Background: Management of abdominal drainage after liver resection has not been well established. Methods: We compared clinicopathological findings between patients with the long-term abdominal drainage (5 days or more, long-term group, 32 patients) and those with the short-term abodaminal drainage (4 days or less, short-term group, 72 patients) to study the risk factors for the long-term (5 days or more) abdominal drainage. We also studied the management of abdominal drainage in postoperative bleeding, biliary leakage, intraabdominal infection, wound infection, refractory pleural effusion, and refractory ascites in 104 patients who underwent liver resection. Results: The drains were removed on postoperative day 4.1±1.3 if the drainage fluid did not contain bile. The risk factors for the long-term abdominal drainage included lager tumor, segmentectomy and bisegmentectomy, a long operation time, massive blood loss, and a large amount of drainage fluid (200 ml/day at the 4th postoperative day) by univariate analysis and a long operation time, massive blood loss, and a large amount of drainage fluid were independent risk factors by multivariate analysis. Postoperative bleeding did not occur. Biliary leakage developed in one patient in whom an RTBD catheter was placed because of stenosis of the bile duct after central bisegmentectomy. In another patient, biliary leakage developed 16 days after surgery, with intraabdominal infection caused by Staphylococcus aureus infection through the catheter after treatment for biliary leakage. The drainage catheter was replaced in 2 patients in whom refractory pleural effusion or ascites developed. Wound infection developed in one patient. Infection of the drainage site occurred in one patient in whom the catheter was removed 7 days after surgery. There were no differences in the incidence of such postoperative complications between the short-term and long-term groups. Conclusions: Removal of abdominal drainage catheters within 4 days after liver resection is reasonable if the drainage fluid does not contain bile.

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Background and Objectives: In the management of abdominal trauma including liver, spleen, and mesentery with hemorrhagic shock, surgeons must decide whether to conduct emergency resuscitative celiotomy and emergency transfusion. We clarified the safety and problems concerning uncrossmatched red cell concentrate (UCM RCC), which involves risks including lethal ABO-incompatible transfusion. Methods: In the last 5 years, we studied the circumstances of surrounding UCM RCC transfusion and the prevention of ABO-incompatible transfusion in 33 patients undergoing emergency UCM RCC transfusion including type O and Rh+ (O+) UCM RCC transfusion. Results: We prepared 426 units of UCM RCC and transfused 338 units (C/T ratio 91%) in 54 cases in 33 patients. The foci of catastrophic bleeding were the liver in 13 cases, spleen in 8 cases, and mesentery in 17 cases. Before transfusion, patients presented systolic blood pressure of 62.5 mmHg, a pulse of 117/minute, shock index (pulse rate/systolic pressure) of 1.97, and a base excess of -12.7 mEq/l. Twenty patients presented conscious disorder worse than 30 on the Japan coma scale. Seven-day-survival was 48%. O+UCM RCC transfusion was conducted in 17 patients without blood typing test (BTT) and in 11 non-type-O. O+UCM RCC transfusion was conducted after only 1 BTT in 8 patients, and in 4 non-type-O. Uncomfirmed non-O group-specific UCM RCC transfusion was conducted after only 1 BTT in 15 patients. Although the total number of patients who underwent UCM RCC transfusion showed no change during the study, the number of patients who underwent uncomfirmed non-O group-specific UCM RCC transfusion decreased. There were no ABO-incompatible transfusion and incident reports concerning emergency transfusion. Conclusions: O+UCM RCC transfusion is safe in emergencies.

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A 62-year-old man suffering from a loss of eyesight and neck pain 2 years after total gastrectomy for gastric cancer had elevated serum CA19-9 but no signs of recurrent disease in imaging examinations. As symptoms worsened, the man underwent cerebrospinal fluid (CSF) cytology to confirm leptomeningeal carcinomatosis, which proved negative (class II). Subsequent brain and cranial nerve symptoms such as blindness, headache, seizures, and mental disturbance rapidly worsened and the patient died 4 months after symptom appearance. Autopsy showed small nodules of the dura mater diagnosed histologically as moderately to poorly differentiated adenocarcinoma. Carcinoma had also infiltrated the cerebral hemispheres, cerebellum, medulla oblongata, and spinal cord. Histologically, carcinoma had infiltrated the optic nerve, causing the loss of eyesight. Even though leptomeningeal carcinomatosis is uncommon in patient with gastric carcinoma, the possibility of leptomeningeal carcinomatosis should be kept in mind and, in this respect, we found repeated CSF cytology to be essential in confirming a definitive diagnosis.

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A 75-year-old woman reporting abdominal fullness from the beginning of February 2008 was found in blood tests to have elevated CEA. Abdominal computed tomography (CT) showed pylorus ring wall thickening with calcification and lymph node swelling. Gastrointestinal endoscopy showed pyloric stenosis but did not confirm any ulcer or tumor. Biopsy of the narrow segment did not indicate malignancy. FDG-PET showed abnormal uptake in the thickened wall and lymph node confirmed by CT. Based on a diagnosis of pyloric stenosis due to gastric or duodenal malignancy indicated by elevated tumor markers and image findings, we conducted surgery, finding a mass on the anal side of the pylorus ring, necessitating distal gastrectomy and D3 lymph node ressection and Roux-en-Y reconstruction. Pathological findings showed moderately differentiated adenocarcinoma with psammoma bodies in the mass, definitively diagnosed as duodenal cancer.

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We report a case of intrahepatic aneurysm with aterioportal shunt. A 57-year-old woman was incidentally diagnosed with a hepatic artery aneurysm during an examination for hepatocellular carcinoma arised from hepatitis C virus-associated liver cirrhosis. Angiography revealed an aneurysm about 3 cm in diameter with an arterioportal shunt at the accessory left hepatic artery originating from the left gastric artery. Arterial embolization for the aneurysm was considered as treatment. However, since there were the collateral circulation and the arterioportal shunt, it was considered that the aneurysm was almost intractable with embolization alone. Therefore, left lobectomy of the liver was performed. Histopathological findings were consistent with true aneurysm. Although hepatic artery aneurysm is relatively rare, mortality from rupture is high. Recently, larger number of hepatic artery aneurysm diagnosed before rupture. For radical cure of the aneurysm, complete blockage of blood flow is necessary. Therefore, in case of intrahepatic aneurysm, the existence of collateral circulation is a major problem. Then careful consideration is required.

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A 61-year-old woman treated for primary biliary cirrhosis, Sjögren's syndrome, and membranous nephropathy since age 53 and reporting right upper quadrant pain was found in abdominal computed tomography to have a 9-cm-diameter tumor occupying the left lateral hepatic segment. She reported pruritus without jaundice. Laboratory data showed elevated biliary enzyme, IgM, and antimitochondrial antibody while serum tumor and hepatitis viral markers were negative. Imaging showed a distinct boundary tumor with a capsule structure containing a rich fat component. The tumor was enhanced in the early phase by contrast medium but it was difficult to determine whether large well-differentiated hepatocellular carcinoma or hepatic angiomyolipoma was involved, necessitating left lobe hepatectomy. The definitive diagnosis on histopathological examination was angiomyolipoma. She has been well for 1 year without recurrence. We report a case of hepatic angiomyolipoma with rapid growth in the follow up of primary biliary cirrhosis.

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We report a rare surgical case of solitary paraaortic lymph node recurrence in hepatocellular carcinoma (HCC) following radiofrequency ablation. A 72-year-old man who had undergone percutaneous ethanol injection therapy twice and radiofrequency ablation therapy three times for HCC suffered rising serum AFP 3 months after radiofrequency ablation therapy. After 8 months, abdominal CT showed a swollen solitary paraaortic lymph node 35 mm in size. The patient had no recurrence in the liver or other organs. Under a diagnosis of solitary HCC recurrence, we excised the lymph node. The elastic soft, capsulated 31×17 mm tumor was found pathologically to be recurrent HCC. Postoperatively, serum AFP decreased immediately to within normal limits. The man remains alive and recurrence-free in the 3 years and 9 months after surgery. We report a rare case of solitary paraaortic lymph node recurrence with a review of the literature.

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No anatomical landmark exists for right portal fissure. We report a patient with a deep notch on the surface of the right hepatic lobe. To assess whether this notch was consistent with right portal fissure, we analyzed it using high-end 3-dimensional liver simulation software. A 72-year-old man seen for metachronous liver metastasis of sigmoid colon cancer was found in CT to have a low-density area, 3 cm in diameter in segment 7 of the liver, necessitating partial resection. A deep notch found during surgery on the surface of the right lobe, coincided with the border between the right paramedian and right lateral sectors. We conclude that this corresponded to a right portal fissure based on simulation software findings. With multidetector-row computed tomography data and high-end 3-dimensional liver simulation software, it is possible to identify a portal fissure accurately.

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A 62-year-old man admitted for a hepatic tumor 4 cm in diameter at right hepatic segment 8 appearing as a hypoechoic lesion in ultrasonography. Computed tomography (CT) showed the tumor to include a markedly low-density slightly enhanced by contrast medium. Magnetic resonance imaging showed the tumor to be rich in fat. Based on suspected hepatocellular carcinoma (HCC) with partial dedifferentiation or angiomyolipoma, we conducted partial hepatectomy of segment 8. Macroscopically, the cut surface of the tumor was whitish-yellow, and the histopathological diagnosis was well-differentiated HCC with massive macrovesicular steatosis in tumor cells. Only ten cases of HCC have, to our knowledge been reported with markable fatty change and exceeding 3.0 cm in diameter. We attribute this unusual condition to circulatory disorders in the tumor.

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We report a case of amputation neuroma accompanied by a surgical clip migrating into the common bile duct following laparoscopic cholecystectomy (LC) 15 years earlier. A 51-year-old man who had undergone LC for cholecystolithiasis 15 years earlier and admitted for suspected bile duct cancer was found in ERCP to have smooth stenosis of the common bile duct adjacent to surgical clips used during LC. We suspected benign bile duct stenosis, but the possibility of bile duct cancer could not be ruled out, so we conducted extrahepatic bile duct resection and hepaticojejunostomy, because no malignant evidence was obtained in frozen sections. We found the amputation neuroma at the bile duct stricture in histological inspection and that a surgical clip had migrated into the bile duct lumen. Biliary amputation neuroma is often caused by surgical injury to nerve fibers around the bile duct.

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A 69-year-old woman referred for epigastralgia was found in computed tomography, to have a solitary 3.5 cm hypovascular hepatic tumor localized at S8 and S4 closely adjoining the right and middle hepatic vein. US, CT, and MRI imaging studies and contrast medium enhancement patterns indicated intrahepatic cholangiocellular carcinoma, metastatic liver tumor, or sclerosing hemangioma. Fluorine-18 fluorodeoxyglucose positron emission tomography (FDG-PET) showed that FDG had not accumulated in the tumor and standard uptake was very low at 2.4. The tumor was diagnosed histologically as adenocarcinoma with ultrasonically guided percutaneous biopsy. No malignant lesions were found in upper gastrointestinal endoscopy and total colonoscopy. Based on the preoperative diagnosis of intrahepatic cholangiocellular carcinoma, the patient underwent central bisegmentectomy with concomitant resection of the right hepatic vein and hepatic hilar lymph node dissection. Histopathological findings showed moderately differentiated cholangiocellular carcinoma without direct infiltration of the right hepatic vein. No lymph node metastases were observed.

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We report a case of rare curatively resected Intrahepatic cholangiocarcinoma of the caudate lobe. A 59-year-old man undergoing endoscopic retrograde biliary drainage for obstructive jaundice due to intrahepatic cholangiocarcinoma and admitted for further examination was found in ultrasonography, computed tomography, endoscpopic retrograde cholangiography, and angiography to have an irregular mass-forming tumor 4.5 cm in diameter. The tumor, located in the caudate lobe, had spread to the bilateral hepatic lobe. The right intrahepatic bile duct was markedly dilated and the right hepatic artery and the transverse portion of the left portal vein in the hilum were involved, although the left hepatic artery was intact. We conducted extended right hepatectomy with caudate lobectomy after percutaneous transhepatic portal vein embolization, concomitantly resecting the common bile duct, left portal vein, and right hepatic artery due to tumor involevement. Pathological findings showed moderately differentiated adenocarcinoma and negative resection margins of the liver parenchyma and left intrahepatic bile duct. A postoperative subphrenic abscess was treated by temporary percutaneous drainage. The man was discharged on postoperative day 40 and remains without recurrence in the 18 months since surgery.

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A 59-year-old man underwent pylorus-preserving pancreaticoduodenectomy with resection of the portal vein and intraoperative radiotherapy for cancer of the head of the pancreas. Three years later, he developed recurring episodes of hematemesis and tarry stool occurred repeatedly. Upper gastrointestinal endoscopy and colonoscopy did not reveal any bleeding points. Abdominal angiography also did not reveal any bleeding points, however, it showed obstruction of the portal vein. Superior mesenteric artery angiography showed stagnant and unclear flow in the collaterals. Therefore, the bleeding was considered to be due to portal hypertension induced by portal vein obstruction. Graft anastomosis between the superior mesenteric vein branch and inferior vena cava was performed to ameliorate the portal hypertension. One year after the graft anastomosis, no bleeding from the digestive tract was noted. Late complications of portal vein coresection include repeated bleeding from the digestive tract resulting from anastomotic obstruction of the portal vein. Decompression of the portal vein by graft anastomosis between the superior mesenteric vein and inferior vena cava should be considered as one of the effective treatment options for intractactable gastrointestinal bleeding after pancreaticoduodenectomy.

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A 40-year-old woman admitted for abdominal pain and melena was found in CT and MRI to have a 10-cm-diameter pelvic cavity mass necessitating ileocecal resection. Preoperative diagnosis was ileal gastrointestinal stromal tumor (GIST). Operative findings showed an 8-cm-diameter submucosal tumor in the terminal ileum. Histopathological findings showed adenocarcinoma arising in a duplicated terminal ileum. The thick-walled cystic tumor contained bloody fluid and the tumor appeared ileal wall. Adenocarcinoma was observed in the mucosa, invading to the muscle and subserosa. The patient was discharged without complications on postoperative day 11, required 7 courses Adjuvant chemotherapy of oral UFT/LV. The woman has had no recurrence or metastasis. To our knowledge, this is the first case of adenocarcinoma arising in a duplicated terminal ileum in Japan.

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We report long-term survival in a patient after resection for sigmoid colon cancer and pulmonary and pancreatic metastasis. A 56-year-old man undergoing sigmoidectomy for sigmoid colon cancer in May 1993 and right lower lobectomy for lung metastasis (S6) in June 1993 showed was elevated serum CEA from June 1994. Abdominal CT in March 1995 showed a mass lesion in the pancreatic tail, based on a diagnosis of pancreatic tumor, necessitating distal pancreatectomy with splenectomy and left adrenalectomy in April 1995. Histopathologically, the diagnosis was metastatic colon cancer. In November 1995, he underwent partial right upper lobectomy for right upper metastasis (S3). Now, 15 years after resection of the primary cancer, he is doing well with no sign of recurrence. The prognosis of metastatic colon cancer of the pancreas is dismal, but pancreatic resection may achieve long-term survival and we feel surgery should be conducted aggressively if curability is promising.

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We report the rare case of a 34-year-old woman with primary cystic teratoma of the rectum, pinpointed in a colonoscopy. A tumor with a hair ball that fled easily was found in the anterior rectum about 8 cm from the anal verge in colonoscopy. Magnetic resonance imaging showed a tumor protruding from the anterior wall of the rectum to ventral side. The tumor showed high intensity in T1-weighted imaging, and low intensity in T2-weighted imaging, which was markedly enhanced in diffusion imaging. Laboratory findings showed anemia, and poor nutrition. At laparoscopy, the tumor was found at Douglas fossa with highly adhesion with uterus, necessitating open total uterectomy and low anterior resection. The tumor was resected en-block with the uterus and rectum. Histopathological findings showed cystic teratoma ruptured into the rectum from the rectal wall.

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