[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.

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.

[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.

[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.

Migration of non-absorbable polymer clips in hepato-biliary-pancreatic surgery: a report of four cases.

BACKGROUND: Ligation clips are used for vessel or tissue ligation in surgery. Although previous reports have described the migration of metallic clips after hepato-biliary-pancreatic surgery, very few reports have described the migration of non-absorbable polymer clips (NAPCs: Hem-o-Lok). CASE PRESENTATION: We present 4 cases of NAPC migration that occurred after laparoscopic surgery. Case 1 was an 81-year-old woman that had undergone a laparoscopic right hemihepatectomy for an intrahepatic bile duct cyst adenocarcinoma at the age of 79 years. Two years after the operation, she underwent an upper gastrointestinal endoscopy to investigate epigastric pain. The endoscopy showed NAPCs lodged at the anterior side of the duodenal bulb. Case 2 was an 80-year-old man that had undergone a laparoscopic cholecystectomy for choledocholithiasis at the age of 77 years. Three years after the operation, follow-up computed tomography and magnetic resonance cholangiopancreatography (MRCP) imaging indicated a mass in the upper bile duct. After a laparoscopic bile duct resection and reconstruction, an NAPC was found inside the inflammatory pseudotumor. Case 3 was a 63-year-old man that had undergone laparoscopic liver S4b and S5 resections and lymph node dissection for gallbladder cancer. Three months after the operation, follow-up MRCP imaging suggested a bile duct stenosis. An endoscopic retrograde cholangiopancreatography (ERCP) was performed, and an NAPC was found inside the bile duct. Case 4 was a 74-year-old man that had undergone a laparoscopic S5 segmentectomy, S7 partial liver resection, and cholecystectomy for liver metastasis of lung cancer and cholelithiasis. A trans-cystic drainage tube was inserted, and it was ligated and fixed with NAPCs. Three months after the operation, follow-up MRCP imaging showed common bile duct stones (CBDS). An ERCP was performed, and two NAPCs were found with the CBDS. CONCLUSIONS: Few previous reports have described complications due to NAPC migration after hepato-biliary-pancreatic surgery. However, with the widespread use of NAPC, postoperative complications due to NAPC migration are expected to increase in the near future. The differential diagnosis of complications should include potential NAPC migration in patients that have undergone laparoscopic surgery.

[A Case of Metachronous Quintuple Cancer Involving the Stomach, Rectum, Colon, Liver and Prostate].

Advances and improvements in cancer diagnosis and treatment have made it possible to find multiple primary cancers. We report here a rare case of metachronous quintuple cancer involving the stomach, rectum, colon, liver and prostate. An 80s‒ year‒old male was referred to our hospital with abnormality on upper GI series. He had undergone a distal gastrectomy in May 2005. Postoperative diagnosis was advanced gastric cancer (pT2N1M0, pStage ⅡA). In August 2006, anterior resection was performed with a diagnosis of advanced rectal cancer(pT3N0M0, pStage Ⅱa). For ascending colon polyps, endoscopic submucosal dissection was performed with a diagnosis of adenocarcinoma in adenoma(pTisN0M0, pStage 0)in September 2007. In June 2016, laparoscopic ileocecal resection was performed with a diagnosis of advanced cecum cancer(pT3N0M0, pStage Ⅱa). Follow up CT images showed a liver tumor in S4. Partial liver resection was performed in October 2010. Postoperative pathological diagnosis was hepatocellular carcinoma(pT2N0M0, pStage Ⅱ). Prostate cancer(cT2aN0M0)was treated by androgen deprivation therapy from February 2018. Although he had high‒frequency microsatellite instability, germline mutations in hMLH1 and hMSH2 genes were not detected. Histopathological examination showed that each tumor was an independent tumor and had not metastasized from any others. The patient had a good clinical course after these treatment until now.

[Long-Term Response of Nivolumab for Recurrent Lymph Nodes after Surgery for Gastric Cancer-A Case Report].

The patient was a 78-year-old man who underwent upper gastrointestinal endoscopy, revealing a sub-circumferential type 2 tumor in the lower body of the stomach. Histopathology revealed poorly differentiated adenocarcinoma. Computed tomography(CT)showed lymph node and liver metastasis(S6, S8), which corresponded to clinical Stage Ⅳ(cT4bcN2cM1 [HEP]). Five courses of XP therapy were administered for Stage Ⅳ disease. The sizes of the primary lesion and metastatic liver tumors were reduced, and a partial response was achieved. Distal gastrectomy and partial hepatectomy were performed. The resected specimen was diagnosed as ypT4b(transverse colon mesenteric), ypN0, ypM1(HEP). Thus, the final Stage was Ⅳ. During adjuvant chemotherapy with S-1, the para-aortic, left common iliac, and external peri-iliac lymph node metastases were detected by CT imaging 6 months after the operation. This prompted XP therapy resumption. The lymph node metastases worsened despite 2 additional XP courses. Progressive disease prompted the change in regimen to PTX plus RAM. After 7 courses, swollen lymph nodes were observed and CPT-11 was initiated. Since the disease continued to progress, nivolumab therapy was administered. The para-aortic, left common iliac, and external peri-iliac lymph nodes shrank after nivolumab initiation. The patient has responded well to nivolumab for more than 3 years without immunological adverse events.

[A Case of Stenosis at the Junction of the Renal Pelvis and Ureter after Laparoscopic Right Hemicolectomy].

A 50s year old woman was referred to former hospital for abdominal pain and melena. Colonoscopy revealed an ascending colon cancer(cT4aN1bM0, cStage Ⅲb, UICC)and gastrointestinal endoscopy revealed an esophagogastric junction cancer(cT1bN0M0, cStage ⅠA, UICC). Preoperative CT showed mild bilateral hydronephrosis. Laparoscopic right hemicolectomy( Lap-RHC, D3)was performed for ascending colon cancer then, and abdominal CT was taken 2 days before the robot-assisted proximal gastrectomy(RAPG, D1+). Right hydronephrosis was observed. No evidence of obvious ureteral damage was found during Lap-RHC. When retrograde pelvic ureterography was performed and a stenosis was found at the right renal pelvis and ureteral junction. It is considered that the ureter stenosis became prominent due to the postoperative inflammatory change of Lap-RHC. RAPG was performed as scheduled. Two months after discharge, a renal fistula was constructed. Pyeloplasty is scheduled to be performed in the future.

[A Long-Term Survival Case of Locally Advanced Unresectable Pancreatic Adenocarcinoma after Chemoradiotherapy and Conversion Surgery].

A 62-year-old man was referred to our hospital with complaints of upper abdominal pain and weight loss while being treated for diabetes mellitus at his family doctor. He was diagnosed as locally advanced unresectable pancreatic adenocarcinoma that involved superior mesenteric artery(SMA). Gemcitabine(GEM)and S-1 combined chemoradiotherapy(CRT) was administered. After CRT, CT test showed improved involvement of SMA, and radical resection was possible. We performed the radical pancreaticoduodenectomy and adjuvant chemotherapy, and he has been followed up for more than 5 years after the operation without recurrence. For locally advanced unresectable pancreatic adenocarcinoma, CRT or chemotherapy is recommended in the Pancreatic Cancer Practice Guidelines(2019 edition). However, the prognosis is extremely poor. We report a case of locally advanced unresectable pancreatic adenocarcinoma that was successfully curatively resected due to the good response of CRT.

[A Case of Cholangiocellular Carcinoma in Lynch Syndrome Treated by an Immune Checkpoint Inhibitor].

We report a case of cholangiocellular carcinoma(CCC)with high-frequency microsatellite instability(MSI-H)in Lynch syndrome that was managed using a multimodal treatment approach including an immune checkpoint inhibitor. The patient was a 74-year-old man who presented with fever as the chief complaint. He had a history of Vater's papilla cancer and colorectal cancer in Lynch syndrome. A diagnosis of CCC in the left lobe of the liver was made, and left hepatectomy and left caudate lobectomy were performed. From about 2 years and 5 months after the operation, the patient developed several episodes of cholangitis, and recurrence of CCC was diagnosed based on the results of biliary cytology. Gemcitabine and cisplatin therapy was started, but exacerbation of bile duct stenosis associated with cancer progression was observed, and pembrolizumab, an immune checkpoint inhibitor, was started as the solid cancer had an MSI-H status. The tumor markers then improved and the cholangitis subsided. We experienced a case of recurrence of CCC with MSI-H in Lynch syndrome managed by multimodal treatment including an immune checkpoint inhibitor.

[Laparoscopic Liver Resection for Cholangiolocellular Carcinoma-A Single Institutional Experience].

Cholangiolocellular carcinoma(CoCC)was first reported by Steiner et al in 1959. CoCC resembles cholangiocellular carcinoma( CCC)grossly and presents a variety of imaging findings, which often makes preoperative diagnosis difficult. In Japan, CoCC is rare, accounting for only 0.56% of primary liver cancers. We report the results of laparoscopic liver resection (LLR)for CoCC at our institution. Among 845 liver resections(678 LLR and 167 open liver resections)performed at Kansai Rosai Hospital from 2010 to 2020, only 13 were CoCC. Eight patients underwent LLR except for 5 patients who required vascular reconstruction and lymph node dissection. Median age was 71 years (55-77), gender was male/female(7/1), stage was Ⅰ/Ⅱ/Ⅲ/ⅣA(3/3/1/1), liver function was Child-Pugh A/B/C(7/1/0), and liver damage A/B/C(6/2/0). The preoperative diagnosis was 1 CoCC, 3 CCC and 4 HCC. The operative procedure was 3 Hr 0, 3 Hr 1 and 2 Hr 2. The operative time was 342 minutes(168-488), the blood loss was 51.3 g(0-400), and the postoperative hospital stay was 14 days(5- 53). The 5-year disease-free survival rate was 83.3%, and the 5-year overall survival rate was 85.7%. Recurrence was seen in 1 patient. The 5-year survival rate after curative resection of CoCC has been reported to be 73-83%, compared with 28- 36% for CCC. LLR for CoCC at our institution showed good perioperative results. Long-term results were comparable to those reported for liver resection. LLR for CoCC was considered an appropriate technique with good perioperative and long- term results.

[Short-Term Outcomes of Laparoscopic Surgery for Gallbladder Cancer-A Single Institutional Experience].

INTRODUCTION: Laparoscopic surgery is a safe, minimally invasive, and effective approach in managing abdominal malignancies. Laparoscopic anatomical resection has been covered by insurance in Japan since 2016. Here, we have reported the short-term outcomes of gallbladder cancer in laparoscopic cholecystectomy, gallbladder bed resection, or S4a/S5 liver resection with lymph node dissection. PATIENTS: Between May 2012 and December 2020, 28 patients underwent laparoscopic cholecystectomy for gallbladder cancer at Kansai Rosai Hospital. Two patients underwent laparoscopic choledochotomy with lymph node dissection, 6 patients underwent gallbladder bed resection, and 7 patients underwent S4a/S5 liver resection. The control group included 13 patients who received open surgery between July 2010 and November 2019. The patient age was 74.2 and 74.4 years, while the male to female ratio was 19/24 and 8/5 in the laparoscopic and open surgery groups, respectively. According to the Japanese Society of Hepato-Biliary-Pancreatic Surgery, the pathological stage was 0/Ⅰ/Ⅱ/Ⅲ A/ⅢB/ⅣA/ⅣB in 4/17/13/4/2/1/2 and 0/1/2/3/1/1/5 patients(p=0.0100)in the laparoscopic and open surgery groups, respectively. This study was approved by the Human Ethics Review Committee of Kansai Rosai Hospital(Certificate Number: 2101001). RESULTS: The laparoscopic surgery group had an average operation time of 223.3 minutes, an estimated blood loss of 18.7 g, and a hospital stay of 8.5 days. The open surgery group had an average operation time of 514.5 minutes, an estimated blood loss of 1,274.3 g, and a hospital stay of 33.9 days. There was no postoperative bleeding or bile leakage in both groups. After laparoscopic cholecystectomy, the 5-year disease-free survival rate was 100% among Stage 0 or Ⅰ patients, 64.8% among Stage Ⅱ patients, and 0% in Stage Ⅲ or Ⅳ patients. The 5-year overall survival rate was 100% among Stage 0 or Ⅰ patient and 66.7% among Stage Ⅱ patients. The 1-year overall survival rate was 50% among Stage Ⅲ or Ⅳ patients. After laparoscopic liver resection with lymph node dissection, the 5-year disease-free survival rate was 100% among Stage Ⅰ or Ⅱ patients and 66.7% among Stage Ⅲ or Ⅳ patients. The 5-year overall survival rate was 100% among Stage Ⅰ or Ⅱ patients and 62.5% among Stage Ⅲ or Ⅳ patients. CONCLUSION: Laparoscopic cholecystectomy in Stage 0 or Ⅰ patients and laparoscopic gallbladder bed resection or S4a/S5 liver resection with lymph node dissection were safe and effective approaches to gallbladder cancer management.

[Secondary Small Bowel Volvulus after Laparoscopic Pancreaticoduodenectomy].

Laparoscopic pancreaticoduodenectomy(LPD)is less invasive and provides better cosmetic outcomes than open pancreaticoduodenectomy( OPD). LPD without vascular excision and lymph node dissection has been covered by insurance since 2016 in Japan. On the other hand, secondary small bowel volvulus is a rare condition caused after abdominal operation. A 77-year-old woman underwent a laparoscopic pancreaticoduodenectomy with pancreatic cancer of pT2N0M0, pStageⅠB. She suffered from epigastric pain after meal. The abdominal CT revealed counterclockwise rotation of the SMV on SMA about 540 degree. Gastrointestinal endoscopy showed no abnormal findings in May 2017. Her abdominal pain was disappeared in July 2017. But the pain was recurred in May 2019. The abdominal CT revealed mesenteric edema and counterclockwise rotation about 810 degree. Her abdominal pain was disappeared again in February 2020. The counterclockwise rotation was decreased about 540 degree. Between May 2012 and February 2020, 50 patients underwent LPD at Kansai Rosai Hospital. 111 patients who received OPD between 2010 and February 2015 were included for comparison. No significant differences were noted between the LPD and OPD groups with respect to patient age(67.9 vs 70.3), gender(M/F: 31/19 vs 70/41). The intraoperative blood loss was lower(106 g vs 1,064 g, p<0.0001)and the operation time was longer (624 vs 535 min, p<0.0001)in the LPD group than the OPD group. Small bowel volvulus over 270 degree was 7/43 vs 5/106(p=0.0338), and over 360 degree was 6/44 vs 1/110(p=0.0014), respectively. Small bowel volvulus after pancreaticoduodenectomy was frequently observed in the laparoscopic group.