Cardiac Tamponade Due to Intrapericardial Hernia Mimicking ST-Segment Elevation Myocardial Infarction.

Intrapericardial hernia is a diaphragmatic hernia that extremely rarely causes cardiac tamponade. We present a case of a cardiac tamponade caused by an intrapericardial hernia in a 78-year-old male patient with a history of coronary artery bypass grafting, mimicking ST-segment elevation myocardial infarction, which was successfully treated by emergent laparotomy.

Machine learning-based model for prediction and feature analysis of recurrence in pancreatic neuroendocrine tumors G1/G2.

BACKGROUND: Pancreatic neuroendocrine neoplasms (PanNENs) are a heterogeneous group of tumors. Although the prognosis of resected PanNENs is generally considered to be good, a relatively high recurrence rate has been reported. Given the scarcity of large-scale reports about PanNEN recurrence due to their rarity, we aimed to identify the predictors for recurrence in patients with resected PanNENs to improve prognosis. METHODS: We established a multicenter database of 573 patients with PanNENs, who underwent resection between January 1987 and July 2020 at 22 Japanese centers, mainly in the Kyushu region. We evaluated the clinical characteristics of 371 patients with localized non-functioning pancreatic neuroendocrine tumors (G1/G2). We also constructed a machine learning-based prediction model to analyze the important features to determine recurrence. RESULTS: Fifty-two patients experienced recurrence (14.0%) during the follow-up period, with the median time of recurrence being 33.7 months. The random survival forest (RSF) model showed better predictive performance than the Cox proportional hazards regression model in terms of the Harrell's C-index (0.841 vs. 0.820). The Ki-67 index, residual tumor, WHO grade, tumor size, and lymph node metastasis were the top five predictors in the RSF model; tumor size above 20 mm was the watershed with increased recurrence probability, whereas the 5-year disease-free survival rate decreased linearly as the Ki-67 index increased. CONCLUSIONS: Our study revealed the characteristics of resected PanNENs in real-world clinical practice. Machine learning techniques can be powerful analytical tools that provide new insights into the relationship between the Ki-67 index or tumor size and recurrence.

[Analysis of Prognostic Factors Considering Absolute Lymphocyte Count of Metastatic Breast Cancer Patients with Eribulin Mesylate Therapy-A Retrospective Study in a Single Institution].

Recently, a study for eribulin mesylate(ERI), which is a useful drug for metastatic and recurrent breast cancer, reported that the absolute lymphocyte count(ALC)before administration is a useful prognostic factor. We retrospectively examined whether the results were reproducible in the patients with ERI. We examined the effect of ERI on the overall survival(OS)in 21 patients with HER2-negative metastatic and recurrent breast cancer who underwent treatment with ERI at our hospital. The clinical benefit ratio(CBR)was 57.1%. The median time to treatment failure(TTF)was 5.8 months and median OS was 19.9 months, showing a positive correlation between the TTF and OS. The factors that significantly prolonged the OS in univariate analysis were the TTF(<3 months vs ≥3 months, p<0.001), NLR(<3 vs ≥3, p=0.037), and ALC(<1,000/ µL vs ≥1,000/µL, p=0.008). In the multivariate analysis, TTF and ALC were the prognostic factors. The ERI outcome at our institution was good regardless of the subtype. The results of the multivariate analysis showed that TTF and ALC were factors that prolonged OS, and patients who received ERI for >3 months had good OS. Long-term administration of ERI was assumed to affect the immune microenvironment and prolong OS. Additionally, our data showed that the lymphocyte count before ERI administration is a simple and useful prognostic factor.

A rare case of synchronous multiple primary malignancies of breast cancer and diffuse large B-cell lymphoma that responded to multidisciplinary treatment: a case report.

BACKGROUND: Multiple primary malignancies of breast cancer and diffuse large B-cell lymphoma (DLBCL) are rare. Here, we report a case of advanced breast cancer and DLBCL managed with multidisciplinary therapy preceded by surgery with a successful outcome. CASE PRESENTATION: During a medical examination, a 71-year-old woman was diagnosed with a right breast mass, enlarged lymph nodes throughout the body, and a splenic tumor. The results of the clinical examination and imaging were suggestive of widely spread breast cancer with lymph node metastasis and malignant lymphoma with systemic metastasis. The histological evaluation of the biopsied breast tissue revealed human epidermal growth factor receptor 2 (HER2)-positive breast cancer, whereas the histological evaluation of the excised inguinal lymph node revealed DLBCL. 18F-FDG PET/computed tomography was performed, and it was determined that both breast cancer and DLBCL were in an advanced stage. Thus, mastectomy was performed, and the axillary lymph nodes showed mixed metastasis of breast cancer and DLBCL. Soon after, the R-CHOP therapy was initiated (375-mg/m2 rituximab, 2-mg/m2 vincristine, 50-mg/m2 doxorubicin, 750-mg/m2 cyclophosphamide, and 125-mg methylprednisolone). After irradiation of the spleen, trastuzumab was administered for 1 year. CONCLUSIONS: We experienced a case of combined breast cancer and DLBCL, which was difficult to treat because both were in advanced stages. Thorough staging of the malignancy and discussion by a multidisciplinary team are necessary to determine the optimal treatment strategy.

No Significant Effect of Daikenchuto (TJ-100) on Peritoneal IL-9 and IFN-γ Levels After Pancreaticoduodenectomy.

AIM AND BACKGROUND: TJ-100 is a traditional Japanese medicine that affects inflammation and gastrointestinal motility, and is used as a preventive and treatment for paralytic ileus. This study aims at determining the effect of TJ-100 on the peritoneal levels of IFN-γ/IL-9, cytokines related to ileus, after pancreaticoduodenectomy (PD) in a clinical setting. METHODS: This was a subsidiary study of the clinical trial investigating the effect of TJ-100 on postoperative bowel function. Ascites was collected from 180 patients using an abdominal drainage tube on postoperative day 1 and 3 after PD (POD 1 or POD 3) and used to measure 27 cytokines. We performed univariate and multivariate analyses using several perioperative variables and administration of TJ-100/placebo to determine the effect of TJ-100 on the levels of IFN-γ and IL-9. RESULTS: Peritoneal levels of IL-9 and IFN-γ decreased between POD 1 and 3 (Wilcoxon signed-rank test p<0.001). Multivariate analysis was performed after univariate analysis to select the variables and patients with a body mass index of ≥22 kg/m2, older age, use of epidural anesthesia, and longer surgery correlated with the levels of IL-9 and IFN-γ. However, we could not detect a correlation between the use of TJ-100 and cytokine levels in ascites either on POD 1 or 3. CONCLUSION: TJ-100 did not affect peritoneal IL-9 and IFN-γ levels after PD. This was in accordance with published clinical findings showing no improvement in bowel function after PD and TJ-100 treatment.

Transition of serum cytokines following pancreaticoduodenectomy: A subsidiary study of JAPAN-PD.

Our previous study aimed to examine the effect of TJ-100, a widely used herbal medicine, on intestinal function following pancreaticoduodenectomy (PD) in a multicenter, randomized, double-blinded, placebo-controlled manner (JAPAN-PD study). This concomitant study investigated the effect of TJ-100 on serum cytokine levels in patients who underwent PD. Due to the fact that several clinical variables can affect the absolute values of baseline serum cytokine levels, the ratios of the cytokine levels on postoperative day (POD)3 to those on POD1 were also used for analysis. The present study enrolled 180/224 randomized patients, of whom 91 received TJ-100 and 89 received placebo. As the main findings of the analysis, Wilcoxon signed-rank test revealed no significant difference in the levels of serum cytokines between the groups; however, patients in the TJ-100 group without severe inflammatory complications exhibited significantly higher ratios of interleukin (IL)-4 (n=123), IL-9 (n=72), IL-10 (n=97), PDGF-BB (n=143) and tumor necrosis factor-α (n=135), compared with patients in the Placebo Group (P<0.05). According to the results of the present study, TJ-100 has an effect on the change in serum cytokine levels from POD1 to POD3 following PD. However, the role of different transition pattern of cytokines in postoperative recovery following PD has to be investigated by further mechanical studies focusing on these extracted cytokines (ClinicalTrials.gov; no. NCT01607307; May 30, 2012).

Evaluation of the efficacy of daikenchuto (TJ -100) for the prevention of paralytic ileus after pancreaticoduodenectomy: A multicenter, double-blind, randomized, placebo-controlled trial.

BACKGROUND: We assessed the efficacy of TJ-100 taken perioperatively to recovery among patients with periampullary tumor or tumor of the head of the pancreas who underwent pancreaticoduodenectomy (PD). PATIENTS AND METHODS: In this multicenter, randomized, double-blinded, placebo-controlled, phase II trial (JAPAN-PD Study), patients were assigned randomly in a 1:1 ratio to receive TJ-100 or placebo. The coprimary endpoints were (1) incidence of postoperative paralytic ileus lasting >72 hours after surgery and (2) time to occurrence of postoperative paralytic ileus. This trial is registered at the UMIN Clinical Trials Registry (000007975) and at ClinicalTrials.gov (NCT01607307). RESULTS: From August 2012 through July 2013, we assessed 273 patients for eligibility, and 224 underwent randomization; 112 patients received TJ-100, and 112 patients received placebo. The population for analysis consisted of 104 patients who received TJ-100 and 103 who received placebo. Paralytic ileus occurred 35 (33.7%) in the TJ-100 group and 38 (36.9%) in the placebo group (P = .626). Time to first flatus was 2.25 (2.00-2.50) days in the TJ-100 group and 2.50 (1.50-2.50) days in the placebo group (P = .343). Among 23 patients who underwent a pylorus ring-preserving PD, time to first flatus was lower in the TJ-100 group than in the placebo group: 0.50 (0.50-1.00) days versus 1.50 (0.50-3.00) days (P = .034). CONCLUSION: Our findings suggest that use of TJ-100 did not improve recovery from paralytic ileus after PD, and may preclude the routine use of TJ-100 in clinical practice after PD operation.

Establishment and characterization of SUIT-58 pancreas cancer cell line and its subline S58-SF adapted to serum-free condition derived from metastatic liver tumor.

A new pancreas cancer cell line, SUIT-58, was established from metastatic liver tumor. The cultured cells exhibited polygonal shape, and proliferated in a form of sheet-structure showing prominent nucleoli and frequent mitotic features. Chromosome count ranged from 54 to 73 with modal chromosome numbers 72 and 73. It was noteworthy that this cell line grew in the serum-free media and maintained in this condition for 30 passages (designated as S58-SF). Both SUIT-58 and S58-SF cell lines were successfully transplanted into nude mice, and their tumor doubling times in xenografts were calculated as 5.4 and 2.8 days, respectively. Histopathologically, the xenografts formed glandular structure that resembled the original tumor. In culture media, the doubling time of SUIT-58 and S58-SF cell lines was calculated as 32 and 35.7 h, respectively. Although the cellular arrangements of SUIT-58 and S58-SF cell lines are different to some extent, their subcellular structures under electron microscope were similar with a large number of lysosomes and distinct desmosomes at cell-cell adhesion sites. The present SUIT-58 and its derivative cell line S58-SF will be applicable for biological studies to develop a new clinical treatment of refractory pancreatic cancer.

Stent Placement for Portal Vein Stenosis After Pancreaticoduodenectomy.

BACKGROUND: Portal vein (PV) stenosis is a worrisome late complication following pancreaticoduodenectomy (PD) that causes intestinal bleeding from varices, which must be diagnosed correctly and treated promptly. Recent reports advocate the usefulness of stent placement to improve PV stenosis. METHODS: We evaluated the cause, diagnosis, and treatment method of PV stenosis after PD and the duration of stent patency in our institution. RESULTS: Intestinal bleeding caused by PV stenosis occurred in 5 (2.4%) of 205 patients. A computed tomography scan was useful to diagnose this complication. Four of 5 patients with PV stenosis underwent percutaneous transhepatic PV stent placement. The duration of stent patency was 21-41 months, and no rebleeding occurred. CONCLUSIONS: Percutaneous stent placement is viable, less invasive option than laparotomy for the management of PV stenosis after PD.

Randomized controlled trial for efficacy of nafamostat mesilate in preventing post-endoscopic retrograde cholangiopancreatography pancreatitis.

OBJECTIVE: The objective of this study was to investigate whether prophylactic administration of nafamostat mesilate reduces the incidence of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP), its efficacy, and risk factors for PEP. METHODS: Potential subjects comprised 876 patients who underwent ERCP between September 2008 and February 2011. Of these, 58 patients were excluded after meeting exclusion criteria, and 818 patients were randomized. Patients in the nafamostat mesilate group were administered 20 mg of nafamostat mesilate dissolved in 500 mL of 5% glucose solution, whereas the control group received 500 mL of 5% glucose solution alone, over 2 hours from the start of ERCP. RESULTS: Post-ERCP pancreatitis occurred in 5.1% (41 patients) overall, with a significantly lower frequency in the nafamostat mesilate group (3.5%) than in the control group (6.7%; P = 0.0349). Analysis of the 322 patients who had undergone ERCP for the first time (n = 158 in the nafamostat mesilate group; n = 164 in the control group) found that PEP again significantly less frequently occurred in the nafamostat mesilate group (5.7%) than in the control group (13.4%; P = 0.0172). CONCLUSIONS: Our randomized controlled study suggested that short-term administration of nafamostat mesilate 20 mg may reduce the incidence of PEP.

Prospective randomized clinical trial of a change in gastric emptying and nutritional status after a pylorus-preserving pancreaticoduodenectomy: comparison between an antecolic and a vertical retrocolic duodenojejunostomy.

BACKGROUND: Although an antecolic duodenojejunostomy was reported to reduce post-operative delayed gastric emptying (DGE) compared with a retrocolic duodenojejunostomy after a pylorus-preserving pancreaticoduodenectomy (PPPD), the long-term effects of these procedures have rarely been studied. The aim of this prospective, randomized, clinical trial was to investigate the influence of the reconstruction route on post-operative gastric emptying and nutrition. METHODS: Reconstruction was performed in 116 patients with an antecolic duodenojejunostomy (A group, n = 58) or a vertical retrocolic duodenojejunostomy (VR group, n = 58). Post-operative complications, including DGE, gastric emptying variables assessed by (13) C-acetate breath test and nutrition, were compared between the two groups for 1 year post-operatively. RESULTS: The incidence of DGE was not significantly different between the procedures (A group: 12.1%; VR group: 20.7%, P = 0.316). At post-operative month 1, gastric emptying was prolonged in the VR versus the A group but not significantly so. At post-operative month 6, gastric emptying was accelerated significantly in the A versus the VR group. Post-operative weight recovery was significantly better in the VR versus the A group at post-operative month 12 (percentage of pre-operative weight, A group: 93.8 ± 1.2%; VR group: 98.5 ± 1.3%, P = 0.015). CONCLUSIONS: A vertical retrocolic duodenojejunostomy was an acceptable procedure for the lower incidence of DGE and may contribute to better weight gain affected by moderate gastric emptying.

Phase II clinical study of alternate-day oral therapy with S-1 as first-line chemotherapy for locally advanced and metastatic pancreatic cancer.

PURPOSE: Based on the results of first-line chemotherapy for advanced pancreatic cancer, S-1 was confirmed to be non-inferior to gemcitabine. However, the recommended regimen of 4 weeks of administration followed by 2 weeks of drug withdrawal frequently causes adverse effects. On the other hand, we experienced in clinical practice that alternate-day administration of S-1 reduced adverse effects and were tolerable for advanced pancreatic cancer patients unwilling to continue the standard daily administration. We therefore conducted a multicenter cooperative prospective study to compare daily with alternate-day administration of S-1 for advanced pancreatic cancer. METHODS: Patients with advanced pancreatic cancer were eligible for enrollment in this trial. S-1 was administered at a dose of 40-60 mg twice daily, calculated according to body surface area, on Monday, Wednesday, Friday, and Sunday. Each treatment cycle was 42 days. The primary end point was overall survival (OS). Secondary end points were safety, response rate (RR), progression-free survival (PFS), and time to treatment failure (TTF). RESULTS: Forty-eight patients were evaluable for response. OS as the primary end point was 8.4 months (95 % CI 5.4-10.8), and the 1-year survival rate was 29.2 %. PFS was 5.5 months, and TTF was 3.9 months. RR was 10.4 %, and the disease control rate was 79.2 %. Grade 3/4 hematological and non-hematological toxicities were minor. All of these adverse reactions were tolerable and reversible. CONCLUSIONS: The current data demonstrate the mitigation of adverse effects with alternate-day administration of S-1, and this appears to be a more sustainable option for advanced pancreatic cancer.

Usefulness of drain amylase, serum C-reactive protein levels and body temperature to predict postoperative pancreatic fistula after pancreaticoduodenectomy.

BACKGROUND: Postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD) is a worrisome and life-threatening complication. Recently, early drain removal has been recommended as a means of preventing POPF. The present study sought to determine how to distinguish clinical POPF from non-clinical POPF in the early postoperative period after PD to aid in early drain removal. METHODS: From March 2002 through December 2010, 176 patients underwent PD and were enrolled in this study to examine factors predictive of clinical POPF after PD. POPF was defined and classified according to the International Study Group of Pancreatic Surgery guideline, and grade B/C POPF was defined as clinical POPF. RESULTS: Grade A POPF occurred in 39 (22.2 %) patients, grade B in 19 (10.8 %) patients, and grade C in 11 (6.3 %) patients. Clinical POPF (grade B/C) occurred in 17.1 % of patients. Multivariate analysis revealed male gender and body mass index (BMI) ≥22.5 kg/m(2) to be the independent preoperative risk factors predictive of POPF. Receiver operating characteristic curves showed that the combination of drain amylase ≥750 IU/L, C-reactive protein (CRP) ≥20 mg/dL, and body temperature ≥37.5 °C on postoperative day 3 could effectively distinguish clinical POPF from non-clinical POPF. Sensitivity, specificity, and accuracy were 84.6, 98.2, and 95.7 %, respectively. CONCLUSIONS: Male gender and BMI ≥22.5 were the independent preoperative predictive risk factors for POPF. We assume that when amylase is <750 IU/L, serum CRP is <20 mg/dL, and body temperature is <37.5 °C the drain can safely be removed, even if POPF is indicated.

Selection of prophylactic antibiotics according to the microorganisms isolated from surgical site infections (SSIs) in a previous series of surgeries reduces SSI incidence after pancreaticoduodenectomy.

BACKGROUND: The incidence of surgical site infections (SSIs) is high after pancreaticoduodenectomy (PD). METHODS: We divided 116 consecutive patients who underwent PD into an early group (n = 58) and a later group (n = 58) according to time of surgery. In both groups, endoscopic retrograde biliary drainage was mainly employed for the patients with obstructive jaundice. In the later group, prophylactic antibiotics were selected according to the susceptibility of microorganisms isolated from SSIs in the early group. The incidence of SSIs was compared between the groups. RESULTS: The background characteristics (including methods of preoperative biliary drainage and microorganisms in the bile obtained before or during operation) of the patients were not significantly different between the groups, except for the serum albumin level, which was lower in the later group than in the early group (P = 0.0026). The incidence of SSIs was significantly lower in the later group (24.1 %) than in the early group (46.6 %) (P = 0.0116). Belonging to the later group was one independent negative risk factor for SSI. CONCLUSIONS: Selection of prophylactic antibiotics on the basis of microorganisms isolated from SSIs in the early group contributed to the reduced incidence of SSIs in the later group after PD.

Comparative study of gastric emptying and nutritional status after pylorus-preserving vs. subtotal stomach-preserving pancreaticoduodenectomy.

BACKGROUND/AIMS: Delayed gastric emptying (DGE) is a specific, worrisome complication after pancreaticoduodenectomy (PPPD), whereas subtotal stomach-preserving pancreaticoduodenectomy (SSPPD) that excises the pylorus ring seems to be effective in reducing DGE. This study compared gastric emptying and nutritional status between PPPD and SSPPD over 1 year. METHODOLOGY: From June 2003 to December 2007, 41 patients (PPPD: 33, SSPPD: 8) were enrolled in this study to evaluate differences in gastric emptying and nutritional status at 1, 3, 6, 9 and 12 months after pancreaticoduodenectomy. Gastric emptying was evaluated by 13C-acetate breath test. Nutritional status (body weight, serum levels of total protein, albumin and total cholesterol) was similarly assessed. RESULTS: At 1 month, gastric emptying evaluated at T1/2 (half-emptying time) was significantly prolonged in the PPPD but not in the SSPPD compared to the preoperative level. Thereafter, T1/2 was decreased and showed function significantly better preserved at 3, 6 and 12 months after PPPD than after SSPPD. Body weight recovery was significantly better at 6 and 12 months after PPPD than after SSPPD. Other nutritional parameters were better preserved in the PPPD during 1-year follow-up. CONCLUSIONS: PPPD seems to be a more suitable surgical procedure than SSPPD in regard to gastric emptying and nutritional status.

Role of hilar resection in the treatment of hilar cholangiocarcinoma.

BACKGROUND/AIMS: The aim of this study was to clarify the role of bile duct resection without hepatectomy (hilar resection) in hilar cholangiocarcinoma. METHODOLOGY: We retrospectively compared surgical results for hilar cholangiocarcinoma between 8 patients treated with hilar resection and 21 patients treated with hepatectomy. RESULTS: All hilar resections were performed for Bismuth type I or II tumors with T2 or less lesions, whereas hepatectomy was done for type III or IV tumors excluding one type II tumor. R0 resection was equally achieved in both groups (62.5% in hilar resection group and 76.2% in hepatectomy group, p=0.469) and overall 5-year survival rates were comparable (21.9% vs. 23.6%, p=0.874). With respect to gross tumor appearance, R0 resection was achieved in all patients with papillary tumor in both groups with the excellent 5-year survivals (100% vs. 100%). In patients with nodular and flat tumors, R0 resection was achieved less frequently in the hilar resection vs. hepatectomy group (50% vs. 77.8%) mainly due to failure to clear the proximal ductal margin, resulting in poorer 5-year survival (0% vs. 18.7%). CONCLUSIONS: Hilar resection may be indicated for papillary T1 or 2 tumors in Bismuth type I or II cholangiocarcinoma.

Characteristics and surgical outcome of HCC patients with low platelet count.

BACKGROUND/AIMS: Hepatocellular carcinoma (HCC) patients often have low platelet count (LPC). The aim of this study was to determine unique features of HCC patients with LPC. METHODOLOGY: HCC patients who underwent surgery were divided into two groups: LPC group (platelet count ≤100,000/mm³, n=84) and control group (platelet count >100,000/mm³, n=240). Surgical outcomes, risk factors for postoperative complications and prognostic factors were retrospectively compared. RESULTS: HCC patients with LPC had poorer liver function, smaller tumors, less anatomical resection and more frequent postoperative liver failure than control group patients. Postoperative survival was not different between the two groups. Tumor invasion to the main branch or trunk of portal vein (Vp3, 4) was the only risk factor for postoperative substantial complications in the LPC group. Postoperative survival was worse in patients with tumor diameter ≥4 cm or multiple tumors and in those who underwent preoperative transcatheter arterial chemoembolization (TACE) in the LPC group by multivariate analysis. Among them, preoperative TACE were not prognostic factors in the control group. CONCLUSIONS: In HCC patients with LPC, Vp3, 4 patients should be carefully monitored after surgery and preoperative TACE is not recommended for long-term postoperative survival.

Verification of Tokyo Guidelines for diagnosis and management of acute cholangitis.

BACKGROUND: This study aimed to verify diagnostic criteria and severity assessment of the Tokyo Guidelines for acute cholangitis. METHODS: We re-examined whether acute cholangitis was concomitant with gallstones according to the Tokyo Guidelines in 248 patients with choledocholithiasis. Our conventional diagnoses based on physician decision were compared with diagnoses from the Tokyo Guidelines. Problems with severity grade criteria were also evaluated. RESULTS: In total, 53 cases of acute cholangitis were determined by using the Tokyo Guidelines, including three false-negative and seven false-positive cases (acute cholecystitis or pancreatitis was concomitant with choledocholithiasis). Sensitivity, specificity, and accuracy were 94%, 96%, and 96%, respectively. Forty of the 53 patients underwent biliary drainage (mean interval between admission and drainage, 1.4 days). Severity grades were mild in 10, moderate in 30, and severe in 13 patients. Of these 13 patients with severe disease, 2 had chronic renal failure, 1 had liver cirrhosis, and 1 had severe acute pancreatitis and liver cirrhosis. No patients died, irrespective of severity grade. CONCLUSIONS: Acute cholangitis should be carefully diagnosed when other inflammatory disease is concomitant with choledocholithiasis. A few patients have absolute acute cholangitis even when they do not meet Tokyo Guidelines diagnostic criteria. Classification into mild or moderate grade using the Tokyo Guidelines is difficult when early biliary drainage is routinely performed. When determining severity grade, clinicians must distinguish between organ dysfunction associated with cholangitis itself and that associated with the underlying/concomitant disease. Apart from a few problems like these, the Tokyo Guidelines are mostly acceptable for the diagnosis and management of acute cholangitis.

Synchronous solid pseudopapillary neoplasm and intraductal papillary mucinous neoplasm of the pancreas: report of a case.

Solid pseudopapillary neoplasm (SPN) of the pancreas, most commonly found in young female subjects, is a rare neoplasm with low potential for malignancy. We report an unusual case of a 66-year-old male patient who had a simultaneous malignant SPN and an intraductal papillary mucinous adenoma (IPMA) of the pancreas. The patient was admitted to our department for the evaluation of the main solid tumor with calcification and small multilocular cystic lesions apart from the main tumor in the pancreatic head. We performed pylorus-preserving pancreaticoduodenectomy to treat the calcified tumor and multilocular cystic lesions. The diagnosis of malignant SPN was confirmed on the basis of histological invasion to the adjacent structures. The separate cystic lesions were diagnosed as a branch-type IPMA. The synchronous occurrence of IPMA and SPN in the present case did not demonstrate that there were tumors maintained through the common abnormal Wnt signaling pathway by immunohistochemical study. To our knowledge, this is the first known case of synchronous SPN and IPMA of the pancreas.

Surgical strategy for hepatocellular carcinoma patients with portal vein tumor thrombus based on prognostic factors.

RATIONALE: Surgical strategy for patients with hepatocellular carcinoma and portal vein tumor thrombus (PVTT) remains to be established. METHODS: From 1990 to 2008, 48 hepatocellular carcinoma patients with PVTT detected by preoperative imaging underwent hepatic resection, and their clinical data were retrospectively analyzed. Possible prognostic factors for survival were analyzed with postoperative survival curves, and significant factors were determined by univariate and multivariate analysis. The frequency of postoperative severe complications was investigated for each prognostic factor. RESULTS: Significant prognostic factors included patient age <60 years, serum total bilirubin (T-Bil) >0.8 mg/dl, serum aspartate aminotransferase >30 IU/L, serum alkaline phosphatase (ALP) >300 IU/L, tumor size >4 cm, PVTT in the main trunk (Vp4), and a surgical margin <1 mm by univariate analysis, and independent prognostic factors were serum T-Bil, ALP, and Vp4. No patient with Vp4 survived for more than 400 days after surgery, and frequency of postoperative severe complications in these Vp4 patients was significantly higher than in other Vp1-3 patients. CONCLUSION: Hepatic resection as a first-choice treatment should be carefully selected in patients with Vp4 unless emergent removal of the PVTT is required.