Proposal of nomograms to predict clinical outcomes in patients with ampulla of Vater cancer based on the Korea-Japan collaborative study.

BACKGROUND: In this study, we aimed to develop and validate a nomogram to predict overall survival (OS) and recurrence-free survival (RFS) in patients who underwent curative resection of ampulla of Vater (AOV) cancer. This is the first study for nomograms in AOV cancer patients using retrospective data based on an international multicenter study. METHODS: A total of 2007 patients with AOV adenocarcinoma who received operative therapy between 2002 January and 2015 December in Korea and Japan were retrospectively assessed to develop a prediction model. Nomograms for 5-year OS and 3-year RFS were constructed by dividing the patients who received and who did not receive adjuvant therapy after surgery, respectively. Significant risk factors were identified by univariate and multivariate Cox analyses. Performance assessment of the four prediction models was conducted by the Harrell's concordance index (C-index) and calibration curves using bootstrapping. RESULTS: A total of 2007 and 1873 patients were collected for nomogram construction to predict 5-year OS and 3-year RFS. We developed four types of nomograms, including models for 5-year OS and 3-year RFS in patients who did not receive postoperative adjuvant therapy, and 5-year OS and 3-year RFS in patients who received postoperative adjuvant therapy. The C-indices of these nomograms were 0.795 (95% confidence interval [CI]: 0.766-0.823), 0.712 (95% CI: 0.674-0.750), 0.804 (95% CI: 0.7778-0.829), and 0.703 (95% CI: 0.669-0.737), respectively. CONCLUSIONS: This predictive model could help clinicians to choose optimal treatment and precisely predict prognosis in AOV cancer patients.

Establishment of a Liver Transplant Patient-derived Tumor Xenograft (PDX) Model Using Cryopreserved Pancreatic Ductal Adenocarcinoma.

BACKGROUND/AIM: There is rapid progression and widespread use of patient-derived tumor xenografts (PDX) in translational pancreatic cancer research. This study aimed to establish a liver transplant PDX model using cryopreserved primary pancreatic ductal adenocarcinoma (PDAC). PATIENTS AND METHODS: Primary PDAC from 10 patients were cryopreserved and transplanted into immunodeficient mice using the liver pocket method. H&E staining and immunohistochemical staining, such as Ki-67, p53, Smad4, and MUC1 were used to evaluate engraftment and histological similarities. RESULTS: Patient-derived xenograft placement was successful in six cases (60%), and 10 mice (33.3%). The Ki-67 index of primary PDAC and the cryopreservation duration were significantly related to successful engraftment (p=0.003 and p=0.007, respectively). CONCLUSION: In this study, we succeeded in establishing a liver transplant PDX mouse model as a preclinical platform. The successful engraftment was affected by the cryopreservation duration and could be detected by the Ki-67 index.

Preoperative Neutrophil-to-lymphocyte Ratio Predicts Tumor-infiltrating CD8+ T Cells in Biliary Tract Cancer.

BACKGROUND/AIM: This study evaluated the prognostic significance of preoperative neutrophil-to-lymphocyte ratio (NLR) and CD8+ tumor-infiltrating lymphocytes (TILs), and whether preoperative NLR was associated with CD8+ TILs in biliary tract cancers (BTCs). PATIENTS AND METHODS: A total of 154 patients with BTCs who underwent surgery were enrolled in this study. We obtained neutrophil and lymphocyte counts, and calculated NLR from preoperative peripheral blood samples. CD8+ TILs were identified by immunohistochemical staining. RESULTS: The overall survival (OS) and recurrence-free survival (RFS) of patients with high NLR were shorter than those with low NLR. The OS and RFS of patients with high CD8+ TILs were longer than those with low CD8+ TILs. Preoperative NLR and CD8+ TILs were negatively correlated. CONCLUSION: NLR and CD8+ TILs were associated with OS and RFS in BTCs. NLR can predict CD8+ TILs infiltrating the cancer microenvironment.

[Assistance for Self-Management of Outpatient Chemotherapy-Introduction of Medical Treatment Diary].

To safely carry out outpatient chemotherapy, it is important that patients participate in their treatment while maintaining their physical condition, and the medical staff have a role in assisting patients in managing themselves. Therefore, we introduced a self-administered chemotherapy treatment diary(hereinafter referred to as a treatment diary). This helped patients in managing themselves and motivated them to participate in their treatment.

The findings of the contrast-enhanced CT and risk factors for hepatic infarction after pancreatoduodenectomy.

PURPOSE: Hepatic infarction is a relatively rare life-threatening complication after pancreatoduodenectomy (PD). Computed tomography (CT) findings and risk factors for hepatic infarctions after PD were investigated. METHODS: One hundred-fifty three patients who underwent contrast-enhanced CT (CECT) after PD between January 2011 and August 2016 were retrospectively analyzed. Hepatic infarction was defined as the non-contrast enhanced area expanding to the liver surface without mass effect on CECT. The relationships between infarctions and preoperative laboratory data or surgical procedures using uni- and multivariate analyses were examined. RESULTS: Twenty-nine patients showed 47 hepatic infarctions on CT. Infarctions most commonly appeared in segment 7 (S7) (17 lesions, 36.2%). Lesions were wedge-shaped in 12 patients and spread over multiple hepatic segments in 11 patients. Univariate analysis identified celiac artery (CA) or common hepatic artery (CHA) resection (p = 0.0029) and portal vein (PV) resection (p = 0.013) as risk factors for infarctions. CA or CHA resection (p = 0.038) remained as a significant factor after multivariate logistic analysis. CONCLUSIONS: Hepatic infarctions after PD were most frequently seen in S7 and PV penetrating sign was characteristic CT findings. CA or CHA resection or PV resection were revealed as risk factors for hepatic infarctions.

[Laparoscopic Resection of Solitary Lymph Node Metastasis of Hepatocellular Carcinoma after Transcatheter Arterial Chemoembolization and Percutaneous Locoregional Therapies].

A 75-year-old woman underwent transcatheter chemoembolization(TACE)for 2 small hepatocellular carcinoma(HCC) lesions associated with severe alcoholic liver cirrhosis that necessitated management for ascites. Over 5 years after the initial TACE, she received multidisciplinary therapies with TACE, transcatheter arterial infusion of anticancer agents, percutaneous ethanol injections, or percutaneous radiofrequency ablation performed on 5 occasions for small recurrent HCC lesions. Computed tomography performed after the last therapy for HCC revealed a solitary lymph node swelling(39 mm in diameter) around the common hepatic artery. Magnetic resonance imaging performed 3 months later revealed that the lymph node had enlarged to 45 mm, without recurrence of the primary HCC, and after 4 months, to 60 mm; she then underwent laparoscopic lymph node resection. Histopathological examination of the resected specimen showed HCC metastasis. A recurrent metastatic lymph node(30 mm in diameter)was detected around the common hepatic artery and was resected laparoscopically 17 months postoperatively. Pancreatic head cancer was diagnosed 22 months after the second surgery; however, the patient refused cancer therapy and died 16 months after this diagnosis. No recurrence of the primary HCC or lymph node metastasis was observed over the 38 months after the second surgery.

[Efficacy and Safety of Paclitaxel plus Ramucirumab Therapy for Unresectable or Recurrent Gastric Cancer].

The RAINBOW trial showed that paclitaxel(PTX)plus ramucirumab(RAM)therapy improved the survival of patients with advanced gastric cancer, previously treated with chemotherapy. We retrospectively investigated 33 patients with unresectable or recurrent gastric cancer who underwent PTX plus RAM treatment as second- or third-line chemotherapy between September 2015 and December 2017. The median age was 68(45-84)years with 22 patients(67%)aged 65 years or older. Seventeen patients had unresectable and 16 patients had recurrent gastric cancer. ECOG PS was 2 in 5 patients(16%). PTX plus RAM was administered as second-line therapy for 24 patients, and as third-line therapy for 9 patients. Best overall response was partial response(PR)in 4 patients, stable disease(SD)in 14 patients, and progressive disease(PD)in 9 patients. Response rate(RR)and disease control rate(DCR)were 14.8% and 66.7%, respectively. Grade 3/4 adverse events were observed in 28(85%)of(leucopenia·neutropenia[64%], neuropathy[9%], etc). Median follow-up period was 7.3(0.4- 22.4)months. Median OS and PFS were 9.3(0.4-22.4)months and 4.7(0.4-22.4)months, respectively. We conclude that PTX plus RAM therapy is useful for treating unresectable or recurrent gastric cancer. In clinical practice, we have many opportunities to provide PTX plus RAM therapy for patients of older age and poorer PS; careful attention to adverse events is essential in such cases.

Long-term outcomes after biliary diversion operation for pancreaticobiliary maljunction in adult patients.

AIM: Pancreaticobiliary maljunction (PBM) with or without congenital biliary dilatation (CBD) is a risk factor for biliary tract cancer. We investigated long-term outcomes after biliary diversion operation with special reference to types of CBD. METHODS: Subjects comprised 40 adult patients who underwent biliary diversion operation for PBM without biliary tract cancer. Group A comprised 20 patients with type Ia or Ic CBD, or non-dilated bile ducts, while group B comprised 20 patients with type IV-A CBD. The clinical findings and postoperative outcomes were compared between groups. RESULTS: Of 40 patients, nine patients suffered from repeated cholangitis and eight of these nine patients suffered from hepatolithiasis after biliary diversion operation. Biliary tract cancer or pancreatic cancer was detected in four patients at 3 years and 2 months to 24 years after the operation. In three of these four patients, the serum concentration of carbohydrate antigen 19-9 increased before detection of carcinoma. One patient died of hepatic failure due to repeated cholangitis. The proportions of patients with repeated cholangitis, hepatolithiasis, and re-operation, and patients who died of biliary tract cancer, pancreatic cancer, or hepatic failure, were significantly higher in group B than in group A. The survival rate was significantly worse in group B than in group A. CONCLUSIONS: Careful long-term follow-up with measurement of serum tumor markers is necessary after biliary diversion operation for PBM, especially in patients with type IV-A CBD or repeated cholangitis.

A case of perforation of a pancreatic duct by a pancreatic stent during chemoradiotherapy for pancreatic head cancer: a case report.

BACKGROUND: Pancreatic injuries are rare, and no treatment plan has yet been established for grade III injuries. In many cases, pancreatic stent placement has resulted in saving patients. However, some cases of perforation of a pancreatic duct during the placement of a stent have been described, and there are also a few cases of delayed perforation by a pancreatic stent. CASE PRESENTATION: A 62-year-old man had obstructive jaundice and pancreatitis due to locally advanced pancreatic head cancer. Both biliary and pancreatic stent were placed by endoscopy, after which chemoradiotherapy was performed. Four months later, he visited our hospital with severe abdominal pain. We performed enhanced CT and diagnosed the patient as having a perforation of a pancreatic duct by a pancreatic stent; therefore, we performed an emergency operation. Since we deemed pancreatectomy risky, we inserted pancreatic tubes into both sides of the perforated site and performed percutaneous transgastric drainage. The postoperative course was uneventful. We thereafter cut the tubes and switched to internal drainage. CONCLUSION: Many cases of pancreatic injuries have reported that pancreatic stent placement results in saving the patient, but there have been few cases in which a pancreatic stent causes perforation of a pancreatic duct. External drainage by pancreatic tubes is very effective in resolving perforation of a pancreatic duct.

A case of complete splenic infarction after laparoscopic spleen-preserving distal pancreatectomy.

BACKGROUND: Laparoscopic spleen-preserving distal pancreatectomy (LSPDP), a newly developed operative procedure, is indicated for benign and low-grade malignant disease of the pancreas. However, few studies have reported on postoperative splenic infarction after LSPDP. CASE PRESENTATION: We report a case of complete splenic infarction and obliteration of the splenic artery and vein after LSPDP. The patient was a 69-year-old woman with a 35-mm cystic tumor of the pancreatic body who underwent LSPDP. Although the operation was completed with preservation of the splenic artery and vein, postoperative splenic infarction was revealed with left back pain and fluid collection around the stump of the pancreas on postoperative day 9. Fortunately, clinical symptoms disappeared within days and additional splenectomy was not needed. Splenic infarction was attributed to scattered micro-embolizations within the spleen after drawing strongly on the tape encircling the splenic vessels. CONCLUSION: Preserving splenic vessels in LSPDP is a demanding procedure. To prevent splenic infarction in LSPDP, we should carefully isolate the pancreatic parenchyma from the splenic vessels, and must avoid drawing tightly on the vessel loop encircling splenic vessels.

[A Case of Male Breast Cancer Suspected of Breast Metastasis from Pancreatic Cancer].

History of male breast cancer and pancreatic cancer are important for diagnosis of hereditary breast and ovarian cancer syndrome(HBOC), while advanced pancreatic cancer is reported to have metastasis to mammary gland tissue. A 67-year-old man visited a local hospital because fever and right hypochondrial pain. Computed tomography scan revealed pancreatic cancer with multiple liver metastasis and peritoneal metastasis. He was referred to our hospital for further evaluation and treatment. No particular family history of malignancy was formed. A palpable lump was found in his left breast. Ultrasonography revealed 2.8 cm sized mass that had heterogenous internal echo and rough border. The background mammary gland showed gynecomastia. Since it was difficult primary breast cancer with metastatic tumor originated from pancreas cancer a core needle biopsy was performed. The finding of pathological examination showed invasive carcinoma with hormonal receptor negative and HER2 negative feature. CK7 and CK19 were both positive. Although it was difficult to male differentiation whether the tumor was primary a metastatic, we diagnosed as synchronous duplicated cancer of pancreas and breast due to existence of gynecomastia. Since hepatic failure due to tumor growth advanced prior to treatment start, the treatment policy became best supportive care.

[A Case of Appendiceal Cancer Wherein the Abdominal Abscess Ruptured into the Urinary Bladder Owing to Obstructive Appendicitis].

A 73-year-old woman presented to her doctor because of lower abdominal pain and distension. A neoplastic lesion in the lower abdomen was revealed, and she was referred to our department. Enhanced CT showed wall thickening in the urinary bladder and a 6 cm mass that extended to the appendix. An appendiceal tumor invading the urinary bladder or a urinary bladder tumor invading the appendix was suspected, and we planned surgical treatment. One month later, we repeated enhanced CT scanning on admission. The mass had shrunk, but the thickening of the urinary bladder wall remained, and an enhanced appendiceal tumor was visible. Surgery was performed and we found a 1 cm appendiceal tumor. Intraoperative pathological examination revealed appendiceal cancer. Therefore, we performed ileocecal resection, D2 lymph node dissection, and partial cystectomy. Final histopathological examination revealed appendiceal cancer with pT2N0M0, pStage Ⅰ. Taking into account the patient's clinical course, we diagnosed obstructive appendicitis with an abscess due to appendiceal cancer rupture into the urinary bladder.

Doublecortin and CaM kinase-like-1 as an independent prognostic factor in patients with resected pancreatic carcinoma.

AIM: To elucidate the effect of expression of doublecortin and CaM kinase-like-1 (DCLK1) in patients with pancreatic ductal adenocarcinoma (PDAC). METHODS: Tumor specimens were obtained from 136 patients with pancreatic cancer who had undergone resection without preoperative therapy between January 2000 and December 2013 at the Department of Surgical Oncology, Osaka City University. The resected specimens were analyzed for associations with clinicopathological data, including DCLK1 expression, epithelial mesenchymal transition (EMT) marker expression, and cancer stem cell (CSC) marker expression. Univariate and multivariate survival analyses were performed and we assessed the association between DCLK1 expression and clinicopathological factors, including the EMT marker and CSC marker. RESULTS: In total, 48.5% (66/136) of the pancreatic cancer samples were positive for DCLK1. Patients with DCLK1-positive tumors had significantly shorter survival times than those with DCLK1-negative tumors (median, 18.7 mo vs 49.5 mo, respectively; P < 0.0001). Positive DCLK1 expression correlated with histological grade (P = 0.0290), preoperative CA19-9 level (P = 0.0060), epithelial cell adhesion molecule (EpCAM) expression (P = 0.0235), and the triple-positive expression of CD44/CD24/EpCAM (P = 0.0139). On univariate survival analysis, five factors were significantly associated with worse overall survival: histological grade of G2 to G4 (P = 0.0091), high preoperative serum SPan-1 level (P = 0.0034), R1/2 (P < 0.0001), positive expression of DCLK1 (P < 0.0001) or CD44 (P = 0.0245). On multivariate survival analysis, R1/2 [odds ratio (OR) = 2.019, 95% confidence interval (CI): 1.380-2.933; P = 0.0004] and positive DCLK1 expression (OR = 1.848, 95%CI: 1.2854-2.661; P = 0.0009) were independent prognostic factors. CONCLUSION: DCLK1 expression was found to be an independent prognostic factor and it may play a crucial prognostic role by promoting acquisition of stemness.

A case of bowel perforation due to traumatic hernia at a pelvic fracture site: a case report and review of the literature.

BACKGROUND: Common complications of pelvic fractures include visceral injury, large-volume hemorrhage, genitourinary injury, rectal injury, and pulmonary embolism. On the other hand, traumatic hernia is a rare complication, especially in association with pelvic fractures. We report a case of bowel perforation due to traumatic hernia at a pelvic fracture site. CASE PRESENTATION: A 65-year-old female was presented at our hospital for further examination and treatment of ileus. She was diagnosed with bowel perforation due to traumatic hernia at a pelvic fracture site, and an emergency operation was thus immediately performed. We performed segmental jejunum resection and constructed jejunostomy, and the iliac bone fracture was fixed with four pins. In the postoperative course, she received antibiotics and vasopressors for septic shock. However, there was no need for either a ventilator, dialysis or admission to the ICU. At seven days after the operation, a residual abscess was detected in the pouch of Douglas. We performed percutaneous drainage (Clavien-Dindo IIIa) and jejunostomy closedown 35 days after the first operation. The postoperative course was without complication, but she received rehabilitation until she was able to walk unaided. She was discharged 64 days after the first operation. CONCLUSION: The occurrence of traumatic hernia is rare, especially in association with pelvic fractures. Although its rarity, traumatic hernia follows a severe course. Thus, proper diagnosis and effective treatment are necessary. Surgeons treating patients with pelvic injuries should consider the possibility of any complications and perform a work-up examination in order to achieve an accurate diagnosis at an earlier time point.

[Clinical Experience of S-1 and Oxaliplatin(SOX)as the First-Line Chemotherapy for Metastatic/Recurrent Gastric Cancer].

We retrospectively investigated the efficacy and safety of S-1 and oxaliplatin(SOX)as the first-line chemotherapy in patients with metastatic/recurrent gastric cancer. A total of 27 patients who received SOX as the first-line chemotherapy in our hospital were considered for the study. The SOX chemotherapy schedule consisted of 1 course every 3 weeks. S-1 was administered orally, at 80-120mg-body, every day for 14 days. Oxaliplatin was infused at 100mg/m2 on day 1 of each course. The median number of treatment courses was 7. The response rate and disease control rate were 47.6% and 76.2%, respectively. The observed adverse events of Grade 3 or more included neutropenia(33.3%); peripheral neuropathy and anorexia(11.1%); thrombocytopenia(7.4%); and anemia, diarrhea, fatigue, and hypercalcemia(3.7%). The median overall survival was not achieved, and the 1-year survival rate was 63.2%. Therefore, SOX is an effective and feasible first-line chemotherapy that is easily available for ambulatory treatment of patients with metastatic/recurrent gastric cancer.

Preoperative predictors for early recurrence of resectable pancreatic cancer.

BACKGROUND: The first-line treatment for resectable pancreatic cancer (RPC) is surgical resection. However, our patients have often experienced early recurrence after curative resection for RPC, with desperately poor prognosis. Some reports indicated that minimally distant metastasis not detected at operation might cause early recurrence. The present study aimed to identify preoperative clinicopathological features of early recurrence after curative resection of RPC. METHODS: Ninety RPC patients who underwent curative resection between 2000 and 2014 at our institution were retrospectively analyzed. RESULTS: Of the 90 patients, 32 had recurrence within 1 year. Univariate analysis demonstrated that preoperative serum carbohydrate antigen (CA19-9) ≥529 U/mL (P = 0.0011), preoperative serum s-pancreas-1 antigen (SPan-1) ≥37 U/mL (P = 0.0038), and histological grades G2-G4 (P = 0.0158) were significantly associated with recurrence within 1 year after curative resection. Multivariate analysis demonstrated that preoperative serum CA19-9 ≥ 529 U/mL (P = 0.0477) and histological grade G2-G4 (P = 0.0129) were independent predictors of recurrence within 1 year. Recurrent cases within 1 year postoperatively had significantly more distant metastasis than cases with no recurrence within 1 year (P < 0.001). CONCLUSIONS: Preoperative serum CA19-9 ≥ 529 U/mL and histological grades G2-G4 were independent predictive factors for recurrence within 1 year after pancreatectomy for RPC. Furthermore, recurrent cases within 1 year had more frequent distant metastasis than cases with no recurrence within 1 year. These results suggest that RPC patients with preoperative serum CA19-9 ≥ 529 U/mL should receive preoperative therapy rather than surgery.

Analysis of the origin of anaplastic pancreatic cancer and the mechanism of its dedifferentiation.

BACKGROUND: We researched the origin and progression of anaplastic pancreatic cancer (APC) from the viewpoints of cell lineage, epithelial-mesenchymal transition (EMT) and cancer stem-like cells (CSC). METHODS: Using specimens from patients with APC and differentiated pancreatic ductal adenocarcinoma (PDAC), expression of sex-determining region Y-box 9 (SOX9), E-cadherin, vimentin, ZEB1, Snail, N-cadherin, CD24 and CD44 was estimated using immunohistochemistry. RESULTS: Almost all cases were positive for SOX9 expression. APC cases were negative, but many PDAC cases were positive for the expression of E-cadherin. A much higher number of APC cases than PDAC cases were positive for the expression of other EMT related proteins and for the expression of CSC related proteins. The ductal cancerous component of APC accounted for an average of 12% of the cancerous lesion and the expression of each marker in this component was similar to that of PDAC cases. CONCLUSIONS: Anaplastic pancreatic cancer had pancreatic duct cell like features and might gain dedifferentiate components through EMT and the acquisition of CSC properties.

[Clinical Outcome of the Patients with Anal Squamous Cell Carcinoma].

We studied 14 patients with anal squamous cell carcinoma(ASCC)who were treated in our hospital between 1994 and 2016. As initial therapies, surgeries were performed in 5 patients. Of these, disease recurrence appeared in 4 patients, and 3 patients died within 1 year after operation. Other 9 patients were treated with chemoradiotherapy. As a result, 9 of 6 patients were considered as complete response(CR), and 4 patients are still alive without recurrence. Although other 2 patients were recurred, recurrent lesions were removed and then, they are still alive. Of 3 patients who were considered as partial response (PR), 1 patient who was treated with local excision is still alive without recurrence, however, 2 patients were died for distant metastases. Chemoradiotherapy is considered to be effective and expected to cure without surgery, however, a careful surveillance should be needed for distant metastases.

The impact of the preoperative peripheral lymphocyte count and lymphocyte percentage in patients with colorectal cancer.

PURPOSE: We evaluated the prognostic significance of the peripheral lymphocyte count and lymphocyte percentage, which reflect the preoperative immune status, in patients with colorectal cancer (CRC) and then compared their accuracy as predictors of the survival. METHODS: We retrospectively reviewed a database of 362 patients. We classified the patients into high lymphocyte count and low lymphocyte count groups. We also classified the patients into high lymphocyte percentage and low lymphocyte percentage groups. RESULTS: The 5-year relapse-free survival (RFS) rate in the high lymphocyte count group tended to be higher than that in the low lymphocyte count group. The 5-year overall survival (OS) rate in the high lymphocyte count group was significantly higher than that in the low lymphocyte count group. In contrast, the 5-year RFS and OS rates in the high lymphocyte percentage group were both significantly higher than those in the low lymphocyte percentage group. A multivariate analysis showed that the lymphocyte percentage was independently associated with the OS. CONCLUSIONS: These findings suggest that the lymphocyte percentage is a good predictor of the OS and may be a stronger predictor of survival than the lymphocyte count in CRC patients.

Giant duodenal ulcers after neurosurgery for brainstem tumors that required reoperation for gastric disconnection: a report of two cases.

BACKGROUND: Despite the efficacy of pharmacotherapy for gastrointestinal ulcers, severe cases of bleeding or perforation due to gastrointestinal ulcers still occur. Giant duodenal ulcer perforation is an uncommon but difficult-to-manage pathology with a high mortality rate. We report two cases of giant duodenal ulcer perforation after neurosurgery for brainstem tumors that needed reoperation for gastric disconnection because of postoperative leakage and bleeding. CASE PRESENTATION: Both cases had undergone neurosurgery for brainstem tumors, and the patients were in a shock state for several days with peritonitis due to giant duodenal perforation. In Case 1, antrectomy with Billroth II reconstruction was performed. However, reoperation for gastric disconnection was needed because of major leakage of gastrojejunostomy and jejunojejunostomy. In Case 2, an omental patch, cholecystectomy, and insertion of a bile drainage tube from the cystic duct were performed for the giant duodenal ulcer, but leakage and bleeding from the ulcer edge required reoperation for gastric disconnection. CONCLUSIONS: Brainstem tumors in these cases might have been related to duodenal ulcer perforation with late diagnosis that progressed to severe sepsis. For giant duodenal ulcer perforation with poor general condition, simple closure including omental patch or antrectomy with reconstruction is hazardous. Antrectomy with gastric disconnection, meaning gastrostomy, duodenostomy, feeding jejunostomy and cholecystectomy, is recommended.