Very few studies have focused on laparoscopic caudate lobectomy. We report a case of hepatocellular carcinoma in the caudate lobe that was resected by laparoscopic caudate lobectomy using a transhepatic approach. A 60-year-old man with a history of chronic hepatitis B was referred to our hospital for evaluation. Angio CT revealed a 2.7×2.5 cm tumor in the paracaval portion of the caudate lobe. Clinical and image findings led to a diagnosis of hepatocellular carcinoma. Laparoscopic caudate lobectomy using a transhepatic approach was performed. Laparoscopic surgery was performed in the left lateral decubitus position and six trocars were inserted. After mobilization of left and right lobes of the liver, short hepatic veins and inferior right hepatic vein were resected. First, liver resection was performed along the Cantlie line, exposing the right and dorsal side of the middle hepatic vein. Then, liver resection was performed toward the Arantius duct. Second, liver resection was performed, exposing the left and dorsal side of the right hepatic vein. Glisson’s sheaths of the caudate lobe were resected at the porta hepatis. Third, liver resection was performed along the demarcation line at the right edge of the caudate lobe. Finally, hepatocytes between the paracaval portion of the caudate lobe and posterior segment of the right lobe were resected, and the specimen was resected. We selected laparoscopic surgery, because it is possible to perform sophisticated procedures due to the enlarged view.

Large cell neuroendocrine carcinoma (LCNEC) is a highly aggressive type of malignancy and is very rare in the digestive tract. We report a case of LCNEC coexisting with adenocarcinoma in the extrahepatic bile duct. A 76-year-old woman with epigastric discomfort complained of tumor in her porta hepatis and dilatation of the intrahepatic bile duct in the hepatic left and caudate lobe. We diagnosed intrahepatic cholangiocarcinoma and performed extended left hepatectomy. The tumor generated from the extrahepatic bile duct and grew up into the porta hepatis. In the extrahepatic bile duct, moderately to poorly adenocarcinoma was observed, meanwhile sheets of large cells with mainly oval nuclear composed were mostly recognized in intrahepatic nodules immunohistochemically, while the tumor coexisted mainly of LCNEC together with adenocarcinoma.

A 63-year-old man underwent left hepatectomy for a mass forming type of intrahepatic cholangiocarcinoma (ICC) without lymph node metastasis. He received adjuvant chemotherapy with S-1 for a year. After three years of hepatectomy, abdominal lymphadenectomy of stations No. 1, 3 and 7–9 were performed for lymph node metastases. Histopathological features of the lymph node specimens were similar to that of the previous ICC lesion. He was then treated with adjuvant gemcitabine therapy for 8 months. After 6 years of hepatectomy, a solitary node in segment 8 of the right lung was resected under video-assisted thoracic surgery. Histopathological findings of the resected lung nodule were compatible with metastatic ICC. He remains alive and disease-free at 8 years after initial surgery. The role of surgery for recurrent extrahepatic metastases from ICC has not yet been established. We herein report this rare case demonstrating that long-term survival could be achieved with repeated resections followed by adjuvant chemotherapy for extrahepatic metastases from ICC.

We report a case of gastric-type intraductal papillary-mucinous neoplasm (IPMN) of the pancreas protruding into the main pancreatic duct with scant mucin secretion which was indistinguishable from intraductal tubulopapillary neoplasm (ITPN) preoperatively. A 71-year-old woman was referred to our hospital following acute pancreatitis for evaluation of an intraductal tumor of the pancreas arising in the main pancreatic duct (MPD). Although the tumor was shown as a filling defect in the MPD with a dilatation of the MPD in the body and tail of the pancreas on MRCP and ERCP, no secreted mucin was visible on ERCP. A Whipple pancreaticoduodenectomy with a regional lymph node dissection was performed with preoperative diagnosis of IPMN or ITPN. Gross inspection of the resected specimen revealed a 15-mm pedunculated tumor arising at the MPD without visible mucin. Histologic examination revealed that the tumor was composed of closely-packed tubular glands, similar to the pyloric gland of the stomach with minimal cytologic atypia and a small amount of mucin was found in the tumor gland microscopically. In the pancreatic duct adjacent to the tumor, small papillary projections were shown. After confirming the diagnosis of gastric-type IPMN with low-grade dysplasia, she was given no adjuvant chemotherapy and remains well with no evidence of the disease 48 months after resection.

A 47-year-old man was admitted to our hospital due to an acute exacerbation of alcoholic chronic pancreatitis with duodenal stenosis. He recovered with conservative treatment and was discharged. After the hospitalization, he could not stop drinking and needed rehospitalization for recurrent pancreatitis. ERCP showed stenosis of the distal common bile duct and CT revealed left pleural effusion. We diagnosed pancreatic pleural effusion caused by pancreaticopleural fistula, and a thoracic drainage tube was inserted. It was impossible to perform endoscopic pancreatic duct drainage, and common bile duct stenosis and pleural effusion did not improve, so we planned to perform surgery. For chronic pancreatitis and common bile duct stenosis, we performed subtotal stomach-preserving pancreaticoduodenectomy (SSPPD). During the operation, the pancreaticopleural fistula was grossly invisible, but we were able to detect and ligate the fistula by injection of contrast medium and indigo carmine into the cut end of the residual pancreas. For surgery of chronic pancreatitis, it is important to balance curability and functional preservation. We report a case in which intraoperative injection of contrast medium and indigo carmine were useful for ligation of fistula and preservation of residual pancreas.

Littoral cell angioma (LCA) is a rare benign splenic tumor with typical histomorphologic features, which is difficult to be distinguished preoperatively from other splenic tumors. A 68-year-old female patient was admitted to our hospital with an abdominal pain and remarkable anemia. An enhanced CT scan showed splenomegaly and ascites with multiple low density lesions in liver. We diagnosed as rupture of spleen and the patient underwent a splenectomy that revealed LCA by pathological evaluation. LCA can have risk of splenic rupture and malignant potential. It was suggested that early surgical resection is important for LCA.

A 42-year-old man with progressive descending colon cancer underwent laparoscopy-assisted left hemicolectomy. The histopathological diagnosis was moderately differentiated tubular adenocarcinoma, pSE, ly1, v0, pN2, H0, P0, M0, stage IIIb. Adjuvant chemotherapy was not carried out on the patient intentionally. The abdominal CT 2 years after surgery showed a soft tissue shadow on the dorsal side of the pancreas and a tumor embolism in the splenic vein. Eighteen FDG-PET-CT also revealed increased FDG accumulation with the tumor. Recurrence of the colorectal cancer or primary pancreatic cancer was suspected, and a distal pancreatectomy was undergone. The portal vein and the duodenum with the tumor invasion were also excised. The tumor was moderately differentiated adenocarcinoma and was similar to the primary colon cancer. We report a rare case of a portal vein tumor thrombosis from the direct invasion to the splenic vein from the local recurrence.

A 58-year-old man with active-phase ulcerative colitis undergoing treatment with aminosalicylate, steroid, immunomodulator, infliximab, and blood component removal therapy, suffered from rectal perforation and generalized peritonitis despite treatment. We performed an emergency operation and rectal perforation was found at the anterior wall of the upper rectal region. Therefore, Hartmann operation was performed. Pathological examination of the resected specimen revealed atypical lymphocyte infiltration and fibrosis in all layers of the rectal wall. Combined with immunohistochemical studies, diffused large B-cell lymphoma was diagnosed. Because significant pathological findings of the active ulcerative colitis were not detected in the resected specimen, it was suggested that rectal perforation was related to the malignant lymphoma. Malignant lymphoma concomitant with ulcerative colitis is rare and it has been reported that Epstein-Barr virus infection, which is induced in an immunosuppressive status by immunomodulator for the treatment of ulcerative colitis, is related to the progression of malignant lymphoma. In our case, Epstein-Barr virus infection was found in the lesion, which might affect the etiology.

Clinical course and prognosis of 17 patients aged under 30 years old with abdominoperineal resection (APR) for severe anorectal Crohn disease were reported. Anorectal complications were anorectal stenosis (n=12), complex perianal fistula (n=9), rectal fistula (n=4), rectovaginal fistula (n=2), pelvic abscess (n=2), rectourethral fistula (n=1), perirectal abscess (n=1), aggressive ulceration (n=1), anal fistulous cancer (n=1). These complications had a deleterious effect on daily life and restricted social activity of all patients. Following APR, their symptoms caused by anorectal Crohn disease were improved and 15 patients (88%) had work or went to school. Post-operative complications occurred in 14 patients (82%), such as stoma-related complications (n=8), surgical site infection (n=5), delayed perineal wound healing (n=3), sexual dysfunction (n=2), adhesive intestinal obstruction (n=2). APR for severe anorectal Crohn disease is effective in terms of improving the symptoms and offering relatively good social life, irrespective of some post-operative complication. APR should be considered for severe anorectal Crohn disease, even in younger patients.