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A 66-year-old Japanese woman was admitted to our hospital for jaundice. Abdominal computed tomography(CT) showed dilatation of the intra- and extra-hepatic bile duct, and a hypovascular lesion measuring 30mm in diameter in the head of the pancreas. This tumor was in contact with the(superior mesenteric vein: SMV)and(inferior vena cava: IVC), but there were no obvious signs of invasion. Upper gastrointestinal endoscopy showed obstruction of the duodenum. We chose to perform an upfront surgery, considering the patient's general condition being stable and the difficulties associated with endoscopic biliary drainage. During surgery, stiff attachment between the tumor and IVC was identified and wedge resection of the IVC wall was performed. SMV resection and end-to-end reconstruction were also carried out. Pathological studies of the surgical specimen revealed direct invasion by the pancreatic adenocarcinoma into the adventitia of the IVC. The postoperative course was uneventful, and the patient was discharged from the hospital on the 27th postoperative day; she underwent adjuvant chemotherapy(S-1 100mg/day)and is still alive without tumor recurrence, 21 months after surgery. Cases of resected pancreatic adenocarcinoma directly invading the IVC are rare. In this case, pancreaticoduodenectomy along with wedge resection of the IVC wall could safely be performed, and no complications were observed. There is a need for further accumulation of similar cases.

A 68-year-old woman underwent Miles' surgery with a diagnosis of a rectalgastrointestinalstromaltumor (GIST)in 2004. In 2005 and 2006, she developed liver metastases that were surgically removed, but once again in June 2006, she presented with liver metastasis, and imatinib therapy(400mg/day)was administered. In October 2016, she was diagnosed with progression of liver metastasis, and a tumor in the pancreatic body was identified on a CT scan. The patient was referred to our institution for treatment. We performed right hepatectomy and distalpancreatectomy in January 2017. Immunohistochemically, the recurrent tumor was positive for c-kit and CD34, and the diagnosis of GIST was confirmed. The pathological diagno- sis was a high-risk GIST showing 43mitoses per 50 high-power fields. Imatinib therapy(400mg/day)was administered after surgery. She is currently alive without recurrence.

Introduction Laparoscopic distal gastrectomy (LDG) with D1+ lymph node dissection (LND) for early gastric cancer has been widely accepted. However, LDG with D2 LND for advanced gastric cancer remains in limited use. The aim of this retrospective study was to clarify the safety of LDG with D2 LND for gastric cancer. Methods From January 2010 to September 2014, 296 patients underwent LDG; those who received D1+ LND (n = 230) or D2 LND (n = 66) were included in this study. The clinicopathological characteristics and short-term outcomes of both groups were investigated and compared. Results There were no significant differences in the incidence of postoperative complications between the two groups. However, the frequency of infectious intra-abdominal complications was higher in the D2 LND group than in the D1+ LND group. Additionally, a lower risk of infectious intra-abdominal complications was seen with certified than with uncertified operators. Conclusion The evaluation of short-term outcomes demonstrated that LDG with D2 LND is generally feasible. However, the risk of infectious intra-abdominal complications is higher with D2 LND than with D1+ LND. Also, D2 LND should be performed by trained operators.

We report the first case of esophageal squamous cell carcinoma (SCC) producing granulocyte colony-stimulating factor (G-CSF) with induction of high uptake of (18)F-fluorodeoxyglucose (FDG) throughout the bone marrow. A close relationship between tumor status and serum G-CSF concentration was also seen. A 65-year-old man was admitted to our hospital because of esophageal SCC with leukocytosis and pyrexia. His leukocyte count and serum G-CSF concentration were 15900/μl and 140 pg/ml, respectively. Positron emission tomography/computed tomography (PET/CT) showed focal intense bone marrow (18)F-FDG uptake. Hypermetabolic activity in the bone marrow was suspected to be an effect of G-CSF. Under the diagnosis of G-CSF-producing esophageal SCC, the patient underwent minimally invasive esophagectomy in the prone position with 2-field lymph node dissection. After removal of the tumor, the leukocyte count and serum G-CSF concentration rapidly normalized. Immunohistochemically, G-CSF expression was found in the cytoplasm of tumor cells. High uptake of (18)F-FDG throughout the bone marrow decreased. The patient left the hospital on postoperative day 10 without any complications. Changes in bone marrow PET/CT findings and serum G-CSF concentration should be helpful in the definitive diagnosis of G-CSF-producing esophageal SCC and serve as an indicator of therapeutic effect.

We report a case of successful laparoscopic distal gastrectomy with D2 lymph node dissection preserving the common hepatic artery branched from the left gastric artery for advanced gastric cancer with an Adachi type VI (group 26) vascular anomaly. A 76-year-old female patient was admitted with a diagnosis of advanced gastric cancer at the anterior wall to the lesser curvature of the antrum (cT3N0M0 cStage IIA). Dynamic computed tomography showed the ectopia of the common hepatic artery branched from the left gastric artery. We made a diagnosis of an Adachi type VI (group 26) vascular anomaly and performed the abovementioned operation. In this anomaly pattern, scrupulous attention is required to remove the suprapancreatic lymph nodes because the portal vein is located immediately dorsal to those lymph nodes and is at increased risk for the injury in this situation. The common hepatic artery is branched from the left gastric artery, and the hepatic perfusion from the superior mesenteric artery is not present in group 26. Planning to preserve the artery will improve safety when it is possible oncologically. There were no postoperative complications, and the patient was discharged 9 days after the operation. To our knowledge, the present case is the first reported case of a laparoscopic distal gastrectomy with D2 lymph node dissection with an Adachi type VI (group 26) vascular anomaly. Preoperative diagnostic imaging is very important to prevent surgical complications because the reliable identification of vascular anomaly during an operation is very difficult.

症例は74歳，女性．高血圧にて近医に通院中，腹部エコーにて肝腫瘍を指摘され当院に紹介となった．腹部エコーにて肝S2に17mm大の境界明瞭で内部均質な低エコー腫瘤を認めた．造影CTでは，動脈相で辺縁部がリング状に濃染され，平衡相で内部が不均一に造影された．EOB-MRIではT1強調像にて低信号，脂肪抑制T2強調像で高信号を呈していた．また造影動脈相では辺縁に輪状の，内部には点状の信号増強を示していた．FDG-PETでは明らかな異常集積を認めなかった．悪性腫瘍を否定できず肝外側区域切除を施行した．術中所見では，肝S2に辺縁不整，比較的軟らかい灰白色の腫瘍を認めた．病理組織学的検査では硬化性の小血管周囲に，硝子化を伴う膠原組織や弾性線維が著明に増生しており，硬化性血管腫と診断された．肝癌類似病変に関して，今回われわれの治療経験に考察を加え報告する．

化学放射線療法で腫瘍縮小が得られ, 根治術後に長期生存が得られた直腸内分泌細胞癌を経験したので報告する. 症例は61歳の男性で, 術前の生検で内分泌細胞癌と診断され, 初回手術で人工肛門造設術のみ施行した切除不能下部進行直腸癌に対し, CPT-11+5-FU+1-LVによる全身化学療法 (IFL療法) と骨盤内に放射線照射を行った. 腫瘍の縮小と腫瘍マーカーが正常値になったことから, 腹会陰式直腸切断術を施行した. 病理組織学的診断は内分泌細胞癌で, わずかに癌細胞を認めるのみで組織学的効果判定はGrade2であった. 術後, UFT-Eを経口投与し, 根治手術後46か月現在無再発生存中である. 大腸内分泌細胞癌は極めて予後不良で外科的切除だけでは限界があり, 術前に化学療法や放射線療法を含めた集学的治療を行うことで治療成績を向上させる可能性があると思われた.

鈍的腹部外傷後41年目に腸閉塞をきたした1例を経験したので報告する．症例は53歳，男性．12歳時に腹部を強打した既往があった．2007年7月下旬に腹痛で近医を受診し，投薬のみで軽快した．8月上旬に再び腹痛を認め近医を再受診，精査加療目的で当院紹介受診し，腸閉塞の診断で緊急入院となった．腹部造影CTおよびイレウス管造影検査で小腸の狭窄を認めたため開腹手術を施行した．開腹所見では小腸間膜はひきつれて広範囲に線状の線維性瘢痕を認め，その一部に索状物が形成されて腸間膜同士が癒着し，同部の小腸が屈曲，狭小化していた．索状物の切離と癒着剥離のみで小腸の狭窄は解除したため腸切除は行わず，術後経過は良好であった．鈍的腹部外傷後，稀に遅発性の腸閉塞をきたすことがあるが，そのほとんどが受傷から1カ月以内に発症するとされている．自験例は受傷後41年という非常に長い期間を経過して腸閉塞を発症したきわめて興味深い症例と思われた．

進行食道小細胞癌に対して術前化学療法を行い，down stagingののち根治手術をしえたものの，術後急速に肝転移が出現し術後46日で死亡した症例を経験した．症例は66歳，男性．右反回神経リンパ節転移を伴った食道癌の診断で術前化学療法を施行後，食道癌根治術を行った．術後の病理検査で食道小細胞癌と診断された．術後1カ月ごろより肝転移，骨転移が出現，その後状態が急速に増悪し術後46日で肝不全のため死亡した．食道小細胞癌は，一般的に悪性度が高く予後は不良であるため，本症例のように臨床的に明らかにリンパ節転移のある進行癌症例についての手術療法は特に慎重であるべきと考えられた．

症例は65歳，男性．数年前より頻尿，混濁尿，排尿困難を主訴に，当院泌尿器科で前立腺炎の診断のもと薬物療法をうけて軽快，再燃を繰り返していた．再び同様の症状が出現したため，2007年3月上旬に当院泌尿器科を受診したところ，尿細菌培養検査で大腸菌が検出された．大腸内視鏡検査と腹部CT検査でS状結腸憩室炎によるS状結腸膀胱瘻と診断されたため，5月上旬に当科紹介受診となった．注腸造影検査では小腸瘻も認め，小腸S状結腸膀胱瘻と診断し，5月下旬にS状結腸と直腸の一部を切除したHartmann手術，回腸部分切除術を施行した．病理組織学的検査で悪性所見は認めず，S状結腸憩室炎による回腸S状結腸膀胱瘻と診断された．今回われわれは，きわめて稀なS状結腸憩室炎による回腸S状結腸膀胱瘻の1例を経験したので，若干の文献的考察を加えて報告する．

症例は68歳の男性で, 1966年胆嚢炎で開腹胆嚢摘出術を施行され, 1998年12月上旬戸谷分類Ia型の先天性胆道拡張症で胆管切除・肝管空腸Roux-Y吻合を施行された. 2006年2月より右上腹部痛と背部痛を認め, 当科入院となった. CT, MRIで膵頭部に腫瘤を認めたが, 膵管の拡張は認めなかった. ERCPで主乳頭は隆起し, 膵管は途中までしか造影されず, 遺残胆管と交通する. 胞性病変を認めた. 腹部血管造影検査で血管増生と腫瘍辺縁部の濃染像を認めた. 以上より, 遺残膵内胆管癌と考え, 膵頭十二指腸切除術を施行した. 病理組織学的診断は遺残膵内胆管より発生した腺扁平上皮癌および, 乳頭部癌と十二指腸癌も併発した同時性3重複癌であった. 分流手術後に遺残膵内胆管より発生した腺扁平上皮癌症例として, また膵内胆管癌, 乳頭部癌および十二指腸癌の同時性3重複癌症例としても本邦報告例はなく, 自験例が初めての報告と思われた.

隣接するS状結腸の腹膜垂どうしがループ状となって絞扼性イレウスを来した極めてまれな1例を経験したので報告する. 症例は61歳の男性で, 2001年他院で開腹胆. 摘出術を施行された. 2006年11月中旬突然の腹痛にて近医を受診, イレウスの診断で当院緊急入院となった. 腹部造影CTにて小腸の拡張を認めたが, 腹水は認めなかった. イレウス管を挿入したところ小腸の拡張がみられ, niveauは認めなかった. イレウス管よりの造影検査で拡張腸管の蠕動運動は認めず, 造影剤は閉塞部まで流入していかなかった. 多量の嘔吐とイレウス管による減圧効果により腹痛は軽減したが, 腹部超音波検査で腹水が出現したため, 絞扼性イレウスと診断し緊急手術を施行した. 開腹所見では血性腹水を認め, 隣接するS状結腸の腹膜垂どうしがループ状となって小腸が絞扼されていた. 腸切除は行わず絞扼の解除のみで手術を終了し, 術後経過は良好であった.

症例は69歳, 男性. 2006年6月下旬に発熱, 心窩部痛を認め, 当院救急外来を受診し, 精査にて総胆管結石による胆管炎, 急性膵炎と診断され, 内科緊急入院となった. 内視鏡的乳頭切開術を施行され, 臨床症状は軽快したが, 経過観察の腹部造影CTにて上行結腸に濃染される, 全周性壁肥厚像を認め, 上行結腸癌と考えられた. 大腸内視鏡検査にて上行結腸に2型の腫瘍を認め, 生検にて中分化腺癌と診断された. 9月上旬に手術目的で当科再入院し, 上行結腸癌, 胆石症の診断にて, 結腸右半切除術, 胆嚢摘出術を施行した. 病理組織学的検査にて上行結腸腺扁平上皮癌と診断された. 今回われわれは, 腹部CT検査にて偶然発見された, 無症状の上行結腸腺扁平上皮癌の1例を経験したので, 若干の文献的考察を加えて報告する.

症例は56歳, 男性. 2007年1月上旬に腹痛および下痢を認め, 翌日, 右下腹部に痛みが移行し近医を受診, 急性虫垂炎の診断で当科紹介受診となった. 保存的治療で経過観察したが, 発熱および右下腹部痛が増強したため, 同日緊急入院となった. 腹部超音波および腹部CT検査で虫垂憩室炎と診断し, 虫垂切除・腹腔ドレナージ術を施行した. 病理組織学的に虫垂炎を合併した虫垂憩室炎と診断された. 虫垂憩室炎の術前診断は極めて困難で, そのほとんどは急性虫垂炎と診断されて手術される. 今回われわれは, 腹部超音波および腹部CT検査で術前に診断しえた虫垂憩室炎の1例を経験したので, 文献的考察を加えて報告する.

症例は64歳, 男性. 2003年2月下旬検診の上部消化管内視鏡検査で胃癌と診断され, 手術目的で当科紹介受診となった. 当科施行の上部消化管内視鏡検査にて, 胃体中部大彎に浅い陥凹性病変を認め, 生検でpor1と診断されたため, 3月下旬に胃全摘術を施行した. 術中, 偶然左横隔膜脚に腫瘤を発見し, 切除した. 切除した腫瘤は弾性軟で, 3.5×2.0×1.5cm大であり, 腫瘤中心部の割面では大小の嚢胞性部分があり, 一部充実性部分も認められた. 病理組織学的にextralobar pulmonary sequestrationと診断された. われわれが検索しえた範囲内では, 横隔膜下の肺葉外肺分画症の本邦報告は自験例を含めて3例しかなく, また, 腹部手術時に発見された成人肺葉外肺分画症は自験例が初めてで, 極めて稀な症例と思われたので文献的考察を加え報告する.

症例は31歳, 男性. 2004年11月下旬に下腹部痛を認め, 当院泌尿器科にて前立腺炎の診断で抗生剤を投与され軽快した. その後も同様の症状を繰り返していたが, 抗生剤の内服で軽快していた. 2006年12月下旬に気尿を自覚, 2007年1月9日に当院泌尿器科を受診し, 尿検査で糞尿を認めたため, 同日, 当科紹介受診となった. 腹部CT検査にて多数のS状結腸憩室を認め, 膀胱内にガス像も認めたため, S状結腸憩室炎によるS状結腸膀胱瘻と診断し, 手術を施行した. 膀胱壁は切除せず, S状結腸部分切除術のみ施行した. 病理組織学的にも悪性所見は認めず, S状結腸憩室炎によるS状結腸膀胱瘻と診断された. 今回われわれは, 非常に稀な若年発症のS状結腸憩室炎によるS状結腸膀胱瘻の1例を経験したので, 若干の文献的考察を加えて報告する.

Laparoscopic distal gastrectomy (LDG) with D1+ lymph node dissection (LND) for early gastric cancer has been widely accepted. However, LDG with D2 LND for advanced gastric cancer remains in limited use. The aim of this retrospective study was to clarify the safety of LDG with D2 LND for gastric cancer.From January 2010 to September 2014, 296 patients underwent LDG; those who received D1+ LND (n = 230) or D2 LND (n = 66) were included in this study. The clinicopathological characteristics and short-term outcomes of both groups were investigated and compared.There were no significant differences in the incidence of postoperative complications between the two groups. However, the frequency of infectious intra-abdominal complications was higher in the D2 LND group than in the D1+ LND group. Additionally, a lower risk of infectious intra-abdominal complications was seen with certified than with uncertified operators.The evaluation of short-term outcomes demonstrated that LDG with D2 LND is generally feasible. However, the risk of infectious intra-abdominal complications is higher with D2 LND than with D1+ LND. Also, D2 LND should be performed by trained operators.

The prognosis of Stage IV b pancreatic cancer is extremely poor; the mean survival time is 2-4 months. However, new anticancer agents can improve the outcome of advanced pancreatic cancer. We present the case of a 50-year-old female patient with Stage IV b pancreatic head cancer with invasion to the superior mesenteric vein(SMV)and multiple liver metastases. The patient received S-1 as first-line chemotherapy. Three months later, a further CT scan showed reduction of the pancreatic tumor, disappearance of the liver metastases, and reduction in SMV invasion. Therefore, a subtotal stomach-preserving pancreatoduodenectomy with partial SMV resection was performed. Following surgery, the patient received S-1 chemotherapy again. However, lung metastasis appeared. Despite the initiation of gemcitabine(GEM)treatment, the patient developed metastases in other parts of the lung and the abdominal wall. She died 46 months after surgery, but it is noteworthy that the liver metastases were manageable. The combination of chemotherapy and surgery was effective in prolonging survival in this patient with Stage IV b pancreatic head cancer.

Esophagectomy with extended lymphadenectomy improves prognosis but it is associated with high morbidity and mortality. The thoracoscopic approach is associated with fewer pulmonary complications. Abdominal wall injury greatly affects pulmonary function and complication rates during the acute postoperative phase. In this study we aimed to compare the incidence of pulmonary complications and respiratory recovery after thoracoscopic esophagectomy in the prone position with hand-assisted laparoscopic surgery (HALS) versus open laparotomy (OL).This was a case-matched control study of patients with esophageal cancer who underwent thoracoscopic esophagectomy in the prone position. Thirty-two patients in the HALS group and 32 patients in the OL group were selected by the use of propensity score matching. Operative outcomes and perioperative changes in respiratory function were compared.There was no operative mortality in either group. Estimated blood loss was less in the HALS group (P .001). The incidence of postoperative pneumonia was 6.2% (4/64) overall; it was less in the HALS group (0%) than in the OL group (12.5%) (P = .016). There were no differences in preoperative vital capacity (VC) and percent predicted vital capacity (%VC). Each parameter, including the ratio of the postoperative to preoperative %VC (%VC ratio), reached its nadir on postoperative day 7 in both groups but was greater in the HALS group (VC, 2.91 ± 0.68 L vs 2.53 ± 0.53 L, P = .018; %VC, 90.62 ± 16.92% vs 78.91 ± 16.65%, P = .007; %VC ratio, 80.90 ± 9.87% vs 72.09 ± 11.95%, P = .002). At 1 and 3 months, respiratory recovery was seen in both groups but more so in the HALS group. At 6 months, further respiratory recovery was seen in both groups, without any significant intergroup differences.During the acute phase after thoracoscopic esophagectomy in the prone position, HALS is associated with less-restrictive ventilatory impairment, fewer subsequent pulmonary complications, and less blood loss than OL. The combination of HALS and thoracoscopic esophagectomy in the prone position is less invasive on respiratory function.

Anastomotic failures that cannot be detected during surgery often lead to postoperative leakage. There have been no detailed reports on the intraoperative leak test for esophagojejunal anastomosis. Our purpose was to investigate the utility of routine intraoperative leak testing to prevent postoperative anastomotic leakage after performing esophagojejunostomy.We prospectively performed routine air leak tests and reviewed the records of 185 consecutive patients with gastric cancer who underwent open total gastrectomy followed by esophagojejunostomy.A positive leak test was found for six patients (3.2 %). These patients with positive leak tests were subsequently treated with additional suturing, and they developed no postoperative anastomotic leakage. However, anastomotic leakage occurred in nine patients (4.9 %) with negative leak tests. A multivariate analysis demonstrated that a patient age75 years and the surgeon's experience30 cases were risk factors for anastomotic leakage.Intraoperative leak testing can detect some physical dehiscence, and additional suturing may prevent anastomotic leakage. However, it cannot prevent all anastomotic leakage caused by other factors, such as the surgeons' experience and patients' age.

小腸innammatory fibroid polyp (以下IFP)による血便の1例および成人腸重積症の1例を経験したので報告する.症例1: 61歳,男性.血便を主訴に当院受診,上部および下部内視鏡検査では明らかな出血源は不明であった.再び下血し当院受診,貧血を認めたため入院となり,諸検査にて小腸出血を疑った.入院中に再度下血したため緊急開腹術を施行した.術中所見では回腸に腫瘍を先進部とした腸重積を認め,回腸部分切除術を施行した.切除標本では頂部にびらんを伴った有茎性腫瘤を認めた.症例2: 59歳,女性.繰り返す腹痛と便秘を主訴に近医受診,腸炎と診断されたが腹痛が増強したため当院受診.腸重積疑いによるイレウスと診断し入院.保存的治療にて軽快,明らかな病変指摘しえず退院したが,再び便秘,腹痛出現,イレウスの診断で再入院となった.イレウス管造影および腹部CT検査にて小腸腫瘍による腸重積と診断し,開腹手術を施行した.術中所見では回腸に腫瘍を先進部とした腸重積を認め,回腸部分切除術を施行した.切除標本では表面平滑な球状有茎性腫瘤を認めた.病理組織学的検索にていずれの症例もIFPと診断された.小腸のIFPは比較的稀で,そのほとんどは腸重積で発症し,下血での発症は稀である.本疾患は術前および術中での質的診断はきわめて困難で,術後の病理組織学的検索に委ねられることがほとんどである.今回われわれは血便および成人腸重積症でそれぞれ発症した回腸IFPの2例を経験したので,若干の文献的考察を加えて報告する.

症例は68歳,女性. 2000年5月に胃癌のため当科にて胃全摘,膵尾部脾合併切除術を施行した.病理診断はtub1, mp, INFβ, ly1, v0, n1, stage IIであった.術後はUFT-E顆粒300mg/日1年間内服した. 2005年2月に右側腹部腫瘤を自覚し近医受診. CA19-9が57U/ml (

In esophageal cancer, lymph nodes along the recurrent laryngeal nerves (RLNs) are thought to be highly involved. Complete dissection of these lymph nodes is recommended but there is limited working space in the left upper mediastinum and advanced dissection skills are required. We present herein a new method for lymphadenectomy along the left RLN, called the Bascule method during prone esophagectomy. The fundamental concept of this new method is to draw the proximal portion of the divided esophagus and tissue that includes the left RLN and lymph nodes through a gap between the vertebral body and the right scapula. Using this technique, a two-dimensional membrane, similar to the “esophageal mesenteriolum” (lateral pedicle), will be easily recognizable. Identification and reliable cutting of the tracheoesophageal artery and distinguishing the left RLN from the lymph nodes should be easy. This technique was evaluated in 39 consecutive cases of prone esophagectomy for squamous cell cancer. There were 18 patients who underwent the new method (Bascule method; Bm) and 21 patients who underwent the conventional method (Cm). The duration of the thoracic procedure and dissection along the left RLN was significantly shorter in Bm group than in Cm group (258 ± 30 vs. 291 ± 39 min; p = 0.007 and 66 ± 9 vs. 75 ± 14 min; p = 0.036, respectively). Estimated blood loss in Bm group was 20 ± 11 g compared to 38 ± 32 g in Cm group (p = 0.028). No intraoperative morbidity related to the left RLN was observed in either group. The hoarseness rate in Bm group was 28 %, which was lower than that in the Cm group (48 %). The Bascule method for lymphadenectomy along the left RLN during prone esophagectomy is technically safe and feasible and reduces operative time and blood loss.

Pancreatic fistula (PF) is a serious complication of pancreatectomy and many techniques and devices have been designed to prevent PF and abdominal bleeding after pancreatectomy. We report a modified technique using a patch of the falciform ligament to prevent PF formation after distal pancreatectomy (DP).On completion of DP, the main pancreatic duct is sutured. The remnant pancreas is then closely patched and sutured vertically to the falciform ligament using 3-0 polypropylene suture. We compared the results of this method (group 1) with those of the simple method of covering the remnant pancreas with the falciform ligament (group 2).We performed this method in 14 patients undergoing DP. The rate of grade B or C PF in group 1 (7.1 %) was lower than that in group 2 (46 %).This is a simple and effective method of preventing PF fistula in DP.

The perivascular epithelioid cell family of tumors (PEComas) includes common lesions such as angiomyolipomas, lymphangioleiomyomas, and clear cell "sugar" tumors of the lung. Less frequently, PEComas arise in various other locations throughout the body, including the soft tissue, bone, and the visceral organs. We report the case of a 64-year-old man who underwent total cystectomy because of a primary malignant PEComa of the bladder in August 2010. The patient was treated with the mammalian target of rapamycin inhibitor for lung and bone metastasis from April 2011 and showed stable disease. Computed tomography showed a growing mass in the neck of the gallbladder 5 months later, which was suspected to be gallbladder cancer. Cholecystectomy and lymphadenectomy was performed in February 2012, and histopathological examination indicated gallbladder metastasis from the primary malignant PEComa of the bladder. This is, to our knowledge, the first report of malignant PEComa metastasis to the gallbladder.

We report a long-term survival case of hepatocellular carcinoma (HCC) with recurrence in the liver and multiple lymph nodes treated with lymph node dissection and percutaneous isolated hepatic perfusion (PIHP). The patient was a 70-year-old man with HCC. In 1999, transcatheter arterial chemoembolozation (TACE) was performed for HCCs. In 2000, partial hepatectomy was achieved for a recurrence in the liver. In 2002, CT scan disclosed multiple lymph node metastases around the hepatic artery and the recurrence in the liver. We performed a lymph node dissection and radio-frequency ablation for the hepatic tumor. After the operation, PIHP was performed for residual lymph node metastases. Then, a recurrence in the liver occurred 3 times, but was treated successfully with local therapy. The patient survives for 10 years after the initial therapy, and 8 years after a lymph node dissection.

We report a rare case of a 73-year-old man with gastric metastasis from colorectal cancer. Tumors of the stomach and the right side abdominal wall were diagnosed by FDG/PET-CT. Upper gastrointestinal endoscopy revealed a submucosal tumor with central depression in the fornix of the stomach. Since sigmoidectomy had been performed for cancer 39 months ago, we suspected metastasis. Proximal gastrectomy and resection of the tumor of the abdominal wall were performed. Histological findings showed moderately differentiated adenocarcinoma in the submucosal tumor. Immunohistochemical studies revealed focal positive staining for CK20 and diffuse for CDX2. These findings were similar to those of his primary sigmoid colon cancer and therefore metastasis was diagnosed.