Exploratory prospective, randomized phase II study of neoadjuvant transcatheter arterial chemoembolization plus surgery versus surgery alone for large hepatocellular carcinoma (CSGO-HBP-005): Clinical Study Group of Osaka University, Hepato-Biliary-Pancreatic Group.

AIM: Neoadjuvant transcatheter arterial chemoembolization (TACE) for large tumors is controversial, especially in the minimally invasive surgery era. The aim of this study was to compare features between groups treated with neoadjuvant TACE followed by surgery (TACE + surgery) or upfront surgery for hepatocellular carcinoma >5 cm. METHODS: In this exploratory, multicenter, randomized phase I study, the primary measure was 2-year disease-free survival (DFS). Secondary measures were resection rate, necrosis rate by TACE, 2-year overall survival, and site of recurrence. A total of 30 patients were randomly allocated to each arm. RESULTS: The two arms did not differ in patient characteristics. The median time to surgery from randomization was 48 days for TACE + surgery and 29 for surgery only (p < 0.001). Postoperative morbidities did not differ between arms. The 2-year DFS, overall survival, and resection rates were 56.7%, 80.0%, and 93.3%, respectively, in the TACE + surgery arm, and 56.1%, 89.9%, and 90.0% in the upfront surgery arm. Minimally invasive surgery was carried out in 35.7% in the TACE + surgery arm and in 29.6% in the upfront surgery arm. The median necrosis rate by TACE was 90.0%. In resected specimens, invasion to the hepatic vein was less with TACE + surgery (3.6% vs. 22.2%, p = 0.0380). In cases of 100% necrosis with TACE, 2-year DFS was 100%. Site of recurrence did not differ between groups. CONCLUSION: Neoadjuvant TACE did not improve 2-year DFS, and neoadjuvant TACE allowed delay of surgical treatment without increased morbidity and cancer progress. CLINICAL TRIAL REGISTRATION: UMIN: 000005241.

[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 Lymphoepithelial Cyst of the Pancreas for Which Malignancy Could Not Be Ruled Out Difficult Preoperative Diagnosis].

Lymphoepithelial cyst(LEC)of the pancreas is a relatively rare benign cystic disease of the pancreas. In this report, we describe a case of LEC in which a malignant tumor could not be ruled out by preoperative diagnosis and surgery was performed. The patient was a 72-year-old man. A simple CT scan of the chest and abdomen performed as a follow-up for another disease incidentally revealed a mass in the pancreatic tail. Enhanced CT of the abdomen showed a tumor approximately 3 cm in size at the pancreatic tail with no contrast effect. MRCP showed moderate signal on T2WI, high signal on T1WI, and high signal on T2WI on some cysts inside the pancreas. PET-CT showed slight uptake of FDG. Both tumor markers CEA and CA19-9 were normal. Therefore, malignant disease such as pancreatic IPMC could not be ruled out, and laparoscopic distal pancreatectomy plus splenectomy was performed. The pathology results showed a diagnosis of pancreatic lymphoepithelial cyst with slight differentiation into sebaceous gland.

[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.

[A Case of Obstructive Rectal Cancer with Huge Liver Metastases Resected by the Liver-First Approach after Chemotherapy].

The patient was a 68-year-old woman without history of surgery. She presented with abdominal pain and leg edema. Ultrasound scan revealed hepatic masses. Colonoscopy and abdominal CT scan revealed unresectable rectal carcinoma with massive multiple liver metastases suspected of invasion of the inferior vena cava. After a transverse colon bi-pore colostomy, 10 courses of FOLFOX plus panitumumab therapy were administered, and the liver tumor was markedly reduced in size and determined to be PR by CT. Considering the possibility of unresectability due to the liver metastases re-growth, surgery was planned with liver-first approach(LFA). First, open resection of the right caudate lobe of the liver, combined resection of the IVC, combined resection of the diaphragm, partial hepatic S2 resection(2 sites), and cholecystectomy were performed, followed by laparoscopic anterior resection(D3)1 month later(R0). Postoperatively, the colostomy was closed after 8 courses of CapeOX(capecitabine alone from the middle of the course). Now the patient is alive and recurrence-free 4 years after the initial diagnosis. Conversion surgery with LFA after chemotherapy can be an effective treatment strategy for colorectal cancer with advanced liver metastases.

[A Case of Advanced Gastric Cancer with Simultaneous Liver Metastasis for Long-Term Survival with Multimodal Therapy].

We report a case of advanced gastric cancer with simultaneous liver metastasis in which long-term survival has been obtained by multimodal therapy. Case 75-year-old, male. Esophagogastroduodenoscopy revealed advanced type 2 cancer in the greater curvature of the angular incisure. Computed tomography showed a single 20 mm mass was found in liver S2. Histopathological findings indicated that differentiated adenocarcinoma(tub1, HER2 3+). Diagnosis was gastric cancer, cT4aN0M1HEP, Stage Ⅳ. Tumor shrinkage was obtained after 2 courses of capecitabine/cisplatin/trastuzumab. Laparoscopic distal gastrectomy and partial liver resection was performed. Histopathological findings indicated tub1, ypT4aN0M1HEP, ypStage Ⅳ, grade 1a. A single 10 mm recurrence was observed in liver S1/2 13 months after first surgery. After chemotherapy, rehepatic resection was performed. Three years have passed since the last hepatectomy, and the patient is currently undergoing recurrence-free follow-up.

[A Case of Rectal Cancer of Skin Metastasis Recurrence Near the Artificial Anus].

A 70s-year-old man visited the gastroenterologist with a complaint of bloody stool. Lower gastrointestinal endoscopy revealed a 50 mm type 0-Ⅰs+Ⅱa lesion in the center of the anterior wall of Rb in 4 cm from anal verge, and he was diagnosed with rectal cancer in cT1bcN0cM0, cStage Ⅰ. Endoscopic submucosal dissection was performed, but it was discontinued due to muscular traction, and was referred to our department at a later date for surgical purposes. Robot-assisted laparoscopic Hartmann's surgery(D2 dissection, sigmoid colon colostomy)was performed, and the pathological result was pT2pN0cM0, pStage Ⅰ with negative resection margins. Three months after the operation, a tumor was found on the left side of the stoma, and he visited us. Biopsy revealed the recurrence of skin metastasis of rectal cancer, and surgical procedure including colostomy and skin tumor resection, ileostomy, and colonic mucus fistula was performed. The patient was transferred to the hospital 3 months after the operation, but 2 months after the transfer, an increasing CEA was observed and CT revealed a local recurrence in the pelvis. Irradiation(45 Gy/15 times)was performed for the pain relief, but the general condition deteriorated thereafter and he died 8 months after the second operation.

[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.

[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.

[A Case of Inguinal Hernial Sac Metastasis of Cecal Cancer Resected with TAPP Approach].

Malignant tumor occurring in the inguinal region are relatively infrequent, and metastatic tumor is extremely rare. We report a case of inguinal hernial sac metastasis of cecal cancer resected with TAPP approach. The case is a 80's man. One year and 6 months after cecal cancer surgery, contrast-enhanced computer tomography(CT)examination revealed a solitary tumor in the right inguinal canal. We diagnosed inguinal hernia sac metastasis of cecal cancer and performed surgery. The mass in the hernia sac was resected with the TAPP approach. Histopathological findings were consistent with peritoneal metastasis directly to the inguinal hernia sac. The patient has been alive without 2 years after metastasectomy. It is necessary to treat patients with a history of malignant disease with keeping the possibility of inguinal hernia sac metastasis in mind.

[A Case of Retroperitoneal Leiomyosarcoma Treated with Repeated Surgical Resection].

A 55-year-old male revealed with a 5 cm-diameter mass in the lower abdomen on ultrasonography incidentally. Computed tomography showed a mass of 7 cm in size on the left side of the bladder. A malignant tumor was suspected, and surgically excised for purpose of diagnosis and treatment. Pathological examination confirmed retroperitoneal leiomyosarcoma, and the resection margins were negative. Follow-up computed tomography scan was performed every 3 months. Repeated resections were performed for twice recurrences within a year after surgery. A year after the first surgery, lung metastasis was detected and chemotherapy was started. Although retroperitoneal leiomyosarcoma is considered to have a poor prognosis, the present case had relatively good prognosis. This may be due to early detection and repeated surgical resection.

[A Case of Rectal Cancer Suspectedly Recurred Seventeen Years after EMR].

We report a case of a 73-year-old man who underwent endoscopic mucosal resection (EMR) for early rectal cancer(i ntramucosal cancer)at other hospital 17 years ago. Ten years later, he underwent a total colonoscopy, which showed no recurrence of the tumor. Twelve years later, a mass with calcification was incidentally detected in front of the sacrum, which was diagnosed as a benign tumor at that time. Seventeen years later, he presented with constipation and diarrhea, and was detected of a sub-circumferential tumor in the rectum by a total colonoscopy. Biopsy revealed that the tumor was malignancy. CT showed a mass in the left lateral liver lobe. The mass was suspected of metastasis. Laparoscopic super lower anterior resection was performed for rectal cancer, and pathological examination showed that the tumor was pT4a, N3, M1(H), Stage Ⅳa. One month after surgery, laparoscopic hepatectomy was performed for liver metastasis. Six months after surgery, CT showed multiple lung metastases. He continues to undergo chemotherapy. Although this case was treated with EMR for intramucosal carcinoma, clinical history and pathological findings suggested local recurrence.

[The Six Cases of Recurrence of Lung Metastasis after Radical Resection of Pancreatic Cancer Performed at Our Hospital].

Prognosis of pancreatic cancer is extremely poor due to recurrence in the early postoperative period. However, there are some reports that the prognosis for lung recurrence alone is relatively better than that of others. In this study, we report the cases of lung recurrence alone after radical resection of pancreatic cancer performed at our hospital. Among 255 cases of radical resection of pancreatic cancer performed at our hospital between July 2010 and August 2021, 6 cases in which the initial recurrence site of recurrence was lung alone were included in the study. The median age of the patients was 72 years (62-82), and there were 5 males and 1 female. Four patients had undergone pancreaticoduodenectomy and 2 patients underwent distal pancreatectomy. Four patients received adjuvant chemotherapy, 3 with S-1 and 1 with GEM. No patients underwent surgical resection for recurrence of lung metastasis, and all patients were treated with chemotherapy. The median time to recurrence was 351 days. As initial therapy after recurrence, 3 patients received GEM plus nab-PTX combination therapy and 3 patients received S-1. The median overall survival after recurrence was 1,979 days, and the 1-year and 3-year overall survival rates after recurrence were 100% and 100%, respectively. The prognosis of patients with recurrence of lung metastasis after surgery for pancreatic cancer at our hospital was similarly good as the previous reports.

[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.

[Peritoneal Recurrence of Gastric Cancer Treated with Chemoradiotherapy-A Case Report].

A 76-year-old male patient underwent a distal gastrectomy for advanced gastric cancer. As the postoperative serum CA19-9 level was elevated, chemotherapy was initiated. Computed tomography(CT)detected a solitary peritoneal recurrence in the left subhepatic space 17 months later. Consequently, chemoradiotherapy(CRT)at a total dose of 60 Gy, combined with S-1 therapy, was administered for local tumor control. After CRT, CT scans revealed a remarkable reduction in the peritoneal recurrence. Presently, 8 months after CRT, the patient remains alive with no indications of regrowth. CRT could prove efficacious as a treatment for gastric cancer patients with localized peritoneal recurrences.

[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.

[A Case of Pathologic Complete Response Achieved with Preoperative Pembrolizumab Therapy for Transverse Colon Cancer].

A 77-year-old female patient presented with a medical history of 4 cancerous lesions, each with a surgical history. She was referred to our hospital due to anemia. Upon examination, she was diagnosed with transverse colon cancer. Duodenal invasion was suspected, which made performing R0 surgery difficult; therefore, the NAC approach was chosen. Three courses of CAPOX were administered, resulting in tumor obstruction, leading to the formation of an ileum stoma. MSI testing revealed MSI-H, and pembrolizumab treatment was initiated. CT scans showed tumor shrinkage, and PET scans indicated no accumulation, resulting in a cCR. Colon resection including the lesion suspected of stenosis was performed with a strong desire for stoma closure and the determination of potential curative resection. Additionally, a partial resection of the duodenum was performed. Pathological examination did not reveal any evident tumor cells, leading to the determination for a pCR. The patient has been under postoperative surveillance for 1 year without any recurrence.

Short- and Long-Term Outcomes of Single-Incision Laparoscopic Surgery for Right-Side Colon Cancer.

INTRODUCTION: There are little data concerning the long-term outcome of single-incision laparoscopic surgery (SILS) for colon cancer. Therefore, we investigated not only the short-term outcomes but also the long-term outcomes of SILS for right-side colon cancer. METHODS: We retrospectively compared short- and long-term outcomes of SILS and conventional laparoscopic surgery (CLS) for right-sided colon cancer in our institution. Intergroup differences of short-term outcomes were evaluated using χ2 or Fisher exact tests and 2-sample Student t tests. The disease-free survival rates (long-term outcome) of stage II and III patients were estimated using the Kaplan-Meier method and compared using log-rank tests. RESULTS: There were 290 operations conducted for right-side (cecum and ascending) colorectal cancers from April 2011 to July 2018. Open surgery was performed in 12 cases from start to the operation. SILS was performed in 196 cases and CLS in 55 cases. One patient underwent intraoperative conversion from SILS to laparotomy for bleeding control. In addition, 1 port was added to SILS in 3 cases. These 4 cases were included in the analysis as the SILS group according to the principle of intent to treat. BACKGROUND: Factors including age, gender, body mass index, performance status, and tumor stage were not statistically different between the SILS and CLS groups. In short-term outcomes, the number of harvested lymph nodes was not statistically different. SILS required less operating time (p < 0.001) and resulted in a reduced bleeding volume (p < 0.001). There was no statistical difference in the frequency of overall complications (p = 0.06). The disease-free survival of stage II and III patients was not statistically different between the 2 groups. CONCLUSIONS: With the proper adaptation of SILS by an experienced surgeon, the short- and long-term outcomes of SILS were not inferior to those of CLS. Therefore, SILS could be a treatment option for right-sided colon cancer.

[A Case of Non-Exposed Endoscopic Wall-Inversion Surgery(NEWS)Performed by TANKO Technique for Gastric GIST].

We report a case of non-exposed endoscopic wall-inversion surgery(NEWS)performed by TANKO technique for gastric GIST. A 52-year-old man was diagnosed as having gastric GIST. A 2 cm-sized tumor was found in the lesser curvature of the middle body of the stomach, and an endoscopic biopsy revealed GIST. A 2.5 cm umbilical incision was made and TANKO surgery was performed. After seromyotomy around the tumor, the outer serosal muscularis was sutured closed to invert the tumor into the stomach. The inverted tumor was resected from the stomach wall and recovered using endoscopic techniques. NEWS is an operation developed to resect a tumor without exposing it into the abdominal cavity and is expected to avoid the risk of postoperative abdominal abscess and peritoneal dissemination. On the other hand, the TANKO is a procedure with excellent plastic technique and can be performed in this operation.