遠藤 和洋

INTRODUCTION: Pancreatic neuroendocrine tumors are rare. Treatment includes aggressive local management of the primary lesion and metastases, and systemic somatostatin. This is the first report of an isolated metachronous metastasis to the adrenal gland from a pancreatic neuroendocrine tumor that presented 90 months after the primary tumor. PRESENTATION OF CASE: The patient presented as a 53yo man with a left upper quadrant mass and synchronous metastases to the spleen and liver (pancreatic neuroendocrine tumor T4N0M1, Stage IV), which were resected (CD56-, synaptophysin+, chromogranin+, Ki-67<1%). Over the next 90 months, he underwent five procedures to treat hepatic recurrences (2 liver resections and 3 percutaneous radiofrequency ablations). Serum PIVKA levels were elevated prior to treatment of four of six lesions and returned to baseline after therapy. He presents now, asymptomatic, with a right adrenal mass found on routine imaging and no other lesions. Serum PIVKA was elevated to 44mg/dL. The adrenal gland was resected and shown to be a metastasis (CD56+, synaptophysin+, chromogranin+, Ki-67 15-20%). DISCUSSION: This patient's clinical course reflects aggressive local therapy of the primary lesion and multiple metastatic lesions to three organs (liver, spleen, adrenal) over nearly eight years. The utility of serum PIVKA levels in patients with pancreatic neuroendocrine tumors is not previously reported and needs further investigation. CONCLUSION: This patient has a pancreatic neuroendocrine tumor with metastases to the spleen, liver and adrenal gland and elevated PIVKA levels with recurrent disease. These unique clinical features add to the diversity of clinical presentation of these rare tumors.

INTRODUCTION: The aim of this study was to compare the clinical outcomes of single-incision transumbilical laparoscopy-assisted appendectomy performed by surgical residents and attending surgeons. METHODS: We reviewed the clinical outcomes of 131 transumbilical laparoscopy-assisted appendectomies performed from January 2011 to June 2014. During the study period, 13 residents and 6 board-certified attending surgeons performed the procedures. For all operations performed by residents and attending surgeons, we reviewed and compared gender, age, BMI, body temperature, white blood cell count, C-reactive protein serum level, and the presence of a fecalith or abscess. Clinical outcomes including operative time, estimated blood loss, need for additional ports, conversion to open surgery, intraoperative complications, postoperative complications, and postoperative hospital stay were compared between the two groups. RESULTS: The mean preoperative white blood cell count in the resident-operated group was significantly higher than in the attending-operated group (14.0 vs 10.8 ×103 /mm3 , P = 0.007). There were no other significant differences in clinical variables between the two groups. Outcomes show that estimated blood loss was significantly higher (23.4 vs 9.8 mL, P = 0.031) and operative time tended to be longer (86.0 vs 72.0 min, P = 0.056) in the resident-operated group. No other significant differences were observed. CONCLUSION: Transumbilical laparoscopy-assisted appendectomy performed by residents is feasible and safe. It is an acceptable as a part of routine surgical training.