BACKGROUND:The optimal neoadjuvant strategy for high-risk locally advanced rectal cancer (LARC) remains a matter of debate. This study evaluated the efficacy and safety of neoadjuvant FOLFOXIRI (fluorouracil, leucovorin, oxaliplatin, irinotecan) plus bevacizumab without radiotherapy in patients with magnetic resonance imaging-defined high-risk LARC. METHODS:A prospective, multicentre, single arm phase II trial was conducted in four Japanese Institutions between 2018 and 2024, enrolling patients with rectal adenocarcinoma and at least one high-risk criterion: clinical T4, lateral pelvic lymph node metastasis, mesorectal fascia involvement, or positive extramural vascular invasion. Patients received four cycles of FOLFOXIRI plus bevacizumab, followed by two cycles of FOLFOXIRI alone, before total mesorectal excision. The primary endpoint was pathological complete response (pCR); secondary endpoints included the R0 resection rate, local recurrence (LR), recurrence-free survival (RFS), overall survival (OS), and safety. RESULTS:OF 50 eligible patients, 31 were enrolled before early trial closure due to a slow accrual (accrual rate 62%). All patients underwent surgery. The pCR rate was 10% (3 of 31) and R0 resection was achieved in 97% (30 of 31) of patients. The median follow-up was 36.7 months. The 3-year cumulative LR rate was 3%, with 3-year RFS and OS rates of 73 and 81%, respectively. Grade ≥ 3 neutropenia occurred in 29% of patients, with acceptable toxicity overall. No cases of gastrointestinal perforation were observed. Grade ≥ III postoperative complications occurred in seven patients (23%), with the most frequent events being anastomotic leakage in two patients (7%). CONCLUSIONS:In this phase II trial, although recruitment was suboptimal, neoadjuvant FOLFOXIRI plus bevacizumab achieved good local control without radiotherapy in patients with high-risk LARC. Although the pCR rate was modest compared with radiotherapy-based regimens, this chemotherapy-only approach may represent a reasonable option for select patients who are not suitable candidates for pelvic radiotherapy. Registration number: UMIN000037367 (https://www.umin.ac.jp/english/).

We report the case of a 76-year-old man who presented with pain in the right upper abdomen. Laboratory and radiological examinations revealed cholangitis, cholelithiasis, and a gallbladder tumor adhering to the transverse colon. After receiving conservative therapy for cholangitis, the patient underwent surgery for the gallbladder disease. On surgery, a cholecysto-colonic fistula communicating the gallbladder and transverse colon was revealed, and combined resection of the gallbladder and partial transverse colon was performed. The resected sample revealed an intracholecystic papillary neoplasm with a focal invasive component, xanthogranulomatous cholecystitis in the gallbladder, and a cholecysto-colonic fistula. Xanthogranulomatous cholecystitis caused fibrous adhesion and penetration from the gallbladder and transverse colon, resulting in the fistula. A noninvasive component of the intracholecystic papillary neoplasm horizontally extended into the transverse colon across the fistula, whereas a small invasive component on the hepatic side was observed. As the intracholecystic papillary neoplasm did not "invade" the transverse colon, we concluded that the pathological T-stage of the intracholecystic papillary neoplasm was pT1b (invading the muscularis propria of the gallbladder). This was a case where a large gap between preoperative diagnosis (cT3) and pathological diagnosis (pT1b) occurred and a careful explanation of the atypical state and cause of the discrepancy in diagnosis was required.

ABSTRACT A sebaceous carcinoma is rarely seen in extracutaneous sites. We present a 75-year-old man who was admitted with epigastralgia and melena. Endoscopic examination revealed an ulcer on the posterior wall of the gastric antrum, and distal gastrectomy was performed. Histopathological examination revealed thin to thick trabeculae of polygonal cells with scattered foci of foamy cells, whereas Sudan 3 staining showed lipid vacuoles. Immunohistochemistry was positive for both p40 and SALL4. After considering these findings, we suggest sebaceous differentiation as the diagnosis. To the best of our knowledge, this is the first case of gastric carcinoma with sebaceous differentiation.

症例は81歳の男性で，他院通院中に肝機能障害を認め，精査目的に当院へ紹介となった．当院での腹部造影CTにて肝門部から左肝管に進展する腫瘍を認め，肝門部領域胆管癌の診断で手術の方針とした．術前に閉塞性黄疸が出現したため，内視鏡的胆道ドレナージ（endoscopic biliary drainage；EBD）tubeの留置を行った．処置後膵炎を生じ，CTにて炎症に起因すると思われる門脈本幹から右枝を充満する血栓を認めた．経上腸間膜動脈的に血栓溶解療法を施行するも，血栓の溶解に至らず，乳頭部から術後出血を併発したため，血栓確認後4日目に開腹下に回結腸静脈経由でカテーテルを留置し，門脈内血栓吸引術を施行した．門脈血流が再開したため，血栓治療開始後30日に左肝切除術・胆管切除術を施行した．病理診断は癌肉腫であった．現在術後3年が経過し，無再発生存中である．残肝予定の門脈に血栓を生じ，治療後に根治術を行った症例を経験したため報告する．

Purpose Gastric cancer patients with para-aortic lymph node metastases may achieve long-term survival with radical gastrectomy and para-aortic lymph nodal dissection (PAND) following neoadjuvant therapy. We introduced the Cattell-Braasch maneuver to facilitate safe and complete PAND for advanced gastric cancer with extensive lymph node metastases. Methods Between January 2014 and March 2020, 7 patients with highly advanced gastric cancer received preoperative chemotherapy followed by radical gastrectomy and PAND using the Cattell-Braasch maneuver. This maneuver consists of mobilization of the right hemi-colon and the total small intestine. Results Five patients received preoperative chemotherapy for para-aortic lymph node metastases and 2 for bulky lymph node metastases around the supra-pancreatic area. All patients received S-1 + cisplatin therapy, and one was additionally treated with paclitaxel chemotherapy followed by nivolumab. After chemotherapy, 2 patients with para-aortic lymph node metastases achieved down-staging on imaging tests. Total gastrectomy with PAND by the Cattell-Braasch maneuver was performed on all patients and was accompanied by splenectomy (n = 5) and distal pancreatectomy (n = 1). Pathological assessments revealed that 3 patients had para-aortic lymph node metastases, and the median number of retrieved para-aortic lymph nodes was 16. Three patients without para-aortic lymph node metastasis survived for more than 5 years without recurrence. Conclusion The Cattell-Braasch maneuver provides a good surgical field and is useful for complete PAND for gastric cancer.

Background Undifferentiated carcinoma of the biliary tree is extremely rare, and biliary undifferentiated carcinoma mostly originates from the gallbladder. We herein present a case of anaplastic undifferentiated carcinoma of the hilar bile duct and reviewed the literature. Case presentation The patient was an 81-year-old male with obstructive jaundice. Contrast-enhanced computed tomography (CT) showed a protruded tumor located at the hepatic hilum. Obstructive jaundice was relieved by endoscopic drainage. Endoscopic biopsy revealed carcinoma without glandular differentiation, and the patient was diagnosed with resectable hilar undifferentiated carcinoma. During the 5-week preoperative examination, the tumor increased in size from 23 to 45 mm. Left hemi-hepatectomy and extrahepatic bile duct resection were performed, and there were no postoperative complications. Histological findings demonstrated that the tumor was mainly composed of non-cohesive polygonal neoplasms with pleomorphic nuclei, and was diagnosed as anaplastic undifferentiated carcinoma of the common hepatic duct (T2a N0 M0 Stage II). One month after surgery, the patient was readmitted to our hospital with pyrexia due to cholangitis, and liver nodules suggestive of multiple liver metastases were detected by CT. Three months after surgery, the patient died of multiple liver metastases. Conclusions This is the first case report of undifferentiated cholangiocarcinoma with anaplastic features. Anaplastic undifferentiated carcinoma of the hilar bile duct showed preoperative rapid growth and early relapse despite a cancer-negative surgical margin.

症例は57歳，女性．前医でRaynaud症状を指摘され，当院を受診した．精査で強皮症と診断され，悪性腫瘍のスクリーニング目的に施行した下部消化管内視鏡検査で，上行結腸に粘液排出を伴う粘膜下腫瘍様の隆起性病変を認めた．腹部単純CTおよびMRIでは，虫垂は盲腸から上行結腸の背側に位置し，約30mm径に腫大しており，PET-CTで同部位にFDGの異常集積を認めた．以上より，上行結腸へ穿通した粘液産生虫垂腫瘍と診断し，結腸右半切除術（D3郭清）を施行した．病理組織検査で虫垂粘液癌pT4b（上行結腸）pN0cM0 pStage II c（大腸癌取扱い規約第9版）と診断した．粘液産生虫垂腫瘍は比較的まれな疾患であるが，腹膜播種から腹膜偽粘液腫をきたすことが知られている．今回，上行結腸に穿通した虫垂粘液癌に対して，R0切除を施行しえた1例を経験したため，文献的考察を加えて報告する．

A 75-year-old man was admitted to our hospital because of abdominal distension and significant renal dysfunction. A large amount of ascites was observed on plain abdominal CT, and ascites mixed with bile was detected by abdominocentesis. Laparotomy was performed with diagnosis of biliary peritonitis. During laparotomy, bile leaked from a small hole on the surface of the hepatic left lobe, and the diagnosis was biliary peritonitis due to intrahepatic bile duct rupture. Surgery was performed by cholecystectomy and T-tube drainage of the left hepatic duct. After waiting for improvement of the general condition, the patient was diagnosed with groove pancreatic cancer by detailed examination and pancreaticoduodenectomy was performed one month after the first operation. In this case, the left and right hepatic ducts were joined at a low level, and the cystic duct was communicating with the right hepatic duct, which is rare. To date, there have been no reports of intrahepatic bile duct rupture due to biliary atresia caused by groove pancreatic cancer. In addition to bile duct obstruction by this cancer, low union of the left and right hepatic ducts was also considered to be the cause of bile duct rupture.

Background Gastrobronchial fistulas are rare, but life-threatening, complications of esophagectomy. They are caused by anastomotic leakage and mainly occur around anastomotic sites. In the present paper, we report a rare case of leakage from the staple line of a gastric tube after esophagectomy for esophageal cancer, which was successfully treated using an intercostal muscle flap and lung resection. Case presentation A 61-year-old male underwent subtotal esophagectomy with regional lymphadenectomy for esophageal cancer. The sutures along the staple line of the gastric tube failed 11 days after surgery, and a pulmonary abscess was also found on imaging. The abscess did not heal after conservative treatment; therefore, right lower lobectomy, gastrobronchial fistula resection, primary closure, and patching of the leaking portion of the gastric tube with an intercostal muscle flap were performed 9 months after the first operation. The patient’s postoperative course was uneventful, and he was discharged on the 354th day. Conclusions We experienced a case involving a gastrobronchial fistula caused by leakage from the staple line of a gastric tube and successfully treated it by performing right lower lobectomy and patching the leak with an intercostal muscle flap.

免疫チェックポイント阻害剤は新しい癌治療薬として注目されているが，今までにない免疫関連有害事象の報告も多い．症例は70歳の男性で，傍大動脈リンパ節転移を伴う切除不能進行胃癌に対して化学療法を開始した．S-1+シスプラチン，パクリタキセルは無効で3rd lineとしてニボルマブに変更したところ，3コースで原発巣，傍大動脈リンパ節ともに縮小した．4コース後に全身に痛みを伴う水疱が出現し，ニボルマブの有害事象である水疱性類天疱瘡と診断した．ニボルマブを中止しステロイド内服で水疱は改善したが，原発巣が再増大した．そのためコンバージョン手術として傍大動脈リンパ節郭清を伴う胃全摘術を施行した．病理診断ではリンパ節転移は化学療法により病理学的完全奏効で，原発巣を含めてR0切除であった．ニボルマブによる有害事象を適切にコントロールすることで最大限の治療効果を引き出し，治癒切除が可能であった．

Background The aims of the present study were to demonstrate the anatomical change of superior mesenteric vein (SMV) branches and to show how the Cattell Braasch maneuver facilitates a safer ligation of these venous branches during a pancreatoduodenectomy (PD). Methods Between January 2010 and December 2019, 97 patients with peripancreatic tumors underwent pancreatectomy. We retrospectively reviewed preoperative triple-phase enhanced computed tomography (CT) images and analyzed variations in SMV branches. Anatomical changes in SMV branches after the Cattell Braasch technique were observed using our operation video and illustrations. Results The first jejunal vein (J1v) in 75% of patients ran posterior to the superior mesenteric artery (SMA), while the remainder (25%) ran anterior to it. The inferior pancreatoduodenal vein (IPDV) was preoperatively detected in 91% of patients. The IPDV drained into the J1v in 74% of patients and into the SMV in 37%. After the Cattell Braasch maneuver, the J1v which ran posterior to the SMA now was found to lie to the right anterolateral side the SMA and the visualization of both the J1v and the IPDV were much more clearly visualized. Conclusions The most frequent venous variation was the IPDV draining into the J1v posterior to the SMA. After the Cattell Braasch maneuver, the IPDV was now located to the right anterolateral anterior aspect of the SMA which facilitates its visualization and should allow a safer ligation.

Journal of Surgical OncologyVolume 122, Issue 8 p. 1831-1831 RESPONSE TO LETTER TO THE EDITOR Response to letter to the editor “Beyond ‘artery-first’ pancreaticoduodenectomy for pancreatic carcinoma: Cattell-Braasch maneuver in ‘mesopancreas-first’ pancreaticoduodenectomy” Masayuki Akita MD, PhD, Corresponding Author Masayuki Akita MD, PhD bokuakkey70033@gmail.com orcid.org/0000-0001-5614-3148 Department of Surgery, Kakogawa Central City Hospital, Kakogawa, Japan Correspondence Masayuki Akita, MD, PhD, Department of Surgery, Kakogawa Central City Hospital, Kakogawa 6758611, Japan. Email: bokuakkey70033@gmail.comSearch for more papers by this authorKunihiko Kaneda MD, PhD, Kunihiko Kaneda MD, PhD Department of Surgery, Kakogawa Central City Hospital, Kakogawa, JapanSearch for more papers by this author Masayuki Akita MD, PhD, Corresponding Author Masayuki Akita MD, PhD bokuakkey70033@gmail.com orcid.org/0000-0001-5614-3148 Department of Surgery, Kakogawa Central City Hospital, Kakogawa, Japan Correspondence Masayuki Akita, MD, PhD, Department of Surgery, Kakogawa Central City Hospital, Kakogawa 6758611, Japan. Email: bokuakkey70033@gmail.comSearch for more papers by this authorKunihiko Kaneda MD, PhD, Kunihiko Kaneda MD, PhD Department of Surgery, Kakogawa Central City Hospital, Kakogawa, JapanSearch for more papers by this author First published: 07 September 2020 https://doi.org/10.1002/jso.26207Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume122, Issue8December 15, 2020Pages 1831-1831 RelatedInformation

Background Bochdalek hernia in an adult is very rare and often needs an immediate surgical repair for the herniation. Although its etiology and surgical techniques have frequently been reported, perioperative complications, especially cardiopulmonary problems, remain unknown. We reported two adults with Bochdalek hernia and reviewed the published literatures with a focus on these issues. Case presentation We experienced two adult cases of Bochdalek hernia with gastrointestinal strangulation. One case had massive herniation of the stomach, colon, spleen, and pancreas in the left chest, causing repeated vomiting. The other had a right-side hernia with strangulation of the colon. We successfully performed emergency repairs of these diaphragmatic hernias without any postoperative complications. Conclusions Our literature review revealed that life-threatening cardiopulmonary complications, such as empyema or cardiac arrest caused by the tamponade effect of the herniated viscera, sometimes occurred in patients with Bochdalek hernia. These complications were found in Bochdalek hernia with gastrointestinal strangulation.

In the last two decades, two surgical concepts in pancreatoduodenectomy (PD) have been attracting attention, particularly in pancreatic ductal adenocarcinoma: “artery‐first” and “mesopancreas.” Artery‐first means a prior approach to the superior mesenteric artery (SMA) and ligation of the inferior pancreaticoduodenal artery (IPDA) and first jejunal artery (J1a) before ligation of the superior mesenteric vein (SMV) branches. Many artery‐first techniques are performed during PD: anterior, left side, right side, and posterior approaches to the SMA.2‐7 The following advantages of this technique have been reported. Since pancreatic cancer often develops along the nerve plexus around the SMA, the artery‐first approach enables surgeons to decide its resectability in an earlier resection phase than conventional PD, in which the SMA is separated from the pancreas head in the last phase of resection. Furthermore, less intraoperative blood loss is expected with early ligation of the IPDA, with decreasing blood inflow into the pancreas head. The mesopancreas is a surgical and anatomical concept that was initially reported by Gockel et al. Although the definition of the mesopancreas remains vague, it refers to the area between the SMA and pancreatic head, including vessels (the root of the IPDA and jejunal branches), lymph ducts, lymph nodes (station 14), and the nerve plexus. Pancreatic cancer, particularly in the uncinate process, often spreads into the mesopancreas, and results in high rates of microscopically margin‐positive resection (R1 resection) in this area. Complete excision of the mesopancreas is vital for prolonging the survival of patients with pancreatic cancer. The Cattell‐Braasch technique was initially introduced as a method to expose the third and fourth portions of the duodenum by restoring the small intestine and hemi‐right colon. This maneuver may also restore the twisted position of the duodenum and jejunum caused by embryonic intestinal rotation. In our institution, this method is applied for PD to facilitate safe, artery‐first, and complete mesopancreas excision.

リンパ管腫は通常，小児に発生するまれなリンパ管奇形であり，成人例での報告は少ない．今回，新規発生から増大経過を観察し，腹腔鏡下手術で切除した成人脾リンパ管腫の1例を経験したため報告する．症例は73歳の女性で，約2年前のCTでは脾臓に病変を認めなかったが，他疾患精査のCTで脾臓に19 mm大の単房性囊胞性病変を認めた．その後3年5か月間経過観察していたが，50 mm大の多房性囊胞性病変へと増大を認めたため，腹腔鏡下脾臓摘出術を施行した．標本の割面で大小さまざまな多房性囊胞性病変を認め，囊胞の内容物は淡黄色の液体であった．病理組織検査では囊胞壁は1層の扁平な内皮で覆われており，内腔に好酸性の液体貯留が散見された．内皮細胞の免疫組織学的検査ではCD34が陰性，D2-40がごく一部で弱陽性であり，CD31，Prox-1が陽性であったことから，リンパ管腫と診断した．

症例は67歳,男性.十二指腸・胆管へ穿破した膵管内乳頭粘液性腺癌(IPMC)に対して亜全胃温存膵頭十二指腸切除(SSPPD)を施行した.術前から腫瘍の圧排による門脈本幹の狭窄と門脈左右分岐部に血栓が併存していたが,術後に増悪したため,手術翌日に経回結腸静脈門脈経路で門脈ステントを留置した.ステント留置後より速やかに肝内門脈の血流の改善を認め,徐々に門脈血栓は消失し,肝膿瘍を生じることなく軽快退院した.腫瘍の圧排および膵炎により門脈狭窄が生じ,術後の門脈血流低下の増悪が原因で血栓が増大したと考えられた.腫瘍は浸潤部の最大径が8mm大のIPMCであり,胆管および十二指腸への穿破部には浸潤所見はなく,膵管内の圧により穿破したと考えられた.今回我々は胆管・十二指腸へ穿破したIPMCに対するSSPPD後に急速進行した門脈狭窄・門脈血栓症に対して,門脈ステント留置が有効であった1例を経験したため報告する.

Metastatic hepatic leiomyosarcoma is a rare malignant smooth muscle tumor. We report a case of metastatic hepatic leiomyosarcoma associated with smooth muscle tumor of uncertain malignant potential (STUMP). A 68-year-old female presented with a liver mass (60 mm × 40 mm, Segment 4). She underwent left salpingo-oophorectomy for an ovary tumor with STUMP in a broad ligament 6 years ago. Though FDG-PET showed obvious metabolically active foci, abnormal metabolically active foci other than the lesion were not detected. A malignant liver tumor was strongly suspected and laparoscopic partial liver resection was performed with vessel-sealing devices using the crush clamping method and Pringle maneuver. Immunohistochemical findings revealed metastatic liver leiomyosarcoma associated with STUMP in a broad ligament. This case is an extremely rare case of malignant transformation from primary STUMP to metastatic hepatic leiomyosarcoma. It provides important evidence regarding the treatment for metastatic hepatic leiomyosarcoma associated with STUMP.

Among the various diagnostic modalities for small bowel hemangioma, video capsule endoscopy (VCE) and double-balloon enteroscopy (DBE) can be recommended as part of the work-up in patients with obscure gastrointestinal bleeding (OGIB). DBE is superior to VCE in the accuracy of diagnosis and therapeutic potential, while in most cases total enteroscopy cannot be achieved through only the antegrade or retrograde DBE procedures. As treatment for small bowel bleeding, especially spout bleeding, localization of the lesion for the decision of DBE insertion facilitates early treatment, such as endoscopic hemostatic clipping, allowing patients to avoid useless transfusion and the worsening of their disease into life-threatening status. Applying endoscopic India ink marking prior to laparoscopic surgical resection is a particularly useful technique for more minimally invasive treatment. We report two cases of small bowel hemangioma found in examinations for OGIB that were treated with combination of laparoscopic and endoscopic modalities.

膵頭十二指腸切除術後の異時性の膵尾部癌に対する膵体尾部切除術において，indocyanine green（以下，ICGと略記）を用いた術中蛍光造影法により残膵の血流評価を行い，膵体部を一部温存しえた1例を報告する．症例は74歳の男性で，66歳時に膵頭部癌に対し膵頭十二指腸切除術を受け，術後胆管空腸吻合部出血に対し右肝動脈にTAEを施行された．術後8年目の検査にて腫瘍マーカーの上昇を認め，精査の結果から膵尾部癌を疑われ，手術を施行した．腫瘍は膵尾部末端にあり，膵体部を一部温存することを目的に術中ICG蛍光造影法を用いた．腫瘍より膵体部側の切離予定付近の脾動脈をクランプし，ICG静注により膵体部への造影効果および，温存予定の膵体部の血流をリアルタイムに評価し，虚血のないことを確認したうえで膵切除を行った．術後膵液漏を認めたが，経過良好にて退院となった．