Fifteen-year survival of a hepatocellular carcinoma extending into the right atrium treated by surgical resection with the heart-first approach under cardiopulmonary bypass: a case report and review of the literature.

Hepatocellular carcinoma with tumor thrombus in the inferior vena cava extending into the right atrium is rare and associated with poor prognosis in most cases. Although liver resection with thrombectomy is the only curative treatment, there is no consensus on the therapeutic options for managing these rare cases. The patient was a 67-year-old man with hepatocellular carcinoma with tumor thrombus in the right atrium. In February 2003, cavo-atrial thrombectomy was first performed using cardiopulmonary bypass with heparinization and cardiac arrest. After thrombectomy, right hepatectomy was performed. The total operative time was 10 h 48 min. Moreover, the total blood loss was 7267 mL. The patient recovered uneventfully except for right pleural effusion. He was cancer-free for approximately 9 years. A new lesion in the remnant liver was detected in March 2012. He underwent transcatheter arterial chemoembolization, followed by sequential administration of sorafenib and sunitinib. Radiation therapy was also administered. Eventually, the patient expired 6 years after recurrence. Cavo-atrial thrombectomy under cardiopulmonary bypass prior to hepatectomy for hepatocellular carcinoma with tumor thrombus in the right atrium could be performed safely. Aggressive surgery with the heart-first approach and multidisciplinary treatments even after recurrence led to long-term survival.

Early enteral nutrition with arginine compensates for negative nitrogen balance in patients undergoing curative total gastrectomy.

The effects of early enteral arginine-rich nutrition (EAN) were analyzed among patients undergoing curative-intent total gastrectomy for gastric cancer. There were 19 patients in this prospective study, all randomly assigned to either a parenteral nutrition (PN) group or an EAN group for the first seven days after surgery. The EAN group received 1.8-fold greater arginine (10.1 g/day) compared with the PN group, which was administered through an enteral tube inserted into the jejunal loop. Both groups were provided almost identical amounts of total amino acids (54 g/day), and the total energy was set at 65% of the total requirement (25 kcal/kg/day). No significant differences were observed between the two groups in postoperative complications, length of hospital stay, oral intake, nutritional status, or body weight. The serum arginine profile was similar in the two groups, as it decreased significantly on postoperative day (POD) 1, and gradually returned to preoperative levels by POD 7. The nitrogen balance remained negative until POD 7 in the PN group, but turned neutral at POD 7 in the EAN group. While we could not confirm body weight loss improvement, these results suggested that early arginine-rich enteral nutrition could improve the nitrogen balance after total gastrectomy. J. Med. Invest. 70 : 325-333, August, 2023.

Malignant solitary fibrous tumor of the pancreas: a case report.

BACKGROUND: Solitary fibrous tumors (SFTs) are rare tumors, mostly derived from connective tissue mesenchymal cells that arise from the pleura. There are very few reports of primary pancreatic SFT. Preoperative diagnosis is difficult owing to the lack of distinctive radiological findings. We report a case of pancreatic SFT with particularly rare malignant findings. CASE PRESENTATION: A 60-year-old man was referred to the hospital because of a right upper quadrant mass and abnormal liver function test results. Contrast-enhanced computed tomography (CT) showed a well-defined enhanced tumor measuring approximately 8 cm in the pancreatic head. Magnetic resonance imaging (MRI) showed T1WI hypointensity, T2WI hyperintensity, and DWI hyperintensity. The main pancreatic duct and common bile duct were dilated owing to obstruction by the tumor. The following tumor markers were mildly elevated: carcinoembryonic antigen (CEA), carbohydrate antigen 19-9 (CA19-9), SPan-1, and DUPAN-2. The histological diagnosis obtained by endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) was negative for pancreatic ductal carcinoma, malignant lymphoma and neuroendocrine tumor, suggesting the possibility of mesenchymal tumor, but the diagnosis was not confirmed. The patient was judged suitable for surgery and underwent subtotal stomach-preserving pancreatoduodenectomy with D2 lymph node dissection. On histopathological examination of the resected specimen, infiltrating spindle-shaped cells had proliferated, containing numerous mitotic figures, with necrotic findings inside the tumor. Immunostaining was positive for cluster of differentiation-34 (CD34), B cell CLL/lymphoma-2 (Bcl-2), and signal transducer and activator of transcription (STAT6). On the basis of these findings, a diagnosis of malignant pancreatic SFT was made. The patient remains free of recurrent disease after 12 months of follow-up without adjuvant therapy and he is being carefully followed up as an outpatient. CONCLUSIONS: We experienced a case of malignant pancreatic head SFT. Immunohistochemical staining of the extracted specimens was useful for diagnosis.

Emergency laparoscopic approach without sufficient preoperative decompression for intersigmoid hernia: A case report.

INTRODUCTION: In acute care surgery, an increasing number of patients operatively treated for small bowel obstruction undergo laparoscopic procedures. However, intersigmoid hernia is a rare condition. In some reports, surgeons have successfully operated on patients with an intersigmoid hernia via a laparoscopic approach. The laparoscopic approach has the advantage of facilitating simultaneous diagnosis and surgical intervention for intersigmoid hernias. In the laparoscopic approach, sufficient decompression of the small bowel is preoperatively performed in most cases. PRESENTATION OF CASE: We encountered a patient with an intersigmoid hernia who underwent an emergency laparoscopic approach without sufficient decompression. Because sufficient decompression of the small bowel was not preoperatively performed, it was difficult to establish a working space and visualize the site of obstruction; however, we performed the laparoscopic approach safely, and diagnosis and surgical intervention were possible. Moreover, the postoperative course was uneventful. DISCUSSION: We successfully performed an emergency surgery using a laparoscopic approach for an intersigmoid hernia without sufficient decompression. The success of the procedure is attributable to the disease-specific surgical strategy, surgical technique, and the recent technological advances in multidetector-row computed tomography. CONCLUSION: We believe that careful preoperative diagnosis and strategy can lead to a good outcome and that the significance of emergency laparoscopic approach without sufficient decompression will keep increasing.

[Postoperative Adjuvant Chemotherapy for Descending Colon Cancer Treated with Imatinib for Chronic Myeloid Leukemia].

A66 -year-old man was diagnosed with chronic myeloid leukemia(CML). Imatinib treatment had been initiated, and a major molecular response(MMR)was achieved. The patient had anemia and was diagnosed with descending colon cancer. The patient was surgically treated, and then received postoperative adjuvant chemotherapy with UFT/LV. However, imatinib was not administered during that period. The patient could undergo postoperative adjuvant chemotherapy for 6 months without acute exacerbation of the CML.

Report on the National Survey of Photodynamic Therapy (PDT) for Gastric Cancer in Japan (a secondary publication).

Background and Aims: A national survey of photodynamic therapy (PDT) was carried out in order to understand the present situation in Japan and the efficacy of PDT for gastric cancer. Materials and Methods: A questionnaire concerning with PDT was sent to all hospitals performing or previously performed PDT. The answers were collected and analyzed. An additional investigation about efficacy of PDT for gastric cancer was conducted for the main 3 hospitals. Results: In 18 of 19 responded hospitals, PDT was performed for 386 cases of superficial early gastric cancer and for 27 cases of advanced gastric cancer. In the 3 main hospitals, a complete response was achieved in 42 of 57 patients (73.7%) of superficial early gastric cancer not indicated for surgery or other endoscopic treatments such as endoscopic submucosal dissection. No serious complication occurred. Conclusions: PDT has been shown to be a safe and effective treatment for early gastric cancer, not only for the intramucosal type, but also for the submucosal invasion. PDT will be one of the important endoscopic treatments for gastric cancer especially in a super ageing society like Japan.

Metachronous double cancer after curative resection for pancreatic adenocarcinoma: report of four cases.

We experienced four cases of metachronous double cancer after curative resection for pancreatic adenocarcinoma without the background of intraductal papillary mucinous neoplasm. Case 1, a 67-year-old Japanese female developed tongue cancer 53 months after a pylorus-preserving Whipple resection for pancreatic head adenocarcinoma. Case 2, a 66-year-old female developed multiple breast cancers 52 months after a pylorus-preserving pancreaticoduodenectomy for pancreatic head adenocarcinoma. Case 3, a 59-year-old male developed an adenocarcinoma in the remnant pancreatic head 63 months after a distal pancreatectomy for pancreatic body cancer. Case 4, a 68-year-old male developed lung cancer 92 months after a Whipple procedure for pancreatic head adenocarcinoma. Gemcitabine was administered to three patients as adjuvant chemotherapy at an average administrated dose of 38,199 mg per body surface area. Since primary pancreatic ductal adenocarcinoma is aggressive and always associated with a devastating outcome, metachronous double cancer is scarcely seen. All four cases received curative-intent surgery for each metachronous cancer and were alive for at least 20 months.

[A case of locally advanced sigmoid colon cancer invading the bladder and seminal vesicle effectively treated with preoperative mFOLFOX6].

A 77-year-old male was admitted to our hospital complaining of dyschezia. Computed tomography (CT) and colonoscopy (CF) revealed a huge sigmoid colon cancer invading the bladder and seminal vesicle. Chemotherapy with mFOLFOX6 was initiated preoperatively, and the tumor shrunk markedly after seven courses of treatment. Pelvic exenteration with negative margins was carried out. The patient is still alive and disease-free 16 months after surgery. It was suggested that mFOLFOX6 may be useful for advanced colon cancer invading other organs when used as neoadjuvant chemotherapy.

Metachronous multiple adenocarcinomas of the pancreas.

We report a rare case of metachronous multiple adenocarcinoma of the pancreas. A 59-year-old Japanese man visited our institute for a routine workup as a hepatitis C virus carrier, resulting in detection of a 3-cm tumor in the pancreatic body by screening echogram. Results from several imaging modalities were consistent with pancreatic carcinoma. Distal pancreatectomy along with dissection of partial gastrectomy, transverse colectomy, and lymph node dissection were performed in November 2003. Histological examination confirmed a pancreatic ductal adenocarcinoma with a clear surgical margin and negative lymph node metastases. Gemcitabine was administered for 5 years, then suspended because no recurrent signs were found. The patient returned to our hospital in March 2009, with obstructive jaundice along with a 2-cm tumor in the head of the remnant pancreas. The condition of the patient was carefully investigated and extra-pancreatic metastatic lesions were not found; a pancreaticoduodenectomy was then carried out. Histological examination revealed a diagnosis of pancreatic adenocarcinoma arising from the remnant pancreas gland.

Gastric outlet obstruction caused by a heterotopic pancreas in a pregnant woman: report of a case.

A 26-year-old Japanese woman who was 23 weeks pregnant presented with nausea, vomiting, and abdominal pain. Gastroduodenal endoscopic examination revealed an oval-shaped submucosal tumor obstructing the gastric outlet at the prepyloric area in the stomach. Magnetic resonance imaging showed a 5-cm cystic tumor and we suspected a degenerated gastrointestinal stromal tumor. No other radiological tests were done because of the associated risks to the fetus. Distal gastrectomy was performed and a histological diagnosis of heterotopic pancreas was confirmed. The patient had an uneventful postoperative course and was discharged 19 days after her operation. She delivered a healthy, full-term male infant 3 months later. This case of an ectopic pancreas obstructing the gastric outlet in a pregnant woman is reported and discussed due to its rarity.

Percutaneous sclerotherapy for intractable external biliary fistula after hepatectomy.

A 59-year-old man was diagnosed with cholangitis and a liver abscess caused by intrahepatic stones and underwent a hepatectomy of the left lobe and a side-to-side hepaticojejunostomy. After the operation, the patient developed an intractable external biliary fistula in the left remnant medial region. For the purpose of closing the fistula as a conservative treatment, an injection of 95% dehydrated ethanol was started after confirming the absence of any communication with the central bile duct; 1.5-5 ml was used for each injection, and the tube was clamped for 2 hours after injection. The excretion of bile juice decreased from the second injection, the excretion became serous, and the fistula completely closed after about 2 months without any particular complications. Percutaneous sclerotherapy by the injection of ethanol was found to be useful for closing a noncommunicating external biliary fistula.

Pancreatic tuberculosis.

A 63-year-old Japanese man visited our institute with fever of unknown origin. Findings on preoperative imaging modalities were consistent with pancreatic carcinoma, but a positive tuberculin skin test indicated tuberculosis infection. Negative results for MycobacteriumDNA polymerase chain reaction from sputum and bone-marrow aspiration biopsy specimens ruled out pulmonary and miliary tuberculosis, respectively. Positron emission tomography (PET) with 2-[fluorine-18]-fluoro-2-deoxy- d-glucose (FDG) showed multiple labeled spots within the pancreas body and chest. Distal pancreatectomy was performed with a diagnosis of suspected pancreatic carcinoma, but the histological and microbiological diagnosis was Mycobacterium infection. A rare case of pancreatic tuberculosis evaluated by FDG PET is reported and discussed herein.