Liver Resection Under Total Hepatic Vascular Exclusion with In Situ Hypothermic Isolated Hepatic Perfusion for Advanced Liver Tumors.

PURPOSE: Continuous dissection or simultaneous reconstruction of the hepatic vein (HV) and inferior vena cava (IVC) was achieved under total hepatic vascular exclusion (THVE) with in situ hypothermic isolated hepatic perfusion (HIHP) in two cases. CASE 1: The patient previously underwent liver resections with the right HV for colorectal liver metastasis (CRLM). This time, the CRLM had invaded the left HV and IVC, and five courses of FOLFILI plus ramucirumab were given, resulting in stable disease. Due to expected high HV pressure, liver parenchymal transection was started under THVE. Sub-segmentectomy with patch graft plasty of the IVC and reconstruction of the left HV using a jugular vein graft were performed under THVE and HIHP. This patient died at home 3 months after surgery; the cause of death was unknown. CASE 2: Hepatocellular carcinoma in the caudate lobe was in extensive contact with the roots of three main HVs and the IVC, and pressed the hepatocaval confluence, with high HV pressure expected. In addition, tumor thrombosis extended to both the main portal vein and the common bile duct, resulting in the inability to introduce chemotherapy. After tumor thrombectomy, liver parenchymal transection was started under THVE. Extended left hepatectomy with wedge resection, and primary suture of the right HV and IVC was performed under THVE and HIHP. Recurrence-free and overall survivals were 8 months (lung metastasis) and 31 months, respectively. CONCLUSIONS: In liver resection for liver tumors located in the hepatocaval confluence, THVE with HIHP is useful for ensuring the safety.

Neoadjuvant S-1 With Concurrent Radiotherapy Followed by Surgery for Borderline Resectable Pancreatic Cancer: A Phase II Open-label Multicenter Prospective Trial (JASPAC05).

OBJECTIVE: This study assessed whether neoadjuvant chemoradiotherapy (CRT) with S-1 increases the R0 resection rate in BRPC. SUMMARY OF BACKGROUND DATA: Although a multidisciplinary approach that includes neoadjuvant treatment has been shown to be a better strategy for BRPC than upfront resection, a standard treatment for BRPC has not been established. METHODS: A multicenter, single-arm, phase II study was performed. Patients who fulfilled the criteria for BRPC received S-1 (40 mg/m 2 bid) and concurrent radiotherapy (50.4 Gy in 28 fractions) before surgery. The primary endpoint was the R0 resection rate. At least 40 patients were required, with a 1-sided α = 0.05 and ß = 0.05 and expected and threshold values for the primary endpoint of 30% and 10%, respectively. RESULTS: Fifty-two patients were eligible, and 41 were confirmed to have definitive BRPC by a central review. CRT was completed in 50 (96%) patients and was well tolerated. The rate of grade 3/4 toxicity with CRT was 43%. The R0 resection rate was 52% among the 52 eligible patients and 63% among the 41 patients who were centrally confirmed to have BRPC. Postoperative grade III/IV adverse events according to the Clavien-Dindo classification were observed in 7.5%. Among the 41 centrally confirmed BRPC patients, the 2-year overall survival rate and median overall survival duration were 58% and 30.8 months, respectively. CONCLUSIONS: S-1 and concurrent radiotherapy seem to be feasible and effective at increasing the R0 resection rate and improving survival in patients with BRPC. TRIAL REGISTRATION: UMIN000009172.

Laparoscopic Left Hepatectomy with Resection of the Spiegel Lobe Using the Modified Caudate Lobe-First Approach.

BACKGROUND: Laparoscopic left hepatectomy with resection of the Spiegel lobe remains a technically demanding procedure as it is a deep-seated area surrounding the inferior vena cava (IVC). Mobilization of the Spiegel lobe requires safe exposure of the ventral side of the IVC while dissecting the short hepatic veins from the IVC. Additionally, wide space is needed to isolate the left Glissonean pedicle (Glt). We used a modified caudate lobe-first approach to overcome this challenge Maeda (J Hepato-Bil Pancreat Sci 25:335-41, 2018), Li (J Gastrointest Surg 23:1084-5, 2019), Homma (Surg Endosc 33:3851-7, 2019). METHODS: The ischemic area was confirmed after isolating the left and middle hepatic artery and left portal vein. After mobilizing the left lateral section, the Spiegel lobe was divided from the notch, which is the boundary between the caudate lobe and the Spiegel lobe, toward the middle hepatic vein (MHV). The Spiegel lobe was safely detached from the IVC with a short hepatic vein transected with the caudo-dorsal view. The Glt could be easily isolated due to the wide space on the ventral side of the IVC. After dividing the left hepatic duct, the MHV was exposed continuously from the root to the periphery, and parenchymal transection was completed by connecting the demarcation line and MHV. RESULTS: The total operation time was 430 min, and estimated blood loss was minimal. The patient was discharged on postoperative day 6 without complications. CONCLUSIONS: The modified caudate lobe-first approach can be used to safely perform laparoscopic left hepatectomy combined with the Spiegel lobe resection.

Laparoscopic Anatomic Liver Resection of the Dorsal Part of Segment 8 Using an Hepatic Vein-Guided Approach.

BACKGROUND: Laparoscopic anatomic liver resection is considered highly challenging, especially in segment 8 (S8), owing to the limited angle of the laparoscope and limited manipulation of the surgical instrument1,2. Additionally, resection is technically difficult when approaching the more peripheral branches since the Glissonean pedicle of S8 has several variations3 and is far from the hepatic hilum. The hepatic vein (HV)-guided approach involves entering from the cranial side of the liver while overcoming these difficulties with the unique view and techniques of laparoscopy4,5. We describe laparoscopic anatomic resection of the dorsal part of S8 using the HV-guided approach for hepatocellular carcinoma. METHODS: The drainage vein of segment 8 (V8), which often runs between the ventral and dorsal parts of S86,7, was exposed from the confluence of the middle HV to the periphery. The dorsal Glissonean branch of S8 (G8dor) was identified by deep dissection of the parenchyma on the right side of the V8. The right HV (RHV) was exposed toward the periphery after dissecting the G8dor. Liver parenchymal dissection was completed by connecting the demarcation line and the RHV. RESULTS: The total operation time was 319 min, estimated blood loss was 5 mL, and the patient was discharged on postoperative day 6 with no complications. CONCLUSION: Laparoscopic anatomic resection of the dorsal parts of S8 could be safely performed by exposing the HVs from their roots and using the HVs as a landmark to identify the intrahepatic Glissonean pedicles.

Intrahepatic Glissonean Approach for Laparoscopic Bisegmentectomy 7 and 8 With Root-Side Hepatic Vein Exposure.

BACKGROUND: Laparoscopic anatomic liver resections of the posterosuperior segments are technically demanding procedures.1-5 The segments are located in a deep-seated area of the liver surrounded by the ribs and the diaphragm, making forceps manipulation difficult. To overcome this limitation, an intrahepatic Glissonean approach and exposure of the hepatic veins from the root side was applied.6-10 The authors describe the technical aspects of performing a bisegmentectomy 7-8. METHODS: Liver parenchymal transection was initiated from the ventral aspect of the root of the middle hepatic vein, which often runs in the intersegmental plane, identifying the Glissonean pedicle of segment 8 (G8). After dissection of the G8, segmentectomy 8 was performed through identification of the ischemic area. After complete mobilization of the right lobe, the Glissonean pedicle of segment 7 (G7), which runs relatively near the liver surface,9, 10 was marked using ultrasonography. After division of the G7, a wide dissection between the caudate lobe and segment 7 was performed and connected to the previously dissected plane from the dorsal side of the right hepatic vein (RHV). Finally, bisegmentectomy 7-8 was performed with RHV resection because of tumor invasion. RESULTS: The operation time was 510 min, and the estimated blood loss was 150 ml. The patient was discharged on postoperative day 10 without any complications. CONCLUSIONS: Application of the intrahepatic Glissonean approach and exposure of the major hepatic veins from their roots using unique laparoscopic principles allows a safe performance of bisegmentectomy 7-8.

Outcomes and management of delayed complication after severe blunt liver injury.

BACKGROUND: The treatment of delayed complications after liver trauma such as bile leakage (BL) and hepatic artery pseudoaneurysms (HAPs) is difficult. The purpose of this study is to investigate the outcomes and management of post-traumatic BL and HAPs. METHODS: We retrospectively evaluated patients diagnosed with blunt liver injury, graded by the American Association for the Surgery of Trauma Liver Injury Scale, who were admitted to our hospital between April 2010 and December 2019. Patient characteristics and treatments were analyzed. RESULTS: A total of 176 patients with blunt liver injury were evaluated. Patients were diagnosed with grade I-II liver injury (n = 127) and with grade III-V injury (n = 49). BL was not observed in patients with grade I-II injury. Eight patients with grade III-V injury developed BL: surgical intervention was not needed for six patients with peripheral bile duct injury, but hepaticojejunostomy was needed for two patients with central bile duct injury. Out of 10 patients with HAPs, only three with grade I-II injury and one with grade III-V were treated conservatively; the rest six with grade III-V injury required transcatheter arterial embolization (TAE). All pseudoaneurysms disappeared. CONCLUSIONS: Severe blunt liver injury causing peripheral bile duct injury can be treated conservatively. In contrast, the central bile duct injury requires surgical treatment. HAPs with grade I-II injury might disappear spontaneously. HAPs with grade III-V injury should be considered TAE.

Short-term outcomes of laparoscopic versus open liver resection for hepatocellular carcinoma in older patients: a propensity score matching analysis.

BACKGROUND: The incidence of hepatocellular carcinoma (HCC) requiring surgical treatment in older patients has been continuously increasing. This study aimed to examine the safety and feasibility of performing laparoscopic liver resection (LLR) versus open liver resection (OLR) for HCC in older patients at a Japanese institution. METHODS: Between January 2010 and June 2021, 133 and 145 older patients (aged ≥ 70 years) who were diagnosed with HCC underwent LLR and OLR, respectively. Propensity score matching (PSM) analysis with covariates of baseline characteristics was performed. The intraoperative and postoperative data were evaluated in both groups. RESULTS: After PSM, 75 patients each for LLR and OLR were selected and the data compared. No significant differences in demographic characteristics, clinical data, and operative times were observed between the groups, although less than 10% of cases in each group underwent a major resection. Blood loss (OLR: 370 mL, LLR: 50 mL; P < 0.001) was lower, and the length of postoperative hospital stay (OLR: 12 days, LLR: 7 days; P < 0.001) and time to start of oral intake (OLR: 2 days, LLR: 1 day; P < 0.001) were shorter in the LLR group than in the OLR group. The incidence of complications ≥ Clavien-Dindo class IIIa was similar between the two groups. CONCLUSIONS: LLR, especially minor resections, is safely performed and feasible for selected older patients with HCC.

How-I-do-it: laparoscopic left medial sectionectomy utilizing a cranial approach to the middle hepatic vein and Laennec's capsule.

BACKGROUND: Laparoscopic anatomic liver resection is technically demanding, given the need to safely isolate the Glissonean pedicles and expose the hepatic veins (HVs) on the liver parenchyma cut surface. Laennec's capsule is observed around the Glissonean pedicles and root of the HVs. However, its existence, particularly on the peripheral side of the HVs, remains controversial. Herein, we describe Laennec's capsule-related histopathological findings around the HVs and a safe laparoscopic left medial sectionectomy utilizing Laennec's capsule. METHODS: The extrahepatic Glissonean approach was performed by connecting Gates II and III, in accordance with Sugioka's Gate theory. Liver parenchymal transection commenced along the demarcation line, which is between the medial and lateral sections, and the G4 was dissected during transection. Subsequently, via the outer-Laennec approach, the middle hepatic vein (MHV) was exposed from the root side in cranial view, while Laennec's capsule was preserved. Parenchymal transection was completed while connecting the MHV with the demarcation line. We obtained the membrane surrounding the HVs and performed histopathological examinations. RESULTS: Six patients underwent laparoscopic left medial sectionectomy from February 2012 to November 2020. There were no cases involving complications (Clavien-Dindo classification; grade II or higher), open-surgery conversion, transfusion, or surgery-related death. The histopathological findings showed Laennec's capsule surrounding both the trunk of the major HVs and the peripheral side of the HVs. CONCLUSIONS: A cranial approach to the major HVs utilizing Laennec's capsule is a feasible and advantageous procedure for laparoscopic left medial sectionectomy. We propose that Laennec's capsule surrounds the entire length of the HVs.

Relationship between surgical R0 resectability and findings of peripancreatic vascular invasion on CT imaging after neoadjuvant S-1 and concurrent radiotherapy in patients with borderline resectable pancreatic cancer.

BACKGROUND: Borderline resectable pancreatic cancer (BRPC) is frequently associated with positive surgical margins and a poor prognosis because the tumor is in contact with major vessels. This study evaluated the relationship between the margin-negative (R0) resection rate and findings indicating peripancreatic vascular invasion on multidetector computed tomography (MDCT) imaging after neoadjuvant chemoradiotherapy (NACRT) in patients with BRPC. METHODS: Twenty-nine BRPC patients who underwent laparotomy after neoadjuvant S-1 with concurrent radiotherapy were studied retrospectively. Peripancreatic major vessel invasion was evaluated based on the length of tumor-vessel contact on MDCT. The R0 resection rates were compared between the progression of vascular invasion (PVI) group and the non-progression of vascular invasion (NVI) group. RESULTS: There were 3 patients with partial responses (10%), 25 with stable disease (86%), and 1 with progressive disease (3%) according to the RECISTv1.1 criteria. Regarding vascular invasion, 9 patients (31%) were classified as having PVI, and 20 patients (69%) were classified as having NVI. Of the 29 patients, 27 (93%) received an R0 resection, and all the PVI patients received an R0 resection (9/9; R0 resection rate = 100%) while 90% (18/20) of the NVI patients underwent an R0 resection. The exact 95% confidence interval of risk difference between those R0 resection rates was - 10.0% [- 31.7-20.4%]. CONCLUSIONS: Patients with BRPC after NACRT achieved high R0 resection rates regardless of the vascular invasion status. BRPC patients can undergo R0 resections unless progressive disease is observed after NACRT. TRIAL REGISTRATION: UMIN-CTR, UMIN000009172 . Registered 23 October 2012.

[Case of Gastric Malignant Lymphoma Invading Other Organs with Bleeding Treated by Surgery].

A female in her late 50s experienced dyspnea and was transported by an ambulance. Her hemoglobin score was low, and CT imaging showed a giant tumor in her stomach. The tumor perforated her liver and invaded the abdominal wall and duodenum around the Treitz ligament. She required surgery because of the massive hemorrhage due to the tumor. Total gastrectomy with lateral segmentectomy of the liver and resection of the duodenum and the ileum around the Treitz ligament were performed. At 1.5 months after surgery, chemotherapy for malignant lymphoma was successfully initiated.

Advanced hepatocellular carcinoma with hepatic vein tumor thrombosis and renal dysfunction after hepatic arterial infusion chemotherapy effectively treated by liver resection with active veno-venous bypass: report of a case.

BACKGROUND: Hepatocellular carcinoma (HCC) patients with hepatic vein tumor thrombosis (HVTT) extending to the inferior vena cava (IVC) have an extremely poor prognosis. Here we report a case of HCC with HVTT and renal dysfunction after hepatic arterial infusion chemotherapy (HAIC) successfully treated by liver resection and active veno-venous bypass. CASE PRESENTATION: A 77-year-old man was diagnosed to have a large HCC with intrahepatic metastases and HVTT extending to the IVC. Due to the advanced stage, HAIC with cisplatin was performed 13 times in a period of 17 months. As a consequence of this treatment, the size of the main HCC markedly decreased, and the advanced part of the HVTT went down to the root of the right hepatic vein (RHV). However, because of renal dysfunction, HAIC with cisplatin was discontinued and right hepatectomy with patch graft venoplasty of the root of the RHV was performed. Because progression of renal dysfunction had to be avoided, veno-venous bypass was activated during IVC clamping to prevent renal venous congestion and hypotension. Histological examination showed foci of a moderately differentiated HCC with extensive fibrosis and necrosis in the main HCC. Histologically, the HVTT in the RHV showed massive necrosis and tightly adhered to the vascular wall of the RHV. The postoperative function of the remnant liver was good, and no further deterioration of renal function was detected. The patient did not show signs of recurrence 15 month after surgery. CONCLUSION: In the present case, HAIC using cisplatin in combination with hepatic resection and patch graft venoplasty of the IVC provided a good long-term outcome with no HCC recurrence. Renal function was preserved by using active veno-venous bypass during IVC clamping to prevent renal venous congestion and hypotension.

A case of pancreatic arteriovenous malformation identified by investigating the cause of upper abdominal pain associated with acute pancreatitis.

A man in his 60s with epigastric pain was diagnosed with acute pancreatitis and subsequently recovered following conservative treatment. However, because of repeated upper abdominal pain and the formation of a pancreatic pseudocyst, he was transferred to our institution for evaluation. Dynamic computed tomography (CT) scanning confirmed abnormal vessels in the tail of the pancreas and early venous return to the splenic vein in the early arterial phase. Abdominal angiography revealed a racemose vascular network in the tail of the pancreas, confirming the presence of an arteriovenous malformation (AVM) in this region. This AVM was thought to be the cause of the acute pancreatitis, so a distal pancreatectomy was performed. The patient's postoperative course was uneventful, and there has been no recurrence at the 7-month postoperative follow-up. Surgical resection has a low recurrence rate and good outcome;thus, if a pancreatic AVM appears difficult to treat with conservative medical therapy, surgical resection appears to be the definitive treatment.

"Hook and roll technique" using an articulating hook cautery to provide a critical view during single-incision laparoscopic cholecystectomy.

We describe a new simple and easy technique called the "Hook and roll technique" (HRT) that uses an articulating hook cautery to provide a critical view during single incision laparoscopic cholecystectomy (SILC). A 2-cm incision is made at the umbilicus to insert three 5-mm trocars or a multichannel port. After dissection of the serosa of the dorsal and ventral sides of the gall bladder, including Calot's triangle, the angled tip of the hook cautery is inserted between the cystic artery and duct with its tip placed dorsally. The tip is then rotated in a clockwise manner to avoid bile duct injury, allowing the connective tissue between them to be hooked, coagulated and cut. This procedure is repeated several times, followed by dissection between the cystic artery and the liver bed to achieve a critical view. From December 2008 to May 2011, 121 patients underwent SILC using HRT in our hospital without any serious complications. This technique is suitable for SILC, as it is consists of simple procedures that can be performed safely and easily, even by left hand in a cross-over approach, and it allows complete dissection of Calot's triangle to achieve a critical view without using any dissector under dangerous in-line viewing.

Hepatic Vein-Guided Approach in Laparoscopic Anatomic Liver Resection of the Ventral and Dorsal Parts of Segment 8.

Laparoscopic ventral and dorsal segmentectomies 8 are an option for parenchymal-sparing liver resection. However, laparoscopic anatomic posterosuperior liver segment resection is technically demanding because of its deep location and the many variations in the segment 8 Glissonean pedicle (G8). In this study, we describe a hepatic vein-guided approach (HVGA) to overcome these limitations. For ventral segmentectomy 8, liver parenchymal transection was initiated at the ventral side of the middle hepatic vein (MHV) and continued exposing it toward the periphery. The G8 ventral branch (G8vent) was identified on the right side of the MHV. Following G8vent dissection, liver parenchymal transection was completed by connecting the demarcation line and G8vent stump. For dorsal segmentectomy 8, the anterior fissure vein (AFV) was exposed peripherally. The G8 dorsal branch (G8dor) was identified on the right side of the AFV. Following G8dor dissection, the right hepatic vein (RHV) was exposed from the root. Liver parenchymal transection was completed by connecting the demarcation line and RHV. Between April 2016 and December 2022, we performed laparoscopic ventral and dorsal segmentectomy 8 in fourteen patients. No complications (Clavien-Dindo classification, Grade ≥ IIIa) were observed. An HVGA is feasible and useful for standardizing safe laparoscopic ventral and dorsal segmentectomies 8.

Large focal nodular hyperplasia of the liver treated with transcatheter arterial embolization and laparoscopic resection: A case report.

Focal nodular hyperplasia (FNH) is a rare benign hepatic tumor which is frequently observed in women of reproductive age, and therapeutic intervention needs to be considered in cases wherein the tumor has a risk of rupture. The laparoscopic approach is beneficial, especially for young women, but is often challenging because the tumor is large and hemorrhagic. Herein, we report a case of large FNH in a 22-year-old woman. The patient was asymptomatic; however, the tumor was approximately 15 cm in diameter and protruded from the liver. Given the risk of rupture, we decided to perform surgical resection. Preoperative transcatheter arterial embolization led to rapid shrinkage of the tumor and control of intraoperative bleeding, which enabled us to safely perform laparoscopic liver resection. The combination of surgical resection with intravascular embolization may be a promising therapeutic option for hypervascular tumors such as FNH.

[A long-term survival case of recurrent pancreatic vipoma with liver metastases treated by a combination of surgical resection and loco-regional therapies].

We report a case of recurrent pancreatic VIPoma with liver and peritoneal metastases who has been surviving over 7 years by a successful treatment with a combination of surgical resection and loco-regional therapies. A 59-year-old female underwent distal pancreatectomy for pancreatic endocrine tumor. Five years after pancreatectomy, she had a recurrence of liver and peritoneal metastases with the symptoms by hypersecretion of VIP, and she underwent hepatectomy and peritoneal tumor resection. Seven months later, multiple liver metastases appeared and were treated with transcatheter arterial chemoembolization (TACE). Additionally radiofrequency ablation( RFA) for remnant viable lesion was performed. Seven years and eight months after primary panceatectomy and two years and six months after resection of the liver and peritoneal recurrences, she is now disease-free with good quality of life. The progression of well-differentiated pancreatic neuroendocrine carcinoma is usually slow. It is potentially useful in controlling of liver metastases to combine the loco-regional therapy like TACE and RFA with surgical resection.

Advance ligation to facilitate pancreaticojejunostomy following pancreaticoduodenectomy by dilating the main pancreatic duct.

BACKGROUND: Duct-to-mucosa pancreaticojejunostomy (PJ) after pancreaticoduodenectomy (PD) is technically challenging, particularly in cases of soft pancreas with a nondilated main pancreatic duct (MPD). We propose a novel procedure that involves ligating the pancreas in advance to allow for MPD dilation. METHODS: We compared the data of 16 patients who underwent PD followed by PJ with advance ligation (AL) for soft pancreas with a nondilated MPD with that of 17 patients who underwent a conventional procedure (conventional group) without AL at a single institution between January 2015 and April 2017. MPD diameters were assessed using preoperative computed tomography and intraoperative ultrasonography. Pancreatic consistency was judged intraoperatively. The pancreatic parenchyma and MPD were ligated in advance to allow time for MPD dilation. After AL, we divided the pancreatic parenchyma. AL led to MPD dilation and facilitated PJ. RESULTS: There were significantly fewer complications in the AL group than in the conventional group (P=0.005). There were no cases of pancreatitis or death in either group. The mean procedural time for occluding the MPD was 43 min (range, 21-134 min). The median MPD dilation rate after AL was 1.6 (0.9-3.8). CONCLUSIONS: AL is a simple, safe, and useful procedure for facilitating PJ.

Milk-based test as a preventive method for chylous ascites following pancreatic resection.

BACKGROUND/PURPOSE: The incidence and natural history of postoperative chylous ascites are not well understood. This complication causes malnutrition and prolonged hospital stay. We investigated our institution's experience involving chylous ascites, especially following pancreatectomy. Additionally, we designed a new intraoperative method dubbed the 'milk test' for preventing chylous ascites. METHODS: Five cases of chylous ascites following pancreatectomy from April 2001 through March 2004 were studied retrospectively. The milk test was carried out prospectively. Such rates as positivity and incidence of ascites were examined. RESULTS: Of 65 cases (40 pancreatoduodenectomy; 25 distal pancreatectomy), 5 (7.7%) developed chylous ascites following pancreatic resection. All cases underwent octreotide and total parenteral nutrition treatment. From April 2004 through March 2009, the milk test was used in 104 cases. Surgical procedures comprised pancreatoduodenectomy (n = 78) and distal pancreatectomy (n = 23). Of these cases, 23 (22.1%) tested positive. No significant difference in positive rates was observed between the procedures and diseases. After initiation of the milk test, chylous ascites incidence decreased from 7.7 to 2.9%. CONCLUSIONS: For chylous ascites, octreotide and total parenteral nutrition treatments are useful. However, the milk test was found to be a safe and effective method for prevention of chylous ascites following pancreatectomy.

Survival of patients treated by an autonomic nerve-preserving gastrectomy for early gastric cancer.

PURPOSE: Autonomic nerve preservation in a gastrectomy for gastric cancer improves the postoperative quality of life. We retrospectively examined the survival of patients treated by an autonomic nerve-preserving gastrectomy in comparison to the survival of the patients treated by a conventional gastrectomy. METHODS: The survival of 385 patients treated by an autonomic nerve-preserving gastrectomy for clinical early gastric cancer (the ANP group) was compared with that of 285 patients treated by a conventional gastrectomy (non-ANP group). RESULTS: Among the ANP group, the numbers of patients with tumor invasion to the mucosa, submucosa, and muscularis propria were 210, 166, and 9, respectively, whereas the numbers of patients with lymph node metastasis grades of N0, N1, and N2 were 360, 21, and 4, respectively. The overall 5-year survival rate of the ANP group was 94.7%, which was superior to that of the non-ANP group (90.4%; P = 0.003). The 5-year survival rates of patients with lymph node metastasis were 94.9% and 91.8% in the ANP and non-ANP groups, respectively (P = 0.733). Only 3 patients in the ANP group died from gastric cancer. CONCLUSIONS: The survival of patients treated by an autonomic nerve-preserving gastrectomy was equivalent to that of patients treated by a conventional gastrectomy, thus suggesting that an autonomic nervepreserving gastrectomy could be a useful procedure for the treatment of early gastric cancer.

Well-differentiated endocrine cell carcinoma of ileum treated by laparoscopy-assisted surgery--a case report.

A 72-year-old woman presented at our hospital with a 1-year history of intermittent right lower abdominal pain. Colonoscopic examination revealed a submucosal tumor with a pitted surface in the terminal ileum. Histopathological diagnosis of the carcinoid tumor was made following biopsy. Blood serotonin and urine 5-hydroxy-indoleacetic acid levels were normal, and carcinoid syndrome was not detected. Enhanced abdominal computed tomography scan and 18F-fluorodeoxyglucose positron emission tomography failed to detect multiple lesions, lymph node swelling or distant metastasis. Laparoscopy-assisted ileocecal resection with lymph node dissection was performed. The resected specimen showed a submucosal tumor with a pitted surface 11 x 11 mm in size, located at the terminal ileum. Histopathological examination revealed a well-differentiated endocrine cell carcinoma with an invasion depth to the muscularis propria. Immunohistochemical analysis showed the tumor cells to be chromogranin A and CD56-positive. The patient had no sign of recurrence for 16 months.