Purpose: Recent advances in CT have resulted in an increasing number of patients with portal venous gas and/or intestinal pneumatosis being treated conservatively. However, in clinical practice, it is often difficult to determine whether surgery is appropriate. This retrospective study was performed to identify predictive factors for surgical indications in patients with portal venous gas and intestinal pneumatosis. Materials and Methods: The subjects were 26 patients diagnosed with portal venous gas and/or intestinal pneumatosis between 2002 and 2022. Clinical findings, including neutrophil-to-lymphocyte ratio and pan-immune-inflammatory value (PIV), were compared between two groups according to their indications for surgery. Results: Compared with the group without an indication for intestinal resection, CT showed that patients with indications for intestinal resection had a high level of peritoneal irritation and high attenuation of the intestinal wall. However, CT showed no significant differences in ascites and intraperitoneal air between the groups. Preoperative white blood cell count, C-reactive protein, creatine kinase and neutrophil-to-lymphocyte ratio were not associated with an indication for intestinal resection. However, higher PIV and serum lactate were associated with this indication. Receiver operating characteristic curve analysis showed that the optimal cut-off values for PIV and serum lactate were 373 (area under the curve, 0.75; sensitivity, 58.3%; specificity, 92.9%) and 1.9 mmol/l (area under the curve, 0.82; sensitivity, 90.9%; specificity, 58.3%), respectively. Conclusion: PIV and serum lactate could help to determine the surgical indication for portal venous gas and intestinal pneumatosis.

Purpose: The aim of the study was to examine actual practice for patients with stage IV colorectal cancer and to investigate the clinical validity of the subclassifications of M factor in the 9th edition of the Japanese Classification of Colorectal Carcinoma from the perspective of prognosis prediction. Materials and Methods: The subjects were consecutive patients diagnosed with stage IV colorectal cancer between 2008 and 2015 at all designated cancer hospitals in Fukushima prefecture, Japan. Patients with unknown outcomes and untraceable cases were excluded. Result: A total of 1,187 patients were enrolled in the study. The median observation period was 18.6 months [interquartile range: 7.5–32.9] and 878 (73.9%) patients had a fatal event. The percentage of metastatic sites was 69.0% for liver, 26.0% for lung, 28.7% for peritoneal dissemination, 24.4% for extra-regional lymph nodes, and 7.8% for other sites. Patients underwent primary tumor resection in 67.3% of cases, distant lesion resection in 18.5%, chemotherapy in 56.4%, and best supportive care in 15.7%. The median overall survival for cases with M classification M1a, M1b, M1c1 and M1c2 was 25.0, 19.6, 21.3 and 12.1 months, respectively. Conclusion: A prefecture-based cohort study showed the descriptive statistics and prognosis of patients with stage IV colorectal cancer. The M subclassification was found to have a certain validity to predict prognosis.

A constitutional indocyanine green (ICG) excretory defect is a rare liver disease, in which histopathological findings indicate no obvious abnormality in the liver; however, excretion of ICG is severely impaired. A 57-year-old man was referred to our department for surgical treatment of advanced esophageal cancer with mediastinal lymph node metastasis. A pretreatment ICG test revealed an abnormally high ICG retention rate of 72.1% at 15 min. ^99m-Tc-galactosyl-human serum albumin liver scintigraphy also indicated decreased liver reserve. Conversely, a blood test indicated Grade A in the Child-Pugh classification. The patient was treated with three courses of docetaxel, cisplatin, and 5-fluorouracil as preoperative chemotherapy with appropriate dose adjustment. Liver biopsy performed after the chemotherapy led to histopathological diagnosis of a constitutional ICG excretory defect with no obvious hepatitis or liver fibrosis. We selected radical surgery, and performed robot-assisted thoracoscopic esophagectomy with mediastinal lymph node dissection and thoracic duct preservation, and posterior mediastinal route gastric conduit reconstruction. Intraoperative morphological findings revealed an almost normal liver. No serious chemotherapy-induced adverse events or postoperative complications were observed. We report this rare case as an example of successful treatment of advanced esophageal cancer with a constitutional ICG excretory defect using multidisciplinary radical therapy.

A 72-year-old male was receiving follow-up of an intraductal papillary mucinous neoplasm. Abdominal CT showed a space-occupying lesion on the liver at S4, and findings similar to hepatocellular carcinoma were identified on EOB-MRI. The patient was diagnosed with hepatocellular carcinoma based on increases in serum AFP and PIVKA-II, and underwent partial liver resection of S4. Pathological findings revealed mainly adenocarcinoma, but diagnosis of intrahepatic cholangiocarcinoma, rather than hepatocellular carcinoma, was made by immunostaining. Five months after surgery, serum AFP and PIVKA-II increased again. Upper endoscopy detected a Borrmann type 1 tumor on the lesser curvature of the stomach, and a biopsy revealed adenocarcinoma. Laparoscopic distal gastrectomy was performed due to suspected gastric cancer or intrahepatic cholangiocarcinoma with gastric metastasis. Pathological findings showed adenocarcinoma similar to hepatectomy specimens, and severe venous invasion was observed. A definitive diagnosis of AFP-producing gastric cancer with liver metastasis was made because immunostaining with an anti-AFP antibody was positive for the liver and stomach. To the best of our knowledge, this is the first report of a metastatic tumor that grew and was removed prior to a primary tumor.

We report a case of long-term survival following resection of lung metastasis subsequent to curative surgery for pancreatic cancer. A 71-year-old man was diagnosed with pancreatic cancer during follow-up of an intraductal papillary mucinous neoplasm of the pancreas. He underwent subtotal stomach-preserving pancreaticoduodenectomy. The histological diagnosis was moderately to highly differentiated adenocarcinoma, pT3N1aM0 pStage IIB according to the 7th edition of the General Rules for the Study of Pancreatic Cancer. Postoperative adjuvant chemotherapy with gemcitabine was administered for one year. Twenty-one months later, a CT scan revealed a nodule in the right upper lobe of the lung. The patient underwent resection of the right upper lobe based on suspected lung metastasis or primary lung cancer. The histological diagnosis was pulmonary metastasis from pancreatic cancer. Ten years after pancreatectomy and 8 years after pneumonectomy, the patient remains alive without recurrence. Previous reports suggest the possibility that resection of postoperative lung oligometastasis from pancreatic cancer can extend survival, depending on appropriate case selection. There is an increasing number of reports of long-term survival after resection of postoperative lung metastasis from pancreatic cancer, and cure is also increasingly likely in these cases.

A 64-year-old woman was referred to our hospital after detection of a pancreatic tumor on abdominal US. Abdominal enhanced CT showed a hypervascular tumor in the pancreatic head. The densities of the pancreatic body and tail and surrounding fatty tissue were similar, making the border between the pancreas and fatty tissue indistinct. Endoscopic ultrasound-guided fine-needle aspiration revealed a Grade 1, well-differentiated, pancreatic, neuroendocrine tumor (NET G1). Given that the tumor was confined to the pancreas, subtotal stomach-preserving pancreaticoduodenectomy was performed. It proved possible to separate the pancreatic body and tail from the surrounding tissue despite its similarity to this tissue. The pancreas was resected at the level of the superior mesenteric vein. Histopathological examination of an intraoperative frozen section of the pancreatic stump revealed only islets of Langerhans. In the absence of exocrine glands and the main pancreatic duct, pancreaticojejunostomy was not performed. The patient did not develop a pancreatic fistula postoperatively and blood glucose control was relatively good. The main tumor was a NET G1, and another NET G1 tumor was identified separately by pathological examination. The exocrine glands of the pancreatic body and tail had been completely replaced by fatty tissue with preservation of the islets of Langerhans. In this case, pancreaticoduodenectomy without pancreaticojejunostomy achieved favorable glucose control by preserving the islets of Langerhans in the remnant pancreas.

A 56-year-old man presented to his primary care physician with abdominal pain and vomiting. These symptoms were temporarily improved by analgesics; however, the abdominal pain worsened on the next day and he was referred to our hospital. An abdominal X-ray showed a dilated small intestine and CT showed herniation of the small intestine on the left dorsal side of the mesentery of the sigmoid colon. These findings led to diagnosis of intersigmoid hernia. Elective laparoscopic surgery was performed after decompression using a long tube. Intraoperative findings showed the small intestine herniated into the dorsal recessus of the mesentery of the sigmoid colon. Incarceration of the small intestine was resolved by retraction. The hernia orifice was 2 cm in diameter, and we dissected the fusion fascia of the mesentery of the sigmoid colon to open the orifice. An intersigmoid hernia is relatively uncommon, and thus, we report this case as a rare example of diagnosis of intersigmoid hernia using CT and treatment by laparoscopic surgery.