum was 11 courses. The best tumor response evaluation was SD, andthe adverse event was an itching sensation in only one patient. It was suggestedthat long-term SD couldbe maintainedwhen the nivolumab treatment was initiatedin a patient with goodPS. In the future, biomarker analysis is expectedto identify effective cases.

[A Case of Stage IV Gastric Cancer Curative Resection by Conversion Therapy].

We experienced a case of curative resection as a multidisciplinary treatment for unresectable gastric cancer that attributed to peritoneal disseminations and direct invasion to other organs.Two courses of triplet chemotherapy(DCS therapy)were performed under enteral stent placement and nasoenteral nutrition for direct infiltration into the transverse colon with entire circumference stenosis.Distal gastrectomy and right hemicolectomy were performed as conversion therapy, and R0 resection was achieved.After the operation, S-1 as adjuvant chemotherapy was performed and there has been no relapse survival for 13 months since the operation.From this case, it seems that conversion therapy plays an important role in prognosis extension as a treatment strategy for Stage IV gastric cancer.

The technical outcomes of delta-shaped anastomosis in laparoscopic distal gastrectomy: a single-center safety and feasibility study.

BACKGROUND: The indications for laparoscopic gastrectomy for early stomach cancer have spread worldwide, and the short-term outcomes have been favorable. Intraabdominal delta-shaped gastroduodenostomy using endoscopic linear staplers, a technique which was developed by Kanaya et al. is one of the feasible reconstructive procedures. Pure laparoscopic surgery is reported to be associated with several intraoperative and postoperative advantages in comparison with laparoscopy-assisted surgery. However, the clinical results remain uncertain. The present study aimed to evaluate both the technical feasibility and safety of delta-shaped anastomosis with LDG according to the short-term outcomes. METHODS: The study group was composed of 229 patients who underwent delta-shaped anastomosis with LDG at Gifu University School of Medicine from December 2004 to December 2014. RESULTS: The median total operative blood loss and operative time were 20 ml and 277 min, respectively. Postoperative complications were detected in 20 (8.7 %) patients. The complications included: anastomotic stenosis, n = 3 (1.3 %); anastomotic leakage, n = 3 (1.3 %); pancreatic injury, n = 8 (3.5 %); anastomotic ulcer, n = 1 (0.4 %); bowel obstruction, n = 1 (0.4 %); abdominal abscess, n = 1 (0.4 %); lymphorrhea, n = 1 (0.4 %); cardiac failure, n = 1 (0.4 %); and infection, n = 1 (0.4 %). The complications were classified as grade 2, n = 4 (1.7 %); grade 3a, n = 12 (5.2 %); grade 3b, n = 4 (1.7 %); and grade 4 and 5, n = 0 (0 %). CONCLUSION: The findings of the present study indicate the safety of Kanaya's procedure and that it should provide better outcomes in patients who undergo intracorporeal gastroduodenostomy after laparoscopic distal gastrectomy.

[A Case Report of Neuroendocrine Carcinoma of the Esophagus Treated with Multidisciplinary Therapy].

A 72-year-old man was referred to our department because of esophageal tumor. Immunohistochemical findings were CD56-positive, synaptophysin-positive, chromogranin A-positive, Ki-67(labeling index)≥90%. The diagnosis was esophageal neuroendocrine carcinoma, categorized as cT4b(106recR-main bronchus), cN1(106recR), cM0, cStage III C. We had initiated irinotecan plus cisplatin(IP)as neoadjuvant chemotherapy(NAC). Biopsy specimens of primary lesion after 1 course chemotherapy showed a change to squamous cell carcinoma(SCC). The target lesion exhibited partial response(PR)after 2 courses of chemotherapy, and the primary lesion was reduced, but was still present. We performed subtotal esophagectomy and subtotal stomach reconstruction with lymphadenectomy(R0, Cur A). The histopathological findings showed the primary lesion was SCC, metastatic lymph nodes(106recR)was NEC. The final diagnosis was SCC plus NEC, categorized as CT-pT1a (MM), pN1(106recR), M0, fStage II B. After that, we selected treatment regimen considering tissue type, and performed surgery and chemotherapy for 2 times of recurrences. At a follow-up examination 1 year and 2 months after the start of first chemotherapy, the patient is alive without recurrence. Esophageal neuroendocrine carcinoma is relatively rare and the prognosis is poor, but there is as yet no standard therapy. We experienced a case of neuroendocrine carcinoma of the esophagus treated with multidisciplinary therapy.

A case report on efficacy of Abound™ for anti-EGFR antibody-associated skin disorder in metastatic colon cancer.

BACKGROUND: Panitumumab is a full human epidermal growth factor receptor (EGFR) monoclonal antibody, an agent for metastatic colorectal cancer therapy. One of the most general adverse events of anti-EGFR monoclonal antibody therapy is skin disorder. At the present time, although prophylaxis of skin disorder is important for continuation of cancer therapy, there are no effective precautionary treatments. CASE PRESENTATION: A 73-year-old male with sigmoid colon cancer and synchronous lung metastasis was treated with panitumumab, an alone anti-EGFR monoclonal antibody as the third-line therapy.During the nine courses of the therapy, the response was stable disease (SD), but skin disorder gradually appeared obviously (CTCAE version 4.0: Grade 2). After 1 month of administration of Abound™, symptoms of the skin disorder improved (CTCAE version 4.0: Grade 1), thus the antibody therapy could be continued. CONCLUSION: We report that Abound™ was apparently effective in the treatment for anti-EGFR antibody-associated skin disorder. In the future, Abound™ could be expected as an agent for skin disorder as one of the side effects of colorectal cancer therapy.

Surgical Indications for Multiple and Synchronous Liver Metastases from Colorectal Cancer.

Surgical indications for resection of synchronous metastasis from colorectal cancer (CRC) are still controversial. 57 patients with synchronous and multiple metastatic liver tumors were studied. 1) The three-year survival rate and MST for synchronous metastasis, 55% and 28.4 ± 15.4 months, were clearly poorer than those of the patients with metachronous, 100% and 39.9 ± 10.8 months. 2) Three-year survival rate and MST for a single tumor were similar to those for multiple tumors but were 83% and 36.6 ± 14.0 months in patients with ≤ 2 tumors, significantly better (p = 0.0127) than those in patients with 3 tumors, 65% and 24.0 ± 13.6 months. 3) In the patients with synchronous liver tumors, 3-year survival rate and MST after staged hepatectomy were significantly better, 82% and 34.5 ± 14.9 months (p = 0.0467), than simultaneous hepatectomy, 29% and 23.9 ± 13.6 months. 4) In patients with repeat hepatectomy, the only difference between first vs. repeat hepatectomy was in tumor number detected, 4.4 ± 1.2 vs. 1.2 ± 0.1. The present data show that neoadjuvant chemotherapy might improve patient prognosis, and with 3 tumors, planning of staged hepatectomy is best, even if technically removed.

Determining timing of hepatectomy for colorectal cancer with distant metastasis according to imaging-based tumor shrinkage ratio.

BACKGROUND: The optimal timing of surgical resection of liver metastasis remains controversial, and guidelines regarding the upper limits of operative indications have not yet been defined. Surgical indication for metastasis from colorectal cancer (CLM) based on results of preoperative chemotherapy and RNF8 was investigated. METHODS: Differences in CLM size on CT were evaluated as shrinkage rate/day by dividing tumor shrinkage rates by the interval in days between CT. Levels of RNF8 of resected colorectal cancer and CLM frozen specimen were detected. RESULTS: When the cut line for shrinkage rate at 12 weeks was set at 0.35%, disease-free survival was significantly better in patients with a shrinkage rate >0.35% vs. ≤0.35% (p=0.003). RNF8 expression was significantly higher in Tis (p=0.001). In liver metastasis, RNF8 expression level was significantly lower in patients with partial response to FOLFOX than with stable disease, (p=0.017). CONCLUSIONS: A strategy of FOLFOX administration for 12 weeks to patients with low RNF8 expression and hepatectomy planned after 4 weeks rest may be accepted as the best therapeutic option for treating CLM.

Laparoscopic technique and safety experience with barbed suture closure for pelvic cavity after abdominoperineal resection.

BACKGROUND: Between April 2005 and December 2012, we performed laparoscopic colorectal resection with regional lymph node dissection on 273 cases of colorectal cancer patients. However, Laparoscopic rectal cancer surgery requires a high degree of skill. Any surgeon who is going to embark on these difficult resections should have at a minimum laparoscopic suturing skills in order to be able to close the peritoneal defect. METHODS: In laparoscopic surgery for rectal cancer, the intracorporeal suture technique required to close the pelvic cavity is very difficult. Barbed sutures have recently been proposed to facilitate laparoscopic suturing. Two patients with rectal cancer who underwent laparoscopic abdominoperineal resection (APR) with intracorporeal closure of the pelvic cavity from September to October 2012 were enrolled in this study. RESULTS: We present our initial experience of two consecutive cases of intracorporeal closure of the pelvic cavity by totally laparoscopic APR. After clinical follow-up, the two patients have no complaints and have shown no signs of recurrence. CONCLUSIONS: We hypothesized that barbed sutures could potentially improve the efficiency of intracorporeal closure of the pelvic cavity after laparoscopic APR. Further, we expect that use of the V-Loc™ will reduce intra-operative stress on the endoscopic surgeon.

Retrospective evaluation of the clinical necessity of external biliary drainage after pancreaticoduodenectomy.

BACKGROUND/AIMS: To evaluate the efficacy of internal biliary drainage after pancreaticoduodenectomy (PD), postoperative gastrointestinal function and complications of PD were compared in patients with and without the use of an external drainage stent for hepaticojejunostomy (HJ). METHODOLOGY: Between June 2005 and September 2011, 66 patients who underwent PD, including 40 patients with externally-stented HJ (ES group) and 26 patients with non-stented HJ (NS group), were included in this study, and postoperative bowel movements, oral intake, and complications were assessed. RESULTS: Time to tolerance of water or solid food were comparable between the two groups, and time to first bowel movement was significantly shorter in the NS group than in the ES group (3.2 +/- 1.6 days versus 4.6 +/- 1.7 days; p = 0.002). There were no differences in the incidence and severity of postoperative complications when comparing the two groups, whereas the incidence of postoperative cholangitis was significantly higher in the ES group (25.0%) than in the NS group (3.8%; p = 0.024). CONCLUSIONS: External biliary drainage may have a negative impact on biliary complications after PD, especially on the incidence of postoperative cholangitis.

Long-term outcomes of treatment of gastric gastrointestinal stromal tumor by laparoscopic surgery: review of the literature and our experience.

BACKGROUND/AIMS: Although the feasibility of laparoscopic resection of gastric gastrointestinal stromal tumors (GISTs) has been established, various aspects are debated. This paper describes the problems of minimally invasive resection of gastric GISTs and compares this experience with an extensive literature review. METHODOLOGY: Between October 2003 and June 2012, 24 consecutive patients undergoing laparoscopic resection of gastric GISTs were enrolled in a prospective study. A comparison with authors' experience with laparoscopic wedge-segmental resection of GISTs was also carried out. RESULTS: Twenty-four patients, mean age 64.0 +/- 11.2 years, were submitted to laparoscopic wedge-segmental gastric resections. Mean tumor size was 3.1 +/- 1.2 cm, mean operative time was 118.0 +/- 57.3 min, mean blood loss was 21.6 +/- 47.7 mL, and mean hospital stay was 7.1 +/- 1.9 days. There were no major operative complications or mortalities. All lesions had negative resection margins. Postoperative complications were detected in 2 patients. The rate of complication of grade 2 was 8.3%. At a mean follow-up of 23.9 months, all patients were disease-free. Morbidity, mortality, length of stay, and oncologic outcomes were comparable to experience with an extensive literature review. The stomach was divided into 3 areas (U, M, L area). When operation time and blood loss were examined, a significant difference was not indicated. However, both operation time and blood loss of M area tended to be low compared with U area. According to the mitotic index, 21 (87.5%) tumors were evaluated as low risk, 2 (7.3%) tumors as medium risk, and 1 (4.2%) tumor as high risk. CONCLUSIONS: Laparoscopic resection is safe and effective in treating gastric GISTs. Therefore, a minimally invasive approach should be the preferred surgical treatment in patients with small- and medium-sized gastric GISTs.

Reconstruction method after pancreaticoduodenectomy. Idea to prevent serious complications.

Pancreatic fistula after pancreaticoduodenectomy represents a critical trigger of potentially life-threatening complications and is also associated with markedly prolonged hospitalization. Many arguments have been proposed for the method to anastomosis the pancreatic stump with the gastrointestinal tract, such as invagination vs. duct-to-mucosa, Billroth I (Imanaga) vs. Billroth II (Whipple and/or Child) or pancreaticogastrostomy vs. pancreaticojejunostomy. Although the best method for dealing with the pancreatic stump after pancreaticoduodenectomy remains in question, recent reports described the invagination method to decrease the rate of pancreatic fistula significantly compared to the duct-to-mucosa anastomosis. In Billroth I reconstruction, more frequent anastomotic failure has been reported, and disadvantages of pancreaticogastrostomy have been identified, including an increased incidence of delayed gastric emptying and of pancreatic duct obstruction due to overgrowth by the gastric mucosa. We review recent several safety trials and methods of treating the pancreatic stump after pancreaticoduodenectomy, and demonstrate an operative procedure with its advantage of the novel reconstruction method due to our experiences.

Strategy for synchronous and multiple liver metastasis.

BACKGROUND/AIMS: Surgical indications for resection of synchronous metastasis from colorectal cancer (CRC) and the optimal timing of hepatectomy are still controversial and widely debated. METHODOLOGY: Synchronous and multiple metastatic liver tumors were detected in 57 patients since May 2005. Our treatment policy was to perform hepatectomy if the resection could be done with no limit on size and number of tumors. However, if curative resection could not be done, chemotherapy was begun and timing for the possibility of a radical operation was planned immediately. RESULTS: In 37 patients whose tumors were located only in the liver, primary tumor resection was performed in 16 patients and after tumor-decreasing by chemotherapy, in 7 patients. In 20 patients in whom chemotherapy was performed first, after controlling the distant metastasis, hepatectomy was performed in 3 patients and staged hepatectomy was performed in 10. Recurrence was detected after hepatectomy in 75.0% of simultaneous resection cases and in 70.0% of staged cases. In the recurrence cases, early detection after tumor resection occurred in 58.3% of the simultaneous and 14.2% of the staged. CONCLUSIONS: The present data show that neoadjuvant chemotherapy does not increase the risk of postoperative complications or the surgical difficulties of hepatectomy for colorectal metastases.

Evaluation of histopathological heterogeneity of colorectal cancer liver metastasis sites after preoperative chemotherapy.

Patients with liver metastases from colorectal cancer (CRLMs) frequently receive chemotherapy prior to liver resection. Histopathological assessment of the resected specimen can evaluate the response to chemotherapy. The present study analyzed the association between histopathological changes in the primary site and liver metastases. The present study comprised 45 patients with resectable CRLMs at the Surgical Oncology Department of Gifu University School of Medicine (Gifu, Japan) between January 2006 and August 2015. The study included 24 men and 21 women. The primary colonic tumor was located in the right side in 13 (28.9%) patients and the left side in 32 (71.9%) patients. The present study evaluated patients with metastatic colorectal cancer (31/45) after excluding those in whom histopathological heterogeneity between the primary and liver metastasis changed to grade 3 after chemotherapy. The group that underwent hepatectomy after chemotherapy (n=25) was compared with the group that underwent hepatectomy alone (n=6). In 16 (53.3%) out of 25 patients, histopathological heterogeneity of the liver metastasis was lost (P=0.04). In conclusion, chemotherapy appeared to change histopathological heterogeneity. The present study suggested that the histopathological change of intratumoral heterogeneity is reflected by the response to chemotherapy.

Early impact of depression symptoms on the decline in activities of daily living among older Japanese: Y-HALE cohort study.

OBJECTIVE: It is well known that depression deteriorates basic activities of daily living (ADLs), such as eating and bathing, among the elderly, but little is known about the early impact of depression symptoms on the next higher level of functioning, namely higher-levels ADLs, such as instrumental self-maintenance, intellectual activities, and social roles. The objective of this study was to determine whether symptoms of depression are associated with a subsequent decline in higher-level ADLs within a 12-month period of time. METHODS: The study cohort consisted of a random sample of 587 non-institutionalized adults aged ≥ 65 years living in Yamanashi prefecture, Japan. The baseline survey was conducted in 2003. After 12 months, a mailed follow-up survey evaluated changes in higher-level ADLs (follow-up rate 98.6%). RESULTS: After adjusting for sociodemographic and behavioral confounders, logistic regression indicated that baseline severe depression symptoms were associated with a 3.2-fold (95% confidence interval 1.6-6.3) higher chance of a subsequent decline in higher-level ADLs compared to those without severe depression symptoms. The presence of severe depression symptoms was selected by stepwise logistic regression in all models, except for the model with intellectual activities as an outcome, while other lifestyle factors were not selected. CONCLUSIONS: Symptoms of severe depression may adversely affect higher-level ADLs even in a relatively short time-frame. In addition, the early effects of depression symptoms may be stronger than those of other traditional lifestyle risk factors. Monitoring a wide range of ADLs in elderly individuals showing signs of depression may be important to prevent a functional decline in health and the need for long-term care.

Splenic artery transposition for hepatic arterial reconstruction in conversion surgery of an initially unresectable, locally advanced pancreatic cancer after gemcitabine/nab-paclitaxel: A case report.

INTRODUCTION AND IMPORTANCE: Recent advances in chemotherapy and chemoradiotherapy allow performance of conversion surgery by improving tumor shrinkage in select patients with initially unresectable locally advanced pancreatic cancer (LAPC), thereby providing curative potential. The number of conversion surgeries requiring arterial reconstruction for select patients with initially unresectable LAPC following favorable responses is expected to increase, so providing effective options for safe arterial reconstruction is critical. CASE PRESENTATION: Herein we report a case of successful conversion surgery for initially unresectable LAPC with splenic artery transposition for hepatic arterial reconstruction after gemcitabine/nab-paclitaxel (GnP). A 71-year-old woman was referred to our hospital for evaluation of a pancreatic head mass after developing diabetes. She was diagnosed with unresectable LAPC, which was in wide contact with the common hepatic artery (CHA), proper hepatic artery (PHA), and splenic artery (SA). She received GnP, and after 6 cycles, durations of disease control and normalization of serum carbohydrate antigen 19-9 (CA19-9) exceeded 7 months. She underwent radical subtotal stomach-preserving pancreaticoduodenectomy with CHA-PHA and portal vein (PV) resection (SA-right hepatic artery anastomosis/PV-superior mesenteric vein direct end-to-end anastomosis). Histopathological examination revealed R0 resection with a histological response of Evans grade IIB. No signs of tumor recurrence have been observed for 14 months postoperatively. CLINICAL DISCUSSION: No consensus has been reached regarding the optimal treatment regimen, duration, or criteria for conversion surgery in patients with LAPC, especially in cases requiring arterial resection. SA transposition for hepatic arterial reconstruction is generally very consistent, easily accessible, and offers adequate length and diameter for successful arterial anastomosis. CONCLUSION: Even for a SA initially in contact with the tumor, SA transposition for hepatic artery reconstruction is a safe and effective option when tumor contact disappears due to chemotherapy.

Atraumatic splenic rupture and infection-related glomerulonephritis in a patient with infected aortic aneurysm: A case report.

INTRODUCTION: Atraumatic splenic rupture is very rare and the case is often difficult to determine. We report a case of atraumatic splenic rupture in a patient with an infected aortic aneurysm. CASE PRESENTATION: A 40-year-old man under evaluation and treatment for renal dysfunction presented with the sudden onset of epigastric pain. The patient had a previous history of aortic arch replacement for Stanford type B aortic dissection. Contrast-enhanced computed tomography revealed intraabdominal hemorrhaging around the spleen and intrasplenic extravasation of contrast medium, and atraumatic splenic rupture was diagnosed. The patient slipped into hemorrhagic shock, and emergency splenectomy was scheduled. The histopathological diagnosis was splenic rupture with splenic infarction. The patient became febrile on postoperative day 10. Repeat contrast-enhanced computed tomography revealed enlargement of a cystic aortic aneurysm that was present prior to splenectomy. Infected aortic aneurysm was suspected, which was confirmed following thoracic endovascular aortic repair performed on postoperative day 12. DISCUSSION: We consider that splenic rupture occurred following infected of the kidney and spleen by an infected aortic aneurysm. CONCLUSION: Infection should be considered as a cause in patients with atraumatic splenic rupture.