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Background Pancreatic body and tail cancer easily invades retroperitoneal tissue, including the transverse mesocolon. It is difficult to ensure a dissected peripancreatic margin with standard distal pancreatectomy for advanced pancreatic body and tail cancer. Thus, we developed a novel surgical procedure to ensure dissection of the peripancreatic margin. This involved performing dissection deeper than the fusion fascia of Toldt and further extensive en bloc resection of the root of the transverse mesocolon. We performed distal pancreatectomy with transverse mesocolon resection (DP-TCR) using a mesenteric approach and achieved good outcomes. Methods There are two main considerations for surgical procedures using a mesenteric approach: 1) dissection deeper than the fusion fascia of Toldt (securing the vertical margin) and 2) modular resection of the pancreatic body and tail, with the root of the transverse mesocolon and adjacent organs in a horizontal direction (ensuring the caudal margin). Results From 2017 to 2019, we performed DP-TCR using a mesenteric approach for six patients with advanced pancreatic body and tail cancer. Histopathological radical surgery was possible in all patients who underwent DP-TCR. No Clavien-Dindo grade IIIa or worse perioperative complications were observed in any patient. Conclusions We believe that DP-TCR is useful as a radical surgery for advanced pancreatic body and tail cancer with extrapancreatic invasion.

Background Characteristics of a cancer-positive margin around a resected uncinate process of the pancreas (MUP) due to a pancreticoduodenectomy are difficult to understand by standardized evaluation because of its complex anatomy. The purposes of this study were to subclassify the MUP with tissue marking dyes of different colors and to identify the characteristics of sites that showed positivity for cancer cells in patients with pancreatic head carcinoma who underwent circumferential superior mesenteric arterial nerve plexus-preserving pancreaticoduodenectomy. Results of this evaluation were used to review operation procedures and perioperative methods. Method We divided the MUP into 4 sections and stained each section with a different color. These sections were the pancreatic head nerve plexus margin (Area A), portal vein groove margin (Area B), superior mesenteric artery margin (Area C), and left of the superior mesenteric artery margin (Area D). The subjects evaluated were 45 patients who had carcinoma of the pancreatic head and were treated with circumferential superior mesenteric arterial nerve plexus-preserving pancreaticoduodenectomy. Results Of the 45 patients, nine cases (90%) of incomplete resection showed cancer-positivity in the MUP. Among the 4 sections of the MUP, the most cases of positive results [MUP (+) ] were found in Area B, with Area A (+), 0 case; Area B (+), 6 cases; Area C (+), 2 cases; and Area D (+), 3 cases (total, 11 sites in 9 patients). Relapse occurred in 7 of the 9 patients with MUP (+). Local recurrence was observed as initial relapse in all 3 patients with Area D (+). In contrast, the most common site of recurrence other than that in patients with Area D (+) was the liver. Conclusion By subclassifying the MUP with tissue marking dyes of different colors, we could confirm regional characteristics of MUP (+). As a result, circumferential superior mesenteric arterial nerve plexus-preserving pancreticoduodenectomy was able to be performed in R0 operations in selected patients while a better postoperative quality of life was maintained. Furthermore, Area D (+) represents an extension beyond the limit of the local disease and may indicate the need for early aggressive adjuvant chemotherapy.

Metastatic spermatic cord tumors are relatively rare, and gastric, colorectal, and pancreatic cancers have been reported as the primary lesion [1, 2]. We experienced a case of metastasis to the spermatic cord 1 year after surgery for gastric cancer. A 68-year-old male developed a painful right inguinal mass 1 year after surgery for gastric cancer and tubular adenocarcinoma was diagnosed by aspiration biopsy cytology from the right inguinal mass. A solitary inguinal metastasis was suspected by FDG-PET, and laparoscopic tumor resection was performed for definite diagnosis. Postoperatively, spermatic cord metastasis of gastric cancer was diagnosed pathologically by hematoxylin and eosin staining and immunohistochemistry (CK7+ and CK20−) of the resected samples. As to the metastasis route to the spermatic cord, development from minimal peritoneal disseminated nodules was suspected. Metastatic routes were speculated by comprehensive analysis of clinical information such as laparoscopic findings and a pathohistological approach including immunohistochemistry.

Background: Freys procedure might be a good alternative to pylorus‑preserving pancreaticoduodenectomy (PPPD for patients with an inflammatory mass of the head of the pancreas because it is technically easy and associated with low morbidity and good pain relief. Purpose: To analyze the short‑term and long‑term outcomes of Freys procedure in comparison with PPPD and to evaluate the efficacy of Freys procedure against preoperative locoregional complications. Patients and Methods: From August 1997 through December 2007 6 patients underwent Freys procedure (as described by Frey and Smith and 10 patients underwent PPPD. The mean follow‑up times were 70.8 months (Freys procedure and 119.8 months (PPPD. Preoperative biliary stricture and duodenal stenosis were observed in 4 and 3 patients respectively of patients undergoing Freys procedure. Pain intensity was assessed with a pain scoring system. Quality of life (QOL was assessed with the European Organization for Research and Treatment of Cancer Quality of‑Life Questionnaire‑Core 30. Exocrine and endocrine pancreatic function was measured during follow‑up. Results: Significant reductions in total pain scores and all QOL scale scores were observed immediately after surgery in all patients (P

Background: In most cases of pancreatic head cancer surgery often results in noncurative resection which is frequently related to inadequate clearance of the mesopancreas. Purpose: The aim of this report is to introduce the surgical technique of left posterior approach pancreaticoduodenectomy (PD with total mesopancreas excision and circumferential lymphadenectomy around the superior mesenteric artery (SMA (LPA‑PD and to examine whether this procedure increases the rate of true curative resection and decreases the rate of locoregional recurrence. Patients and Methods: Nineteen patients underwent standard PD and 19 patients underwent LPA‑PD. The demographic characteristics intraoperative outcomes (mean operative time and mean blood loss postoperative outcomes (complications type of recurrence and survival and pathological findings (R number number of removed regional lymph nodes and positive resection margins were evaluated. Results: The patient characteristics did not differ significantly between the groups. The mean blood loss in the LPA‑PD group was significantly less than that in the standard PD group (p

Chronic pancreatitis (CP) is a painful, yet benign inflammatory process of the pancreas. Surgical management should be individualized because the pain is multifactorial and its mechanisms vary from patient to patient. Two main pathogenetic theories for the mechanisms of pain in CP have been proposed: the neurogenic theory and the theory of increased intraductal/intraparenchymal pressures. The latter theory is strongly supported by the good results of drainage procedures in the surgical management of CP. Other possible contributing factors include pancreatic ischemia; a centrally sensitized pain state; and the development of complications, such as pseudocysts and stenosis of the duodenum or common bile duct. Common indications for surgery include intractable pain, suspicion of neoplasm, and complications that cannot be resolved with radiological or endoscopic treatments. Operative procedures have been historically classified into 4 categories: decompression procedures for diseased and obstructed pancreatic ducts; resection procedures for the proximal, distal, or total pancreas; denervation procedures of the pancreas; and hybrid procedures. Pancreaticoduodenectomy and pylorus-preserving pancreaticoduodenectomy, once the standard operations for patients with CP, have been replaced by hybrid procedures, such as duodenum-preserving pancreatic head resection, the Frey procedure, and their variants. These procedures are safe and effective in providing long-term pain relief and in treating CP-related complications. Hybrid procedures should be the operations of choice for patients with CP.

We describe a 43-year-old woman who underwent laparoscopic distal pancreatectomy preserving the spleen and splenic vessels for the treatment of insulinoma in the pancreatic body. The patient experienced cold sweats on fasting, received diagnosis of insulinoma, and was referred to our hospital for laparoscopic surgery. Blood biochemistry studies showed low fasting blood glucose of 42 mg/dL, serial immunoreactive insulin of 15.2 microU/mL, and a Fajans index (immunoreactive insulin/blood glucose) of 0.36 (normal

Torsion of the gallbladder is a rare condition that most commonly affects the elderly. This condition is rarely diagnosed preoperatively despite advances in diagnostic imaging. We report a case of torsion of the gall bladder diagnosed preoperatively. An 81-year-old woman presented with right upper quadrant pain. Initial laboratory tests revealed elevation of the white blood cell count to 15,900/μL(normal, 4,000 to 8,000/μL) and mild liver dysfunction. Ultrasonography and computed tomography revealed swelling of the gall bladder with increased wall thickness, but neither examination showed any gallstones. Percutaneous transhepatic gall bladder drainage was performed, and bloody bile juice was obtained. Cholangiography via the drainage catheter of the gall bladder and endoscopic retrograde cholangiography revealed smooth tapering of the neck of the gall bladder. We diagnosed acute torsion of gallbladder and brought the patient to the operating theatre for laparoscopic cholecystectomy. Intraoperatively, we observed that the gallbladder had undergone complete torsion and appeared gangrenous. Routine cholecystectomy was then performed, and the patient recovered without incident.

Few studies have compared laparoscopic distal pancreatectomy (Lap-DP) and open distal pancreatectomy (open-DP). The aim of this study was to evaluate the clinical outcome of Lap-DP and compare it to that of open-DP.A total of 37 patients who underwent distal pancreatectomy (Lap-DP, 21 patients; open-DP, 16 patients) between January 2000 and March 2007 were enrolled in this study. Prior to January 2004, open-DP was the standard procedure for patients with a lesion in the distal pancreas without invasive ductal cancer; thereafter, Lap-DP was also an approved procedure. All 16 open-DP procedures were performed prior to January 2004.The operating times for the Lap-DP and open-DP patients were 308.4 +/- 124.6 and 281.5 +/- 83.3 min, respectively, and these were not significantly different (P = 0.4635). Blood loss for the Lap-DP group (249.0 +/- 239.8 ml) was significantly smaller than that for the open-DP group (714.1 +/- 650.4 ml) (P = 0.0055), and none of the patients in the Lap-DP group received transfusions. The frequency of complications for the Lap-DP and open-DP groups was 0 and 18.8%, respectively, which is not significantly different (P = 0.0784). The average hospital stay for the Lap-DP group was significantly shorter than that for the open-DP group (10.0 +/- 2.6 vs. 25.8 +/- 8.8 days; P0.0001).In pancreatic diseases, other than invasive ductal cancer, arising in the distal pancreas, Lap-DP might be a more feasible and safer than open-DP.

A 46-year-old woman was readmitted to our hospital in August 2005 because of severe abdominal pain and nausea. Computed tomography demonstrated a huge cystic lesion in the retroperitoneal space behind the hepatoduodenal ligament and lesser peritoneal cavity. Endoscopic retrograde pancreatography revealed communication between the dilated main pancreatic duct and a pseudocyst. The condition was preoperatively diagnosed as chronic pancreatitis associated with a pseudocyst or an intraductal papillary mucinous neoplasm without mucin hypersecretion. The patient underwent a distal pancreatectomy with splenectomy. The pathologic diagnosis was multicentric pancreatic intraepithelial neoplasia (PanIN), and histological examination revealed a positive surgical margin around the remnant pancreas. Four months after the surgery, the patient underwent a total pancreatectomy. Macroscopic observation revealed diffuse fibrosis of the pancreatic parenchyma compatible with chronic pancreatitis. Histological examination revealed a constellation of noninvasive intraductal neoplasias with high-grade atypia, diffusely distributed in the small pancreatic ducts of the resected pancreas. Localized fibrosis and cystic dilation of the small ducts were detected in a lobule of exocrine glands draining into a ductule involved by PanIN lesions in the head of the pancreas. In summary, multicentric PanIN lesions are associated with lobular atrophy of the pancreatic parenchyma and chronic pancreatitis-like changes that follow. Total pancreatectomy may be recommended for patients with multicentric precursor lesions throughout the entire pancreas.

A 70-year-old man was admitted to our hospital for evaluation of multiple pancreatic tumors. Twelve years earlier he had undergone left radical nephrectomy for renal cell carcinoma (RCC). Computed tomography revealed two well-defined mass lesions in the head and tail of the pancreas, with strong contrast enhancement in the arterial phase. Fluorine-18 fluorodeoxyglucose positron emission tomography detected an elevated uptake within the lesions but no extrapancreatic uptake. The preoperative diagnosis was isolated multifocal metastatic pancreatic tumors from RCC. The patient underwent total pancreatectomy with splenectomy. Both of the tumors were well-demarcated, gray-white, and firm on gross observation. Microscopic examination, meanwhile, revealed solid tumors consisting of clear oval cells with severe nuclear atypia. These pathologic findings were consistent with the preoperative diagnosis of pancreatic metastasis from RCC. Radical resection improves the long-term survival of patients, and total pancreatectomy may be an appropriate procedure.

We developed short-term pancreatic cancer models in hamsters using PGHAM-1 cells and examined the utility of the models for research on metastasis and for therapeutic trials. With 3 PGHAM-1 models, including 1) primary pancreatic cancer and simultaneous liver metastasis by intrapancreatic transplantation, 2) liver metastasis alone by intrasplenic transplantation, 3) peritoneal dissemination by intraperitoneal transplantation, within 21 days after inoculation, we studied the specific characteristics of metastases and the effects of several antiangiogenic substances on primary and metastatic pancreatic tumors. Several experiments showed that vascular endotherial growth factor and anatomical characteristics were important factors for metastasis. In therapeutic experiments, the incidence, size, diameter, microvessel density, and apoptotic index of the tumors were preferably influenced by the antiangiogenic substances. In addition, PGHAM-1-Luc, which is luciferase-positive PGHAM-1 cell line, was newly developed and is expected to be a useful new animal model. These models would be suitable for the study of pathogenesis of pancreatic cancer and its metastasis and for preclinical trials of chemotherapeutic agents, such as antiangiogenic substances.

This study evaluates the efficiency of color Doppler ultrasonography-guided intraoperative pancreatic biopsy (CDUS-IPB) using Levovist injected into the bile duct in conjunction with stimulated acoustic emission (SAE) in patients with biliary strictures. The study was performed on 12 patients. After completing a conventional intraoperative pancreatic biopsy (c-IPB), each subject underwent CDUS with SAE imaging using Levovist. Upon identification of the biliary stricture, the IPB was taken from the area surrounding the stricture on the same imaging setting. Section diagnosis of the CDUS-IPB specimen was compared to that of the c-IPB specimen and resected tissue. Biliary strictures were identified as enhanced areas of color Doppler signal on CDUS. CDUS-IPB provided adequate specimens from the biliary strictures in all cases and corrected false-negative diagnoses by c-IPB in three cases. Section diagnosis by CDUS-IPB corresponded to the permanent section diagnosis. There were no complications. CDUS-IPB with Levovist is an accurate diagnostic tool. The method is especially useful for patients with a suspected malignant biliary stricture who show no tumor mass in preoperative images and no evidence of malignancy on cytologic examinations.

症例は75歳の女性で, 腹痛, 嘔吐を主訴に当院入院となった. 既往歴には胃潰瘍による胃切除術, 胆嚢結石症による胆嚢摘出術があった. 入院時腹部CTにて臍部近傍の小腸内に約3cm大の円形の層構造を有するhigh densityを示すmassを認め, イレウスを呈していた. イレウス管にて症状が軽快するも, 1か月後に再び同様の症状が出現し, CTにて前回同様のmassを認めたが, 小腸内で移動していた. 繰り返す小腸内異物によるイレウスの診断にて手術を施行したところ, 腸石により輸入脚が閉塞していた. 腸石を除去後, ブラウン吻合を造設した. 腸石は外殻, 中核に分かれ, 層構造を成していた. 本症例は小さな胆. 結石が総胆管より排石され, それが中核となり輸入脚内で停滞するうちに外殻が形成された腸石と推測された. 胃切除後の腸石による輸入脚閉塞症は極めてまれであり, 文献的考察を加えて報告した.

A 54-year-old man was admitted to our hospital with the symptoms of palpitation, dyspnea, and tarry stool. Upper gastroduodenal endoscopy revealed submucosal lesions with vascular ectasia in the second part of the duodenum. Dynamic computed tomography (CT) detected a hypervascular lesion in the pancreatic head and the duodenum. Selective angiography showed proliferation of a vascular network and early filling of the portal vein at the early arterial phase. With a diagnosis of pancreatic arteriovenous malformation (AVM), we performed pylorus-preserving pancreaticoduodenectomy. At laparotomy, localized and meandering vessels were seen on the surface of the head of the pancreas. Histological examination showed dilated tortuous vessels accompanied by severed elastic fibers in the vessel media and blood clot formation. The incidence of pancreatic AVM remains extremely low, and recurrent gastrointestinal bleeding is a frequent complication. To prevent recurrent bleeding and progressive portal hypertension, surgery may be the definitive management of symptomatic AVM.

Purpose: Vascular endothelial growth factor（VEGF） is thought to play a crucial role in the process of cancer growth and metastasis. In this study the expression of VEGF in liver metastases of pancreatic cancer was investigated using an established hamster model. Methods: Pancreatic cancer cells（PGHAM‑1 1×10 6 ）derived from N‑nitrosobis（2‑ oxopropyl）amine（BOP） ‑induced pancreatic tumors in Syrian golden hamsters were transplanted into the pancreas of female hamsters. All hamsters were sacrificed at 21 days after transplantation and used for the histopathological examination of pancreatic and metastatic lesions（primary transplantation model） . The metastatic liver tumors were minced with scissors and 1 mm 3 tumors were retransplanted into the pancreas of a second hamster. All hamsters were sacrificed 21 days after retransplantation and the pancreatic tumors were removed（back transplantation model） . Immunohistochemical analyses using antibody against VEGF were performed for all pancreatic and liver tumors. Reverse transcription‑polymerase chain reaction（RT‑PCR）was performed to examine the expression of VEGF mRNA in the tumors. In addition we investigated the proliferation of each tumor using Ag‑NOR staining. Results: In the primary transplantation models VEGF expression in the pancreatic tumors was positive but that in the liver metastases was only weakly positive or negative. On the other hand VEGF expression in the pancreatic tumors that had developed from the retransplantation of the liver tumors（back transplantation model）was strongly positive. VEGF mRNA was expressed in the pancreatic tumors of both primary and back transplantation models. In the metastatic liver tumors of the primary transplantation model VEGF mRNA was expressed in all cases although the immunohistochemical staining pattern was weakly positive or negative. Similarly in the metastatic liver tumor of the back transplantation model VEGF mRNA was expressed in all cases although the immunohistochemical staining pattern was weakly positive or negative. No significant differences in Ag‑NOR scores were found between the models. Conclusion: Our results suggest that VEGF expression usually occurs in PGHAM‑1 cells but that VEGF expression is reduced during the process of liver metastasis and revived by retransplantation. Thus the interrelationship between cancer cells and the organ environment might play an important role in VEGF expression. （J Nippon Med Sch 2005; 72: 155―164）

症例は73歳, 女性. パーキンソン症候群で加療中に偶然, 膵腫瘍を指摘された. 腹部超音波検査で膵鉤部に30×38mm, 均一な低エコー性腫瘤を認め, 造影CTでは腫瘍辺縁と内部の一部が星芒状に造影された. 腹部MRI検査ではT 1強調像で低信号, T 2強調像で高信号を示し, 血管造影検査では後膵十二指腸動脈領域に淡い腫瘍濃染像を認めた. 膵頭部漿液性嚢胞腺腫を疑い, 幽門輪温存膵頭十二指腸切除術を施行した. 病理組織学的には立方形腫瘍細胞が索状, 腺房様に配列し, 一部に嚢胞性変化を認めた. 免疫組織化学的検討にて, 非機能性膵内分泌腫瘍と診断した. 一般に膵漿液性嚢胞腺腫と膵内分泌腫瘍は, 画像上で酷似した所見を呈することが多いが, 膵漿液性嚢胞腺腫honeycomb typeと嚢胞性膵内分泌腫瘍の鑑別診断は困難であり, 術前より十分念頭におく必要がある.

Background: Pancreaticoduodenectomy（PD）has become a standard operation for malignant and benign periampullary diseases. Although the operative mortality of PD has decreased to less than 4％ in hospitals with many cases of PD the leakage of pancreaticointestinal anastomosis（PIA）still carries a substantial risk of lethal outcome. The aim of this study was to evaluate the local factors that affect the incidence of PIA leakage by evaluation of exocrine function and fibrosis in the pancreatic remnant following PD. Method: Twenty‑eight patients（17 pancreatic disease 8 bile duct cancers and 3 ampullary cancers）underwent PD with complete extracorporeal pancreatic juice drainage. The cut‑end of the pancreatic remnant was histologically studied for its grade of fibrosis in comparison with the exocrine activity of the pancreatic remnant（EAPR）calculated by the value of the product of volume of drained pancreatic juice and its amylase activity. The influences of those factors and other clinicopathologic data on PIA outcome were evaluated. Results: The histological grade of fibrosis in the pancreatic stump was inversely correlated with EAPR（rs＝0.5848 p＝0.0011） . Three patients had major leakages and 6 had minor leakages of PIA; all the patients with leakages had biliary or ampullary diseases but not pancreatic diseases. The incidence of leakage of PIA was significantly higher in the patients with high values of EAPR（p＜0.05） . None with EAPR less than 10 7 had PIA leakage. The incidence of PIA leakage in low‑grade fibrosis of the pancreatic stump was significantly higher than that in high‑grade fibrosis（p＜0.05） . Other clinicopathologic data did not influence the incidence of leakage of PIA. Conclusions: The degree of fibrosis in the pancreatic stump is significantly related t ot he EAPR and affects the development of PIA insufficiency as a local factor. （J Nippon Med Sch 2002; 69: 549―556）

The patient, a 56-year-old woman, was found during routine checkup to have a disorder of hepatic function. Abdominal ultrasonography showed an ill-defined hypoechoic mass in the head and body of the pancreas; however, no blood-flow signal was observed within the tumor on Doppler ultrasonography. Abdominal computed tomography showed a low-density area in the arterial and portal venous phases. The lesion was visualized as an area of low signal intensity on both T1- and T2-weighted magnetic resonance images, whereas fluorodeoxyglucose positron emission tomography showed fluorodeoxyglucose accumulation in the tumor. Although a preoperative diagnosis was difficult to make, a rapid cytologic examination revealed evidence of a pancreatic endocrine tumor, and subtotal stomach-preserving pancreaticoduodenectomy with portal vein resection was performed. Histopathological examination showed tumor cell nests scattered in abundant fibrotic tissue; the tumor cells had proliferated in a cord-like fashion and showed immunostaining for chromogranin A. Staining for fibroblast activation protein α was seen in the fibroblastic cells contained within the fibrous stroma surrounding the tumor cell nests, whereas both the fibroblastic cells in the tumor and those in the stroma showed a high rate of staining for thrombospondin. We presume that tumor-associated fibroblasts were involved in the fibrosis of the tumor stroma.

The patient, a 56-year-old woman, was found during routine checkup to have a disorder of hepatic function. Abdominal ultrasonography showed an ill-defined hypoechoic mass in the head and body of the pancreas; however, no blood-flow signal was observed within the tumor on Doppler ultrasonography. Abdominal computed tomography showed a low-density area in the arterial and portal venous phases. The lesion was visualized as an area of low signal intensity on both T1- and T2-weighted magnetic resonance images, whereas fluorodeoxyglucose positron emission tomography showed fluorodeoxyglucose accumulation in the tumor. Although a preoperative diagnosis was difficult to make, a rapid cytologic examination revealed evidence of a pancreatic endocrine tumor, and subtotal stomach-preserving pancreaticoduodenectomy with portal vein resection was performed. Histopathological examination showed tumor cell nests scattered in abundant fibrotic tissue; the tumor cells had proliferated in a cord-like fashion and showed immunostaining for chromogranin A. Staining for fibroblast activation protein α was seen in the fibroblastic cells contained within the fibrous stroma surrounding the tumor cell nests, whereas both the fibroblastic cells in the tumor and those in the stroma showed a high rate of staining for thrombospondin. We presume that tumor-associated fibroblasts were involved in the fibrosis of the tumor stroma.

A 69-year-old woman was admitted to our hospital for the treatment of a dorsal pancreatic artery aneurysm detected with abdominal computed tomography. Angiography revealed celiac axis occlusion, a large aneurysm in the dorsal pancreatic artery, and small aneurysms in the celiac and splenic arteries. Transcatheter arterial embolization with microcoils, N-butylcyanoacrylate, and lipiodol was successfully performed for the dorsal pancreatic artery and the aneurysm. In the 2 years after treatment the dorsal pancreatic artery aneurysm has not recurred, and other aneurysms have not enlarged.

s / Pancreatology 14 (2014) S1eS129 S116 Conclusion: Pancreatoduodenectomywithportal vein resection and left renal grafting is a safe procedure without risk of renal failure. During CT a collateral flow through left ovarian veinwere observed. The left renal vein is an adequate vessel for grafting because of relatively easy access with a good chance to obtain a vessel of suitable length and vessel diameter.

A 55-year-old man was admitted to our hospital to evaluate a large pseudocyst. Computed tomography showed a 5-cm pseudocyst filled with contrast medium in the head of the pancreas, and color Doppler ultrasonography revealed high-velocity pulsatile flow inside the cyst. Celiac angiography confirmed bleeding from the superior anterior pancreaticoduodenal artery into the cyst. Pancreaticoduodenectomy was performed. Pathologic examination showed a thick-walled pseudocyst filled with clots. The postoperative course was uneventful. Five years after the operation, the patient remained free from bleeding. Bleeding from pancreatic pseudoaneurysms may cause sudden death in patients with chronic pancreatitis, therefore, this entity should be borne in mind, and prompt treatment is of utmost importance in cases of major bleeding.

Purpose: We investigated the clinicopathological features of borderline resectable invasive carcinomas (BRICs derived from intraductal papillary mucinous neoplasms (IPMNs and examined the significance of the aggressivesurgery firstapproach com pared with the treatment of conventional borderline resectable pancreatic ductal adenocarcinomas (BRPDAs. Patients and Methods: We retrospectively studied 7 patients with BRICs derived from IPMNs and 14 patients with conventional BRPDAs. Several factors were reviewed: initial symptoms preoperative imaging serum level of CA19‑9 perioperative factors pathological findings adjuvant chemotherapy and outcome. Results: All BRICs derived from IPMN were huge tumors (more than 3 cm in diameter suspected to involve

Introduction: The recent advances of surgical techniques and technology allow minimally invasive surgery to be applied in patients with benign and malignant diseases of the pancreas. About malignancy, we still have concerns regarding the oncologic adequacy of laparoscopic pancreatectomy, with fewer studies reporting oncologic outcomes. We describe the surgical technique to improve the curability of laparoscopic pancreatectomy in the treatment of Pancreatic Adenocarcinoma (PDAC) and focuse on the oncologic outcomes and long-term outcomes of laparoscopic surgery for PDAC patients. Methods: From January 2004, patients who had been diagnosed with the tumor in the pancreas without suspicion for vascular involvement were eligible for laparoscopic pancreatectomy at Nippon Medical School. In Lap- PD for PDAC patients, we apply laparoscopic left mesenteric approach, which enables both accurate laparoscopic lymph node retrieval and complete pancreatic nerve plexuses dissection to achieve R0 resection. In Lap-DP for PDAC patients, we perform retroperitoneal tissue dissection, which often includes adrenalectomy. Results: We have experienced laparoscopic pancreatectomies in 148 patients including 25 PDAC patients. In the 25 patients with PDAC, the mean number of lymph nodes dissected was 22.4 ± 12.6 (6–57). Metastasis to the lymph nodes was observed in 8 of the 25 patients (32%). R0 resection was performed in 22 patients (88%). The median follow-up period for the PDAC patients undergoing laparoscopic pancreatectomy was 16 months (1–71 months). Six of the 25 patients died, at 2.5 months (stage IV), 15 months (stage IA), 29 months (stage IIB), 33 months (stage IIB), 24 months (stage IIA), and 18 months (stage IIB). Surviving 19 patients had no recurrence. Conclusion: Laparoscopic pancreatectomy for pancreatic cancer seems to achieve similar oncologic and longterm outcomes to open approach.

Introduction: Combination chemotherapy with gemcitabine and S-1 (GS) in metastatic advanced pancreatic cancer patients is superior to gemcitabine alone in response rate and progression free survival. We investigated this combination chemotherapy as neoadjuvant therapy for resectable and borderline resectable pancreatic cancer. Methods: Eleven patients with resectable or borderline resectable pancreatic cancer were administered to neoadjuvant chemotherapy with GS (NeoGS) from June 2011 to March 2013 at Nippon Medical School, and shortterm outcome was evaluated. Results: The median age was 69.1 years. According to NCCN criteria, 6 patients were resectable diseases and 5 were borderline resectable diseases. All patients received Neo GS with a median cycle of 3.5 (range: 2-11). No serious adverse events including death or life-threatening complications happened. Grade 3 or 4 chemotherapyrelated toxicities included neutropenia (81.8%), anemia (18.2%), thrombocytopenia (18.2%), and febrile neutropenia (9.1%). Other non-hematological toxicities with grade 1 or 2 were anorexia (36.4%), constipation (36%), nausea (27.3%), diarrhea (18.2%), dysgeusia (9.1%), and stomatitis (9.1%). Radiologically, partial response was documented in 3 patients (27.3%), and the remaining 8 patients (72.7%) had stable disease. All patients underwent pancreatic resection with lymphadenectomy. An R0 resection was achieved in 10 of 11 (90.9%), and negative nodal involvement (N0) was found in 6 (54.5%). Pathologically, all specimens showed at least Evans grade I, while eight of eleven (72.7%) had Evans grade IIa. There was no mortality and severe morbidity including clinically relevant pancreatic fistula. All patients received adjuvant chemotherapy with either gemcitabine or S1. Conclusion: This pilot study suggests NeoGS is feasible in patients with resectable and borderline resectable pancreatic cancer and may be associated with a high R0 resection rate and a low lymph node metastasis rate, suggesting that further phase 2 and 3 trials are warranted.

Dedifferentiated liposarcoma of the mesentery is an extremely rare tumor. A 71-year-old man with a 2-month history of abdominal distention was admitted to our department for evaluation and treatment of an abdominal mass. Computed tomography and magnetic resonance imaging revealed an 11 × 9 cm mass lesion with fat density in the upper right abdominal cavity, displacing the ascending and transverse colon ventrally. Abdominal angiography showed small feeding vessels of the tumor from the ileocolic artery and the middle colic artery. On basis of these findings, liposarcoma arising from the mesocolon ascendens was diagnosed, and complete removal of the tumor and central pancreatectomy (partial resection of the body of the pancreas) were performed. The histopathological diagnosis was dedifferentiated liposarcoma, and the patient is free from recurrence 6 months after surgery. The treatment strategy for abdominal dedifferentiated liposarcoma is surgical resection with a wide surgical margin.

A 73-year-old man was admitted with bloody stool. Duodenoscopy showed a hemorrhagic ulceration in the duodenum on the side opposite to the papilla of Vater. Abdominal CT demonstrated a well-defined hypervascular mass, adjacent to the lesion of the duodenum. Although as duodenal GIST was diagnosed, histologic examination for frozen sections during the procedure revealed tubular adenocarcinoma of the duodenum and pancreaticoduodenal lymph node metastasis of neuroendocrine carcinoma. He underwent a subtotal stomach-preserving pancreaticoduodenectomy. Clinicopathologically, the neuroendocrine carcinoma of the pancreaticoduodenal lymph node was considered to be metastasis from an unknown primary lesion.

A case of esophageal leiomyosarcoma, for which CT scan, endoscopic ultrasonography (EUS) and angiography were employed for preoperative diagnosis is reported. CT scan identified an exophytic mass which had no rim-enhancement in the lower end of the esophagus. EUS revealed a homogeneous mass originating from the muscularis propria. Angiography showed a mildly hypervascular tumor. Histologically, the resected specimen was a leiomyosarcoma. These results suggest that the evaluation by EUS combined with CT scan and angiography is useful in differentiating smooth muscle tumors from other submucosal tumors.

黄疸を主訴とし, Vater乳頭に異所性に発生した非機能性膵島腫瘍の1例を経験したので報告する. 症例は61歳の女性. 黄疸, 皮膚掻痒感を主訴に来院し, 精査目的にて当科入院. 超音波, computed tomography, endoscopic retrogade cholangiopancreatography検査にて下部胆管癌または乳頭部癌が疑われた. 術中, 乳頭部腫瘍を確認し術中迅速病理診断にて悪性腫瘍と診断されたため, 膵頭十二指腸切除術を施行した. 組織学的に, 腫瘍細胞は豊富な毛細血管を伴い索状に配列し, ラ島細胞に類似していた. さらに免疫組織化学的には, insulin, glucagon, somatostatin, pancreatic polypeptideのすべてに陰性を示したため, 非機能性膵島腫瘍と診断した. Vater乳頭部に発生する非機能性膵島腫瘍は本邦でもきわめてまれであるが, 本症の術前診断は諸検査によってもきわめて困難なものと考えられた.

Background Our previous study demonstrated that bFGF-GH promoted healing of the pancreaticojejunostomy (PJ) in an animal model. We examined the healing process in detail to investigate the significance of treatment with basic fibroblast growth factor (bFGF) incorporated in gelatin hydrogel (GH) microspheres for anastomotic healing. Materials and Methods The optimal dose of bFGF was determined by administering bFGF concentrations of 1, 10, and 100μg in six beagle dogs and assessing the results on d 7. Next, 28 dogs received a jejunal subserosal injection of 10μg bFGF-GH or GH alone. The healing process was sequentially analyzed on d 4, 7, 21, and 28. The following types of assessment were performed: breaking strength test, pathologic examination, and calculations of collagen content, terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling (TUNEL) index, and microvessel density (MVD). Results The administration of a bFGF dose of more than 10μg induced a significantly higher breaking strength and more abundant granulation tissues. Histologic observations of the bFGF-GH group on d 7 and the GH-alone group on d 21 revealed abundant granulation tissue with migrating fibroblasts, inflammatory cells, and capillaries. Marked neovascularization and dense collagen deposition were detected in both groups on d 28. The collagen content and breaking strength did not significantly differ between both groups on d 28. A significantly higher TUNEL index and a rapid decline in the number of vimentin-positive cells were detected in the bFGF-GH group from d 21 onward. The MVD in the bFGF-GH group was significantly higher from d 7 onward Conclusions Basic FGF-GH administration can promote the rapid completion of PJ anastomosis and may help improve the quality of the healing of granulation tissue by conferring potent angiogenesis and accelerating apoptosis.

Laparoscopic pancreatic resection began to be reported in the first half of the 1990s, with subsequent reports focusing primarily on the safety and usefulness of laparoscopic distal pancreatectomy (Lap-DP) for benign and low-malignancy lesions of the pancreatic body and tail (such as chronic pancreatitis, neuroendocrine tumor, mucinous cystic neoplasm, and intraductal papillary mucinous neoplasm). Recently we have also begun to see retrospective case–control studies comparing these techniques with open surgery, with Lap-DP showing advantages not only in terms of esthetics related to the surgical wound, but also with regard to reduced intraoperative bleeding, postoperative recovery time, and days of postoperative hospitalization. Prospective randomized controlled trials are still needed for confirmation, but it appears likely that this technique will become a standard surgical procedure for the treatment of diseases of the pancreatic body and tail. In contrast, laparoscopic pancreatoduodenectomy (Lap-PD) remains controversial in the minds of many pancreatic surgeons. This is primarily due to the difficulty of laparoscopic reconstruction following resection. However, there have recently been a number of single-center reports on the use of this procedure in at least 20 patients per center, showing that Lap-PD is associated with considerable reduction in intraoperative bleeding. Our own experience has been similar. In carefully selected patients, we find Lap-PD to be a useful surgical procedure.

症例は21歳男性.慢性反復性の下血を主訴に来院し, 上腸間膜動脈造影検査にて回結腸動脈末端部のarteriovenous malformationと診断した.下血による高度の貧血が保存的に改善しないため, 回盲部切除術を施行した.切除標本の病理組織学的検索では, 粘膜固有層と粘膜下組織に壁の薄い小血管の拡張, 蛇行が著明で, 破綻血管も認められ, 盲腸を中心とする回盲部のangiodysplasiaと診断した.本症は, 高齢者の右側結腸に好発し, 血管造影あるいは内視鏡による診断が有用とされている.本邦では若年発症例は非常にまれであり, 文献的考察を加え報告した.