Prognostic Factors for Distal Bile Duct Carcinoma After Surgery.

BACKGROUND: Distal bile duct carcinoma continues to be one of the most difficult cancers to manage in terms of staging and radical resection. Pancreaticoduodenectomy (PD) with regional lymph node dissection has become the standard treatment of distal bile duct carcinoma. We evaluated treatment outcomes and histological factors in patients with distal bile duct carcinoma. METHODS: Seventy-four cases of resection of carcinoma of the distal bile ducts treated at our department during the period from January 2002 and December 2016 using PD and regional lymph node dissection as the standard surgical procedure were investigated. Survival rates of factors were analyzed using uni- and multivariate analyses. RESULTS: The median survival time was 47.8 months. On univariate analysis, age of 70 years or older, histologically pap, pPanc2,3, pN1, pEM0, v2,3, ly2,3, ne2,3 and postoperative adjuvant chemotherapy were statistically significant factors. On multivariate analysis, histologically pap was identified as a significant independent prognostic factor. The multivariate analysis identified age of 70 years or older, pEM0, ne2,3 and postoperative adjuvant chemotherapy as showing a significant trend towards independent prognostic relevance. CONCLUSION: The good news about resected distal bile duct carcinoma is that the percentage of those who achieved R0 resection has risen to 89.1%. Our multivariate analysis identified age of 70 years or older, pEM0, ne2,3 and postoperative adjuvant chemotherapy as prognostic factors. In order to improve the outcome of treatment, it is necessary to improve preoperative diagnostic imaging of pancreatic invasion and lymph node metastasis, establish the optimal operation range and clarify whether aortic lymph node dissection is needed to control lymph node metastasis, and establish effective regimens of chemotherapy.

Assessing the incidence of complications and malignancies in the long-term management of benign biliary strictures with a percutaneous transhepatic drain.

ABSTRACT: Percutaneous drainage catheters (PDCs) are required for the management of benign biliary strictures refractory to first-line endoscopic treatment. While biliary patency after PDC placement exceeds 75%, long-term catheterization is occasionally necessary. In this article, we assess the outcomes of patients at our institution who required long-term PDC placement.A single-institution retrospective analysis was performed on patients who required a PDC for 10 years or longer for the management of a benign biliary stricture. The primary outcome was uncomplicated drain management without infection or complication. Drain replacement was performed every 4 to 12 weeks as an outpatient procedure.Nine patients (three males and six females; age range of 48-96 years) required a long-term PDC; eight patients required the long-term PDC for an anastomotic stricture and one for iatrogenic bile duct stenosis. A long-term PDC was required for residual stenosis or patient refusal. Drain placement ranged from 157 to 408 months. In seven patients, intrahepatic stones developed, while in one patient each, intrahepatic cholangiocarcinoma or hepatocellular carcinoma occurred.Long-term PDC has a high rate of complications; therefore, to avoid the need for using long-term placement, careful observation or early surgical interventions are required.

Hepatic Epithelioid Hemangioendothelioma Presenting Synchronously with Hepatocellular Carcinoma.

Hepatic epithelioid hemangioendothelioma (EHE) is a rare malignant tumor with unknown pathogenesis. Herein, we report a case of a hepatic EHE presenting synchronously with a hepatocellular carcinoma (HCC). To the best of our knowledge, this is the second case report of synchronous hepatic EHE and HCC. An 84-year-old man presented with back pain. During examination, a tumor in liver segment 3 was coincidentally detected. Tumor marker (carbohydrate antigen 19-9, alpha-fetoprotein, and protein induced by vitamin K absence or antagonist-II) levels were elevated. Contrast-enhanced computed tomography revealed perinodular enhancement in the arterial and portal phases. Another tumor was detected in liver segment 2, which was homogeneously enhanced in the arterial phase, followed by washout in the portal and late phases. Based on these imaging findings, we diagnosed the tumor in segment 3 as a solitary cholangiocellular carcinoma and the tumor in segment 2 as a solitary HCC. Lateral sectionectomy of the liver was performed. Microscopically, spindle-shaped and epithelioid cells were present in the tumor in segment 3. On immunohistochemistry, the tumor cells were positive for CD31 and CD34, focally positive for D2-40, and negative for AE1/AE3. Therefore, the tumor in segment 3 was ultimately diagnosed as an EHE and the tumor in segment 2 as a well-differentiated HCC. Preoperative diagnosis of EHE is difficult owing to the lack of specific findings. Intratumoral calcification, halo sign, and lollipop sign are occasionally found in EHE and are useful imaging findings for diagnosis. Clinical behavior is unpredictable, ranging from indolent growth to rapid progression. Clinical or pathological predictors of the course of EHE are urgently required.

Successful nonoperative management by endoscopic and percutaneous drainage for penetrating pancreatic duct injury: a case report.

BACKGROUND: Pancreatic trauma is a rare condition with a wide presentation, ranging from hematoma or laceration without main pancreatic duct involvement, to massive destruction of the pancreatic head. The optimal diagnosis of pancreatic trauma and its management approaches are still under debate. The East Association of Surgery for Trauma (EAST) guidelines recommend operative management for high-grade pancreatic trauma; however, several reports have reported successful outcomes with nonoperative management (NOM) for grade III/IV pancreatic injuries. Herein, we report a case of grade IV pancreatic injury that was nonoperatively managed through endoscopic and percutaneous drainage. CASE PRESENTATION: A 47-year-old Japanese man was stabbed in the back with a knife; upon blood examination, both serum amylase and lipase levels were within normal limits. Contrast-enhanced computed tomography (CT) showed extravasation of the contrast medium around the pancreatic head and a hematoma behind the pancreas. Abdominal arterial angiography revealed a pseudo aneurysm in the inferior pancreatoduodenal artery, as well as extravasation of the contrast medium in that artery; coil embolization was thus performed. On day 12, CT revealed a wedge-shaped, low-density area in the pancreatic head, as well as consecutive pseudocysts behind the pancreas; thereafter, percutaneous drainage was performed via the stab wound. On day 22, contrast radiography through the percutaneous drain revealed the proximal and distal parts of the main pancreatic duct. The injury was thus diagnosed as a grade IV pancreatic injury based on the American Association for the Surgery of Trauma guidelines. On day 26, an endoscopic nasopancreatic drainage tube was inserted across the disruption; on day 38, contrast-enhanced CT showed a marked reduction in the fluid collection. Finally, on day 61, the patient was discharged. CONCLUSIONS: Although the EAST guidelines recommend operative treatment for high-grade pancreatic trauma, NOM with appropriate drainage by endoscopic and/or percutaneous approaches may be a promising treatment for grade III or IV trauma.

[A Case of Pancreatoduodenectomy for Pancreatic Head Cancer with Invasion to the Hepatic Artery from the Pancreatic Arcade].

This case pertained a 53-year-old man who underwent nab-PTX plus GEM therapy for BR-A pancreatic head cancer. He achieved a partial response and underwent pancreatoduodenectomy. Dynamic CT showed blockage of the original common hepatic artery branching from the celiac artery. Hepatic blood flow was maintained by a pancreatic arcade branching from the superior mesenteric artery which ran along the ventral side of the pancreatic head. The cancer had invaded the same location; therefore, the hepatic artery and portal vein were both resected and reconstructed. The patient had no complications, such as postoperative pancreatic fistula, and was discharged 45 days postoperatively. Currently(5 months postoperatively), postoperative S-1-based adjuvant chemotherapy is being administered, and the patient had a recurrence-free survival.

A case of reactive lymphoid hyperplasia of the liver in a patient with autoimmune hepatitis.

BACKGROUND: Reactive lymphoid hyperplasia (RLH) of the liver is a benign disorder. It is usually observed in the skin, orbit, thyroid, lung, breast, or gastrointestinal tract, but rarely in the liver. Since the first report of RLH of the liver in 1981, only 75 cases have been described in the past literature. Herein, we report a case of RLH of the liver in a patient with autoimmune hepatitis (AIH), which was misdiagnosed as hepatocellular carcinoma (HCC) preoperatively and resected laparoscopically. CASE PRESENTATION: A 43-year-old Japanese woman with autoimmune hepatitis was followed up for 5 years. During her medical checkup, a hypoechoic nodule in segment 6 of the liver was detected. The nodule had been gradually increasing in size for 4 years. Abdominal ultrasound (US) revealed a round, hypoechoic nodule, 12 mm in diameter. Contrast-enhanced computed tomography (CT) demonstrated that the nodule was slightly enhanced in the arterial dominant phase, followed by perinodular enhancement in the portal and late phases. A magnetic resonance imaging (MRI) scan showed low signal intensity on the T1-weighted image (T1WI) and slightly high signal intensity on the T2-weighted image (T2WI). The findings of the Gd-EOB-DTPA-enhanced MRI were similar to those of contrast-enhanced CT. Tumor markers were all within the normal range. The preoperative diagnosis was HCC and a laparoscopic right posterior sectionectomy was performed. Pathological examination revealed that the nodular lesion was infiltrated by small lymphocytes and plasma cells, and germinal centers were present. Immunohistochemistry was positive for B cell and T cell markers, indicating polyclonality. The final diagnosis was RLH of the liver. CONCLUSIONS: The pathogenesis of RLH of the liver remains unknown, and a definitive diagnosis based on imaging findings is extremely difficult. If a small, solitary nodule is found in female patients with AIH, the possibility of RLH of the liver should be considered.

Significance of neoadjuvant chemoradiotherapy for borderline resectable pancreatic head cancer: Pathological local invasion and microvessel invasion analysis.

Borderline resectable pancreatic head cancer (BR-PHC) has low resectability due to vascular invasion. Although the clinical effects of neoadjuvant chemoradiotherapy (NAC-RT) for BR-PHC have been examined, few studies have reported its pathological aspects. The present study retrospectively investigated the effect of NAC-RT on the histological features of BR-PHC. A total of 29 patients with BR-PHC who underwent NAC-RT, and 55 controls with resectable PHC, who underwent pancreaticoduodenectomy at the Kurume University Hospital. Tumor staging, lymphovascular invasion (LVI), and microvessel invasion (MVI) were evaluated. The median tumor size in the NAC-RT group was 2.0 cm, and it was smaller than that of the control group (P=0.006). The rates of lymph node metastasis, LVI, and MVI were significantly lower in the NAC-RT group (P<0.001, 0.002, and 0.015, respectively). Overall survival in the NAC-RT group was comparable to that in the control group, although patients with BR-PHC generally had a poorer prognosis than those with resectable PHC. Patients in the NAC-RT group without portal vein invasion (PVI) had a significantly better prognosis than those with PVI in the control group (P=0.002). NAC-RT may be beneficial for patients with BR-PHC by inhibiting local invasion and metastasis as prognosis following resection could be equivalent to that of patients with conventional ductal adenocarcinoma.

Expression of Matrix Metalloproteinases in Intraductal Papillary Mucinous Neoplasm of the Pancreas.

BACKGROUND/AIM: Intraductal papillary mucinous neoplasm (IPMN) has a variety of histological and morphological appearances. Matrix metalloproteinases (MMPs) have been considered to be associated with tumor progression or poor prognosis. The aim of this study was to elucidate the molecular basis of IPMN variation in different types of lesions. MATERIALS AND METHODS: The expression of MMP-1,2,7,9 in 51 cases of IPMN were investigated. The MMP score was calculated as the sum of the score of staining distribution and the score of the intensity staining. RESULTS: MMP scores were correlated with histological grade, histological subtype, and type of invasion. MMP high expression groups (MMP score ≥5) had worse prognosis than low-expression groups. CONCLUSION: MMP expression varied between different types of IPMN, a result supporting differences in molecular basis of malignancies. These considerations may be helpful for optimal management or treatment according to various types of IPMN.

Sinusoidal Obstruction Syndrome and Postoperative Complications Resulting from Preoperative Chemotherapy for Colorectal Cancer Liver Metastasis.

BACKGROUND/AIM: The aim of this study was to investigate the effects of preoperative chemotherapy on the healthy, metastasis-free part of the liver in colorectal cancer patients with liver metastasis, and the relationship between chemotherapy and postoperative complications. PATIENTS AND METHODS: Our study included 90 cases of colorectal cancer liver metastasis resected after preoperative chemotherapy. The patients were divided into three groups according to the received chemotherapy regimen: 20 cases received mFOLFOX6, 54 cases a combination of mFOLFOX6 with bevacizumab, and 16 cases a combination of mFOLFOX6 and cetuximab or panitumumab. RESULTS: The mean numbers of sinusoidal injuries for each chemotherapy type were compared. The group treated with the combination of mFOLFOX6 and bevacizumab showed a lower extent of sinusoidal injury relative to other groups; this intergroup difference became increasingly remarkable as the number of chemotherapy cycles increased. Complications of various extents were found in all three groups, but no significant differences were observed between the three groups. CONCLUSION: In cases where preoperative chemotherapy was extended over a long period, combined use of bevacizumab was thought to be effective because of stabilization of disturbed liver hemodynamics resulting from sinusoidal injury suppression effects, allowing effective distribution of anti-cancer agents to tumors.

Clinical and Prognostic Significance of Neoplastic Spindle Cells in Gallbladder Cancer.

BACKGROUND/AIM: Neoplastic spindle cells (NSCs) are believed to play a role in cancer invasion and metastasis, as well as in poor prognosis. The clinicopathological characteristics and prognostic relevance of NSCs was investigated in gallbladder cancer. MATERIALS AND METHODS: Specimens were obtained from 62 patients with gallbladder cancer who underwent surgery. The emergence of NSCs and their correlation with clinicopathological factors, prognosis, and EMT markers was evaluated. RESULTS: The NSC grade correlated with tumor size, preoperative CA19-9, surgical margin, the degree of differentiation, the depth of invasion, lymph node metastasis, lymphatic invasion, vascular invasion, and perineural invasion. Multivariate analysis of overall survival showed that NSCs were an independent prognostic factor. A correlation between NSCs and EMT was also suggested. CONCLUSION: NSCs are an independent prognostic factor for patients with postoperative gallbladder cancer, which also suggests a correlation between NSCs and EMT.

Sarcomatous Component in Pancreatic Adenosquamous Carcinoma: A Clinicopathological Series of 7 Cases.

BACKGROUND/AIM: The aim of this study was to examine the clinicopathological features of pancreatic adenosquamous carcinoma (PASC). PATIENTS AND METHODS: Our study included seven patients who underwent resection of PASC. RESULTS: PASC is characterized by large tumors and strong infiltration into the major blood vessels and other organs, forcing many patients to undergo extended resections. In addition, all patients experienced liver metastasis recurrence following surgery, with a very poor prognosis. Histopathologically, a poorly differentiated sarcomatous component existed in all patients in addition to an adenocarcinoma component and squamous carcinoma component. Although P40 staining for the sarcomatous component was positive along with squamous carcinoma, E-cadherin expression disappeared while vimentin was expressed. It has been suggested that it is highly likely that these sarcomatous components are derived from squamous carcinoma and have an impact on prognosis. CONCLUSION: The sarcomatous component may be related to the biological malignancy of PASC.

Clinicopathological Study of Resections of Intraductal Papillary Neoplasm of the Bile Duct.

BACKGROUND/AIM: The aim of this study was to examine the clinicopathological features of intraductal papillary neoplasm of the bile duct (IPNB) and investigate their relationships with intraductal papillary mucinous neoplasm (IPMN). PATIENTS AND METHODS: Our study included 104 patients who underwent resection of tumors that showed papillary growth within the bile duct and pancreas. RESULTS: Comparisons were performed based on subtypes and histological grades. The presence of various histological grades was confirmed in both the IPNB group and the IPMN group, and statistical significance was found in the between-group comparisons of subtypes and histological grades. It was shown that while all patients who underwent IPNB resection did not match the classifications proposed by Nakanuma et al., they did reflect classification characteristics. CONCLUSION: IPNB and IPMN have common clinical histological features. Common features between IPNB subtype classifications were also identified, which may provide novel diagnostics.

[Two Cases of Afferent Loop Obstruction Treated with Percutaneous Bowel Drainage(PBD)].

Here, we report our experiences with 2 cases of afferent loop obstruction with percutaneous bowel drainage(PBD)and present a review of the literature. Case 1 involved a 60-year-old woman. She underwent pancreaticoduodenectomy for pancreatic cancer. Eighteen months postoperatively, a recurrence marked by a jejunal elevation and expansion on the cecal side near the porta hepatic lymph nodes appeared. We performed PBD because intestinal depression via the endoscopic approach was difficult. She was discharged from the hospital 7 days after PBD. Case 2 involved a 51-year-old woman. She underwent total gastrectomy and Roux-en-Y reconstruction for progressive stomach cancer. We detected a local recurrence in the Y anastomosis following a chief complaint of vomiting 10 months postoperatively. Fifteen months postoperatively, she developed acute pancreatitis with afferent loop syndrome. We performed PBD via a trans-liver route. The patient was discharged from the hospital 11 days after PBD. By devising a puncture route, we could safely perform PBD for an afferent loop obstruction.

Atherosclerosis of the right posterior hepatic artery in a patient with hilar cholangiocarcinoma undergoing left trisectionectomy: a case report of a therapeutic pitfall.

BACKGROUND: We experienced a rare case of benign arterial stricture of the right posterior hepatic artery (RPHA) caused by atherosclerosis in a patient with hilar cholangiocarcinoma. CASE PRESENTATION: A 75-year-old man was referred to our hospital for the detailed investigation of serum hepatobiliary enzyme elevation. The patient had a history of hypertension, type 2 diabetes mellitus, and an operative history of coronary artery bypass grafting 10 years before. Endoscopic retrograde cholangiography found strictures of the right and left hepatic ducts with involvement of right anterior and posterior bile ducts. Adenocarcinoma was evident by brush cytology. We diagnosed these findings as hilar cholangiocarcinoma and planned left trisectionectomy including bile duct reconstruction. Although the tumor and RPHA were not adjacent, preoperative multidetector computed tomography revealed a stricture of the RPHA that was 5.6 mm in length. We suspected that atherosclerosis caused the stricture, and we performed digital subtraction angiography and intravascular ultrasonography that showed stricture of the RPHA accompanied by thick plaques in the arterial wall. We placed a bare-metal stent in the RPHA and then performed left trisectionectomy. Since this patient developed bile leakage postoperatively, percutaneous drainage was performed. The bile leakage was successfully controlled, and the patient was discharged 3 months after surgery. Unfortunately, 4 months after hepatectomy, he was re-hospitalized with multiple pyogenic liver abscesses. We performed intensive multimodal treatment for the liver abscesses and stabilized the disease; however, we eventually lost this patient due to liver failure 14 months after surgery. CONCLUSION: To the best of our knowledge, there is no previous literature on atherosclerosis of the RPHA, which was evident preoperatively in our case. Because arterial complications may lead to critical biliary complications in patients who undergo left trisectionectomy, we first performed prophylactic arterial stent placement. We speculate that existing chronic microscopic injury of the peribiliary plexus might have caused the liver abscesses. We successfully diagnosed atherosclerosis of the RPHA preoperatively. However, further investigation of patients is warranted to determine if left trisectionectomy is contraindicated in these patients.

Evaluation of Surgical Procedures for T2 Gallbladder Cancer in Terms of Recurrence and Prognosis.

T2 (tumor invades perimuscular connective tissue; no extension beyond serosa or into liver) gallbladder cancer has generally been treated by S4aS5 subsegmentectomy (S4aS5 HR). We investigated the therapeutic effect of full-thickness cholecystectomy (FC) and gallbladder bed resection (GBR), in terms of tumor location and resection margin (distance from the tumor). At our department we employ the following protocol to determine the extent of resection needed to achieve R0 status: (1) A tumor located in the gallbladder fundus (Gf) or body (Gb) and only on the free peritoneal side was classified as P-type, for which full-thickness cholecystectomy and regional lymph node dissection were performed. (2) A tumor located in Gf or Gb and in contact with the liver bed was classified as H-type, for which gallbladder bed resection and regional lymph node dissection were performed. (3) A tumor located in the gallbladder neck (Gn) was classified as N-type, for which gallbladder bed resection, bile duct resection, and regional lymph node dissection were performed. Twenty-two patients admitted to our department between January 2000 and December 2014 with pT2gallbladder cancers were included in our study. Surgical procedures performed were compared with those specified in our protocol, and patients in whom the extent of resection was greater than that specified in our strategy were evaluated clinicopathologically and in terms of recurrence and the prognosis. Six (27.2%), 7 (31.8%), and 9 (40.9%) patients underwent limited, standard, and extended surgery, respectively. Ten (66.7%) of 15 patients with tumors close to the liver bed underwent cholecystectomy or extended surgery, 7 (85.7%) of 8 patients with tumors close to the bile duct underwent bile duct resection, and 16 (72.7%) of 22 patients underwent regional lymph node dissection. Recurrence at the bile duct resection margin, para-aortic lymph node metastasis, and hepatic metastasis occurred in 2, 1, and 3 patients, respectively. The 3-year survival rates (for patients including those dying of noncancer causes) were 50, 100, and 75% after limited, standard, and extended surgery, respectively. There was a significant difference in the survival rate of patients who underwent standard or extended surgery (P=0.0273). Favorable results were obtained in T2 gallbladder cancer patients without performing S4aS5 subsegmentectomy. Depending on the tumor location, neither full-thickness cholecystectomy nor gallbladder bed resection appeared to pose problems regarding recurrence or prognosis. In conclusion, surgical treatment based on our protocol, which aims to achieve the condition of R0, may result in a sufficient therapeutic effect.

[A Case of Laparoscopic Resection of Peritoneal Hepatocellular Carcinoma Recurrence after Percutaneous Ethanol Injection Therapy].

Needle tract implantation after percutaneous ethanol injection therapy(PEIT)for hepatocellular carcinoma(HCC)is rare. Surgical treatment of such HCC implants is still controversial. We herein report the case of a patient who underwent laparoscopic resection for peritoneal dissemination after PEIT. An 81-year-old man underwent PEIT for primary HCC at another hospital. Thereafter, percutaneous radiofrequency ablation(RFA)was performed twice for intrahepatic recurrence. After the second RFA, a mass lesion was detected at the subhepatic space on computed tomography(CT). We reevaluated the CT and diagnosed the patient with peritoneal dissemination after PEIT. Laparoscopic resection was performed. However, the patient developed recurrences at the thoracic wall and peritoneum 12 months after laparoscopic surgery. Those 2 tumors were resected, and he remains alive, approximately 30 months after the laparoscopic resection. Laparoscopic extirpation of tract seeding may provide better clinical outcomes in select patients.

[Two Cases of Effective Hepatic Arterial Infusion Chemotherapy for Liver Metastases of Colon Cancer Resistant to Systemic Chemotherapy].

A 69-year-old man underwent right hemicolectomy for ascending colon cancer with liver metastases. Postoperative systemic chemotherapy did not reduce the metastases, and therefore, hepatic arterial infusion chemotherapy (HAI) was administered. The metastases decreased in size after 26 rounds of therapy, and the patient underwent resection. He is recurrence-free 63 months after the primary operation. A 57-year-old man underwent Hartmann's operation for sigmoid colon cancer with liver metastases. He underwent hepatic left lobe resection after metastases reduction by systemic chemotherapy. However, multiple liver metastases were detected 2 months later. Because the disease progressed despite the administration of systemic chemotherapy, HAI was utilized instead. The metastases decreased in size remarkably, and resection was performed. The patient is surviving 52 months after the primary operation while being continuously treated with HAI, resection, and systemic chemotherapy for re-recurrence. HAI is a potential alternative treatment for patients with colorectal liver metastases resistant to systemic chemotherapy.

[A Case of Pancreatic Head Cancer Showing Pathological Complete Response to Neoadjuvant Chemoradiation Therapy].

The patient was a 64-year-old woman. She was referred to our institute because of a chief complaint of upper abdominal pain. Abdominal computed tomographic scan revealed a 35 mm hypovascular tumor in the pancreatic head and superior mesenteric vein (SMV), as well as thrombosis. We chose neoadjuvant chemoradiation therapy (NACRT) (S-1/RT, 50.4 Gy/28 Fr) and anticoagulants. After the treatment, the primary lesion showed a partial response, and the SMV thrombosis was reduced. We performed pancreaticoduodenectomy. Histopathological examination revealed no cancer cells in the pancreas. Pathological evaluation revealed grade Ⅳ tumor according to the Evans classification. The patient had had no recurrence for 10 months after the pancreaticoduodenectomy.

Evaluation of endoscopic biliary stenting for obstructive jaundice caused by hepatocellular carcinoma.

AIM: To review the usefulness of endoscopic biliary stenting for obstructive jaundice caused by hepatocellular carcinoma and identify problems that may need to be addressed. METHODS: The study population consisted of 36 patients with obstructive jaundice caused by hepatocellular carcinoma (HCC) who underwent endoscopic biliary stenting (EBS) as the initial drainage procedure at our hospital. The EBS technical success rate and drainage success rate were assessed. Drainage was considered effective when the serum total bilirubin level decreased by 50% or more following the procedure compared to the pre-drainage value. Survival time after the procedure and patient background characteristics were assessed comparatively between the successful drainage group (group A) and the non-successful drainage group (group B). The EBS stent patency duration in the successful drainage group (group A) was also assessed. RESULTS: The technical success rate was 100% for both the initial endoscopic nasobiliary drainage and EBS in all patients. Single stenting was placed in 21 patients and multiple stenting in the remaining 15 patients. The drainage successful rate was 75% and the median interval to successful drainage was 40 d (2-295 d). The median survival time was 150 d in group A and 22 d in group B, with the difference between the two groups being statistically significant (P < 0.0001). There were no statistically significant differences between the two groups with respect to patient background characteristics, background liver condition, or tumor factors; on the other hand, the two groups showed statistically significant differences in patients without a history of hepatectomy (P = 0.009) and those that received multiple stenting (P = 0.036). The median duration of stent patency was 43 d in group A (2-757 d). No early complications related to the EBS technique were encountered. Late complications occurred in 13 patients (36.1%), including stent occlusion in 7, infection in 3, and distal migration in 3. CONCLUSION: EBS is recommended as the initial drainage procedure for obstructive jaundice caused by HCC, as it appears to contribute to prolongation of survival time.

[A case of postoperative recurrent hilar cholangiocarcinoma in the lower bile duct treated with pancreatoduodenectomy].

When surgery is selected to treat postoperative recurrent hilar cholangiocarcinoma in the intrapancreatic bile duct, attention should be paid to the following: 1 ) technical resectability of the lesion, 2) reconstruction, and 3) high risk of complications. Eight cases, including the present case, of pancreatoduodenectomy (PD) for postoperative recurrent hilar cholangiocarcinoma in the intrapancreatic bile duct have been reported thus far. In October 2009, a 73-year-old man noticed that his stools were gray and visited a physician. He was diagnosed with cholangiocarcinoma on close examination and underwent left hepatic and caudate lobectomy in January 2010. After the surgery, he was treated with TS-1 (80 mg) and followed up at the outpatient clinic of our hospital. In July 2013, he was diagnosed with cancer of the lower bile duct and was admitted for surgery. The first and second pathological findings were carcinoma of the bile duct and papillary adenocarcinoma, respectively. The findings from the immunostaining were also inconsistent. The histopathological examination result suggested multicentric recurrence. The surgery was highly invasive, increasing the patient's risk of complications, in addition to the presence of postoperative adhesion. Therefore, surgery may be an important option for cases of localized recurrence but not for multicentric recurrence.