[A case of concomitant pancreatic neuroendocrine neoplasm and intraductal papillary mucinous neoplasm in which preoperative diagnosis was difficult].

A 75-year-old male patient has been followed-up for mixed-type intraductal papillary mucinous neoplasm (IPMN) in the tail of the pancreas for about 20 years. Upon close examination, he was diagnosed of high-risk stigmata due to a nodule having a contrast effect of 5mm or more in the tumor. Based on this, a distal pancreatectomy was performed. Histopathological analysis revealed concomitant IPMN (low-grade) and pancreatic neuroendocrine neoplasm (PNEN) (G1). This prompted us to report a very rare case of coexisting PNEN and IPMN with an interesting pathological finding that might suggest its pathogenic mechanism.

[Vitamin K deficiency caused by nutritional malabsorption accompanying afferent loop obstruction:a case report].

This case involves a 73-year-old man who visited a clinic because he was experiencing dyspnea on exertion and acid reflux. He was diagnosed with anemia and referred for a medical check-up and treatment by his primary care physician. Iron deficiency anemia and prolonged prothrombin time were confirmed with a blood test and an abdominal enhanced CT revealed marked expansion of the afferent loop after a gastrectomy. The medical check-up revealed abnormal blood coagulation due to afferent loop obstruction, which resulted in vitamin K deficiency. He was supplemented with vitamin K, and surgery was performed for the afferent loop obstruction. Postoperatively, his anemia, nutritional status, serum vitamin K levels, and prothrombin time improved steadily. In conclusion, nutrient malabsorption may occur in cases of afferent loop obstruction and abnormal blood coagulation due to vitamin K deficiency.

[Successful biliary drainage by percutaneous transhepatic puncture common bile duct and rendezvous technique for a case of recurrent biliary pancreatitis with a Roux-en-Y reconstruction and without extension of the bile duct].

A 92-year-old woman was hospitalized with upper abdominal pain. She had a history of acute biliary pancreatitis and chronic heart failure and had undergone gastrectomy with Roux-en-Y reconstruction. She was admitted with recurrent pancreatitis and an exacerbation of heart failure. Biliary drainage could not successfully be achieved endoscopically or with percutaneous transhepatic biliary drainage and EUS-guided biliary drainage because of the Roux-en-Y reconstruction and non-dilation of bile duct. We successfully accomplished biliary drainage in one session with percutaneous transhepatic puncture of the common bile duct with ultrasound guidance and the rendezvous technique. We report this case because it is rare.

[A case of relapsed hemosuccus pancreaticus successfully treated with interventional radiology].

A 67-year-old male with chronic pancreatitis presented with upper abdominal pain and melena. Abdominal dynamic computed tomography revealed a splenic artery aneurysm in the main pancreatic duct. Esophagogastroduodenoscopy showed active bleeding from Vater's papilla. The patient was diagnosed with hemosuccus pancreaticus (HP) due to rupture of the aneurysm and treated with interventional radiology (IVR). The patient's poor lung function did not allow for a radical operation and a follow-up examination was recommended. The HP relapsed 7 months later and was successfully retreated with IVR. Although IVR is associated with a high recurrence rate, it is less invasive and therefore effective for treating relapsing HP in patients with a poor general condition.

A case of resected hepatocellular carcinoma after drug-eluting bead transarterial chemoembolization.

We report a case of resected hepatocellular carcinomas (HCCs) after drug-eluting bead transarterial chemoembolization (DEB-TACE). A 67-year-old man with alcoholic liver disease was diagnosed with HCCs. Serological markers for hepatitis B and C viruses were negative. Among tumor markers, alpha-fetoprotein was 2.7ng/mL, and protein induced by vitamin K absence II was 868mAU/mL. Two HCCs were detected using dynamic computed tomography: one was 9cm in diameter in S8 and the other was 2cm in diameter in S4. We performed DEB-TACE using HepaSphere(®) and epirubicin. DEB-TACE was repeated three times in three months. Severe postembolization syndrome was not seen with any treatment. Four weeks after the last DEB-TACE, we performed surgical resection. Histopathological study revealed dense distribution of numerous bead particles in necrotic tumor tissue. Otherwise, in non-cancerous tissue, some beads were in portal areas, without necrotic change. Granulomas from foreign body reaction with giant cells were present around the beads. There were no necrotic changes in the smaller HCC, the intrahepatic metastatic nodules, or the microscopic invasion to the portal vein. In conclusion, DEB-TACE would be a useful treatment for huge HCCs; however, patients should be monitored for early recurrence from residual tumor tissue. This study will be helpful to perform DEB-TACE in the future.

[A patient with sepsis and a gas-forming liver abscess caused by Clostridium perfringens treated with continuous perfusion drainage].

A 64-year-old man presented with diarrhea, fever, and disturbance of consciousness; he was subsequently diagnosed with acute renal and hepatic disorder. Abdominal computed tomography identified a gas-forming liver abscess, and the patient underwent emergency drainage. However, his condition did not improve, and Clostridium perfringens was observed in his blood culture. Continuous perfusion drainage was performed by placing an additional drainage tube, which resulted in abscess shrinkage and improved the patient's general condition. Despite the low survival rate in patients with gas-forming liver abscesses caused by C. perfringens, therapy was successful in this patient.

A case of ectopic hepatocellular carcinoma in the jejunum.

We describe the case of a 72 year-old man with a huge tumor in his lower abdomen and extremely high serum alpha-fetoprotein levels (99,100 ng/ml). The patient had no risk factors for hepatocellular carcinoma (HCC) or liver disease. Computed tomography, magnetic resonance imaging, and hepatic angiography detected no tumors in the liver before surgery. The arteries feeding the tumor arose from the superior mesenteric artery, but were not recognized on celiac angiography. Histologically, the tumor cells had features of HCC. Immunohistochemical staining revealed that the tumor cells were positive for AFP and the hepatocyte paraffin 1 monoclonal antibody. Furthermore, the tumor cells were strongly positive for cytokeratin 8 and cytokeratin 18, which are usually expressed on hepatocytes in HCC, and negative for both cytokeratin 7 and cytokeratin 20, which are not usually expressed in HCC. Hence, the tumor was diagnosed as an ectopic HCC that possibly developed from ectopic liver tissue in the jejunum. Approximately 2 months after the operation, transarterial chemoembolization was performed for liver metastasis from this tumor. One year after the transarterial chemoembolization procedure, the patient remains well with no evidence of a recurrent tumor or serum AFP elevation.

[A case of advanced gastric cancer with peritoneal dissemination responding remarkably to TS-1/CDDP combination chemotherapy].

A 57-year-old woman visited a physician with complaints of anorexia and pollakiuria. Because a pelvic tumor and ascites were detected, she was referred to our department. Douglas pouch puncture revealed adenocarcinoma cells. Further examination showed an advanced gastric cancer with peritoneal dissemination. The cancer was judged to be unresectable. Chemotherapy with a combination of TS-1 and CDDP was performed before the operation. After 2 courses of the chemotherapy, her complaints disappeared, although abdominal CT confirmed remaining peritoneal dissemination. After 7 courses of chemotherapy, abdominal CT showed that the peritoneal dissemination had disappeared. Total gastrectomy and lymph node dissection were performed. Histological findings of the stomach revealed complete disappearance of cancer cells in the stomach and the regional lymph nodes. We confirmed that the TS-1/CDDP therapy resulted in a complete response to advanced gastric cancer and peritoneal dissemination. We recommend that chemotherapy be continued until the peritoneal dissemination disappears.