Takeomi Hamada

Laparoscopic anterior pelvic exenteration for locoregionally advanced rectal cancer directly invading the urinary bladder: A case report of low anterior resection with en bloc cystectomy for sphincter preservation

Laparoscopic multi‐visceral resection in patients with T4 colorectal cancer remains controversial. A 73‐year‐old man was admitted to the hospital for rectosigmoid cancer directly invading the urinary bladder trigone without distant metastasis. We successfully performed complete resection by laparoscopic anterior pelvic exenteration while preserving the anus. After laparoscopic mobilization of the rectum, urinary bladder, and prostate, the urethra and urethral catheter were dissected to reveal the lower rectum. By pulling the urethral catheter toward the head, the prostate was excised retrogradely from the lower rectum anterior wall. The lower rectum was resected and anastomosed by the double stapling technique with a safe distal margin from the tumor. Pathological findings of the resected specimen indicated no residual tumor in the surgical margin. There was no evidence of recurrence 34 months after surgery. En bloc, R0, laparoscopic anterior pelvic exenteration for T4 rectal cancer is feasible. However, further studies with long‐term follow‐up are required to resolve oncological outcomes.

Preoperative maximal removal rate of technetium-99m-galactosyl-human serum albumin of the remnant liver is associated with postoperative tumor relapse in hepatitis C virus-related hepatocellular carcinoma

Background Prognosis in patients with hepatocellular carcinoma (HCC) is not only influenced by tumor-related factors but also by the background liver functions. The maximal removal rate of technetium-99m-galactosyl human serum albumin (GSA-Rmax) of the remnant liver (rGSA-Rmax) is a useful candidate for predicting the liver function and clarifying the relationship between the remnant liver functional reserve and tumor-free survival in patients who have undergone hepatectomy. Patients and methods One hundred and sixty-five patients with HCC who underwent curative hepatectomy were divided into three groups of hepatitis B virus (B-HCC; n=42), hepatitis C virus (C-HCC, n=58), and non-B, non-C (NBNC-HCC, n=65). The relationship between rGSA-Rmax and survival was examined by univariate and multivariate analyses. Results In the C-HCC group, the albumin, or LHL15, level was significantly lower, and alanine aminotransferase, ICGR15, and the prevalence of grade B liver damage were significantly higher than other two groups (P<0.05). GSA-Rmax or rGSA-Rmax was not different between the three groups. Lower GSA-Rmax and rGSA-Rmax were only significantly associated with lower tumor-free survival in the C-HCC group by the univariate analysis (P<0.05) but not significantly by the multivariate analysis. Conclusion GSA-Rmax and rGSA-Rmax reflect the severity of liver dysfunction and furthermore, the lower rGSA-Rmax is useful as a complementary factor to predict the early HCC recurrence after hepatectomy.

Curative distal pancreatectomy in patients with acinar cell carcinoma of pancreas diagnosed by endoscopic aspiration via esophago-jejunostomy: A successful case report

Highlights • This is a rare report of acinar cell carcinoma of pancreas diagnosed preoperatively.• Accurate histological diagnosis was performed by endoscopic FNA via jejunal loop after gastrectomy.• Accurate histological diagnosis is useful in the field of pancreatic surgery, especially in cases of rare or small malignant lesions.

Intrahepatic portal vein thrombosis due to postoperative biliary obstruction successfully treated by a partial thrombectomy combined with thrombolytic drug therapy

Highlights • Portal vein thrombosis due to constriction of hepaticojejunostomy is rarely occured, in which increased biliary pressure by obstructive jaundice decreased portal flow.• Re-anastomosis and postoperative thromolytic therapy recovered occluded portal flow.

A resected case of hepato-pancreaticoduodenectomy for widely extended cholangiocarcinoma undergoing previous intra-abdominal poly-surgery

Highlights • Patients undergoing poly surgery have been increased due to improvement of postoperative managements.• We experienced a patient with widely spreading cholangiocarcinoma who had previously undergone polysurgery.• Even though the complicated prior surgery in the abdomen, the R0 operation can be safely completed by expert surgeons.

A successfully resected case of left trisectionectomy with arterio-portal combined resection for advanced cholangiocarcinoma

Highlights • In case of cholangiocarcinoma invading hilar vessels, adequate simulations and expert skills are required to achieve R0 resection.

Rendezvous biliary recanalization with combined percutaneous transhepatic cholangioscopy and double-balloon endoscopy

Despite advances in biliary stenting in patients with altered gastrointestinal anatomy, it is still a challenging procedure [1]. We present a case where percutaneous transhepatic cholangioscopy (PTCS) was combined with double-balloon endoscopy (DBE) for biliary stenting in a patient with complete obstruction of a choledochojejunostomy. A 71-year-old woman, who had a history of distal cholangiocarcinoma and had undergone pancreaticoduodenectomy 7 years previously, experienced recurrent cholangitis. DBE-assisted balloon dilation had been performed 7 months previously for stricture of the choledochojejunal anastomosis. However, she developed complete obstruction of the anastomosis (▶Fig. 1). A 7.2-Fr percutaneous transhepatic biliary drainage (PTBD) catheter was initially placed, and the fistula tract was dilated up to 12Fr within 4 weeks. DBE-assisted endoscopic retrograde cholangiopancreatography was then attempted. First, the double-balloon endoscope (EI-580BT; Fujifilm, Tokyo, Japan) was advanced to the afferent limb, and a percutaneous transhepatic cholangiogram revealed complete obstruction of the anastomosis. Next, a PTCS scope (BF type P260F; Olympus, Tokyo, Japan) was inserted via the PTBD route. However, a guidewire (0.018-inch, Pathfinder Exchange; Boston Scientific Japan, Tokyo, Japan) through the PTCS scope could not pass the anastomosis (▶Video1). Therefore, we attempted direct precutting (KD-V451M; Olympus) at the anastomosis, using the double-balloon endoscope and guided by transillumination from the percutaneous transhepatic cholangioscope’ (▶Fig. 2, ▶Video1). A small incision was carefully made in order to create a fistula (▶Fig. 3). This was followed by successful passage of the guidewire (0.032-inch, Radifocus Guidewire M; Terumo, Tokyo, Japan) Video 1 Biliary recanalization, using a rendezvous technique with combined percutaneous transhepatic cholangioscopy and double-balloon endoscopy, for a completely obstructed choledochojejunostomy. ▶ Fig. 1 Percutaneous transhepatic cholangiogram showing complete obstruction of the choledochojejunal anastomosis in a patient who had undergone pancreaticoduodenectomy 7 years previously. ▶ Fig. 2 Left panel: The choledochojejunal anastomosis has an appearance similar to an ulcer scar. Right panel: Transillumination from the percutaneous transhepatic cholangioscope guides direct precutting using the double-balloon endoscope. E-Videos

Preoperative regional maximal removal rate of technetium-99m-galactosyl human serum albumin is correlated with liver functional parameters, but did not predict postoperative morbidity

Background Recently, posthepatectomy complications have been predicted by advances of new liver functional parameters, and the technetium-99m-galactosyl human serum albumin (GSA) liver scintigraphy has been applied widely for this purpose. We evaluated the clinical significance of the regional maximal removal rate (GSA-Rmax) in patients with various liver diseases as predictors of posthepatectomy complications. Patients and methods Between 2012 and March 2016, we examined 200 patients who underwent hepatectomy for liver and biliary diseases. The patients’ background liver conditions included chronic viral liver diseases in 147 patients, normal liver in 44 patients, and others in nine patients. Hepatectomy-related postoperative complications (i.e. long-term ascites, intra-abdominal infection, and hepatic failure) occurred in 69 (35%) patients. A multivariate logistic analysis was carried out to detect the predictive parameters for complications. Results The median and mean preoperative GSA-Rmax was 0.420 and 0.448±0.148 mg/min, respectively. The GSA-Rmax was significantly correlated with liver functional parameters of ICGR15, LHL15, HH15, platelet count, prothrombin activity, and serum hyaluronic acid level (P<0.01), and was significantly correlated with postoperative total bilirubin level and C-reactive protein level (P<0.05). With respect to patient outcomes, GSA-Rmax was significantly lower in patients with long-term ascites (P<0.05). The predictive cutoff value for posthepatectomy long-term ascites for GSA-Rmax was 0.421 mg/min. However, the multivariate logistic regression analysis identified that a higher serum hyaluronic acid level and a lower platelet count were significant, independent factors, but not lower GSA-Rmax. Conclusion GSA-Rmax is one of the liver functional parameters and is a complementary parameter to predict postoperative hyperbilirubinemia, inflammatory responses, and ascites when 99mTc-GSA scintigraphy is performed.

Accompanying role of hepato-biliary-pancreas surgeon in urological surgery

Highlights • Accompanying support by full use of procedure of general or cardiovascular surgeons for urological surgery in malignancies provide curability.• Cardiovascular intervention should be necessary to remove long extension of tumor thrombus into the vena cava or right atrium.• Hepatic or pancreatic mobilization or combined resection is required for invasive or metastatic urological malignancies.• Operative safety is also required by precise preoperative planning and arrangement of procedure during operation by the good combination in each.

Horizontal traumatic laceration of the pancreas head: A rare case report

Highlights • A woman involved in a car crash sustained blunt pancreatic head trauma that resulted in hemorrhagic shock.• A rare horizontal laceration and complete transection of pancreatic head was discovered during surgery.• The main pancreatic duct was not injured. The lower part of the pancreatic head including the uncus and attached duodenum was partially resected and the remnant duodenum was anastomosed with the Roux-en Y limb of the jejunum by functional side-to-side anastomosis.• The patient recovered without developing major complications.