[A Greater Than Four-Year Survival of a Patient with Inoperable Hilar Cholangiocarcinoma following Portal Vein Embolization and Administration of S-1]

We report a patient with inoperable hilar cholangiocarcinoma due to invasion at the umbilical portion who survived more than 4 years after right portal vein embolization and administration of S-1(50 mg/day). A 64-year-old male patient was immediately hospitalized for liver dysfunction and a high level of HbA1c. The disease was diagnosed as hilar cholangiocarcinoma mainly extending along the right hepatic duct. We made a request for operation to Nagoya University. He received right portal vein embolization in order to grow the residual liver but was deemed inoperable because of invasion at the umbilical portion. He refused chemotherapy but accepted administration of S-1(50 mg/day). Approximately 3 months after starting S-1, his ALP level normalized and about 9 months later stenting tube was lost. Subsequently, he returned to his job. Approximately 2 years and 2 months later, administration of S-1 was interrupted due to a harmful side effect. After approximately 13 months without S-1, the levels of CA19-9 and ALP again became elevated and administration of S-1 was restarted. He was temporarily hospitalized for abdominal pain and fever, but quickly recovered. Although CA19-9 and ALP levels re-normalized, he died after returning home. We emphasize the possibility of maintaining long-term health by minimal- dose S-1 therapy for inoperable hilar cholangiocarcinoma.

[Surgical Outcomes and Clinicopathological Analysis of Non-Ampullary Duodenal Tumors]

Non-ampullary duodenal tumors are relatively rare; however, in recent years, they have been encountered more frequently. We analyzed the surgical outcomes and clinicopathological findings in 20 patients who underwent surgery based on preoperative diagnoses of non-ampullary duodenal tumors at our hospital between January 2011 and April 2021. We performed surgery for 3 cases of GIST, 4 cases of adenoma, and 13 cases of adenocarcinoma. The average age of the patients was 64.3 years and the male-to-female ratio was 17:3. The location of the tumor was the blub in 5 cases, the superior duodenal angle in 2 cases, the descending portion in 9 cases, the horizontal portion in 3 cases, and the ascending portion in 1 case. The histological type of adenocarcinoma was tub1 in all cases of early cancer, whereas in advanced cancer, there were many cases with histological types other than tub1. Various surgical procedures from duodenal local resection to pancreatoduodenectomy can be performed for treating non-ampullary duodenal tumors depending on the tumor location and the necessity of lymph node dissection. It is important to establish a treatment policy that considers both curability and invasiveness.

[Penrose Method Independent of the Rib Arch for Retraction of the Liver in Laparoscopic Gastrectomy y-Shape+1 Method]

We report the y-shape+1 method, which is a retraction of the liver method, independent of the position of the costal arch. Additionally, we report changes in liver enzymes induced by different methods of liver retraction. Three Penrose No. 6 drains were cut into 6 cm pieces. Penrose 1 was fixed with a thread attached to the end and Penrose 2 in a y-shape. A knitting thread with needles was prepared, and a loop was made at the end of the thread. The needle thread was passed over the abdominal wall and through the Penrose 2. The needle thread was passed over the diaphragmatic leg and through the Penrose 3. The thread was pulled over the abdominal wall and diaphragmatic leg and fixed to the end of Penrose 1 out of the body, and the liver was drained. The rate of change in liver enzymes from the preoperative to postoperative stages was examined separately in the Penrose and Nathanson groups. In the y-shape+1 technique, retraction of the liver can be performed regardless of the position of the rib arch; however, intracorporeal suture ligation is necessary. This method is useful when the conventional Penrose method is inappropriate because of the position of the rib arch.

Migration of an ingested fishbone to the uterine wall: A case report

This paper reports the first case of the removal of an ingested fishbone from the uterus. A 77-year-old woman presented with a 3-day history of lower abdominal pain. An abscess-like lesion in the posterior wall of the uterus was revealed by transvaginal ultrasonography and pelvic magnetic resonance imaging. Moreover, a curvilinear calcium density in the anterior uterine wall was revealed by abdominal computed tomography. A recto-sigmoidal perforation and uterine abscess were suspected. Thus, hysteroscopic drainage of the abscess was performed. Hysteroscopy revealed a fishbone partially embedded in the myometrium. Its removal resulted in full recovery. This study believed that adhesions between the uterus and rectosigmoid colon after partial gastrectomy for gastric cancer may have limited abdominal symptoms by limiting the leakage of intestinal fluids. Although rare, it should be considered that migration of a fishbone into the uterus could occur.

[More than Four-Year Survival of Appendiceal Adenocarcinoma Due to Goblet Cell Carcinoid and Manifesting as an Abdominal Tumor and Hydronephrosis]

An 89-year-old woman with complete blindness presented with a right lower abdominal tumor and weight loss. The CT scan showed a huge mass approximately 9 cm in diameter in the ileocecum, invading the right urinary tract and right iliac artery and vein. Findings of the TCS biopsy led to the suspicion of ileocecal carcinoid. Another punch biopsy specimen acquired under general anesthesia indicated mucinous cell carcinoma. When she suffered from right leg pain approximately 3 months later, we provided radiation therapy(50 Gy)because of intolerance to UFT. Consequently, pain disappeared, and the tumor size decreased significantly. We administered TS-1 but discontinued it because of intolerance. Further, 2.8 years after the first medical examination, the tumor recurred, and she developed ileus. We performed ileocolectomy, and pathological findings indicated that the adenocarcinoma in the appendix had progressed from goblet cell carcinoid(sig, si[right ovary], ly1b, v1a, n0). Four years after the first medical examination, CEA had elevated rapidly, and lung metastases were found. She died approximately 4.2 years after the first medical examination. The last measured CEA level had been 596.7 ng/mL. Starting from the lowest level at the first examination, the CEA level had slowly elevated until before the operation and rapidly elevated postoperatively. Immunopathological findings showed that the operated specimen stained diffusely for CEA, without any mucinous component. We suspected that radiation therapy modified goblet cell carcinoid to adenocarcinoma.

[Application of Sugar to the Edematous Stoma for Obstructive Rectal Cancer-A Case Report]

We herein report a case of application of sugar to the edematous stoma for obstructive rectal cancer. A 70-year-old male patient was diagnosed with rectal cancer, bowel obstruction and multiple lung metastases. Colostomy was performed. Seven days after operation, severe edema and congestion of stoma continued. We started spraying of sugar to stoma, and a few days later, edema and congestion of stoma improved. Before discharge, stoma size markedly reduced. Steady state of stoma and achievement the ability to self-care their stoma is important for introduction of chemotherapy. Application of sugar to reduce edema of rectal prolapse and prolapsed stoma have reported. Although the number of reported cases is still small, effectiveness of sugar to reduce edema of stoma have reported. In our case, application of sugar to the stoma is effective in reduction of edema. Application of sugar might be effective in reduction edema of stoma.

[The Efficacy of Endoscopic Esophageal Stent Placement for Malignant Esophageal Stenosis]

Malignant esophageal stenosis adversely affects the quality of life(QOL)on account of poor oral intake. Endoscopic esophageal stenting is one of palliative therapy for improve QOL because of minimally invasive and simple procedure. We investigated the outcomes of esophageal stenting in our institution. Twenty patients with malignant esophageal stenosis who underwent esophageal stenting in our institution between April 2014 and December 2019 were included in this study. Six(30%)out of 20 patients showed fistula. Dysphagia score was improved significantly before and after stenting(3.3± 0.6 vs 1.8±0.9, p<0.01). Complications associated with stenting occurred in 6(30%)cases. Thirteen(65%)patients were able to be discharged from the hospital, but 7(35%)patients including 4 with fistula were outcomes of death in the hospital. Esophageal stenting for malignant esophageal stenosis improved food ingestion and QOL. The prognosis in the case of malignant esophageal stenosis with fistula is extremely poor.

[A Case of Malignant Lymphoma Undergoing HAI Treatment for Multiple Liver Metastases of Carcinoid That Appeared about Nine Years after Resection of Rectal Carcinoid with Liver Metastases]

The present case pertained to a 70-year-old woman. The fecal occult blood test was positive. Colonoscopyrevealed rectal cancer. She underwent the first operation of low anterior resection. Pathological diagnosis was carcinoid, se, ly2, v0, n1. Approximately2 months later, multiple liver metastases were found. Because of strong enhancement at angiography, transarterial chemoembolization(TACE)was selected. After 3 rounds of TACE, we operated the residual liver metastasis approximately1 year and 7 months after the first operation. However, approximately8 years and 9 months after the first operation, multiple liver metastases were found again. Hepatic arterial infusion(HAI)was chosen because tumors showed weak en- hancement on CT. First, we tried high-dose HAI(5-FU 1 g/dayat 1-3 and 5-7, amount: 6 g/week), and liver metastases was almost in CR. However, extrahepatic metastasis was found on PET-CT. Because of rapid growth, we operated the growing lymph node. Pathological diagnosis was diffuse large-cell type B-cell malignant lymphoma. Thus, we extended the interval of HAI(weekly, biweekly, and monthly)and simultaneously4 courses of R-THP-COP(R: rituximab, THP: pirarubicin, C: cyclophosphamide, O: vincristine, P: prednisolone)therapyfor malignant lymphoma was administered. She is now an outpatient. Liver metastases continue to be in CR at approximately1 year and the IL-2R value is almost within normal range.

[Endoscopy Guided Single-Incision Laparoscopic Partial Duodenectomy of Duodenal Tumor]

The use of endoscopic submucosal dissection(ESD)for the treatment of duodenal tumors has increased recently. ESD is less invasive than surgical resection of duodenal tumors. However, a high rate of complication, including perforation and bleeding, has been reported to be associated with ESD. Here, we report the minimally invasive surgical procedure called "endoscopy guided single-incision laparoscopic partial duodenectomy" for the treatment of duodenal tumors, along with its and safety and treatment outcomes. Five patients were included in this study. We mounted the LAP PROTECTORTM and EZ access®in the umbilical incision. Single-incision laparoscopic surgery was performed using 3 trocars(5mm)that were placed into the EZ access®. First, we mobilized the duodenum and pancreatic head from the retroperitoneum using the laparoscopic "Kocher maneuver". Next, the peritumoral site was marked by an endoscopic procedure using a clip and electric needle knife. Using an endoscope, we performed laparoscopic full-thickness resection of the duodenal wall including the tumor. The defect in the duodenal wall was then closed by suturing.

[Skin Ulcer Caused by Bevacizumab-A Case Report]

A case of a skin ulcer caused by bevacizumab(Bmab)is reported here, which recurred with re-administration of bevacizumab. A 69-year-old male patient was diagnosed with cecal cancer, multiple liver metastases, multiple lung metastases, and bone metastasis. Resection of the cecal cancer was performed, and the patient was post-operatively treated with XELOX and Bmabchemotherapy. After the second cycle of chemotherapy, a skin ulcer developed. The ulcer improved after cessation of chemotherapy, debridement, and treatment with antibiotic medication. In spite of re-administration of XELOX chemotherapy, the skin ulcer healed completely, however, the dermatopathy recurred after re-administration of Bmab. Bmab chemotherapy is associated with various risks, including dermatopathy and protracted wound healing, and some cases of skin ulcers caused by Bmab have been reported. Because the skin ulcer was suspected to be cutaneous actinomycosis, Bmab chemotherapy was reintroduced while the patient was treated using antibiotic agent feeding, but the skin ulcer reoccurred. Reported cases of skin ulcers caused by Bmab in Japan show that skin ulcers often recur after re-administration of Bmab. Therefore, if skin ulcers caused by Bmab develop, re-administration of Bmabshould be considered carefully.

[Small Intestinal Metastasis from Lung Cancer with Infiltration into Other Organs-Review of the Literature]

We report a case of metastasis to the small intestine from squamous cell carcinoma of the lung with fistula formation in the adjacent small intestine as well as an analysis of reported cases in Japan of small intestinal metastasis from lung cancer invading other organs. A 63-year-old man was diagnosed with squamous cell carcinoma of the lung as a result of pneumonia. Chemoradiotherapy was administered and sequential chemotherapy was performed, but a single brain metastasis of right parietal lobe was detected 6 months later. Tumor resection was performed. Twelve months after the lung cancer diagnosis, metastasis of the small intestine was detected. Single-incision laparoscopic surgery with partial resection of the small intestine was performed. The tumor had invaded the abdominal wall and 2 parts of the small intestine and had formed a fistula with part of the small intestine. Subsequently, peritoneal dissemination recurred and the patient received the best supportive care. There are 10 reported cases in Japan of small intestinal metastasis from lung cancer invading other organs. Analysis of the reported cases indicates a poor prognosis for patients with fistula. Resection can improve prognosis in patients with primary lung cancer and without distant metastasis. Surgical resection should be considered even if metastasis in the small intestine from lung cancer has invaded other organs.

[Laparoscopy-Assisted Surgery for Descending Colon Cancer in a Patient with Persistent Descending Mesocolon-A Case Report]

Persistent descending mesocolon(PDM)is caused by absence of fusion of the descending colon to the retroperitoneum. We report a case of laparoscopy-assisted surgery for descending colon cancer in a patient with PDM. An 88-year-oldfemale patient complaining of abdominal pain was diagnosed with bowel obstruction, and referred to our hospital. A computed tomography(CT)scan showed bowel obstruction due to descending colon cancer. After decompression of the colon by insertion of a transanal drainage tube, she underwent laparoscopy-assistedleft hemicolectomy. Intraoperatively it was observed that the descending colon was not fixed to the retroperitoneum, and the patient was diagnosed with persistent descending mesocolon. The accessory middle colic artery and the inferior mesenteric vein branched radially. In patients with PDM, the inferior mesenteric artery often branches radially. However, the various morphologies of branching of the accessory middle colic artery and the inferior mesenteric vein have not been reported. It is not clear whether the radial branching of the accessory middle colic artery and the inferior mesenteric vein is characteristic of patients with PDM. We should however expect radial branching of the accessory middle colic artery and the inferior mesenteric vein in such cases.

[Laparoscopic Transverse Colectomy by Cranial Approach Preceding Medial Approach after Stenting for Obstructive Transverse Colon Cancer]

Surgery for obstructive colon cancer was highly invasive due to poor nutritional status of patients, risk of emergency surgery, and unavoidable colostomy formerly. However, recently, we have been able to perform laparoscopic elective surgery safely without colostomy, by using self-expanding metallic stents(SEMS). Laparoscopic colectomy for transverse colon cancer is inherently very difficult because of variations in the vascular system, small number of patients, and absence of large, randomized trials. Laparoscopic complete mesocolic excision(CME)for colectomy has been shown to be technically feasible and effective. We report the treatment strategy for obstructive transverse colon cancer which involves laparoscopic transverse colectomy by cranialapproach preceding medialapproach after successfuldecompression by stenting, along with a review of relevant literature. We consider it a s minimally invasive treatment for obstructive transverse colon cancer.

[A Very Elderly Patient Successfully Treated by Multimodality Treatment for Pancreas Cancer with Synchronous Multiple Liver Metastases and Liver Dysfunction]

We report an 86-year-old patient successfully treated by multimodality treatment for advanced pancreatic cancer with synchronous multiple liver metastases and liver dysfunction. Systemic chemotherapy(SC)(gemcitabine[GEM]1 g and 5-FU 1 g biweekly)was initiated. Two weeks after, the radiation therapy(55 Gy/25 days)was added. Three weeks after, the short period's high dose hepatic artery infusion(SPHDHAI)(5-FU[1 g]×3 days: 1 day rest: 5-FU[1 g]×3 days)was started. By these treatments, liver dysfunction was completely improved and abdominal pain was disappeared. After 2 times of weekly high dose hepatic artery infusion(WHDHAI)(5-FU 1,500mg), the mixed chemotherapy(MC)(GEM 800 mg[systemic] and 5-FU 1,500 mg hepatic artery infusion:[HAI]biweekly)were started. She could live without admission for about 1 year. About 13 months after lung metastases was appeared and she died about 19 months after first chemotherapy. Our multimodality treatment(systemic and HAI therapy and radiation)was effective for keeping patient quality of life and for improving the survival even if the patient was a very old age and showed liver dysfunction.

[Two Cases of Colon Metastasis of Gastric Cancer by Different Metastasis Pathway]

We treated 2 cases ofcolon metastasis ofgastric cancer considered to be caused by different pathway. Case 1 was a 55- year-old male with gastric cancer associated with metastases for lymph node, gallbladder, and liver. Curative surgical treatment of distal gastrectomy, partial hepatectomy, cholecystectomy and lymph node dissection was performed. The final find- ing was, L, Less, Type 3, pT4b(GB), tub2, pN3a(10/20), sP0, CY0, pH1, pM1, Stage IV , R0. Ten months after, ileocecal resection was performed, as a tumor was detected in the cecum. It was a submucosal tumor of well to moderately differentiated adenocarcinoma, and diagnosed as a metastasis ofgastric cancer. Case 2 was a 59-year-old male who received total gastrectomy. The final finding was UE, Less, Type 4, tub2-por2, pT4a, pN2(5/19), cM0, sP0, CY0, Stage III B, R1. One year and 10 months later, unevenness and redness in the mucosal membrane ofthe transverse colon occurred. Signet-ring cells were observed by the endoscopic biopsy, and colon metastasis ofstomach cancer was diagnosed. Consequently, transverse colectomy was performed. Diffused invasion of cancer cells was observed in all layers of the wall, which was considered as metastasis via gastrocolic ligament. Although colon metastasis ofstomach cancer is rare, its pathway varies, such as infiltration, direct invasion, hematogenous, and lymphogenous. Form oflesion also varies. For diagnosis ofcolon lesion occurring during follow-up after gastric cancer, these points should be noted.

[Single Incision Laparoscopic Ileocecal Resection for Small Intestinal Malignant Lymphoma - A Case Report]

A 76-year-old man with the chiefcomplaint ofmelena visited our hospital. A mass was palpable in the right lower abdomen. We diagnosed the illness as small intestinal malignant lymphoma in the terminal ileum and performed a single incision laparoscopic ileocecal resection "TANKO-ICR" with D3 lymph node dissection with the idea ofobtaining a wide visualization and surgical field. The Aesculap®internal organ retractor(B BRAUN)is very useful in such cases. We grasped the pedicle of the ileocecal artery using the retractor and pulled out the nylon line connected to the retractor by using ENDO CLOSETM (COVIDIEN)to extraabdomen for drawing the pedicle. Single incision laparoscopic surgery can be performed with only an umbilical wound; therefore, it is minimally invasive and has a superior aesthetic outcome. Small intestinal malignant lymphoma is a relatively rare malignant tumor ofthe digestive organs. We report this case demonstrating that single incision laparoscopic surgery was possible and provide a review ofthe relevant literature.

[Combination Treatments to the Huge Ovarian Cancer with Liver Metastases]

We report a CR case of huge ovarian cancer with peritoneal and liver metastases who was operated bilateral ovaries, uterus and peritoneal metastases at first, followed by systemic chemotherapy and performed 4 times of radiofrequency ablation (RFA)and 2 times of liver resection(LR). The case was a 50-year-old woman. She suffered with bowel enlargement from over 1 year ago. Preoperative MRI finding was huge ovarian serous cyst with partial solid tumor inside. The major axis was about 30 cm. CA125 and CA19-9 levels were elevated. Tumor reduction surgery was performed with bilateral salpingooophorectomy and hysterectomy with resecting peritoneal metastatic lesions. Postoperative systemic chemotherapy(carbo- platin 550mg/day 1 plus paclitaxel 130mg/day 1, 8, 15)(CBDCA plus PTX)were performed amount 6 courses. Unfortu- nately liver metastases at S3, S4, S6, S7 and S8/5 appeared about 7months after operation.We restarted the CBDCA plus PTX therapy from 15 months after operation when the tumor maker elevated. After 18 courses of CBDCA plus PTX therapy liver metastases remained only at S3. But gradually tumors grew up and size of tumors increased in spite of 3 more courses of CBDCA plus PTX therapy. So we challenged 2 times of RFA at S8/5 metastases that grew most rapidly and the values of increasing tumor makers stopped elevating. Then we performed LR at S3 and S4 metastases and the values of tumor makers returned to the normal level. But next S6 and S7 metastases appeared, we chose the RFA at first. At last recurrence of S7 was resected and all of liver metastases were treated. We checked no peritoneal metastases twice at the time of operation. The values of tumor makers became the normal level. Now she is alive well without metastases over 6 years after first operation. RFA and LR were effective at liver metastases from ovarian cancer that became resistant to systemic chemotherapy.

Role of Micro-Chimerism in Inducing Immunological Tolerance by Intraportal Injection of Donor Spleen Cells in Rats

Recently, we reported that intraportal (IP) injection of donor spleen cells (SPCs) prevented liver allograft rejection. Moreover, we developed a new method using polymerase chain reaction (PCR)-mediated restriction fragment length polymorphism (RFLP) analysis, and demonstrated micro-chimerism (MC) at the DNA level in the spleen 14 days after IP injection. In the present study, the long-term presence of injected allogeneic SPCs was investigated at the cellular level by immunofluorescence staining as well as the DNA level using RFLP analysis. Male ACI (RT1a rats were used as the donors and Lewis (RT11) rats as the recipients. After DNA preparation from the lymphoid organs, RT1Bβ domain 1 region was amplified by PCR, and RFLP analysis was performed with PVuII restriction enzyme. In the immunofluorescence staining, the monoclonal antibody, MN4-91-6, was used to detect the injected donor ACI SPCs in a frozen specimen. We did not detect MC in Lewis rats intravenously injected with 5 x 107 ACI SPCs on day 14. On the other hand, stable chimerism in the spleen was observed in intraportally injected rats up to 28 days after injection at not only the DNA level but also the cellular level. No chimerism was detected in other organs (including the thymus, lymph nodes, and liver). In conclusion, the long-term presence of injected allogeneic SPCs in the spleen was demonstrated after IP injection but not after IV injection, and this phenomenon may be one of the mechanisms involved in portal venous immunosuppression.

[Efficacy of Combined Therapy(Drainage of the Bile Duct, High-Dose Hepatic Artery Infusion, and Radiation)for Hilar Cholangiocellularcarcinoma with Complete Portal Vein Obstruction]

We reported a case of hilar cholangiocellularcarcinoma with complete obstruction of the portal vein. The patient, who was a 65-year-old woman, suffered from fever and general fatigue as a result of acute cholangitis after insertion of a tube stent into the right bile duct. The main tumor was present on the right side of S1 and spread to both sides of the bile duct. S1 lobe was swollen and diffuse intrahepatic invasion was noted in the right lobe and S1. The portal vein was completely obstructed at the porta hepatis with a coronary vein-left renal vein shunt. We immediately administered a high-dose hepatic arterialinfusion( 5-FU 1 g×3 days: one day off 1 g×3 days)(HDHAI)to the right hepatic artery using a transient catheter insertion method. After 2 courses of HDHAI, the intrahepatic invasion decreased. However, after 4 courses of HDHAI(2 on the right side and 2 on the left side), the invasion on the left side of the IVC had increased. We then chose radiation therapy. Subsequently, transient cystic changes were observed; however, 4 months after radiation, the invasion on the left side of the IVC had regrown into the cardia. The patient suffered from vomiting as a result of the narrowing of the esophagus. We chose HDHAI and dilation of the esophagus using a balloon. Finally, the invasion on the left side of the IVC and S1 swelling decreased, and she could eat again. Thirteen months later, she remains an outpatient. We recommend HDHAI and radiation therapy to hilar cholangiocellularcarcinoma even if the portal vein is completely obstructed.

[Two Year Recurrence Free Survival after Resection of Cutaneous Metastasis from Pancreatic Cancer - A Case Report]

The patient was a 73-year-old woman who underwent distalpancreatectomy for pancreas tailcancer (T3, N0, M0, stage III ). Hepatic arterialinfusion(HAI)using high-dose 5-fluorouracil(5-FU)(6,000mg/week)was performed 35 days after curative resection to prevent liver metastases. Although chemotherapy with gemcitabine(GEM)was administered for 2 weeks, the patient was aware of a nodule(1 cm in diameter)on the right lower quadrant of the abdomen. Resection of the cutaneous mass was performed and histological findings revealed metastatic adenocarcinoma from the pancreas cancer. Six courses of chemotherapy with GEM were administered as adjuvant therapy. Two years after the treatment with GEM, neurological symptoms appeared, and computed tomography(CT)and magnetic resonance imaging(MRI)revealed a solitary metastatic thalamus tumor(2 cm in diameter). After stereotactic radiotherapy, the patient was transferred to a different hospitalfor physicaltherapy. Herein, we report on a case of 2 year recurrence free survivalafter the resection of a cutaneous metastasis from pancreatic cancer.

[The New Liver Retraction Method "V-Shape+1 Method" Using Penrose Drains for Laparoscopic Surgery of the Stomach]

Liver retraction is a necessary operative procedure for enabling greater visualization and a wider surgical field during laparoscopic surgery of the stomach. We have developed a new liver retraction method for laparoscopic surgery that uses penrose drains, is very easy to perform and in minimally invasive. We call this method the "V-Shape+1 method". We performed laparoscopic surgery using this method on 16 patients within 8.3(5.3-13.7)min(median). We analyzed the postoperative changes in the serum levels of AST, ALT, and T-Bil, which are indicators of liver function. The serum AST, ALT values were elevated at postoperative day 1. Thereafter, the values improved immediately. This early liver function failure is acceptable. We have not experienced any complication related to this method. Therefore, we believe this method is useful for obtaining wide visualization easily for not only laparoscopic gastrectomy but also for laparoscopic upper abdominal surgery.

[Pre-Operative Treatment with Transcatheter Arterial Chemoembolization (TACE) and Hepatic Arterial Infusion (HAI) for Liver Metastasis from Gastric Cancer--A Case Report]

The patient was an 83-year-old man who underwent distal gastrectomy for gastric cancer (T3, N1, M0, P0, M0, stage ⅡB) at a different hospital from ours. A metastatic lesion was detected in the liver 5 months after gastrectomy. Although chemotherapy with S-1 or bi-weekly CPT-11 was administered for 6 months, the liver tumor increased in size. The patient was referred to our hospital for treatment of the liver metastasis. Abdominal-computed tomography (CT) and magnetic resonance imaging (MRI) revealed a solitary metastatic liver tumor (9 cm in diameter: S7/S6/S8) with a hypervascular tumor stain. Transcatheter arterial chemoembolization (TACE) using degradable starch microspheres (DSM) plus mitomycin C, and hepatic arterial infusion (HAI) using high-dose 5-fluorouracil (5-FU) (6,000 mg/week), were performed 54 days before curative resection of the liver (S6+S7+S8+S5b/c). Histological findings revealed metastatic adenocarcinoma with a tumor thrombus in the posterior branch of the portal vein. The patient was treated with 2 courses of adjuvant chemotherapy with paclitaxel. No recurrence was observed 8 months after hepatectomy. This case suggests that combined treatment with TACE/HAI as a multimodal treatment might be effective in the management of hypervascular liver metastasis from gastric cancer.

[A Case Report of Huge Liver Synchronous Metastases of Colon Cancer that Occurred after Right Liver Lobectomy]

We report a patient who experienced a weight loss, general fatigue, and appetite loss and had huge hepatic metastases of colon cancer after right lobectomy for hepatic stone. After 2 courses of treatment with high-dose hepatic arterial infusion of 5-FU (HDHAI; 5-FU 6 g/week), the appetite loss decreased, and low anterior resection was performed. Unfortunately, the other symptoms continued, and she received 5 additional courses of HDHAI during about 6 months. Finally, all of the symptoms disappeared, and she could receive systemic chemotherapy and HAI. Bone metastasis at vertebra TH 9 was observed about 9 months after radiotherapy, and local recurrence at the anastomosis site was observed at about 1 year 1 months after radiotherapy. Both the metastasis and local recurrence were well controlled. Although the lung metastases were growing slowly (number and size), the patient was well enough to go to the hospital on her own and her weight loss almost disappeared. If liver metastases were the most threatening factor of life, HDHAI may be effective for the improvement of symptoms.

[Laparoscopic Surgery for Adult Intussusception Due to Rectal Cancer--A Case Report]

An 87-year-old woman with the chief complaint of bloody stool was referred to our hospital from an institution for the aged. The abdomen was soft and flat, and a tumor was not palpable on digital rectal examination. Tumor markers were within normal ranges. Abdominal enhanced CT scan showed a multiple concentric ring sign at the rectum. Colonoscopic and barium examination led to a diagnosis of rectal intussusception due to rectal cancer. We first tried to reposition it preoperatively, but it was impossible. She fortunately had no symptoms of ileus; therefore, we chose to perform laparoscopic surgery. We achieved the reposition intraoperatively and performed Hartmann's operation with D2 lymph node dissection because she was a very elderly patient with high-risk comorbidities. The pathological diagnosis was as follows: RS, 40×40 mm, type 2, tub2, pT3 (SS), pN0, ly0, v0, pStageⅡ, R0, Cur A. Adult intussusception due to rectal cancer is extremely rare. We report that in this case that laparoscopic surgery was possible, along with a review of the relevant literature.

[Five-year-survival in a case of large synchronous liver metastases from colon cancer treated with local (operation, HAI, RFA, and TAE) and systemic combined therapy]

A 58-year-old woman was suffering from abdominal pain due to large liver metastases(LM)and lung metastasis from sigmoid colon cancer. After laparoscopic sigmoidectomy, three 6 g/wk high dose hepatic arterial infusions(HDHAI)of5 - fluorouracil (5-FU) were administered and the tumor decreased in size. Unfortunately, the patient had an infectious pseudoaneurysm at the site of puncture. She was given a drainage and femoro-femoral(F-F)bypass. At last, a hepatectomy, radiofrequency ablation(RFA), and catheter insertion from gastroepiploic artery, were performed successfully. Subsequently, she received a half HDHAI and several systemic chemotherapy drugs. However, residual liver metastases developed thrice and we operated on all of them. Finally, when the hepatic arterial infusion(HAI)catheter became unavailable, we only continued the systemic therapy (Erbitux+FOLFIRI). However, inoperable residual liver metastases(maximum 13 cm in size)occurred. We chose to administer hepatic transarterial embolization(TAE)therapy 3 times. From the second time, we performed TAE from the right subphrenic artery and in the third time, we added 1-day HAI therapy. Finally, the tumor size decreased(maximum 9 cm). The patient is still an outpatient 5 years after the first HDHAI.

[A case of metastatic colon carcinoma following curative resection for advanced gastric cancer associated with metastases to the liver and gallbladder]

A 55-year-old man suffering from gastric cancer associated with metastases to the lymph node, gallbladder, and liver was administered chemotherapy with S-1 and cisplatin. Before initiation of therapy, the primary tumor, lymph node metastases, and liver metastases showed fluorodeoxyglucose (FDG) accumulation by positron emission tomography (PET). After 1 course of chemotherapy, the patient received curative surgical treatment including distal gastrectomy, partial hepatectomy, cholecystectomy, and lymph node dissection. The final pathological finding was moderately differentiated adenocarcinoma, T4b(SI), N3a(10/20), P0, CY0, pH1, pM1, Stage IV. Five months after surgery, the serum carcinoembryonic antigen (CEA) level was found to be increasing and PET examination identified an FDG-accumulating nodule in the ascending colon. Colonoscopy identified a submucosal tumor diagnosed as a metastasis from the gastric cancer. Right colectomy was performed 7 months after the first surgery resulting in a curative resection. In each surgery, PET examination indicated that no other distant metastases existed, and curative resection would be possible. Furthermore, although solitary metastatic colorectal lesions are rare, PET examination revealed them accurately. Thus, FDG-PET is very useful for identifying metastases in patients with gastric cancer.

[Efficacy of combined local therapy especially with hepatic arterial infusion for liver metastasis from gastric cancer]

Herein, we report four cases of a single liver metastasis after gastric cancer resection. Initially, we chose to perform hepatic arterial infusion( HAI) with high-dose 5-fluorouracil( 5-FU)( 6,000 mg/week) or weekly 500-750 mg of 5-FU. Three patients showed a partial response (PR) and one patient showed no change (NC). Therefore, we performed hepatectomy or radiofrequency ablation( RFA) 300-350 days after HAI. All four patients received postoperative HAI. Two patients survived without recurrence for 12 and 21 months. One patient developed prostate cancer but survived for 22 months as an outpatient. Finally, one patient experienced recurrence in the residual liver, but at a site not supplied by the hepatic artery. This patient survived for 36 months as an outpatient. In conclusion, HAI, liver resection, and RFA are effective in the management of single liver metastasis from gastric cancer.

[Combination therapy for inoperable cholangiocellular carcinoma-systemic chemotherapy and hepatic arterial injection]

We report the case of a 52-year-old woman with cholangiocellular carcinoma (CCC) involving the lymph node and lung metastases who was admitted to our hospital because of right abdominal pain and anorexia. We started systemic chemotherapy(SCT) comprising 5-fluorouracil(5-FU; 1 g) and gemcitabine(GEM; 1 g) biweekly. After 1 course of SCT, we treated her with high-dose hepatic arterial injection (6 g 5-FU/1 week). This chemotherapy regimen improved her symptoms. After placing an arterial port into the right femoral artery, we continued SCT comprising GEM biweekly and hepatic arterial injection(HAI) of 5-FU weekly. Finally, we opted for weekly HAI and simultaneous SCT of 5-FU and GEM biweekly. The SCT dose of 5-FU was 1,000 mg and the dose of GEM ranged from 800 to 1,000 mg. For HAI, the dose of 5-FU was changed to between 250 and 750 mg. Lymph node metastases disappeared and lung metastases were reduced by this treatment. Because the lung metastases had progressed after 10 months, we increased the SCT dose of 5-FU to 1,500 mg and the dose of GEM to 1,200 mg. We also added systemic mitomycin C and prolonged the injection time of systemic 5-FU from 3 hours to 3 days. The lung metastases were reduced by this treatment. Our patient is still alive and has worked for more than 1 year. We recommend combination therapy of SCT and HAI for CCC with metastases.

[A case of huge liver metastases from the colon cancer suffered from abdominal pain (an amount of LDH was beyond 4,000 IU/L)]

We report a case suffered from an abdominal pain with huge hepatic metastases from the colon cancer. After laparoscopic partial colectomy with a three-time treatment of high dose hepatic arterial infusion by 5-FU (HDHAI), the tumor was decreased in size. Unfortunately she had an infectious pseudoaneurysm at the site of puncture. She was given with a drainage and F-F bypass. She has at last successfully done hepatectomy, radiofrequency ablation (RFA), and insertion of catheter at the site of common hepatic artery from gastroepiploic artery. Then she received a half HDHAI and systemic chemotherapy of CPT-11. However, residual liver metastases happened twice, but we could have them operated all (9.3 months after and 20.5 months after from first operation). If the liver metastases were the most threatening factor of life, HDHAI and repeated hepatectomy maybe effective for prolongation of life.

[Multicenter phase II study of pre-administered uracil/tegafur (UFT) plus gemcitabine for unresectable/recurrent pancreatic cancer]

Our objective was to evaluate the efficacy and toxicity of the pre-administration of UFT (uracil/tegafur: prodrug of 5-FU) and GEM combination therapy for unresectable/recurrent pancreatic cancer in the outpatient setting. UFT (250mg/m(2)/day) was orally administered from day 1 through day 6 and from day 8 through 13, and GEM (800mg/m(2), div/30 min) was administered on day 7 and 14, with a one-week rest every 3 weeks based on results of the previous phase I study. Thirty-six pts (24 male, 12 female) were enrolled (median age, 63.8 yrs). There were 8 partial responses (25%). Eighteen pts (56%) had stable disease, and 6 pts (19%) had a progression. The median survival time was 7. 0 months( range 1.5 -66). Grade 3 toxicities were leucopenia (17%), thrombocytopenia (3%), nausea (3%), and liver dysfunctions(3%). There were no Grade 4 toxicities. Pre-administered UFT plus GM is a promising treatment for unresectable/recurrent pancreatic cancer in the outpatient setting.

[Efficacy of short-term high volume (6 g of 5-FU in a week) hepatic arterial infusion for synchronous diffuse liver metastases of sigmoid colon cancer with over 40 thousand ng/mL of CEA of ascites]

We report a case of patient who recovered from liver failure with synchronous diffuse liver metastases of sigmoid colon cancer by a short-term high volume (6 g of 5-FU in a week) hepatic arterial infusion (STHV-HAI). After four times of STHV-HAI, she had sigmoidectomy and bilateral oohorectomy and continued a weekly hepatic arterial infusion therapy until now. The case was a 75-year-old lady. She admitted of general fatigue. Serum bilirubin was about 2 mg/dL, GOT about 200 U/L and CEA over 40 thousand ng/mL. She started STHV-HAI next day of her admission. After 4-course, her liver function became normal and the amount of CEA level became about 1,000 ng/mL. We had the operation of sigmoidectomy and bilateral oohorectomy. After that, she received the HAI every week as an outpatient. The lowest level of CEA became at the 90 ng/mL. The liver metastases were also almost CR. STHV-HAI will be safe and effective to a patient of liver metastases with ascites and jaundice.

[A new method of short-term high volume (6 g of 5-FU in a week) intermittent hepatic arterial infusion using repeated transient catheter insertion]

We report a case of liver metastases, which had hepatectomy twice and a partial lung resection after sigmoidectomy with partial bladder resection for advanced sigmoid colon cancer. The patient could not be tolerated the systemic chemotherapy, and percutaneous implantation of a catheter also could not have done with subcutaneous reservoir for hepatic arterial infusion because of an anomaly of hepatic artery branched-out from super mesenteric artery. Therefore, we tried an intermittent hepatic arterial infusion using a transient insertion of catheter to control the liver metastases' growth. A total amount of 6 g of 5-FU was continuously injected in a week by one insertion of catheter at the hepatic artery taking one day rest at day 4. During the next 21 months, a total of 11 courses have been done. CEA and CA19-9 were changed from 15 ng/mL, 48 U/ mL to 18, 30, respectively. The patient was able to keep working except for the duration of this treatment. This procedure could be one of the hepatic arterial infusion options.

[Case report of infected pseudo-aneurysm after intra-arterial chemotherapy]

A 63-year-old man admitted to emergency center of our hospital with fever and obstructive jaundice. Computed tomography (CT) showed a mass in the head of the pancreas and a dilated bile duct. After performing preoperative biliary drainage, we conducted pancreatico-duodenectomy (PD-II: T3, N1, stage III). As adjuvant chemotherapy, the patient received a hepatic arterial infusion with 5-FU to prevent liver metastasis. A catheter was placed in the right femoral artery and intra-arterial chemotherapy was carried out for one week. After the completion of chemotherapy, swelling and redness of the right inguinal region was observed. CT revealed an infected pseudo-aneurysm of the femoral artery. Despite intravenous antibiotic therapy for 2 days, bleeding and pus discharge at the catheter root were observed. He immediately underwent drainage and primary suture to stop the bleeding. Two weeks after surgery for the infected pseudo-aneurysm, a right external iliac-femoral bypass operation was performed. Five weeks after surgery, he was discharged without further incident. In such cases, it is advisable to drain the infected pseudo-aneurysm following a prompt diagnosis, and perform a secondary bypass operation.

[A case report-advanced pancreas cancer with liver and lung metastases well controlled over one year by combination therapy with systemic chemotherapy, radiation and hepatic arterial infusion in an outpatient setting]

We report a case of advanced pancreatic cancer with liver and lung metastases that was well controlled over one year by combination therapy with systemic chemotherapy, radiation and hepatic arterial infusion in an outpatient setting. The patient was a 74-year-old woman. Chief complaints were back pain and anorexia. She was diagnosed with pancreas cancer with liver and lung metastases at the time of first visit. We started systemic chemotherapy with gemcitabine 1 g/body and 5-FU 1 g/body alternately every other week on an outpatient basis. At 1.5 months (M) after initiation of chemotherapy, we started radiation therapy to the main tumor at a total dose of 40 Gy. After radiation, chemotherapy was resumed. As a result, the size of the main tumor decreased but metastatic liver tumors got larger. Then we changed to combination therapy with systemic chemotherapy (gemcitabine and 5-FU) and hepatic arterial infusion (5-FU weekly). Liver metastases almost disappeared after 7.5 M. Despite all these treatments, however, the number of metastatic lung tumors increased. The patient was hospitalized for 15 M and died after 17 M. We focused on and succeeded in the prolongation of lifetime and maintenance of QOL by combination therapy with systemic chemotherapy, radiation and hepatic arterial infusion therapy.

Metachronous double cancer of the gallbladder and pancreas associated with pancreaticobiliary maljunction

A 50-year-old Japanese woman complained of abdominal and back pain. Ten years previously she had undergone cholecystectomy, choledochectomy, and Roux-en-Y choledochojejunostomy for gallbladder cancer associated with pancreaticobiliary maljunction without bile duct dilatation. On the present admission, ultrasonography (US) and computed tomography (CT) demonstrated a large mass, 60 mm in size, in the pancreatic tail. Endoscopic retrograde cholangiopancreatography (ERCP) showed obstruction of the main pancreatic duct in the tail of the pancreas and revealed that the pancreatic duct was joined to the bile duct 25 mm above the papilla of Vater. The patient underwent distal pancreatectomy, splenectomy, left adrenalectomy, and partial gastrectomy. Histological examination revealed moderately differentiated ductal adenocarcinoma that had invaded to the proper muscle of the stomach. Double cancer of the gallbladder and pancreas in a patient with pancreaticobiliary maljunction is rare. Although the etiology of cancer of the pancreas associated with pancreaticobiliary maljunction is unclear, we should pay close attention to the pancreas as well as the biliary tract during the long-term follow-up of patients with pancreaticobiliary maljunction after they have undergone a choledochojejunostomy.

[Four cases of successful multidisciplinary treatment for hepatocellular carcinoma with portal venous thrombus]

CASE 1: TAI and radiation therapy were performed for a lateral segment and tumor thrombus extended into the left portal branch. Then, we diagnosed a tumor thrombus that extended into the right portal branch and TAI and operation were performed. The patient died about 9 months after the diagnosis of tumor thrombus. CASE 2: An operation was performed for hepatoma involving the right lobe and the tumor thrombus extended into the right portal branch. TAI and TAE were performed for residual tumor. The patient died about 12 months after diagnosis of tumor thrombus. CASE 3: An operation was performed for hepatoma involving an anterior segment and tumor thrombus extended into the right portal branch. Then, TAI, TAE and PMCT were performed for residual tumor. The patient is alive for 33 months with recurrence after the diagnosis of tumor thrombus. CASE 4: An operation was performed for hepatoma involving a posterior segment and tumor thrombus extended into the right portal branch. For recurrent TAI and TAE, radiation therapy was performed. The patient is alive for 20 months without recurrence after the diagnosis of tumor thrombus.

[Effectiveness of radiation therapy to the venous thrombosis between the inferior vena cava and right ventricle]

In the management of hepatocellular carcinoma (HCC), a tumor thrombus occurrence between the hepatic vein and right ventricle is life threatening. We studied the effectiveness of radiation therapy to the venous thrombosis between the inferior vena cava and right ventricle. CASE 1: A 66-year-old man who suffered from no hepatic viral infection had hepatectomy of the huge HCC (over 20 cm) and recurrence at the post dperated liver and lung. After transarterial embolization, he suffered from dispnea and was found with tumor thrombus from the left hepatic vein to right atrium. Radiation therapy to the tumor thrombus was done and dispnea disappeared. He died by pneumonia at 5 months after the radiation. CASE 2: A 74-year-old woman who had hepatecomy and RFA for multiple HCC. For the recurrence of HCC, TAE and RFA were performed. After the tumor thrombus in the inferior vena cava, mammarian cancer was found and radiation therapy was performed. She died after 4 months from lung edema, but no growth of tumor thrombus was found. CASE 3: A 79-year-old man who had TAE, hepatectomy, RFA and MCT for multiple hepatoma. After these treatments, tumor thrombus at the right ventricle was found. Although he suffered from portal tumor thrombosis, lung metastases, bone metastases and colon cancer after the radiation therapy, he is still alive at the 19 month of treatments. Radiation therapy is safe and effective for venous tumor thrombosis of HCC.

[A case of colon cancer liver metastases treated by combined therapies]

A 46-year-old male patient underwent sigmoidectomy with D2 lymph node dissection and partial resection of the bladder for advanced colon cancer in January 2000. The lesion was judged to be pT2, pN0, sP0, sH0, sM0 and Stage II, and the patient was treated on a regular schedule as an outpatient. Fourteen months after the first operation, liver metastases (S4, S5) were found and partial resections of the liver were performed. However, a recurrence had often been detected in the residual liver for five years afterwards. Liver resections had been repeated for four times before radiofrequency ablation was performed in January 2005. The patient received adjuvant chemotherapy with 5'-DFUR, 5-FU/l-LV (RPMI method), and TS-1. In January 2006, obstructive jaundice due to tumor growth occurred and a self-expandable metallic stent was placed in the narrowed portion of the intrahepatic bile duct. The patient is,currently undergoing FOLFOX4 and FOLFIRI regimens.

[A case of primary duodenal cancer near the papilla of Vater which had initial symptoms of obstructive jaundice]

A 63-year-old man visited our hospital complaining of brown urine. A physical examination showed jaundice of the skin and conjunctiva bulbar. Blood tests showed elevated serum levels of bilirubin and hepatobiliary enzymes. A type 2-like mass lesion was found near the papilla of Vater during the endoscopic retrograde cholangiopancreatography and was histologically proven to be a well-differentiated adenocarcinoma. A diagnosis of obstructive jaundice due to primary duodenal cancer arising near the papilla of Vater was made. After the jaundice was decreased by endoscopic biliary stenting, a pancreatoduodenectomy was performed. A histopathological examination of the resected specimen concerning the location and manner of invasion of cancer cells revealed that the cancer arose from the duodenal mucosa near the papilla of Vater.