Successful laparoscopic resection for giant mature cystic teratoma of the pancreas: a case report and surgical refinements.

BACKGROUND: Mature cystic teratomas or dermoid cysts of the pancreas complicate surgical approaches because of their anatomical position and ever-growing size. Herein, we report a case of a giant mature cystic teratoma of the pancreas that was successfully resected via complete laparoscopic distal pancreatectomy (LDP). CASE PRESENTATION: A 39-year-old female patient was referred to our hospital for the evaluation of a pancreatic tumor. Three years of follow-up revealed that the tumor had increased in size to 18 cm, with hyperintense solid components on diffusion-weighted magnetic resonance imaging. Considering the possibility of malignancy, we decided to perform an LDP. The capsule appeared solid enough to withstand the retraction of the endoscopic forceps. Tumor size made it difficult to dissect the dorsal side of the tumor from the caudal to the cranial side. Early transection of the pancreas and additional ports facilitated dissection of the dorsal side of the tumor. We completed the LDP without intraoperative cyst rupture. On pathological examination, the tumor was diagnosed as a mature cystic teratoma originating from the pancreatic tail. The patient was discharged on postoperative day 13 with no complications. CONCLUSION: LDP may be an option for surgical procedures in patients with large cystic lesions of the pancreatic body or tail. Intraoperative observation of the tumor and surgical refinement are necessary to complete the laparoscopic procedure without tumor rupture.

Strategies to Perform Emergency Laparoscopic Partial Liver Resection for Ruptured Hepatocellular Carcinoma.

BACKGROUND/AIM: Laparoscopic hepatic resection is currently used for ruptured hepatocellular carcinoma (HCC); however, it is technically challenging. We developed and implemented surgical strategies for emergency laparoscopic partial liver resection in selected patients with peripheral lesions who were hemodynamically stable and without severe liver dysfunction. PATIENTS AND METHODS: The surgical techniques used were as follows. First, the Pringle maneuver was performed to control hepatic blood inflow (step 1). Next, strong hemostatic agents were applied at the rupture point of the tumor (step 2). The hanging tape was positioned along the dorsal side of the resection line to control the partial blood inflow and outflow of the tumor, as well as to expose the surgical plane (step 3). The liver parenchyma was dissected along the hanging tape (step 4). We performed emergency laparoscopic partial liver resection in three patients who were in a pre-shock status. RESULTS: The tumors were located in segments 6 (cases 1 and 2) and 2 (case 3). The tumor diameters were 90, 62, and 80 mm. The Preoperative Child-Pugh scores were B7, B9, and B8. The hemostatic products performed well and controlled bleeding from the ruptured HCC. The hanging tape facilitated the dissection of the liver parenchyma. The operative time and intraoperative blood loss were 135 min and 400 ml, 266 min and 200 ml, and 191 min and 495 ml for cases 1, 2, and 3 respectively. There were no in-hospital deaths. CONCLUSION: Emergency laparoscopic partial liver resection could be an option for patients with ruptured HCC.

Effect of Risk Factor Score on Early Recurrence After Pancreatectomy for Invasive Pancreatic Ductal Adenocarcinoma.

BACKGROUND/AIM: This study aimed to identify the risk factors for early recurrence (ER) after pancreatic ductal adenocarcinoma (PDAC) resection to create a novel scoring system for ER and analyze their effect on the recurrence pattern. PATIENTS AND METHODS: Sixty patients with PDAC who underwent pancreatectomy were included. The predicted risk factors for ER were analyzed. A new score defining ER was created and analyzed for recurrence pattern and prognosis. RESULTS: Independent predictors included high CA 19-9 (≥147 U/ml), high lymph node ratio (LNR of ≥0.1277), and no adjuvant chemotherapy (AC). The 5-year overall survival rates with a score of 0, 1, and 2 were 55.8%, 11.0%, and 0%, respectively. In the moderate- risk score group, prognosis was improved by induction of AC within 58 days. CONCLUSION: Preoperative high CA19-9, high LNR, and no AC could be ER predictors. Induction of postoperative chemotherapy within 58 days may improve prognosis.

Prognostic Significance of Sarcopenia and Eicosapentaenoic Acid (EPA) Levels in Patients With Unresectable Pancreatic or Biliary Tract Cancer.

Background/Aim: This study aimed to investigate the relationship between prechemotherapy blood eicosapentaenoic acid (EPA) levels, sarcopenia, and overall survival in patients with pancreatic and biliary tract cancer undergoing chemotherapy. Patients and Methods: Forty-five patients with recurrent, non-resected pancreatic or biliary tract cancer undergoing chemotherapy were retrospectively analyzed. The skeletal muscle mass was measured at the third lumbar vertebra. Sarcopenia cut-off values were based on the Japanese Society of Hepatology sarcopenia assessment criteria. Two months after starting chemotherapy, the patients received enteral nutrition containing omega-3 fatty acids. Results: Patients with pancreatic and biliary tract cancers with low pre-treatment blood EPA levels had significantly more intense sarcopenia than those with high EPA levels (p=0.023). Patients with sarcopenia before chemotherapy had significantly lower overall survival than those without sarcopenia. Multivariate analysis revealed blood EPA concentration as an independent prognostic factor (p<0.01). Lumbar muscle volume, a marker of sarcopenia, showed a clear positive correlation with prechemotherapy EPA concentration (p=0.008). In patients administered with enteral nutrition containing omega-3 fatty acids, both EPA concentration and lumbar muscle volume were significantly higher than those prior to intervention, indicating sarcopenia improvement due to the intervention. Conclusion: In patients with recurrent non-resected pancreatic and biliary tract cancer, low blood EPA levels before chemotherapy are associated with sarcopenia and poor prognosis.

Osteosarcopenia impacts treatment outcomes for Barcelona Cancer Liver Classification stage A hepatocellular carcinoma.

AIM: To study the effect of preoperative osteosarcopenia (OSP) on the prognosis of treatment (surgery or radiofrequency ablation (RFA)) in patients with Barcelona Cancer Liver Classification stage A hepatocellular carcinoma (BCLC A HCC). METHODS: This study enrolled 102 patients with BCLC A HCC who underwent surgical resection (n = 45) and RFA (n = 57); the patients were divided into two groups: OSP (n = 33) and non-OSP (n = 69). Overall survival (OS) and disease-free survival (DFS) curves for both the groups and treatment methods (surgery and RFA) were generated using the Kaplan-Meier method and compared using the log-rank test. Univariate analyses for OS and DFS were performed using log-rank test. Multivariate analyses were performed for factors that were significant at univariate analysis by Cox proportional hazard model. RESULTS: Multivariate analysis showed that OSP (HR 2.44; 95 % CI 1.30-4.55; p < 0.01) and treatment (HR 0.57; 95 % CI 0.31-0.99; p = 0.05) were significant independent predictors of DFS; and treatment (HR, 0.30; 95 % CI 0.10-0.85; p = 0.03) was a significant independent predictor of OS in the non-OSP group, in which the OS rate was significantly lower in patients treated with RFA than in those treated by resection (p = 0.01). CONCLUSIONS: OSP is a prognostic factor for BCLC A HCC treatment. Surgical approach was associated with a significantly better prognosis in patients without OSP compared to those who underwent RFA.

The Signal Intensity Ratio of Pancreas to Spleen in Magnetic Resonance Imaging Can Predict Nonalcoholic Fatty Liver Disease After Pancreaticoduodenectomy.

OBJECTIVES: Signal intensity ratio of pancreas to spleen (SI ratio p/s ) on fat-suppressed T1-weighted images of magnetic resonance imaging has been associated with pancreatic exocrine function. We here investigated the predictive value of the SI ratio p/s for the development of nonalcoholic fatty liver disease (NAFLD) after pancreaticoduodenectomy (PD). MATERIALS AND METHODS: This study comprised 208 patients who underwent PD. NAFLD was defined as a liver-to-spleen attenuation ratio of <0.9 calculated by a computed tomography 1 year after surgery. SI ratio p/s was calculated by dividing the average pancreas SI by the spleen SI. We retrospectively investigated the association of clinical variables including the SI ratio p/s and NAFLD by univariate and multivariate analyses. RESULTS: NAFLD after 1 year was developed in 27 patients (13%). In multivariate analysis, the SI ratio p/s < 1 ( P < 0.001) was an independent predictor of incidence of NAFLD. The SI ratio p/s < 1 was associated with low amylase level of the pancreatic juice ( P < 0.001) and progressed pancreatic fibrosis ( P = 0.017). According to the receiver operating characteristics curve, the SI ratio p/s had better prognostic ability of NAFLD than the remnant pancreas volume. CONCLUSIONS: The SI ratio p/s is useful to predict NAFLD development after PD. Moreover, the SI ratio p/s can be a surrogate marker, which represents exocrine function of the pancreas.

The Impact of Fibrinogen to Prognostic Nutritional Index Rate on Prognosis of Pancreatic Ductal Adenocarcinoma.

INTRODUCTION: The aim of the present study was to evaluate the prognostic value of the ratio of serum fibrinogen to prognostic nutritional index (PNI; Fbg/PNI) in patients undergoing resection for pancreatic ductal adenocarcinoma. METHODS: A total of 140 patients who had undergone resection for pancreatic cancer were included. Patients were divided into two groups according to a Fbg/PNI ≥8.8 or <8.8. Survival data were analyzed using the log-rank test for univariate analysis and Cox proportional hazards for multivariate analysis. RESULTS: Fbg/PNI was a significant prognostic indicator in univariate analysis for overall survival (OS) and disease-free survival (DFS). Fbg/PNI retained significance in multivariate analysis for OS (hazard ratio, 1.81; 95% confidence interval, 1.19-2.77; P < .01) in addition to tumor differentiation and nodal involvement. Fbg/PNI was a significant independent prognostic indicator of poor DFS on multivariate analysis (hazard ratio, 1.54; 95% confidence interval, 1.05-2.26; P = .03). CONCLUSION: Preoperative Fbg/PNI is a novel significant independent prognostic indicator for OS and DFS following resection of pancreatic cancer with curative intent.

Superior mesenteric vein/portal vein contact in preoperative imaging indicates biological malignancy in anatomically resectable pancreatic cancer.

BACKGROUND: Pancreatic cancer in contact with the superior mesenteric vein/portal vein is classified as resectable pancreatic cancer; however, the biological malignancy and treatment strategy have not been clarified. METHODS: Data from 186 patients who underwent pancreatectomy for pancreatic cancer were evaluated using a prospectively maintained database. The patients were classified as having resectable tumors without superior mesenteric vein/portal vein contact and with superior mesenteric vein/portal vein contact of ≤180°. Disease-free survival, overall survival, and prognostic factors were analyzed. RESULTS: In the univariate analysis, superior mesenteric vein/portal vein contact in resectable pancreatic cancer was a significant prognostic index for disease-free survival and overall survival. In the multivariate analysis for poor disease-free survival, the superior mesenteric vein/portal vein contact remained significant (hazard ratio = 2.13, 95% confidence interval: 1.29-3.51; p < 0.01). In the multivariate analysis, superior mesenteric vein/portal vein contact was a significant independent prognostic index for overall survival (hazard ratio = 2.17, 95% confidence interval: 1.27-3.70; p < 0.01), along with sex, tumor differentiation, nodal involvement, and adjuvant chemotherapy. Portal vein resection for superior mesenteric vein/portal vein contact did not improve the overall survival (p = 0.86). CONCLUSIONS: Superior mesenteric vein/portal vein contact in resectable pancreatic cancer was found to be an independent predictor of disease-free survival and overall survival after elective resection. Thus, pancreatic cancer in contact with the superior mesenteric vein/portal vein may be considered as borderline resectable pancreatic cancer.

Liver Only Living Donor Transplantation for Polycystic Disease in a Patient on Chronic Hemodialysis: Case Report.

BACKGROUND: Polycystic liver disease (PLD) is characterized by the progressive development of polycystic lesions in the kidney and the liver, possibly resulting in dual organ failure. We indicated living donor liver transplantation (LDLT) for a patient with end-stage liver and kidney disease (ELKD) due to PLD on uncomplicated chronic hemodialysis. CASE PRESENTATION: A 63-year-old man with ELKD and uncontrolled massive ascites due to PLD and hepatitis B on uncomplicated chronic hemodialysis was referred to us with a single possible 47-year-old female living donor. Because of the necessity of right lobe liver procurement from this small middle-aged donor and uncomplicated hemodialysis on this recipient, we considered LDLT, rather than dual organ transplantation, could be the most well-balanced option to save the life of this recipient with acceptable risk limits for this donor. A right lobe graft with 0.91 for graft recipient weight ratio was implanted with an uneventful operative procedure under intra- and postoperative continuous hemodiafiltration. The recipient was rescheduled on routine hemodialysis on day 6 after transplantation and recovered with a gradual decrease in ascites output. He was discharged on day 56. He continues to have a very good liver function and quality of life without ascites and uncomplicated routine hemodialysis 1 year after transplantation. The living donor was discharged 3 weeks after surgery and is also doing well. CONCLUSION: Although combined liver-kidney transplantation from a deceased donor could be the best option for ELKD due to PLD, LDLT can also be an acceptable option for ELKD with uncomplicated hemodialysis, considering the double equipoise theory for both lifesaving of the recipient and acceptable donor risk.

A Multidisciplinary Treatment Strategy With Conversion Surgery for Hepatocellular Carcinoma.

BACKGROUND/AIM: Sorafenib was previously the only targeted therapy for hepatocellular carcinoma (HCC). However, pharmaceutical therapy for HCC has undergone remarkable advances in recent years. Herein, we report cases of unresectable advanced HCC responding to pharmaceutical therapy resulting in improved prognosis through surgical intervention. PATIENTS AND METHODS: Five patients with intermediate and advanced stage HCC treated with lenvatinib followed by hepatectomy between October 2019 and September 2022 were retrospectively reviewed. Patient characteristics, tumor factors, and treatment factors were compared. RESULTS: The median patient age was 66 (60-79) years, and all patients (100%) were male. The median follow-up period was 10.4 months. All five patients received lenvatinib treatment for more than 2 months before surgery. Three patients achieved partial responses and 2 patients had stable disease with modified RESIST in response to lenvatinib. Three patients had a partial pathological response (50% or more tumor necrosis). Four patients underwent R0 resection and 3 cases had no recurrence. CONCLUSION: Lenvatinib might be useful for intermediate and advanced HCC and long-term survival may be obtained by combining lenvatinib therapy with surgery.

D1 Distal Pancreatectomy for Left-sided Pancreatic Ductal Adenocarcinoma Is Justifiable: A Propensity-score Matched Multicenter Study.

BACKGROUND/AIM: Evidence on the optimal extent of lymph node dissection for left-sided pancreatic ductal adenocarcinoma (PDAC) is scarce. The aim of the current study was to compare the long-term outcomes of patients who underwent D1 distal pancreatectomy (DP) with D2 DP for left-sided PDAC. PATIENTS AND METHODS: Patients undergoing DP for left-sided PDAC at the four institutions affiliated to The Jikei University were enrolled in this study. Patients were divided into D1 and D2 groups. Patients' clinical characteristics, overall survival (OS), and relapse-free survival (RFS) were compared between the two groups before and after propensity-score matched (PSM) analysis. RESULTS: Of 145 patients with left-sided PDAC, 55 patients underwent D1 DP and 90 underwent D2 DP, of whom 38 matched pairs were included in the PSM analytic cohort. In the unmatched cohort, no significant difference was found between the D1 and D2 groups for both OS (median 2.51 vs. 3.07 years; p=0.709) and RFS (median 1.47 vs. 1.27 years; p=0.565). After PSM, OS (median 2.37 vs. 3.56 years; p=0.407) and RFS (median 1.35 vs. 1.11 years; p=0.542) were not significantly different between the two groups. In a comparison of regional and systemic recurrence sites, no significant difference was observed between the two groups (p=0.500). CONCLUSION: The long-term survival of D1 DP for left-sided PDAC was not inferior to D2 DP. In an era in which the importance of multidisciplinary treatment for PDAC has been documented, unnecessary extended surgery should be avoided.

A rare case of pseudoaneurysmal hemorrhage, necrotizing fasciitis, and costochondritis after pancreaticoduodenectomy.

BACKGROUND: Necrotizing fasciitis after pancreaticoduodenectomy (PD) has never been reported. We experienced a case of necrotizing fasciitis caused by pseudoaneurysmal hemorrhage after PD. CASE PRESENTATION: A 72-year-old male was diagnosed with cholangiocarcinoma and underwent PD. Bile leakage was detected postoperatively, conservatively resolved, and the patient was discharged on the 36th day after surgery. On the 42nd day after surgery, a pseudoaneurysm of the gastroduodenal artery ruptured. Transcatheter arterial embolization was performed for hemostasis: however, a large intra-abdominal abscess caused by an infected hematoma was recognized. On the 57th day after surgery, the patient developed necrotizing fasciitis. He underwent debridement with skin reconstruction using a latissimus dorsi flap and skin transplantation. Costochondritis and liver metastasis were detected on the 267th day after surgery. Infection was controlled by rib cartilage resection, debridement, and negative pressure wound therapy. Chemotherapy involving gemcitabine and cisplatin was initiated on the 460th day after the initial surgery with a partial response (PR) and was continued for more than one year. CONCLUSIONS: We herein reported a rare case of necrotizing fasciitis following hematoma infection after PD that was treated using multidisciplinary therapy with PR following chemotherapy.

Effects of an enteral nutrient-rich therapy with omega-3 fatty acids in patients with unresectable or recurrent biliary tract cancer or pancreatic cancer during chemotherapy: a case-control study.

To evaluate omega-3 fatty acid-rich enteral nutrient effects in patients with unresectable or recurrent biliary tract or pancreatic cancers during chemotherapy. Enteric nutritional supplements containing omega-3 fatty acids (Racol®) was administered to aforementioned patients with cancers during chemotherapy. The skeletal muscle mass and blood test data were obtained pre-administration and 28 and 56 days after. Patients with pancreatic cancer were administered the digestive enzyme supplement pancrelipase (LipaCreon®) 28 days after the start of Racol® administration. The number of chemotherapies skipped due to neutropenia was recorded for 2 months before and after enteral nutrient initiation. In all 39 patients, the skeletal muscle mass increased on day 56 versus baseline (median 17.3 kg vs. 14.8 kg, p < 0.01), number of chemotherapies skipped decreased (mean: 0.65 times/month vs. 1.3 times/month, p = 0.03), and retinol-binding protein (mean: 2.56 mg/dL vs. 2.42 mg/dL, p = 0.05) increased. Patients with pancreatic cancer showed increased blood eicosapentaenoic acid concentration on day 56 versus baseline (median: 48.1 µg/mL vs. 37.0 µg/mL, p = 0.04) and increased skeletal muscle mass (median 16.8 kg vs. 14.4 kg, p = 0.006). Baseline median neutrophil count increased significantly from 2200/µL at baseline to 2500/µL (p = 0.04). Patients with biliary tract cancer during chemotherapy also exhibited increased skeletal muscle mass following omega-3 supplementation (median 17.3 kg vs. 15.8 kg, p = 0.01). In patients undergoing chemotherapy for unresectable or post-recurrence pancreatic and biliary tract cancers, high-omega-3 fatty acid nutrition therapy use improved skeletal muscle maintenance and chemotherapy dosing intensity.

New Scoring System for Prediction of Surgical Difficulty During Laparoscopic Cholecystectomy After Percutaneous Transhepatic Gallbladder Drainage.

Background: The surgical difficulty of laparoscopic cholecystectomy (LC) after percutaneous transhepatic gallbladder drainage (PTGBD) remains unknown. This study aimed to establish a scoring system (SS) to predict the necessity of a bailout procedure during LC after PTGBD and to evaluate the relationship between SS and perioperative complications. Methods: We retrospectively studied 70 patients who underwent LC after PTGBD. Preoperative factors potentially predictive of the need for the bailout procedure were analyzed. The SS included significantly predictive factors, with their cutoff values determined by receiver operating characteristic curves. Patients were assigned a score of 1 when exhibiting only one of these abnormalities. We compared the perioperative factors between three groups with scores of 0, 1, or 2. The SS was applied to another series of 65 patients for validation. We compared the score-2 patient perioperative factors between LC with the bailout procedure and open cholecystectomy from the beginning (OC). Results: Independent predictors were time until PTGBD after symptom onset and the maximal wall gallbladder thickness (cutoff values: 3 days and 10 mm, respectively). The high-score group was significantly associated with bile duct injury (BDI). The sensitivity and specificity of our SS were 75.0% and 98.1% in validation, respectively. The score-2 OC and laparoscopic subtotal cholecystectomy (LSC) groups had no BDI. Conclusions: The SS using time until PTGBD after symptom onset and gallbladder wall thickness for predicting the need for the bailout procedure correctly predicted the need. The scores might be associated with the risk of BDI, and LSC or OC might be a better choice for score-2 patients.

Development of recognised position-guided navigation system.

BACKGROUND: Previously, we developed an image-guided navigation system (IG-NS) incorporating augmented reality technology. Nevertheless, the system could still only aid the operator by presenting imagery and was short of achieving the goal of developing a real navigation system. Therefore, we developed a recognised position-guided navigation system (RP-NS) and herein reported the functionality and usefulness of this system in a phantom model for clinical applications. METHODS: We developed RP-NS which was reconstructed by adding the positional recognition and instruction functions with the cautions by displaying the images on the monitor with a voice to the IG-NS. We evaluated accuracy of positional recognition and instruction functions using phantom model. By utilising the chronological recording of the tip position of the surgical apparatus, the surgical precision of the operators was assessed. Finally, the feasibility of improvements in surgical precision using this system was evaluated. RESULTS: The RP-NS indicated an accuracy of the position recognition functions with an error of 2.7 mm. The surgeons could perform partial hepatectomies within mean value of 7.5% error as compared with calculated volume according to the instruction. Improvements in surgical precision using this system were obtained on the surgeons with different levels. CONCLUSIONS: The RP-NS was highly effective as a navigation system owing to precise positional recognition and adequate instruction functions. Therefore, these results indicate that the use of this system may complement differences in proficiency, and numerically evaluate surgical skills and analyse tendencies of surgeons.

Retroperitoneal lymphangioma mimicking malignant tumor treated by pancreaticoduodenectomy.

Lymphangiomas are classified as lymphatic malformations, which are more common in children and rare in adults. It frequently occurs in the cervical and axillary regions and uncommonly in the retroperitoneum. A 39-year-old woman presented to our department for the investigation for a 55 mm asymptomatic mass in the right anterior adrenal cavity. Abdominal ultrasound showed a tumor containing cysts in the right anterior adrenal cavity. Contrast-enhanced computed tomography showed that the tumor was poorly contrasted and ill-defined. Magnetic resonance imaging suggested that the tumor contained a small amount of fat. The tumor tended to grow, and the possibility of malignant diseases such as liposarcoma could not be excluded. Therefore, surgical resection was performed. Since intraoperative findings showed that the tumor tightly invaded to the duodenum and pancreatic head, a pancreaticoduodenectomy was selected. The entire tumor was removed without exposing the tumor. Macroscopic findings indicated that the specimen was 55 mm in size, indistinctly demarcated, yellow-white in color, and polycystic. Histologically, lymphovascular proliferation was observed with infiltration of the pancreatic head and the duodenal muscle layer. The diagnosis of lymphangioma was finally made. There was no recurrence 2 years after surgery.

Impact of osteopenia on surgical and oncological outcomes in patients with pancreatic cancer.

INTRODUCTION: Osteopenia, which is defined as a decrease in bone mineral density, has been recently recognized as a metabolic and an oncological biomarker for surgery in patients with malignancy. We aimed to study the prognostic impact of osteopenia in patients with pancreatic cancer (PC) after resection. METHODS: A total of 56 patients who underwent curative resection of PC were retrospectively investigated. The skeletal muscle index at the third lumbar spine and bone mineral density at the 11th thoracic vertebra were measured using computed tomography. RESULTS: Sarcopenia and osteopenia were identified in 24 (43%) and 27 (48%) patients, respectively. The overall and disease-free survival rates were significantly lower in the sarcopenia group than in the non-sarcopenia group (p < 0.01 and p < 0.01, respectively) and in the osteopenia group than in the non-osteopenia group (p < 0.01 and p < 0.01, respectively). In multivariate analysis, sarcopenia (odds ratio [OR] 4.05; 95% confidence interval [CI] 1.23-13.38; p = 0.02) was a significant independent predictor of 1-year disease-free survival. Further, sarcopenia (OR 6.00; 95% CI 1.46-24.6; p = 0.01) and osteopenia (OR 4.66; 95% CI 1.15-18.82; p = 0.03) were significant independent predictors of 2-year overall survival. CONCLUSION: Osteopenia is a significant negative factor for 2-year overall survival after curative resection of PC.

Laparoscopic fenestration for a huge symptomatic splenic cyst in a patient with Gaucher's disease.

A 34-year-old woman visited our hospital for treatment of a huge splenic cyst with epigastric pain. She had been diagnosed with Gaucher's disease (Type 1) at 3 years of age and had been receiving enzyme replacement therapy (ERT) from 15 years of age. Abdominal MRI showed a low-intensity area, 30 cm in diameter, with a well-defined border on T1-weighted images. The patient underwent laparoscopic fenestration of the huge splenic cyst for relief of worsening epigastric pain caused by the cyst. The cyst contained 2,500 ml of brownish-red fluid. The patient recovered satisfactorily and was discharged on postoperative day 11. Gaucher's disease is an extremely rare metabolic disease; only about 6,000 patients are registered in the International Collaborative Gaucher Group Gaucher Registry. An extremely rare case of a huge symptomatic splenic cyst treated by laparoscopic fenestration in a patient with Gaucher's disease is described.

Effects of ω-3 Fatty Acid Supplementation in Patients with Bile Duct or Pancreatic Cancer Undergoing Chemotherapy.

BACKGROUND/AIM: Omega-3 fatty acids may improve cancer cachexia, but only in patients with pancreatic and bile duct cancer. Patients with pancreatic cancer commonly suffer from exocrine pancreatic insufficiency, and the ingestion of digestive enzyme supplements may improve absorption. PATIENTS AND METHODS: Racol®, an enteral nutrient formulated with omega-3 fatty acids, was administered to patients with unresectable pancreatic and bile duct cancer. The skeletal muscle mass and blood test data were taken pre-administration and at 4 and 8 weeks after. Patients with pancreatic cancer were given the digestive enzyme supplement LipaCreon® from the fifth week after the start of administration. RESULTS: In all 27 patients, skeletal muscle mass was significantly increased at both 4 and 8 weeks after the start of administration versus pre-administration (p=0.006, p=0.002, respectively). CONCLUSION: Omega-3 fatty acid supplementation in patients with unresectable pancreatic and bile duct cancer may improve cancer cachexia.

Repeated Clostridium difficile infection after living donor liver transplantation.

Liver transplant recipients are considered to be at high risk for Clostridium difficile infection, with an incidence of 2.7-8.0%, which is three times higher than that among other patients. A case of a patient who suffered from pseudomembranous colitis five times after living donor liver transplantation is reported. A 60-year-old woman underwent splenectomy and living donor liver transplantation using the left lobe of her spouse for primary biliary cirrhosis. The patient made a satisfactory recovery, except for splenic vein thrombosis. She was discharged on postoperative day 36; however, she developed pseudomembranous colitis due to Clostridium difficile infection five times within 6 months after transplant and was treated with oral vancomycin each time. At the fifth recurrence of pseudomembranous colitis, the patient received vancomycin taper treatment, dietary counseling, and repeat instructions regarding hand hygiene and house cleaning. The patient recovered and is currently well without recurrence of Clostridium difficile infection 36 months after living donor liver transplantation.