細川 勇

Background: Anastomotic leak is one of the most serious postoperative complications, and intraoperative adequate perfusion plays a key role in preventing its development in gastric cancer surgery. This study aimed to investigate the relationships between anastomotic leak and the parameters defined by an assessment of intraoperative anastomotic perfusion using a near-infrared indocyanine green (ICG) fluorescence system and to evaluate the usefulness of this ICG fluorescence assessment in gastric cancer surgery. Methods: We retrospectively reviewed data of 100 patients who underwent gastric cancer surgery. In a visual assessment based on fluorescence intensity, we classified ICG fluorescence image patterns as homogeneous, heterogeneous, or faint. In a chronological assessment, the first or second time point of ICG fluorescence appearance on one or the other side of the anastomosis was defined as FT or ST, respectively. The time difference in ICG fluorescence appearance between FT and ST was defined as TD. The relationships between anastomotic leak and the evaluated clinical factors, including the parameters identified by the ICG fluorescence assessment, were evaluated using univariate or multivariate analysis. Results: Although no signs of leak were found by surgeons’ subjective judgments, four patients developed postoperative anastomotic leak of Clavien–Dindo grade III or IV. Multivariate analysis revealed that TD was an independent predictor of anastomotic leak (odds ratio 35.361, 95% confidence interval 1.489–839.923, p = 0.027). Conclusions: A novel parameter identified using near-infrared ICG fluorescence assessment may be useful to predict anastomotic leak in gastric cancer surgery. Trial Registration: UMIN Clinical Trials Registry: #UMIN000030747 (https://www.umin.ac.jp/ctr/index.htm).

Left trisectionectomy [(LT) resection of segments 2, 3, 4, 5, 8, and 1] for perihilar cholangiocarcinoma is still a challenging procedure with high postoperative morbidity and mortality. To perform LT safely, the liver transection-first approach was developed. In this approach, liver transection is started without dividing the right anterior hepatic artery (RAHA) and right anterior portal vein (RAPV). After the completion of liver transection, the RAHA and RAPV, which run into the future resected liver, can be easily identified and divided under the wide surgical field at the hepatic hilus. The liver transection-first approach appears to be safer than the conventional LT, leading to less postoperative morbidity and mortality.

BACKGROUND: Laparoscopic transverse colectomy is technically difficult. In mini-laparotomy surgery, colectomy for midtransverse colon cancer can easily be performed, but exact D2 lymph node dissection is very difficult for a variety of vessels in the transverse colon. Using 3D-CT imaging, we present a case of D2 lymph node dissection where mini-laparotomy transverse colectomy was performedby a small incision similar to that usedin laparoscopic surgery. METHOD: The patient was a 60-yearoldwoman with early transverse colon cancer, which was locatedin the mid-transverse colon. Surgical treatment was plannedfor pT1b(1.5mm)andpVM1 in pathological findings after EMR. Using CT colonography(CTC), the location of the primary tumor was identified. Using simulation CTC(sCTC), composedof CTC and 3D imaging of the arteries andveins, the dominant artery was identified and D2 lymph node dissection was simulated. In addition, body surface 3D imaging and permeable surface 3D imaging of the abdominal trunk were performed. Using body surface 3D-sCTC, composedof sCTC and body surface 3D imaging, the minimum incision to enable D2 lymph node dissection was simulated. RESULT: Using sCTC, it was identified that the dominant artery was the right branch of the middle colic artery(MCA Rt)andthe accompanying vein was branchedfrom the gastrocolic trunk(GCT). D2 lymph node dissection to separate the branching root of MCA Rt and the accompanying vein was simulated. Next, surgical incision was simulated using body surface 3D-sCTC. Because the branching roots of MCA Rt andGCT were locatedabout 5 cm cranial from the upper rim of the navel, a 7 cm upper abdominal midline incision was designed in addition to a 2 cm umbilical incision. Mini-laparotomy transverse colectomy with a 7 cm incision was performedin accordance with the simulation. The operation time was 2 hours and5 1 minutes, andbloodloss was due to occult bleeding. The patient was discharged 7 days after surgery without complications, and the final diagnosis was pT1bN0M0, StageⅠwith no recurrence for 4 years and2 months after surgery. The cranial incision from the upper rim of the navel has shrank about 3 cm, and the umbilical incision is not noticeable. CONCLUSION: D2 lymph node dissection of minilaparotomy transverse colectomy can be a treatment option for early transverse colon cancer through using body surface 3DsCTC.

Low anterior resection syndrome (LARS) commonly develops after an anal sphincter-preserving operation (SPO). The etiology of LARS is not well understood, as the anatomical components and physiological function of normal defecation, which may be damaged during the SPO, are not well established. SPOs may damage components of the anal canal (such as the internal anal sphincter, longitudinal conjoint muscle, or hiatal ligament), either mechanically or via injury to the nerves that supply these organs. The function of the rectum is substantially impaired by resection of the rectum, division of the rectococcygeus muscle, and/or injury of the nervous supply. When the remnant rectum is small and does not function properly, an important functional role may be played by the neorectum, which is usually constructed from the left side of the colon. Hypermotility of the remnant colon may affect the manifestation of urge fecal incontinence. To develop an SPO that minimizes the risk of LARS, the anatomy and physiology of the structures involved in normal defecation need to be understood better. LARS is managed similarly to fecal incontinence. In particular, management should focus on reducing colonic motility when urge fecal incontinence is the dominant symptom.

Purpose: Left trisectionectomy (LT) extending to the segment I with bile duct resection for perihilar cholangiocarcinoma (PHC) is a technically demanding procedure with high morbidity. Liver transection during LT is generally conducted to expose the right hepatic vein (RHV) on the remnant side. In clinical practice, we have often encountered a discrepancy between the theoretical RHV-oriented plane and the actual right intersectional plane. Methods: To enable anatomical LT safely, the three-dimensional right intersectional transection plane based on portal inflow was investigated using multidetector-row computed tomography, and it was compared to the theoretical RHV-oriented plane in 100 patients with hepatobiliary disease. Results: The posterior portion of RHV just below the diaphragm was supplied by the dorsal portal branches of segment VIII in 85 cases of 100 (85.0%). The median volume of this portion was 82 mL (25–169 mL). On the other hand, the anterior region of the peripheral RHV was supplied by a few small ventral portal branches of segment VI in 24 of 90 cases (26.7%). The median volume of this portion was 53 mL (20–104 mL). In ten cases with a large inferior RHV, the RHV trunk was relatively short and did not reach the caudal part of the liver. Conclusions: The portal inflow-oriented right intersectional plane does not coincide with the RHV-oriented plane in most cases. The cranial part of the actual transection plane becomes hollow, whereas the caudal part is protruded in relation to the RHV. Hepatobiliary surgeons should recognize this complicated transection plane to avoid postoperative complications when performing LT for PHC.

Background: Right hepatectomy (RH) is the standard surgical procedure for perihilar cholangiocarcinoma (PHC) with right-sided predominance in many centers. Although left trisectionectomy (LT) is aggressively performed for PHC with left-sided predominance in high-volume centers, the surgical and survival outcomes of LT are unclear. Therefore, this study aimed to compare the outcomes of LT and RH for PHC. Methods: Consecutive patients who underwent surgical resection for PHC at Chiba University Hospital from 2008 to 2016 were retrospectively reviewed. The outcomes of patients with PHC who underwent LT were compared with those who underwent RH following one-to-one propensity score matching. Results: Of 171 consecutive PHC resection patients, 111 were eligible for the study; 41 (37%) underwent LT, and 70 (63%) underwent RH. In a matched cohort (LT: n = 27, RH: n = 27), major complication rates (67% vs. 52%; p = 0.42), 90-day mortality rates (15% vs. 0%; p = 0.11) and R0 resection rates (56% vs. 44%; p = 0.58) were similar in both groups. The 3-year recurrence-free survival rates (27% vs. 47%; p = 0.27) and overall survival rates (45% vs. 60%; p = 0.17) were also similar in both groups. Conclusions: In patients with PHC, LT could achieve similar surgical and survival outcomes as RH.

The aim of this study was to assess the impact of partial gastrectomy on postoperative outcomes in elderly patients with gastric cancer. Sixty -three consecutive elderly patients aged 75 years and older with histologically proven Stage ⅠA gastric adenocarcinoma who underwent partial gastrectomy(PG, n=7)or normal gastrectomy(NG, n=56)were investigated. PG was performed by segmental gastrectomy or local gastrectomy due to poor performance status, severe comorbidities, and social background instead of normal gastrectomy(distal, proximal, and total gastrectomy). Both body mass index(BMI)and body weight changes 12 months postoperatively were significantly higher in those who underwent PG(20.5 kg/m2 vs 18.4 kg/m2, p=0.043; and 96.6% vs 86.4%, p=0.016)despite being statistically similar preoperatively. The 5-year cause-specific survival rate of those who underwent PG was 100% excluding relapse cases. The 5-year overall survival rates were 86% in those who underwent PG and 67%in those who underwent NG, although they differed significantly. Partial gastrectomy may be a valid surgical procedure that may yield better prognosis compared to that with normal gastrectomy for elderly patients with Stage ⅠA gastric cancer.

BACKGROUND AND PURPOSE: It is reported that simulation computed tomography colonography(S-CTC), which combines CTC and 3-dimensional(3D)vascular imaging, is useful in colorectal cancer surgery. However, it is difficult to create 3D vascular images using non-contrast CT. Laparoscopic transverse colectomy is said to be technically difficult. Mini-laparotomy surgery for mid-transverse colon cancer is quite easy to perform. However, exact D2 lymph node dissection is very difficult. We present a case of D2 lymph node dissection during mini-laparotomy transverse colectomy performed using S-CTC, which involves the creation of 3D vascular images using non-contrast CT. PATIENT AND METHOD: The patient was a 77-year-old man with transverse colon cancer located in the mid-transverse colon, cT2N0M0, Stage Ⅰ. He had coexisting chronic renal failure. Non-contrast CT was performed prior to surgery, and the images were processed using workstation Zaiostation2. RESULTS: Both the artery and the vein created from non-contrast CT could be visualized clearly until the marginal vessels. Using noncontrast S-CTC in combination with CTC and 3D artery imaging, it was identified that the dominant artery was the left branch of the middle colic artery(MCA Lt), while the right branch of the MCA(MCA Rt)and accessory MCA(AMCA)were 10 cm or more apart. The fusion of 3D artery and vein imaging made it evident that the vein accompanying MCA Lt branched from the superior mesenteric vein. Using non-contrast S-CTC, D2 lymph node dissection, dissection of the branching root of MCA Lt and the vein at the same level was simulated. Thus, mini-laparotomy transverse colectomy was performed through a 7 cm incision, in accordance with the simulation. CONCLUSION: Non-contrast S-CTC was useful for performing D2 lymph node dissection during mini-laparotomy transverse colectomy.

Background: Although multidetector-row computed tomography (MDCT) before biliary drainage is useful for the assessment of the resectability of perihilar cholangiocarcinoma (PHC), the impact of biliary drainage on MDCT images before surgical resection for PHC has been poorly studied, and its possible consequences for R0 resection of PHC remain unclear. This study was performed to compare the surgical outcomes of patients with PHC who underwent MDCT before versus after biliary drainage. Methods: All consecutive patients who underwent major hepatectomy extending to segment 1 with extrahepatic bile duct resection for PHC from 2009 to 2016 were retrospectively evaluated. R0 resection was defined as no residual cancer at all surgical margins. Patients with pathological stage IV PHC were excluded. Results: Of 142 patients who underwent major hepatectomy, 108 were eligible for this study. Of these 108 patients, 64 (59%) and 44 (41%) underwent MDCT before and after biliary drainage, respectively. The total bilirubin concentration at presentation was lower in patients who underwent MDCT before than after biliary drainage (4.1 ± 5.9 vs. 8.0 ± 7.1 mg/ml, respectively; p = 0.002). Although there were no significant differences in the surgical characteristics or pathological stages between the two groups, R0 resection was more frequently achieved in patients who underwent MDCT before than after biliary drainage [46/64 (72%) vs. 22/44 (50%), respectively; p = 0.03]. On multivariate analysis, MDCT before biliary drainage was independently associated with R0 resection of PHC (risk ratio: 2.38, 95% CI 1.05–5.41; p = 0.04). Conclusions: In selected patients, MDCT should be performed before biliary drainage to achieve R0 resection of PHC.

Background: The clinical findings of early anal gland carcinoma (AGC) have not been well delineated because AGC is a rare malignancy usually diagnosed at an advanced stage. Knowledge of the characteristic findings will be helpful for both diagnosis and determination of the treatment options for early AGC. Case presentation: A 62-year-old man was referred to our hospital for treatment of a rectal submucosal tumor (SMT) detected during a medical checkup at another hospital. Trans-sacral resection of the tumor was performed under the diagnosis of a rectal benign cyst. Pathological examination of the resected tumor showed a mucin-producing adenoma. About 14months later, a new cystic lesion was found by follow-up examination, and trans-sacral resection of the tumor was performed again. The second pathological diagnosis was a mucinous adenocarcinoma with a possible remnant tumor at the local site. After providing sufficient informed consent, the patient underwent intersphincteric resection (ISR) of the rectum to preserve anal function. The final diagnosis was mucinous adenocarcinoma of the anal gland, T1N0M0. The patient remained alive without recurrence or complications for 6years 7months postoperatively. Conclusion: We have herein reported a case of early AGC with a characteristic SMT-like appearance. Because the anal gland is located within both the submucosal layer and the internal sphincter muscle, ISR may be selected when the tumor is limited to inside the gland.

Background Occasionally, right hepatectomy, rather than parenchyma-preserving hepatectomy, has been performed for solitary small colorectal liver metastasis. The relative oncologic benefits of parenchyma-preserving hepatectomy and right hepatectomy are unclear. This study compared the outcomes of patients with solitary small colorectal liver metastasis in the right liver who underwent parenchyma-preserving hepatectomy and those who underwent right hepatectomy. Methods The study population consisted of a multicentric cohort of 21,072 patients operated for colorectal liver metastasis between 2000 and 2015 whose data were collected in the LiverMetSurvey registry. Patients with a pathologically confirmed solitary tumor of less than 30 mm in size in the right liver were included. The short- and long-term outcomes of patients who underwent parenchyma-preserving hepatectomy were compared to those of patients who underwent right hepatectomy. Results Of the 1,720 patients who were eligible for the study, 1,478 (86%) underwent parenchyma-preserving hepatectomy and 242 (14%) underwent right hepatectomy. The parenchyma-preserving hepatectomy group was associated with lower rates of major complications (3% vs 10%; P <.001) and 90-day mortality (1% vs 3%; P =.008). Liver recurrence occurred similarly in both groups (20% vs 22%; P =.39). The 5-year recurrence-free survival and overall survival rates were similar in both groups. However, in patients with liver-only recurrence, repeat hepatectomy was more frequently performed in the parenchyma-preserving hepatectomy group than in the right hepatectomy group (67% vs 31%; P <.001), and the overall 5-year survival rate was significantly higher in the parenchyma-preserving hepatectomy group than in the right hepatectomy group (55% vs 23%; P <.001). Conclusion Parenchyma-preserving hepatectomy should be considered the standard procedure for solitary small colorectal liver metastasis in the right liver when technically feasible.

Background: Transjugular intrahepatic portasystemic stent shunt (TIPSS), instead of surgical shunt, has become the standard treatment for patients with complicated portal hypertension. This study compared outcomes in patients who underwent TIPSS or surgical shunting for complicated portal hypertension. Methods: This was a retrospective study of all consecutive patients who received portasystemic shunts from 1994 to 2014 at a single institution. Patients who underwent surgical shunting were compared with those who had a TIPSS procedure following one-to-one propensity score matching. The primary study endpoints were overall survival and shunt failure, defined as major variceal rebleeding, relapse of refractory ascites, irreversible shunt occlusion, liver failure requiring liver transplantation, or death. Results: A total of 471 patients received either a surgical shunt or TIPSS. Of these, 334 consecutive patients with cirrhosis who underwent elective surgical shunting (34) or TIPSS (300) for repeated variceal bleeding or refractory ascites were evaluated. Propensity score matching yielded 31 pairs of patients. There were no between-group differences in morbidity and 30-day mortality rates. However, shunt failure was less frequent after surgical shunting than TIPSS (6 of 31 versus 16 of 31; P = 0·016). The 5-year shunt failure-free survival (77 versus 15 per cent; P = 0·008) and overall survival (93 versus 42 per cent; P = 0·037) rates were higher for patients with surgical shunts. Multivariable analysis revealed that a Model for End-Stage Liver Disease (MELD) score exceeding14 and TIPSS were independently associated with shunt failure. In patients with MELD scores of 14 or less, the 5-year overall survival rate remained higher after surgical shunting than TIPSS (100 versus 40 per cent; P < 0·001). Conclusion: Surgical shunting achieved better results than TIPSS in patients with complicated portal hypertension and low MELD scores.

Background: Although efficient chemotherapy regimens have improved outcomes after R1 resection (positive margins) for colorectal liver metastases (CLMs), the long-term survival benefit and potential for cure after R1 resection have not been clearly demonstrated. The aim of this study was to evaluate the long-term outcome after R1 resection for CLM, and to identify factors predictive of cure. Methods: All resected CLM patients at our institution from 2000 to 2009 were prospectively evaluated. Cure was defined as a disease-free interval ≥5 years from the last hepatic or extrahepatic resection to last follow-up. Results: Of 628 patients consecutively resected for CLM, 428 were eligible for the study, of whom 219 (51 %) underwent R0 resection (negative margins) and 209 (49 %) underwent R1 resection. Overall, 130 patients with R0 resection and 141 patients with R1 resection had more than 5 years of follow-up. Five- and 10-year overall survival rates were 56 and 34 % for R0 patients, and 48 and 36 % for R1 patients, respectively (p = 0.37). Of the 141 patients who underwent R1 resection, 26 patients (18 %) were considered ‘cured’, and 106 patients (75 %) were considered ‘noncured’. Independent predictive factors of cure after R1 resection included ≤10 total cycles of preoperative chemotherapy and objective response to preoperative chemotherapy. Conclusions: Overall, potential cure can be achieved in 18 % of patients after R1 resection for CLM. The best conditions to achieve long-term survival after R1 resection rely on a good response to efficient and short first-line chemotherapy.

Acites accompanying a malignancy is often refractory to conventional treatment with saline diuretics, making it difficult to control. We administered a new diuretic, Tolvaptan, to 10 individuals with malignancy and heart failure accompanied by ascites, which was refractory to saline diuretics, and assessed its efficacy and adverse events. We observed a significant reduction in abdominal distension following 2 weeks of Tolvaptan administration. However, we also observed significant increases in serum potassium, urea nitrogen, and creatinine levels, but no serious adverse events. This suggests that Tolvaptan may also be effective as treatment for ascites.

Full understanding of the hilar anatomy is crucial for successful surgical resection of perihilar cholangiocarcinoma (PHC).The three-dimensional positional relationship between the left hepatic artery (LHA) and the umbilical portion of the left portal vein (UP) was evaluated using multidetector-row computed tomography (CT) in 58 consecutive patients who underwent right-sided hepatectomy for Bismuth-Corlette IIIa or IV tumors. The positional relationship of the LHA related to UP was classified into the following three types: L-UP type, LHA runs into the left lateral section (LLS) from the left caudal side of the UP; R-UP type, LHA runs into the LLS from the right cranial side of the UP; and combined type, one branch of the LHA runs into the LLS from the right cranial side of the UP, and the other from the left caudal side of the UP.L-UP-type LHA was observed in 53 cases (91.4 %), R-UP type in three cases (5.2 %), and combined type in two cases (3.4 %). No cancer involvement of the LHA was seen in any cases with L-UP type. In one case with R-UP type (one of three; 33.3 %) and one case with combined type (one of two, 50 %), cancer invasion to the LHA was observed at the right side of the UP, requiring combined resection of the involved LHA.R-UP-type LHA running just along the left hepatic duct may be easily involved by right-side predominant PHC when extending to the left hepatic duct. Hepatobiliary surgeons should recognize this anatomical variant and carefully evaluate the running courses of LHA to successfully perform R0 resection in right-sided hepatectomy for PHC.

A 64-year-old male was admitted to a local hospital with epigastric pain. Diagnostic imaging revealed hepatolithiasis in the atrophic left lobe. However, endoscopic intervention was impossible because of the presence of many large stones. He was referred to our hospital for surgical treatment. Enhanced multidetector-row computed tomography revealed that the right posterior portal vein (PV) was branched from the portal trunk as a first-order branch, and the bile duct of segment 3 ran caudally to the umbilical portion of the left PV. Furthermore, the umbilical portion of the left PV, which was located between the dilated bile ducts of segment 2 and segment 3, and also the right anterior PV, was occluded with thrombus. Based on these findings, he underwent left hepatic trisectionectomy. Although the indications for left hepatic trisectionectomy for hepatolithiasis are limited, it is therefore extremely important to determine the most appropriate surgical procedure based on the anatomy and findings of hepatic hilus in individual cases.

Background Preoperative diagnosis of solid pseudopapillary neoplasm of the pancreas (SPN) remains difficult and optimal surgical management for SPN has yet to be fully defined.Methods Retrospective analysis was undertaken of all 10 patients (six women, four men) who underwent surgery for SPN between 2001 and 2013.Results Mean age was 26 years (range, 16-33 years) for women, and 50 years (range, 35-76 years) for men. Although large SPN showed typical imaging findings, small SPN (<= 3.0 cm) appears as almost entirely solid tumors. Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) was performed in six patients with atypical findings of SPN for differentiation from other pancreatic neoplasms. Definitive preoperative cytological diagnosis was achieved in all patients who underwent EUS-FNA. All 10 patients underwent surgical exploration. One patient with portal vein invasion and multiple lung metastases underwent pancreaticoduodenectomy combined with portal vein resection and reconstruction, followed by two pulmonary resections. This patient remains alive as of 34 months after the initial operation.Conclusions Endoscopic ultrasound-guided fine-needle aspiration is useful for definitive preoperative diagnosis of SPN. As long-term survival after surgical resection can be achieved even in patients with locally advanced and metastatic SPN, aggressive surgical resection should be performed.

Objective: To evaluate recent surgical strategy for hilar cholangiocarcinoma (HC) of the left-side predominance.Background: When employing left hemihepatectomy (LH) for HC, vasculobiliary anatomy of the right liver often makes it difficult to achieve a tumor-free margin of the right posterior sectional bile duct (RPSBD). Because left trisectionectomy (LTS) can produce a longer resection margin for the RPSBD, we have expanded the indications for LTS over the last 5 years.Methods: Sixty-one consecutive patients underwent left-sided hepatectomy for HC, divided into 2 groups according to the operative periods: period 1 (2001-2007; n = 29) and period 2 (2008-2012; n = 32). Clinicopathological outcomes of the groups were compared. The difference in the length of the resectable RPSBD between LH and LTS was radiologically investigated using multidetector-row computed tomography.Results: The proportion of LTS increased from 10.3% (3/29) in period 1 to 46.9% (15/32) in period 2. R0 resection rates were also improved in period 2. The most common margin positive site in period 1 was the stump of the proximal bile duct; high rates of positive RPSBD stump were noted after LH. The positive proximal ductal margin ratio decreased significantly in period 2. The difference in the length of resectable RPSBD between LH and LTS was 9.0 +/- 1.3 mm. There was no mortality in period 2, even after LTS.Conclusions: LTS for HC of the left-side predominance improved R0 resection rates without affecting postoperative mortality. LTS should be aggressively performed in patients with appropriate hepatic function, even if tumors are possibly resectable by LH.

The number of patients undergoing laparoscopic hepatectomy has rapidly increased in recent years, and indications for this procedure are gradually expanding. Pure laparoscopic hepatectomy is reportedly useful in cases with severe liver cirrhosis. A 55-year-old woman under observation for liver cirrhosis was found to have hepatocellular carcinoma in liver segment III and was referred to our hospital for surgery. The tumor was located in the edge of liver segment III, where percutaneous ablation therapy was unsuitable. Since her hepatic functional reserve was poor, pure laparoscopic partial hepatectomy was performed. The postoperative course was favorable, with no ascites retention, edema or weight gain. The greatest advantage of pure laparoscopic hepatectomy for hepatocellular carcinoma with concomitant liver cirrhosis is that postoperative ascites retention is minimal, meaning that there is little risk of water-electrolyte imbalance associated with ascites retention or hypoproteinemia. This is believed to be because the abdominal incision is small and mobilization of the liver is minimized, reducing the destruction of the routes of collateral lymph flow and blood flow generated in patients with liver cirrhosis. Pure laparoscopic hepatectomy may be a treatment choice for patients with hepatocellular carcinoma and concomitant severe liver cirrhosis.

To perform safe and radical pancreaticoduodenectomy, adequate knowledge of the branching and running course of the common hepatic artery is necessary. Formation of a common trunk by the common hepatic artery and superior mesenteric artery, called the hepatomesenteric trunk, is very rare. When it occurs, the common hepatic artery arising from the hepatomesenteric trunk usually runs behind the pancreas head. In the present case, however, it ran through the pancreatic parenchyma. Therefore, pancreaticoduodenectomy for duodenal carcinoma was performed with preservation of the intrapancreatic common hepatic artery. When pancreaticoduodenectomy is performed in patients with a replaced common hepatic artery running through the pancreatic parenchyma, it is necessary to preoperatively determine whether to preserve or resect the common hepatic artery in the pancreas with consideration of the curability. If resected, whether to reconstruct it must also be determined. If reconstructed, the reconstruction method must be determined, and if not, it is important to perform preoperative coiling of the common hepatic artery and intraoperative measurement of the hepatic blood flow with a Doppler flow meter.

INTRODUCTION: Malignant afferent loop obstruction following pancreaticoduodenectomy is a rare complication and may be fatal if suppurative cholangitis or obstructive jaundice develops. Effective and safe therapeutic strategies for malignant afferent loop obstruction following pancreaticoduodenectomy are scarce at present. CASE PRESENTATION: A 51-year-old Japanese man underwent pancreaticoduodenectomy for carcinoma of the papilla of Vater. Seven months postoperatively, he developed a high-grade fever, jaundice, and right upper abdominal pain. Abdominal contrast-enhanced computed tomography showed afferent loop obstruction and intrahepatic bile duct dilatation due to nodal recurrence. Percutaneous transhepatic biliary drainage was performed, and a self-expanding metallic stent (WallFlex™ duodenal stent) was placed across the stricture using the transhepatic route. CONCLUSIONS: There are surgical and nonsurgical treatments for malignant afferent loop obstruction following pancreaticoduodenectomy. Nonsurgical treatments include either an endoscopic or percutaneous approach to the afferent loop. Of these methods, percutaneous transhepatic insertion of a self-expanding metallic stent is the preferred treatment for malignant afferent loop obstruction following pancreaticoduodenectomy because it is more prompt and less invasive.

We investigated the contamination of room door handles by Staphylococcus aureus in wards of a university hospital. Door handles in 53 (27.0%) of 196 rooms were contaminated by methicillin-sensitive Staphylococcus aureus (MSSA) and/or methicillin-resistant Staphylococcus aureus (MRSA); MSSA was detected on door handles of 41 rooms (20.9%), MRSA on door handles of 17 rooms (8.7%), and MSSA and MRSA on the same door handles of five rooms (2.6%). The density of MSSA contamination was 1-2.6x10(4) colony forming units (cfu)/door handle, and that of MRSA was 1-6.0x10(3) cfu/door handle. The MRSA contamination rate on door handles of rooms with patients with MRSA was 19.0% (4/21 rooms) while that on door handles of rooms with patients without MRSA was 7.4% (13/175); the difference was not significant. These results suggest extensive contamination of MSSA and MRSA in the hospital environment.