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Laparoscopic liver resection for hepatocellular carcinoma (HCC) in patients with Child-Pugh A cirrhosis has been shown to be beneficial. However, less is known regarding the outcomes of such treatment in patients with Child-Pugh B cirrhosis. We conducted a retrospective study to evaluate the outcomes of laparoscopic liver resection for HCC in patients with Child-Pugh B cirrhosis, focusing on surgical risks, recurrence, and survival.357 patients with HCC who underwent laparoscopic liver resection from 2007 to 2021 were identified from our single-institute database. The patients were divided into three groups by their Child-Pugh score: the Child-Pugh A (n = 280), Child-Pugh B7 (n = 42), and Child-Pugh B8/9 groups (n = 35). Multivariable Cox regression models for recurrence-free survival (RFS) and overall survival (OS) were constructed with adjustment for preoperative and postoperative clinicopathological factors.The Child-Pugh B8/9 group had a significantly higher complication rate, but the complication rates were comparable between the Child-Pugh B7 and Child-Pugh A groups (Child-Pugh A vs. B7 vs. B8/9: 8.2% vs. 9.6% vs. 26%, respectively; P = 0.010). Compared with the Child-Pugh A group, the risk-adjusted hazard ratios (95% confidence intervals) in the Child-Pugh B7 and B8/9 groups for RFS were 1.39 (0.77-2.50) and 3.15 (1.87-5.31), respectively, and those for OS were 0.60 (0.21-1.73) and 1.80 (0.86-3.74), respectively. There were no significant differences in major morbidities (Clavien-Dindo grade II) (P = 0.117) or the proportion of retreatment after HCC recurrence (P = 0.367) among the three groups.Among patients with HCC, those with Child-Pugh A and B7 cirrhosis can be good candidates for laparoscopic liver resection in terms of complications and recurrence. Despite poor postoperative outcomes in patients with Child-Pugh B8/9 cirrhosis, laparoscopic liver resection is less likely to interfere with retreatment and can be performed as part of multidisciplinary treatment.

The Senhance Digital Laparoscopy System (Asensus Surgical Inc, Morrisville, NC, United States), which was introduced for the first time in Japan by our hospital, is a new surgical assistive robot following the da Vinci Surgical System. We herein report the short-term outcomes of 55 colorectal cancer surgery cases using this system at our hospital to assess the feasibility and safety of our procedures.We retrospectively reviewed the patient backgrounds and surgical outcomes of 55 patients who underwent Senhance-assisted laparoscopic colorectal cancer surgery.The median age was 71 years. There were 31 males and 24 females, and the median body mass index was 23.1 kg/mThe short-term results of 55 colorectal cancer surgery cases using the Senhance Digital Laparoscopy System were excellent and the system was introduced and surgery was safely performed.

Lymphoid hyperplasia is a type of tumor-like hyperplasia of lymphoid tissue. There have been few reports on lymphoid hyperplasia of the gallbladder. Here, we report a case of lymphoid hyperplasia with a polyp form of the gallbladder macroscopically mimicking carcinoma. Liver dysfunction was diagnosed in a 75-year-old woman who presented with a gallbladder mass measuring 20 mm during an annual health checkup. Antibody tests for infectious diseases were positive for anti-HBs and anti-HBc antibodies. Accordingly, a laparoscopic cholecystectomy was performed. Macroscopically, the mass was a papillary/sessile tumor (29 × 25 mm) located in the fundus of the gallbladder. Histologically, the tumor was accompanied by an erosion on a portion of the surface layer, while the remaining epithelium showed regenerative changes and mild hyperplasia. No atypia was observed in the constituent epithelium. Hyperplasia of the polarized lymphoid follicles was observed in the interstitium, and tingible body macrophages were scattered in the germinal center. Immuno-histologically, the germinal center showed CD20 positivity, weak CD10 positivity, Bcl-2 negativity, and a high Ki-67 index (MIB-1). These findings suggested that the proliferating lymphoid follicles were reactive rather than neoplastic. Therefore, we diagnosed the patient with lymphoid hyperplasia of the gallbladder and chronic cholecystitis.

Background The effectiveness of prophylactic lateral lymph node dissection (LLND) in treating patients with lower rectal cancer remains controversial and has not been clearly established. Therefore, we aimed to retrospectively analyze the survival impact of prophylactic LLND in patients with lower rectal cancer. Methods Data of 301 patients with lower rectal cancer (tumor’s lower edge on the anal side of the peritoneal reflexion) with clinical T3 disease and negative preoperative lateral lymph node metastasis, who underwent radical resection (R0) at our hospital between April 2007 and March 2017, were included in this study. Patients who received preoperative chemotherapy or radiotherapy were excluded. The relapse-free survival (RFS) and overall survival (OS) rates were compared between the dissection (prophylactic LLND, n = 37) and non-dissection (no prophylactic LLND, n = 264) groups. Results Significantly fewer men and younger patients were noted in the dissection group than in the non-dissection group. Post-surgery 3- and 5-year RFS rates were 69.6% and 66.8% in the dissection group and 75.1% and 72.5% in the non-dissection group, respectively (5-year post-surgery RFS, p = 0.58). In the dissection and non-dissection groups, the 5-year OS rates were 86.5% and 79.7%, respectively (p = 0.29), and the 5-year cancer-specific survival rates were 88.9% and 86.0%, respectively (p = 0.29), with no significant differences. Lateral lymph node recurrence was observed in one (2.7%) and 10 patients (3.8%) in the dissection and non-dissection groups, respectively, and there was no significant difference between the groups. Conclusions In this study, the effectiveness of prophylactic LLND was limited in patients with > T3 lower rectal cancer with no evidence of preoperative lymph node metastasis. Prophylactic LLND may not be necessary if there is no preoperative lymph node metastasis, even if the invasion depth is T3 or higher.

Bleeding from unresectable gastric cancer is a localized condition that adversely affects quality of life. Radiotherapy can be used to treat gastric cancer bleeding when surgery, endoscopic treatment, and intravascular embolization are ineffective. This study evaluated the utility of radiotherapy for unresectable hemorrhagic gastric cancer. We retrospectively analyzed data from 33 patients with gastric cancer bleeding who underwent palliative radiotherapy in our hospital between April 2013 and May 2020. In this study, successful hemostasis was defined as > 1 month after starting radiotherapy with the patient alive and showing no need for blood transfusion, no drop in hemoglobin, and no evidence of melena or hematemesis. Patients comprised 26 men (79%) and 7 women (21%), with a median age of 71 years (range, 41–78 years). Hemostasis was achieved in 24 patients (73%). Thirty-two patients (94%) have been discharged home or transferred to the hospice. Patients with successful hemostasis from radiotherapy showed significantly longer overall survival than patients with unsuccessful hemostasis (p = 0.0026). No toxicities of grade 2 or more were encountered. This retrospective study found that palliative radiotherapy for gastric cancer bleeding was useful and safe and can improve remaining quality of life in patients with poor prognosis.

Portal vein aneurysms are rare vascular findings for which there are no optimal treatment guidelines. The scarce knowledge about their etiology, natural history, and management mean that there are limited treatment options. Here, we describe the case of a 69-year-old woman who presented with a 35-mm hypoechoic area in the hilar region of the liver that was accidentally detected by ultrasonography. Color Doppler ultrasonography demonstrated a mass with internal flow contiguous with portal vein, which was confirmed to be a portal vein aneurysm by computed tomography. Given that she experienced no symptoms of impending rupture or thrombosed aneurysms, we adopted a conservative treatment. Follow-up imaging demonstrated slow progression of the aneurysm diameter, from 35 to 43 mm at 3 years, and to 48 mm at 6 years; subsequent imaging after 6 years did not show any change in the diameter from 48 mm. However, the portal vein aneurysm completely regressed with no complications at a follow-up of over 10 years. This case suggests that long-term observation with periodic imaging may be an acceptable therapeutic option for asymptomatic portal vein aneurysms that show no short-term improvement. This case report contributes to a better understanding of how to treat this rare disease.

Background Although the novel coronavirus disease 2019 did not lead to a serious medical collapse in Japan, its impact on treatment of oesophageal cancer has rarely been investigated. This study aimed to investigate the influence of the pandemic on consultation status and initial treatment in patients with primary oesophageal cancer. Methods A retrospective study was conducted among 546 patients with oesophageal cancer who visited our hospital from April 2018 to March 2021. Pre-pandemic and pandemic data were compared with the clinical features, oncological factors and initial treatment as outcome measures. Results Diagnoses of oesophageal cancer decreased during the early phase of the pandemic from April to June (P = 0.048); however, there was no significant difference between the pre-pandemic and pandemic periods throughout the year. The proportion of patients diagnosed with distant metastases significantly increased during the pandemic (P = 0.026), while the proportion of those who underwent initial radical treatment decreased (P = 0.044). The rate of definitive chemoradiotherapy decreased by 58.6% relative to pre-pandemic levels (P = 0.001). Conclusions Patients may have refrained from consultation during the early phase of the coronavirus disease 2019 pandemic. The resultant delay in diagnosis may have led to an increase in the number of patients who were not indicated for radical treatment, as well as a decrease in the number of those who underwent definitive chemoradiotherapy. Our findings highlight the need to maintain the health care system and raise awareness on the importance of consultation., The delay in diagnosis due to the coronavirus disease 2019 pandemic was associated with an increase in the number of patients with primary oesophageal cancer in the non-adapted stage of radical treatment.

Covered stent placement (CSP) is gaining popularity for the management of delayed massive hemorrhage (DMH) after pancreatic or biliary surgery. However, early studies have produced conflicting results regarding the potential advantages of the procedure. We aimed to compare the short- and medium-term outcomes of arterial embolization (AE) and CSP for DMH.We analyzed data for patients who underwent AE or CSP as an endovascular treatment (EVT) for DMH from the common hepatic artery (CHA) and its distal arteries between January 2009 and December 2019. We evaluated the major hepatic complications, in-hospital mortality, and 1-year mortality associated with the procedures, according to age, sex, reintervention, arterial variant, interval between surgery and EVT, and portal vein stenosis.All hemorrhages were treated using AE (n = 50) or CSP (n = 20). CSP was associated with no in-hospital mortality (32% vs. 0%, p = 0.003), and lower incidences of major hepatic complications (44% vs. 10%, p = 0.011) and 1-year mortality (54% vs. 25%, p = 0.035) compared with AE, respectively. There was no significant difference in technical success and reintervention rates. Compared with AE, the risk-adjusted odds ratios for CSP (95% confidence intervals) for major hepatic complications and 1-year mortality were 0.06 (0.01-0.39) and 0.19 (0.05-0.71), respectively.CSP is superior to AE regarding major hepatic complications and in-hospital- and 1-year mortality in patients with DMH from hepatic arteries.

Salvage surgery after curative chemoradiotherapy for cT4 thoracic esophageal cancer is the only treatment that can be expected to cure, but the incidence of postoperative complications is also high, and its indication and timing should be carefully considered. In our hospital, radical chemoradiotherapy was positively performed for cT4 chest esophageal cancer, and salvage surgery was positively performed. Methods We examined 24 salvage surgery cases after chemo radiotherapy for cT4 esophageal cancer, which was conducted at our hospital from April 2012 to June 2018. The effect of treatment is determined after radical chemoradiotherapy. In the case of PR/SD, salvage surgery or salvage surgery is performed after additional chemotherapy. Salvage surgery was actively considered when it was considered resectable and resistant. In cases where CR was obtained, salvage surgery was performed in cases where relapse was observed during the course. Invasion organs were 9 cases of aorta, 11 cases of tracheobronchial, and 4 cases of others. Results No hospital deaths.Postoperative complications were 50%. Pneumonia 21%, anastomotic leak 13%. The period from the start of radical chemoradiotherapy to salvage surgery was 2.2 to 17.0 months (median 3.8 months). Grade 3 was observed in 4 cases. The 3-year OS was 80%, and the 3-year PFS was 43%. The recurrence rate of cT4b (Ao) was 75%, and that of cT4b (tracheobronchial) was 57%. In addition, the recurrence rate was high in the cases that were cN (+) and all the cases had postoperative recurrence in the cases that were pN (+) in the histopathological examination after salvage surgery. Conclusion Since cT4 was down-staged and enabled for radical surgery, dCRT could eventually be a powerful preoperative treatment. There was no death at the hospital, and postoperative complications are considered acceptable.Consideration of multidisciplinary treatment for patients with positive lymph node metastasis is needed. There are not a few cases of pCR, and surgical indications and informed consent are more important.

Standardized thoracoscopic esophagectomy for thoracic esophageal carcinoma in the left lateral decubitus position under artificial pneumothorax is slightly more difficult to dissect the middle and lower mediastinum than in prone position, but it is possible to operate the upper mediastinum with good visual field. In salvage surgery after definitive chemoradiotherapy, it is difficult to complete the operation only by throscopic surgery, and it is thought that sometimes small thoracotomy can be performed safely and reliably. Methods If this procedure is considered feasible, start with thoracoscopic surgery. If it is decided that the procedure cannot be completed, add a small thoracotomy of about 10–15 cm to allow one hand. Thoracoscopy not only reduced invasiveness, shared detailed anatomy, but also improved operability by taping the esophagus and ensured emergency safety. Results This standardized procedure is applied to salvage surgery after definitive chemoradiotherapy from January 2016 to March 2019. Thoracoscopic surgery was performed in 14 of the 27 cases (52%). Thoracoscopic surgery was completed in 10 cases and small thoracotomy was used in 4 cases. There are no serious complications such as bleeding. Conclusion Starting surgery with a thoracoscopy and adding small thoracotomy as appropriate can share the advantages of thoracotomy and throcoscopic surgery. This technique has the advantage that it can be easily converted to thoracotomy even in an emergency, and is considered to be superior to advanced cancer. Video https://www.dropbox.com/sh/47jcqu3palpsfvg/AAC4PvReWDP_WPBkJufxWU3da?dl=0.

OBJECTIVE The aim of the study was to develop a formula for predicting the probability of malignancy of mucinous cystic neoplasm (MCN) of the pancreas with ovarian-type stroma. METHODS A total of 364 patients were enrolled. A total score was calculated as the sum of the approximate integers of the odds ratios of the predictive factors identified by multivariate analysis. The relationship between the total score and pathological results was assessed. RESULTS A total of 321 patients had benign MCN and 43 had malignant MCN. Five possible predictive factors were analyzed: 56 years or older, high serum carcinoembryonic antigen level, high carbohydrate antigen 19-9 level, tumor size of 51 mm or greater, and the presence of mural nodules. The total score was significantly higher in patients with malignant MCN (median, 24; range, 0-37) compared with benign MCN (median, 5; range, 0-33; P < 0.001). Receiver operating characteristic curve analysis demonstrated that the area under the curve was 0.86, and the sensitivity and specificity of the total score for discriminating malignant MCNs were 72% and 83%, respectively, using a cut-off value of 22. CONCLUSIONS The current simple formula can predict the malignancy of MCN and may thus contribute to the adequate management of patients with MCN.

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is widely used as a first-line procedure for the definitive diagnosis of pancreatic solid tumor. Adverse events associated with the EUS-FNA procedure include acute pancreatitis, bleeding, infection, and duodenal perforation. Rarely, pancreatic tumors disseminate in the peritoneal cavity or seed in the gastric wall via the biopsy needle tract after EUS-FNA. Such seeding has been noted primarily in cases of adenocarcinomas and has not been associated with solid pseudopapillary neoplasm (SPN), a rare and potentially malignant tumor of the pancreas. This is the first report of a case of tumor seeding in the gastric wall after EUS-FNA of pancreatic SPN.

Abdominal ultrasonography in a 70-year-old woman showed a hypoechoic mass, 14 mm in diameter, in the pancreatic body. Computed tomography showed a mass with contrast effect in the pancreatic body. Test results for endocrine factors or tumor markers were normal. The initial consideration was nonfunctional pancreatic neuroendocrine tumor. Over 8 years of monitoring, the tumor diameter increased to 18 mm, until pancreatic tumor enucleation was performed. The postoperative diagnosis was pancreatic hamartoma, a rare type of benign pancreatic tumor. The preoperative diagnosis of pancreatic hamartoma is difficult, but consideration must be given to the possibility of hamartoma when encountering pancreatic tumors.

There are various reconstruction methods for Laparoscopic proximal gastrectomy (LPG), such as esophagogastrostomy (EG), double-tract reconstruction, and jejunal interposition. We have performed EG using a circular stapler (OrVil) from 2013 and using a linear stapler from 2017. The aim of this retrospective study was to clarify which stapler is better for EG for LPG. The data of 84 patients who underwent EG for LPG between January 2013 and September 2019 were analyzed. EG with fundoplication was done using a circular stapler (OrVil) in 45 patients (CS group) and a linear stapler in 39 patients (LS group). The patients’ medical records were reviewed. Clinical symptoms were obtained by interview at each outpatient consultation. All patients underwent postoperative 1-year follow-up endoscopy. To minimize bias between the two groups, propensity scores were calculated using a logistic regression model. After propensity-score matching, 60 patients (30 in the CS group and 30 in the LS group) were studied. Patient characteristics, operative outcomes were similar in two groups. Anastomotic leakage occurred in one patient (3.3%) in both groups. Anastomotic stenosis occurred in five patients (16.7%) in the CS group and two patients (6.7%) in the LS group. The rate of patients with severe reflux esophagitis (grade C or D) was significantly lower in the LS group (3.4%) than in the CS group (26.7%) (p = 0.026). EG with a linear stapler could reduce the risk of severe reflux esophagitis, and it could be a safe and feasible anastomosis for patients after LPG.

In esophageal cancer, long-term outcomes of minimally invasive surgery using endoscopic surgery are currently being verified. However, most trials have compared thoracic procedures; few studies have focused on the abdominal procedures, which are important for lymph node dissection in radical esophageal cancer surgery. Hand-assisted laparoscopic surgery (HALS) is a simple and minimally invasive procedure. Although HALS superiority in short-term outcomes has been reported, its oncological safety in esophageal cancer remains unclear. Therefore, we retrospectively evaluated oncological safety of HALS compared with that of conventional open laparotomy (OL) in radical surgery for thoracic and abdominal esophageal cancer. We retrospectively analyzed the postoperative survival in 142 patients who underwent radical esophageal cancer surgery at our hospital between May 2012 and May 2017, with and without propensity score matching (PSM) between groups. Before PSM, OL (n = 65) and HALS (n = 77) groups differed significantly in overall survival (OS) (3-year OS rate: 74.2% and 87.3%, respectively; log-rank p = 0.040). Additionally, clinical abdominal lymph node metastasis (cALNM) independently predicted OS (p = 0.031). After PSM, the OL and HALS groups did not differ significantly in OS (3-year OS rate: 80.5% and 89.8%, respectively; log-rank p = 0.716). There was no statistically significant difference in abdominal-specific recurrence-free survival between the OL and HALS group before and after PSM. HALS may be a well-accepted procedure for radical esophagectomy in esophageal cancer, with oncological safety, including local control specific to the abdomen, comparable to that of the conventional OL.

The prognosis for hepatocellular carcinoma (HCC) patients with lymph node (LN) metastasis is generally poor, and no consensus has yet been reached on the optimum treatment strategy. We observed 3 cases involving patients with HCC and associated metachronous LN metastasis, who benefited from surgical resection of the metastatic LNs. Each of the 3 patients had solitary LN metastasis for which selective LN resection was performed, and all had C-type cirrhosis as a background disease. There were no other uncontrolled lesions at the time of LN resection. However, additional treatments were required in cases 1 and 3 to control intrahepatic lesions that recurred following the lymphadenectomy. The overall survival in cases 1 and 3 has been >5 years, with case 1 still under observation. Case 2 also remains under follow-up at 6 months after surgery. Surgical resection could be a beneficial strategy for treatment of metachronous LN metastasis arising from HCC in some cases, particularly those involving a solitary LN metastasis with no other uncontrolled lesions.

Compared to other esophageal cancers, clinical stage IA esophageal cancer generally has a good prognosis, although a subgroup of patients has a poor prognosis. Unfortunately, clinical diagnoses of invasion depth or lymph node metastasis are not always accurate, which make it difficult to identify patients with a high risk of postoperative recurrence using the tumor-node-metastasis staging system. Fluorodeoxyglucose-positron emission tomography may help guide the identification of malignant tumors and the evaluation of their malignant grade based on glucose metabolism. We aimed to evaluate the association between pre-operative fluorodeoxyglucose-positron emission tomography findings and the postoperative prognosis of patients with clinical stage IA esophageal cancer. This single-center retrospective study evaluated pre-esophagectomy fluorodeoxyglucose-positron emission tomography findings from 38 patients with clinical stage IA esophageal cancer. Receiver operating characteristic curve analysis was performed to evaluate the prognostic significance of the primary tumor having low and high SUVmax values (cut-off: 3.56). Overall survival (log-rank p = 0.034) and progression-free survival (log-rank p = 0.008) were significantly different between the groups with low SUVmax values (n = 18) and high SUVmax values (n = 20). Furthermore, the primary tumor’s SUVmax value was related to pathological vascular invasion (p = 0.045) and distant metastasis (p = 0.042). The SUVmax of the primary tumor is a predictor of postoperative survival for clinical stage IA esophageal cancer. Thus, using fluorodeoxyglucose-positron emission tomography to evaluate the primary tumor’s glucose metabolism may reflect the tumor’s grade and potentially compensate for inaccuracies in tumor-node-metastasis staging.

Solid pseudopapillary neoplasms (SPNs) may have an aggressive clinical course, but clinical predictors of this condition have not been thoroughly evaluated. We performed a retrospective study of 11 cases of SPN managed in our hospital between January 2007 and April 2015. Of these 11 cases, we encountered a single case with an aggressive clinical course. Histological, immunohistochemical, and clinical features were compared to identify predictors of poor prognosis. The 11 patients comprised four women and seven men with a median age of 41 years (range, 26-58 years). Clinical symptoms were nonspecific and the median tumor size was 4.6 cm (range, 1.4-18 cm). The patient with an aggressive clinical course developed multiple liver metastases within three months and died seven months after surgery. Pathological features of the tumor in this case included lymph node metastases, a diffuse growth pattern, extensive tumor necrosis, high mitotic rate, and immunohistochemistry. These features were not observed in patients who survived without recurrence at a median follow-up of 25 months (range, 6-82 months). Characteristic pathological features and a high proliferative index, as assessed by Ki-67 staining, may predict poor outcome in cases of SPN.

Background: A gastric tube (GT) is most often selected as a reconstruction conduit in esophageal reconstruction. Although some leakage from esophagogastric anastomoses is induced by blood flow failure in reconstruction conduits, the association between the GT and the anastomotic leakage (AL) is unclear. Objectives: We retrospectively evaluated the incidence of AL according to the GT shape. Methods: Between February 2013 and September 2017, 188 consecutive patients who underwent esophagectomy with GT reconstruction were enrolled in this cohort study. We performed GT reconstruction using a narrow GT (Gr.N) until May 2016. Subsequently, we began preparing and using a stretched GT (Gr.S). Results: AL occurred in 29 of 188 (15.4%) patients. The frequency of AL was lower with Gr.S than with Gr.N (p = 0.034). Sex, body mass index, Brinkman index, hypertension, and anemia were significantly associated with AL (p = 0.033, 0.041, 0.003, 0.030, and 0.042, respectively). In a multivariate logistic regression analysis, the GT shape and the Brinkman index were shown to be independent risk factors for AL (p = 0.016 and 0.020, respectively). Conclusions: The GT preparation method is an independent risk factor for AL after cervical esophagogastrostomy. Thus, improved GT preparation methods could contribute to the reduction of AL after esophagectomy.

Background/aim Elderly patients usually have various comorbidities. Laparoscopic gastrectomy as a minimally-invasive treatment might be feasible for these patients. The aim of this study was to evaluate the safety and efficacy of laparoscopy-assisted distal gastrectomy (LADG) in elderly patients with gastric cancer by comparing the surgical outcomes and prognosis. Patients and methods We analyzed 136 patients who had undergone LADG between January 2013 and December 2014. We compared elderly patients (75 years old or more) with non-elderly patients. Results The incidence of all postoperative complications did not differ between groups, and there were no significant differences in the time to first oral intake or the duration of postoperative hospital stay. The 3-year overall and recurrence-free survival rates were not significantly different between the groups. Conclusion LADG is a safe and less invasive treatment for gastric cancer in elderly patients, who have a greater incidence of comorbidity.

The aim of this study was to investigate whether an artificial bile duct made of bioabsorbable polymer could serve as a substitute for narrowed portions of the bile duct. The experiments were performed using hybrid pigs (n = 11). After laparotomy under general anesthesia, the extrahepatic bile duct was identified and ligated around the confluence with the cystic duct. A week later, repeat laparotomy was performed on the animals, and the bile duct on the hepatic side of the ligature was resected. The cut end was connected to the duodenum using a bioabsorbable artificial bile duct fabricated from a copolymer of polycaprolactone and polylactic acid fibers. The grafts were recovered for gross, histologic, and blood chemical studies at 4 months after the surgery. All recipient pigs survived until they were humanely killed for collection of the implants. A week of ligation of the extrahepatic bile duct dilated the duct to approximately 1 cm in diameter and increased total bilirubin. Total bilirubin had returned to the pre-implantation level in all animals at 4 months post implantation. Examinations of the grafts revealed complete freedom of stricture and the regeneration of a neo-bile duct of approximately 1 cm in diameter from the graft site in 10 of 11 animals. Gross observation of the graft from the 1 remaining animal revealed stricture at the anastomosis site and poor bile duct epithelization. We have concluded that this bioabsorbable polymer bile duct can serve as a replacement for narrowed portions of the bile duct.

We report the case of a 79-year-old man, with gastric cancer detected on upper gastrointestinal endoscopic examination performed by a nearby medical clinic, and referred to our hospital, in April 201X. He was diagnosed with gastric cancer(ML, less, 0- II a+ II c, tub 1-2, cT1bN0M0, cStage I A). We performed laparoscopy assisted distal gastrectomy, D1+lymph node dissection, and Billroth I (B- I )reconstruction. Abdominal CT scan before surgery confirmed vascular anomaly of the celiac artery. We diagnosed Adachi type VI, preserved hepato-gastric artery trunk, and performed D1 plus dissection plus B- I reconstruction with small incision in the epigastrium. The operation time was 244 minutes and the blood loss was 5 mL. There were no postoperative complications, and the patient was discharged from hospital 7 days after the surgery. Pathological findings revealed pT4aN0M0, pStage II B, and the patient has been treated with TS-1®postoperative adjuvant chemotherapy. At present, there is no recurrence. As vascular anomalies of the celiac artery branch exhibit various forms, occasional blood vessel preventing surgery is required. Examining blood vessels through CT scan before the surgery made it possible to perform Laparoscopic gastrectomy safely.

Salvage surgery(S-surgery)was performed for residual or relapse tumor after definitive chemoradiotherapy (dCRT)for resectable esophageal cancer. When it becomes possible to perform surgery after dCRT for unresectable cases is called conversion surgery(C-surgery).To examine the outcomes of S-surgery and C-surgery after dCRT for thoracic esophageal cancer and clarify the significance as a multidisciplinary treatment.We reviewed 27 patients who underwent S-surgery for thoracic esophageal cancer in our hospital. 23 cases were residual tumor, 4 were relapse after complete response. Sixteen cases(59%)were C-surgery.Five cases(19%)had non-radical resection. Two cases were postoperative hospital death(7%). Postoperative complications(Clavien-Dindo classification Grade II and more) 11 cases(41%). Four cases were anastomotic leakage, 4 cases vocal cord paralysis, etc. Pathological complete response cases 6 cases(22%). The recurrence cases were 7 except for 5 cases of non-radical resection. Three-year overall survival rate was 47%. Twelve cases(75%)in C-surgery could perform radical resection by down stage.The postoperative hospital mortality and complications can be considered as acceptable. dCRT is a powerful pre-operative treatment for such cases, and S-surgery plays an important role.

Solid pseudopapillary neoplasms (SPNs) may have an aggressive clinical course, but clinical predictors of this condition have not been thoroughly evaluated. We performed a retrospective study of 11 cases of SPN managed in our hospital between January 2007 and April 2015. Of these 11 cases, we encountered a single case with an aggressive clinical course. Histological, immunohistochemical, and clinical features were compared to identify predictors of poor prognosis. The 11 patients comprised four women and seven men with a median age of 41 years (range, 26-58 years). Clinical symptoms were nonspecific and the median tumor size was 4.6 cm (range, 1.4-18 cm). The patient with an aggressive clinical course developed multiple liver metastases within three months and died seven months after surgery. Pathological features of the tumor in this case included lymph node metastases, a diffuse growth pattern, extensive tumor necrosis, high mitotic rate, and immunohistochemistry. These features were not observed in patients who survived without recurrence at a median follow-up of 25 months (range, 6-82 months). Characteristic pathological features and a high proliferative index, as assessed by Ki-67 staining, may predict poor outcome in cases of SPN.

The popularity of laparoscopic liver resection (LLR) is spreading, worldwide, because the intraoperative blood loss is less than for open hepatectomy and it is associated with a shorter hospitalization period [1–6]. During LLR, intraoperative hemostasis is difficult to achieve, unlike during laparotomy where bleeding can be stopped instantly [7–10]. Our LLR method for the treatment of hepatocellular carcinoma (HCC) includes maximal control of intraoperative bleeding using a monopolar soft-coagulation device. Although we use a monopolar soft-coagulation device to control bleeding during LLR, while coagulating the thin blood vessels, we also developed a maneuver (the hepatocyte crush method: HeCM) to allow liver transection to progress while liver parenchymal cells are being crushed. Between January 2008 and March 2016, we performed total LLR on 150 hepatocellular carcinoma patients (144 partial liver resections and six left lateral sectionectomies) using the maneuver shown in the video. The patients had Child–Pugh Scores of grade A (n = 100), B (42), or C (n = 8) and the localizations of tumor were segment (S) 1(n = 7), S2 (19), S3 (23), S4 (28), S5 (17), S6 (26), S8 (17), and S8 (29). The median blood loss was 30 (range 0–490) g during a median surgical time of 207 (range 127–468) min. One patient required conversion to a laparotomy due to the presence of severe adhesions; none of the patients required conversion due to intraoperative hemorrhage. The peak aspartate aminotransferase (AST) level was 320 (range 57–1964) IU/L. Although some patients showed high AST levels, none showed signs of hepatic failure. The median postoperative hospital stay duration was 6 (range 3–21) days. Postoperative complications occurred in seven cases (4.7%), including intraabdominal abscesses (n = 2), wound infections (2), intraabdominal hemorrhage (1), bile duct stricture (1), and umbilical hernia (1). The mortality was zero. HeCM, combined with the use of a monopolar soft-coagulation device, is a good technique for reducing bleeding during liver resection in patients with HCC.

With the widespread adoption of laparoscopic cholecystectomy and living-donor liver transplantation in recent years, complications involving the biliary system, stenosis in particular, are increasing. Various invasive and non-invasive techniques are now available for the treatment of biliary stenosis, but all are compromised by a high risk of recurrence and other problems. As a potential solution, our group has developed a bioabsorbable polymer (BAP) tube for implantation as a bypass graft. In the study reported here, we implanted this BAP tube and confirmed bile duct regeneration at the graft site after the tube had been degraded and absorbed into the body. We briefly describe our findings on extrahepatic biliary tissue regeneration, focusing on the possibility of its clinical application. This artificial bile duct may promote the development of novel treatments for biliary disease.

Bilioenteric anastomosis allows reflux of bowel fluid into bile ducts, resulting in reflux cholangitis. We sought to develop a reflux-free procedure of bilioenteric anastomosis endowed using an artificial bile duct (ABD).The study was performed in four groups of pigs. In Group A, end-to-side choledochoduodenostomy using the interposed ABD with its distal end wrapped by the duodenal seromuscular layer was performed. In Group B, conventional end-to-side choledochoduodenostomy using the ABD was performed. In Group C, conventional end-to-side choledochoduodenostomy was performed. In Group D, sham operation was performed. In each groups, 12 weeks later, animals were evaluated.Bile amylase levels were significantly lower in Group A (36.9 +/- 21.7 U/L) compared with Group B (469 +/- 140.9 U/L). No significant differences were observed in bile amylase levels between Groups A and D or between Groups B and C. On histology, the neo-bile duct in Group A was covered with the duodenal muscular layer at the orifice into the intestinal tract.This study suggests that the ABD is useful in the regeneration of extrahepatic bile ducts and that to bury the ABD in the duodenum can be a preventive measure against reflux of bowel fluid to bile ducts.

We report a case in which hepatectomy was performed to treat a patient with metastatic liver cancer 12 years after nephrectomy for renal cell carcinoma. The patient was a 56–year old man. Abdominal CT and MRI showed tumors with diameters of 8.5 cm and 2.5 cm in S2 and S4, respectively, of the liver, and many nodules with a diameter of 1 cm or less, all in the left hepatic lobe. FDG–PET/CT revealed a SUVmax of the tumors of 35, suggesting very high accumulation of FDG. Based on the history of renal cell carcinoma and normal hepatitis virus marker values a diagnosis of metastatic liver cancer from renal cell carcinoma was made. Distant metastasis was found only in the liver. Extended left hepatectomy was carried out, and the histologic findings confirmed metastasis by renal cell carcinoma. The patient had a good surgical postoperative course and was discharged on postoperative day 7. No signs of recurrence were observed at the 20 month follow–up examination. Hepatic metastasis by renal cell carcinoma generally has a poor prognosis, and since no specific, effective pharmacotherapy has been established, hepatectomy is an option, if the safety of surgery can be assured.

As a general principle, the procedure of isolating a cancer region from surrounding tissues (skeletonization) is not taken until the last stage of a cancer operation. This principle is often disregarded in surgery for cancers of the hepatic hilar duct, however, as it may be mandatory to skeletonize the region before resecting the liver. Our group invented ‘extended left hepatic lobectomy’, a new surgical procedure for hepatic hilar bile duct cancer, in which we isolate the liver and transect the right hepatic duct before skeletonizing the cancer region in the hepatoduodenal ligament.

Background Maintaining sufficient blood flow to the gastric tube after a subtotal esophagectomy for esophageal cancer is crucial for decreasing esophagogastric anastomotic leakage. Methods After subtotal esophagectomy for esophageal cancer, the supercharge technique was performed in 21 esophageal reconstruction patients to additionally revascularize the gastric tube using the splenic artery and vein, external carotid artery, and internal jugular vein. Operative results of the supercharge group were retrospectively compared with those of the control group (patients not receiving the technique). Results Both operation time and operative blood loss in the supercharge group were significantly longer and larger than those of the control group. However, the incidence of anastomotic leakage was significantly lower in the supercharge group than in the control group. Conclusion This practical supercharge technique reduces leakage during esophageal anastomosis.

滑膜肉腫は四肢大関節近傍に好発する病変であり,その発育は比較的緩徐とされている.今回われわれは,非常に稀な腹壁原発滑膜肉腫の急速な増大により,腎不全,呼吸不全,肝機能障害をきたした,いわゆるabdominal compartment syndromeを呈した病例に対し,腫瘍切除減圧を行い救命しえた.病例は36歳,男性.約40cm大の巨大腹部腫瘤,両肺結節影の精査を目的として2004年12月に入院となった.生検など行うも確定診断には至らず,腫瘍の急速な増大により腹部膨満感,肝腎機能障害,呼吸不全が進行した.保存的治療は限界と判断され, 2005年1月に腫瘍切除術が実施され,腫瘍は病理組織学的に腹壁原発滑膜肉腫と診断された.術後,多臓器不全は劇的に改善し,遺残腫瘍に対する化学療法を施行しつつ,術後11カ月現在,外来通院で経過観察されている.

症例は36歳,男性.右下腹部の腫脹を主訴に当院初診となった.初診時理学的所見では右下腹部に約10×8cm大の腫瘤性病変を触知した.血液生化学検査に異常はなかった.腹部超音波検査では右腹直筋内に多房性のhypoechoic massを認めた.腹部CT検査では右腹直筋内に最大径12cm大の中心に造影効果を認める腫瘤性病変を認めた.腹部MRIではT1WIでlow intensity, T2WIでややhigh intensityを示した.悪性腫瘍の可能性も否定できなかった為,腫瘤摘出術を行った.摘出腫瘤は全体で10×8×5cmの多房性で病理組織学的診断はschwannomaであった.患者は術後7日目に軽快退院した.腹直筋内に発生するschwannomaは,過去15年間に本邦報告例が無く極めて稀であるが,腹壁腫瘤の鑑別診断として銘記すべきと考えられた.

Background The growing prevalence of endoscopic surgery in recent years has led to the minimization of postoperative scarring. However, this procedure does not allow for the regeneration of the resected digestive tract, which compromises the postoperative maintenance of digestive function. In this preliminary study, we developed an artificial gastric wall (AGW) using bioabsorbable polymer (BAP), and evaluated the ability of this BAP patch to repair and regenerate a widely defective gastric wall in an animal model. Methods Pigs were laparotomized under general anesthesia. An 8 × 8-cm, round portion of the anterior gastric wall was excised and replaced by an AGW. The AGW was composed of a copolymer comprising 50% lactic acid and 50% caprolactone. The animals were relaparotomized 4, 8, or 12 weeks after implantation, after which they underwent resection of the entire stomach for gross and histologic evaluation of the graft sites. Results All recipient pigs survived until killing. By 4–8 weeks, the graft site revealed progressively fewer mucosal defect after each day. Moreover, the grafted area was indistinguishable from the native stomach 12 weeks after AGW implantation. The structures of the regenerated mucous membrane and muscle layers were identical to those of the native stomach. Furthermore, proton pumps were found in the regenerated tissue. Conclusion The BAP sheets helped to restore extensive gastric defects without causing any deformation. The use of BAP sheets may become a new therapeutic method that prevents alterations of gastric volume after extensive gastrectomy for stomach cancer and other diseases.

We herein report a case of postoperative fecal fistula following an appendectomy which was successfully treated by the use of autologous fibrin glue. An 82-year-old man had acute appendicitis and underwent an appendectomy. Later, a fecal fistula developed and he underwent drainage treatment twice. After 4 weeks of drainage and during the third recurrence, the remaining fistula was successfully treated using autologous fibrin glue, instead of surgery, due to potential complications and the risks of associated with advanced age. No recurrence has been observed for 5 months. In conclusion, autologous fibrin gluing for fecal fistula was found to be a safe, economical, and effective treatment. A search of Medline from 1980 until 2002 revealed no other report of this treatment for postoperative fecal fistula following an appendectomy.