A case of successful removal of a migrated fish bone in the bile duct after pancreaticoduodenectomy using overtube-assisted cholangioscopy.

Fish bone migration into the bile duct in patients with surgically altered anatomy is a very rare cause of bile duct stones. Recently, balloon-assisted endoscopic retrograde cholangiopancreatography (BAERCP) is performed for biliary lesions in patients with surgically altered anatomy. We report on a 73-year-old Japanese man with a history of pancreaticoduodenectomy for intraductal papillary mucinous adenoma. A 20 mm long linear hyperattenuating structure in the left intrahepatic bile duct was noted on routine follow-up computed tomography 14 years postoperatively. The linear structure persisted until follow-up computed tomography performed 15 years postoperatively, and the left intrahepatic bile duct was shown to be dilated. We performed BAERCP for the diagnosis and treatment of the linear structure but could not visualize the linear structure in the left intrahepatic bile duct via enteroscopy and fluoroscopy. We removed the enteroscope, leaving the overtube, and inserted the cholangioscope through the overtube over the guide wire. We observed a brown rod-shaped linear structure in the left intrahepatic bile duct and removed it under direct visualization via overtube-assisted cholangioscopy. We conclude that overtube-assisted cholangioscopy was useful for assessing undiagnosed biliary lesions using conventional BAERCP and removing fish bones in the bile duct of the patient with altered gastrointestinal anatomy.

[A Case of Long-Term Survival by Multidisciplinary Surgical Treatment for Metastatic Multi-Organ Metastasis after Radical Resection of Esophageal Cancer].

A 78-year-old man with advanced thoracic esophageal cancer underwent radical esophagectomy after neoadjuvant chemotherapy with cisplatin plus 5-FU. He had left adrenal metastasis 10 months after surgery and removed it, but 3 months later he had liver metastases. After 2 courses of chemotherapy with nedaplatin plus 5-FU, resection was performed. One course of nedaplatin plus 5-FU for adjuvant chemotherapy was added, but the patient was followed up without another chemotherapy after surgery because of intestinal obstruction due to infection and increase of the lymphatic cyst in the abdominal cavity. Six months after the liver resection, nodules appeared in the right lung, and 4 months later, multiple nodules extending to both lungs were observed. Therefore, it was judged that there were multiple lung metastases, and administration of nivolumab was started. He has been 3 years since the recurrence of esophageal cancer and 17 months after the start of nivolumab administration, but the recurrence lesion is only progressing to lung metastasis.

[A Case of Dedifferentiated Liposarcoma with Reducing Surgery Followed by Chemotherapy and Additional Reducing Surgery].

Dedifferentiated liposarcoma shows poor prognosis because of poor resectability due to aggressive invasion of adjacent organs with multicentric growth and its low sensitivity to chemotherapy. We report herein a case of a giant dedifferentiated liposarcoma, successfully treated by pancreaticoduodenectomy(PD)for tumor reduction and chemotherapy for 1 year after surgery, followed by additional surgery for tumor reduction. The patient is a woman in 50s. CT showed an 18.5×9 cm main mass surrounding the superior mesenteric artery(SMA and SMV)with multiple tumors in the pelvis. Needle biopsy revealed dedifferentiated liposarcoma. Although complete resection or chemotherapy was not feasible, surgery was performed for local control and introduction of chemotherapy. The main tumor was resected by PD with SMV resection and right colectomy. Chemotherapy with doxorubicin followed by eribulin was administered after surgery. The residual lesions were controlled for 1 year. Partial resection of the tumors in the mesentery was performed. Eribulin were administered starting postoperatively. One year and 10 months after the initial surgery, there was no progress in residual disease. Although R2 resection for dedifferentiated liposarcoma shows extremely poor prognosis. Even when complete resection would be difficult, multidisciplinary treatment including debulking surgery might be effective for disease control.

A case of a smooth transition to subsequent percutaneous transjejunal biliary intervention for hepatolithiasis after biliary reconstruction by adding jejunostomy during an emergency operation for perforation due to balloon-assisted endoscopy.

Treatments for hepatolithiasis include peroral endoscopy, percutaneous cholangioscopy, and surgery. Balloon-assisted endoscopic retrograde cholangiopancreatography (BAERCP) has been widely performed in recent years for patients with hepatolithiasis after biliary reconstruction. However, accidental bowel perforation caused by BAERCP may need emergency surgery. Here, we describe a 77-year-old Japanese woman diagnosed with acute cholangitis due to hepatolithiasis after biliary reconstruction (a biliary diversion operation for pancreaticobiliary maljunction). She underwent BAERCP for treatment of hepatolithiasis, however, a small-bowel perforation occurred. She underwent an emergency operation to suture the perforation and add a catheter jejunostomy. She had no postoperative complications after surgery and was discharged 11 days after surgery. One month later, she was readmitted and underwent percutaneous transjejunal cholangioscopy-guided lithotripsy with complete removal of the calculi. Although endoscopists should be careful to avoid small-bowel perforation during BAERCP, if perforation occurs, addition of a catheter jejunostomy during emergency surgery can be easily transitioned to subsequent treatment of the hepatolithiasis.

Severe acute pancreatitis 5 years after pancreaticoduodenectomy: A case report.

INTRODUCTION: Acute pancreatitis is a known complication of pancreaticoduodenectomy (PD). However, no reports in the literature describe a late delayed severe acute pancreatitis. We report a case of acute pancreatitis 5 years after PD in a patient who needed intensive care for his complication. PRESENTATION OF CASE: A 64-years-old man presented with upper abdominal pain and reported a history of PD 5 years prior to presentation. Contrast-enhanced computed tomography revealed an edematous pancreatic remnant with inflammation of the surrounding tissue, and he was diagnosed with acute pancreatitis. His condition worsened, and he was transferred to our hospital the following day. He was admitted to the intensive care unit to manage respiratory and circulatory insufficiency. Although his condition improved, an abdominal abscess was identified, and necrosectomy was performed on day 43 of hospitalizaiton. We carefully removed as much necrotic tissue as was possible without injury to the pancreaticojejunal anastomosis and the ascending colon. Inflammation gradually subsided, and he was discharged on day 111 of hospitalization. The last drain was removed in day 133 of admission to our hospital. Pancreatitis and abdominal abscess have not recurred until the time of writing this paper. DISCUSSION: Delayed severe acute pancreatitis is rare. Necrosectomy can treat an abdominal abscess; however it is important to avoid injury to other organs. CONCLUSION: Clinicians should be aware that severe acute pancreatitis can occur after PD.