Purpose: We assessed the surgical outcomes and prognostic factors of colorectal cancer (CRC) cases with peritoneal carcinomatosis who underwent primary tumor resection (PTR). Materials and Methods: Patients with colorectal adenocarcinoma who underwent treatment at our department between 2000 and 2010 were reviewed. Result: Of 1,484 patients with CRC, 77 patients (5.2%) presented with peritoneal carcinomatosis. 74 patients of CRC patients with peritoneal carcinomatosis underwent PTR, and curativity B resection (Cur B: without macroscopic residual tumor) was performed in 12 patients. Of 65 CRC patients with peritoneal carcinomatosis who underwent curativity C resection (Cur C: with macroscopic residual tumors), the overall survival rate was significantly higher in 62 patients with PTR than three patients without PTR. Of 74 patients with peritoneal carcinomatosis who underwent PTR, 32 patients were categorized as P1, 17 patients as P2, and 25 patients as P3. The 3-year overall survival rate (median survival time) of the patients with P1, P2 and P3 was 34.4% (20.2 months), 41.2% (24.7 months) and 8.0 % (14.8 months), respectively. The survival rate was significantly lower in P3 patients than in P1 patients and in P2 patients (P=0.008, P=0.008). Multivariate analysis showed that histological type (poorly differentiated adenocarcinoma, mucinous carcinoma and signet-ring cell carcinoma), P3 and Cur C were significant prognostic factors affecting overall survival (P<0.001, P=0.015, P=0.002). Conclusion: This study suggests that the complete curative resection of primary tumor and peritoneal carcinomatosis could improve outcomes in patients with colorectal cancer with peritoneal carcinomatosis.

Pancreatic cancer remains one of the representative solid cancers which have dismal outcome. Neoadjuvant therapy has received attention as one of the possible breakthrough methods because the limit of extensive surgery has been reported and effective chemotherapy has been introduced clinically for pancreatic cancer. To establish the standard neoadjuvant therapy, the safety, acceptability and effectiveness need to be proven through clinical trials. The resectability classification of pancreatic cancer has been proposed in the General Rules of Pancreatic Cancer 7th edition issued by the Japan Pancreatic Society. The treatment strategies should be planned following the new resectability classification. In this article, clinical guidelines of pancreatic cancer in the United States, Europe and Japan have been summarized and large cohort studies, phase I, II trials and meta-analyses have been reviewed concerning neoadjuvant therapy for pancreatic cancer.

The patient was a 67-year-old woman. She was given a diagnosis of systemic lupus erythematous (SLE) 4 years previously and treated by steroids. The amount of steroids could be tapered, and no internal organ disease was present. However, the difficulty with swallowing increased gradually, and esophageal achalasia was diagnosed. We performed laparoscopic Heller-Dor procedure. Mucosal injury occurred presumably due to prolonged steroid use, but the postoperative course was uneventful. Here, we report a rare case of concomitant esophageal achalasia and SLE.

The patient was a 63-year-old man who had undergone laparoscopic distal gastrectomy (LDG) for early gastric cancer and a gastrointestinal stromal tumor (GIST). An abdominopelvic CT scan performed during an annual medical checkup revealed a weakly enhanced solid tumor, measuring 26 mm in diameter, at the site of the anastomosis produced during the LDG. The tumor had grown to 35 mm in diameter by 18 months after the LDG. As we suspected locoregional recurrence of the gastric cancer or GIST, we decided to surgically resect the tumor. Partial resection of the remnant stomach and re-anastomosis using the Roux-en-Y procedure were performed laparoscopically. A histological examination of the tumor showed proliferating spindle cells with collagen fibers, and immunohistochemistry detected positivity for β-catenin and α-smooth muscle actin. These findings were compatible with a desmoid tumor. The patient remains well at 24 months after the second surgical procedure and has not suffered any recurrence of gastric cancer, GIST, or desmoid tumor. Surgical trauma was reported to be an important etiological factor for desmoid tumors. In our case, laparoscopic partial resection of the remnant stomach was carried out successfully and safely, even after LDG.

We report a case of early gastric cancer with a portosystemic shunt. A 59-year-old man was given a diagnosis of early gastric cancer by an upper gastrointestinal endoscopy and referred to our hospital for surgery. A preoperative blood test showed no abnormalities in the hepatic function, but the serum ammonia level was slightly elevated and abdominal enhanced CT revealed a shunt blood vessel from the left gastric vein to the left renal vein. The patient was a social drinker and had no history of liver disease. A laparoscopic distal gastrectomy was performed for early gastric cancer and the left gastric vein as the shunt vessel was cut off during the nodal dissection at the upper level of the pancreas. After surgery, the serum ammonia level became normal and the patient’s irritability, which was attributed to his character before surgery, improved. As the symptoms of hepatic encephalopathy are diverse, sometimes diagnoses are difficult. In addition, a portosystemic shunt may cause hyperammonemia in patients without a history of liver disease. Even in extremely rare vascular patterns, such as in this case, it is possible to perform laparoscopic surgery successfully by simulation using preoperative CT-angiography.

A 16-year-old girl consulted her local physician for newly-appearing abdominal pain and pre-existing unrelenting fever. A tumor was pointed out in her liver on abdominal screening CT scan and she was referred to our hospital for further evaluation and treatment. Her laboratory work-up was unremarkable, including no elevation of CEA, AFP and PIVKA-II levels. Upper gastrointestinal endoscopy and pancolonoscopy revealed no abnormal findings. On abdominal US, a hyperechoic lesion, about 60×55 mm, partially cystic and locally indented, was detected between segments 4 and 8 of the liver. Heterogeneous enhancement was detected on contrast CT scan and the enhancement gradually intensified during the arterial phase, partially washed out in the portal phase and faded out in the equilibrium phase. On dynamic MRI as well, heterogeneous intensity was detected during the arterial phase and no signal intensity was detected in the hepatocellular phase. Intense tumor stain was observed on hepatic arteriography. The tumor was resected and diagnosed as a liver carcinoid by immunohistochemical pathology. Four years have passed from surgery without the occurrence of carcinoid tumors in other organs and her tumor was diagnosed as primary onset in the liver.

A 60-year-old man was referred to our department with a complaint of right hypochondralgia. CT showed a huge hepatic cell carcinoma (HCC), 14 cm in diameter, in S6 and multiple small nodules in both lobes, and the portal bifurcation was not identified at the hepatic hilum. After the ramifications of the right branches of the portal vein, the portal vein formed an arch and extended from the right lobe to the left lobe, connecting to the umbilical portion. This anomaly is called absence of portal bifurcation. This anomaly is important when surgeons perform right hepatectomy because ligation of the right main portal vein may cause complete loss of portal blood flow to the left lobe, which may result in a fatal outcome. We performed S6 partial resection for the purpose of mass reduction after TAE. This anomaly shows a normal appearance and is difficult to diagnose without intraoperative ultrasonography (IOUS) intraoperatively. This anomaly must be diagnosed before operation and can be visualized by preoperative 3D reconstruction of the portal system.

A 68-year-old man was admitted to our hospital with a diagnosis of resectable perihilar cholangiocarcinoma. In a preoperative indocyanine green (ICG) test, the ICG retention rate at 15 minutes (ICG R15) was more than 100%. Despite this finding, Child-Pugh classification and 99m-Tc-galactosyl-human serum albumin (GSA) liver scintigraphy did not show any abnormal findings and there was no background disease. Thus, we diagnosed constitutional ICG excretory defect and decided to perform radical surgery. We performed right hemihepatectomy extending to segment 1, extrahepatic bile duct resection and portal vein resection, and there were no postoperative complications. For patients requiring hepatectomy with this disease, it was concluded that the indications for surgery and the surgical procedure should be considered comprehensively, based on findings of liver function tests other than the ICG test, such as a general liver function test and GSA liver scintigraphy.

A 35-year-old woman consulted a doctor at a nearby medical clinic with fever, abdominal pain and diarrhea. Abdominal CT scan and MRI demonstrated a 10-cm cystic lesion with air density in the left subphrenic space, and we treated by percutaneous drainage. Content was mucinous fluid and cytodiagnosis revealed class IIIa. This case was diagnosed as infection of a mucinous cystic neoplasm (MCN). We performed distal pancreatectomy and partial resection of the transverse colon. The resected cystic tumor contained mucinous fluid, and formed a fistula into the colon. The histopathological diagnosis was MCN with low-grade dysplasia. MCN is a relatively rare disease, and there is no other report of MCN with a colonic fistula formation. We present a case of MCN with a fistula into the transverse colon treated by distal pancreatectomy and partial resection of the transverse colon.

The patient was a 74-year-old woman who was examined in our hospital because of a chief complaint of abdominal pain. We made a diagnosis of right-sided strangulated femoral hernia and performed emergency surgery. Diagnostic laparoscopy revealed small bowel perforation as a result of Richter-type strangulation of the small bowel. The hernia sac was reflected and ligated, and we only performed small bowel resection through a minilaparotomy. The patient was temporarily discharged on postoperative day 7, and 30 days after the first-stage operation we repaired the hernia in the second stage by the transabdominal preperitoneal (TAPP) method. When mesh repair is used to treat cases of strangulated inguinal hernia associated with severe intraperitoneal contamination, there is concern about infection, and tissue suturing has been performed in the past. However, in view of the fact that, in addition to the small bowel perforation, the patient was taking an anticoagulant drug and that tissue suturing is followed by a higher rate of recurrence and chronic pain than the mesh method, we performed TAPP method in a 2-stage procedure. Because 2-stage laparoscopic hernia repair appeared to be a possible option for the treatment of strangulated inguinal hernias, we report this case.