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Background: Pancreaticoduodenectomy (PD) is a standardized strategy for patients with middle and distal bile duct cancers. The aim of this study was to compare clinicopathological features of bile duct segmental resection (BDR) with PD in patients with extrahepatic cholangiocarcinoma. Methods: Consecutive cases with extrahepatic cholangiocarcinoma who underwent BDR (n = 21) or PD (n = 84) with achievement of R0 or R1 resection in Kobe University Hospital between January 2000 and December 2016 were enrolled in the present study. Results: Patients who underwent PD were significantly younger than those receiving BDR. The frequency of preoperative jaundice, biliary drainage and cholangitis was not significantly different between the two groups. The duration of surgery was longer and there was more intraoperative bleeding in the PD than in the BDR group (553 vs. 421 min, and 770 vs. 402 mL; both PClavien-Dindo IIIa) were observed in the PD group (46% vs. 10%, P

Resected bile duct cancers often relapse during postoperative follow-up. The aim of this study was to detect predictors of early recurrence in patients with extrahepatic bile duct cancer.Consecutive cases (n = 162) of extrahepatic bile duct cancer in which R0 or R1 resection was achieved in Kobe University Hospital between 2000 and 2016 were divided into three groups [early recurrence (ER), within 6 months of surgery, late recurrence (LR), and no recurrence (NR)] and their clinicopathological features were compared.Twenty-two patients (14%) developed ER and 69 (43%) developed LR after surgery. The rates of lymph node metastasis and residual cancer status were similar in all three groups. Liver metastasis was more common in the ER group than in the LR group (59% vs. 32%, p = 0.02). ER had a significantly worse prognosis than LR and NR (7% vs. 44% vs. 85% at 1 year, p 0.01, respectively). Multivariate analysis showed that age 75 years, serum CA19-9 1008 U/ml and perineural invasion were independent predictors of early recurrence.High serum CA19-9 values ( 1008 U/ml) were an independent predictor of early recurrence. Neoadjuvant therapy and aggressive adjuvant therapy may be beneficial for patients who show highly elevated CA19-9 values before surgery.

This study aimed to evaluate the clinical relevance of hepatectomy for Barcelona Clinic Liver Cancer (BCLC) stages B and C advanced hepatocellular carcinoma (HCC). A total of 314 patients (149 and 165 BCLC stages B and C, respectively) who underwent hepatectomy were included. Complete hepatectomy (without residual tumors after hepatectomy) and reductive hepatectomy (apparent residual tumors after hepatectomy) were performed for 212 and 102 patients, respectively. Short-term operative and postoperative outcomes, as well as long-term outcomes, were evaluated. The median survival times of patients with stage B disease undergoing complete hepatectomy and reductive hepatectomy were 48.9 and 20.1 months, respectively (p = 0.0075), whereas those of patients with stage C disease were 19.5 and 17.6 months, respectively (p = 0.0140). The 3-year overall survival rates of patients with stage B disease undergoing reductive hepatectomy with and without subsequent local treatments after surgery were 47.5% and 0%, respectively, whereas those of patients with stage C diseases were 18.6% and 0%, respectively. Survival benefits are obvious for both BCLC stages B and C HCC when complete hepatectomy can be performed safely. Reductive hepatectomy is also acceptable for BCLC stages B and C when subsequent local treatment for remnant liver tumors can be performed safely after reductive hepatectomy. Without subsequent local treatment, reductive hepatectomy has little clinical relevance. Thus, a cautious approach to patient selection is required for this aggressive strategy.

BackgroundIntussusception occurs when a segment of the bowel (the intussusceptum) telescopes into an adjacent segment (the intussuscipiens). Adult intussusception occurs rarely and often requires surgical resection for its treatment. We describe the case of an adult patient with extremely rare cecorectal intussusception treated using a novel combined transabdominal and trans-anal approach, which has not yet been reported in the literature.Case presentationA 71-year-old woman was transferred to our hospital for the treatment of upper abdominal pain. Physical examination, laboratory tests, and imaging inspections showed strangulated bowel obstruction induced by intussusception associated with the intra-rectal mass. We performed an emergency operation and treated the intussusception using a combined transabdominal and trans-anal approach. The intraoperative findings revealed bloody ascites and a potentially malignant tumor that had moved toward the anal side from peritoneal reflection. The tumor served as the lead point in the cecum with mobile cecum. After reducing the intussusception using the combined procedure, we removed the ileocecal portion. The intraoperative and histopathological findings suggested that cecum cancer with mobile cecum had caused the cecorectal intussusception. The patient had an uneventful postoperative course, except for postoperative pulmonary pneumonia.ConclusionTo the best of our knowledge, this is the first reported case of adult cecorectal intussusception due to cecum cancer with mobile cecum successfully treated using the combined transabdominal and trans-anal approach. This combined procedure may be useful in treating the intussusception where the lead point is distal from the peritoneal reflection.

Objective This study aimed to determine whether retrocolic alimentary tract reconstruction is noninferior to antecolic reconstruction in terms of DGE incidence after pancreatoduodenectomy (PD) and investigated patients' postoperative nutritional status. Summary of background data The influence of the route of alimentary tract reconstruction on DGE after PD is controversial. Methods Patients from 9 participating institutions scheduled for PD were randomly allocated to the retrocolic or antecolic reconstruction groups. The primary outcome was incidence of DGE, defined according to the 2007 version of the International Study Group for Pancreatic Surgery definition. Noninferiority would be indicated if the incidence of DGE in the retrocolic group did not exceed that in the antecolic group by a margin of 10%. Patients' postoperative nutrition data were compared as secondary outcomes. Results Total, 109 and 103 patients were allocated to the retrocolic and antecolic reconstruction group, respectively (n = 212). Baseline characteristics were similar between both groups. DGE occurred in 17 (15.6%) and 13 (12.6%) patients in the retrocolic and antecolic group, respectively (risk difference; 2.97%, 95% confidence interval; -6.3% to 12.6%, which exceeded the specified margin of 10%). There were no differences in the incidence of other postoperative complications and in the duration of hospitalization. Postoperative nutritional indices were similar between both groups. Conclusions This trial could not demonstrate the noninferiority of retrocolic to antecolic alimentary tract reconstruction in terms of DGE incidence. The alimentary tract should not be reconstructed via the retrocolic route after PD, to prevent DGE.

Background To explore best practices for acute cholecystitis, it is necessary to construct a system to assess the difficulty of laparoscopic cholecystectomy (LC) based on intraoperative findings. In this study, multiple evaluators assessed videos of LC to assemble a library of typical video clips for 25 intraoperative findings. Methods We have previously identified 25 items that contribute to surgical difficulty in LC. For each item, roughly 30-second video clips were submitted from videos of LC performed at member institutions. We then selected one typical video from the collected clips based on simple tabulation of the instances of agreement. Inter-rater agreement was assessed with Fleiss's κ and Gwet's agreement coefficient (AC). Results Except in the case of two assessment items ("edematous change" and "easy bleeding"), κ or AC significantly exceeded 0.5 and the typical videos were judged to be applicable. For the two remaining items, the evaluation was repeated after clarifying the definitions of positive and negative findings. Eventually, they were recognized as typical. The completed video clip library contains 31 clips and is divided into five categories (http://www.jshbps.jp/modules/project/index.php?content_id=13). Conclusions This clip library may be highly useful in clinical settings as a more objective standard for assessing surgical difficulty in LC.

Background/aim Hepatic venous isolation and extracorporeal charcoal hemoperfusion (HVI-CHP) can reduce systemic exposure to hepatic arterial infusion (HAI) chemotherapy. The pre-existing HVI-CHP system has limited effectiveness against high-dose cisplatin; therefore, we designed a new system and evaluated its efficacy in a canine model. Materials and methods Cisplatin was administered via HAI under HVI-CHP. HVI-CHP was performed using one charcoal column in group I and two charcoal columns in group II; it was not performed in group III. The plasma cisplatin levels in the systemic circulation and at the column inlet and outlet, and the column extraction rate of were analyzed. Results The column extraction rates of free and total cisplatin in group II were significantly higher than those in group I. The systemic concentration of free cisplatin was significantly lower in group II than in groups I and III after HAI. No significant differences were observed in cisplatin concentrations in the liver tissue among all groups. Conclusion A novel HVI-CHP system for HAI of cisplatin was successfully developed.

Among the various diagnostic modalities for small bowel hemangioma, video capsule endoscopy (VCE) and double-balloon enteroscopy (DBE) can be recommended as part of the work-up in patients with obscure gastrointestinal bleeding (OGIB). DBE is superior to VCE in the accuracy of diagnosis and therapeutic potential, while in most cases total enteroscopy cannot be achieved through only the antegrade or retrograde DBE procedures. As treatment for small bowel bleeding, especially spout bleeding, localization of the lesion for the decision of DBE insertion facilitates early treatment, such as endoscopic hemostatic clipping, allowing patients to avoid useless transfusion and the worsening of their disease into life-threatening status. Applying endoscopic India ink marking prior to laparoscopic surgical resection is a particularly useful technique for more minimally invasive treatment. We report two cases of small bowel hemangioma found in examinations for OGIB that were treated with combination of laparoscopic and endoscopic modalities.

Although surgical resection is the first-line treatment for biliary tract cancer(BTC), elderly patients often have underlying diseases and decreased cardiopulmonary function that place them at a high risk of undergoing surgery. We examined the safety and efficacy of surgical resection in elderly BTC patients. Among the BTC cases that underwent surgical resection at Kobe University Hospital from 2009 to 2015, the safety and prognosis ofthose aged 75 years or older(Group 1)were compared to those younger than 75 years(Group 2)at the time ofsurgery. Fifty-two patients with perihilar cholangiocarcinoma( Bp), 29 patients with intrahepatic cholangiocarcinoma(ICC), and 40 patients with ampulla ofVater cancer(AV) were included. There was no significant difference between the 2 groups with respect to complications of Grade Ⅲor above, while surgery-related death was more common in Bp and ICC ofGroup 1. The median survival ofGroup 1 following hepatectomy for Bp and ICC(22 months)was significantly shorter than that of Group 2(40 months)(p=0.023). There was no significant difference in overall survival of Group 1 and Group 2 patients with AV(p=0.094). Surgical resection for BP and ICC for elderly patients has a higher risk of hepatectomy; therefore, precise assessment of oncologic and patient risk factors should be performed. As we can expect to achieve similar prognoses between non-elderly and elderly patients with AV, aggressive treatments should be considered for elderly patients with AV.

BACKGROUND Acute cholecystitis (AC) after cardiovascular surgery (CS) tends to have a serious postoperative course; however, there are few reports of AC after CS. In this study, we investigated the clinical features of AC after CS. METHOD Of 26 patients who underwent surgery for AC after CS between 2001 and 2018 were investigated. Of these patients, the severity of AC, onset time, surgical outcomes, and postoperative pathological findings were evaluated. RESULTS Grade III accounted for 46% (12/26) of the AC after CS patients. Gallbladder drainage did not produce sufficient outcomes in all CS cases. The postoperative hospital days of AC after CS were extended (31/21 days, P = 0.07) and the postoperative pathologic findings revealed a higher rate of gangrenous cholecystitis (88/41%, P

A 47-year-old woman who had unresectable locally advanced gallbladder cancer(GBC)accompanied with liverinvasion, duodenum invasion, transverse colon invasion, and surrounding lymphatic metastasis received 5 courses of chemotherapy with gemcitabine plus cisplatin. Afterthe chemotherapy, imaging showed down-staging of the GBC, indicating tumor shrinkage. The initial laparoscopic examination revealed no peritoneal seeding or distant metastasis. Subsequently, we performed cholecystectomy with a partial hepatectomy at the gallbladder bed. Malignant findings were not observed in the histopathological examination and the pathological diagnosis was CR with pT0N0M0, Stage 0. The patient was discharged on day 11 after the operation. There has been no recurrence at 14 months after surgery. Although the prognosis of advanced GBC with local invasion is generally poor, chemotherapy might be an effective treatment for patients with initially unresectable locally advanced gallbladder carcinoma.

Although the first-line treatment for hepatocellular carcinoma(HCC)is hepatectomy, extreme elderly(80 years or older) patients often tend to have a variety of underlying diseases and decreased cardiopulmonary function, which means that surgery involves a high risk. In this case, we examined the safety and efficacy of hepatectomy performed in an extreme elderly patient with HCC. Of the patients with HCC that underwent initial hepatectomy at Kobe University Hospital(n=348)between 2009 and 2015, 23 patients aged 80 years or older at the time of surgery(Group 1, n=23)and those younger than 80 years at the time(Group 2, n=325)were compared, based on parameters related to safety and prognosis. We did not identify differences between the 2 groups with respect to blood loss and operating time. Intraoperative blood transfusion was more common in Group 1. There was no significant difference between the 2 groups with respect to complications of Grade Ⅲ or higher. The median survival of Group 2 patients following hepatectomy(42 months)was better than that of Group 1 patients(34 months), but there was no significant difference between the 2 groups(p=0.429). Furthermore, when the same parameters were compared after adjusting for and matching propensity scores, there were no significant differences in complications, hospitalization periods, and prognosis between the 2 groups. Through proper assessment of oncologic factors and patient risk factors, hepatectomy can be performed safely and effectively even for extreme elderly patients with HCC. If there is no other disease regulating the prognosis, we can expect to achieve similar prognosis in non-extreme elderly patients. Hence, treatments should not be limited solely based on a patient being extremely elderly; rather, proactive treatments should be considered.

The patient was a 63-year-old man with hepatitis C. He discontinued combination therapy containing interferon and ribavirin because of the development of skin symptoms. A screening examination showed multiple early-stage hepatocellular carcinomas. He refused treatment and was followed up as an outpatient. During follow-up, his PIVKA-Ⅱ level remarkably elevated to 59,994mAU/mL. Computed tomography(CT)showed an enlarged tumor with portal invasion(vp2)in segment 8 and intrahepaticmetastasis. We performed right and partial hepatectomy. Three months later, CT showed multiple lung metastases. We initiated the daily administration of 800 mg of sorafenib. However, 6 months after hepatectomy, the lung metastases increased in size and number. We considered the therapeutic effect as progressive disease(PD)according to the RECIST criteria. We then initiated administering 120 mg of regorafenib daily as second-line therapy. In a course of the treatment containing sorafenib and regorafenib, the dose was reduced due to hand-foot skin reactions. 8.5 months after hepatectomy, the lung metastases significantly decreased in size. One year after hepatectomy, almost complete response(CR) was obtained, and no intrahepatic recurrence was found.

A 71-year-old woman underwent right nephrectomy for the treatment of clear cell renal cell carcinoma at the age of 53. After 15 years, surgical removal of a solitary tumor was performed in the right adrenal gland and thyroid gland; both were diagnosed as metastases of renal cell carcinoma. Eighteen years after the initial resection, computed tomography(CT) showed multiple hypervascular tumors spreading across the entire area of the pancreas. She was referred to our hospital, and endoscopic ultrasound-guided fine needle aspiration biopsy(EUS-FNA)revealed that they were metastases from the renal cell carcinoma. Total pancreatectomy and splenectomy were performed, and the patient remains alive and well with no evidence of recurrent disease 7 months after the pancreatectomy. Furthermore, her blood glucose level is well controlled with insulin therapy.

We report a case of bilobar multiple hepatocellular carcinoma(HCC)with peritoneal dissemination successfullytreated by dual treatment with reductive surgeryplus percutaneous isolated hepatic perfusion(PIHP). A 73-year-old man had sudden abdominal pain and was diagnosed bilobar multiple HCC through some examinations. The abdominal CT scan demonstrated onlya peritoneal dissemination under the liver. We performed partial hepatectomyof the lateral segment and the Spiegel lobe, and resected a peritoneal dissemination. Subsequently, we underwent PIHP twice. The tumor marker was normalized, and CT images demonstrated complete response according to the RECIST. Dual treatment is considered to be a unique therapeutic modalityfor severe advanced HCC.

A 72-year-old woman had severe watery diarrhea and weight loss. Computed tomography demonstrated a 55mm tumor in pancreatic tail with enlargement of para-aortic lymph nodes. There was no apparent liver metastasis. Endoscopic ultrasound demonstrated a well-circumscribed heterogenous tumor, which was diagnosed neuroendocrine tumor by endoscopic ultrasound-guided fine needle aspiration biopsy. For suspected VIPoma with para-aortic lymph node involvement, distal pancreatectomy and para-aortic lymphadenectomy was performed. The tumor was diagnosed as VIPoma by immunohistochemistry. The diarrhea improved after surgery. No evidence of recurrence was detected after a follow-up of 11 months.

Introduction Bile reflux into the pancreatic duct (BRPD) is sometimes demonstrated during intraoperative cholangiography (IOC) even in patients without pancreaticobiliary maljunction. However, the clinical significance of this finding in laparoscopic and open cholecystectomy is unclear. Methods Among 484 patients who underwent cholecystectomy (372 laparoscopic, 112 open), patients whose pancreatic duct was depicted in IOC were selected. The value of pancreatic amylase (p-amylase) of the gallbladder bile, histological changes, and the immunohistochemical expression of proliferating cell nuclear antigen (PCNA) in the gallbladder mucosa were analyzed in patients with BRPD. The data were then compared to those in patients without BRPD whose gallbladder bile p-amylase was measured (control group, n = 20). Results The success rate of IOC was 93.6%. The rate of BRPD in laparoscopic and open cholecystectomy was 5.2% and 5.7%, respectively. The value of gallbladder bile p-amylase in patients with BRPD was significantly higher than in the control group (790.5 vs 14.0 IU/L, P = 0.034). The value of the PCNA labeling index in patients with BRPD was significantly higher than that of the control group (15.4% vs 4.1%, P = 0.0026). Among the 24 patients with BRPD, pathological changes in the gallbladder mucosa were detected in five (two hyperplasia, three metaplasia), but there was no correlation between the presence of pathological change and PCNA labeling index or gallbladder bile p-amylase. Conclusions IOC could detect BRPD both in laparoscopic and open cholecystectomy at a similar rate. Patients with BRPD had high levels of gallbladder bile p-amylase and PCNA labeling index, findings similar to those in patients with pancreaticobiliary maljunction.

Although preoperative biliary drainage in jaundiced patients is controversial, external biliary drainage (EBD) is beneficial for infection control in patients with biliary cancers. When EBD is performed, additional bile replacement (BR) has the benefit of improving impaired intestinal barrier function, but the detailed mechanism remains unknown. We examined the effect of bile replacement on immune functions over the duration of BR in jaundiced patients. Fifteen patients were enrolled into this prospective study. BR was started soon after the total serum bilirubin concentration reached 5.0 mg/dl and was continued for 14 days. Drained bile was given two times orally (2 × 100 ml/day). Concanavalin A (Con A)- and phytohemagglutinin (PHA)-stimulated lymphocyte proliferation and serum diamine oxidase (DAO) activity were measured before starting and during BR. Twenty patients with EBD and no BR were analyzed as a control group. Serum liver enzymes, prothrombin time–international normalized ratio (PT-INR), and responses to Con A and PHA gradually improved over the 14 days of BR, but percentages of lymphocytes and DAO levels did not. PT-INR, and Con A and PHA responses did not improve during EBD in the control group. PT-INR significantly decreased in patients with a greater fraction of their drained bile replaced. Our results indicate that preoperative BR using as large a quantity of bile as possible is useful for improving blood coagulability and cellular immunity in patients with EBD.

Changes in the microbiota composition are able to affect nutrient absorption and energy metabolism, but there are few human studies. The aims were to analyze fecal constituents quantitatively and compare them with liver dysfunction in hepatic cancer patients and to evaluate the relationships among intestinal microbiota, fecal organic acids and plasma lipid composition.Fecal samples collected from 46 hepatic cancer patients (with liver cirrhosis, chronic hepatitis or liver fibrosis and normal liver) were evaluated for fecal constituents. Blood organic acid, lipid and fatty acid concentrations were analyzed.Fecal microbiota and organic acids showed no significant differences among different liver dysfunction patients. In normal liver patients, fecal Candida was positively correlated with plasma phospholipid while Bifidobacterium was negatively correlated with plasma eicosapentaenoic acid and eicosapentaenoic acid/arachidonic acid ratio (all p 0.05). In cirrhotic liver patients, positive correlations were noted for Lactobacillus and docosahexaenoic acid and Candida and eicosapentaenoic acid or eicosapentaenoic acid/arachidonic acid ratio (all p 0.01). It was suggested that intestinal biota affected serum fatty acid metabolism and were modified by liver disorders.Intestinal microbiota and organic acid concentrations in hepatic cancer patients had positive and/or negative correlations with serum lipid levels.

A 25-year-old woman was referred to our hospital with persistent upper abdominal pain. Preoperative imaging studies revealed a hilar bile duct stricture with portal venous encasement, and the patient underwent curative resection involving extended left hepatectomy and segmental portal vein resection. The pathological findings demonstrated a well-differentiated tubular adenocarcinoma of the bile duct with regional lymph node metastasis (stage IIIB according to the UICC TNM classification), as well as the overexpression of p53 proteins and the K-ras gene mutation in tumor cells. The patient has shown no evidence of recurrence in the 10 months since the operation. Although there are several reports of relatively young adults with cholangiocarcinoma, the majority of such patients demonstrate either an anomalous arrangement of the pancreaticobiliary duct system or primary sclerosing cholangitis. The absence of any morphological abnormalities in this patient's biliary system implicates de novo carcinogenesis as the most likely cause of the cholangiocarcinoma.

The aim of this study was to assess the effect of preoperative and postoperative synbiotic treatment in hepatectomy patients with or without liver cirrhosis.Sixty-one patients with hepatic cancer were assigned randomly to receive either oral synbiotics that consisted of Bifidobacterium, Lactobacillus, and galactooligosaccharides or no synbiotics (control) preoperatively for 14 days and postoperatively for 11 days. Infectious complications, intestinal mucosal integrity as measured by serum diamine oxidase (DAO) activity, and fecal flora and organic acid concentrations were compared between synbiotic treatment (n = 32) and control (n = 29) groups.Fecal flora culture and organic acid concentrations were changed after hepatectomy in both groups. The postsurgery decrease in DAO activity was less profound in the synbiotic-treated group (P.01) and was correlated negatively with serum interleukin 6 and C-reactive protein concentrations (P.001). Infectious complications occurred in 5 (17.2%) patients in the control group and no patients in the synbiotic-treated group (P.05).Perioperative synbiotic treatment attenuated the decrease in intestinal integrity and reduced the rate of infectious complications in patients with or without liver cirrhosis who underwent hepatic surgery.

79歳，男性．心窩部痛を主訴に近医を受診し，上部消化管内視鏡検査にて前庭部胃癌と十二指腸乳頭部癌を認め当院に紹介された．術前生検ではいずれも腺癌と診断され，標準膵頭十二指腸切除術により両者を一期的に切除した．病理組織学的検索では胃は腺癌（por2>tub2，pT2（MP），pN1，fStage II）で，十二指腸乳頭部病変は免疫組織学的検索にてsynaptophysin，chromogranin A陽性の内分泌細胞癌（pT3，pN1，fStage III）と診断された．また，複数のリンパ節に内分泌細胞癌および腺癌の起源の異なる転移を認めた．術後6カ月目で内分泌細胞癌が肝転移再発をきたし，13カ月目に癌死した．十二指腸乳頭部内分泌細胞癌の報告は複数あるが，胃癌との重複例はこれまで皆無であった．また，自験例は膵頭十二指腸切除術により両者の切除が一期的に可能であった興味ある症例と考え報告する．

本研究では受信機が測位に必要な時間TTFF (Time To First Fix） を短縮するために，新しい航法メッセージを受信せずに，過去の航法メッセージを初期値として使う衛星位置予測法を提案する．測位衛星の位置予測結果に対して，精密暦で求められた衛星位置を用いて予測精度を評価した上で，最適な摂動モデルを決定する．実験により，全衛星に対して，地球ポテンシャルモデルをJGM-3モデルで次数が8次，太陽輻射圧のモデルがGSPMモデルでのシミュレーション結果から，72時間以内の衛星軌道予測によるユーザー視線方向のレンジ誤差が約90m以内になっていることが確認され，提案した予測法の有効性が示された．

The area near the left gastric vein (LGV) is a challenging site at which to perform dissection of the lymph nodes during gastrectomy. Therefore, knowledge of the precise location of the LGV is important. The objective of this study was to examine the usefulness of multidetector computed tomography (MDCT) for the identification of the LGV.Eighty-one patients with gastric cancer underwent MDCT, which was performed with contrast media in 76 patients and without contrast media in 5 patients. A 5-mm thin slice of the frontal image was reconstructed. These images were examined preoperatively to detect the location of the LGV. Upon gastrectomy, the LGV was identified and its location compared to that determined by MDCT.The LGV was identified by MDCT in 76 of the 81 patients (93.8%). The LGV was subsequently located during the operation in all 81 patients. The LGV was located dorsal to the common hepatic artery in 40 patients (49.4%), ventral to the common hepatic artery in 18 patients (22.2%), ventral to the splenic artery in 17 patients (21.0%), dorsal to the splenic artery in 2 patients (2.5%) and in other positions in 4 patients (4.9%). In all patients, the location of the LGV detected using MDCT was consistent with that identified during gastrectomy. In the 4 patients with relatively unusual locations of the LGV, these 4 LGV variants were identified preoperatively by MDCT.MDCT was useful for identifying the location of the LGV prior to gastrectomy.

症例は66歳の男性．門脈本幹に腫瘍栓の進展を認める肝細胞癌に対してlow dose FP動注療法を行いCRが得られた．以後外来にて5-Fu 750 mgの動注治療を1年4カ月にわたり継続した．治療開始2年後に両側の多発性肺転移・単発脳転移を認めた．QOLを考慮し脳の転移巣を切除し，5-Fuを基本とした全身化学療法（CDDPおよびEPIを併用）を行なうも効果は得られなかった．肺転移の増悪のため化学療法をすべて中止し，十全大補湯（TJ-48）の投与を開始した．十全大補湯投与開始5カ月後に血清AFPおよびPIVKAIIは正常値になり，肺転移巣は痕跡となり，CRを2年維持している．肺転移は化学療法終了時増悪傾向を呈しており，その治癒には十全大補湯が強く関与していると考えられた．文献的考察を加え報告する．

症例は63歳,男性.下腹部痛を主訴に来院.急性腹症の診断にて緊急手術施行.回腸の約60cmの範囲に多発性の腫瘍を認め,その一部が小腸間膜に穿通していた.穿通部を含め約70cmの小腸切除と所属リンパ節の可及的な郭清を行い手術を終了した.化学療法 (CHOP) を施行したが,術後73日目に永眠された.病理組織学的所見上は小腸原発のT細胞性悪性リンパ腫で,新WHO分類上enteropathy typeであった.また免疫染色上CD56, CD8ともに陽性であった.本症例は複数の予後不良因子を併せ持つ悪性リンパ腫で,術後の化学療法でもほとんど効果が得られず,極めて予後不良な経過をたどったと考えられた.

Recently, T cells were classified into two categories: intrathymic T cells (ITCs; thymus-derived T cells) and extrathymic T cells (ETCs). ETC, localized in the liver and intestinal intraepithelium (IE), play an important immunologic role in the suppressed condition of T-cell development in the thymus. Given the fact that complications of surgery in patients with obstructive jaundice are often related to immunosuppression in the gut-liver circulation, we attempted to investigate the changes in the proportion of ETCs in mice with obstructive jaundice. Three mice models were prepared ( n = 10 per group): sham group with simple laparotomy; ligation group with common bile duct ligation; deoxycholic acid (DCA) group with an oral intake of DCA as a model of the presence of bile salts in the gut lumen. In each model, total mononuclear cells (MNCs), ITCs in the thymus, and ETCs in the liver and IE were counted using monoclonal antibodies in conjunction with a two-color immunofluorescence test by flow cytometry. In the ligation group the number of MNCs was reduced in the thymus and IE, and only those in the IE recovered after oral intake of DCA. A decrease of ITCs in the thymus and the increase in ETCs in the liver and IE occurred simultaneously during the early phase of biliary obstruction. At day 7 after biliary obstruction, ETCs in the livers of the DCA and ligation groups decreased to nearly the level in the sham group. However, on day 7 the ETCs in the IE remained significantly higher in the DCA group than in the ligation group. These results suggested that ETCs can act in place of ITCs at an early phase of obstructive jaundice, and the presence of bile in the gut lumen may be associated with the consumption of ETCs in the IE, a reaction that may bring about improved immunoreactivity.

The present paper proposes two estimation methods for estimating not only the coefficients of roll damping moment but also the coefficients of roll restoring moment without calculation of hydrostatics. The first method is an energy method which involves expanding Proude’s method [5] to the case for which the restoring moment is nonlinear. The second method can identify the coefficients of arbitrary form of nonlinear damping and restoring moments by genetic algorithm. The advantage of these methods is that identification of a highly precise coefficient is very easy compared to other conventional methods. This advantage is most important in applications to practical problems. These methods are first applied to numerical simulation data and then to real free-decay data obtained from scale models.

Bile reflux into the pancreatic duct (BRPD) is sometimes demonstrated during intraoperative cholangiography (IOC) even in patients without pancreaticobiliary maljunction. However, the clinical significance of this finding in laparoscopic and open cholecystectomy is unclear.Among 484 patients who underwent cholecystectomy (372 laparoscopic, 112 open), patients whose pancreatic duct was depicted in IOC were selected. The value of pancreatic amylase (p-amylase) of the gallbladder bile, histological changes, and the immunohistochemical expression of proliferating cell nuclear antigen (PCNA) in the gallbladder mucosa were analyzed in patients with BRPD. The data were then compared to those in patients without BRPD whose gallbladder bile p-amylase was measured (control group, n = 20).The success rate of IOC was 93.6%. The rate of BRPD in laparoscopic and open cholecystectomy was 5.2% and 5.7%, respectively. The value of gallbladder bile p-amylase in patients with BRPD was significantly higher than in the control group (790.5 vs 14.0 IU/L, P = 0.034). The value of the PCNA labeling index in patients with BRPD was significantly higher than that of the control group (15.4% vs 4.1%, P = 0.0026). Among the 24 patients with BRPD, pathological changes in the gallbladder mucosa were detected in five (two hyperplasia, three metaplasia), but there was no correlation between the presence of pathological change and PCNA labeling index or gallbladder bile p-amylase.IOC could detect BRPD both in laparoscopic and open cholecystectomy at a similar rate. Patients with BRPD had high levels of gallbladder bile p-amylase and PCNA labeling index, findings similar to those in patients with pancreaticobiliary maljunction.

This study assessed the results of preoperative evaluation of ductal invasion by perihilar cholangiocarcinoma, imaged using 3-dimensional (3D) CT cholangiography compared to conventional endoscopic retrograde cholangiography (ERC) and magnetic resonance cholangiopancreatography (MRCP).ERC, MRCP and 3D-CT cholangiography were planned in 24 patients with preoperatively diagnosed perihilar cholangiocarcinoma. Evaluations of bile duct images using each of 3 modalities were classified into 2 groups (the Visualization uncertain (VU) group and the Visualization certain and clear (VCC) group) according to the quality of biliary images. The results of pathological assessments and preoperative radiological evaluations were compared.In the bile duct evaluation, the rates between the 2 groups were not significantly different across the three modalities. 3D-CT cholangiography evaluated tumour involvement most clearly in patients with obstructive jaundice (p = 0.044), and ERC evaluated biliary tree more clearly compared to MRCP or 3D-CT cholangiography in patients without obstructive jaundice (p = 0.051). For evaluation of pathological tumor invasion in the VCC group, 3D-CT cholangiography enabled a correct diagnosis in 7 of 11 patients, and R0 resection was achieved in 8 of 11 patients.3D-CT cholangiography offers accurate preoperative assessment of bile duct invasion by perihilar cholangiocarcinoma, especially in patients with obstructive jaundice.

胃切除後の癒着性イレウス術後,ステント用として留置したイレウス管が誘因で発症した小腸重積症の手術症例を経験したので報告する.症例は70歳男性.胃切除術後85日目にイレウス発症し入院.イレウス管留置の上保存的療法行うも改善せず,入院後17日目に手術施行.術後3日目にイレウス管抜去.抜去後嘔吐と軽度の腹痛持続.術後7日目に造影施行. Treitz靱帯よりやや肛門側の部位に狭窄認めた.術後8日目に施行したCTにて同部位の腸重積が疑われさらに造影検査でその肛門側にも狭窄部位を認めたため術後9日目再手術施行. Treitz靭帯より10cm肛門側の部位と120cm肛門側の部位にそれぞれ順行性3筒性の腸重積を認めたため2箇所の腸切除を行った.イレウス管留置の際,頻度は低いが腸重積の合併も念頭に置くべきであると考えられた.

We report a 65-year-old man who developed sclerosing encapsulating peritonitis (SEP) 15 months after converting from continuous ambulatory peritoneal dialysis (CAPD) to hemodialysis because of intraabdominal hemorrhage following a traffic accident. In January 1999, he suffered acute abdominal pain and vomiting. He was referred to our hospital from a nearby clinic with suggested adhesional intestinal obstruction. Physical examination showed a palpable mass in the lower abdomen. He underwent an emergency operation with a diagnosis of strangulated intestinal obstruction. The laparotomy revealed a large amount of bloody ascites and dense fibrous adhesions that entrapped the small intestine in a thick membrane. We resected the loop of the ileum because separation of the bowel mass, simulating cocoon, seemed impossible. The diagnosis of SEP was made postoperatively. He was started on oral prednisolone therapy after the operation. SEP is a rare and serious complications of CAPD, and develops even after CAPD has bees discontinued. The diagnosis of SEP should be kept in mind in CAPD patients presenting with recurrent adbominal pain or intestinal obstruction.

Laparoscopic cholecystectomy (Lap-C) is a standard surgery for symptomatic gallbladder stones and acute or chronic cholecystitis. Resident surgeons often perform this operation early in their training, but they sometimes encounter difficulties for various technical reasons. Although encountering a gallbladder buried deep within the gallbladder bed is a common operative difficulty, literature on the subject scarcely exists.Forty-two patients underwent Lap-C at our hospitals and were analyzed retrospectively. We defined the gallbladder bed pocket score (GBPS) as the maximum ratio between the height and width of the gallbladder bed measured based on multi-detector computed tomography (MDCT) images. GBPS and clinical factors were assessed in terms of their correlation with the time required for gallbladder dissection from the gallbladder bed.Of the 42 patients, 20 had histories of acute or chronic cholecystitis. The mean gallbladder dissection time was 14.9 min, and the mean GBPS was 0.43 in the coronal MDCT section and 0.56 in the sagittal section. The correlation coefficient between the GBPS and gallbladder dissection time was 0.40 (P = 0.01) in the coronal section and 0.38 (P = 0.02) in the sagittal section of the MDCT images. There was no statistically significant correlation between gallbladder dissection time and the surgeon's experience, patient's history of cholecystitis, gallstone size, or blood loss. However, GBPS 0.4 predicted more difficult and prolonged dissection.GBPS is a useful tool for preoperatively predicting the time needed to dissect the gallbladder from the gallbladder bed during Lap-C. Cases with GBPS0.4 seem more suitable for resident surgeons who are performing gallbladder dissection early in their Lap-C training.

Small Japanese fishing vessels do not have smooth bodies, therefore the old damping function in a single degree of freedom rolling equation with no excitation cannot be applied to these vessels. This paper presents a new type of damping function which is applicable to small fishing vessels, outlines a method for determining parameters in the nonlinear equation of free rolling and describes characteristics of roll damping of small fishing vessels.

A 69-year-old woman who had locally advanced pancreatic cancer underwent proton beam radiotherapy(67.5 GyE/25 Fr) concurrent with gemcitabine chemotherapy (GEM 800 mg/m2 day 1, 8) at Hyogo Ion Beam Medical Center, followed by GEM chemotherapy (1,000 mg/m2 day 1, 8, 15/28 day)at Kobe University Hospital. She visited our hospital because she was suffering from dyspnea 212 days after first administration of GEM. A chest computed tomography revealed that infiltrations were spreading in the bilateral lung fields. A bronchoscopy showed diffuse alveolar hemorrhage. We diagnosed GEM related interstitial lung disease with diffuse alveolar hemorrhage. We introduced steroid pulse therapy (methylprednisolone 1 g/day) for 3 days followed by oral prednisolone (40 mg/day), which was tapered gradually. She recovered and was discharged on the 24th day after admission.

(18)F-Labeled fluorodeoxyglucose positron-emission tomography (FDG-PET), a rapidly evolving functional imaging modality, has recently been shown to be useful in the diagnosis and staging of various malignant tumors due to focal uptake of FDG-labeled glucose in malignant cell populations. However, the role of FDG-PET in the diagnosis and staging of biliary tract cancer is still controversial and has not yet been fully evaluated. The aim of this study was to determine the clinical importance of FDG-PET in the preoperative evaluation of biliary tract cancer and retrospectively clarify the characteristics of false-negative and false-positive cases. We retrospectively analyzed data for 73 consecutive patients diagnosed with cancer of the biliary tract and were admitted to the Department of Hepato-Biliary-Pancreatic Surgery at Kobe University Hospital for treatment, from January 2007 to August 2009. Since the sensitivity, specificity and positive predictive value (PPV) of FDG-PET in the diagnosis of bile duct carcinoma are usually relatively high, FDG-PET is considered to be a useful tool in diagnosing biliary tract cancer. FDG-PET also seems to be useful in clinical decision-making, regarding treatment strategy, including surgery. Our results showed that FDG-PET is highly sensitive in delineating the primary focus of biliary cancer and is a useful tool in preoperative examination. A disadvantage of FDG-PET is its inability to indicate small metastases and false-positive findings of inflamed gallbladder and bile duct lesions.

Routine performance of intraoperative cholangiography (IOC) during cholecystectomy is controversial. The aim of this study was to evaluate the role of IOC during cholecystectomy in addition to preoperative magnetic resonance cholangiopancreatography (MRCP) in our institution over a 12-year period. A total of 425 consecutive patients who underwent IOC during cholecystectomy were included in this study. MRCP was performed preoperatively for bile duct evaluation in all patients. When common bile duct (CBD) stones were detected, they were removed endoscopically before the operation. We estimated the results of IOC in terms of the success rate, the detection rate of anatomic abnormality of the biliary system, and the incidence of residual CBD stones. MRCP preoperatively identified 6 (1.4 %) patients with abnormal biliary systems and 56 with CBD stones, which were endoscopically removed. The success rate of IOC was 93.8 % (399/425). Abnormalities of the biliary system were detected in 12 patients (12/399, 3.0 %) and CBD stones in 8 (8/399, 2.0 %). Of the eight patients with stones, seven had been examined by endoscopy preoperatively and found to have CBD stones. The detection rate of bile duct stones in patients with preoperative endoscopic removal of CBD stones (7/56, 12.5 %) was significantly higher than those with CBD stones first detected during IOC (1/365, 0.3 %) (p