Although hepatic portal venous gas (HPVG) is considered to have poor prognosis, there have been recent reports on a number of conservatively treated cases. However, few studies have reported on the cause of HPVG, its pattern of progression, or its relationship with severity. We hypothesized that the distribution of HPVG correlates with severity and we conducted a retrospective review of 32 patients given a diagnosis of HPVG based on multi-dimensional computed tomography MDCT between August 2008 and December 2011. Patients were divided into two groups based on the area of gas distribution as follows: Group L (left lobe; 15 patients) and Group LR (both lobes; 17 patients). Data collected included demographics, clinical characteristics, MDCT findings, presence of bowel necrosis, and outcome. The chi-square test, Fischer’s exact test and Student’s t-test were used to compare variables. The groups were similar with regard to age, gender, symptoms, clinical findings, vital signs, and laboratory data. MDCT findings revealed that Group LR had significantly more cases than Group L of gastroduodenal dilatation (82.4% vs. 46.7%; P=0.040), small intestine dilatation (94.1% vs. 53.3%; P=0.011), pneumatosis intestinalis (100% vs. 46.7%; P<0.001) and main portal vein gas (70.6% vs. 33.3%; P=0.035). No respective significant differences in the number of operations performed (26.7% vs. 41.2%; P=0.314), presence of intestinal necrosis (33.3% vs. 52.9%; P=0.265), or mortality (53.3% vs. 52.9%; P=0.982) were found between group L and group LR. No significant correlation was confirmed between the distribution of HPVG and clinical severity, however, Group LR was considered to be more severe pathologically than Group L.

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We report a case of presently disease-free 5.5 year survival from metachronous metastatic liver tumors of alpha-fetoprotein (AFP)-producing gastric cancer treated by multidisciplinary therapies including three hepatectomies. A 62-year-old man had a medical examination, and upper gastrointestinal series and endoscopic examination revealed a type 0-IIa+IIc early gastric cancer in the lesser curvature, upper body of the stomach. Total gastrectomy with D1+β lymph node dissection was performed, and histological examination showed AFP-producing gastric cancer. Ten and 19 months after the operation, solitary liver tumors in segments 5 and 6, respectively, were detected, and partial liver resections were performed. Both of the specimens were diagnosed as metastases from the gastric cancer. Chemotherapy using S-1, PTX, CPT-11/CDDP were not sufficiently effective, and another recurrent liver tumor in segments 5–8 was pointed out. Radiofrequency ablation and transcatheter arterial embolization was performed and serum AFP level fell temporarily, but then increased again. The recurrent tumor also increased, and extended right lobectomy was performed 4 years after the first operation. After that, serum AFP level returned to a normal range, and the patient is presently alive with no recurrent tumor, five and a half years after the first operation.

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Total gastrectomy was performed on a 79-year-old man for early gastric cancer in October 2005. Small cell carcinoma of the stomach was diagnosed based on findings of neuroendocrine characteristics on immunopathological and histopathological examination. Abdominal CT showed a tumor 4 cm diameter in S4 of the liver six months later. Angiographic examination showed a hypervascular tumor in S4 of the liver, from small cell carcinoma of the stomach was diagnosed. No other recurrences were seen, so partial resection of S4 of the liver was performed in May 2006. Metastasis to the liver from small cell carcinoma of the stomach was diagnosed by immunopathological and histopathological examination. Now he is alive and there has been no other recurrence for 6.6 years from the first operation.

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A 74-year old man who underwent resection of a tumor of the ampulla of Vater in 2002, which was histologically diagnosed as severely atypical adenoma, but with a negative surgical margin, was admitted to our hospital because of jaundice in 2008. Upper gastrointestinal endoscopy showed a sessile papillary tumor in the ampulla of Vater, and biopsy showed moderately differentiated adenocarcinoma. Colonoscopy for screening of other malignancies revealed an irregular ulcerative tumor with converging folds and peripheral ridge in the sigmoid colon. The biopsy specimen from the sigmoid colon tumor showed atypical cells invading the submucosal layer but normal mucosal epithelium, therefore, metastatic carcinoma was diagnosed. Subtotal stomach-preserving pancreatoduodenectomy and sigmoid colectomy were performed. The pathological diagnosis was moderately differentiated adenocarcinoma, Panc 1b, Du2, N2 (#13b, #14d, #17d), EM0, M1 (sigmoid colon), Stage IVb. In this case, the sigmoid colon metastasis was thought to be either lymphatic or hematogenous. Colorectal metastasis from carcinoma of the ampulla of Vater is very rare; however, this case was preoperatively diagnosed based on endoscopic and histological findings.

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Impaired liver function and increased serum CEA levels were detected in a 63-year-old man with bilateral pedal edema. Contrast-enhanced CT showed dilatation of the left intrahepatic bile duct in the S2/S3 segments of the liver. ERCP showed complete obstruction of the left intrahepatic bile duct right after the B1 branch. We suspected intrahepatic cholangiocarcinoma and examined the bile and brushing cytology of the stricture, but both results showed no malignancy. In August 2008, we performed left hepatectomy including the caudate lobe. The resected specimen showed stricture of the intrahepatic bile duct in the S2 segment of the liver and a multilocular cystic lesion. There was no connection between the cystic lesion and the intrahepatic bile duct. The bile duct stricture was encircled by cuboidal epithelia with no cellular atypia, and there was fibrosis of the cystic wall, glandular proliferation, and mild lymphocyte infiltration. The patient is still alive without recurrence at 44 months following surgery. Benign intrahepatic bile duct stricture is very rare and only 12 cases have been reported to date in Japan. It is difficult to distinguish between benign intrahepatic bile duct stricture and intrahepatic cholanciocarcinoma, therefore, surgical resection should be performed after thorough explanation.

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A 64-year-old man with general fatigue visited a local hospital and received medical treatment for liver abscess. After that he was referred to our hospital because his symptoms did not improve. He had remittent fever and a marked granulocytosis was observed. Dynamic CT showed a huge liver tumor with a cystic lesion in the left lobe. We diagnosed it as cholangiocellular carcinoma and performed extended left lobectomy. Intraoperative findings were hemorrhagic ascites and ruptured tumor, but we carried out the operation in order to control bleeding from the tumor. Histopathological examination revealed intrahepatic cholangiocarcinoma with a tubular structure and sarcomatous component. Immunostaining with G-CSF revealed malignant cells. His preoperative serum G-CSF concentration was high (170 pg/ml). His condition gradually deteriorated after surgery. On postoperative day 14, CT revealed peritoneal dissemination, multiple liver metastases and metastasis to the gluteus muscle. He died of uncontrollable bleeding from peritoneal disseminated tumors on postoperative day 19. Only 7 cases of G-CSF-producing intrahepatic cholangiocarcinoma have been reported and their outcome was very poor because of their rapid tumor growth.

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We report a case of a 71-year-old man with a 4-cm nodular lesion in S4 and S9 of the liver. The tumor was seen as a hypoechoic irregular mass by US and was slightly enhanced by dynamic CT. The portal blood flow was decreased by CT-AP. Moreover, the tumor was slightly contrasted in the arterial phase of Gd-EOB-DTPA. It was diagnosed as early HCC (well differentiated HCC), central 2 segmentectomy was performed. The inner parts of the tumor had spots of white ingredients and residual hepatic tissue. Infiltration of many small CD20- and CD79a-positive, and CD10- and cyclin D1-negative lymphocytes were identified by immunohistochemistry. The tumor was diagnosed as hepatic mucosa-associated lymphoid tissue (MALT) lymphoma. Here, we focus on the differential diagnosis of MALT lymphoma.

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A-73-year old man who was given a diagnosis of hepatocellular carcinoma (HCC) underwent posterior sectionectomy. He found a palpable mass on the left frontal part of the skull 18 months postoperatively. The tumor marker levels were within normal range. Bone scintigraphy found no bone metastatic lesion apart from the one in the left frontal area. A skull bone tumor was suspected, and tumor resection was performed. Skull metastasis from HCC was revealed by histopathological examination. A mass lesion, on the right 10th rib with osteolysis was revealed by chest computed tomography at 3 years and 8 months following the resection of HCC. The serum level of PIVKA-II was elevated. Rib metastasis from HCC was suspected from elevated AFP levels. The tumor was resected with a portion of the10th rib. Rib metastasis from HCC was shown by a histopathological study. The patient is currently well, 5 years after the resection of HCC and 3 years and 7 months after the last metastasectomy without recurrence. Concerning bone metastases, strict observation during the postoperative course is essential for early detection and treatment.

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We report a resected case of oncocytic type intraductal papillary carcinoma (IPMC) of the pancreas head complicated with pancreaticobiliary maljunction (PBM). A 67-year-old man was admitted for liver dysfunction. Detailed investigations revealed a papillary tumor from the lower bile duct to the papilla of Vater, and biopsy showed a moderately differentiated adenocarcinoma. Subtotal stomach-preserving pancreaticoduodenectomy was performed. The resected specimen revealed that the cyst-shaped common bile duct joined the pancreatic duct, and there was a pancreaticobiliary maljunction with the common channel of 2 cm. The papillary tumor, which had originated from the pancreatic duct or the common channel, grew through the pancreatic duct and protruded into the common bile duct and the papilla of Vater. No report of oncocytic type IPMC with PBM has been made, as far as we know. In this case, it is easy to misdiagnose the tumor as lower bile duct carcinoma, so careful attention is necessary to diagnose it.

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An 83-year-old woman was admitted to the emergency department with fever. She had a past history of transvaginal hysterectomy due to uterine prolapse. A physical examination revealed the presence of a painful mass in the lower abdomen. Abdominal computed tomography (CT) showed the presence of a cystic tumor containing air in the lower abdomen. CT also revealed that the tumor nutritional vessels arose from the left gonadal artery. Enema revealed the presence of a fistula between the rectum and the lumen of the cystic tumor. A drainage tube was placed inside the cavity through the fistula, and the patient’s fever quickly resolved. Colonoscopic biopsy of the fistula yielded a diagnosis of ovarian carcinoma. Laparotomy revealed a hard tumor arising from the left ovary that had invaded the rectum. The Hartmann procedure and bilateral salpingo-oophorectomy were performed. Histological findings showed that the ovarian endometrioid carcinoma had penetrated the rectum. The patient was transferred without complications to the gynecology ward to receive adjuvant chemotherapy 14 days after surgery. She is alive without recurrence 6 months after surgery.

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Chylothorax is a comparatively rare complication of esophagectomy for carcinoma. We encountered a case in which etilefrine infusion was an effective strategy for postoperative chylothorax resistant to conventional treatments, which had never been reported in Japan. The patient was a 75-year-old man, and a radical esophagectomy was performed after preoperative chemoradiotherapy for thoracic esophageal carcinoma (T3N2M0), including subtotal esophagectomy with right thoracotomy, reconstruction with a posterior mediastinal gastric tube and 3-field lymph node dissection. Milky fluid drainage appeared on the day of starting oral intake, postoperative day (POD) 9, and chylothorax was diagnosed. The chylothorax was treated with fasting and total parental nutrition, lymphangiography with lipiodol, ligation of the thoracic duct with right re-thoracotomy, and octreotide acetate subcutaneous injection, but all these strategies were unsuccessful. Finally, etilefrine infusion was started on POD 30 for the resistant chylothorax. The drainage immediately decreased without any side effects, and etilefrine was discontinued on POD 71.

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