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Highlights • Gastric heterotopic pancreas (HP) rarely expands due to inflammation or malignant transformation. • Enlarged gastric HP caused by retention cysts is a rare case. • Symptomatic enlarged gastric HP should be resected for histological diagnosis., Introduction Gastric heterotopic pancreas (HP) is usually asymptomatic and benign; however, it may become evident when it is complicated by pathological changes such as inflammation, bleeding, and malignant transformation. Presentation of case A 43-year old man was diagnosed with gastric HP 18 years prior suffered a haemorrhage from the enlarged gastric HP with multiple cystic lesions. Although endoscopic ultrasonography–guided fine needle aspiration showed no malignancy, he underwent a partial gastrectomy for diagnosis and treatment. Postoperative histological findings revealed ectopic pancreatic tissue with retained cysts that consisted of dilated pancreatic ducts without malignancy. Discussion This is a first report of enlarged gastric HP due to the expansion of retained cysts. Gastric HP is rarely enlarged by pathological changes including inflammation, retention cysts, or malignant neoplasms. Conclusion Symptomatic enlarged gastric HP should be respected and further examined histologically to ensure diagnostic accuracy.

Acute mesenteric ischemia (AMI) is a rare life-threatening condition that causes intestinal necrosis. Prompt intervention is essential to mitigate high mortality. In this report, we describe a case of AMI where precise diagnosis using indocyanine green (ICG) imaging to confirm sufficient bowel perfusion and viability, helped in preventing intestinal resection.A 91-year-old male was diagnosed with AMI associated with superior mesenteric artery thrombosis using computed tomography and underwent exploratory laparotomy. Under white light, there was no outward evidence of small-bowel necrosis. Hence, ICG was used to confirm adequate bowel perfusion and viability. The operation was terminated without resection of the small intestine. When anticoagulation therapy was initiated postoperatively, the thrombus subsided. Although the patient had no subsequent recurrence, he died of dysphagic pneumonia two months after the surgery.Physicians often choose to perform trial laparotomy to diagnose intestinal ischemia due to AMI. However, it was difficult to assess the viability of the entire intestinal tract using white light alone, and the introduction of ICG in the evaluation of intestinal perfusion will facilitate the identification and objective evaluation of the intestinal ischemic zone. There have been few reports on application of fluorescent-guided determination of the viable zone of the small intestine, which will help surgeons to make precise diagnosis.This case demonstrates ICG fluorescence imaging as a useful method for objectively assessing bowel viability.

Highlights • SANT displayed a rapid growth in size from 20 mm to 70 mm during 3 years after adrenalectomy. • Splenectomy was performed by hand assisted laparoscopic surgery (HALS). • Corticosteroids might be useful for treating SANT., Introduction Sclerosing angiomatoid nodular transformation (SANT) is a rare benign lesion with an unknown natural history and pathogenesis. So far fewer than 100 cases were documented, but detailed incidence and prevalence are unknown. Presentation of case We report a case of SANT of the spleen in a 37-year-old man that showed rapid growth after adrenalectomy for primary aldosteronism. Computed tomography showed a nodule in the spleen that increased in size from 2.0 cm to 7.0 cm during 3 years of observation. Discussion This case is reported because data regarding growth rates and natural history of these lesions are limited and few cases have been reported to show the rapid growth progression seen in this case. Conclusion Decreases in glucocorticoid concentrations following adrenalectomy may have contributed to the rapid growth of SANT of the spleen, because SANT is considered to be related to immunoglobulin G4-associated disease.

Background: Postoperative pancreatic fistula (POPF) is a harmful complication after pancreaticoduodenectomy (PD). Grade C POPF, as defined by International Study Group of Pancreatic Fistula (ISGPF), is the most life-threatening complication. This study aims to evaluate risk factors for Grade C POPF after PD. Methods: This is a prospective, multicenter collaboration study based in Japan and Taiwan. Between 2014 and 2017, 3,022 patients were enrolled in this study and 2,762 patients were analysed after 260 patients were excluded (discontinuation of protocol treatment: n=241, incomplete information: n=19). We analysed risk factors of Grade C POPF based on the 2005 ISGPF scheme (sepsis, organ dysfunction, haemorrhage, reoperation, and/or death) and then separately by the updated 2016 ISGPF scheme (organ failure, reoperation, and/or death). Findings: Among 2,762 patients that underwent PD, 93 patients (3∙4%) developed Grade C POPF as defined by 2005 ISGPF and 46 patients (1∙7%) developed Grade C POPF as defined by 2016 ISGPF. We found eight independent risk factors associated with Grade C POPF as defined by 2005 ISGPF on multivariate analyses; male sex, body mass index (BMI) ≥25∙0 kg/m2, chronic steroid use, preoperative serum C-reactive protein ≥1∙0 mg/dL, soft pancreas, main duct size

Highlights • Adrenal cortical carcinoma (ACC) is rare, often recurring, and has a poor prognosis. • Surgery remains the optimal treatment for ACC, due to chemotherapy’s ineffectiveness. • Our patient developed 2 liver metastases after right adrenalectomy (1.5 and 4 years). • Therefore, complete surgical resection should be considered in similar cases., Introduction Adrenal cortical carcinoma (ACC) is a very rare type of tumor that generally has a poor prognosis. Little has been reported on repeated liver resections with recurrent metastasis still confined to the liver. In this report, we describe a case of functioning ACC in a 65-year-old woman with 2 liver metastases of the ACC (at 1.5 and 4 years) after the right adrenalectomy. Presentation of case A 65-year-old woman was referred to our hospital based on a suspicion of hyperaldosteronism. Abdominal computed tomography revealed a lesion at the right adrenal gland; therefore, we performed right adrenalectomy and subsequently diagnosed the lesion as ACC. However, follow-up computed tomography at 1.5 and 4 years after the right adrenalectomy revealed liver metastasis of ACC; liver resection was performed for both metastases. Discussion Complete surgical resection is the established approach for the treatment of ACC. The prognosis of ACC is usually dismal, and recurrence rates of up to 85% have been reported. However, the appropriate treatment for recurrent ACC is not well established, and the effectiveness of other modalities, such as chemotherapy and radiotherapy, is not proven. Therefore, surgical resection may currently be the most appropriate treatment modality, as the patient achieved a disease-free interval of 2.5 years after the first liver resection. Conclusion In selected patients with recurrent or metastatic ACC, resection is likely to be associated with prolonged survival. However, a full cure is generally not achievable, and a multidisciplinary approach is likely needed to achieve long-term disease-free status and survival.

Background Intraportal administration of alloantigen is reported to reduce antigen-specific immune responses, although the underlying mechanisms for the reduced immunological reactions, especially those of the graft, are poorly understood. We examined intracellular cytokine production by graft-infiltrating lymphocytes (GILs) and peripheral blood lymphocytes (PBLs) to elucidate the underlying mechanisms of beneficial effects on intraportal infusion of donor cells in rat small bowel transplantation (SBT). Methods Recipient rats (Lewis) were transplanted with small bowel from ACI rats. Tacrolimus (Tac) was injected daily from days 0 to 4. Bone marrow cells of ACI rats were infused via the portal or tail vein on the day of surgery. On day 5, both GILs and PBLs collected from SBT graft and peripheral blood, respectively, were analyzed for intracellular cytokine production of recipient-derived αβ-T cells. The Th1/Th2 balance in each group was designated as the ratio of the percentage of GILs or PBLs staining positive for intracellular IL-4 or IFN-gamma, respectively. The total cell numbers of GILs from SBT graft were also counted. Results Survival of recipients was markedly prolonged by the combination of Tac and donor-specific bone marrow infusion via the portal vein (DS BMI -PV-Tac) compared with the untreated control, Tac alone, or DS BMI tail vein plus Tac. DS BMI -PV-Tac significantly decreased the total cell numbers of GILs and also induced remarkable Th2-type response in GILs. Conclusions Our results indicate that DS BMI -PV-Tac decreased GILs and enhanced Th2-type response in SBT graft, both of which are associated with a significant prolongation of graft survival in SBT.

We investigated whether intraoperative infusion of fat emulsion could suppress postoperative endotoxemia and improve energy status in the transplanted liver graft using a swine orthotopic liver transplantation (OLT) model. Intraoperative free fatty acid (FFA) concentration, hepatic FFA clearance, serum hyaluronic acid levels, ATP content and hepatic energy charge (HEC) in liver grafts, postreperfusional endotoxin levels and recipient outcome were compared between a fat emulsion-treated group (LCT-treated group, n =6) and a saline infused-group (control group, n =7). Independent of massive surgical stress and administration of heparin, FFA concentration was significantly elevated in the LCT-treated group ( P =0.003). Since FFA clearance, ATP contents and HEC were also increased in the LCT-treated group ( P =0.024, 0.006, 0.005, respectively), intraoperative LCT-treatment was shown to increase FFA concentration and improve energy status of liver grafts. Because there were no significant differences in postoperative hyaluronic acid levels, infused fat emulsion (0.1 g/kg per hour) prevented endothelial cell injury. Significant improvement of postoperative endotoxemia was obtained at 1 and 2 h after reperfusion ( P =0.01 and 0.003, respectively). Energy booster effect and antiseptic effect led to prolonged survival of recipients in the LCT-treated group (28.5±13.3 days, P =0.013 vs. control). We concluded that the hepatic energy booster effect and the lipo-modulatory effect on postreperfusional endotoxemia caused by intraoperative infusion of fat emulsion may be of great use in human liver transplantation.