[A Rare Case of Cronkhite-Canada Syndrome Associated with Gastric Cancer and Gastric Outlet Obstruction].

Cronkhite-Canada syndrome(CCS)is a rare non-inherited disease characterized by gastrointestinal polyposis and ectodermal abnormalities. We report a rare case of CCS associated with gastric cancer and gastric outlet obstruction with a review of the literature. A 75-year-old man was admitted because of frequent vomiting and hypoproteinemia. He was diagnosed with CCS due to typical clinical and laboratory findings including alopecia, nail atrophy, hypoproteinemia, and typical gastrointestinal polyposis. Upper endoscopic examination also pointed out a large gastric cancer mainly located in the antrum and the reversible pyloric obstruction caused by the gastric tumor. Biopsy of the tumor revealed tubular adenocarcinoma. Computed tomography demonstrated the dilated duodenum caused by packing of the gastric tumor. 1.5 months after prednisolone therapy, he underwent total gastrectomy with complete resection of the dilated duodenal bulb. Histological examination revealed gastric cancer(pap>tub1)classified into Stage ⅢC. Postoperative course was uneventful and he moved to another hospital. To our knowledge, including the present case, there were 20 reported cases of CCS associated with gastric cancer from Japan(1979-2022). Also, 7 cases of CCS associated with gastric outlet obstruction was reported.

Optimal Region of Lymph Node Dissection in Distal Pancreatectomy for Left-Sided Pancreatic Cancer Based on Tumor Location.

BACKGROUND: The optimal lymph node (LN) dissection for left-sided pancreatic cancer based on tumor location has remained unknown. In particular, the efficacy of LN dissection around the common hepatic artery and the celiac axis for distal tumors has not been established. This study was designed to elucidate the frequency and prognostic impact of LN metastasis, focusing on tumor location. METHODS: Data from 110 patients with invasive pancreatic cancer who underwent distal pancreatectomy between 2007 and 2020 were collected. We used a quantitative value-the distance between the left side of the portal vein and the right side of tumor (DPT)-to define the tumor location. LN stations were divided into two groups: peripancreatic lymph nodes (PLN) and non-PLN. We then analyzed the frequency of LN metastasis based on the tumor location and prognostic factors. RESULTS: Non-PLN metastasis was observed in 7.3% of patients. Non-PLN metastasis was found only in patients with a DPT < 20 mm. Patients with non-PLN metastasis exhibited a significantly worse prognosis than those with only-PLN metastasis (median survival time: 20.3 vs. 42.5 months, p = 0.048). Multivariate analysis for survival indicated that tumor size > 4 cm (hazard ratio [HR]: 2.23, p = 0.012) and metastasis in the non-PLN region (HR: 3.02, p = 0.015), and inability to undergo adjuvant chemotherapy (HR: 2.81, p = 0.0018) were also associated with poor prognosis. CONCLUSIONS: Dissection of the non-PLN region can be avoided in selected patients with DPT ≥ 20 mm.

Strategy of Pancreatectomies for Pancreatic Ductal Adenocarcinoma in Patients with a History of Gastrectomy.

Recently, the incidence of pancreatectomy for patients with a history of upper abdominal surgery has been increasing. The clinical courses of 307 patients who underwent the pancreatectomy for pancreatic ductal adenocarcinoma (PDAC) were retrospectively reviewed to clarify the impact of a history of gastrectomy in patients undergoing a pancreatectomy for PDAC. Among 307 patients, 28 (9.1%) had a history of gastrectomy, while 279 did not. We compared the difference in clinical course and prognostic outcomes between the groups. In patients with a history of gastrectomy, the 5-year survival rate was 17.6%, which was relatively poorer than that of patients without it (33.4%, P = 0.1329). A multivariate analysis of factors associated with the overall survival rate identified the low preoperative body mass index [BMI < 20.3 kg/m2, hazard ratio (HR) 1.646, P = 0.0190] and adjuvant chemotherapy (not-completed, HR 1.652, P = 0.0170) as independent prognostic factors. In patients with a history of gastrectomy, there were significantly more patients with poor prognostic factors, including a low preoperative BMI (P = 0.0009) and low completion rate of adjuvant chemotherapy (P = 0.0294) as compared with those without a history of gastrectomy. A low preoperative BMI significantly reduced the completion rate of adjuvant chemotherapy (P = 0.0186), which may lead to poor prognostic outcomes. In conclusion, perioperative nutritional management is important to reduce postoperative BMI loss and obtain a better prognosis after a pancreatectomy for PDAC in patients with a history of gastrectomy.

The interplay of KRAS mutational status with tumor laterality in non-metastatic colorectal cancer: An international, multi-institutional study in patients with known KRAS, BRAF, and MSI status.

BACKGROUND: Although the prognostic relevance of KRAS status in metastatic colorectal cancer (CRC) depends on tumor laterality, this relationship is largely unknown in non-metastatic CRC. METHODS: Patients who underwent resection for non-metastatic CRC between 2000 and 2018 were identified from institutional databases at six academic tertiary centers in Europe and Japan. The prognostic relevance of KRAS status in patients with right-sided (RS), left-sided (LS), and rectal cancers was assessed. RESULTS: Of the 1093 eligible patients, 378 had right-sided tumors and 715 had left-sided tumors. Among patients with RS tumors, the 5-year overall (OS) and recurrence-free survival (RFS) for patients with KRASmut versus wild-type tumors was not shown to differ significantly (82.2% vs. 83.2% and 72.1% vs. 76.7%, respectively, all p > .05). Among those with LS tumors, KRAS mutation was associated with shorter 5-year OS and RFS on both the univariable (OS: 79.4% vs. 86.1%, p = .004; RFS: 68.8% vs. 77.3%, p = .005) and multivariable analysis (OS: HR: 1.52, p = .019; RFS: HR: 1.32, p = .05). CONCLUSIONS: KRAS mutation status was independently prognostic among patients with LS tumors, but this association failed to reach statistical significance in RS and rectal tumors. These findings confirm reports in metastatic CRC and underline the possible biologic importance of tumor location.

Loss of ARID1A induces a stemness gene ALDH1A1 expression with histone acetylation in the malignant subtype of cholangiocarcinoma.

Genomic analyses have recently discovered the malignant subtype of human intrahepatic cholangiocarcinoma (ICC) characterized by frequent mutations of chromatin remodeling gene ARID1A; however, the biological and molecular functions still remain obscure. We here examined the clinical and biological significances of ARID1A deficiency in human ICC. Immunohistochemical analysis demonstrated that the loss of ARID1A was an independent prognostic factor for overall survival of ICC patients (P = 0.023). We established ARID1A-knockout (KO) cells by using the CRISPR/Cas9 system from two human cholangiocarcinoma cell lines. ARID1A-KO cells exhibited significantly enhanced migration, invasion, and sphere formation activity. Microarray analysis revealed that ALDH1A1, a stemness gene, was the most significantly elevated genes in ARID1A-KO cells. In addition, ALDH enzymatic activity as a hallmark of cancer stem cells was markedly high in the KO cells. ARID1A and histone deacetylase 1 were directly recruited to the ALDH1A1 promoter region in cholangiocarcinoma cells with undetectable ALDH1A1 expression by chromatin immunoprecipitation assay. The histone H3K27 acetylation level at the ALDH1A1 promoter region was increased in cells when ARID1A was disrupted (P < 0.01). Clinically, inverse correlation between ARID1A and ALDH1A1 expression was also identified in primary ICC (P = 0.018), and ARID1A-negative and ALDH1A1-positve ICCs showed worse prognosis than only ARID1A-negative cases (P = 0.002). In conclusion, ARID1A may function as a tumor suppressor in ICC through transcriptional downregulation of ALDH1A1 expression with decreasing histone H3K27 acetylation. Our studies provide the basis for the development of new epigenetic approaches to ARID1A-negative ICC. Immunohistochemical loss of ARID1A is an independent prognostic factor in intrahepatic cholangiocarcinoma patients. ARID1A recruits HDAC1 to the promoter region of ALDH1A1, a stemness gene, and epigenetically suppresses ALDH1A1 expression with decreasing histone H3K27 acetylation in cholangiocarcinoma cells.

Downregulated Pancreatic Beta Cell Genes Indicate Poor Prognosis in Patients With Pancreatic Neuroendocrine Neoplasms.

OBJECTIVE: To predict metachronous liver metastasis after pancreatectomy for pancreatic neuroendocrine neoplasms (Pan-NENs). SUMMARY OF BACKGROUND DATA: Liver metastasis determines the prognosis of patients with Pan-NENs, but no index exists in the WHO 2017 classification for this prediction. METHODS: Between April 2014 and March 2018, resected primary tumors from 20 patients with or without simultaneous liver metastasis were examined using genome-wide gene expression analysis. For validation analysis, resected primary tumors from 62 patients without simultaneous liver metastasis were examined for PAX6 expression. RESULTS: Gene expression profiling revealed pancreatic beta cell genes (NES, -2.0; P < 0.001) as the most downregulated set in patients with simultaneous liver metastasis. In the test study, PAX6 was the most valuable index for liver metastasis (log FC, -3.683; P = 0.0096). Multivariate analysis identified PAX6 expression (hazard ratio, 0.2; P = 0.03) as an independent risk factor for metachronous liver metastasis-free survival (mLM-FS). The 5-year mLM-FS of patients with high versus low PAX6 expression was significantly better (95% vs 66%, respectively; P < 0.0001). The 5-year overall survival rate of was also better than in those with high versus low PAX6 expression (100% vs 87%, respectively). Patients with low PAX 6 expression were significantly younger and leaner, had a higher Ki-67 index (P = 0.01, 0.007, 0.008, respectively), and showed a higher mitotic rate than patients with high PAX6 expression. CONCLUSIONS: Downregulated pancreatic beta cell genes involving PAX6 in primary tumors may predict mLM and poor overall survival after primary tumor resection in Pan-NEN patients.

Position of the Pancreas Division Line and Postoperative Outcomes After Distal Pancreatectomy.

BACKGROUND: In distal pancreatectomy (DP), the position of the pancreas division line (PDL) changes depending on the location or nature of the tumor. Here, we investigated the relationship between PDL and postoperative complications after DP. METHODS: We retrospectively analyzed data of 140 patients who underwent DP at Tokyo Medical and Dental University Hospital between January 2011 and September 2018. PDL was defined as the distance from the left margin of the portal vein to the edge of the pancreatic stump on the coronal plane of computed tomography. RESULTS: The mean PDL was 15.1 (range 0-74.3) mm. PDL was significantly longer in patients with portal venous system thrombosis (PVST) than in those without PVST (47.6 vs. 0 mm, p < 0.001). The PDLlong (≥ 20 mm) group underwent surgery with a significantly shorter duration (253 vs. 294 min, p < 0.001) and experienced a lower volume of blood loss (20 vs. 256.5 mL, p < 0.001) than the PDLshort (< 20 mm) group. Six months after surgery, the increase in HbA1c level was significantly higher in the PDLshort group than in the PDLlong group (0.5 vs. 0.35%, p = 0.041). Except for PVST, there was no significant difference in postoperative complications between the two groups. CONCLUSIONS: In DP, pancreas resection with a longer PDL resulted in a significantly shorter duration of surgery, lower estimated blood loss, and superior glucose tolerance than that with a shorter PDL.

Loss of KDM6A characterizes a poor prognostic subtype of human pancreatic cancer and potentiates HDAC inhibitor lethality.

Although genomic analysis have recently discovered the malignant subtype of human pancreatic ductal adenocarcinoma (PDAC) characterized by frequent mutations of histone demethylase KDM6A, the biological and molecular roles still remain obscure. We herein elucidated the clinical and biological impacts of KDM6A deficiency on human PDAC and identified the therapeutic potential by pathological and molecular evaluation. Immunohistochemical analysis suggested that loss of KDM6A in cancerous tissues was an independent prognostic factor for both recurrence-free and overall survival in the 103 tumor specimens surgically resected from patients with PDAC. We established KDM6A knocked out cells by using the CRISPR/Cas9 system and KDM6A-expressed cells by doxycycline-inducible system from each two human PDAC cell lines, respectively. KDM6A knockout enhanced aggressive traits of human PDAC cell lines, whereas KDM6A overexpression suppressed them. Microarray analysis revealed reduced expression of 22 genes including five well-known tumor suppressors, such as CDKN1A, and ChIP-PCR analysis displayed depleted enrichment of histone H3 lysine 27 acetylation (H3K27ac) at the promoter regions of the five candidates. The epigenetic alterations were induced by the impaired recruitment of histone acetyltransferase p300, which cooperatively interacted with KDM6A. Consistent with these results, the KDM6A knockout cells demonstrated higher vulnerability to histone deacetylase (HDAC) inhibitors through the reactivation of CDKN1A in vitro and in vivo than the KDM6A wild-type. In conclusion, KDM6A exhibited essential roles in human PDAC as a tumor suppressor and KDM6A deficiency could be a promising biomarker for unfavorable outcome in PDAC patients and a potential surrogate marker for response to HDAC inhibitors.

The Clinical Implications of Peripancreatic Fluid Collection After Distal Pancreatectomy.

OBJECTIVES: Pancreatic fistula after distal pancreatectomy (DP) remains an unsolved problem, and postoperative CT imaging often demonstrates fluid collection (FC) around the pancreatic remnant. This study sought to clarify the clinical implications of FC. METHODS: This study enrolled 146 patients who underwent DP. FC was defined as a cyst-like lesion ≥ 10 mm in diameter on CT imaging at postoperative day (POD) 7. FC size, irregularity of FC margin, and air bubbles in FC were investigated. In addition, clinical data were retrospectively collected, and useful predictive factors for postoperative pancreatic fistula (POPF) were analyzed. RESULTS: Clinically relevant POPF was observed in 26 patients (17.8%), and FC was detected in 136 patients (94.4%). Multivariate analysis identified FC size and drain amylase levels on POD3 as significant risk factors for POPF. Cutoff values were determined by ROC analyses, and the levels of the FC size and drain amylase on POD3 were determined as 41 mm and 1026 IU/L, respectively. The sensitivity and specificity of FC diameters > 41 mm were 76.9% and 75.0%, respectively, while those of drain amylase levels > 1026 IU on POD3 were 73.1% and 75.8%, respectively. CONCLUSIONS: While treating some FCs after DP was necessary for the management of POPF, others did not require any intervention since most of them spontaneously disappeared. FC size and drain amylase levels on POD3 were found to be significantly associated with POPF and could potentially help to determine appropriate treatment.

The RAS mutation status predicts survival in patients undergoing hepatic resection for colorectal liver metastases: The results from a genetic analysis of all-RAS.

INTRODUCTION: We investigated the impact of mutations in KRAS exons 3-4 and NRAS exons 2-3 in addition to KRAS exon 2, so-called all-RAS mutations, in patients with colorectal liver metastasis (CLM) undergoing hepatic resection. METHODS: We analyzed 421 samples from CLM patients for their all-RAS mutation status to compare the overall survival rate (OS), recurrence-free survival rate (RFS), and the pattern of recurrence between the patients with and without RAS mutations. RESULTS: RAS mutations were detected in 191 (43.8%). Thirty-two rare mutations (12.2%) were detected in 262 patients with KRAS exon 2 wild-type. After excluding 79 patients who received anti-EGFR antibody therapy, 168 were classified as all-RAS wild-type, and 174 as RAS mutant-type. A multivariate analysis of factors associated with OS and RFS identified the RAS status as an independent factor (OS; hazard ratio [HR] = 1.672, P = 0.0031, RFS; HR = 1.703, P = 0.0024). Recurrence with lung metastasis was observed significantly more frequent in patients with RAS mutations than in patients with RAS wild-type (P = 0.0005). CONCLUSIONS: Approximately half of CLM patients may have a RAS mutation. CLM patients with RAS mutations had a significantly worse survival rate in comparison to patients with RAS wild-type, regardless of the administration of anti-EGFR antibody therapy.

[Status of Hepatic Lymph Node Involvement in Patients with Resectable Liver Metastasis of Colorectal Cancer after Preoperative Chemotherapy].

The liver is the most common metastatic site for colorectal cancer(CRC).The 5-year survival rate of resected cases has been reported to be about 40%.Hepatic lymph node metastasis is reportedly associated with a poor prognosis in patients with liver metastases of CRC.The incidence of hepatic lymph node involvement in patients with liver metastases of CRC ranges from 5% to 28%.However, few reports have focused on hepatic lymph node involvement in patients with resectable liver metastasis who have undergone preoperative chemotherapy.This retrospective study was undertaken to address this issue.The subjects were 33 consecutive patients who had undergone the resection of liver metastases of CRC with hepatic lymph node sampling after preoperative chemotherapy between 2001 and 2016. Hepatic lymph node metastasis was confirmed in only one patient(3%).There was no significant difference in the frequency of hepatic lymph node metastasis between the cases with or without preoperative chemotherapy.The further collection of data is warranted to elucidate the significance of hepatic lymph node involvement in patients with liver metastases of CRC treated with preoperative chemotherapy.

[Prognostic Impact of Tumor Location of Colorectal Cancer in Patients with Resected Liver Metastasis].

Recently, metastatic colorectal cancer(CRC)patients with a left-side primary tumor have been reported to have a significantly longer survival period than those with a right-side primary tumor. However, the impact of the location of the primary lesion on the survival outcomes of patients with resectable liver metastases of CRC has not yet been fully investigated. The subjects of this retrospective study were 113 consecutive patients who underwent a hepatic metastatectomy for CRC between 2001 and 2016 at our institution. The background data and survival times were compared between 32 patients whose primary lesions were located in the cecum or the ascending colon(right-side group)and 81 patients whose primary lesions were located in the descending colon, sigmoid colon, or rectum(left-side group). No significant differences in various clinicopathological variables were observed between the 2 groups. The 5-year overall and relapse-free survival rates after hepatectomy were 62.1% for the right-side group vs 49.2% for the left-side group(p=0.55)and 37.1% for the right-side group vs 33.4%for the left-sided group(p=0.76), respectively. In conclusion, colorectal liver metastasis should be resected regardless of the primary tumor location.

[A Case of Local Recurrence with Negative FDG/PET Findings after a Total Proctocolectomy for Ulcerative Colitis Associated with Colon Cancer with Retroperitoneal Penetration].

We report the case of a 55-year-old man who successfully underwent resection of a recurrence of ulcerative colitis(UC)- associated colon cancer located in the pancreatic body and left kidney. The patient had undergone an emergency laparotomy (total proctocolectomy with stapled ileal-pouch anal anastomosis)for the treatment of a descending colon cancer with retroperitoneal penetration associated with UC at the age of 50 years. At that time, histological examinations revealed a mucinous carcinoma that was classified as Stage II colon cancer. Three years after the patient's initial operation, a CT scan revealed a small mass located between the pancreatic tail and the left kidney. However, the accumulation of FDG was not observed during a positron emission tomography(PET)examination, resulting in close observation. As the size of the tumor and the levels of serum carcinoembryonic antigen and carbohydrate antigen 19-9 gradually increased, recurrence was highly suspected. A distal pancreatectomy and left nephrectomy were performed. Pathological examination showed findings concurrent with a local recurrence of colon cancer. Special histological types, such as mucinous carcinoma, often occur in some colitic cancers. For the postoperative surveillance of patients with colitic cancer, it should be noted that the sensitivity of FDG/PET is lower for mucinous carcinoma of the colon than it is for more common colon cancers.

[A Case of Advanced Gastric Cancer Successfully Treated with Curative Conversion Surgery after Chemotherapy with S-1 plus Oxaliplatin].

This report describes a patient with unresectable advanced gastric cancer who was successfully treated with potentially curative conversion surgery after chemotherapy with S-1 plus oxaliplatin(SOX). An 82-year-old man was diagnosed with type 5 gastric cancer(por1, HER2-negative)with multiple granular mucosal necroses that had metastasized throughout his body. Computed tomography revealed multiple lymph node metastases, tumor thrombosis in the splenic and portal veins, and peritoneal dissemination. After 9 courses of first-line chemotherapy with SOX, there was no tumor thrombosis in the splenic and portal veins or peritoneal dissemination, and the primary tumor and lymph node metastases were markedly reduced in size, indicative of a partial response(PR). The patient subsequently underwent total gastrectomy as curative conversion surgery. The histological diagnosis was ypT2N0M0, ypStage I B, and the primary lesion was categorized as Grade 2 gastric cancer. At present, 1 year after surgery, the patient remains alive without tumor recurrence.

[A Family with Peutz-Jeghers Syndrome Having Various Malignant Diseases].

We report a 27-year-old female who was diagnosed with adenocarcinoma of the uterine cervix associated with Peutz- Jeghers syndrome(PJS). She had undergone 5 surgeries for intestinal intussusception and had been diagnosed with PJS. She was referred to our hospital, complaining of watery vaginal discharge, and was diagnosed with adenocarcinoma of the uterine cervix. Following neoadjuvant chemotherapy, radical hysterectomy and small intestinal polypectomy by intraoperative endoscopy were performed. Among the third-degree relatives of her family, 10 had been diagnosed with PJS; of these 10, uterine cervical adenocarcinoma occurred in 3 relatives, pancreatic cancer in 2, cholangiocellular carcinoma in 1, and colon cancer in 1. Patients with PJS are at increased risk of developing malignant tumors in various organs. A recent review of the literature from Japan revealed that the cumulative cancer risk was estimated to be 83%by the age of 70 years, with especially high incidence rates of uterine cervical adenocarcinoma, colorectal cancer, and pancreas cancer. Surveillance for malignant neoplasms in patients with PJS is recommended, focusing on the sex and age of the patients.

[A Case of Familial Adenomatous Polyposis with a Desmoid Tumor Probably Communicating to the Intestinal Lumen That Was Successfully Treated with Non-Surgical Therapy].

A 44-year-old man with familial adenomatous polyposis underwent laparoscopic-assistedtotal proctocolectomy with ilealpouch anal anastomosis(IPAA). Computed tomography conducted 21 months after IPAA demonstrated bilateral hydronephrosis andan intra-abdominal mass with a maximal diameter of 22 cm, leading to a diagnosis of stage IV desmoid disease, according to the classification by Church and associates. Six courses of combination chemotherapy with doxorubicin plus dacarbazine were administered. Computed tomography after chemotherapy demonstrated marked shrinkage of the desmoidtumor with intraabdominal air andfluidcollection extending just below the skin of the ileostomy closure site. Stoollike fluidoverflowedspontaneously through the site of the ileostomy closure andthe abscess cavity was successfully drained. The patient was discharged 30 days after the start of drainage. The patient is doing well 10 months after the drainage without regrowth of the desmoid tumor, even though a cavity-like lesion encapsulatedby a thick wall remains.

[A Case of a Patient with Distal Bile Duct Carcinoma Who Underwent Surgical Resection Three Times for Pulmonary Metastases].

A 63-year-old woman attended our hospital after diagnosis of a solitary pulmonary metastasis from a distal bile duct carcinoma. She had undergone a subtotal stomach-preserving pancreaticoduodenectomy 1 year 9 months prior to the current presentation. She was treated with right thoracoscopic pulmonary partial resection. The specimen was a solitary nodule 5 mm in diameter. In addition, she was treated with adjuvant chemotherapy involving GEM for 6 months. One year 5 months later, she was diagnosed with a second pulmonary metastasis and was treated with a left thoracoscopic partial resection. Four months later, she experienced recurrence in the right lung stump and was treated with right thoracoscopic partial resection. The specimen was a solitary nodule 21 mm in diameter. Cytopathologic examination of the pleural fluid resulted in a diagnosis of Class Ⅴ. She was treated with adjuvant chemotherapy involving TS-1 for 6 months. Seven months later, she was experienced recurrence with multiple pulmonary metastases and an affected hilar lymph node. GEM/CDDP chemotherapy was started, but bone multiple metastases developed. After she received 30 Gy of radiotherapy, her pain improved. She died of cancer 5 years and 4 months after her initial pancreaticoduodenectomy, which was 3 years and 4 months after her initial pulmonary resection. We identified 14 other case reports of long-term survivors of distal bile duct carcinoma.

[Useful device for hepatectomy in patients with a surgical history of bile duct-GI tract anastomosis at the porta hepatis].

We experienced three hepatectomies in patients with a history of bile duct-gastrointestinal (GI) tract anastomosis at the porta hepatis. Patient 1 had a history of pancreaticoduodenectomy for bile duct cancer. Because the third liver metastasis of cecal cancer postoperatively invaded the right kidney, after 5 courses of FOLFOX we performed partial resection of the liver (S6) and the right kidney using microwave pre-coagulation and a cavitron ultrasonic surgical aspirator (CUSA) without the Pringle method. Patient 2 had a history of splenectomy for congenital spherocytosis, cholecystectomy, choledocholithotomy, and bile duct duodenal anastomosis for hepatolithiasis. Partial (S5) liver resection was performed to treat hepatocellular carcinoma. Patient 3 had a history of bile duct resection and choledochojejunostomy for congenital cystic dilatation of the common bile duct. She had repeated episodes of cholangitis in the year following surgery. Extended liver segmental (S4) resection was performed to treat intrahepatic bile duct carcinoma. Bile duct jejunum anastomosis was performed, and the portal vein and the hepatic artery in the porta hepatis were exfoliated. Hepatectomy was performed using the Pringle method and a CUSA. Surgical procedures using various devices are necessary for hepatectomy in patients with a history of bile duct-GI tract anastomosis at the porta hepatis.

[Surgical management for more than 10 liver metastases from colorectal cancer].

We examined the clinical course of patients with multiple liver metastases (≥10) from colorectal cancer after hepatectomy. Of 455 patients, 336 patients had 1-4 metastases, 71 had 5-9 metastases, and 48 had ≥10 metastases (31 patients had undergone chemotherapy along with hepatectomy and 17 had not undergone chemotherapy). Chemotherapy was effective in improving the 5-year survival rate of patients with 5 or more metastases. The 5-year survival rate in patients who underwent hepatectomy along with chemotherapy (52.7%[1-4 metastases], 49.9%[5-9 metastases], and 42.3% [≥10; n=5]) was better than that in patients who did not undergo chemotherapy( 56.1%[not significant: ns], 13.1% [p=0.0003], and 0%[p<0.0001], respectively). Five patients with ≥10 liver metastases survived for 5 years after hepatectomy, of which, 1 received FOLFOX (Leucovorin plus 5-FU plus oxaliplatin) adjuvant chemotherapy, 2 received preoperative FOLFOX, and 2 received LV5FU2 (5-FU plus Leucovorin) hepatic arterial infusion chemotherapy. Our results suggest that long-term improvement in prognosis could be possible with aggressive repeat hepatectomy along with effective chemotherapy.