Curative resection via right hemicolectomy and regional lymph node dissection for colonic adenomatous polyposis of unknown etiology with adenocarcinomas localized in the right side of the colon: a case report.

BACKGROUND: APC and MUTYH are both well-known colorectal polyposis causative genes. However, 30-50% of colorectal adenomatous polyposis cases are classified as colonic adenomatous polyposis of unknown etiology and lack identifiable pathogenic variants. Although guidelines recommend total proctocolectomy for colonic adenomatous polyposis of unknown etiology with over 100 adenomas, evidence is lacking. This study presents a unique case of localized colonic adenomatous polyposis of unknown etiology with multiple adenocarcinomas, treated with hemicolectomy and regional lymph node dissection. CASE PRESENTATION: The patient was a 72-year-old woman whose colonoscopy revealed numerous polyps and two adenocarcinomas localized in the right side of the colon, with no lesions in the left side. The patient had no family history of polyposis or colorectal cancer. No extracolonic lesions, enlarged lymph nodes, or distant metastases were found. Considering the patient's age and lesion localization, laparoscopic right hemicolectomy with regional lymph node dissection was performed. Histopathological diagnosis revealed three adenocarcinoma lesions with no lymph node metastasis. The most advanced pathological stage was T2N0M0 Stage I (UICC 8th edition). The patient was alive 5 years postoperatively, without recurrence of cancer or polyposis in the remaining colon and rectum. To diagnose hereditary colorectal cancer/polyposis, a germline multigene panel testing for APC, EPCAM, MBD4, MLH1, MLH3, MSH2, MSH3, MSH6, MUTYH, NTHL1, PMS2, POLD1, POLE, and TP53 was performed using DNA extracted from blood samples: however, no pathogenic variant was detected. Therefore, the patient was diagnosed with colonic adenomatous polyposis of unknown etiology. CONCLUSIONS: In this rare case, colonic adenomatous polyposis of unknown etiology, with numerous adenomatous polyps and multiple adenocarcinomas localized in the right side of the colon, was successfully treated with right hemicolectomy and regional lymph node dissection. Despite genetic analysis, no causative germline variants were identified. Segmental colectomy according to the distribution of polyps might be a curative approach.

[A Case of Hilar Cholangiocarcinoma Arising during Long-Term Follow-Up of Hepatolithiasis].

A 91-year-old man had a history of cholecystectomy and choledochostomy for cholecystolithiasis and choledocholithiasis. Eleven years earlier, intrahepatic stones were found in the posterior bile duct, and he did not wish to undergo treatment. Over time, worsening of the intrahepatic stones and dilation of the intrahepatic bile duct were observed. At 91 years old, enhanced abdominal CT revealed wall thickening of the hilar bile duct, and MRCP showed stenosis of the hilar bile duct. Endoscopic retrograde cholangiography showed no contrast in the right intrahepatic bile duct and marked dilation of the left intrahepatic bile duct. Brush cytology confirmed adenocarcinoma, leading to a diagnosis of hilar cholangiocarcinoma. He underwent open right and caudal lobectomy with biliary reconstruction. Histopathological examination revealed a hilar cholangiocarcinoma, T3N1M0, Stage Ⅲc, mainly located at the confluence of the right and left hepatic ducts. This case suggests a potential association between hepatolithiasis and hilar cholangiocarcinoma, emphasizing the importance of regular imaging examinations for timely surgical resection. Early intervention, including liver resection, is recommended for the management of hepatolithiasis.

[A Case of Repeat Pancreatectomy-Robotic Spleen-Preserving Distal Pancreatectomy after Robotic Pancreaticoduodenectomy].

Laparoscopic pancreaticoduodenectomy has been covered by insurance since 2016 in Japan, and advance laparoscopic and robotic pancreaticoduodenectomy has been also covered by insurance since 2020 in Japan. It has been reported that laparoscopic pancreatectomy causes few postoperative adhesions in the abdominal cavity and that repeat laparoscopic surgery could be performed. However, in robotic pancreatectomy, there have been no such reports yet. We reported that even after robotic pancreaticoduodenectomy, there were few adhesions in the abdominal cavity, and we were able to perform the robotic distal pancreatectomy with preservation of the splenic artery and vein. This suggested that robotic surgery was an effective treatment method for repeat pancreatectomy, given its low invasiveness and minimal adhesion.

Cardiac tamponade complicating esophagectomy and retrosternal gastric tube reconstitution in a patient with an abnormal ascending aorta position: a case report.

BACKGROUND: Cardiac tamponade is a rare postoperative complication of esophageal cancer surgery, which leads to rapid hemodynamic changes and can be fatal if not treated properly and promptly. Herein, we report a case of cardiac tamponade after thoracoscopic subtotal esophagectomy and retrosternal gastric tube reconstitution for esophageal cancer that was successfully treated with surgical drainage. CASE PRESENTATION: An 86-year-old man with lower thoracic esophageal cancer underwent thoracoscopic subtotal esophagectomy and retrosternal gastric tube reconstitution. No intra-operative complications were observed. On the first postoperative day, tachycardia and hypotension were observed, and pericardial effusion was identified on computed tomography images. The patient was diagnosed with obstructive shock secondary to cardiac tamponade. As percutaneous puncture drainage was not possible due to the presence of a retrosternal gastric tube, pericardiotomy with a small left anterior thoracotomy was performed, and a large amount of hematogenous fluid was drained, which instantly improved circulation. On the second postoperative day, the patient showed decreased pulse pressure, and computed tomography revealed a residual and enlarged hematoma around the right ventricle. The patient underwent surgical drainage and another pericardiotomy with a small right anterior thoracotomy was performed to drain the hematoma. At this time, multiple injuries to the fatty tissue, epicardium, and myocardium with active bleeding were observed on the anterior surface of the right ventricle near the root of the pulmonary artery. In this patient, the ascending aorta ran further to the right and dorsal sides than usual, causing the anterior wall of the right ventricle near the root of the pulmonary artery to be closer to the back of the sternum. This abnormality may have contributed to injury during the creation of the retrosternal pathway, leading to cardiac tamponade. CONCLUSIONS: Cardiac tamponade after esophagectomy can occur because of manipulation during creation of the retrosternal route, with an anomaly in the aortic position being present in this case. Gentle manipulation and selection of the reconstruction route according to the patient's condition are necessary in cases with such anatomical abnormalities.

Minimally invasive liver resection for cholangiolocellular carcinoma: A single-institution experience.

INTRODUCTION: Cholangiolocellular carcinoma (CoCC) resembles cholangiocellular carcinoma (CCC) and presents a variety of imaging findings; thus, preoperative diagnosis is often difficult. METHODS: We retrospectively studied patients who were diagnosed with CoCC at the Kansai Rosai Hospital from 2006 to 2021 and treated by laparoscopic liver resection (LLR) or open liver resection (OLR). RESULT: Among 918 liver resections, 15 patients were diagnosed with CoCC: 11 underwent LLR and 4 OLR. For LLR and OLR, respectively, patient age was 69.9 ± 6.8 and 72.8 ± 10.6, sex was M/F: 10/1 and 2/2, Child-Pugh was A/B/C: 10/1/0 and 4/0/0, liver damage was A/B/C: 8/3/0 and 4/0/0, preoperative diagnosis was CoCC/CCC/HCC: 1/2/8 and 2/2/0, pathological stage of Union for International Cancer Control (UICC) was IA/IB/II/IIIA/IIIB/IV: 8/0/2/1/0/0 and 0/0/3/0/1/0 (p = .0312), and extent of liver resection was Hr0/HrS/Hr1/Hr2/: 3/0/5/3 and 1/1/0/2. In LLR and OLR, respectively, operation time was 417.5 ± 191.0 and 407.5 ± 187.9 min, blood loss was 123.3 ± 217.4 and 1385.0 ± 1038.7 mL, and postoperative hospital stay was 12.2 ± 13.7 and 15.0 ± 6.6 days. For stages I and II/III, respectively, the 5-year disease-free survival rates were 100.0% and 34.3%, and the 5-year overall survival rates were 100.0% and 55.6%. For stage II/III LLR and OLR, respectively, the 3-year disease-free survival rates were 33.3% and 37.5% (p = .8418), and the 5-year overall survival rates were 66.7% and 50.0% (p = .8084). CONCLUSION: Although further studies are still needed to confirm, minimally invasive liver resection without lymph node dissection is one of a safe and effective approach to the management of CoCC.

[A Case of Multiple Postoperative Recurrence of Hepatocellular Carcinoma Successfully Treated with Atezolizumab plus Bevacizumab].

We report a case of postoperative multiple recurrence of hepatocellular carcinoma(HCC)treated with atezolizumab plus bevacizumab. A 73-year-old man with a chief complaint of abdominal distention was indicated a 90-mm-sized tumor extending from the lateral hepatic segment to the extrahepatic region by a contrast-enhanced CT scan of the abdomen. He underwent a laparoscopic liver resection of the lateral segment for suspected HCC, and was diagnosed as pStage Ⅱ HCC. Six months after surgery, multiple recurrent at intrahepatic lesions and suspected lymph node recurrence or peritoneal dissemination were observed, and tumor markers were markedly elevated. The patient was diagnosed with multiple intrahepatic and extrahepatic recurrences of postoperative HCC and started combination chemotherapy with atezolizumab (1,200 mg/body)plus bevacizumab(15 mg/kg). After the initiation of the therapy, tumor size reduction and normalization of tumor markers were observed, and at 17 months postoperatively, tumor size reduction has been maintained and tumor markers were in the normal range. We report a case of postoperative intrahepatic and extrahepatic multiple recurrences of he patocellular carcinoma treated with atezolizumab plus bevacizumab.

[The Investigation about Cases Performed Laparoscopic Pancreas-Sparing Duodenectomy in Our Hospital].

INTRODUCTION: There are few reports of surgery which preserve the function of pancreas for benign or low malignant tumors. While we have introduced laparoscopic pancreaticoduodenectomy (LPD), we have also performed laparoscopic pancreas-sparing duodenectomy (LPSD). In the present study, we investigated surgical techniques and results of LPSD. MATERIALS AND METHODS: Between October 2019 and January 2022, 3 patients were underwent LPSD. The procedure was performed after obtaining approval from the Ethics Review Committee of our hospital. RESULTS: Three patients conducted LPSD were all males with a median age of 74 years, and diagnoses were adenomas of duodenum in 2 cases and gastrointestinal stromal tumor of duodenum in 1 case. The median blood loss was small amount. The median operative time was 430 minutes, and the median postoperative hospital stay was 13 days. One of the cases was performed with conversion to HALS. In LPSD, an intraoperative ultrasonography and an intraoperative radiographic contrast study were performed to confirm that the ampulla of Vater was preserved. There were no postoperative complications. CONCLUSION: We experienced cases performed LPSD in our hospital. We need further research for feasibility and safety of the procedure.

[GEM plus CDDP Combination Therapy for Unresectable Biliary Tract Cancer-A Single Institution Experience].

BACKGROUND: Since a randomized phase Ⅲ trial conducted in the UK in 2009 showed the superiority of gemcitabine (GEM)plus cisplatin(CDDP)combination therapy over GEM monotherapy, GEM plus CDDP combination therapy has been first-line chemotherapy for unresectable biliary tract cancer. METHODS: GEM plus CDDP combination therapy was administered to 29 patients with unresectable biliary tract cancer from 2016 to 2021. RESULTS: The mean age was 71.9 years, male/ female 19/10. The target of chemotherapy was below, local progression was 3 cases, first distant metastasis 7 cases, metastatic recurrence 19 cases. The type of cancer was below, intrahepatic bile duct carcinoma was 8 cases, hepatic hilar bile duct carcinoma 6 cases, gallbladder carcinoma 5 cases, cystic duct carcinoma 1 case, distal bile duct carcinoma 6 cases, and papilla Vater's cancer 3 cases. The dosing period was 23.1 weeks(range 2-52 weeks). The relative dose intensities of GEM and CDDP were 73.7% and 75.1%. The adverse events were below, the hematological toxicities of Grade 3 or higher were neutropenia(65.5%), leukopenia(3.4%), and thrombocytopenia(10.3%). Non-hematological toxicities of Grade 2 or higher were fatigue(13.7%)and skin rash(6.9%). There was no interstitial pneumonia. The disease control rate was 66.7 %(complete response, n=0; partial response, n=6; stable disease, n=10; progressive disease, n=8). CONCLUSION: GEM plus CDDP combination therapy was safe to perform and was an effective treatment for unresectable biliary tract cancer.

The impact of weight loss during neoadjuvant chemotherapy on postoperative infectious complications and prognosis in patients with esophageal cancer: exploratory analysis of OGSG1003.

BACKGROUND: Neoadjuvant therapy followed by surgery is the standard treatment for locally advanced esophageal cancers. During neoadjuvant therapy, tumor-induced esophageal stenosis or adverse events often cause weight loss. However, little is known about the effects of weight loss during neoadjuvant therapy on postoperative complications or prognosis. We investigated the association between weight loss during neoadjuvant chemotherapy, postoperative infectious complications, and prognosis. METHODS: Data from OGSG1003, a randomized phase-II trial comparing two regimens of neoadjuvant chemotherapy, cisplatin and fluorouracil plus Adriamycin and cisplatin and fluorouracil plus docetaxel, for locally advanced esophageal squamous cell carcinoma were used. Body weight was measured before neoadjuvant chemotherapy and esophagectomy. Multivariate analysis for infectious complications and prognosis was performed. RESULTS: The study included 134 patients. The median weight loss during neoadjuvant chemotherapy was 2.83% (-2.07% to 6.29%). Postoperative infectious complications were observed in 37 patients who had a significantly higher weight loss during neoadjuvant chemotherapy (5.18% vs. 1.90%, P = 0.002). Multivariate analysis revealed that > 5% of weight loss during neoadjuvant chemotherapy was the only independent factor associated with postoperative infectious complications (odds ratio 2.69, 95% confidence interval 1.12-6.46, P = 0.027). Weight loss during neoadjuvant chemotherapy was significantly associated with worse recurrence-free survival in the univariate analysis (log-rank test, P = 0.002), but this association was marginal in the multivariate analysis (hazard ratio 1.73, 95% confidence interval 0.98-3.08, P = 0.058). CONCLUSIONS: Severe weight loss during neoadjuvant chemotherapy was an independent risk factor for postoperative infectious complications. Weight maintenance during neoadjuvant chemotherapy may reduce the incidence of postoperative infectious complications.

[Robotic and Laparoscopic Pancreaticoduodenectomy for the Elderly Patients-A Single Institutional Experience].

INTRODUCTION: Laparoscopic pancreaticoduodenectomy(LPD)has been covered by insurance since 2016 in Japan. Advance LPD and robotic pancreaticoduodenectomy(RPD)has been also covered by insurance since 2020 in Japan. The aim of this study was to analyze the perioperative results and outcomes of RPD and LPD for the elderly patients and to compare to the non-elderly patients. PATIENTS AND METHOD: Between July 2020 and April 2023, 67 patients underwent RPD and between May 2012 and February 2021, 63 patients underwent LPD at Kansai Rosai Hospital. Sixty-seven RPD and 62 LPD patients without extended resection were divided into 2 groups those who were over 75 years old(R/LPD E)(n=55)and under 74 years old(R/LPD non-E)(n=74). Control patients who received open pancreaticoduodenectomy(OPD)without extended resection between April 2010 and April 2023 were also divided into 2 groups those who were over 75 years old(OPD E)(n =60)and under 74 years old(OPD non-E)(n=78). The patient age was 79.0 and 60.5 years, the male to female ratio was 35/20 and 45/29, disease ratio(invasive ductal carcinoma or not)was 7/48 and 9/65 in R/LPD E and R/LPD non-E groups, respectively. The patient age was 79.0 and 79.5 years, the male to female ratio was 35/20 and 31/29, disease ratio (invasive ductal carcinoma or not)was 7/48 and 30/30(p<0.0001)in R/LPD E and OPD E groups, respectively. This study was approved by the Human Ethics Review Committee of Kansai Rosai Hospital(Certificate Number: 2001019). RESULTS: The average operation time was 644.6 and 675.2 minutes, an estimated blood loss was 220.8 and 134.4 g, postoperative pancreatic fistula(ISGPS 2016, [-]/BL/Grade B/C)was 24/18/13/0 and 28/25/21/0, delayed gastric emptying(ISGPS 2007, [-]/Grade A/B/C)was 48/0/4/3 and 61/2/6/5 and postoperative hospital stay was 27.9 and 25.9 and in R/LPD E and R/LPD non-E groups, respectively. No significant differences were noted between the groups, However, postoperative complication over Ⅲa Clavien-Dindo classification was 8(15.7%)and 3(4.4%)cases(p=0.0319)in R/LPD E and R/ LPD non-E groups. The average operation time was 644.6 and 492.1 minutes(p<0.0001), an estimated blood loss was 220.8 and 534.8 g(p=0.0004), postoperative pancreatic fistula(ISGPS 2016, [-]/BL/Grade B/C)was 24/18/13/0 and 27/8/24/1(p=0.0442), postoperative hospital stay was 27.9 and 42.0(p=0.0490)in R/LPD E and OPD E groups, respectively. CONCLUSION: The R/LPD was undergone in safety, even for the over 75 years old patients.

[A Case of TMB-High Recurrent Peritoneal Seeding in Hilar Cholangiocarcinoma Treated with Pembrolizumab Therapy].

Tumor mutation burden(TMB)-High is known to potentially elicit a favorable response to immune checkpoint inhibitors. In this report, we present a case of recurrent hilar cholangiocarcinoma with TMB-High, in which we performed comprehensive treatment including immune checkpoint inhibitor pembrolizumab. The patient was a 58-year-old male diagnosed with hilar cholangiocarcinoma who underwent extended right hepatectomy, caudate lobe resection, bile duct excision, and bile duct reconstruction. Postoperatively, peritoneal seeding recurrence and liver metastasis were observed, indicating TMB-High. Therefore, pembrolizumab therapy was administered. The tumor marker CA19-9 significantly decreased, and the peritoneal seeding and liver metastatic lesions disappeared on imaging. In this case, we experienced the use of pembrolizumab monotherapy for TMB-High recurrent bile duct cancer with early postoperative peritoneal seeding recurrence. Further accumulation of cases is needed, but pembrolizumab monotherapy holds promise as a treatment option for TMB-High bile duct cancer at the hepatic hilum.

[Laparoscopic Liver Resection for the Elderly Hepatocellular Carcinoma Patients-A Single Institutional Experience].

INTRODUCTION: Laparoscopic liver resection(LLR)has been reported as a safe, minimally invasive, and effective approach to the management of liver tumor. The aim of this study was to analyze the perioperative results and outcomes of LLR for the elderly hepatocellular carcinoma(HCC)patients and to compare to the non-elderly HCC patients. PATIENTS AND METHOD: Between May 2010 and November 2021, 725 patients(HCC 407, CRC Mets 171, others 147)patients underwent LLR at Kansai Rosai Hospital. 407 patients who underwent LLR for HCC were divided into 2 groups those who were over 80 years old(n=67)and under 79 years old(n=340). The patient age was 82.7 and 68.8 years, while the male to female ratio was 41/26 and 238/102 in the elderly and non-elderly groups, respectively. According to the liver cancer study group of Japan, the pathological Stage 0/Ⅰ/Ⅱ/Ⅲ/Ⅳ was 23/34/8/2 and 117/146/57/20 patients(p=0.1086)in the elderly and non- elderly groups, respectively. This study was approved by the Human Ethics Review Committee of Kansai Rosai Hospital(Certificate Number: 2101006). RESULTS: The elderly group had an average operation time of 316.1 minutes, an estimated blood loss of 277.3 g, and a hospital stay of 14.3 days. The non-elderly group had an average operation time of 347.2 minutes, an estimated blood loss of 233.7 g, and a hospital stay of 12.9 days. No significant differences were noted between the elderly patients and the non-elderly patients with respect to the rate of procedure, operation time, intraoperative blood loss, hospital stay, morbidity, and postoperative laboratory data. CONCLUSION: The LLR was undergone in safety, even for the over 80 years old patients. The results of LLR for HCC over 80 years old were comparable both in short-term results with under 79 years old group. It was considered that the minimally invasiveness of LLR allows comparable surgical treatment for the elderly with non-eldery.

[Laparoscopic Liver Resection for Liver Metastasis of Colorectal Cancer].

The laparoscopic surgery is less invasive and better cosmetic. The laparoscopic liver resection(LLR)has been accepted for the insurance in April 2010, and increasingly performed in many hospitals, and also expected in metastasis of colorectal cancer. We retrospectively examined the results of LLR for liver metastasis of colorectal cancer. From June 2010 to July 2021, 174 cases of LLR for liver metastasis of colorectal cancer were performed in our hospital. The operation time was 384.5 minutes, the blood loss was small amount, and the postoperative hospital stay was 8 days. The complications were post-bleeding in 1 case, bile leakage in 7 cases, SSI in 16 cases, and no surgery-related deaths were observed. The 3-year disease-free survival rate was 22.8%, and the 5-year overall survival rate was 53.3%. In the comparison between single LLR and multiple LLR, the operation time and the blood loss increased, but there was no significant difference in the length of postoperative hospital stay. In initial LLR and repeat LLR, there were no significant differences in the operation time, blood loss, and postoperative hospital stay. In the primary lesion and simultaneous LLR and heterochronous LLR, the operation time and blood loss were not significantly different, but postoperative intra-abdominal abscess and SSI were more happened, and the postoperative hospital stay was significantly extended. LLR for liver metastasis of colorectal cancer can be safely performed at multiple sites or multiple times, and good treatment results have been obtained, so it was considered to be an effective treatment method.

[Experience with Thoracoscopic and Endoscopic Cooperative Surgery for Gastric Tube Cancer after Thoracic Esophagectomy].

Surgical treatment of gastric tube cancer after thoracic gastrectomy is highly invasive, especially for gastric tube cancer of the posterior mediastinal tract, and in some cases, a reduction surgery is an option. We have experienced 4 cases of posterior mediastinal reconstructive gastric tube cancer in which local resection by thoracoscopic and endoscopic cooperative surgery( TECS)was conducted. All cases had undergone video-assisted thoracoscopic subtotal esophagectomy and posterior mediastinal gastric tube reconstruction for thoracic esophageal cancer. In 1 case, endoscopic submucosal dissection was performed, but it showed positive for vertical margins. Other cases were not indicated for endoscopic resection. Considering the patient's background, we decided to preserve the gastric tube and planned local resection by TECS. One patient was transferred to open thoracotomy due to severe adhesion, and 1 patient underwent segmental resection and 2-stage reconstruction due to narrowing of the gastric tube lumen at the suture closure. In all cases, the resection margins were negative and the patients are alive without recurrence of gastric tube cancer. Local resection of gastric tube with TECS for posterior mediastinal tract reconstructive gastric tube cancer may be useful as a less invasive surgical treatment.

[Techniques and Short-Term Outcomes of Robotic Pancreaticoduodenectomy].

INTRODUCTION: Laparoscopic pancreaticoduodenectomy(LPD)has been covered by insurance since 2016 in Japan. Advance LPD and robotic pancreaticoduodenectomy(RPD)has been also covered by insurance since 2020 in Japan. We report our technique and the short-term outcome of RPD performed in our institution. SURGICAL PROCEDURES: As a first step, the resection phase was performed laparoscopically. Pancreato-jejunostomy and choledocho-jejunostomy were performed robotically (hybrid-RPD). As a second step, Kocher maneuver and jejunal transection were performed laparoscopically. Other procedures were performed robotically(modified-RPD). As a final step, all procedures were performed robotically(pure-RPD). SURGICAL TECHNIQUES: RPD is performed in reverse Trendelenburg supine position. An extended Kocher maneuver is performed. The common bile duct is then identified and transected after proximal aspect is secured with a surgical bulldog clamp. IPDA is divided by using an energy device after clip placement. The pancreatic neck is then divided with the use of scissors. Pancreato-jejunostomy was performed by modified Blumgart and pancreatic duct to jejunal mucosa method. Choledocho- jejunostomy was performed with continuous and interrupted suturing. PATIENTS AND METHOD: Between 2020 and 2022, 45 patients underwent RPD at our institution. Cases were divided into hybrid-RPD(n=20), modified-RPD(n=9) and pure-RPD(n=16). RESULTS: No significant differences were noted between hybrid-RPD, modified-RPD and pure-RPD groups with respect to patient age(73.6, 68.7, 70.6 years old), gender(male/female 15/5, 6/3, 8/8), respectively. The operation time was longer(667, 770, 746 minutes)and the resection time was longer(286, 399, 380 minutes)in modified- RPD and pure-RPD than hybrid-RPD group. In the pure-RPD group, the resection time was decreasing(y=-12.0×+ 481.5)as a learning curve. No significant differences were noted between hybrid-RPD, modified-RPD and pure-RPD groups with respect to reconstruction time(388, 371, 367 minutes)and the estimated blood(261, 199, 293 mL), respectively. All postoperative pancreatic fistula was under Grade B. CONCLUSION: Although further studies are still needed to confirm the benefit of RPD, RPD is safe, minimally invasive, and effective approach to the management of pancreatic tumor.

Successful treatment of remnant gastric cancer with afferent loop syndrome managed by percutaneous transhepatic cholangial drainage followed by elective gastrectomy: a case report.

BACKGROUND: There are only few reported cases of remnant gastric cancer with concomitant afferent loop syndrome. Emergency surgery is the standard treatment strategy for this disease. However, some afferent loop syndrome cases, especially those with complete obstruction, can lead to a septic state, which makes performing emergency surgery risky. We describe a case of remnant gastric cancer with complete afferent loop obstruction, which was successfully managed by radical surgery following percutaneous transhepatic cholangial drainage of the afferent loop. CASE PRESENTATION: A 71-year-old man presented with nausea and abdominal discomfort. When he was 27 years old, he had undergone distal gastrectomy for a benign gastric ulcer, with gastrojejunostomy (Billroth II reconstruction). Abdominal computed tomography revealed thickening of the anastomosis site and significant dilation of the afferent loop. Gastrointestinal fiberscopy revealed advanced remnant gastric cancer at the anastomosis site, and the stoma of the afferent loop was completely obstructed. We diagnosed the patient with remnant gastric cancer with afferent loop syndrome. Percutaneous transhepatic cholangial drainage was performed twice before surgery to decompress the afferent loop. This provided more time for the patient to recover. Radical surgery of total remnant gastrectomy and Roux-en-Y reconstruction were performed electively. There were no severe postoperative complications. The patient died 8 months following the operation owing to peritoneal dissemination recurrence. CONCLUSION: We encountered a case of remnant gastric cancer with afferent loop obstruction, which was successfully managed by radical surgery following decompression of the afferent loop by percutaneous transhepatic cholangial drainage. Percutaneous transhepatic cholangial drainage effectively managed the afferent loop syndrome, resulting in the safe performance of elective surgery.

[Robotic Surgery Can Complete Radical Surgery and Urinary Tract Reconstruction for Locally Advanced Rectal Cancer with Ureteral Invasion-A Case Report].

A 82-year-old man presented with diarrhea and fatigue. He had no past medical or surgical history except chronic renal failure. Locally advanced rectal cancer with invasion to left ureter was detected in computed tomography. Colonoscopy revealed a circular lesion 12 cm from the anal verge. Biopsy showed moderately differentiated adenocarcinoma. There was no sign of distal metastasis and we decided to conduct radical surgery. Robot-assisted laparoscopic lower anterior resection with partial resection of left ureter, and diverting ileostomy were carried out. Besides, urinary tract reconstruction of ureterocystoneostomy using Lich-Gregoir technique was conducted by urologists also with robot assistance. The pathological stage of the disease was pT4b(left ureter)N1bM0, pStage Ⅲc. The resection margin was secured and radical surgery was achieved. The patient was discharged on postoperative day 22nd without postoperative complication. He is alive without recurrence at 6 months after the operation.