Phosphorylated mTOR expression as a predictor of survival after liver resection for colorectal liver metastases.

BACKGROUND: Phosphorylated mammalian target of rapamycin (p-mTOR) plays a crucial role in the process of cancer progression. Common gene mutations of colorectal cancer lead to the activation of the PI3k/Akt/mTOR pathway. In this study, we determined whether p-mTOR expression in colorectal liver metastases is a predictive marker of prognosis following liver resection. METHODS: Eighty-one patients with colorectal liver metastases who had undergone curative resection were evaluated using immunohistochemistry of p-mTOR. Data regarding clinicopathological features and patient survival were analyzed. RESULTS: The p-mTOR expression in colorectal liver metastases was detected in 55 (67.9%) patients. Patients whose metastases had high p-mTOR expression showed a significantly lower overall survival rate after resection as compared to patients with low p-mTOR expression (p = 0.016), while there was no significant difference in the disease-free survival between the two groups. Repeat resection for recurrence was performed more frequently in patients with p-mTOR positive than others (p = 0.024). Multivariate analysis showed that p-mTOR expression was an independent prognostic factor of overall survival after liver resection (p = 0.019). CONCLUSIONS: mTOR was frequently activated in colorectal liver metastases, and the p-mTOR expression was a biological marker for predicting the overall survival of patients with colorectal liver metastases following liver resection.

[A Case Report of Cancer Chemotherapy for Disseminated Carcinomatosis of the Bone Marrow Associated with Gastric Cancer Accompanied by Disseminated Intravascular Coagulation].

A 72-year-old woman was admitted to our hospital because of symptoms of bleeding diathesis such as hematuria and purpura. A blood test revealed disseminated intravascular coagulation(DIC). Upper gastrointestinal endoscopy showed advanced gastric cancer. Bone marrow aspiration cytology demonstrated diffuse hyperplasia of large atypical cells, and metastasis of the epithelial tumor was suspected on immunohistochemical examination. She was diagnosed with disseminated carcinomatosis of the bone marrow associated with gastric cancer accompanied by DIC. She was treated with weekly infusion of methotrexate 100 mg/m2 plus 5-fluorouracil 600 mg/m2 for 4 courses; and she completely recovered from DIC. She received oral tegafur/gimeracil/oteracil as an outpatient. However, DIC recurred 126 days after the initial chemotherapy, and 5-fluorouracil plus cisplatin was administered subsequently. After 1 course, she died 166 days after the initial chemotherapy. Although the prognosis of patients with disseminated carcinomatosis of the bone marrow associated with gastric cancer accompanied by DIC is extremely poor, this case shows that secession of DIC and prognostic improvement by chemotherapy could occur. Chemotherapy could be considered a potentially effective treatment in this case.

Splenic enlargement induced by preoperative chemotherapy is a useful indicator for predicting liver regeneration after resection for colorectal liver metastases.

BACKGROUND: Conversion chemotherapy may downsize unresectable colorectal liver metastases (CRLMs), but may cause liver injury and splenic enlargement. The effect of preoperative chemotherapy on liver regeneration after liver resection remains undetermined. The aim of this study was to examine whether splenic enlargement induced by preoperative chemotherapy is an indicator to identify high-risk patients for impaired liver regeneration and liver dysfunction after resection. METHODS: We retrospectively reviewed 118 Japanese patients with CRLMs. Fifty-one patients had conversion chemotherapy. The other 67 patients underwent up-front liver resection. We clarified effects of conversion chemotherapy on splenic volume, liver function, and postoperative liver regeneration. Perioperative outcome was also analyzed. RESULTS: A ratio of the splenic volume before and after chemotherapy (SP index) in the oxaliplatin-based chemotherapy group was significantly greater than other chemotherapy groups after 9 or more chemotherapy cycles. Patients whose SP index was 1.2 or more had significantly higher indocyanine green retention rate at 15 min (ICG-R15) than patients without chemotherapy. Analyses of covariance showed liver regeneration rate after resection was decreased in patients whose SP index was 1.2 or more. The incidence of postoperative liver dysfunction in patients whose SP index was 1.2 or more was significantly greater than patients without chemotherapy. Multivariate analysis showed SP index was a significant predictive factor of impaired liver regeneration. CONCLUSIONS: Splenic enlargement induced by preoperative chemotherapy was a useful indicator for impaired liver regeneration after resection and a decision-making tool of treatment strategy for unresectable CRLMs.

Combined hepatic arterial resection in pancreatic resections for locally advanced pancreatic cancer.

PURPOSE: Arterial involvement in advanced pancreatic cancer generally defines local unresectability. This study was aimed to evaluate the clinical outcomes of combined common hepatic arterial resection with pancreaticoduodenectomy or total pancreatectomy in patients with locally advanced pancreatic cancer involving the hepatic artery. METHODS: Of 348 patients with pancreatic head cancers who underwent surgical resection between June 1999 and September 2015, 21 underwent combined common hepatic arterial resection with pancreaticoduodenectomy (17) or total pancreatectomy (4). Preoperative common hepatic arterial embolization was performed in 12 patients. Preoperative CT findings of hepatic arterial involvement, postoperative complications, survival rates, and prognostic factors for survival were analyzed. Twenty-one unresectable patients with locally advanced pancreatic cancer who underwent laparotomy in this study period were selected as the control group. RESULTS: Rates of pathological arterial invasion were significantly higher in patients with level III (>1800) CT findings (90%,9/10) than in patients with levels I and II (<1800) (27%, 3/11) (p < 0.01). No surgical deaths occurred. Survival after surgical resection in all 21 patients was 47.6%, 6.6%, and 6.6% at 1, 3, and 5 years, and median survival was 11 months. The preoperative serum CA19-9 level was a significant prognostic factor for overall survival, median survivals were 21.5 and 8.3 months in the low CA19-9 and high CA19-9 groups, respectively. No significant difference in survival between the high-CA19-9 group and the unresectable group was found. CONCLUSIONS: Combined common hepatic arterial resection in pancreaticoduodenectomy or total pancreatectomy might be feasible with an acceptable rate of surgical complications, and may have a beneficial effect on the prognosis only in patients with low preoperative serum CA19-9 levels.

Downsizing Chemotherapy for Initially Unresectable Locally Advanced Biliary Tract Cancer Patients Treated with Gemcitabine Plus Cisplatin Combination Therapy Followed by Radical Surgery.

BACKGOUND: We have treated patients with initially unresectable locally advanced biliary tract cancer (BTC) by administering gemcitabine and have found that surgical resection became feasible in some downsized patients. The aim of this study was to investigate the usefulness of downsizing combination chemotherapy using gemcitabine plus cisplatin to treat initially unresectable locally advanced BTC. METHODS: The subjects of the study were 150 consecutive patients who were treated for BTC between October 2011 and April 2014. Downsizing chemotherapy was carried out for 39 patients (26.0 %) whose lesions were unresectable because of locally advanced BTC. RESULTS: Reduction in tumor size with downsizing chemotherapy was seen in 18 patients, and surgical resection was performed in 10 of 39 patients (25.6 %). Median survival time in patients with surgical resection following downsizing chemotherapy and those with chemotherapy alone was 17.9 and 12.4 months, respectively (p = 0.0378). According to the historical comparison between gemcitabine and gemcitabine plus cisplatin chemotherapy, there is no significant difference in overall survival. However, there was a significant difference for the pathologic response rate (≥Grade III) to be higher in patients with gemcitabine plus cisplatin chemotherapy compared with gemcitabine monotherapy. CONCLUSIONS: Preoperative downsizing chemotherapy with gemcitabine plus cisplatin provides longer survival by the conversion to the surgical resection in patients with initially unresectable locally advanced BTC. It may have the potential for disease eradication as a new multidisciplinary approach for initially unresectable locally advanced BTC.

[A Case of Long-Term Survival in a Patient with Colorectal Liver Metastasis Treated with Multidisciplinary Therapy].

A-71-year-old man underwent right hemicolectomy combined with partial resection of the small intestine and duodenum for an ascending colon carcinoma in July 2009. He presented with a liver metastasis adjacent to the inferior vena cava in November 2009. He received 6 courses of FOLFOX4, but the therapeutic effect was SD, so he underwent an extended posterior sectionectomy combined with partial S8 resection, inferior vena cava resection, and cholecystectomy. He developed remnant liver recurrence in February 2011 and another partial S8 resection was performed. He presented with remnant liver recurrence in October 2011, and radiofrequency ablation and systemic chemotherapy were performed, but were not effective. In June 2013, we performed an extended S8 segmentectomy combined with median hepatic vein and diaphragm resection. He is alive 2 years after the third hepatectomy without any recurrence. Although non-anatomical resection is often performed in repeat liver resections for colorectal liver metastases, sometimes detection of recurrent lesions in the same segment indicates Glisson invasion; therefore, anatomic resection may prolong long-term survival.

[Hepatocellular Carcinoma with Vp3 Tumor Thrombosis Treated with Multidisciplinary Treatment--Report of Two Cases].

Hepatic resection of hepatocellular carcinoma (HCC) with portal vein tumor thrombus (PVTT) at the bifurcation of the portal has the potential to cure the disease. Herein, we report 2 cases of HCC with Vp3 treated with a multidisciplinary approach that might include preoperative transcatheter arterial chemoembolization (TACE) or postoperative hepatic arterial infusion chemotherapy (HAIC). Case 1: A 73-year-old man was diagnosed with HCC with Vp3 located in segment 1 during follow up that was treated by performing a left hepatectomy with removal of the tumor thrombus. After surgery, the patient underwent HAIC, and he was alive without disease recurrence 2 years and 2 months after surgery. Case 2: A 77-year-old man with cirrhotic nonalcoholic steatohepatitis underwent liver resection followed by TACE. However, recurrent HCC with Vp3 was detected in segments 2 and 5, so we performed a repeat liver resection. The patient was alive without disease recurrence 1 year and 8 months after surgery without having received postoperative adjuvant chemotherapy. In select patients diagnosed with HCC with PVTT (Vp3/4), long-term survival can be obtained with multidisciplinary treatment such as surgery and preoperative TACE or postoperative HAIC.

Pancreaticoduodenetomy combined with hepatic artery resection following preoperative hepatic arterial embolization.

BACKGROUND: The possibility of resection for locally advanced pancreatic ductal adenocarcinoma (PDAC) with involvement of hepatic or superior mesenteric artery is low. The treatment strategy for these locally advanced PDAC needs to be elucidated. METHODS: We retrospectively reviewed the medical records of 107 patients undergoing pancreaticoduodenectomy for PDAC between 2007 and 2012. Among these patients, seven patients who had unresectable PDAC because of cancer involvement of hepatic artery underwent preoperative hepatic arterial embolization and subsequent pancreaticoduodenectomy combined with resection of hepatic artery without reconstruction (PDCAR). We specifically focused on these seven patients to clarify the benefit and drawback of PDCAR. RESULTS: Serum alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels on 1 day after hepatic arterial embolization increased, but returned to baseline before pancreaticoduodenectomy. There was no arterial embolization-related complication before surgery. Serum ALT and AST levels increased 1 day after surgery, but thereafter returned to baseline. Although postoperative morbidity such as hepatic infarction was observed in one case, there were no in-hospital deaths. The median survival time was 12.6 months and 5-year survival rate was 19%. CONCLUSION: Preoperative hepatic arterial embolization and subsequent PDCAR might be a feasible procedure in selected patients with unresectable locally advanced PDAC with hepatic artery involvement.

Preoperative immunonutrition decreases postoperative complications by modulating prostaglandin E2 production and T-cell differentiation in patients undergoing pancreatoduodenectomy.

BACKGROUND: An immune-enhancing diet has been used to alter eicosanoid synthesis, cytokine production, and immune function in an attempt to limit the undesired immune reactions after injury from surgery. This prospective randomized study was designed to investigate the effect of preoperative immunonutrition on operative complications, and the participation of prostaglandin E2 (PGE2) on T-cell differentiation in patients undergoing a severely stressful surgery. METHODS: The enrolled patients who were scheduled to undergo pancreatoduodenectomy were randomized into two groups. Patients in the immunonutrition group (n = 25) received oral supplementation containing arginine, ω-3 fatty acids, and RNA for 5 days before the procedure in addition to a 50% reduction in the amount of regular food. Patients in the control group (n = 25) received no artificial nutrition and were allowed to consume regular food before surgery. All patients received early postoperative enteral infusion of a standard formula intended to provide 25 kcal/kg/day. The primary endpoint was the rate of infectious complications; the secondary endpoint was immune responses. This study is registered with ClinicalTrials.gov (NCT01256034). RESULTS: Infectious complication rate and severity of complications (Clavien-Dindo classification) were lesser in the immunonutrition group than in the control group. mRNA expression levels of T-bet were greater in the immunonutrition group than in the control group (P < .05). Serum eicosapentaenoic acid and eicosapentaenoic acid/arachidonic acid ratios were greater in the immunonutrition group than in the control group (P < .05). The levels of plasma PGE2 were lesser in the immunonutrition group than in the control group (P < .05). CONCLUSION: Preoperative immunonutrition modulates PGE2 production and T-cell differentiation and may protect against the aggravation of operative complications in patients undergoing pancreatoduodenectomy.

Surgical strategy for hilar cholangiocarcinoma of the left-side predominance: current role of left trisectionectomy.

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.

Left hepatic trisectionectomy for hepatolithiasis with occluded left and right anterior branches of the portal vein: report of a case.

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.

Protective effects of simultaneous splenectomy on small-for-size liver graft injury in rat liver transplantation.

Splenectomy is an effective technique in living donor liver transplantation (LDLT) with small-for-size (SFS) liver grafts for overcoming SFS liver graft injury. However, the protective mechanism of splenectomy is still unclear. The aim of this study was to investigate how splenectomy could attenuate SFS graft injury through the measurement of biochemical factors, particularly the expression of endothelin (ET)-1, which is a key molecule of microcirculatory disorders by mediating sinusoidal vasoconstriction. We performed rat orthotopic liver transplantation using SFS liver grafts with or without splenectomy. We investigated intragraft expression of ET-1 mRNA and hepatic protein levels of ET-1. In addition, portal pressure, hepatic injury and morphological changes, and survival rate were evaluated. In result, intragraft ET-1 mRNA expression after SFS liver transplantation was significantly downregulated by splenectomy, and hepatic expression of ET-1 in SFS grafts was rarely observed. Splenectomy inhibited the increase in portal pressure, ameliorated SFS liver graft injury and improved the graft survival rate after SFS liver transplantation. In conclusion, splenectomy improved the SFS liver injury and decreased the expression of ET-1 by attenuating portal hypertension on SFS liver transplantation. Downregulation of intragraft ET-1 expression plays important roles in the protective mechanism of splenectomy in SFS liver transplantation.

Optimal cut-off value for the number of colorectal liver metastases: a project study for hepatic surgery of the Japanese Society of Hepato-Biliary-Pancreatic Surgery.

BACKGROUND: The optimal cut-off value of the number of colorectal liver metastases (CRLM) to predict prognosis after hepatic resection remains unclear. This study was conducted to determine a suitable cut-off value. METHODS: A total of 727 hepatectomized patients with CRLM were evaluated. We proposed the following optimal cut-off values: first, a small P-value for the log-rank test with no overlapping of the 95% confidence interval (CI) for median survival time using the Kaplan-Meier method and the hazard ratio (HR) using the Cox proportional hazards model and, second, the maximum HR value for accurate separation. RESULTS: For disease-free survival analysis, of the three group separations, A2 (1, 2-4, and ≥5) showed a small P-value and the largest HR, whereas two group separations, B2, B3 and B4 showed similarly small P-values, but B4 (1-4, ≥5) indicated the largest HR. Regarding the overall survival analysis, of the three group separations, A2 showed the smallest P-value, whereas the two group separations, B4 showed similarly small P-values, with the largest HR. CONCLUSIONS: Tumor number separation in patients with CRLM after hepatic resection should be performed using the A2 (1, 2-4, and ≥5) or B4 (1-4 and ≥5) classifications.

Repeat pancreatectomy for pancreatic ductal cancer recurrence in the remnant pancreas after initial pancreatectomy: is it worthwhile?

BACKGROUND: The clinical implications of repeat completion pancreatectomy for recurrent pancreatic cancer in the remnant pancreas after initial pancreatectomy have not been clarified. We retrospectively analyzed our patients and evaluated the clinical implications of repeat pancreatectomy for isolated local recurrence in the remnant pancreas after initial resection for pancreatic cancer. METHODS: One-hundred seventy patients who had recurrence of pancreatic cancer out of 326 patients who had initially undergone resection for pancreatic cancer were included in this study. Sixty-seven of 170 recurrent patients were diagnosed as having isolated local recurrence of pancreatic cancer. Eleven of these 67 patients with isolated local recurrence only in the remnant pancreas underwent repeat pancreatectomy. Characteristics and operative outcomes for these 11 patients with repeat pancreatectomy were analyzed and evaluated in comparison with other recurrent patients. RESULTS: Among 170 patients with recurrence after initial resection for pancreatic cancer, the median survival time was 78.2 and 20.3 months after initial resection, in the repeat pancreatectomy group and the unresectable group, respectively (P < .001), and the 2- and 5-year survival probability rates after initial resection were 91%, and 82% vs 42%, and 13%, respectively. Among 67 patients with isolated local recurrence, the median survival time after repeat resection or diagnosis of recurrence was 25.0 and 9.3 months, and the 2- and 5-year survival probability rates after repeat resection or diagnosis of recurrence were and 61% and 46% vs 19% and 6.2% in the repeat pancreatectomy group and the unresectable group, respectively (P < .01). There was no difference in survivals between the unresectable isolated local recurrence group and the unresectable nonlocal recurrence group. CONCLUSION: Repeat pancreatectomy might bring about beneficial effects on prognosis in selected patients with isolated local recurrence in the remnant pancreas after initial pancreatectomy for pancreatic cancer without increased operative morbidity or mortality.

Cytoskeleton-associated protein 2 is a potential predictive marker for risk of early and extensive recurrence of hepatocellular carcinoma after operative resection.

BACKGROUND: De principe transplantation is an attractive strategy for the treatment of patients with hepatocellular carcinoma (HCC). The most important issue for this strategy is how to predict the risk of early and extensive recurrence. The present study aimed to identify a molecule associated with early and extensive recurrence of HCC after resection. METHODS: Differentially expressed genes were screened by DNA microarray analysis with the use of 12 HCC samples from patients who had different clinical courses based on the timing and extent of recurrence after operative resection. Furthermore, the obtained results were validated in 60 independent samples by quantitative real-time reverse transcription-polymerase chain reaction. Immunohistochemistry was performed to assess gene expression at the protein level. RESULTS: Microarray analysis and quantitative reverse transcription-polymerase chain reaction revealed cytoskeleton-associated protein 2 (CKAP2) as a candidate gene associated with early and extensive recurrence of HCC after resection. This observation was confirmed through examination of independent set samples, in which patients with greater-level CKAP2 mRNA expression exhibited shorter recurrence-free survival. Immunohistochemistry showed CKAP2 protein expression was associated with early (≤3 years) and extensive recurrence (beyond Milan criteria) after operative resection. CONCLUSION: Immunohistochemical CKAP2 expression might be a potential biologic marker for identifying HCC patients at risk of early and extensive recurrence after operative resection.

Kinetics and protective role of autophagy in a mouse cecal ligation and puncture-induced sepsis.

INTRODUCTION: It is not well understood whether the process of autophagy is accelerated or blocked in sepsis, and whether it is beneficial or harmful to the immune defense mechanism over a time course during sepsis. Our aim was to determine both the kinetics and the role of autophagy in sepsis. METHODS: We examined autophagosome and autolysosome formation in a cecal ligation and puncture (CLP) mouse model of sepsis (in C57BL/6N mice and GFP-LC3 transgenic mice), using western blotting, immunofluorescence, and electron microscopy. We also investigated the effect of chloroquine inhibition of autophagy on these processes. RESULTS: Autophagy, as demonstrated by increased LC3-II/LC3-I ratios, is induced in the liver, heart, and spleen over 24 h after CLP. In the liver, autophagosome formation peaks at 6 h and declines by 24 h. Immunofluorescent localization of GFP-LC3 dots (alone and with lysosome-associated membrane protein type 1 (LAMP1)), as well as electron microscopic examination, demonstrate that both autophagosomes and autolysosomes are increased after CLP, suggesting that intact autophagy mechanisms operate in the liver in this model. Furthermore, inhibition of autophagy process by chloroquine administration immediately after CLP resulted in elevated serum transaminase levels and a significant increase in mortality. CONCLUSIONS: All autophagy-related processes are properly activated in the liver in a mouse model of sepsis; autophagy appears to play a protective role in septic animals.

[Treatment strategy for multiple colorectal liver metastases: role for two-stage hepatectomy].

Hepatic resection is recognized as a potentially curative treatment for colorectal liver metastases. Recent progress in chemotherapy and molecular target agents has made initially unresectable colorectal liver metastases converted to resectable and may prolong survival. The definition of unresectable colorectal liver metastases was because of the lack of the future remnant liver volume due to multiple bilobar metastases. The two-stage hepatectomy combined with portal vein embolization may contribute to treatment for such multiple bilobar metastases. We describe an advantage and adverse effect of two-stage hepatectomy on treatment for multiple bilobar colorectal liver metastases.

Surgical resection after downsizing chemotherapy for initially unresectable locally advanced biliary tract cancer: a retrospective single-center study.

BACKGROUND: Surgical resection is the only method for curative treatment of biliary tract cancer (BTC). Recently, an improved efficacy has been revealed in patients with initially unresectable locally advanced BTC to improve the prognosis by the advent of useful cancer chemotherapy. The aim of this study was to evaluate the effect of downsizing chemotherapy in patients with initially unresectable locally advanced BTC. METHODS: Initially unresectable locally advanced cases were defined as those in which therapeutic resection could not be achieved even by proactive surgical resection. Gemcitabine was administered intravenously once a week for 3 weeks followed by 1 week's respite. Patients whose disease responded to chemotherapy were reevaluated to determine whether their tumor was resectable. RESULTS: Chemotherapy with gemcitabine was provided to 22 patients with initially unresectable locally advanced BTC. Tumor was significantly downsized in nine patients, and surgical resection was performed in 8 (36.4%) of 22 patients. Surgical resection resulted in R0 resection in four patients and R1 resection in four patients. Patients who underwent surgical resection had a significantly longer survival compared with those unable to undergo surgery. CONCLUSIONS: Preoperative chemotherapy enables the downsizing of initially unresectable locally advanced BTC, with radical resection made possible in a certain proportion of patients. Downsizing chemotherapy should be proactively carried out as a multidisciplinary treatment strategy for patients with initially unresectable locally advanced BTC with the aim of expanding the surgical indication.

[A case of pancreaticoduodenectomy for duodenal carcinoma with a replaced common hepatic artery running through the pancreatic parenchyma].

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.