Purpose: Combined resection of the caudate lobe of the liver is necessary to achieve curative resection for perihilar cholangiocarcinoma (PHCC). However, the location of the right boundary of the caudate lobe, which should be removed in the left-sided hepatectomy for PHCC, is still controversial. The aim of this study was to investigate the configuration of the portal and biliary branches in the dorsal sector using preoperative multidetector CT (MDCT) images in patients with PHCC and to clarify the optimal extent of the caudate lobe in the resection for PHCC. Methods: Between January 2008 and May 2012, 110 consecutive patients with PHCC underwent preoperative MDCT. The regions of the dorsal sector were classified as l-, b-, c-, d- and cp-region, according to the areas supplied by portal branches of the dorsal sector proposed by Couinaud, namely l, b, c, d and cp veins. The number and the ramification patterns of the portal (P-l, P-b, P-c, P-d, P-cp) and biliary (B-l, B-b, B-c, B-d, B-cp) branches in each region were investigated. Results: Eighty-five percent of P-d and 91% of B-d diverged from the anterior or posterior trunk, while 91% of P-c and 96% of B-c were from the left or right portal vein/hepatic duct. Ninety-eight percent of P-b and all of P-cp and P-l diverged from the first bifurcated branches. In addition, 92% of B-cp and all of B-b and B-l converged to the first bifurcated branches. Moreover, 61% of B-c and 35% of B-cp converged around the bifurcation of the anterior and posterior trunk. Conclusion: The boundary between c- and d-regions in the dorsal sector closely corresponds to the right margin of the caudate lobe, which was shifted to the d-region in 5–10% of cases. In left-sided hepatectomy with caudate lobectomy for PHCC, complete resection of the c-region and clearance of the confluence of the posterior/anterior bifurcation should be performed, while in cases in which the right margin shifted to the d-region, removal of the d-region should be considered.

A 69-year-old woman was admitted to our department because of a liver tumor. CT angiography revealed a single liver tumor at the S6 region 35 mm in diameter. The tumor was stained in the arterial phase but was not stained in the portal phase. The patient was given a diagnosis of metachronous liver metastasis from rectal cancer due to imaging findings and history of rectal cancer. Laparoscopic partial liver resection of S6 was performed. Immuno­histochemically, the tumor cells were positive for synaptophysin, chromogranin A and CD56. MIB-1 labeling index was over 90 percent. The final diagnosis was primary hepatic neuroendocrine carcinoma. The patient suffered from lung and remnant liver recurrence during the early postoperative period. In spite of sequential chemotherapy, she died 19 months after surgery. Primary hepatic neuroendocrine carcinoma is extremely rare, and has a poor prognosis.

A 71-year-old woman was admitted to our hospital because of a work-up for severe anemia. She was found to have advanced transverse colon cancer and 2 lesions of liver metastases in segments 5 and 8, respectively. At this point, unawareness of the right-sided ligamentum teres (RSLT) in this patient misled us into thinking that a central bisegmentectomy would be required to eradicate the liver tumors. Thus the left hemicolectomy was preceded, as the simultaneous colon and major liver resections were considered to be highly invasive. Five months later, we planned hepatectomy following six courses of chemotherapy. The 3-dimensional CT (3D-CT) analysis and simulation before hepatectomy revealed that the ligamentum teres was located in the right side of the Rex-Cantlie line, establishing the diagnosis of RSLT along with the portal vein anomalies. R0 resection was achieved by parenchymal-preserving hepatectomy with anatomical resection of the dorsal area of the right paramedian sector in accordance with preoperative 3D-CT simulation. She is doing well without recurrence 3 years after the first operation. Because RSLT frequently accompanies the portal system anomalies, it is of great importance for surgeons to first be aware of the presence of this anomaly before surgery and to make a careful resection plan using 3D-CT simulation for safe anatomical liver resections in patients with RSLT.

A 73-year-old man was found to have gallbladder enlargement by abdominal ultrasound examination. CT and MRI showed a perihilar bile duct tumor as a wall thickening with contrast effect. The patient was diagnosed as a perihilar bile duct cancer. Left hepatic lobe and caudate lobe resection, subtotal stomach preserving pancreatoduodenectomy, and portal vein resection was performed. Histopathological examination revealed the keratinocytes tendency of the tumor. Immunohistochemical examination of the resected specimen revealed the expression of CK5/6 and p63 as a squamous epithelial marker. In addition, the component of adenocarcinoma could not confirm in this tumor. Therefore, the tumor was finally diagnosed as a squamous cell carcinoma of the perihilar bile duct. The patient is alive without recurrence for 45 months after surgery.

A 64-year-old man was admitted for epigastralgia. Abdominal CT showed an enhanced tumor at the lower biliary duct causing obstructive jaundice. Tumor cells with high nuclear-cytoplasmic (N/C) ratio and rosette formation were confirmed by biopsy. Immunostaining findings were positive for chromogranin A，synaptophysin, and neuron specific enolase. Preoperatively, we suspected neuroendocrine carcinoma (NEC) of the bile duct, and performed subtotal stomach-preserving pancreatoduodenectomy. Histological examination of the specimen demonstrated large cell NEC of the bile duct. The Ki-67 index was 40%. As adjuvant chemotherapy, tegafur-gimeracil-oteracil potassium was administered for 24 months, and he has no evidence of recurrence after surgery. NEC of the bile duct are rare and highly malignant diseases with a dismal prognosis. To the best of our knowledge, 50 cases of biliary NEC have been reported in Japan, and only 6 cases of biliary large cell NEC have been reported in the English literature. Analysis of reported cases indicates that curative resection can improve survival rate among patients with biliary NEC. Further evaluation is needed to elucidate optimal adjuvant therapy for biliary NEC.

A 71-year-woman was admitted to our hospital because of jaundice. Abdominal US and contrast-enhanced CT suggested a distal bile duct tumor. Blushing cytology of the bile duct revealed Group V, adenocarcinoma. Pancreaticoduodenectomy with regional lymph node dissection was performed. Pathological examination indicated the presence of both neuroendocrine carcinoma (NEC) and poorly-differentiated tubular adenocarcinoma components in the mass, which was finally diagnosed as mixed adenoneuroendocrine carcinoma (MANEC). CDDP and CPT-11 was started postoperatively according to the standard regimen for the NEC. Ten months after the operation, as CT depicted multiple liver metastases, chemotherapy was changed to gemcitabine and CDDP. The patient is still alive at 13 months after operation. According to previous reports, MANEC of the distal bile duct shows an enormously poor prognosis. Although the treatment algorithm of MANEC has not yet been established, the present case suggests that MANEC could be managed in accordance with the histology of the neuroendocrine component.

We report a case of delayed massive hemorrhage from the common hepatic artery (CHA) that was successfully treated after pancreatoduodenectomy (PD) with arterioportal shunting to compensate for the sacrificed arterial flow to the liver secondary to the ligation of CHA. The choledocho-jejunostomy was performed to expose the operative field, which was reconstructed electively with intrahepatic biliary-jejunostomy. A 76-year-old man with a diagnosis of middle bile duct cancer underwent subtotal stomach preserving pancreatoduodenectomy. The procedure was complicated with pancreatic fistula and intra-abdominal infections. Subsequently the patient underwent surgery for an emergent exploratory laparotomy for massive intra-abdominal bleeding 17 days after surgery. The bleeding was from behind the choledocho-jejunostomy, which was removed to identify the bleeding point. The bleeding was from CHA, which did not look feasible to reconstruct because of the fragility of the arterial wall. Therefore, CHA was ligated and ileocolic arteriovenous shunting was performed in order to improve oxygenation of the liver via the portal vein. We chose not to undergo reconstruction of the choledocho-jejunostomy during the emergent operation. Eight months after the primary surgery, intrahepatic biliary-jejunostomy was successfully performed with Longmire’s method attempting to avoid adhesiolysis. He is alive at 24 months after the primary operation without recurrence.

We report a case of giant splenic hamartoma combined with thrombocytopenia. The patient was a 39-year-old man in whom thrombocytopenia was detected during an annual health check, which resulted in him being referred to our hospital. Abdominal US revealed a 10-cm hypoechoic splenic tumor that displayed internal blood flow. Enhanced CT showed a relatively well-defined circular splenic mass. MRI showed that the splenic tumor exhibited the same intensity as the normal splenic parenchyma on T1-weighted images, and the same to high signal intensity on T2-weighted images. ¹⁸F-FDG-PET/CT revealed a quite strong FDG accumulation (SUVmax=3.0) in the splenic tumor. We performed splenectomy due to the possibility of a malignant tumor, thrombocytopenia related to splenic hyperactivity, and the risk of rupture. No infiltration into the surrounding splenic tissue was observed during an intraoperative examination. The tumor was pathologically diagnosed as a hamartoma since immunohistochemical staining showed that CD8+ cells and CD34+ cells were equally distributed throughout the tumor. The patient’s platelet count normalized after the operation.

A 74-year-old woman had an intensive examination at a local hospital for lumbago. Multiple lesions were detected in the spleen on CT. Gastrointestinal endoscopy and total colonoscopy showed no abnormal findings, and PET-CT showed abnormal FDG-uptake only in the spleen. These findings were suggestive of malignant lymphoma and the patient was referred to our hospital for histological diagnosis. Laparoscopic splenectomy was performed. Histopathologically, it was characterized by a large number of noncaseating granulomas composed of epithelioid cells and multinucleated giant cells with asteroid bodies, and splenic sarcoidosis was diagnosed. The patient became disease-free but iridocyclitis occurred 3 months after surgery. We diagnosed the recurrence of the sarcoidosis. To the best of our knowledge, splenic sarcoidosis without extrasplenic lesions that recur in other organs postoperatively is rare. Therefore we report our experience with a review of the literature.

A 69-year-old man was seen at the hospital because of sudden onset abdominal pain. Enhanced abdominal CT revealed small bowel ischemia and superior mesenteric artery (SMA) obstruction. Abdominal angiography revealed SMA occlusion and spasm of the branching artery. Because of peritoneal irritation, emergency surgery was performed. We resected the necrotic bowel and performed primary anastomosis. During the operation, continuous intravenous high-dose prostaglandin E1 (PGE1) was started, after that, we treated with intra-arterial high-dose PGE1. Even for SMA obstruction, early administration of continuous intravenous high-dose PGE1 could contribute to improved survival by lowering the risk of the potential intestinal ischemia onset.

Internal hernias are rare causes of small bowel obstruction, and one such internal hernia is the paracecal hernia. We report a case of a small bowel obstruction related to a paracecal hernia. A 73-year-old woman was brought to our emergency department because of sudden onset lower abdominal pain, nausea and vomiting. The abdomen was distended diffusely and tender in the right lower quadrant. Laboratory data was normal. Abdominal CT showed a closed small bowel loop caudal and lateral to the cecum. Strangulation of the small bowel due to paracecal hernia was diagnosed clinically, and emergency laparoscopic surgery was performed. On exploring the abdominal cavity, a loop of distal ileum was found incarcerated in the paracolic sulci near the cecum and strangulated. After release of the 20-cm segment of viable ileum, the hernia sac was dissected and opened completely. The patient’s postoperative course was uneventful and she was discharged on postoperative day 10 without any complications.