Laparoscopic distal pancreatectomy for pancreatic cancer is being applied increasingly in selected cases. Open radical antegrade modular pancreatosplenectomy (RAMPS) was introduced to obtain a higher rate of tumor-free margins and a higher lymph node (LN) count. However, there is no standard laparoscopic technique for pancreatic cancer. We treated three patients with RAMPS using a ligament of Treitz approach. We started each procedure by dissecting the ligament of Treitz. We entered and spread the anterior space of the aorta and inferior vena cava. We then dissected the LN of the root of the supra-mesenteric artery and performed RAMPS. The mean number LN retrieved from the patients was 43 ± 22. All three patients underwent pancreatectomy to obtain tumor-free margins, and two patients began adjuvant chemotherapy by postoperative day 14. The ligament of Treitz approach in laparoscopic modified RAMPS offered tumor-free margins and the resection of sufficient regional LN. The procedure also allowed adjuvant chemotherapy to be started early.

This report describes a case of carcinosarcoma of the duodenum. Carcinosarcoma of the duodenum is a very rare tumor. A 72-year-old man was referred to the hospital because of appetite loss. Endoscopy demonstrated an irregularly depressed lesion (type 3) in the descending portion of the duodenum opposite to the ampulla of Vater. Computed tomography showed a thickened duodenal wall and swelling of the abdominal para-aortic lymph nodes. A biopsy specimen revealed a well-differentiated adenocarcinoma. A diagnosis of duodenal carcinoma was made (cT3, cN1, cM1, cStage IV according to the TNM classification). A subtotal stomach-preserving pancreatoduodenectomy and a lymph node resection were performed. On microscopic examination, adenocarcinoma cells and spindle type sarcoma cells were observed separately in the descending portion of the duodenum opposite to the ampulla of Vater. The adenocarcinoma cells were stained with antibodies against epithelial markers keratin and carcinoembryonic antigen for immunohistochemical analyses. In contrast, the sarcoma cells were stained with antibodies to vimentin and smooth muscle actin. The pathological diagnosis of a true duodenal carcinosarcoma was thus made.

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Total remnant pancreatectomy after pancreaticoduodenectomy (PD) is a difficult procedure. Recently, distal pancreatectomy and PD have been performed laparoscopically. Herein, we present the first case report of a laparoscopic total remnant pancreatectomy. A 72-year-old woman underwent a totally laparoscopic pylorus-preserving PD for inferior bile duct cancer. The tumor was composed of moderately differentiated tubular adenocarcinoma and was diagnosed as pStage III according to the UICC-TNM classification. Eighteen months later, CT showed a low-density mass in the remnant pancreas. We conducted a total resection of the remnant pancreas laparoscopically. Histologically, it was diagnosed as a primary pancreatic cancer. The patient's postoperative course was uneventful. She was discharged on postoperative day 14. When an initial PD is performed laparoscopically, laparoscopic total remnant pancreatectomy is technically feasible and safe in selected patients.

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