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Using a self-expanding metal stent as a bridge to surgery (BTS) is considered a reasonable strategy for patients with acute malignant large bowel obstruction. Since postoperative complications have a negative impact on patient survival, we aim to clarify the predictors of complications in patients undergoing BTS using a self-expanding metal stent.We conducted a retrospective review of 61 patients with colorectal cancer (CRC) who underwent stenting as a BTS at our institution. We analyzed the association of postoperative complications with clinicopathologic, surgical, and patient factors, and with the prestenting or preoperative laboratory data.Both postoperative complications in general and severe complications were significantly associated with a longer stenotic-section length (p = 0.007 and p = 0.003), lower preoperative hemoglobin levels (p 0.001 and p = 0.081), and lower prestenting hemoglobin levels (p = 0.006 and p = 0.042). Multivariate logistic regression analysis showed that lower prestenting (13.0 g/dl) and preoperative (11.5 g/dl) hemoglobin levels were independent predictive factors for postoperative complications (odds ratio [OR]: 4.15; 95% confidence interval [CI]: 1.07-18.90; p = 0.040; and OR: 4.93; 95% CI: 1.35-20.28; p = 0.016). A stenotic-section length of 5.0 cm or greater was predictive of severe complications (OR: 25.67; 95% CI: 1.95-1185.00; p = 0.011).Our data suggest that lower hemoglobin levels before stenting and a longer length of the stenotic section of bowel might predict postoperative complications in patients with CRC undergoing BTS for obstruction.

A 65-year-old male patient presented with a chief complaint of abdominal pain. Abdominal computed tomography (CT) showed slight intestinal dilation and obstruction of the upper right quadrant of the small intestine, while ectopic gastric mucosal scintigraphy revealed abnormal accumulation in agreement with the CT-identified structure. The cause of bowel obstruction was diagnosed as Meckel’s diverticulum; the patient was referred for surgery. A small laparotomy was performed with a 35-mm skin incision to the center of the navel. Once a lap disk was attached, a laparoscope was inserted to visualize the abdominal cavity. The small intestine that includes the structure was pulled out from the umbilicus to the outside of the peritoneal cavity and partially resected. On the pathological tissue findings, the patient was diagnosed with Meckel’s diverticulum. We report our experience with single-lap laparoscopic surgery for a case of intestinal obstruction caused by Meckel’s diverticulum and review pertinent literature.

Hypogenesis or agenesis of right hepatic lobe is a rare abnormality and is generally associated with gallbladder and biliary tract abnormalities. Cases of biliary injury following cholecystectomy have been reported in patients with agenesis of right hepatic lobe because the anatomical anomalies complicate the surgical approach. We report a case of laparoscopic cholecystectomy in a patient with hypogenesis of right hepatic lobe. A 92-year-old male patient was admitted to our hospital with fever and right lower abdominal pain with suspected acute appendicitis. Abdominal computed tomography revealed gallstones with acute cholecystitis and hypogenesis of right hepatic lobe. He underwent laparoscopic cholecystectomy with the left semilateral decubitus position. The patient's postoperative course was uneventful. In conclusions, some patients with liver lobe hypoplasia do not present with the typical symptoms of acute cholecystitis due to dislocation of the gallbladder. The left semilateral decubitus position with modified placement of port sites is useful for laparoscopic cholecystectomy in patients with hypogenesis of right hepatic lobe.

Background To date, the optimal surgical strategy for remnant gastric cancer has not been determined. The purpose of this study was to clarify the significance of lymphadenectomy with splenectomy in remnant gastric cancer surgery. Methods This retrospective cohort study was conducted at the Kumamoto Regional Medical Center. The primary endpoint was overall survival after surgery. We retrospectively analyzed the clinicopathologic features, surgical treatments, and long-term prognosis of remnant gastric cancer patients treated with total gastrectomy. Results A total of 80 patients with gastric cancer in the remnant stomach after distal gastrectomy and who underwent total gastrectomy were enrolled in the study. Splenectomy was performed in 38 patients. Lymph node metastasis in the splenic hilum was not observed in the patients with pT1/pT2 tumors, whereas nodal metastasis at the splenic hilum was detected in 30.4% of the patients with pT3/pT4 tumors. The survival rate of the patients with pT3/pT4 tumors who underwent splenectomy was significantly higher than that of the patients who did not undergo splenectomy, although there was no difference in the patients with pT1/pT2 tumors. Among the patients classified as R0, the survival rate of the patients with pT3/pT4 tumors who underwent splenectomy was significantly higher than that of the patients who did not undergo splenectomy. Conclusion Lymphadenectomy with splenectomy in radical surgery is beneficial for patients with advanced (pT3/pT4) remnant gastric cancer.

Pancreatic neuroendocrine tumor (PNET) is relatively rare and has a generally better prognosis than does pancreatic cancer. However, as its prognosis in patients with lymph node metastasis (LNM) is unclear, lymph node dissection for PNET is controversial. Our study aimed to clarify the significance of LNM in PNET. We retrospectively examined 83 PNET patients who underwent pancreatic resections with lymph node dissection at Kumamoto University Hospital, Saiseikai Kumamoto Hospital, and Kumamoto Regional Medical Center from April 2001 to December 2014. Their clinicopathological parameters were analyzed by the absence or presence of LNM, and with regard to the disease-free survival (DFS) and overall survival (OS). A predictive score of LNM was also made using the age, tumor size, primary tumor location, and tumor function. Although the 5-year OS was 74.8% for LNM+ and 94.6% for LNM− (P = 0.002), LNM was not an independent risk factor for the OS in a multivariate analysis. However, tumors larger than 1.8 cm were found to be an independent prognostic factor, and the cut-off value for the predictive score was 1.69. Although LNM was not an independent prognostic factor, lymph node dissection is recommended for patients whose predictive score is larger than 1.69.

We report a case of adenocarcinoma of the minor duodenal papilla, a rare type of duodenal neoplasm. A 76-year-old man with a history of surgery for rectal cancer and gastric cancer was referred to us after a follow-up upper gastrointestinal endoscopy revealed an abnormal elevation in the minor duodenal papilla. The pathological diagnosis of a biopsy specimen was adenocarcinoma. Preoperative examination of other organs revealed a tumor in the ascending colon, which was also identified as adenocarcinoma. We performed synchronous pancreatoduodenectomy and ileocecal resection with lymph node dissection. Histopathological examination of the resected specimen revealed that the papilla tumor arose from the duodenal mucosa and infiltrated the submucosa of the duodenal wall, but not the pancreatic parenchyma. Based on these findings, we diagnosed primary adenocarcinoma of the minor duodenal papilla. To our knowledge, this is only the sixth such case reported in the English-language literature, and we review all six cases after this case report.

消化管重複症は非常に稀な消化管奇形であり消化管のいずれの部位にも発生するが，炎症所見を伴うものは報告では8.6％と少ない．今回われわれは腹腔内膿瘍を契機に発見された消化管重複症の1例を経験したので報告する．症例は69歳，男性．間歇的な腹痛を主訴に当院を受診した．腹部USとCTにて石灰化を伴う小腸壁肥厚を認め，魚骨を誤飲した可能性があることから，消化管異物による腹腔内膿瘍の診断で入院となった．抗生剤などによる保存的加療を行うも炎症所見の増悪を認めたため開腹手術を行った．腹腔内には約5cmの腫瘤を認め，腸間膜内に腸管壁様の構造物を認めた．重複腸管症と判断し，重複腸管とともに小腸部分切除を行った．摘出標本には腸管様構造物が小腸に沿って存在し，病理所見から管状重複腸管と診断された．本例は炎症を伴って発症した消化管重複症であり，異所性胃粘膜，異所性膵組織を伴い，その報告は本例を含めて6例と極めて稀な症例であった．

症例は72歳の男性で, 55歳の時に胸腺腫にて胸腺摘出術をうけていた. 1週間前頃から発熱あり, 近医にて投薬治療中, 突然の腹痛あり近医受診した. 汎発性腹膜炎との診断で当科紹介され緊急手術施行した. 回腸末端から30センチの部位に穿孔を認めた. 術後, 肺炎を併発し多臓器不全で永眠された. 切除標本の病理組織学的検査ではサイトメガロウイルス腸炎による穿孔であった. 本症例では胸腺腫術後の低免疫状態から, サイトメガロウイルス腸炎を併発し回腸穿孔を来したものと考えられた. 本症例は残念ながら死亡後に確定診断がついたが, このことを教訓として胸腺摘出後の患者の消化管穿孔では日和見感染的なCMV腸炎による潰瘍穿孔も念頭におくべきであると考えられた. 高齢者のCMV腸炎も増加傾向にあり, 免疫低下状態と考えられる患者だけでなく高齢者の消化管穿孔では, サイトメガロウイルス感染症を考慮して末梢血リンパ球数を測定する必要があると考える.

GC-associated DNA primase (GANP) contains two functionally important regions, the N-terminal RNA/DNA primase and C-terminal MCM3-associated/import domains, which might be involved in DNA replication. Here, we investigated the functions of these regions by transfection studies. In addition to the C-terminal MCM3-binding (Gmap80) region, the RNA/DNA primase region (Gp) possesses an additional MCM3-interaction activity that mediates its translocation between the nucleus and the cytoplasm. Gp with an N-terminal nuclear localization signal sequence (NLS) is present in the nucleus, but Gmap80 with a C-terminal NLS appeared in the cytoplasm. The whole GANP (Ganp) protein is present in both nuclear and cytoplasmic compartments, in a Crm1-dependent manner. Gp associated with MCM3 through the NLS, and MCM3 induced nuclear localization of Ganp. NLS-negative MCM3 does not have such activity. These results suggest that the NLS of MCM3 is involved in nuclear translocation of Ganp. The nuclear-cytoplasm MCM3 translocation was demonstrated in mammalian cells, and over-expression of Ganp, but not of Gp or Gmap80, facilitated this translocation of MCM3 in co-transfectants. Moreover, introduction of Ganp induced DNA synthesis in the transfectants but dominant-negative mutants did not. It is concluded that GANP is translocated from the nucleus to the cytoplasm in association with MCM3 and is involved in DNA synthesis.

Myoepithelial carcinoma is a well-known tumor of salivary gland, representing 1% of all salivary gland tumors. They have also been reported in other sites as skin/soft tissue, breast and lung. This paper reports a rare case of primary myoepithelial carcinoma in the liver, as well as discusses the findings of immunohistochemistry. The clinical manifestations, imaging characteristics, and histopathological changes of myoepithelial carcinoma in this case were described. The patient was a 33 years old female presented with a cystic tumor in the right lobe of the liver. As the liver tumor increased in size within six months, malignant neoplasm was suspected and thus anterior hepatic segmentectomy was performed. The mass composed of glandular-like structures and trabecular sheets of spindled shaped cells and epithelioid cells which were positive for myoepithelial markers. The tumor recurred within one year, in the left lobe of the liver and partial left lobe lobectomy was performed. The tumor resected showed similar histology to the primary tumor. Three months later, another recurrence was noted for which radiofrequency ablation was performed. This report presents a recurrent case of myoepithelial carcinoma in the liver and suggests the possibility of biliary origin of such tumor.

333 Background: Ampullay cancer (AC) is relatively good prognosis in the biliary tract cancer. Such as LN metastasis, pancreatic invasion is a prognostic factor in AC. On the other hand, Distal bile duct cancer (DBDC) is somewhat good prognosis in the biliary tract cancer. Such as ductal resection margin positive is a prognostic factor in DBDC. There are few papers considered to both difference. Therefore, we conducted this study to examine the difference of AC and DBDC. Methods: To evaluate Cancer-Specific Survival (CaSS), Recurrence-Free Survival (RFS) and prognostic factors after pancreatoduodenectomy (including pylorus-preserving pancreatoduodenectomy: PPPD, subtotal stomach-preserving pancreatoduodenectomy: SSPPD) based on a series of 80 patients of AC and 36 patients of DBDC from 1996 to 2015. We reviewed and analyzed the clinicopathologic data, recurrence and survival. Results: Five years CaSS and RFS of AC were 72.3% and 72.5%. In univariate analysis, pancreatic invasion, R1or R2 resection, duodenal invasion and lymph node metastasis are significantly poor prognosis. In multivariate analysis, pancreatic invasion and R1or R2 resection are poor prognostic factors (pancreatic invasion, p = 0.0012, hazard ratio (HR) 5.65 [confidence interval (CI) 1.92-19.5 95%], R1or R2 resection, p = 0.0043, HR 6.22 [CI 1.68-40.2 95%]). On the other hand, five years CaSS and RFS of DBDC were 35.8% and 46.8%. In univariate analysis, pancreatic invasion (+) ≥ 5 mm in depth, and duodenal invasion are significantly poor prognosis. In multivariate analysis, duodenal invasion is the only poor prognostic factors (p = 0.0227, HR 2.90 [CI 1.16-7.39 95%]). Conclusions: DBDC is considerable poor prognosis compared with AC. Lymph node metastasis is not prognostic factor depends on D2 LN dissection in AC, than pancreatic invasion. Cancer cells invaded pancreatic parenchyma in AC; pancreatic invasion may be the most important prognostic factor by biology-like pancreatic cancer. Duodenal invasion in DBDC was prognostic factor reflects the degree of development of the cancer beyond pancreatic parenchyma. Further clinicopathological and biological studies are needed to confirm our findings.

To determine the safety and usefulness of a novel anticancer drug, miriplatin, in transarterial chemoembolization (TACE) for unresectable hepatocellular carcinoma.Patients (n=115) who underwent TACE with miriplatin-lipiodol suspension (miriplatin group), and control patients (n=131) who underwent TACE with cisplatin-lipiodol suspension (CDDP group) took part in this study.The overall incidence of adverse events was significantly lower in the miriplatin group. The percentage of patients attaining treatment effect 4 in both groups was not significantly different. The proportion exhibiting a50% decrease in positive tumor markers following TACE was significantly greater in the CDDP group for alpha-fetoprotein, but not significantly different for des-gammma-carboxy prothrombin.Miriplatin-lipiodol suspension was associated with reduced intensity of adverse events and had comparable short-term therapeutic effects to cisplatin-lipiodol suspension, thereby indicating its usefulness in TACE.

The purpose of this study was to predict the postoperative organ derangement before surgery and to select the optimal surgical methods for a perforation due to colorectal cancer. The Mannheim Peritonitis Index (MPI) was used to determine the preoperative status and Sequential Organ Failure Assessment (SOFA) score for postoperative status, retrospectively. There were 25 cases of colorectal cancer-related colon perforation. These patients were classified as having a preoperative MPI ≤ 29 or ≥ 30 and the mean postoperative SOFA scores were 2.30 ± 2.45 and 7.93 ± 3.45 (p = 0.0002), respectively. Seven of 20 patients who underwent tumor resection received a bowel anastomosis without a stoma. The MPI of these seven patients was low (23.1 ± 7.47) and there were no severe postoperative organ disorders (SOFA score 1.86 ± 2.26). Eighteen of the 25 patients had no distant metastasis. Eight of these 18 patients underwent lymph node (LN) dissection, including intermediate LNs, while the other 10 cases only had the pericolic/perirectal LNs dissected. The average preoperative MPI was 23.9 ± 7.68 and 32.8 ± 5.77, and the postoperative SOFA scores were 3.75 ± 3.01 and 7.10 ± 5.34, respectively. The MPI could be used to predict postoperative organ disorders and thus represents a useful index that can be used to determine the optimal surgical methods.

210 Background: Pancreatic neuroendocrine tumor (PNET) is uncommon, and its prognosis is generally better than that of pancreatic cancer. Although some PNET patients have lymph node metastasis, its effect on their prognosis is unclear, lymph node dissection for PNET is controversial. Our study aimed to clarify the significance of lymph node metastasis in PNET. Methods: We retrospectively examined 83 PNET patients who underwent pancreatic resections at Kumamoto University Hospital, Saiseikai Kumamoto Hospital and Kumamoto Regional Medical Center from April 2001 to December 2014. We excluded NET G3 from them. Their clinicopathological parameters were analyzed by the absence or presence of lymph node metastasis, and with regard to disease-free survival (DFS) and overall survival (OS). Results: Although 5-year DFS was lymph node metastasis group: 73.3%, and no lymph node metastasis group: 85.0% (P = 0.474); and 5-year OS was lymph node metastasis: 91.7% and no lymph node metastasis: 96.2% (P = 0.055), lymph node metastasis was not an independent risk factor for DFS or OS in multivariate analysis. However, tumors larger than 1.8 cm were found to be an independent prognostic factor. Conclusions: Although lymph node metastasis was not an independent prognostic factor, tumors larger than 1.8 cm were an independent prognostic factor, and warrant lymph node dissection for PNET patients with tumors of this size.

270 Background: General rules for biliary tract cancer in Japan were revised and Stage of biliary tract cancer was compliant with the seventh UICC. Carcinoma of the Ampulla Vater (CAV) is relatively good prognosis among the biliary tract cancer, such as lymph node metastasis, pancreatic invasion and perineural invasion has been reported to be prognostic factors. We investigated the validity of TNM-Stage by examining the prognostic factors from the outcome of resection experienced. Methods: To evaluate prognostic factors after surgery based on a series of 70 patients of CAV from 1996 to 2014. Twenty-eight patients received pancreatoduodenectomy (PD), 25 patients received pylorus-preserving pancreatoduodenectomy (PPPD) and 17 patients received subtotal stomach-preserving pancreatoduodenectomy (SSPPD). We reviewed and analyzed the clinicopathologic data, surgical outcomes, recurrence and survival. Results: Actuarial disease-specific survival (DSS) was 65 % at five years. In univariate analysis, pancreatic invasion, lymph node metastasis and duodenal invasion are significantly poor prognosis. In multivariate analysis, pancreatic invasion is the only poor prognostic factor (p = 0.0023, hazard ratio (HR) 5.31 [confidence interval (CI) 1.77-18.9 95%]); lymph node metastasis and duodenal invasion are not significantly different (p = 0.0672 and 0.8769, respectively). Also, in the study of relapse risk factors, pancreatic invasion and lymph node metastasis are significantly different. In TNM-Stage II, those of T3N0, 1 are poor prognosis than T1, 2N1 (p = 0.0334). Conclusions: Pancreatic invasion is an independent poor prognostic and recurrence risk factor. The Stage of Japanese Society of Biliary Surgery has reflect prognosis than TNM-Stage in carcinoma of the Ampulla Vater.