[A Case of Gastric Cancer Invading the Pancreas with Pathological Complete Response Treated by Preoperative S-1 plus Oxaliplatin Therapy].

A 66-year-old man with severe anemia was diagnosed with gastric cancer. CT examination revealed primary gastric tumor, which involved the pancreas body, with regional lymph nodes that were enlarged(T4b[panc], cN2, cM0, cStage ⅣA). He received three courses of preoperative S-1 plus oxaliplatin therapy. Primary tumor and metastatic lymph nodes were reduced remarkably. We performed a curative distal gastrectomy(D2)without pancreas resection. Histopathological examination revealed Grade 3 pathological complete response in both primary tumor and metastatic lymph nodes.

[A Case of Intraductal Pancreatic Mallignant Tumor with Difficulty in Differentiating between IPMN and ITPN].

The patient was a male in his early 60s. Diabetes had aggravated 6 months earlier, and the patient was referred to our hospital for close examination. On contrast CT, enhanced mass shadows filling the lumen of the main pancreatic duct, which was dilated throughout the pancreas, were observed, and the mass was diagnosed as an adenocarcinoma on EUS-FNA. Based on these findings, main-duct IPMN was suspected and total pancreatectomy was performed. On macroscopic observation of the resected specimen, outgrowth of a solid tumor was observed in the main pancreatic duct, whereas only low-level mucus retention was noted in the pancreatic duct. Histopathological examination revealed a papillary/tubular tumor growth, suggesting interstitial infiltration throughout the pancreas. On immunostaining, the tumor was partially positive for MUC5AC, based on which the patient was diagnosed with an intraductal pancreatic mallignant tumor, with difficulty in differentiating between IPMC and ITPC. Clinicopathologically, many aspects regarding ITPN remain unclear. Further accumulation of such cases and investigation of the tumor pathology are necessary.

Preoperative evaluation of accessory hepatic ducts by drip infusion cholangiography with CT.

BACKGROUND: This retrospective study aimed to investigate the incidence of each type of accessory hepatic duct by drip infusion cholangiography with CT (DIC-CT). METHODS: Five hundred sixty nine patients who underwent preoperative DIC-CT and laparoscopic cholecystectomy were reviewed. Accessory hepatic ducts were classified as follows: type I (accessory hepatic ducts that merged with the common hepatic duct between the confluence of the right and left hepatic ducts and the cystic duct confluence), type II (those that merged with the common hepatic duct at the same site as the cystic duct), type III (those that merged with the common bile duct distal to the cystic duct confluence), type IV (the cystic duct merged with the accessory hepatic duct), and type V (accessory hepatic ducts that merged with the common hepatic or bile duct on the left side). RESULTS: Accessory hepatic ducts were observed in 50 patients. Type I, II, III, IV, and V accessory hepatic ducts were detected in 32, 3, 1, 11, and 3 patients, respectively. Based on their drainage areas, the accessory hepatic ducts were also classified as follows: a posterior branch in 22 patients, an anterior branch in 9 patients, a combination of posterior and anterior branches in 16 patients, a left-sided branch in 2 patients, and a caudate branch in 1 patient. None of the patients with accessory hepatic ducts suffered bile duct injuries. CONCLUSION: There are a number of variants of the accessory hepatic duct. DIC-CT is useful to detect the accessory hepatic duct.

[Metastatic Pancreatic Carcinoma from Renal Cell Carcinoma Indistinguishable from Primary Pancreatic Endocrine Tumor - A Case Report].

A hypervascularized tumor was detected in a 65-year-old man who had underwent a nephrectomy for a right renal cell carcinoma at the age of 55 years. We diagnosed the tumor as a non-functioning pancreatic neuroendocrine tumor or a metastatic tumor from the renal cell carcinoma. We performed distal pancreatectomy with splenectomy and lymph node dissection. The tumor was histopathologically diagnosed as metastatic renal cell carcinoma.

Modified high dorsal procedure for performing isolated anatomic total caudate lobectomy (with video).

BACKGROUND: Isolated anatomic total caudate lobectomy is indicated in patients who have liver tumors limited to the caudate lobe. However, isolated caudate lobe resection is a challenging surgical procedure that required safe and reliable techniques. All portal and hepatic veins that connect this area originate from the first branch of the portal vein or vena cava; therefore, the operator must be cautious of the potential for massive bleeding. METHODS: The important points regarding the safety of our procedure include creating an optimal surgical view and preparing for accidental bleeding before parenchymal dissection. Sufficient mobilization and removal of Spiegel's lobe from the left to the right side of the vena cava allows the operator to perform parenchymal dissection under a right- or front-side view. RESULTS: We have performed this technique in two patients with HCC and one patient with primary cystadenocarcinoma. The average operative time and amount of blood loss were 435 min and 1137 ml, respectively. No operative mortalities or postoperative complications were observed in any of the patients. Our three patients are currently doing well without any recurrence. CONCLUSION: Our modified high dorsal resection procedure can be used to safely remove the entire caudate lobe.

True left-sided gallbladder with variations of bile duct and cholecystic vein.

A left-sided gallbladder without a right-sided round ligament, which is called a true left-sided gallbladder, is extremely rare. A 71-year-old woman was referred to our hospital due to a gallbladder polyp. Computed tomography (CT) revealed not only a gallbladder polyp but also the gallbladder located to the left of the round ligament connected to the left umbilical portion. CT portography revealed that the main portal vein diverged into the right posterior portal vein and the common trunk of the left portal vein and right anterior portal vein. CT cholangiography revealed that the infraportal bile duct of segment 2 joined the common bile duct. Laparoscopic cholecystectomy was performed for a gallbladder polyp, and the intraoperative finding showed that the cholecystic veins joined the round ligament. A true left-sided gallbladder is closely associated with several anomalies; therefore, surgeons encountering a true left-sided gallbladder should be aware of the potential for these anomalies.

Significance of Hepatectomy for AJCC/UICC T3 Hepatocellular Carcinoma.

BACKGROUND: It is difficult to treat the American Joint Committee on Cancer (AJCC)/International Union against Cancer (UICC) T3 hepatocellular carcinoma (HCC), curatively. PATIENTS AND METHODS: We compared the clinicopathology of T3 group (n=44: T3a 25, T3b 19) with that of the T1 (n=257) or T2 group (n=120) and evaluated favorable conditions of hepatectomy for T3 HCC patients. RESULTS: The T3 group had significantly higher hepatitis B surface antigen (HBsAg)-positive rates and better liver function. Infiltrative large tumors located beyond one sub-segment with intrahepatic metastasis were significantly more common. Significantly, more non-curative large hepatectomies with transarterial embolization were performed. There was no significant difference between T3 and 2 groups in 5-year disease-free survival (DFS) and survival (S). Tumor size more than 55 mm and serum albumin less than 3.5 g/dl were risk factors of hepatectomy for T3 HCC patients by multivariate analysis. CONCLUSION: Surgeons should resect AJCC/UICC T3 HCC lesions if the patient is able to tolerate surgery.

The expression and role of Aquaporin 5 in esophageal squamous cell carcinoma.

BACKGROUND: Aquaporins (AQPs) are water channel proteins that facilitate transcellular water movements. Recent studies have shown that AQP5 is expressed in various cancers, and plays a role in tumor progression. However, its expression and role in esophageal squamous cell carcinoma (ESCC) have not been investigated. We examined the pathophysiologic role of AQP5 in cell proliferation and survival, and also investigated its expression and effects on the prognosis of ESCC patients. METHODS: AQP5 expression in human ESCC cell lines was analyzed by Western blot testing. Knockdown experiments with AQP5 siRNA were conducted, and the effects on cell proliferation, cell cycle progression, and cell survival were analyzed. The cells' gene expression profiles were analyzed by microarray analysis. Immunohistochemistry of AQP5 for 68 primary tumor samples obtained from ESCC patients undergoing esophagectomy was performed. RESULTS: AQP5 expression was high in TE2 and TE5 cells. In these cells, the knockdown of AQP5 using siRNA inhibited cell proliferation and G1-S phase progression, and induced apoptosis. The AQP5 siRNA transfected TE5 cells showed significant increase in p21 and decrease in CCND1 mRNA expression, respectively. The expression pattern of AQP5 and p21 protein was sharply contrasted, but AQP5 and CCND1 protein expression showed a similar pattern in ESCC tissue. These findings agree with the microarray results. Immunohistochemical staining of 68 ESCC patients showed the AQP5 expression is associated with tumor size, histological type, and tumor recurrence. CONCLUSION: The AQP5 expression in ESCC cells may affect cell proliferation and survival, and impact on the prognosis of ESCC patients.

Mesohepatectomy with total caudate lobectomy of the liver for hepatocellular carcinoma.

BACKGROUND: Mesohepatectomy with total resection of the caudate lobe and extrahepatic bile duct is sometimes performed for hilar cholangiocarcinoma or gallbladder carcinoma; however, only a few reports on mesohepatectomy with total caudate lobectomy of the liver for hepatocellular carcinoma are available. METHODS: A 71-year-old woman was preoperatively diagnosed with hepatocellular carcinoma in the central bisections (Couinaud's segments 4, 5, and 8) and the paracaval portion of the caudate lobe. Mesohepatectomy with total caudate lobectomy of the liver permitted the removal of tumors to provide a cancer-free raw surface of the liver. Mobilization of the caudate lobe is an important procedure in this surgery. Before the liver parenchyma was dissected, all short hepatic veins were ligated and divided from the left to the right side as the left lateral section was retracted to the right, and the caudate lobe branches of the portal vein and hepatic artery were ligated and divided. After the liver parenchymal dissection, both between the left lateral and medial sections and between the right anterior and posterior sections, the Glissonean branches of the caudate lobe were ligated and divided as the central bisections were anteriorly retracted. Finally, liver parenchymal dissection was performed between the caudate lobe and the right posterior section, which was along the right side of the inferior vena cava. RESULTS: The surgery time was 538 minutes and blood loss was 1,207 mL. No blood transfusions were required during or after surgery. The postoperative course was uncomplicated. The patient is still alive 25 months after hepatectomy. CONCLUSION: Although mesohepatectomy with total caudate lobectomy of the liver is technically more difficult than mesohepatectomy of the liver because the caudate lobe must be completely detached from the inferior vena cava and the hilar plate, it is a safe and effective treatment method in selected patients with hepatocellular carcinoma located at both the central bisections and the paracaval portion of the caudate lobe.

Enhancement of the cytocidal effects of hypotonic solution using a chloride channel blocker in pancreatic cancer cells.

BACKGROUND: Tumor cells exfoliated during surgery for pancreatic cancer can cause peritoneal recurrence. Peritoneal lavage with distilled water has been performed during surgery, but there have been no systematic studies for its efficacy and no experimental data demonstrating the cytocidal effects of distilled water on pancreatic cancer cells. This study investigated the cytocidal effects of hypotonic shock and enhancement using chloride channel blocker in pancreatic cancer cells. METHODS: Three human pancreatic cancer cell lines, KP4-1, PK-1, and PK45-H, were exposed to distilled water, and the resultant morphological changes were observed under a differential interference contrast microscope connected to a high-speed video camera. Analysis of cell volume changes was performed using a high-resolution flow cytometer. To investigate the cytocidal effects of water, re-incubation of cells was performed after exposure to hypotonic solution. Additionally, the effects of 5-nitro-2-(3-phenylpropylamino)-benzoic acid (NPPB), a Cl(-) channel blocker, on cells during exposure to hypotonic solution were analyzed. RESULTS: Video recordings demonstrated that hypotonic shock induced cell swelling followed by cell rupture. Measurement of cell volume changes indicated that severe hypotonicity increased broken fragments of cancer cells within 5 min. Re-incubation experiments demonstrated the cytocidal effects of hypotonic shock. In all cell lines, treatment with NPPB increased cell volume by inhibiting regulatory volume decreases, which are observed during hypotonic shock, and enhanced the cytocidal effects of hypotonic solution. CONCLUSIONS: These findings support the efficacy of peritoneal lavage with distilled water for pancreatic cancer and suggest that regulation of Cl(-) transport enhances the cytocidal effects of hypotonic shock.

Total pancreatectomy for pancreatic carcinoma: evaluation of safety and efficacy.

BACKGROUND/AIMS: To determine the safety and the efficacy of total pancreatectomy for the curative treatment of pancreatic carcinoma. METHODOLOGY: Retrospective analysis was performed using 10 patients receiving total pancreatectomy. RESULTS: The median duration of the operative procedure was 8.7 hours and the median estimated blood loss was 2,700mL. Seven patients developed postoperative complications, including infections in 5 cases. There was no death associated with the operative procedure itself. Median period of postoperative hospital stay was 55 days. Anastomotic ulcer was prevented by administration of proton- pump inhibitors. Blood glucose level was well controlled by subcutaneous injection of sliding scale insulin during the postoperative period and the dosage of insulin required was 0.45±0.13units/kg body weight/ day at the time of discharge. The mean HbA1c level at 3 months after the operation was 6.1%. Four patients needed medication with anti-diarrheal drugs. CONCLUSIONS: Total pancreatectomy could be performed safely and postoperative daily performance was reasonable with effective medication. We suggest that total pancreatectomy should be considered for the treatment of pancreatic carcinoma when the patient status is appropriate for this procedure.

Anatomical liver segmentectomy 2 for combined hepatocellular carcinoma and cholangiocarcinoma with tumor thrombus in segment 2 portal branch.

BACKGROUND: Hepatic resection is the only effective treatment for combined hepatocellular carcinoma and cholangiocarcinoma. CASE PRESENTATION: A 52-year-old man was preoperatively diagnosed with hepatocellular carcinoma in segment 2 with tumor thrombus in the segment 2 portal branch. Anatomical liver segmentectomy 2, including separation of the hepatic arteries, portal veins, and bile duct, enabled us to remove the tumor and portal thrombus completely. Modified selective hepatic vascular exclusion, which combines extrahepatic control of the left and middle hepatic veins with occlusion of left hemihepatic inflow, was used to reduce blood loss. A pathological examination revealed combined hepatocellular carcinoma and cholangiocarcinoma with tumor thrombus in the segment 2 portal branch. No postoperative liver failure occurred, and remnant liver function was adequate. CONCLUSION: The separation method of the hepatic arteries, portal veins, and bile duct is safe and feasible for a liver cancer patient with portal vein tumor thrombus. Modified selective hepatic vascular exclusion was useful to control bleeding during liver transection. Anatomical liver segmentectomy 2 using these procedures should be considered for a patient with a liver tumor located at segment 2 arising from a damaged liver.

Blockade of chloride ion transport enhances the cytocidal effect of hypotonic solution in gastric cancer cells.

BACKGROUND: Cancer cells that are exfoliated into the peritoneal cavity during surgery are viable and have the potential to produce peritoneal recurrence. Although peritoneal lavage with distilled water is applied in some cancer surgeries to kill tumor cells, there is no consensus regarding the optimal methodology and its effects. METHODS: Three human gastric cancer cell lines, MKN28, MKN45, and Kato-III, were exposed to distilled water, and the resultant morphologic changes were observed using a microscope. Analysis of cell volume changes was performed using a flow cytometer. To investigate the cytocidal effects of the water, re-incubation of the cells was performed after exposing them to hypotonic solution. Additionally, the effects of 5-nitro-2-3-phenylpropylamino)-benzoic acid (NPPB), a Cl(-) channel blocker, and R(+)-[(dihydroindenyl)oxy] alkanoic acid (DIOA), a blocker of the K(+)/Cl(-) co-transporter, on the cells during their exposure to hypotonic solution were analyzed. RESULTS: After the cells had been exposed to the distilled water, a rapid increase in cell volume occurred followed by cell rupture. In the MKN45 and Kato-III cells, treatment with NPPB increased cell volume by inhibiting regulatory volume decrease and enhanced the cytocidal effects of the hypotonic solution, whereas no such effects were observed in the MKN28 cells. On the other hand, treatment of the MKN28 cells with DIOA inhibited RVD and enhanced the cytocidal effects of hypotonic shock. CONCLUSION: These findings support the efficacy of peritoneal lavage with distilled water during surgery for gastric cancer and suggest that the regulation of Cl(-) transport enhances the cytocidal effects of hypotonic shock.

Use of multidetector-row computed tomography to evaluate branch duct type intraductal papillary mucinous neoplasms of the pancreas: influence on surgical decision-making.

BACKGROUND/AIMS: The purpose of this study was to evaluate factors predictive of the malignant grade associated with branch duct type intraductal papillary mucinous neoplasm (BD-IPMN) using multidetectorrow computed tomography (MDCT). METHODOLOGY: We reviewed the morphological features of 26 BDIPMNs using MDCT. Tumor size, caliber of the main pancreatic duct, number of mural nodules, diameter of the largest mural nodule and volume of the largest mural nodule were assessed and correlated with the pathological findings. RESULTS: By multiple- and single-regression analyses and Mann-Whitney U test, significant differences in the caliber of the main pancreatic duct and number of mural nodules were observed between adenoma and non-invasive carcinoma and in the number of mural nodules between adenoma and invasive carcinoma. No significant differences were observed between non-invasive carcinoma and invasive carcinoma. Based on the differential diagnostic criterion of 1 or more mural nodules for distinguishing adenoma from non-invasive carcinoma and invasive carcinoma, the sensitivities were 60% and 100%, respectively, and the specificity was 93% for both. CONCLUSIONS: Although it was impossible to distinguish non-invasive carcinoma from invasive carcinoma, MDCT was reliable for distinguishing adenoma from non-invasive carcinoma and invasive carcinoma.

Risk factors and management of postoperative bile leakage after hepatectomy without bilioenteric anastomosis.

BACKGROUND/AIMS: Bile leakage frequently causes major complications after hepatic resection. We investigated perioperative risk factors and management of postoperative bile leakage after hepatic resection without extrahepatic biliary resection and reconstruction. METHODS: We included 247 consecutive patients who underwent elective hepatic resection without bilioenteric anastomosis at our institution between 2002 and 2009. Perioperative risk factors, including patient and surgical variables, were evaluated using univariate and logistic regression analyses. RESULTS: Postoperative bile leakage occurred in 26 patients (10.5%). The surgical drain was retained in 6 patients (23%); 9 (35%) underwent drain salvage and 11 (42%) underwent percutaneous puncture under computed tomography or ultrasound guidance. Eight patients underwent endoscopic nasobiliary drainage (ENBD) for postoperative bile leakage, and bile leakage healed at a median interval of 19.5 days after ENBD. By univariate analysis, postoperative bile leakage was associated with central bisectionectomy, surgical time and intraoperative blood loss. Logistic regression analysis identified central bisectionectomy as an independent risk factor for postoperative bile leakage (p = 0.0003, odds ratio 16.724). CONCLUSION: Meticulous procedures are necessary during parenchymal hepatic resection, especially during central bisectionectomy. Drain management should be precise in the case of postoperative bile leakage. We believe ENBD may rapidly cure postoperative major bile leakage.

Surgical treatment of hepatocellular carcinoma with severe intratumoral arterioportal shunt.

We report a case of hepatocellular carcinoma (HCC) that caused a severe arterioportal shunt (APS). A 49-year-old man was admitted to hospital due to esophagogastric variceal hemorrhage and HCC, and underwent endoscopic variceal ligation (EVL) and endoscopic injection sclerotherapy (EIS). He was then referred to our hospital. Abdominal computed tomography revealed a low-density lesion in the posterior segment of the liver and an intratumoral APS, which caused portal hypertension. Although the patient underwent EVL, EIS, Hassab's operation, and transcatheter arterial embolization for APS, he vomited blood due to rupture of esophagogastric varices. Right hepatectomy was performed for the treatment of HCC and APS, although the indocyanine green retention value at 15 min after intravenous injection was poor (30%). The patient's postoperative course was uneventful. Eventually, APS disappeared and the esophagogastric varices improved.

[A case of esophageal cancer with sigmoid colon tumor treated by laparoscopic surgery].

We performed a subtotal esophagectomy with gastric tube reconstruction by hand assisted laparoscopic surgery and laparoscopic sigmoidectomy simultaneously for the patient with middle thoracic esophageal cancer and lateral spreading tumor in the sigmoid colon. Upper abdominal and transumbilical incisions were made and Lap Discs (regular, mini) were set respectively. Two 12 mm ports were inserted in the right flank and lower quadrant, and two 5 mm ports were inserted in the left flank and lower quadrant. First, by using video-scope from upper Lap Disc, laparoscopic sigmoidectomy was performed. Anastomosis was performed via lower Lap Disc. For the gastric tube reconstruction, upper Lap Disc was used for hand assistance, and video-scope was inserted from lower Lap Disc. The patient was discharged at 26 days after surgery without complications. In conclusion, our surgical procedure provided a good surgical view and decreased a surgical stress.

Treatment of double carcinoma of the esophagus and lung.

We report four cases of double carcinoma of the esophagus and the lung. Case 1: a patient with synchronous double carcinoma of the esophagus and the lung underwent chemoradiotherapy (CRT) because of respiratory dysfunction. Case 2: a patient who was diagnosed with esophageal carcinoma after the surgery for lung carcinoma underwent CRT because of respiratory dysfunction. Case 3: a patient with synchronous double carcinoma underwent a two-stage operation. Case 4: a patient with synchronous double carcinoma underwent CRT at another hospital. To further treat the patients, we chose a two-stage operation. CRT is believed to be a feasible treatment in inoperable patients because patients 1 and 2 are alive 28 and 21 months after CRT, respectively. A two-stage operation is considered a suitably safe surgical procedure because no fatal postoperative complications occurred in cases 3 and 4.