Purpose: We investigated prognostic factors for patients with severe peritonitis who had undergone emergency digestive surgery and had been treated with polymyxin B immobilized fiber column direct hemoperfusion (PMX-DHP). Methods: Sixty-eight patients that had PMX-DHP over the past 8 years were enrolled in this study. The patients were divided into two groups: the survival group and the non-survival group. The patients’ backgrounds and other parameters were compared between the two groups and analyzed by univariate and multivariate analysis. Results: The univariate analysis revealed that age, catecholamine index (CAI), Cr, platelet counts (Plt), Glasgow Coma Scale (GCS), acidosis, Acute Physiology and Chronic Health Evaluation II (APACHE II) score, and Sequential Organ Failure Assessment (SOFA) score were important factors affecting prognosis. The multivariate analysis found that the SOFA score was the only isolated risk factor. Conclusion: There was a high mortality rate for patients with severe diffuse peritonitis, particularly those with high SOFA scores; the effectiveness of PMX-DHP was limited in these patients.

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Purpose: To elucidate the malignant potential of intraductal papillary mucinous neoplasms (IPMNs) and the biological behavior of minimally invasive carcinoma. Methods: Seventy patients with 71 IPMNs were operated on in our department. There were 46 benign IPMNs (intraductal papillary mucinous adenoma; IPMA, low and intermediate grade dysplasia) and 25 malignant IPMNs (intraductal papillary mucinous carcinoma; IPMC, high grade dysplasia and invasive carcinoma). We classified IPMNs by the diameter of the main pancreatic duct (MPD) and the depth of stromal invasion, evaluating them in terms of malignant potential and prognosis. Results: There were 16 IPMNs with an MPD diameter of ≥10 mm, 24 with an MPD diameter of 5–9 mm, and 31 had an MPD diameter of ≤5 mm. There were 7 IPMCs with an MPD diameter of ≥10 mm (malignant rate: 43.7%), those with an MPD diameter of 5–9 mm were 9 (37.5%), and those with an MPD diameter of ≤5 mm were 9 (29.0%). Among the malignant predictive factors examined, only the size of mural nodules was significant (P<0.05). Of the 25 IPMCs, there were 8 noninvasive IPMCs (high grade dysplasia), 7 T1a IPMCs (stromal invasion: ≤0.5 cm), 2 T1b IPMCs (>0.5 cm to ≤1.0 cm), 5 T1c IPMCs (>1 cm to ≤2 cm), and 3 T2 IPMCs (>2 cm). A total of 132 patients with pancreatic invasive ductal carcinoma (IDC) were operated on in our department from 1996. Compared with patients with IDC, patients with T1a or earlier IPMCs (5 year survival rate: 100%) showed significantly better prognosis than those with T1b or more advanced IPMCs (38.5%, P=0.013) and T1 IDC (41.6%, P=0.03). Conclusions: These results suggested that IPMNs with an MPD of ≥10 mm and/or the existence of the mural nodules were recommended for surgical resection. The patients with T1a or less IPMCs showed favorable prognosis, therefore they were suggested to be early cancers or early IPMCs.

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The treatment for anastomotic recurrence after total gastrectomy for gastric cancer is still controversial, because of its rareness. We report two cases of anastomotic recurrence after total gastrectomy for gastric cancer that were successfully reoperated after preoperative chemotherapy. The patient in case 1 was a 64-year-old man, and was found to have an anastomotic recurrence of gastric cancer 31 months after the total gastrectomy. After two courses of chemotherapy with S-1 and CDDP, lower esophago-jejunectomy including the recurrent site was performed. There was no tumor in the specimen, thus a pathologically diagnosis of complete response (CR) was made. He remains alive without recurrence seven months after the reoperation. The patient in case 2 was a 65-year-old man, and we also diagnosed anastomotic recurrence of gastric cancer 30 months after the total gastrectomy. He had twelve courses of chemotherapy with weekly paclitaxel. Because of no other recurrence after the chemotherapy, the patient underwent lower esophagojejunectomy including the recurrent site. He is still alive without recurrence three months after the reoperation.

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A 54-year-old woman was referred to our hospital for further examination of a hepatic mass detected on abdominal US. The blood test revealed a positive but mild inflammatory response. Hepatic virus markers were negative. Abdominal CT showed a fatty mass, 10 cm in diameter, in segments 7 and 8, containing hypervascular nodules showing early enhancement in the arterial phase and washout in the equilibrium phase. She presented with a high fever of over 39°C during a work-up period, and the blood test revealed a marked inflammatory response. Abdominal CT and MRI after developing fever indicated intratumoral hemorrhage. There was no other evidence of infection. We suspected hepatocellular carcinoma with intratumoral hemorrhage based on these imaging findings. Although we considered other benign tumors in the differential diagnosis, she underwent right hepatectomy because the tumor was symptomatic. Histologically, the tumor was composed of smooth muscle cells, vessels, and adipose cells with marked infiltration of inflammatory cells and bleeding. On immunohistochemical staining, the tumor was positive for human melanoma black-45. The tumor was diagnosed as inflammatory angiomyolipoma of the liver with intratumoral hemorrhage.

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We report a case of colorectal liver metastasis (CRLM) resected as a salvage operation after proton beam radiotherapy. A 62-year-old man underwent a low anterior resection and wedge resection of the liver for rectal cancer and synchronous CRLM in February, 2008, at another hospital. However, recurrence of CRLM occurred 11 months after surgery, and a tumor 4×3 cm in size was found in segment 7 of the liver. His first choice of treatment was ion beam radiotherapy. Therefore, proton beam radiotherapy (66 Gy/10 times/15 days) was performed and the tumor diminished temporarily. However, the tumor recurred in approximately the same site of the liver as tumor thrombi of the right branch of the portal vein and short hepatic vein. He was referred to our hospital, and a right hepatectomy with a wedge resection of the inferior vena cava was performed. In recent years, ion beam radiotherapy has become widespread in Japan because of its therapeutic effects. However in cases of CRLM, hepatectomy continues to be the basic method of treatment. To the best of our knowledge, there have been no reports of salvage operations after ion beam radiotherapy for CRLM, and we believe that our report could be useful in decision-making for therapy for CRLM.

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A 61-year-old woman with a 40 mm cystic lesion of the pancreatic body was kept under observation by a local physician. When follow-up imaging showed enlargement of the tumor, she was subsequently referred to our institution. We investigated by CT and discovered the tumor had grown to 130 mm. The same CT also revealed a small amount of blood accumulated in the Douglas pouch (recto-uterine pouch). We diagnosed the condition as ruptured mucinous cystoadenocarcinoma (MCC) of the pancreatic body with intra-abdominal bleeding and we opted to surgically remove the tumor. Intra-operatively, we visually confirmed the blood accumulation in the Douglas pouch. We also observed whitish nodules surrounding the tumor suggesting peritoneal dissemination. We resected the tumor en-bloc to halt the abdominal hemorrhaging. The resected organs were: the pancreatic tail and body, the spleen, the stomach, the left hepatic lobe, and part of the transverse colon. The pathology report confirmed the diagnosis of anaplastic carcinoma derived from mucinous cystadenocarcinoma with ovarian-like stroma. The whitish nodules were also confirmed as peritoneal dissemination. Her postoperative recovery was uneventful and the patient was discharged three weeks after the operation. However, liver metastasis and peritoneal dissemination advanced rapidly and the patient passed away 3 months after surgery. Previously, only two cases of ruptured MCC were reported in Japan; this case marks the third.

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We report a resected case of advanced pancreatic head cancer with para-aortic lymph node metastases after successful gemcitabine (GEM)+S-1 chemotherapy. A 66-year-old woman with back pain was found to have pan­creatic head cancer with para-aortic lymph node metastases, based on CT and FDG-PET. We gave 1,000 mg/body GEM on days 1 and 8, and S-1 was administered orally at 80 mg/day for two weeks, followed by a 1-week recovery period. After 3 cycles of chemotherapy, there was a notable reduction in para-aortic lymph node size, and FDG-PET showed a negative response. Thus, after the addition of 1 cycle of chemotherapy, we performed a pylorus-preserving pancreaticoduodenectomy with para-aortic lymph node dissection. Histologically, cancer cells in para-aortic lymph nodes were absent. We performed an R0 resection. Currently, at 13 months after surgery, the patient is in good health without recurrence. GEM+S-1 chemotherapy for unresectable pancreatic cancer is considered to be one of the options in cases that are expected to convert to the resection.

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Cases of portal annular pancreas treated by pancreatectomy are very rare. We report a surgical case of intraductal papillary mucinous carcinoma of the pancreas head and intraductal papillary mucinous adenoma of the pancreas tail with portal annular pancreas Type III a. A 72-year-old woman was admitted for treatment of intraductal papillary mucinous carcinoma of the pancreas head and intraductal papillary mucinous adenoma of the pancreas tail. Preoperative enhanced CT showed the uncinated process connecting with the pancreas body completely and surrounding the portal vein at the cranial side of the splenic vein. Middle-preserving pancreatectomy was performed. Anterior pancreas and posterior pancreas relative to the portal vein were cut separately. The main pancreatic duct was in the anterior pancreas, and Roux-en-Y reconstruction was performed. The incidence of portal annular pancreas is about 2%. However, to the best of our knowledge, only 20 cases of portal annular pancreas underwent pancreatectomy, including this case, have been reported. This suggests that the posterior pancreas tissue of the portal vein is ligated without being noticed in many cases, which may cause postoperative pancreatic fistula and subsequent surgical site infection. It is easy to diagnose the anomaly of portal annular pancreas by enhanced CT preoperatively. In cases of portal annular pancreas, it is necessary to diagnose the anomaly preoperatively and decide on the surgical procedure.

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We report two cases of delayed splenic rupture that were treated successfully by transcatheter arterial embolization (TAE), with a review of the literature. Case 1: A 35-year-old woman presented to our hospital with trauma to the left ‍side of the abdomen. Because CT on admission revealed splenic injury (Type IIIb according to the 2008 Classification of Splenic Injury of the Japanese Association for the Surgery of Trauma), she was treated with TAE. Six days after admission, she complained of acute abdominal pain. Based on abdominal CT findings of an enlarged spleen with fluid collection in the peritoneal cavity, delayed splenic rupture was subsequently diagnosed. Splenic arteriography demonstrated a pseudoaneurysm, and the middle pole branch of the splenic artery was occluded by micro coils. The patient recovered uneventfully and was discharged after 21 days. Case 2: A 34-year-old man injured his left lateral abdomen in an accident. He visited his primary care physician, 20 days after the event, because of acute abdominal pain. He was referred to our hospital for hypotension. CT on admission showed splenic injury (Type III b), and therefore, he underwent selective TAE. Delayed splenic rupture was diagnosed due to the length of time between his injury and the occurrence of symptoms. The patient recovered and was discharged after 5 days.

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Purpose: This study aimed to retrospectively evaluate the feasibility of early laparoscopic cholecystectomy for acute cholecystitis in patients receiving antithrombotic therapy. Methods: Between April 2011 and August 2014, 49 patients underwent early laparoscopic cholecystectomy for mild or moderate acute cholecystitis. Among these patients, 15 were receiving antithrombotic therapy, while the remaining 34 patients were not receiving antithrombotic therapy. We compared the clinical features and surgical outcomes of these two patient groups. Results: Patients receiving antithrombotic therapy were significantly older and had a longer prothrombin time; furthermore, a greater number of patients from this group had diabetes mellitus. Although antithrombotic therapy did not influence blood loss or bleeding complications, the postoperative duration of stay was longer. Conclusion: Laparoscopic cholecystectomy for acute cholecystitis in patients receiving antithrombotic therapy was performed without any particular issues. Although such cases are expected to further increase in the future, our results suggest that laparoscopic cholecystectomy can be safely performed by careful surgical procedures, even in emergency surgeries.

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