Background: Renal cell carcinoma is likely to metastasize to the lung or bone, while metastasis to the pancreas is relatively rare. Patients: We retrospectively reviewed 13 patients with pancreatic metastasis from renal cell carcinoma treated during the past 23 years at our hospital. Of these 13 patients, 8 underwent metastasectomy. Here, we report on the surgical procedures, prognosis, morbidity, and mortality in each case. Results: Among the 8 patients who underwent resective surgery, 1 underwent pylorus-preserving pancreaticoduodenectomy; 4, distal pancreatectomy; 2, total pancreatectomy; and 1, middle pancreatectomy. No perioperative mortality was observed. Morbidity was observed in 2 patients. After pancreatic metastasectomy, 1 patient had recurrence within the remnant pancreas. Among these 8 patients, 5 are still alive and 2 have shown no evidence of recurrence. The median survival time of patients undergoing metastasectomy is 152 months. The 5 patients who did not undergo resection developed lung, bone, or liver metastases or thrombus in the inferior vena cava. Four of these patients died. Their survival time ranged from 22 to 90 months, with a median survival time of 38 months. Six patients had synchronous lesions, and 7 had metachronous lesions. Two of the patients with synchronous lesions/cancers showed long prognosis. Conclusion: If no uncontrollable metastasis, other than in the pancreas, is present, pancreatic metastasectomy could be acceptable. However, careful consideration of the surgical procedure is essential.

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A 63-year-old man with idiopathic bilateral instep pain and high serum alkaline phosphatase was seen again at two months after the initial visit for epigastralgia. Chest X-ray imaging showed diffuse osteoblastic change, and bone scintigraphy revealed diffusely increased bone uptake (super bone scan). He was given a diagnosis of gastric cancer with disseminated bone marrow metastasis by gastric fiber and bone scintigraphy, necessitating surgery. The definitive staging was T1a, N3b, H0, P0, M1 (LYM, MAR), Stage IV (Japanese classification of gastric carcinoma). He underwent chemotherapy following surgery but died 28 months after surgery of disseminated bone marrow metastasis of gastric cancer. A small number of patients with early gastric cancer present distant metastasis, therefore careful follow-up is essential.

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A 66-year-old man visited our hospital for further examinations. Upper gastrointestinal endoscopy and barium meal showed a 3 cm submucosal tumor at the greater curvature of the gastric body. Biopsies did not yield a diagnosis of gastric cancer, so we performed laparoscopic partial gastrectomy as total biopsy for this submucosal tumor. Pathological findings showed severe focal lymphocytic infiltration and poorly differentiated adenocarcinoma (sm2, ly0, v0), positive for cytokeratine AE1/AE3, Cyclin D1, MIB-1 and EBER-1. The diagnosis was gastric carcinoma with lymphoid stroma. The surgical margin was free of tumor. Three months after the operation, upper gastrointestinal endoscopy showed 0-IIb cancer at the posterior wall of the gastric body. We performed distal gastrectomy. Pathological findings showed moderately differentiated adenocarcinoma (m, ly0, v0, n0) with positive EBER-1. The final diagnosis was Epstein-Barr virus-associated multiple gastric carcinoma.

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A 67-year-old man presented complaining of tarry stool. His hemoglobin level was 3.8 g/dl. Upper gastrointestinal endoscopy revealed a 7 cm submucosal tumor with a deep ulcer near the papilla of Vater. Contrast-enhanced CT showed the tumor was the origin of the marked bleeding. Melena from the tumor continued after admission, and we were requested to stop the bleeding immediately. Abdominal angiography revealed the tumor was supplied from the anterior and posterior superior pancreaticoduodenal arteries, inferior pancreaticoduodenal artery, and middle colonic artery. Portal vein flow was enhanced in the early phase, indicating an AV shunt. Selective transarterial embolization (TAE) was performed through all the pancreaticoduodenal arteries except for the colonic artery. The TAE was effective. After 9 days, pylorus preserving-pancreaticoduodenectomy with partial colonic resection was performed. Based on the histopathological findings, a final diagnosis of duodenal gastrointestinal tumor was made. He lost about 600 g blood volume during the operation, which was similar to conventional operations. Although few articles reported TAE from primary gastrointestinal stromal tumors, TAE may be useful to avoid of emergency operation, and reduce intraoperative bleeding during the operation.

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The patient was 62-year-old man who was found to have an intrahepatic bile duct stricture localized in the lateral segment of the liver during a routine medical check-up. He was found to have pleural thickness, and malignant mesothelioma was suspected, because he had a history of exposure to asbestos. After extensive examination, we diagnosed cholangiocarcinoma and malignant mesothelioma. At first, we performed laparoscopic assisted left hepatectomy. Recovery was uneventful and he was discharged on postoperative day 9. Pathological diagnosis was IgG4-related sclerosing cholangitis. One month after surgery, computed tomography-guided biopsy was performed for pleural thickness. The pleural thickness was not due to malignant disease, and there were no IgG4-positive plasma cells. Therefore, we considered the pleural lesion to be related with past exposure to asbestos, and unassociated with IgG4 related disease. It is rare for localized intrahepatic bile duct stricture without intrahepatic stone to be benign, as many are malignant diseases such as cholangiocarcinoma. Extrahepatic bile duct, especially intrapancreatic bile duct is a common site for IgG4-related sclerosing cholangitis. We present a case of IgG4-related sclerosing cholangitis with intrahepatic bile duct stricture mimicking cholangiocarcinoma, with a review of the literature.

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A 67-year-old woman had a 5 cm hepatic tumor of the lateral hepatic segment, associated with a peripheral lesion effect, based on abdominal contrast-enhanced CT, which was conducted when a diagnosis of dermatomyositis was made. The patient was negative for HBV as well as HCV, and the levels of AFP and PIVKA-2 were within the normal range. PET scan did not reveal extrahepatic primary lesions. Laparoscopic partial hepatectomy was performed for diagnosis and treatment. HE staining revealed the proliferation of small tumor cells with a high nucleoplasmic ratio and nuclear grade. As she was positive for CD56 and synaptophysin based on immunostaining, a diagnosis of small cell carcinoma of the liver was made. Two courses of CDDP and VP-16 were given postoperatively. However, she had recurrence of intra-abdominal lymph nodes 10 months postoperatively, and recurrence in the right adrenal gland 12 months postoperatively. She has survived for 16 months postoperatively without treatment. Small cell carcinoma of the liver is an extremely rare disease, and there is no consensus on the prognosis of and treatment methods for the disease.

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We report a case of congenital absence of gallbladder associated with a bile duct-colic fistula. A 67-year-old man with bouts of fever around 39°C was given a diagnosis of internal biliary fistula, because an abdominal CT scan showed liver abscess and pneumobilia, and the contrast medium in ERCP was leaked from the bile duct to the transverse colon. No diagnostic imaging method was able to show the gallbladder. Peroral cholangioscopy after endoscopic sphincterotomy and lithotripsy for choledocholithiases demonstrated no malignant findings but the inflammatory changes of the bile duct mucosa. Colonoscopy showed granulation at a fistula, but did not suggest the cause of the fistula. Laparotomy showed the transverse colon located in the recess of the liver where formation S4/5 was insufficient and adhered strongly to hepatic hilum. The structure of gallbladder was not seen. The biliary side of the fistula was the right side of the confluence of the bilateral hepatic ducts. Congenital absence of gallbladder is known to be associated with choledocholithiasis. In the present case, cholangitis due to choledocholithiases is thought to have caused the internal biliary fistula to the adjacent transverse colon.

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An 82-year-old-man, with a history of repeated episodes of chronic pancreatitis and cholangitis, was admitted to our hospital due to fever and abdominal pain. A diagnosis of pancreatitis and cholangitis was made. Furthermore, intraductal papillary-mucinous carcinoma (IPMC) in the pancreatic head and cancer in the lower part of the bile duct was detected by CT and ERCP. Pylorus-preserving-pancreaticoduodenectomy was performed. Gall bladder cancer was also observed in the removed specimen. Triple cancers with IPMC, bile duct cancer and gall bladder cancer were finally diagnosed after surgery and this combination has never been previously reported. It is well known that intraductal papillary-mucinous neoplasm (IPMN) induces other malignant neoplasms, but the origin is unclear. In this case, a history of repeated pancreatitis and cholangitis may have significantly affected the overlapped carcinogenesis.

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There has been little report on the presence of a hypertrophic uncinate process of the pancreas wrapping the superior mesenteric vein , and has been described as a portal annular pancreas or circumportal pancreas. We recently experienced a case of a patient in whom the pancreatic uncinate process surrounded the superior mesenteric vein. An 84-year-old woman with jaundice was given a diagnosis of lower bile duct cancer, and underwent surgery. During pancreatoduodectomy, we found an anomaly of the pancreas encasing the superior mesenteric vein. A computed tomography (CT) scan confirmed that the main pancreatic duct was passing through the anterior portion of the superior mesenteric vein, and we performed standard dissection of the pancreatic parenchyma antecedent to the superior mesenteric vein. After exposing the main pancreatic duct, we dissected the retroportal region, and the anomalous pancreatic parenchyma with autosutures on the left border of the superior mesenteric vein. Postoperatively, a pancreatic fistula, classified as Group A according to the International Study Group on Pancreatic Fistulas Classification, developed but improved with conservative management.

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We report a case with postoperative pancreatic fistula successfully treated by endoscopic transgastric drainage. A 79-year-old man with cancer of the head of the pancreas underwent subtotal stomach-preserving pancreatoduodenectomy. On postoperative day 9, based on a high amylase level in drainage fluid, we suspected postoperative pancreatic fistula. The drainage tube was withdrawn on the 26th postoperative day after confirming closure of the fistula. He complained of upper abdominal pain and fever on the 36th postoperative day. CT scan revealed an abdominal fluid collection 2.5 cm in diameter around the pancreatojejunostomy. As percutaneous drainage was abandoned due to the presence of the small bowel between the abdominal wall and the lesion, endoscopic ultrasound (EUS)-guided transgastric drainage was attempted. Immediately after the procedure, the patient recovered and became asymptomatic. Since EUS-guided transgastric drainage for postoperative pancreatic fistula appears to be safe and feasible, it is an option for selected patients.

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We present a case of a 65-year-old woman with high standardized uptake value (SUV) in the tail of the pancreas on fluoro-deoxyglucose-positron-emission tomography (FDG-PET). She had undergone right lobectomy of the thyroid 2 years and a half previously due to papillary carcinoma of the thyroid. A year after that surgery, local papillary carcinoma of the thyroid recurred. She experienced difficulty in breathing and required emergency tracheotomy and repeated tumor resection. One year and a half after tracheotomy, the cancer recurred in mediastinal and neck lymph nodes, and lymph node dissection was performed. Three months after lymph node dissection, she underwent fine needle aspiration biopsy following identification of high SUV in the tail of the pancreas on FDG-PET. Metastasis from the papillary carcinoma of the thyroid was diagnosed in the tail of the pancreas. As no distant metastases were apparent, hand-assisted laparoscopic surgery (HALS) distal pancreatectomy with splenectomy was performed. Histopathological examination confirmed the diagnosis of metastatic tumor from the papillary carcinoma of the thyroid. Postoperative course was uneventful and the patient was discharged 10 days after surgery. Resectable metastatic pancreatic tumor from the thyroid is rare, and no reports have described metastatic pancreatic tumors from the thyroid treated using HALS. This patient has remained alive without relapse for 18 months after HALS.

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A 34-year-old man was admitted to our department with right lower abdominal pain and fever suffering for two days. Computer tomography (CT) and abdominal ultrasound (US) showed a linear high intensity lesion in the small intestine and a part of this lesion was detected throughout the wall of the small intestine. Emergency surgery was performed and revealed that a fish bone penetrated from a Meckel diverticulum to the epiploic appendix of the ascending colon. We herein, report this case in addition to the investigation of reported similar cases.

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We report a case of bleeding of the small intestine following total colectomy for ulcerative colitis. A 39-year-old woman underwent total proctocolectomy, ileal pouch-anal anastomosis and loop ileostomy for refractory ulcerative colitis. The postoperative clinical course was uneventful, and she underwent closure of the ileostomy about 4 months after the primary operation. She developed postoperative bowel obstruction, and required therapy with long tube intercalation. Massive melena appears on postoperative day 39. She fell into pre-shock condition, so we performed an emergency laparotomy on postoperative day 41. On intraoperative transanal endoscopy, we found diffuse erosion and oozing in the small intestine but no active bleeding point was seen. Biopsy was performed from the area of erosion point of the small intestine. The pathology suggested that the mucosal inflammation was similar to ulcerative colitis, so we started intravenous administration of prednisolone. Angiography 6 days after the re-operation revealed extravasation from the peripheral region of the second jejuna artery was seen. We performed transcatheter arterial embolization. Thereafter, the melena disappeared, and she was discharged 27 days after the emergency laparotomy.

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The patient is a 51-year-old man who underwent surgery for descending colon cancer in December 2007 (D, type 3, 40×50 mm, tub2, SE, N1, H0, P0, M0, Stage a, D2, PM0, DM0, RM0, R0, Cur A). He visited our hospital because a larger mass was found and he had pain in the left inguinal region since September 2008. We diagnosed left cryptorchidism and testicular tumor, and performed high orchiectomy. With histological assessment, we found high columnar tubular adenocarcinoma proliferating in the epididymal stroma. In addition, immunohistochemical tests revealed positive results for Cytokeratin 20, but negative results for Cytokeratin 7 and Calretinin. Considering the above, the tumor was diagnosed as metastasis from colon cancer. After the operation, bloody stool and constipation were recognized. Colon fiberscopy revealed tumors at the anastomosed colon and the rectum. We performed surgery again to resect these tumors. With histological assessment, we found another new metachronal cancer at the anastomosed colon, and it is assumed that its peritoneal dissemination caused the metastasis to the large bowel and epididymidis.

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We report a case of descending colon cancer with synchronous hepatic metastasis and metachronous pancreatic metastasis and local recurrence, ureteral and pulmonary metastasis, and the complete resection of all metastatic lesions suggested a good prognosis. A 53-year-old man who had undergone a left hemicolectomy for descending colon cancer and left lateral lobectomy for synchronous liver metastasis in 1996, showed elevated serum CEA in 1998. Abdominal CT showed a nodular lesion in the tail of the pancreas. Distal pancreatectomy with splenectomy was performed. A local recurrent tumor found by chance was also resected. Pathological examination showed a metastatic tumor in the pancreatic tail and in the retroperitoneum. Two months later, partial resection of the left upper lobe was performed for pulmonary metastasis. Chest CT showed two metastatic lesions in the right lung and pelvic CT showed metastasis to the left ureter simultaneously in 1999. After left partial ureterectomy, we resected the 2 pulmonary metastases. In 2000, partial lung resection was performed for right pulmonary metastasis. All resected specimens showed metastatic adenocarcinoma from the descending colon cancer. Now, 10 years after resection of the last pulmonary metastasis, he is doing well with no sign of recurrence. Aggressive resection is recommended for metachronous or synchronous metastasis of colon cancer, if the metastatic lesions are considered resectable.

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