Background: Many reports have questioned the routine use of prophylactic drainage after liver resection, although many centers still continue using drainage after hepatectomy. We retrospectively evaluated the need for post-liver-resection abdominal drainage. Method: Subjects numbered 259 in a "drainage" group undergoing hepatectomy without biliary or enteric resection or reconstruction with the use of abdominal drainage from May 2001 to December 2007 compared retrospectively to 118 in a "nondrainage" group without drainage from Jan 2008 to Oct 2009. The two groups were compared for postoperative complications, including bile leakage, and postoperative day (POD) discharge to determine the need for posthepatectomy drain placement. Results: Wound infection was significantly lower at 5.9% vs. 13.5% and median POD stay significantly shorter at POD12 vs. POD18 in the nondrainage than the drainage group. Three patients in the nondrainage group had a drain reinserted early postoperatively period before POD 7 and all had undergone extended right hepatectomy for hepatocellular carcinoma with portal vein thrombus followed by postoperative liver failure. Identified risk factors for postoperative bile leakage included repeat hepatectomy, operative procedure exposing of the major Glisson's sheath (i.e. central bisegmentectomy and anterior segmentectomy), and intraoperative bile leakage. The onset of postoperative bile leakage was as late as POD 19.5 (median), prophylactic drainage would not appear useful. Conclusions: While our results indicate that routine abdominal drainage is not necessary after liver resection without concomitant biliary or enteric surgery, prophylactic drainage may be useful in cases in which (1) extended hepatectomy is undergone for hepatocellular carcinoma with portal vein thrombus where postoperative liver failure prediction is extremely important and (2) central bisegmentectomy or anterior segmentectomy is required with intraoperative bile leakage noted where bile leakage would potentially occur postoperatively. In (2), prolonged drainage placement would be expected.

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A 67-year-old man seen for dysphagia was found in upper gastric endoscopy to have a submucosal tumor at the gastric cardia. Computed tomography (CT) showed a huge tumor at the mid mediastinum, extending from the right pulmonary hilum to the gastric cardia. Biopsy yielded a pathological diagnosis of gastrointestinal stromal tumor (GIST) of the esophagogastric junction. To avoid excessive surgical invasion, we started neoadjuvant chemotherapy with imatinib at 400 mg/day to shrink the tumor. Two weeks later, the tumor had decreased, but CT after eight weeks showed air within the tumor and an esophago-tumor fistula. Upper gastrointestinal tract X-ray showed a cavity communicating with the esophageal lumen. When conservative 4-week treatment failed to alleviate the fistula, we conducted surgical intervention involving lower right thoracolaparotomic esophagectomy, proximal gastrectomy, intrathoracic esophagogastrostomy, and complete tumor resection. The 12×10× 8 cm tumor showed a fistula between the posterior wall and tumoral cavity. Pathologically, most tumor cells appeared atrophic with fibrotic changes throughout the tumor. The man has remained recurrence-free in the 16 months since surgery.

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We report an adult case of a Bochdalek's hernia with gastric perforation. A 65-year-old man admitted for abdominal pain and septic shock was found in chest radiography and abdominal computed tomography to have a diaphragmatic hernia with gastrointestinal perforation. We conducted partial gastrectomy, hernial orifice closure, and abdominal drainage. Bochdalek's hernia accounts for 70% of congenital diaphragmatic hernia, although occurrence in an adult is rare. Since impacting or perforation of the herniated organ may rapidly worsen, we recommend early surgery regardless of whether the patient is a symptomatic.

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Both gastric cancer recurrence over 10 years after initial surgery and umbilical metastasis known as Sister Mary Joseph's nodule are rare. We report an unusual case of umbilical gastric cancer metastasis over 10 years after surgery. A 50-year-old woman who underwent total gastrectomy (curativity B) in June 1996 was diagnosed postoperatively as pathological StageIII_A (poorly differentiated adenocarcinoma (por2), T3 (SE), N1, H0, P0, M0). Adjuvant chemotherapy with UFT was administered for five years without evident recurrence. After reporting left back pain and an umbilical tumor in August 2006, she was found in computed tomography (CT) to have left hydronephrosis and a 1.2 cm umbilical tumor. Based on the diagnosis of peritoneal dissemination and umbilical gastric cancer metastasis, she was treated with TS-1 and cisplatin (CDDP) combined chemotherapy. Hydronephrosis disappeared after one course, but the umbilical tumor grew and paclitaxel was ineffective. The woman died in September 2001.

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Neuroendocrine carcinoma of the ampulla of Vater is very aggressive and has a dismal prognosis, but no consensus has been reached on multimodality therapy. We report such a case indicating the possible positive effect of adjuvant chemotherapy. A 71-year-old woman seen for jaundice and fatigue was diagnosed with endocrine cell carcinoma of the ampulla of Vater, necessitating pancreatoduodenectomy with regional lymph node dissection. Resected specimens showed minimal invasion of pancreatic tissue by the tumor and lymph node metastasis at the inferior pancreaticoduodenal artery root. Histologically, the tumor showed sheets of small round cells with hyperchromatic nuclei and scanty cytoplasm. Immunohistochemically, positive staining was seen for CAM5.2, chromogranin A, and NSE. Adjuvant chemotherapy with CDDP/CPT-11 or CDDP/VP-16 conducted based on small-cell lung carcinoma chemotherapy yield 27 months of postoperative recurrence-free survival. This case thus shows the possibility that adjuvant chemotherapy can be effective in treating advanced neuroendocrine carcinoma of the ampulla of Vater.

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We report five-year posthepatectomy survival in early hepatic metastasis from carcinoma of the papilla of Vater. A 66-year-old woman who had pancreatoduodenectomy for carcinoma of the papilla of Vater with multiple lymph node involvements underwent extended left hepatic lobectomy five months after the first operation for a solitary metastatic liver tumor. She then underwent biweekly adjuvant chemotherapy with gemcitabine for 15 months and has remained well without recurrence in the five years since the second operation. Few reports have been made of long-term survivors after hepatectomy for metastatic liver tumors in biliary tract cancer. The woman we treated with hepatectomy and adjuvant chemotherapy has thus survived despite multiple lymph node metastasis and early hepatic recurrence.

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Macroscopic intrabiliary tumor growth in colonic liver metastasis warrants surgery whose favorable prognosis requires a significantly related clear resection margin, as indicated by the case we report here. A 65-year-old man undergoing right hemicolectomy with D3 lymph node dissection in pR0 in June 1998 for type 2 transverse colon cancer was diagnosed pathologically with moderately differentiated adenocarcinoma StageIIIb (ss, n₃ (+), P₀, H₀, M (-)). Follow-up found liver tumors with intrahepatic bile duct dilation twice metachronously-first in Couinaud nomenclature segment 6, 3 years after primary resection and second in segment 3, 4 years thereafter. Diagnostic imaging suggested that liver tumors were colonic metastasis. We conducted hepatic posterior segmentectomy first, followed by hepatic lateral segmentectomy, rather than partial hepatectomy to maintain a clear resection margin, both resulting in a negative tumor cell margin. Both resected specimens showed macroscopic intrabiliary tumor growth and the pathological diagnosis was moderately differentiated adenocarcinoma from colonic liver metastasis. The final diagnosis was colonic liver metastasis with macroscopic intrabiliary tumor growth.

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We report a rare case of cholangiolocellular carcinoma with sarcomatous change. A 62-year-old man was diagnosed with a segment 8 liver tumor in computed tomography (CT) following up on chronic hepatitis B. We diagnosed the tumor as hepatocellular carcinoma (HCC) based on precise visual examination and laboratory data on evaluated AFP and PIVKA-II HCC tumor marker. Following anterior segment resection, histological findings showed two main tumor components contained. (1) pleomorphic spindle cells, and (2) small anastomosing pattern ductules. The final diagnosis was cholangiolocellular carcinoma with sarcomatous change. The man's postoperative recovery was uneventful, but he encountered breathing difficulty three months postoperatively, and CT showed numerous recurrent nodules in the remnant liver, lymphadenopathy around the aorta, and pleural effusion on the right side. The man died four months postoperatively. Cholangiocellular carcinoma, which is rare, is even rarer when involving sarcomatous change. To the best of our knowledge, no report has been made of cholangiolocellular carcinoma with sarcomatous change, making this case vital to research and treatment.

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Although hemosuccus pancreaticus is a rare complication of chronic pancreatitis, it should be considered in cases of unexplained gastrointestinal bleeding. We report two cases of hemosuccus pancreaticus. Case 1: A 77-year-old man seen for repeated hematemesis was found in computed tomography (CT) to have a splenic artery aneurysm. Hematemesis was considered due to aneurysm rupture into the main pancreatic duct, necessitating surgery. Pathological examination showed the resected specimen to be a true aneurysm without a pseudocyst. Case 2: A 58-year-old man with upper abdominal pain was found in upper gastrointestinal (GI) endoscopy to have bleeding from the papilla of Vater. Abdominal magnetic resonance imaging (MRI) showed a cystic pancreatic tail lesion. We operated based on a diagnosis of hemosuccus pancreaticus due to the pancreatic cyst. Pathological findings of the resected specimen showed mucin-secreting columnar epithelial cells with varying degrees of atypia but without ovarian-type stroma. The definitive diagnosis was hemosuccus pancreaticus due to intraductal mucinouspapillary neoplasm.

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We report a case of groove pancreatitis (GP) with a pseudocyst in the muscular layer on the right side of the duodenum-the first such case reported to our knowledge. A 55-year-old man reporting abdominal discomfort for 6 months and vomiting for 1 month was found in abdominal enhanced computed tomography (CT) and magnetic resonance imaging (MRI) to have a 10×5 cm cystic lesion along the right side wall of the duodenal second to third portions and a 1 cm low-enhanced nodule of the pancreatic head. Upper gastrointestinal tract (GI) series and GI Endoscopy showed duodenal stenosis. Serum DUPAN-2 was elevated at 747 U/ml. Under a tentative diagnosis of pancreatic head cancer and duodenal stenosis, we conducted pancreaticoduodenectomy. The resected specimen showed a white 1 cm nodule of the pancreatic head, and a 7×5 cm cystic lesion of the duodenum. Histologically, the pancreatic nodule was focal fibrosis with chronic pancreatitis and the cystic lesion was in the muscular layer of the duodenal wall. The final diagnosis was GP with focal fibrosis and an intramural pancreatic duodenal wall pseudocyst. GP is difficult to diagnose preoperatively because imaging of a GP-associated nodule resembles that of pancreatic head cancer.

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We report a case of fatty replacement of pancreatic body and tail (FRPBT) with an intraductal papillary mucinous neoplasm (IPMN) in a subject undergoing pancreatoduodenectomy (PD). A 75-year-old woman found in computed tomography (CT) to have a multilocular cystic pancreatic head tumor during a checkup for poor diabetes mellitus control was found in magnetic resonance imaging (MRI), endoscopic retrograde cholangiopancreatography (ERCP), and endoscopic ultrasound (EUS) to have pancreatic head mixed type IPMN. CT and MRI also showed severe atrophy and steatotic pancreatic body and tail change indicating FRPBT. ERCP showed the main pancreatic duct to be obstructed at the pancreatic body. She thus underwent PD without pancreatic reconstruction for IPMN with FRPBT. Only thick fatty tissue was recognized macroscopically in the pancreatic body and tail. Postoperative insulin control of diabetes mellitus was adequate, without hyperglycemia or hypoglycemia, resembling total pancreatectomy results. Histopathologically, the cystic pancreatic head tumor was intraductal papillary mucinous adenoma and the islets of Langerhans remained in the pancreatic body portion replaced by fatty tissue. PD is considered appropriate in FRPBT because postoperative insulin control is comparatively stable because the islets of Langerhans remain in pancreatic fatty tissue.

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A 67-year-old man referred for appetite and weight loss was found in laboratory data to have severe liver function disturbance and mild jaundice. Abdominal ultrasonography (US) showed common bile duct (CBD) dilation and a low echoic mass in the duct. Magnetic resonance imaging (MRI) showed a 2 cm nodule in the pancreatic head with low-intensity T1 and high-intensity T2. Magnetic resonance cholangiopancreatography (MRCP) showed common bile duct to be obstructed by a smooth stone-like mass. Celiac arteriography showed pancreas-head tumor staining without encasement. These findings suggested a malignant bulging pancreatic head tumor intruding into the common bile duct, necessitating pancreatoduodenectomy. Surgical findings showed a pancreatic head tumor that had grown intraductally into the common bile duct. Histological findings showed tumor cells with acinar patterns, and the common bile duct tumor resembled the prior specimen with an acinar pattern. Immunohistochemically, tumor cells showed positive staining for trypsin and lipase. Based on these histological findings, we made a definitive diagnosis of acinar cell carcinoma of the pancreas.

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Clinical characteristics and the treatment of the lung metastases from pancreatic cancer have not been fully investigated. We report clinical features of 4 cases with isolated lung metastases that had been proven by immunohistochemical method and examined the efficacy of chemotherapy. Four cases received gemcitabine chemotherapy after primary pancreatectomy. Thoracic high resolution CT detected lung nodules in all cases. Disease free survival was 26-78 months. All cases received resection of lung nodule; 2 cases with single nodule were diagnosed as primary lung cancer and another 2 cases with two nodules were diagnosed as lung metastases. In all cases, pathological and immunohistochemical examination revealed lung metastasis from pancreatic cancer. All but one patient received combination with gemcitabine and TS-1 chemotherapy after lung resection. Two cases died of relapse at 32, 14 months after lung resection, while another 2 cases are alive at 36, 14 months. Isolated lung metastasis after radical surgery for pancreatic cancer showed delayed recurrence and low malignant potential. Long survival term was obtained by chemotherapy after lung resection. It is suggested that close follow-up after pancreatectomy and effective chemotherapy seem to be essential for improving the prognosis of the lung recurrence.

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A 59-year-old man admitted for lower right abdominal pain was found in blood test to have leukocytosis (WBC count 18,870/mm³) and elevated C-reactive protein (CRP 12.3 mg/dl). Abdominal computed tomography showed a swollen appendix, necessitating appendectomy based on a preoperative diagnosis of acute appendicitis. Postoperative histopathological examination of the resected appendix showed signet ring cell carcinoma from the mucosa to the serosal membrane and mesoappendix. Twenty one days after initial surgery, we conducted ileocecal resection with D3 lymph node dissection, but neither residual tumor nor lymph node metastasis was seen. The man underwent postoperative chemotherapy for six months and has remained in good health in the interim 18 months without clinical recurrence. Signet ring cell carcinoma is extremely rare in appendiceal cancer, with many cases initially diagnosed as appendicitis and only after postoperative histopathological examination found to be cancer. Postappendectomy histopathological examination is therefore necessary. Additional surgery and chemotherapy may then be considered based on the pathological stage disease.

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We report a case of ileocolic fistula with delayed colon stenosis one year after abdominal blunt trauma. A 71-year-old man treated conservatively for mesenteric injury in a traffic accident was hospitalized one year later for abdominal fullness and vomiting that did not improve in conservative treatment. Colonoscopy and enterography showed a fistula between the sigomoid colon and ileum, necessitating sigomoidectomy with associated ileal resection and sigmoidostomy. Bowel and mesenteric injury are common in abdominal trauma, but delayed posttraumatic colon stenosis is especially rare, with ileocolic fistula such as in this case never, to our knowledge, reported in Japan. Delayed stenosis should be considered in those reporting ileal symptoms following abdominal trauma. Enterography is very useful in diagnosing bowel stenosis and fistula formation.

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A 62-year-old man with generalized atherosclerotic disease and atrial fibrillation seen for postprandial abdominal pain was found in enhanced computed tomography to have proximal superior mesenteric artery (SMA) occlusion and reconstituted mid and distal SMA via collaterals. Post-fasting, he was symptom-free, but postgrandial abdominal pain severity increased, necessitating mesenteric artery reconstruction requiring preoperative consideration of surgical alternatives, including conventional bypass grafting from the supraceliac aorta and iliac artery. We decided to provide SMA inflow via the splenic artery due to his recent iliac artery bypass grafting and aortic calcification. Current open surgical intervention involves arterial bypass using a vein or graft with aorta or iliac artery inflow and bypass to the SMA, in which the splenic artery provides an additional treatment option for revascularizing the SMA.

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[in Japanese]

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