Sclerosing angiomatoid nodular transformation (SANT) is a rare, benign vascular lesion of the spleen that usually presents as a solitary mass. Multifocal SANT is extremely uncommon. We describe a 37-year-old man who was incidentally found to have multiple splenic lesions during a routine health checkup. Contrast-enhanced computed tomography revealed three solid masses, raising concern for primary splenic lymphoma. Laparoscopic splenectomy was performed, and intraoperative frozen section suggested SANT. Histopathological analysis confirmed the diagnosis, showing three distinct vascular components without malignant features. Although most reported cases of SANT present with a solitary mass, this case highlights a rare multifocal pattern. The lack of a characteristic imaging finding, the spoke-wheel pattern, and the rather small number of reported cases of multiple SANTs made it difficult to differentiate them from malignant tumors. Multifocal SANT is exceedingly rare and may mimic malignant splenic tumors, complicating preoperative diagnosis. This case underscores the need to include SANT in the differential diagnosis of splenic masses and suggests that partial splenectomy combined with intraoperative frozen section analysis may offer a less invasive management option. Broader recognition of multifocal SANT could help refine diagnostic algorithms and surgical strategies for splenic tumors.

Pancreatitis following endoscopic retrograde cholangiopancreatography (ERCP), known as post-ERCP pancreatitis (PEP), is the most common and potentially serious complication of the procedure. Pancreatic spontaneous dislodgement stents (PSDSs) are widely used to reduce the incidence of PEP in high-risk patients. Although these stents are generally safe, migration-related complications such as intestinal perforation are extremely rare but potentially life-threatening. We present a case of descending colon perforation caused by migration of a PSDS placed for PEP prophylaxis. An 87-year-old man underwent ERCP for common bile duct stones, during which a 5 Fr, 3 cm straight-type PSDS was placed to prevent pancreatitis. Nineteen days later, he developed a fever, and computed tomography revealed perforation of the descending colon caused by the migrated stent. Laparoscopic exploration followed by open surgery confirmed the perforation and peritonitis. Partial colectomy with functional end-to-end anastomosis was performed, and the patient recovered without complications. This case highlights a rare but critical complication of PSDS use, particularly in patients with colonic diverticula or other anatomical variations. It emphasizes the importance of recognizing the risks associated with PSDS placement, conducting appropriate follow-up, ensuring early detection of complications, and facilitating timely intervention. Additionally, development and selection of safer stent designs may help reduce the risk of migration-related adverse events in the future.

症例は69歳，男性．30年前より慢性甲状腺炎に伴う甲状腺機能低下症を指摘され，レボチロキシンナトリウム水和物による補充療法が行われていた．約20年前より増大する甲状腺右葉結節に対して穿刺吸引細胞診が行われ，好酸性細胞型濾胞性腫瘍が疑われ，当院を紹介受診となった．頸部エコーでは濾胞癌の可能性も否定できず，診断的治療として手術を行う方針とし，甲状腺右葉切除術を施行した．病理検査所見では散在する腫瘍胞巣は扁平上皮細胞への分化を伴った細胞と粘液産生細胞を示し，部分的に腺腔構造も認められた．線維性間質に好酸球・リンパ球・形質細胞の浸潤が目立ち，好酸球増多を伴う硬化性粘表皮癌（sclerosing mucoepidermoid carcinoma with eosinophilia:以下，SMECE）と診断した．

Multicystic biliary hamartoma （以下MCBH）は，小嚢胞が集簇する多房性嚢胞性の胆管過誤腫である．今回，MCBHに対して内側区域切除を施行した症例を経験したので報告する．症例は36歳，男性．急性腸炎時に単純CTで偶然発見された肝腫瘤で当院へ紹介となった．造影CTでは，肝S4に数mmから17mmまでの嚢胞が集簇した45×35mm大の多房性嚢胞性腫瘤を認めた．MRIでは，その多房性嚢胞性腫瘤はT1強調画像で低信号，T2強調画像で高信号を呈した．CEA 1.4ng/ml，CA19-9 4.0U/mlと腫瘍マーカーは正常値であった．Intraductal papillary neoplasm of the bile ductの可能性を否定できず，手術適応と判断して肝内側区域切除を施行した．病理検査所見では，嚢胞壁は核異型のない単層円柱上皮で覆われていた．嚢胞の周囲には，胆管周囲付属腺や血管を含んだ線維性結合織がみられ，嚢胞内腔には胆汁様の内容液貯留がみられた．最終診断はMCBHであった．術後合併症なく，術後8日目に退院となった．術後3年10カ月現在，無再発生存中である．

症例は69歳，男性．S状結腸癌および肝転移の疑いに対し，腹腔鏡補助下S状結腸切除術，二期的に肝切除術を施行した．病理所見で肝病変は肝血管腫の診断であった．最終診断はS状結腸癌（pT4a N0 M0）Stage IIb，脈管侵襲があり，術後補助化学療法としてカペシタビン内服を半年間施行した．術後2年半のCTで右肺S2に7mm大の孤発性小結節影を認めた．PET-CTで同部位に集積を認め，転移性肺癌が疑われ胸腔鏡下肺部分切除術を施行した．病理所見では壊死性肉芽腫性病変および菌体を認め，肺クリプトコックス症の所見であり，転移は認めなかった．肺クリプトコックス症は多彩な画像所見を呈するため，時に原発性・転移性肺癌，炎症性腫瘤との鑑別が困難となり，手術による治療的診断も考慮される．しかしながら，もし本症例で結節が多発し切除不能と考えられた場合には，転移性肺癌として化学療法を選択していた可能性もある．示唆に富む症例と考えられ，若干の文献的考察を加え報告する．

症例は73歳,男性で膵尾部癌に対し膵体尾部切除術(D2郭清)を行った.術後補助化学療法S1を半年間内服した.膵切除後2年10か月で,CEA,CA19-9の上昇とCT検査で肝浸潤を伴う上行結腸腫瘍を指摘された.下部内視鏡検査で上行結腸の壁肥厚と狭窄を認めたが,粘膜面の変化がなく,生検では悪性所見を得られなかった.膵癌上行結腸転移または原発性上行結腸癌の術前診断で,右半結腸切除術(D2郭清,リンパ節No.223はサンプリング),肝部分切除術を行った.病理検査で粘膜下層から漿膜下層を中心に前回膵癌に類似する中分化型腺癌像を認め,CK7陽性CK20陰性であったことから膵癌上行結腸転移と診断した.膵切除後5年7か月(大腸切除後2年9か月)時点で,無再発生存中である.膵癌大腸転移は非常に稀であり,診断には免疫染色検査CK7とCK20が有用である.膵癌大腸転移では大腸の所属リンパ節に57%と高率に転移を認めた.

Background: Recently, double cancer is no longer uncommon. It is Particularly difficult to determine whether swollen lymph nodes (LNs) indicate malignant lymphoma or metastasis of other carcinoma. We experienced a case of rectal carcinoma complicated with adult T-cell leukemia/lymphoma (ATLL). Case presentation: We encountered a 77-year-old woman who had visited a previous hospital due to bloody stool. Colonoscopy revealed a 10-cm tumor in the lower rectum. Given its pit pattern and surface and vessel pattern, she was suspected of having adenocarcinoma in situ. However, enhanced computed tomography (CT) showed LN swelling around the rectum, and her bilateral inguinal LNs were palpable. Colonoscopy and a biopsy performed at our hospital showed adenoma (Group 3) with no malignant findings. We performed an inguinal LN biopsy and diagnosed her with ATLL. We suspected the rectal mass either be rectal carcinoma or ATLL invasion. We performed chemotherapy for ATLL. The inguinal LNs became no longer palpable, but the rectal mass did not shrink, so we performed operative resection for diagnostic treatment. Thereafter, we diagnosed her with double cancer of rectal adenocarcinoma and ATLL. Conclusion: It is difficult to determine whether swollen LNs indicate malignant lymphoma or metastasis of other carcinoma without performing an LN biopsy. However, a diagnosis of metastasis or non-metastasis does not influence either the staging of the carcinoma or the treatment plan.

症例1は52歳,女性.上腹部痛を主訴に来院.腹部超音波検査を施行し,膵尾部嚢胞性病変を指摘された.CTでは3cm大の多房性嚢胞性病変であり,MRIでT1低信号,T2高信号であった.悪性の可能性が否定できず,脾温存腹腔鏡下膵尾部切除術を施行した.症例2は66歳,女性.3年前にCTで偶発的に3cm大の膵尾部単房性嚢胞性病変を指摘され,今回5cmにまで増大.また,CA19-9 42U/mLと高値を認めた.MRIで嚢胞内部は拡散強調像で高信号,主膵管とは交通は認めなかったことから,粘液性嚢胞腫瘍を第一に疑い,腹腔鏡下膵尾部・脾合併切除を施行した.病理組織検査では,いずれの症例も嚢胞周囲に脾組織を認め,嚢胞壁は扁平上皮や粘液上皮で被覆されており,膵内副脾に発生した類上皮嚢胞と診断した.副脾は比較的多く認められるが,膵内副脾に嚢胞が発生することは稀である.術前診断が困難な膵尾部嚢胞性病変に対し,低侵襲かつ診断的治療を兼ねた腹腔鏡下手術は妥当な術式と考えられる.

BACKGROUND:IgG4-related disease (IgG4-RD) is a pathological condition that is characterized by an infiltrate composed of IgG4-positive plasma cells and recently recognized as an immune-mediated condition. It causes tissue throughout the body to become stiff and thickened due to autoimmune reactions that cause fibrosis and scarring. Disease-related changes commonly occur in the salivary glands, bile duct, pancreas, and lungs, but are seldom seen in the small bowel. A diagnosis of IgG4-RD is suspected if a high level of IgG4 is found on a blood test. The ideal diagnostic method is pathological examination, but because the clinical manifestations of IgG4-RD are very diverse and nonspecific, the disease may often go undiagnosed until an unrelated biopsy or resection specimen is obtained. The most common treatment for IgG4-RD is steroid use. However, tapering or stopping steroid administration is seen to result in recurrence in approximately 50% of cases. A complete cure is therefore considered extremely difficult.CASE PRESENTATION:A 69-year-old man with gastrointestinal obstruction underwent small bowel resection for two lesions. On histopathological examination, the specimen showed features of IgG4-RD. We performed several tests to detect other characteristics of IgG4-RD, but were unable to find any. The patient is being followed up regularly for a year and is being observed for any symptoms of recurrence.CONCLUSIONS:We present a case of IgG4-RD wherein the ileum wall was significantly sclerosed, leading to gastrointestinal tract obstruction; therefore, we resected two sections of the ileum. We believe that resection of IgG4-RD lesions can help avoid long-term steroid use in patients, because the surgery completely eliminates the pathological origins of the condition.

Peripheral arterial (PA) aneurysms show a frequency of 20% of whole aortic aneurysms, and deep femoral artery (DFA) aneurysms account for 0.5% of PA aneurysms. We report a case of a ruptured aneurysm of the medial circumflex femoral artery (MCFA) a branch of the DFA. A 76-year-old woman noticed swelling and pain of the right femur. We diagnosed aneurysmal rupture and performed an emer-gency operation because of the risk of compartment syndrome. DFA aneurysms are rare because : 1) PA are rarely affected by arteriosclerosis, 2) the DFA is surrounded by adductor muscles, and 3) DFA dilata-tion is rare because the vessel is composed of a muscle layer rather than elastic fibers. Thus, DFA aneurysms remain silent until they rupture. This patient revealed no history of trauma, catheter intervention, infection, or collagen disease ; thus, the cause of the MCFA aneurysm was unclear. An addition of further cases to the literature may reveal the mechanism underlying the development of DFA aneurysms and the associated risk factors, which could help to establish appropriate treatment guidelines.

A 69-year-old woman was admitted to our hospital with the chief complaints of fever and fatigue. We initially treated the patient for a tick-borne disease after noticing a pustule on her leg; however, abdominal computed tomography (CT) showed multiple low-density areas in the liver and Chromobacterium violaceum was isolated from a blood culture. We diagnosed her with multiple liver abscesses secondary to Chromobacterium violaceum bacteremia. The patient was successfully treated with ciprofloxacin.

Preoperative evaluation of liver functional reserve is important to predict severe complication after hepatectomy, which has been more enhanced because the indication for hepatic resection has been expanded along with the development of surgical techniques and perioperative management protocols (1-5). Among many indicators of liver functional reserve (3,4,6-13), the indocyanine green retention rate at 15 minutes (ICG-R15) is the gold standard technique (1,14,15). However, the patients should be rested for 2 to 3 hours in a horizontal position and the pretest fasting is necessary before ICG-R15 test, which usually necessitates hospitalization of the patients. Moreover, the technique of ICG-R15 test is somewhat complex because three times of blood sampling after injecting ICG should be performed accurately with time-lag less than a few seconds. Additionally, the results can be inconclusive in patients with obstructive jaundice or congenital ICG excretory defects (16). Another auxiliary or even alternative examination for estimating the liver functional reserve is desired. Technetium-99m diethylenetriamine-penta-acetic acid-galactosyl human serum albumin (Tc-GSA) scintigraphy is one of the prevalent examinations performed for evaluation of liver functional reserve (1725). Conventional indices of Tc-GSA scintigraphy, namely the blood clearance index (HH15) and the receptor index (LHL15), use accumulation counts of only two time points. The index of convexity (IOC) was proposed by Miki et al. (26) as a novel alternative to Summary Preoperative evaluation of liver functional reserve is important in hepatobiliary surgery. Although the indocyanine green retention rate at 15 minutes (ICG-R15) is the gold standard for this purpose, a new method without technical complexity would be preferable. We assessed the usefulness of the previously established index of convexity (IOC). In total, 159 consecutive patients who underwent both technetium-99m-galactosyl human serum albumin (Tc-GSA) scintigraphy and the ICG-R15 were included. Correlation coefficients between indices from Tc-GSA scintigraphy and blood examinations including ICG-R15 were evaluated, and a conversion formula from the IOC to the ICG-R15 was established. The IOC was calculated as [L(15) × 2 − L(3) − L(27)] / [L(27) − L(3)], where L(t) indicates the radiation counts within the whole liver at t minutes after Tc-GSA injection. The IOC showed a significantly stronger correlation with the ICG-R15 (r = −0.532, p < 0.001) than the index of blood clearance (HH15) and the receptor index (LHL15). A formula for estimating ICG-R15 from IOC was "ICG-R15 = −31.0 × IOC + 30.1". In conclusion, the IOC is a better index for evaluating preoperative liver functional reserve than the conventional indices. A formula for estimating ICG-R15 from the IOC will be useful.

Preoperative evaluation of liver functional reserve is important in hepatobiliary surgery. Although the indocyanine green retention rate at 15 minutes (ICG-R15) is the gold standard for this purpose, a new method without technical complexity would be preferable. We assessed the usefulness of the previously established index of convexity (IOC). In total, 159 consecutive patients who underwent both technetium-99m-galactosyl human serum albumin (99mTc-GSA) scintigraphy and the ICG-R15 were included. Correlation coefficients between indices from 99mTc-GSA scintigraphy and blood examinations including ICG-R15 were evaluated, and a conversion formula from the IOC to the ICG-R15 was established. The IOC was calculated as [L(15) × 2 - L(3) - L(27)] / [L(27) - L(3)], where L(t) indicates the radiation counts within the whole liver at t minutes after 99mTc-GSA injection. The IOC showed a significantly stronger correlation with the ICG-R15 (r = -0.532, p < 0.001) than the index of blood clearance (HH15) and the receptor index (LHL15). A formula for estimating ICG-R15 from IOC was "ICG-R15 = -31.0 × IOC + 30.1". In conclusion, the IOC is a better index for evaluating preoperative liver functional reserve than the conventional indices. A formula for estimating ICG-R15 from the IOC will be useful.

当院にて過去3 年間に施行した幽門輪温存・亜全胃温存膵頭十二指腸切除術（PPPD・SSPPD）後の経腸栄養において投与栄養剤を半消化態栄養剤（PF）から消化態栄養剤（OF）へ変更したことの有効性について後方視的に検討した．その結果栄養学的パラメーターにおいては両群間に差は認められなかったが，OF 群ではPF 群に比べ有意に下痢発症を抑制し｛OF vs PF/18.8％ vs75％：P＝0.025｝，有意な投与期間の短縮｛OF vs PF/9 日（4-27 日）vs 20.5 日（3-84 日）：P＝0.02｝がみられた．在院日数もOF 群において短縮傾向がみられた．合併症を抑制できたことで短期間の栄養剤投与からスムーズな経口摂取再開につながり，さらには在院日数の短縮傾向につながったと考えられた．これよりPPPD・SSPPD の術後経腸栄養にOF は有効であると考えられた．

OBJECTIVE:To describe the details of the surgical technique of pancreatoduodenectomy (PD) with systematic mesopancreas dissection (SMD-PD), using a supracolic anterior artery-first approach.BACKGROUND:An artery-first approach in PD has been advocated in pancreatic cancer to judge resectability, clear the superior mesenteric artery margin from invasion, or reduce blood loss. However, the efficacy of an artery-first approach in mesopancreas dissection remains unclear.METHODS:This study involved 162 consecutive patients who underwent PD with curative intent. The patients were divided into 82 SMD-PDs and 80 conventional PDs (CoPD) and then stratified further according to the dissection level, that is, level 1 was applied to 24 simple mesopancreas divisions for early inflow occlusion including 11 SMD-PDs, level 2 for 63 en bloc mesopancreas resections (26 SMD-PDs), and level 3 for 75 patients who underwent a hemicircumferential superior mesenteric artery plexus resection to keep the margin free from cancer invasion (45 SMD-PDs). The clinical and imaging results were collected to assess the feasibility and validity of SMD-PD with an artery-first approach.RESULTS:Blood loss and operation duration were significantly less in the SMD-PD group than in the CoPD group among the total 162 patients. The imaging analysis showed that four fifths of pancreatic arterial branches came from the right dorsal aspect of the superior mesenteric artery and cancer abutment occurred exclusively from the same direction indicating the validity of an artery-first approach.CONCLUSIONS:SMD-PD using an SAA is feasible across PD cases, with acceptable short-term outcomes, and we propose this procedure as a promising option for PD.

BACKGROUND:The rate of recurrence after liver resection for colorectal liver metastases (CLM) is high, and repeat resection (RR) is reserved with curative intent in selected patients. This study evaluated the benefit of RR for recurrence after liver resection for CLM.METHODS:Data were collected on 287 consecutive patients who underwent primary curative hepatectomy between January 1999 and October 2008 for CLM at our institution.RESULTS:After median follow-up of 63 months, 211 patients (73 %) developed recurrence and RR was conducted in 102 (48 %) patients. Five-year overall survival (OS) was significantly higher in the RR group than in those patients not selected for RR (70 vs. 45 %, P = 0.002). On multivariate analyses, RR was identified as an independent factor for good prognosis. According to the first recurrence sites, 5-year OS after recurrence was significantly better in patients with liver or lung only recurrence (55, 51 %, respectively) than in locoregional/lymph node metastases and other/multiple sites recurrence (33, 9.0 %, respectively). In patients with liver- or lung-only recurrence, 5-year OS after recurrence was significantly higher in RR patients than in those without RR (liver; 67 and 0 %, lung; 88 and 24 %, respectively; P < 0.001).CONCLUSION:Given similar indication criteria as the primary CLM, nearly half of all recurrence cases after liver resection for CLM could be salvaged by RR. In patients with liver-or lung-only recurrence, RR warrants a favorable outcome.

BACKGROUND/AIMS:The significance of surgical resection for non-colorectal non-neuroendocrine tumor liver metastasis (NCNNLM) remains controversial. The present study sought to clarify the long-term outcomes of surgical resection for NCNNLM and prognostic factors after hepatectomy in a single institution.METHODOLOGY:From 1993 to 2009, 145 patients underwent hepatectomy for NCNNLM. The primary sites of the hepatic tumors were gastrointestinal carcinoma in 80 cases, breast in 30, genitourinary in 12, gastrointestinal stromal tumor in 11, and miscellaneous in 12.RESULTS:The cumulative 1-, 3-, and 5-year overall survival rates of those who underwent hepatectomy for NCNNLM were 83.9, 55.4, and 41.0%, respectively, with median overall survival times of 41.8 months. Multivariate analysis revealed that postoperative complication was the only independent poor prognostic factor impacting on survival. Postoperative morbidity and mortality rate were 17.9% and 1.4%. There are 38 cases survived more than 5 years including 21 patients without remnant tumors due to the repeat hepatic and/or pulmonary resection for recurrence. A total of 32 patients survived without tumor and without any kinds of chemotherapy in the latest condition.CONCLUSIONS:Hepatectomy for NCNNLM may be beneficial and might relieve patients from excursive chemotherapy in selected patients. Meticulous surgery avoiding complication may enhance the outcome.

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