Successful Surgical Treatment of a Recurrent Pelvic Solitary Fibrous Tumor of Uterine Origin Accompanied by Doege-Potter Syndrome: A Case Report.

BACKGROUND Solitary fibrous tumors (SFT), rare soft-tissue neoplasms, are usually found in the thoracic cavity, and a uterine origin is extremely rare. SFTs with insulin-like growth factor-II (IGF-II) production induce non-islet cell tumor-induced hypoglycemia (NICTH), referred to as Doege-Potter syndrome. CASE REPORT A 70-year-old woman presented with urinary retention, and imaging revealed a huge mass occupying almost the entire pelvic space. She had a history of hysterectomy for leiomyoma of the uterus 7 years earlier. In her present course, she developed hypoglycemia, and NICTH was suspected. Her previous uterine specimen was reexamined, and immunohistochemistry (IHC) revealed the specimen to be CD34-positive and alpha-smooth muscle actin-negative, indicating that the uterine specimen was not leiomyoma but SFT. Therefore, the present pelvic tumor was considered to be a recurrence of SFT with NICTH, namely Doege-Potter syndrome. Surgical resection was performed, and the pathological examination showed the same histologic features as the previous uterine specimen, while IHC revealed the present specimen to be positive for CD34, signal transducers and activator of transcription 6, and IGF-II, consistent with the diagnosis of recurrent SFT with IGF-II production. The patient's hypoglycemia improved after tumor resection. To confirm the IGF-II secretion from the SFT, we conducted immunoblotting of the patient's perioperative serum, with results showing that the strong band of IGF-II in the preoperative serum disappeared after surgery. CONCLUSIONS Because SFTs, especially those with Doege-Potter syndrome, often recur, sometimes with a very long interval, long-term cautious surveillance is required, even after complete tumor resection.

Impact of anatomical liver resection on patient survival in KRAS-wild-type colorectal liver metastasis: A multicenter retrospective study.

BACKGROUND: Liver resection is a standard therapy for colorectal liver metastasis. However, the impact of anatomical resection and nonanatomical resection on the survival in patients with Kirsten rat sarcoma-wild-type and Kirsten rat sarcoma-mutated colorectal liver metastasis remain unclear. We investigated whether anatomical resection versus nonanatomical resection improves survival in colorectal liver metastasis stratified by Kirsten rat sarcoma mutational status. METHODS: Among 639 consecutive patients with colorectal liver metastasis who underwent primary liver resection between January 2008 and December 2017, 349 patients were excluded due to their unknown Kirsten rat sarcoma mutational status, or due to receiving anatomical resection with concomitant non-anatomical resection, radiofrequency, or R2 resection. Accordingly, 290 patients with colorectal liver metastasis were retrospectively assessed. The relationships between resection types and survival were investigated in Kirsten rat sarcoma-wild-type and -mutated groups. RESULTS: Anatomical resection was performed in 77/186 (41%) and 44/104 (42%) patients with Kirsten rat sarcoma-wild-type and Kirsten rat sarcoma-mutated genetic statuses, respectively. For both, the clinical-pathologic factors were comparable, except a larger maximum tumor size and surgical margin were observed in anatomical resection cases. Anatomical resection patients had significantly longer recurrence-free survival and overall survival than nonanatomical resection cases in the Kirsten rat sarcoma-wild-type group (recurrence-free survival, P < .001; overall survival, P = .005). No significant recurrence-free survival or overall survival differences were observed between Kirsten rat sarcoma-mutated anatomical resection and non-anatomical resection (recurrence-free survival, P = .132; overall survival, P = .563). Although, intrahepatic recurrence in Kirsten rat sarcoma-wild-type and -mutated colorectal liver metastasis was comparable (P = .973), extrahepatic recurrence was increased in Kirsten rat sarcoma-mutated versus -wild-type colorectal liver metastasis (P < .001). CONCLUSION: In contrast to Kirsten rat sarcoma-mutated colorectal liver metastasis with higher extrahepatic recurrence after liver resection, local liver control via anatomical resection improved the postoperative survival in patients with Kirsten rat sarcoma-wild-type colorectal liver metastasis.

Redo pancreaticojejunal anastomosis for late-onset complete pancreaticocutaneous fistula after pancreaticojejunostomy.

BACKGROUND: Pancreaticojejunal (PJ) anastomosis occasionally fails several months after pancreaticoduodenectomy (PD) with Child reconstruction and can ultimately result in a late-onset complete pancreaticocutaneous fistula (Lc-PF). Since the remnant pancreas is an isolated segment, surgical intervention is necessary to create internal drainage for the pancreatic juice; however, surgery at the previous PJ anastomosis site is technically challenging even for experienced surgeons. Here we describe a simple surgical procedure for Lc-PF, termed redo PJ anastomosis, which was developed at our facility.  METHODS: Between January 2008 and December 2020, six consecutive patients with Lc-PF after PD underwent a redo PJ anastomosis, and the short- and long-term clinical outcomes have been evaluated. The abdominal cavity is carefully dissected through a 10-cm midline skin incision, and the PJ anastomosis site is identified using a percutaneous drain through the fistula tract as a guide, along with the main pancreatic duct (MPD) stump on the pancreatic stump. Next, the pancreatic stump is deliberately immobilized from the dorsal plane to prevent injury to the underlying major vessels. After fixing a stent tube to both the MPD and the Roux-limb using two-sided purse-string sutures, the redo PJ anastomosis is completed using single-layer interrupted sutures. Full-thickness pancreatic sutures are deliberately avoided by passing the needle through only two-thirds of the anterior side of the pancreatic stump. RESULTS: The redo PJ anastomosis was performed without any intraoperative complications in all cases. The median intraoperative bleeding and operative time were 71 (range 10-137) mL and 123 (range 56-175) min, respectively. Even though a new mild pancreatic fistula developed postoperatively in all cases, it could be conservatively treated within 3 weeks, and no other postoperative complications were recorded. During the median follow-up period of 92 (range 12-112) months, no complications at the redo PJ anastomosis site were observed. CONCLUSIONS: This research shows that the redo PJ anastomosis for Lc-PF we developed is a safe, feasible, and technically no demanding procedure with acceptable short- and long-term clinical outcomes. This procedure has the potential to become the preferred treatment strategy for Lc-PF after PD.

The feasibility of combined resection and subsequent reconstruction of the right hepatic artery in left hepatectomy for cholangiocarcinoma.

BACKGROUND: Combined resection of the right hepatic artery (RHA) is sometimes required to achieve complete resection of hilar cholangiocarcinoma. The present study aimed to evaluate the feasibility of combined resection and subsequent reconstruction by continuous suture of the RHA during left hepatectomy for cholangiocarcinoma. MATERIALS AND METHODS: We retrospectively compared the outcomes after left hepatectomy with biliary reconstruction for cholangiocarcinoma between patients with and without RHA resection and reconstruction. RESULTS: Of the 25 patients who underwent left hepatectomy combined with biliary reconstruction, eight patients (32%) underwent combined resection and reconstruction of the RHA (AR group). The demographic characteristics were not different between the AR and non-AR groups. The amount of intraoperative bleeding was significantly greater in patients with AR (2350 mL vs. 900 mL, p = 0.017). The prevalence of early complications above grade III in Clavien-Dindo classification and late complications were not significantly different between the AR and non-AR groups. In the AR group, complications directly associated with AR, such as thrombosis or reanastomosis, were not observed. On Kaplan-Meier analysis, recurrence-free survival (p = 0.618) and overall survival (p = 0.803) were comparable between the two groups despite the advanced T stages in the AR group. CONCLUSIONS: Combined resection and subsequent reconstruction of the RHA during left-sided hepatectomy is a feasible treatment alternative for cholangiocarcinoma.

Multiple Gastric Carcinomas Associated with Epstein-Barr Virus and Helicobacter pylori: A Thought-Provoking Case.

BACKGROUND Epstein-Barr virus (EBV) and Helicobacter pylori (HP) infections are associated with gastric carcinoma (GC). We present a thought-provoking case of multiple GCs associated with EBV and HP infections. CASE REPORT HP infection was incidentally detected in an asymptomatic 60-year-old man. Upper endoscopy revealed gastric "kissing" ulcers. The lesions were located in the body of the stomach and measured 25 and 27 mm, respectively. They were diagnosed on pathology as moderately differentiated tubular adenocarcinoma. Imaging revealed no enlarged lymph nodes or distant metastatic lesions. Distal gastrectomy with lymphadenectomy was performed and surgical cure was obtained. The multiple GCs were categorized on pathology as infß ly0 v0 pT1b(SM)UL1N0M0H0P0CY0 pStage IA according to the Japanese classification and as T1bN0M0 Stage IA according to the tumor, node, metastasis classification. Pathological examination revealed remarkable lymphocytic infiltration into the stroma, as shown by in situ hybridization of EBV. These lymphocytic infiltrations were observed only at the sites of GC. In the immunohistochemical examination, in situ hybridization of EBV was positive for EBV-encoded small ribonucleic acid. The patient's postoperative course was uneventful. Hence, an unexpected relationship between EBV infection and multiple GCs was suggested by pathology. Quantitative determination of EBV DNA in peripheral blood was normal postoperatively. Adjuvant chemotherapy was not recommended. HP eradication therapy was successful. The patient remained asymptomatic and developed no recurrence or metastasis for 3 years after surgery. CONCLUSIONS This thought-provoking case suggests that coinfection with EBV and HP increases GC occurrence.

A Thought-Provoking Case of Successfully Treated Carcinoma of the Head of the Pancreas with Metachronous Lung Metastasis: Impact of Distal Spleno-Renal Shunt for Regional Invasion on Long-Term Period after Pancreaticoduodenectomy.

When performing pancreaticoduodenectomy with resection of the confluence of the superior mesenteric vein and portal vein, division of the splenic vein may cause sinistral portal hypertension resulting in gastrointestinal bleeding, splenic congestion, and hypersplenism. To prevent these adverse events, it is important to intentionally decompress the splenic vein. This report is of a 68-year-old woman with stage IA carcinoma of the head of the pancreas who survived for more than six years following tumor resection and pancreaticoduodenectomy and distal splenorenal shunt. A 68-year-old woman was diagnosed with carcinoma of the head of the pancreas that involved the confluence of the superior mesenteric vein, portal vein, and splenic vein. No unresectable cancer sites or distant metastases were detected. Pancreaticoduodenectomy with resection of the confluence of the superior mesenteric vein and portal vein was performed. The superior mesenteric vein and portal vein were anastomosed in the end-to-end fashion, and the remnant splenic vein was anastomosed to the superior aspect of the left renal vein in the end-to-side fashion. At 22 months after the initial surgery, the patient underwent partial lung resection for a metachronous lung metastasis. For 6 years after the initial surgery, the venous reconstructions have maintained their patency without any obstruction of splenic venous flow, and the patient has remained in good health without further metastases or recurrences. This case has shown the importance of early diagnosis of carcinoma of the head of the pancreas, as appropriate and timely surgical management can result in good outcome. This patient responded well and remains alive six years following pancreaticoduodenectomy and preservation of the spleen with the use of a distal splenorenal shunt.

Fatal arterial hemorrhage after pancreaticoduodenectomy: How do we simultaneously accomplish complete hemostasis and hepatic arterial flow?

BACKGROUND: Although arterial hemorrhage after pancreaticoduodenectomy (PD) is not frequent, it is fatal. Arterial hemorrhage is caused by pseudoaneurysm rupture, and the gastroduodenal artery stump and hepatic artery (HA) are frequent culprit vessels. Diagnostic procedures and imaging modalities are associated with certain difficulties. Simultaneous accomplishment of complete hemostasis and HA flow preservation is difficult after PD. Although complete hemostasis may be obtained by endovascular treatment (EVT) or surgery, liver infarction caused by hepatic ischemia and/or liver abscesses caused by biliary ischemia may occur. We herein discuss therapeutic options for fatal arterial hemorrhage after PD. AIM: To present our data here along with a discussion of therapeutic strategies for fatal arterial hemorrhage after PD. METHODS: We retrospectively investigated 16 patients who developed arterial hemorrhage after PD. The patients' clinical characteristics, diagnostic procedures, actual treatments [transcatheter arterial embolization (TAE), stent-graft placement, or surgery], clinical courses, and outcomes were evaluated. RESULTS: The frequency of arterial hemorrhage after PD was 5.5%. Pancreatic leakage was observed in 12 patients. The onset of hemorrhage occurred at a median of 18 d after PD. Sentinel bleeding was observed in five patients. The initial EVT procedures were stent-graft placement in seven patients, TAE in six patients, and combined therapy in two patients. The rate of technical success of the initial EVT was 75.0%, and additional EVTs were performed in four patients. Surgical approaches including arterioportal shunting were performed in eight patients. Liver infarction was observed in two patients after TAE. Two patients showed a poor outcome even after successful EVT. These four patients with poor clinical courses and outcomes had a poor clinical condition before EVT. Fourteen patients were successfully treated. CONCLUSION: Transcatheter placement of a covered stent may be useful for simultaneous accomplishment of complete hemostasis and HA flow preservation.

Diffuse large B-cell lymphoma in the liver accompanied by primary biliary cholangitis: A rare and difficult-to-diagnose tumor with portal venous thrombosis.

INTRODUCTION AND IMPORTANCE: The most common liver malignancies are hepatocellular carcinoma, intrahepatic cholangiocarcinoma, and metastatic tumors. Hepatocellular carcinoma and intrahepatic cholangiocarcinoma may invade the portal vein (PV). An association between diffuse large B-cell lymphoma (DLBCL) and primary biliary cholangitis (PBC) remains unclear. We herein report a thought-provoking case of a difficult-to-diagnose liver tumor with PV thrombosis in a PBC patient. PRESENTATION OF CASE: A 66-year-old woman had PBC, systemic sclerosis, diabetes, and osteoporosis. A solitary liver tumor accompanied by macrovascular thrombosis in the PV was detected incidentally. Based on dynamic imaging findings, we considered the tumor to be intrahepatic cholangiocarcinoma, and right lobectomy with lymphadenectomy was performed. Unexpectedly, pathological assessment made a definitive diagnosis of DLBCL that did not invade the vessels and bile duct. In fluorine-18-fluorodeoxyglucose positron emission tomography, abnormal accumulations were clearly observed in the breast tissue and peritracheal, parasternal, mediastinal, and pericardial lymph nodes. The patient achieved complete remission after systemic chemotherapy, and there has been no recurrence 3 years after surgery. CLINICAL DISCUSSION: Primary lymphoma in the liver is rare, and we did not consider our patient's tumor as primary liver lymphoma. Our case actually showed no tumor thrombosis in the PV. Although autoimmune disorders may increase the risk of non-Hodgkin's lymphoma, an association between DLBCL and PBC is still unclear, and we must remember that DLBCL may develop rarely in a PBC patient. CONCLUSION: Our case report provides a timely reminder for clinicians and surgeons in the fields of hepatology and hematology.

Aggressive Resection of Malignant Paraaortic and Pelvic Tumors Accompanied by Arterial Reconstruction with Synthetic Arterial Graft.

BACKGROUND Advanced malignancies in the lower abdomen easily invade the retroperitoneal and pelvic space and often metastasize to the paraaortic and pelvic lymph nodes (LNs), resulting in paraaortic and/or pelvic tumor (PPT). CASE REPORT A total of 7 cases of aggressive malignant PPT resection and orthotopic replacement of the abdominal aorta and/or iliac arteries with synthetic arterial graft (SAG) were experienced during 16 years. We present our experience with aggressive resection of malignant PPTs accompanied by arterial reconstruction with SAG in detail. The primary diseases included 2 cases endometrial cancer and 2 cases of rectal cancer, and 1 case each of ovarian carcinosarcoma, vaginal malignant melanoma, and sigmoid cancer. Surgical procedures are described in detail. Briefly, the abdominal aorta and iliac arteries were anastomosed to the SAG by continuous running suture using unabsorbent polypropylene. Five Y-shaped and 2 I-shaped SAGs were used. This en bloc resection actually provided safe surgical margins, and tumor exposures were not pathologically observed in the cut surfaces. Graphical and surgical curability were obtained in all cases in which aggressive malignant PPT resections were performed. The short-term postoperative course of our patients was uneventful. From a vascular perspective, the SAGs remained patent over the long term after surgery, and long-term oncologic outcomes were satisfactory. CONCLUSIONS To our knowledge, this case series is the first report of aggressive malignant PPT resection accompanied by arterial reconstruction with SAG. This procedure is safe and feasible, shows curative potential, and may play a role in multidisciplinary management of malignant PPTs.

Adrenocorticotropic hormone-dependent hypercortisolism caused by pancreatic neuroendocrine carcinoma: A thought-provoking but remorseful case of delayed diagnosis.

INTRODUCTION AND IMPORTANCE: Definitive diagnosis of functioning neuroendocrine neoplasms (NENs) in the pancreas is challenging. Adrenocorticotropic hormone (ACTH) regulates adrenal cortisol production. Ectopic ACTH secretion by functioning NENs may cause hypercortisolism. PRESENTATION OF CASE: A 62-year-old woman who was receiving medications for hypertension and hyperlipidemia was referred to our hospital because of abnormal blood tests. Diabetes mellitus was initially diagnosed. Dynamic computed tomography and endoscopic ultrasound revealed a 35-mm diameter hypovascular tumor in the distal pancreas and multiple liver metastases. Endoscopic ultrasound-guided fine-needle aspiration resulted in a diagnosis of neuroendocrine carcinoma. The patient developed pancreatic leakage progressing to peritonitis, abscess formation, pleural effusion, and ascites after the fine-needle aspiration biopsy. Her clinical condition deteriorated to a septic state, necessitating emergency surgery comprising distal pancreatectomy, intraperitoneal lavage, and drainage. Wound healing was protracted and accompanied by ongoing high white blood cell counts and neutrophilia. She also developed a gastric ulcer postoperatively. Systematic endocrine investigations were performed because hypercortisolism caused by a functioning NEN was suspected. Eventually, a definitive diagnosis of an ACTH-producing NEN in the pancreas was made. Systemic chemotherapy was proposed; however, the patient and her family opted for palliative treatment only. She died 42 days after the initial diagnosis. CLINICAL DISCUSSION: We here present a patient with ACTH-dependent hypercortisolism attributable to a pancreatic NEN who died of progressive cancer after a delay in definitive diagnosis. CONCLUSION: Detailed investigation, including systematic endocrine examination and functional imaging studies, are important for precise diagnosis of, and appropriate treatment for, NENs.

Acute intestinal infarction caused by initially unexplained splanchnic venous thromboses in a patient with protein C deficiency: A thought-provoking emergency case.

INTRODUCTION AND IMPORTANCE: Splanchnic venous thrombosis (SVT) originating in the superior mesenteric vein (SMV) is rare and may cause acute intestinal infarction (AII). Protein C deficiency (PCD) results in thrombophilia. PRESENTATION OF CASE: Acute unexplained SVT originating in the SMV and portal vein was detected in 68-year-old man. Pan-peritonitis and AII were diagnosed and emergency surgery performed. Part of the small intestine was necrotic and partial resection without anastomotic reconstruction was performed. Heparin was administered intravenously continuously from postoperative day (POD) 1. Hereditary, heterozygous, type 1 PCD was diagnosed postoperatively. The anastomosis was reconstructed on POD 16. Warfarin was substituted for heparin on POD 22. No recurrent thrombosis occurred during 2 years of follow-up. CLINICAL DISCUSSION: Patients with the rare condition of SVT require prompt diagnosis and treatment and may have underlying disease. PCD can cause SVT even in intact veins and anticoagulation therapy should be administered immediately postoperatively. Misdiagnosis and/or delayed treatment of SVT can result in AII, a life-threatening condition with a high mortality rate. Insufficient clinician awareness can result in serious mismanagement of patients with PCD and SVT; emergency patients with AII caused by unexplained SVT should therefore be further investigated for prothrombotic states and assessment of coagulation-fibrinolysis profiles to clarify the underlying mechanism. CONCLUSION: We here present a thought-provoking emergency case of AII associated with acute SVT caused by underlying PCD that was successfully treated by two-stage surgery and anticoagulation therapy. This case provides a timely reminder for emergency clinicians and gastrointestinal surgeons.

Do liver metastases from gastric cancer contraindicate aggressive surgical resection? A 14-year single-center experience.

BACKGROUND: Advanced gastric cancer (GC) with liver metastasis is often characterized by multiple and bilobular metastases and may also be associated with extrahepatic metastatic lesions. Hence, many physicians consider that radical surgeries are contraindicated for liver metastases from GC (LMGC). According to the 2017 Japanese treatment guideline for GC, a smaller number of liver metastases without unresectable factors may be an indication for liver resection (LR) with curability. The actual 5-year overall survival (OS) rate ranges from 0 to 0.37. AIM: To present the institutional indications for LR for LMGC and identify important factors for prognostic outcomes. METHODS: In total, 30 patients underwent LR for LMGC during a 14-year period, and we evaluated the clinical, surgical, and oncological findings. In all patients, radical surgery with intentional lymphadenectomy was performed for the primary GC. The median follow-up duration after the initial LR was 33.7 mo, and three patients with no recurrence died of causes unrelated to the LMGC. The OS and recurrence-free survival rates after the initial LR were assessed. RESULTS: Seventeen patients had metachronous LMGC. The initial LR achieved curability in 29 patients. Perioperative chemotherapy was introduced in 23 patients. The median greatest LMGC dimension was 30 mm, and the median number of LMGC was two. Twenty-two patients had unilobular LMGC. The 5-year OS and recurrence-free survival rates were 0.48 and 0.28, respectively. The median survival duration and recurrence-free duration after the initial LR were 16.8 and 8.6 mo, respectively. Twenty-one patients developed recurrence after the initial LR. Additional surgeries for recurrence were performed in nine patients, and these surgeries clearly prolonged the patients' survival. Pathological serosal invasion was an independent predictor of a poor prognostic outcome after the initial LR. Aggressive LR may be indicated for carefully selected patients with LMGC. CONCLUSION: Our results of LR for LMGC seem acceptable. Additional surgeries for recurrence after the initial LR might prolong OS. Pathological serosal invasion is important for poor prognostic outcomes.

Surgical treatment of gallbladder cancer: An eight-year experience in a single center.

BACKGROUND: Gallbladder cancer (GBC) is the most common biliary malignancy and has the worst prognosis, but aggressive surgeries [e.g., resection of the extrahepatic bile duct (EHBD), major hepatectomy and lymph node (LN) dissection] may improve long-term survival. GBC may be suspected preoperatively, identified intraoperatively, or discovered incidentally on histopathology. AIM: To present our data together with a discussion of the therapeutic strategies for GBC. METHODS: We retrospectively investigated nineteen GBC patients who underwent surgical treatment. RESULTS: Nearly all symptomatic patients had poor outcomes, while suspicious or incidental GBCs at early stages showed excellent outcomes without the need for two-stage surgery. Lymph nodes around the cystic duct were reliable sentinel nodes in suspicious/incidental GBCs. Intentional LN dissection and EHBD resection prevented metastases or recurrence in early-stage GBCs but not in advanced GBCs with metastatic LNs or invasion of the nerve plexus. All patients with positive surgical margins (e.g., the biliary cut surface) showed poor outcomes. Hepatectomies were performed in sixteen patients, nearly all of which were minor hepatectomies. Metastases were observed in the left-sided liver but not in the caudate lobe. We may need to reconsider the indications for major hepatectomy, minimizing its use except when it is required to accomplish negative bile duct margins. Only a few patients received neoadjuvant or adjuvant chemoradiation. There were significant differences in overall and disease-free survival between patients with stages ≤ IIB and ≥ IIIA disease. The median overall survival and disease-free survival were 1.66 and 0.79 years, respectively. CONCLUSION: Outcomes for GBC patients remain unacceptable, and improved therapeutic strategies, including neoadjuvant chemotherapy, optimal surgery and adjuvant chemotherapy, should be considered for patients with advanced GBCs.

Conversion to complete resection with mFOLFOX6 with bevacizumab or cetuximab based on K-RAS status for unresectable colorectal liver metastasis (BECK study): Long-term results of survival.

BACKGROUND/PURPOSE: To investigate the long-term outcome and entire treatment course of patients with technically unresectable CRLM who underwent conversion hepatectomy and to examine factors associated with conversion to hepatectomy. METHODS: Recurrence and survival data with long-term follow-up were analyzed in the cohort of a multi-institutional phase II trial for technically unresectable colorectal liver metastases (the BECK study). RESULTS: A total of 22/12 patients with K-RAS wild-type/mutant tumors were treated with mFOLFOX6 + cetuximab/bevacizumab. The conversion R0/1 hepatectomy rate was significantly higher in left-sided primary tumors than in right-sided tumors (75.0% vs 30.0%, P = .022). The median follow-up was 72.6 months. The 5-year overall survival (OS) rate in the entire cohort was 48.1%. In patients who underwent R0/1 hepatectomy (n = 21), the 5-year RFS rate and OS rate were 19.1% and 66.3%, respectively. At the final follow-up, seven patients had no evidence of disease, five were alive with disease, and 20 had died from their original cancer. All 16 patients who achieved 5-year survival underwent conversion hepatectomy, and 11 of them underwent further resection for other recurrences (median: 2, range: 1-4). CONCLUSIONS: Conversion hepatectomy achieved a similar long-term survival to the results of previous studies in initially resectable patients, although many of them experienced several post-hepatectomy recurrences. Left-sided primary was found to be the predictor for conversion hepatectomy.

ALPlat criterion for the resection of hepatocellular carcinoma based on a predictive model of posthepatectomy liver failure.

BACKGROUND: The indocyanine green test is used widely to evaluate the risk of posthepatectomy liver failure for hepatocellular carcinoma. A more convenient and reliable scoring system is desired owing to limited accuracy and availability of the indocyanine green test. This study aimed to establish a new selection criterion for liver resection in HCC. METHODS: We reviewed retrospectively 876 patients undergoing a partial hepatectomy for hepatocellular carcinoma between 2007 and 2015 in 8 affiliated hospitals. Posthepatectomy liver failure grades B and C were regarded as posthepatectomy liver failure. We identified the risk factors for posthepatectomy liver failure and established a predictive model based on a formula for the probability of posthepatectomy liver failure. External validation was performed in an additional cohort of 250 patients. RESULTS: Posthepatectomy liver failure occurred in 92 patients (11%). The area under the receiver operating characteristic curve for the prediction of posthepatectomy liver failure was 0.646 for the platelet count, 0.641 for albumin, 0.623 for the percentage of liver remnant, and 0.607 for the plasma disappearance rate of indocyanine green. Logistic regression analysis provided a formula for the probability of posthepatectomy liver failure consisting of platelet count, albumin, and liver remnant. We defined platelet count + 90 × albumin as the ALPlat index and established an ALPlat-based criterion for operative resection that secured the same risk assumed by the indocyanine green-based criterion (Makuuchi's criterion). This criterion exhibited a greater sensitivity and specificity than the indocyanine green-based criterion in the validation cohort. CONCLUSION: The ALPlat criterion is a simple and useful method to assess liver function and to make therapeutic decisions in patients with hepatocellular carcinoma.

Metachronous Pancreatic Metastasis from Rectal Cancer that Masqueraded as a Primary Pancreatic Cancer: A Rare and Difficult-to-Diagnose Metastatic Tumor in the Pancreas.

BACKGROUND Pancreatic metastasis from colorectal cancer is rare and can masquerade as primary pancreatic cancer. CASE REPORT A 70-year-old male was diagnosed with advanced rectal cancer with multiple liver metastases. After neoadjuvant chemotherapy, he underwent radical surgery for the primary tumor and hepatectomy for multiple liver metastases. Adjuvant chemotherapies and additional surgeries were subsequently required for recurrences in the liver, lung, and lymph nodes. A diffuse hypovascular nodule in the pancreatic head and a solitary liver metastasis were detected 2.5 years after the initial surgery and he accordingly underwent further chemotherapy. However, the pancreatic tumor progressed, invading the pancreatic duct and biliary tract. Obstructive jaundice finally prompted discontinuation of chemotherapy and he underwent biliary drainage. His diffuse and hypovascular tumor was clinically and radiographically diagnosed as a primary pancreatic cancer. Pancreatic resection for the pancreatic tumor and hepatectomy for the liver metastasis were performed 4.2 years after the initial surgery, achieving radiographic and surgical curative resection. Pathological examination of the surgical specimen resulted in a definitive diagnosis of metachronous pancreatic metastasis from his primary rectal cancer. Despite further chemotherapy, his general condition worsened; however, he remains alive 5.4 years after the initial surgery, with best supportive care. CONCLUSIONS Pancreatic metastasis originating from rectal cancer can masquerade as primary pancreatic cancer clinically and radiologically. Multimodality treatment is mandatory for metastatic colorectal cancer. Aggressive surgeries for pancreatic metastasis should be considered if curative resection appears possible radiographically and/or intraoperatively.

Impact of continuous local lavage on pancreatic juice-related postoperative complications: Three case reports.

BACKGROUND: Postoperative pancreatic leakage readily results in intractable pancreatic fistula and subsequent intraperitoneal abscess. This refractory complication can be fatal; therefore, intensive treatment is important. Continuous local lavage (CLL) has recently been reevaluated as effective treatment for severe infected pancreatitis, and we report three patients with postoperative intractable pancreatic fistula successfully treated by CLL. We also discuss our institutional protocol for CLL for postoperative pancreatic fistula. CASE SUMMARY: The first patient underwent subtotal stomach-preserving pancreaticoduodenectomy, and pancreatic leakage was observed postoperatively. Intractable pancreatic fistula led to intraperitoneal abscess, and CLL near the pancreaticojejunostomy site was instituted from postoperative day (POD) 8. The abscess resolved after 7 d of CLL. The second patient underwent distal pancreatectomy. Pancreatic leakage was observed, and intractable pancreatic fistula led to intraperitoneal abscess near the pancreatic stump. CLL was instituted from POD 9, and the abscess resolved after 4 d of CLL. The third patient underwent aneurysmectomy and splenectomy with wide exposure of the pancreatic parenchyma. Endoscopic retrograde pancreatic drainage was performed on POD 15 to treat pancreatic fistula; however, intraperitoneal abscess was detected on POD 59. We performed CLL endoscopically via the transgastric route because the percutaneous approach was difficult. CLL was instituted from POD 63, and the abscess resolved after 1 wk of CLL. CONCLUSION: CLL has therapeutic potential for postoperative pancreatic fistula.

Treatment of Labial Fistula Communicating with the Duodenal Stump After Gastrectomy.

BACKGROUND Anastomotic failure after gastroenterological surgery is usually treated by intraperitoneal drainage and a mature ductal fistula. A ductal fistula may develop into a labial fistula. Although a ductal fistula is controllable, a labial fistula is intractable. We report a case of a labial fistula that communicated with the duodenal stump after gastrectomy. This condition was successfully treated by intraluminal drainage with continuous suction (IDCS) via a rectus abdominis musculocutaneous flap (RAMF). CASE REPORT A 70-year-old male underwent distal gastrectomy with intentional lymphadenectomy because of advanced gastric cancer. Digestive reconstruction was completed by the Billroth II method. Pancreatic leakage, intraperitoneal abscess, and anastomotic failure of gastrojejunostomy occurred after surgery. The duodenal stump was ruptured at postoperative day (POD) 26, and ductal fistula associated with the duodenum was observed. Unfortunately, this ductal fistula developed into a labial fistula at POD 90, and a high output of duodenal juice was observed. Additional surgery was proposed at POD 161. The broken stump and labial fistula were covered by a pedunculated RAMF, and a dual drainage system (a combination of a Penrose drain and a 2-way tube) travelled through the RAMF. The tip position of the drainage system was located in the duodenum, and the IDCS was effectively introduced. The secondary ductal fistula finally matured through the RAMF, and was subsequently closed at POD 231. The intractable labial fistula was successfully treated, and the patient was discharged at POD 235. CONCLUSIONS A high-output labial fistula, which communicated with the duodenal stump after gastrectomy, was refractory in our patient. Effective IDCS through an RAMF was useful for replacement of the labial fistula with a secondary ductal fistula.

Inferior Pancreaticoduodenal Artery Aneurysm Related with Groove Pancreatitis Persistently Repeated Hemosuccus Pancreaticus Even After Coil Embolization.

BACKGROUND Aneurysm of the inferior pancreaticoduodenal artery (IPDA) is rare among visceral artery aneurysms. Aneurysm and/or pancreatitis may have a causal relation with hemosuccus pancreaticus (HP). HP causes an obscure bleeding in the digestive tract, and this rare disease may lead to life-threatening condition. Although interventional radiology is generally employed as the initial treatment for visceral aneurysms, aneurysmic recanalization is a critical problem. CASE REPORT A 58-year-old male was incidentally diagnosed as groove pancreatitis, and his pancreatitis was successfully treated by conservative management. One year later, an IPDA aneurysm was detected in image studies. Gastrointestinal bleeding was objectively observed, and a diagnosis of asymptomatic HP was made. Arterio-pancreatic duct fistula was suspected, but was not identified. Coil embolization was successfully completed. Six months later, he suffered a relapse of HP, and visited our emergency unit. Pseudocystic lesion around metallic coils were confirmed. Subtotal stomach-preserving pancreaticoduodenectomy without any extended resections was performed. Intentional dissections of nerve plexuses and lymph nodes were all waived. Even a pancreatography of the resected specimen did not clarify his arterio-pancreatic duct fistula. He was discharged at postoperative day 10, and smoothly returned to his work. CONCLUSIONS Pancreatic juice-related complications after advanced pancreaticoduodenectomy for malignancies are often intractable. However, simple pancreaticoduodenectomy which omits extended resections and intentional dissections is safe and feasible for benign diseases. After the initial interventional radiology for pancreatic aneurysms, an elective pancreatic surgery should be considered to avoid unwanted recanalization and refractory HP.