A 62-year-old man with positive secondary screening was diagnosed with unresectable advanced gastric cancer with a tumor thrombus in the superior mesenteric vein (SMV). A total of 10 courses of systemic chemotherapy were administered and the tumor thrombus was reduced, but still persisted. The patient was unable to continue chemotherapy due to adverse events and underwent conversion surgery of standard gastrectomy with removal of the tumor thrombus. In the surgery, an approach could be made from the SMV to the portal vein with preservation of the pancreas. The thrombus was sclerotic and adherent, so the SMV was resected and revascularized with a left femoral vein graft. Pathologically, the diagnosis was complete response and all tumor thrombi were fibrotic with no residual tumor. The postoperative course was good and the patient has survived without recurrence to date.

A 66-year-old male presented to a local clinic with chief complaints of melena and palpitations. Upper gastrointestinal endoscopy revealed a type 2 lesion in the duodenum, and he was referred to our department with a diagnosis of duodenal cancer. CT imaging indicated that the 12p lymph nodes were compressing the inferior vena cava and the portal vein, initially suggesting that curative resection was not feasible. To address the obstruction, gastrojejunostomy was performed. The patient then underwent three courses of chemotherapy with S-1 and CDDP, resulting in substantial shrinkage of the primary tumor and the involved lymph nodes. Four months after bypass surgery, pancreatoduodenectomy was performed with curative intent. Pathological examination of the resected specimen, including the 12p lymph nodes, revealed no residual malignancy, showing a pathological complete response (pCR). The achievement of pCR in this case illustrates the effectiveness of neoadjuvant chemotherapy and suggests that S-1/CDDP may be a useful preoperative option for advanced duodenal cancer with lymph node metastasis.

A 75-year-old woman was referred to our hospital due to an elevated CA19-9 level and a mass in the pancreatic head on abdominal ultrasonography. CT and MRI revealed a mass in the uncinate process of the pancreas, which exhibited gradual contrast enhancement and less than 180° contact with the superior mesenteric vein (SMV) just above the confluence of the gastrocolic trunk and the first jejunal vein. In addition, the pancreatic body and tail were absent at the left margin of the SMV. FDG-PET/CT showed nodular FDG uptake with a maximum standardized uptake value of 6.3. The patient was diagnosed with resectable pancreatic cancer of the uncinate process with congenital agenesis of the dorsal pancreas. After preoperative chemotherapy, she underwent total pancreatectomy, SMV resection, and regional lymph node dissection. A pathological examination confirmed invasive ductal adenocarcinoma (pT3N1M0). Considering the presence of the main and accessory pancreatic ducts and the absence of pancreatic fat replacement, congenital agenesis of the dorsal pancreas of the hypoplastic type was diagnosed. Postoperatively, the patient’s diabetes was managed with intensive insulin therapy consistent with type 1 diabetes, and she was discharged on postoperative day 22. We report this case as a rare example of pancreatic cancer with congenital agenesis, with a review of previous cases reported in Japan.

A superior mesenteric artery (SMA) embolism blocks blood flow to the intestines, leading to intestinal necrosis. In such cases, surgical resection of the affected bowel is critical. However, accurate determination of the required extent of bowel resection under ischemic conditions can be challenging. If the patient survives the surgery, there is often a risk of development of short bowel syndrome (SBS), which severely impacts QOL due to decreased nutrient absorption. We encountered two cases in which patients developed SBS following surgery for SMA embolism at a higher-level hospital. Both patients were transferred to our care-mix hospital, where they received teduglutide treatment. Teduglutide is believed to support intestinal healing by promoting nutrient absorption, maintaining mucosal integrity, and aiding in intestinal repair. In both cases, this treatment resulted in significant improvement in intestinal absorption capacity, leading to a noticeable enhancement in QOL. One case, in particular, involved a patient who had been struggling with SBS complications for over a year. The patient was expected to have a poor prognosis due to severe malabsorption and associated complications. However, following teduglutide administration, the patient experienced dramatic improvements in nutrient absorption and was eventually able to be discharged home, marking a remarkable turnaround in their condition. These cases highlight the potential of teduglutide as an effective therapy in managing SBS and improving outcomes after extensive bowel resection.

A 62-year-old man visited our hospital with a chief complaint of abdominal pain. Abdominal contrast-enhanced CT revealed ileo-colonic intestinal stacking and a neoplastic lesion in the terminal ileum. Colonoscopy showed that the tumor at the end of the ileum was evacuated towards the mouth during insufflation, and that the ileum was evacuated into the ascending colon with the tumor during deflation, reproducing the intestinal accumulation. A diagnosis of mucosa-associated lymphoid tissue (MALT) lymphoma was made on biopsy. After decompression, laparoscopic ileal resection was performed. Diffuse large B-cell lymphoma (DLBCL) and other high-grade lymphomas have been reported in many adult patients with intussusception caused by malignant lymphoma, but low-grade lymphomas such as MALT lymphoma have only rarely been reported. Here, we describe a case of ileal MALT lymphoma with intestinal accumulation, in which a histological diagnosis was obtained preoperatively and curative resection was achieved by laparoscopic surgery.

In 2024, a law related to work style reform will apply to physicians, but there is a large gap with current working conditions. To reduce working hours, an understanding of current work practices will enable effective and feasible streamlining of work. Therefore, we surveyed the current working conditions in our department using two surveys. A reduction in working hours was found from the first to the second survey. In the first survey, the average working hours were 13.8 hours on operating days and 11.0 hours on non-operating days. This was thought to be due to conferences held outside of working hours, keeping of postoperative records, and ward visits. In the second survey, working hours were reduced to 12.6 hours on operating days and 8.5 hours on non-operating days, due to thorough implementation of a team system and task shifting. A future challenge is to shorten the working hours on operating days. These results show that surveys on actual working conditions can lead to a reduction in working hours, and that this kind of survey is an important first step in reform of work conditions for physicians.