Influence of Percutaneous Transhepatic Gallbladder Aspiration and Drainage for Severe Acute Cholecystitis on the Surgical Outcomes of Subsequent Laparoscopic Cholecystectomy: Post Hoc Analysis of the CSGO-HBP-017 (CSGO-HBP-017C).

OBJECTIVE: Percutaneous transhepatic gallbladder aspiration (PTGBA) and/or drainage (PTGBD) are useful approaches in the management of acute cholecystitis in patients who cannot tolerate surgery because of poor general condition or severe inflammation. However, reports regarding its effect on the surgical outcomes of subsequent laparoscopic cholecystectomy (LC) are sparse. The aim of this retrospective study was to investigate the influence of PTGBA on surgical outcomes of subsequent LC by comparing the only-PTGBA group, including patients who did not need the additional-PTGBD, versus the additional-PTGBD group, including those who needed the additional-PTGBD after PTGBA. PATIENTS AND METHODS: We conducted a post hoc analysis of our multi-institutional data. This study included 63 patients who underwent LC after PTGBA, and we compared the surgical outcomes between the only-PTGBA group (n = 56) and the additional-PTGBD group (n = 7). RESULTS: No postoperative complications occurred among the 63 patients, and the postoperative hospital stay was 11 ± 12 days. Fourteen patients (22.2%) had a recurrence of cholecystitis, of whom 7 patients (11.1%) needed the additional-PTGBD after PTGBA. Significantly longer operative time (245 ± 74 vs 159 ± 65 min, P = 0.0017) and postoperative hospital stay (22 ± 27 vs 10 ± 9 d, P = 0.0118) and greater intraoperative blood loss (279 ± 385 vs 70 ± 208 mL, P = 0.0283) were observed among patients in the additional-PTGBD group compared with the only-PTGBA group, whereas the rates of postoperative complications (Clavien-Dindo grade ≥3: 0% each) and conversion to open surgery (28.6% vs 8.9%, P = 0.1705) were comparable. CONCLUSION: PTGBA for acute cholecystitis could result in good surgical outcomes of subsequent LC, especially regarding postoperative complications. However, we should keep in mind that the additional-PTGBD after PTGBA failure, which sometimes happened, would be associated with increased operative difficulty and longer recovery.

Effect of Preserving the Percutaneous Gallbladder Drainage Tube Before Laparoscopic Cholecystectomy on Surgical Outcome: Post Hoc Analysis of the CSGO-HBP-017.

BACKGROUND: When percutaneous transhepatic gallbladder drainage (PTGBD) is followed by laparoscopic cholecystectomy (LC), there is no consensus regarding whether the drainage tube should be preserved or removed before LC. We hypothesized that the surgical results of LC might differ between cases with PTGBD tube preservation versus removal. Here, we investigated how drainage tube preservation or removal affected the surgical outcome of LC. METHODS: Using data from our previous multicenter study, we compared LC outcomes after PTGBD between patients with PTGBD tube preservation versus removal. This study included 208 patients who underwent LC over 12 days after PTGBD. In 83 cases, the PTGBD tube was preserved until LC, and in 125 cases, the tube was removed before LC. The results were verified by propensity score matching with 50 patients in each group. RESULTS: Cases with tube preservation versus removal exhibited significantly longer surgery duration (174 ± 105 min vs 145 ± 61 min, P = .0118) and postoperative hospital stay (14 ± 16 days vs 7 ± 7 days, P < .0001), a significantly higher postoperative complication rate (13.2% vs 3.2%, P = .0061), and a marginally higher incidence of open conversion (12.0% vs 4.8%, P = .0547). Propensity score matching verified the inferior surgical outcomes in cases with tube preservation. CONCLUSIONS: These results imply that when LC is performed > 12 days after PTGBD, the surgical outcome may be inferior when the drainage tube is preserved rather than removed before LC.

Preoperative risk score to predict subtotal cholecystectomy after gallbladder drainage for acute cholecystitis: Secondary analysis of data from a multi-institutional retrospective study (CSGO-HBP-017B).

INTRODUCTION: Subtotal cholecystectomy (STC) has become recognized as a "bailout procedure" to prevent bile duct injury in patients undergoing laparoscopic cholecystectomy (LC). Predictors of conversion to STC have not been identified because LC difficulty varies based on pericholecystic inflammation. We analyzed data from patients enrolled in a previously performed multi-institutional retrospective study of the optimal timing of LC after gallbladder drainage for acute cholecystitis (AC). These patients presumably had a considerable degree of pericholecystic inflammation. METHODS: In total, 347 patients who underwent LC after gallbladder drainage for AC were analyzed to examine preoperative and perioperative factors predicting conversion to STC. RESULTS: Three hundred patients underwent total cholecystectomy (TC) and 47 underwent conversion to STC. Eastern Cooperative Oncology Group Performance Status (ECOG PS) (P < .01), severity of cholecystitis (P = .04), previous history of treatment for common bile duct stones (CBDS) (P < .01), and surgeon experience (P = .03) were significantly associated with conversion to STC. Logistic regression analyses showed that ECOG PS (odds ratio 0.2; P < .0001) and previous history of treatment for CBDS (odds ratio 0.37; P = .0073) were independent predictors of conversion to STC. Our predictive risk score using these two variables suggested that a score ≥2 could discriminate between TC and STC (P < .0001). CONCLUSION: Poor ECOG PS and previous history of treatment for CBDS were significantly associated with conversion to STC after gallbladder drainage for AC.

Optimal timing of laparoscopic cholecystectomy after gallbladder drainage for acute cholecystitis: A multi-institutional retrospective study.

BACKGROUND: There is no consensus on the optimal timing of laparoscopic cholecystectomy (LC) after gallbladder drainage for acute cholecystitis (AC). To obtain evidence for a consensus, we investigated surgical outcomes of LC after gallbladder drainage with respect to the time elapsed from gallbladder drainage to surgery in a multi-institutional retrospective study. METHODS: This study enrolled 347 patients who underwent LC after gallbladder drainage for AC at 15 institutions. Surgical outcome of LC was investigated in the cases based on the interval from gallbladder drainage to surgery. RESULTS: The median interval from gallbladder drainage to surgery of the patients was 34 days, with a mean ± standard deviation of 58 ± 99 days. Patients were divided into four groups based on quartiles of the interval: Group A, cases with an interval of 1-12 days; Group B, cases with an interval of 13-34 days; Group C, cases with an interval of 35-73 days; and Group D, cases with an interval of ≥74 days. Surgical outcomes, which were evaluated with respect to intraoperative blood loss, operation time, postoperative hospital stay, rate of intraoperative accident, conversion from laparoscopic to open surgery, and postoperative complication, were worse in Group B than in the other groups. The finding was verified by propensity score-matched analysis. CONCLUSIONS: Surgical outcome of LC after gallbladder drainage for AC was inferior in Group B compared with the other groups. This finding could be useful for determining the optimal timing of LC after gallbladder drainage for AC.

Laparoscopic surgery for idiopathic adult intussusception successfully reduced by colonoscopy.

Most cases of adult intussusception are caused by neoplastic lesions, and idiopathic adult intussusception is very rare. We present a case in which laparoscopic surgery was performed for idiopathic adult intussusception initially reduced by colonoscopy. A 53-year-old woman presented to the emergency department of our hospital with intermittent lower abdominal pain. Contrast-enhanced computed tomography and ultrasonography of the abdomen showed a concentric structure in the ascending colon. We diagnosed intussusception. Colonoscopy achieved successful reduction before surgery. Twelve days after this reduction, laparoscopic surgery was performed. Histopathological examination did not reveal any causative pathology; therefore, idiopathic adult intussusception was diagnosed. The postoperative course was uneventful, and the patient was discharged on postoperative day 14. Preoperative colonoscopy should be utilized to diagnose the main lesion and may be useful for reducing adult intussusception. Laparoscopic surgery is both minimally invasive and safe and can be performed following endoscopic reduction.

Surgical outcomes of laparoscopic cholecystectomy for acute cholecystitis in elderly patients.

INTRODUCTION: The clinical significance of laparoscopic cholecystectomy (LC) for acute cholecystitis in elderly patients aged 80 years or older has not been determined. This study aimed to investigate surgical outcomes of LC for acute cholecystitis in elderly patients compared to non-elderly patients. METHODS: Patients who underwent urgent LC for acute cholecystitis were enrolled. Older (≥80 years) and younger patients (<80 years) were compared for perioperative factors to assess surgical outcomes of LC. RESULTS: A total of 351 patients were included; 52 (14.8%) and 299 (85.2%) were categorized as older and younger, respectively. The older group had a significantly higher proportion of patients with concomitant physiological diseases than the younger group and a significantly higher ASA classification. No significant differences between the two groups were found in operation time, intraoperative blood loss, or conversion rate to open surgery. Incidence of postoperative complications and duration of postoperative hospital stay also were not significantly different between the two groups. CONCLUSION: Surgical outcomes of LC for acute cholecystitis in older patients are comparable to those in younger patients, which confirms the feasibility of LC for acute cholecystitis in elderly patients.

Ruptured Cystic Artery Pseudoaneurysm Successfully Treated with Urgent Cholecystectomy: A Case Report and Literature Review.

BACKGROUND Cystic artery pseudoaneurysm is rare, and some cases are associated with inflammation of the gallbladder. There is limited information regarding this condition, and the clinical features remain unclear. This report is a case of ruptured cystic artery pseudoaneurysm diagnosed by computed tomography (CT) imaging and treated with urgent cholecystectomy and is supported by a literature review of previous cases. CASE REPORT A 90-year-old man, who had developed acute cholecystitis due to a gallstone one month previously, was referred to our hospital. He developed fever and epigastric pain while waiting for a scheduled elective cholecystectomy. Laboratory investigations showed elevated markers of inflammation and elevated hepatobiliary enzyme levels. Computed tomography (CT) imaging showed cholecystitis and pseudoaneurysm of the cystic artery. The pseudoaneurysm had ruptured and was accompanied by the formation of a hematoma within the gallbladder that involved the liver bed. Having made the preoperative diagnosis, an urgent open laparotomy was performed, during which the gallbladder was found to have perforated. The hematoma penetrated into the liver bed. Cholecystectomy was performed, and the pseudoaneurysm of the cystic artery was extirpated. There were no serious postoperative complications. A literature review identified 50 previously reported case of cystic artery pseudoaneurysm. CONCLUSIONS A case of ruptured cystic artery pseudoaneurysm, successfully treated with urgent cholecystectomy is reported, supported by a literature review of previous cases and characterization of the clinical features of this rare condition.

Clinical significance of CD13 and epithelial mesenchymal transition (EMT) markers in hepatocellular carcinoma.

BACKGROUND & AIMS: To improve prognosis in patients with hepatocellular carcinoma (HCC), the molecular mechanisms of tumor thrombus formation and metastasis must be clarified. The epithelial-mesenchymal transition (EMT) and cancer stem cells (CSCs) play crucial roles in tumor invasion and metastasis. This study aimed to reveal the clinical significance of the expression of the functional CSC marker, CD13, and investigate the correlation between CD13 expression and two EMT markers, E-cadherin and vimentin. METHODS: We acquired clinical samples from 86 patients with HCC that underwent radical liver resections. We performed immunohistochemistry to evaluate CD13, E-cadherin and vimentin expression. We investigated the relationships among protein expression levels, clinicopathological factors and prognosis. RESULTS: Based on CD13 expression, patients were categorized into CD13high (n = 30, 34.9%) and CD13low (n = 56, 65.1%) groups. The mean tumor size was significantly larger in the CD13high group than in the CD13low group (P = 0.049). Compared with the CD13low group, the CD13high group showed significantly earlier recurrences and shorter survival times. In the multivariate analysis, CD13high was an independent prognostic factor for overall survival (hazard ratio, 1.98; P = 0.044). The disease-free survival time was shorter in the vimentin-positive group than that in the vimentin-negative group (P = 0.014). In an analysis of the relationship between CD13 and EMT, there was no significant correlation between CD13 and EMT markers. CONCLUSIONS: Our findings suggested that CD13 enrichment was correlated with early recurrences, and poor prognosis in patients with HCC and that vimentin was associated with early recurrences. CD13 represents a potential therapeutic target for HCC, because CSC regulation and EMT suppression are essential in cancer therapy.

Distance from Left Renal Vein to Inferior Pancreaticoduodenal Artery: A Landmark for Identifying Inferior Pancreaticoduodenal Artery in Pancreatoduodenectomy.

BACKGROUND/AIM: During pancreatoduodenectomy, early ligation of major afferent arteries to pancreatic head prior to dissection of the corresponding veins may reduce intraoperative bleeding. Inferior pancreaticoduodenal artery (IPDA), one of the major afferent arteries, is difficult to identify. We measured the distance from left renal vein to IPDA based on preoperative multi-detector row computed tomography (MDCT) images for use as a new landmark for IPDA. METHODS: The distance between left renal vein and IPDA was measured in 417 patients using MDCT images. RESULTS: IPDA was identified on MDCT images in 415 out of the 417 patients (99.5%). The root of IPDA was located on cranial side of the root of left renal vein in 88 among the 415 patients (21.2%), and the distance was expressed as negative in these cases. The distance was 6.09 ± 7.46 mm. The distance when IPDA formed a common vessel with first jejunal artery (8.03 ± 6.74 mm; 323 cases, 77.8%) was significantly longer than when IPDA branched directly from superior mesenteric artery (SMA; -0.81 ± 5.74 mm; 62 cases, 15.0%) or posterior and anterior IPDAs branched separately from SMA (-2.04 ± 5.36 mm; 30 cases, 7.2%). CONCLUSIONS: The distance between left renal vein and IPDA can serve as a landmark for IPDA identification.

Omitting perioperative urinary catheterization in laparoscopic cholecystectomy: a single-institution experience.

PURPOSE: In 2009, the Centers for Disease Control and Prevention published Guidelines for the Prevention of Catheter-Associated Urinary Tract Infections, which limited the indications for perioperative urinary catheter use. We conducted this study to evaluate the safety of elective laparoscopic cholecystectomy (LC) without urinary catheter placement and to investigate whether it reduces the incidence of urinary complications. METHODS: Of 244 patients who underwent elective LC between March, 2010 and April 2011, 192 patients fulfilled the eligibility criteria and underwent surgery without urinary catheterization (non-catheterized group). We compared the clinical features and surgical outcomes of the non-catheterized group with those of an historical control of 90 patients who underwent LC with routine urinary catheterization. RESULTS: The operating times were similar in the two groups and there was no case of conversion to open surgery. The postoperative hospital stay was slightly shorter and the incidence of urinary complications was significantly lower in the non-catheterized group. Three patients in the non-catheterized group suffered urinary retention, which resolved after temporary catheterization. CONCLUSION: Our study demonstrated that elective LC without urinary catheter placement is feasible for most patients and might reduce the incidence of perioperative urinary complications.

Outcomes in Colorectal Surgeon-Driven Management of Obstructing Colorectal Cancers.

BACKGROUND: Emergency surgery for obstructing colorectal cancer is associated with high mortality and morbidity rates. OBJECTIVE: The purpose of this study was to assess outcomes of emergency surgery for obstructing colorectal cancer in a single hospital, where care was primarily provided by colorectal surgeons. DESIGN: This was a retrospective cohort study. SETTINGS: The study was conducted at the Toyonaka Municipal Hospital. PATIENTS: The study included 208 consecutive patients who underwent emergency surgery for obstructing colorectal cancer between 1998 and 2013. MAIN OUTCOME MEASURES: Surgical outcomes, including mortality and morbidity, were evaluated. RESULTS: The obstructing cancers involved the right colon, left colon, and rectum in 78, 97, and 33 of the included patients. Many patients had poor performance indicators, such as age ≥75 years (42%), ASA score of III or more (38%), stage IV colorectal cancer (39%), obstructive colitis (12%), and perforation or penetration (9.6%). Colorectal surgeons performed the operations in all but 5 of the patients. Primary resection and anastomosis were accomplished in 96%, 70%, and 27% of cases involving the right colon, left colon, and rectum. Intraoperative colonic irrigation (n = 32), manual colonic decompression (n = 11), and subtotal or total colorectal resection (n = 34) were performed before left-sided anastomoses. Anastomotic leak was reported in only 2 patients. The in-hospital mortality and morbidity rates were 1.3% and 34.0%. LIMITATIONS: This study was a retrospective analysis of data from a single hospital. CONCLUSIONS: Surgical outcome analysis for obstructing colorectal cancers managed by specialized colorectal surgeons demonstrates low mortality and morbidity rates. Therefore, we concluded that our management of this condition is safe and feasible.

Tubular adenoma of the common bile duct with uptake in 18F-FDG PET: A case report.

A 64-year-old man presented with epigastric discomfort and nausea. Laboratory analyses revealed increased levels of total and direct bilirubin, and increased levels of aminotransferases. Computed tomography revealed the presence of a mass in the distal common bile duct. Endoscopic retrograde cholangiopancreatography and intraductal ultrasonography revealed a 25 mm filling defect in the distal common bile duct, and biopsy of the lesion disclosed the presence of tubular adenoma. Using fluorine-18 fluorodeoxyglucose positron emission tomography (18F-FDG PET) revealed an increased accumulation of the tracer in the lesion, with a maximum standard uptake value (SUVmax) of 3.3. The patient received a pylorus-preserving pancreatoduodenectomy. The histopathological examination revealed a tubular adenoma with low-grade atypia. The patient remains alive 15 months following the surgery, with no evidence of recurrence of the adenoma. 18F-FDG PET has been successfully applied in clinical practice to detect a wide variety of tumor types, including lymphoma, lung, colon and bile duct cancer. In the present study, a case of bile duct adenoma with low-grade atypia was reported, revealing the uptake of 18F-FDG. 18F-FDG PET may be able to detect premalignant tumors of the bile duct, although whether 18F-FDG PET is able to differentially discriminate between diagnoses of adenoma and carcinoma of the bile duct remains to be fully elucidated, and the assessment of further case studies is required.

[Effect of Post-Gastrectomy Adjuvant S-1 Chemotherapy on Muscle Volume in Gastric Cancer Patients].

OBJECTIVE: To examine the effect of S-1 adjuvant chemotherapy on muscle volume after curative gastrectomy in gastric cancer patients. PATIENTS: Forty-eight gastric cancer patients (31 men and 17 women) who underwent curative gastrectomy (distal gastrectomy: n=37, and total gastrectomy: n=11) between April 2010 and July 2011 were enrolled in this study. Sixteen patients underwent S-1 adjuvant chemotherapy (S-1 group) for 1 year after the operation, and 32 patients did not (NT group). METHODS: The psoas muscle areas were measured at the fourth lumbar vertebrae on CT images obtained before the operation, and at 6, 12, and 24 months after the operation. Muscle areas was statistically examined by comparing the preoperative and postoperative ratios. RESULTS: The muscle areas 12 months after the operation decreased to 0.86 ± 0.11 in the S-1 group and to 0.96 ± 0.08 in the NT group (p<0.05), and the significant difference disappeared at 24 months (0.93 ± 0.10 vs. 0.93 ± 0.11, NS). In the patients who underwent distal gastrectomy, the muscle areas decreased to 0.90 ± 0.05 in the S-1 group and to 0.96 ± 0.09 in the NT group at 12 months (p<0.05). Meanwhile, in those who underwent total gastrectomy, the muscle areas decreased to 0.80 ± 0.15 and 0.93 ± 0.03, respectively (NS). CONCLUSIONS: S-1 adjuvant chemotherapy affected muscle volume loss after gastrectomy in the gastric cancer patients, but the patients recovered from the adverse effect by 12 months after chemotherapy.

Feasibility and Safety of Urgent Laparoscopic Cholecystectomy for Acute Cholecystitis After 4 Days from Symptom Onset.

BACKGROUND: It is preferable to perform laparoscopic cholecystectomy for acute cholecystitis in the acute phase, within 72 h of symptom onset. The feasibility and safety of performing urgent laparoscopic cholecystectomy in the late phase (4-7 days after symptom onset) are unclear. The aim of this study was to clarify the feasibility and safety of late phase urgent laparoscopic cholecystectomy. METHODS: Between 2005 and 2014, 233 patients underwent urgent laparoscopic cholecystectomy for acute cholecystitis within 7 days. We compared clinical features and perioperative outcomes between patients who underwent laparoscopic cholecystectomy within 3 days (early phase group) and 4-7 days after symptom onset (late phase group). RESULTS: There were 193 patients in the early phase group and 40 patients in the late-phase group. Performing laparoscopic cholecystectomy in the late phase did not influence operation time, postoperative complications, or postoperative hospital stay. The rate of conversion to open surgery and blood loss were slightly higher in the late-phase group (8 % and 140 ml) compared with the early phase group (3 % and 69 ml) but were still acceptable. CONCLUSIONS: Late phase urgent laparoscopic cholecystectomy for acute cholecystitis was feasible and safe.

[Liver Metastasis in a Gastric Cancer Patient--A Case of Successful Radiofrequency Ablation Combined with Degradable Starch Microspheres Transcatheter Arterial Chemoembolization].

A 60-year-old male patient underwent curative surgical resection for gastric cancer. After the surgery, the patient was diagnosed with T4b, N3b, ly3, v2, CY0, fStageⅢc gastric cancer, and adjuvant systemic chemotherapy using S-1 and CDDP was administered. However, follow-up computed tomography (CT) scan examination taken 2 months after surgery revealed a pancreatic fistula and retroperitoneal abscess, and percutaneous drainage was performed. After 1 month, the enhanced CT scan detected liver metastasis measuring 25 mm in diameter at segment 7. The CT-guided percutaneous radiofrequency ablation (RFA) combined with transcatheter arterial chemoembolization (TACE) procedure was performed on the liver metastasis using degradable starch microspheres (DSM). Two months after the RFA, a follow-up CT scan revealed local recurrence of the lesion in the medial side of the ablated area in segment 7. A second CT-guided RFA, which was combined with DSM-TACE, was performed on the recurrent lesion. The patient has since survived more than 2 years after the second treatment without any further recurrences. This case report suggests that RFA treatment combined with DSM-TACE might be a safe and feasible treatment for liver metastasis from gastric cancer.

[A Case of Intractable Bile Leakage after Surgery for Gallbladder Cancer Successfully Treated by Transcatheter Arterial Embolization].

An 83-year-old man underwent extended cholecystectomy for gallbladder cancer. On postoperative day 13, he developed fever and computed tomography (CT) revealed fluid collection at the cut surface of the liver. Ultrasound-guided fluid drainage was conducted, and he was diagnosed with biliary leakage. Radiological examination using a contrast agent revealed that the anterior branch of the bile duct (B5) was completely interrupted. Simple drainage and ethanol injections into the bile duct proved ineffective. Thus, we performed transcatheter arterial embolization (TAE) in the anterior segmental artery (A5) to stop the production of bile in the injured part of anterior segment. The treatment was effective, and he was discharged 15 days after TAE. TAE might be a useful method for treating intractable interrupted-type bile leakage.

[A Case of Surgical Treatment for Mixed Adenoneuroendocrine Carcinoma of the Ampulla of Vater].

A 56-year-old woman was referred to our hospital because of epigastric discomfort and jaundice. Contrast-enhanced computed tomography and gastrointestinal endoscopy revealed an ampullary tumor. A biopsy specimen showed adenocarcinoma of the ampulla of Vater. The carbohydrate antigen (CA19-9) level was elevated, but insulin and glucagon levels were in the normal range. Based on a diagnosis of adenocarcinoma of the ampulla of Vater, we performed subtotal stomach-preserving pancreatoduodenectomy with regional lymph node dissection. Postoperative histopathological examinations indicated both neuroendocrine carcinoma (40%) and adenocarcinoma (60%) components in the ampulla of Vater and regional lymph node metastasis. According to the 2010 WHO Classification of Tumours of the Digestive System, the diagnosis of mixed adenoneuroendocrine carcinoma (MANEC) of the ampulla of Vater was confirmed. The patient was treated for 6 months with oral administration of TS-1 as adjuvant chemotherapy. Currently, the patient is alive without recurrence 8 months after surgery. MANEC of the ampulla of Vater is rare. It is a highly malignant tumor, and the standardization of its treatment, including surgery, chemotherapy, and radiotherapy requires further study.

[Long-Term Survival with Multidisciplinary Therapy for Rectal NET with Liver Metastases--A Case Report].

We report a case of a 71-year-old man with liver metastases from a rectal neuroendocrine tumor(NET). The patient's chief complaint was melena. He was diagnosed with rectal carcinoma with liver metastases during his initial visit. Therefore, we started UFT/LV as first-line chemotherapy. After 2 courses, the patient's disease had progressed, so the treatment was changed to S-1 as second-line chemotherapy. The patient showed a partial response. In February 2010, we performed an anterior resection, and in April 2010 we performed a posterior segment and S2/8 partial hepatectomy. Histopathological examination showed rectal NET with liver metastases. In December 2011, multiple liver metastases were found, and multimodal treatment including TACE, RFA and somatostatin analogues was selected to treat the recurrent tumor. The patient survived for 10 years after his first visit and for 3 years and 6 months after the recurrence. Multidisciplinary therapy was effective for treating rectal NET with liver metastases.

Safety of early laparoscopic cholecystectomy for patients with acute cholecystitis undergoing antiplatelet or anticoagulation therapy: a single-institution experience.

BACKGROUND/AIMS: Early cholecystectomy is recommended for patients with acute cholecystitis, particularly when less than 72 hours have passed since symptom onset. The safety of early laparoscopic cholecystectomy for patients receiving anticoagulants or antiplatelet agents is unclear. We retrospectively analyzed the safety of early laparoscopic cholecystectomy for patients with acute cholecystitis undergoing antiplatelet or anticoagulation therapy. METHODOLOGY: Between 2005 and 2012, a total of 239 patients were diagnosed with acute cholecystitis, 183 of whom underwent early laparoscopic cholecystectomy. We compared the clinical features and surgical outcomes of 21 patients undergoing antiplatelet or anticoagulation therapy with those of 162 patients not undergoing antiplatelet or anticoagulation therapy. RESULTS: Of the 21 patients, 15 patients took aspirin and four took clopidogrel sulfate. Three patients received dual therapy with two agents. The distributions of the severity of acute cholecystitis, a past history of abdominal operations, body mass index, blood test results, operation time, and blood loss were not significant between the two groups. Neither conversion to open surgery nor bleeding-related complications occurred in the patients undergoing antiplatelet and anticoagulation therapy. CONCLUSIONS: Early laparoscopic cholecystectomy for selected patients with acute cholecystitis undergoing antiplatelet and anticoagulation therapy is feasible and safe.

[A case report of surgical treatment for hepatocellular carcinoma with a Hugely swollen lymph node that showed high FDG uptake].

A 74-year-old man with chronic hepatitis C was diagnosed with liver tumors. Contrast-enhanced computed tomography (CT) and ethoxybenzyl diethylenetriamine pentaacetic acid-enhanced magnetic resonance imaging (EOB-MRI) revealed hepatocellular carcinomas(HCC) in segments 8 (S8)and 5/8 (S5/8), and detected a lymph node (LN) swelling of 75 mm diameter in the posterior aspect of the pancreatic head. Fluorine-18-fluorodeoxyglucose positron emission tomography (FDG-PET) was positive for the swollen LN (SUVmax 12.3), but negative for the intrahepatic HCCs. The alpha-fetoprotein (AFP) and protein induced by vitamin K absence or antagonist-II (PIVKA-II) values were elevated, and soluble interleukin- 2 receptor levels were also increased (1,440 U/mL). Based on a diagnosis of HCCs with either LN metastasis, or with malignant lymphoma, partial hepatectomy (S8 and S5/8), lymphadenectomy (#13LN), and cholecystectomy were performed. Histopathological examination indicated well differentiated HCC in S5/8, and moderately to poorly differentiated HCC in S8, while poorly differentiated HCC was detected in the LN. Therefore, the final diagnosis was HCCs with metastasis to #13LN originating from the HCC in S8. At present, the patient is alive without further extrahepatic recurrence. The extent of FDG accumulation is related to the degree of differentiation of the HCC; furthermore, there are discrepancies between the FDG uptake in intrahepatic and extrahepatic lesions.