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Surgical resection is the standard treatment for bile duct cancer. However, even when surgical resection is possible, the 5-year survival rate is reportedly 25.0-55.0%. Therefore, bile duct cancer is associated with poor prognoses. We conducted a clinicopathological investigation, focusing on the histological phenomenon of tumour budding, which has previously been reported to be correlated with the survival of patients with a variety of cancers.To investigate the significance of tumour budding in distal bile duct cancer, we recruited 65 patients who underwent pancreatoduodenectomy at our institution between 1995 and 2011. Tumour budding was observed and evaluated using the 'hot spot method'. The 'low' budding group comprised 0-4 cell clusters and the 'high' budding group ≥5 cell clusters. Additionally, immunostaining was performed in high-budding areas.Tumour budding and stage were confirmed using a Cox proportional hazards model as independent prognostic factors for overall survival (p0.05) in all patients. There was a significant association between budding and zinc finger E-box binding homeobox 1 expression, an endothelial-mesenchymal transition-induced transcription factor. In stage II cases, the prognosis was significantly worse in the 'high' budding group compared to that in the 'low' budding group.The budding phenomenon is an independent prognostic factor for patients with distal bile duct cancer. Understanding the mechanisms underlying tumour budding in distal bile duct cancer and its relationship with poor prognoses may be useful for the development of novel treatments for this disease.

Studies have indicated that liver mobilization during hepatectomy could cause the dissemination of tumor cells. However, the data are still limited in terms of the relationship between circulating tumor cells (CTCs) and surgical procedures.Fifteen patients who underwent hepatectomy for primary hepatocellular carcinoma (HCC) were included in the study. Blood samples were collected from the portal vein, central vein, and peripheral artery at three time points, namely, before mobilization (BM) of the liver, during transection (DT) of parenchyma, and after resection (AR) of the tumor. To detect CTCs, a real-time PCR assay was performed using primers for the epithelial cell adhesion molecule, cytokeratin 18, and glypican 3. Patients were divided into anterior approach (AA) and non-AA (NA) groups. In the AA group, patients underwent an initial hilar vascular dissection followed by a liver hanging maneuver during transection.Seven patients were allocated to the AA group, and eight to the NA group. In the NA group, CTC levels in the portal vein were significantly increased at DT and AR compared to BM. In cases with large HCC (70 mm), CTC levels in central venous blood were significantly increased at DT and AR in the NA group.The AA liver resection technique may minimize CTC dissemination, improving the prognosis of patients with HCC.

Right hepatectomy and extended right hepatectomy (Rt-Hr) are identified as risk factors for the development of post-hepatectomy liver failure (PHLF). Although portal vein embolization (PVE) has made it possible to safely perform extended hepatectomy, to ensure safety, in our department, PVE is performed prior to Rt-Hr for hepatocellular carcinoma (HCC) regardless of the resection rate. This study aimed to retrospectively investigate the clinical course of PVE prior to Rt-Hr for HCC cases resected in our department and the appropriateness of our policy by clarifying complications and deaths.The target period was from 2005 to 2020. Among the HCC cases resected at our hospital, those in which PVE was performed prior to Rt-Hr were included in this study. For PHLF, the definition of the International Study Group of Liver Surgery was used. The Clavien-Dindo classification was used for postoperative complications. Perioperative mortality was defined as the overall mortality within 30 days following surgery and surgery-related deaths within 90 days following surgery.A total of 79 cases were included. Rt-Hr was possible in all cases after PVE and there were no cases in which serious complications occurred after PVE. PHLF was found in 14 cases (17.7%)/5 cases (6.4%)/0 cases (0%) of Grade A/B/C, respectively. Regarding postoperative complications, there were no Grade IV, and Grade IIIa/IIIb were found in 13 cases (16.5%). There were no perioperative deaths.Our department's policy of performing PVE prior to all Rt-Hr was considered to be a safe and reasonable treatment strategy.

Sulphite oxidase (SUOX) is a metalloenzyme that catalyses ATP synthesis via oxidative phosphorylation in the mitochondria. Although SUOX has been reported to affect the invasiveness and differentiation of cancer cells, its clinicopathological significance in pancreatic adenocarcinoma (PDAC) remains unclear. In this study, we investigated the utility of SUOX expression as a prognostic factor in PDAC.This study included 56 patients with PDAC who underwent pancreatic resection at the Kurume University Hospital between 2014 and 2018. SUOX immunohistochemistry was evaluated using tissue microarray specimens from patients. Patients were classified into a high SUOX expression group (≥10% of cells stained) or a low SUOX expression group (10% of cells stained), and the associations of SUOX with clinicopathological characteristics and survival were analysed. Statistical analysis was performed using Cox regression analysis, the Kaplan-Meier method, and log-rank test.SUOX was expressed in the cytoplasm of normal pancreatic ductal epithelium, pancreatic acinar cells, and islets of Langerhans. Although we did not find any significant correlation between SUOX expression and clinicopathological factors, SUOX was identified as an independent prognostic factor based on univariate and multivariate analyses. Pathological stage was also an independent prognostic factor. The high SUOX expression group showed a significantly poorer prognosis than the low SUOX expression group (p=0.018).SUOX-mediated mitochondrial metabolism in PDAC may be a factor influencing prognosis and SUOX may be a potential novel prognostic biomarker.

Background/aim Hepatocellular carcinoma (HCC) remains one of the biggest medical issues. Pigment epithelial-derived factor (PEDF) is a glycoprotein that belongs to the superfamily of serine protease inhibitors. PEDF interacts with its two receptors, adipose triglyceride lipase (ATGL) and laminin receptor (LR). Materials and methods We conducted immunohistochemical staining for PEDF, LR and ATGL in 151 resected HCCs and their background liver tissues. Results High expression of LR in HCC was associated with high histological grade and portal vein invasion, while high expression of PEDF in HCC was associated with absence of portal vein invasion. High LR expression in background liver was statistically associated with low serum albumin levels and was an independent prognostic factor of worse outcomes. No cases with more than 5% fatty degeneration in the background liver tissue showed high PEDF expression. Conclusion PEDF/LR/ATGL could be potential biomarkers in HCC and various chronic hepatic disorders.

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.

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.

Highlights • The prognosis of patients with advanced HCC remains poor even if appropriate treatments are administered. • Spontaneous regression of lung metastases of hepatocellular is a rare condition. • We discuss the mechanism for spontaneous regression of multiple pulmonary recurrences of hepatocellular carcinoma., Introduction Spontaneous regression of hepatocellular carcinoma (HCC) is a rare condition. However, although there have been multiple reports of spontaneous regression, the definitive pathogenic mechanism of this phenomenon is still unclear. Case presentation We encountered a case of a 78-year-old man who was undergoing dialysis for end-stage kidney disease with hepatitis C virus-associated chronic hepatitis presenting with HCC. The patient had previously undergone right lobectomy of the liver, but the cancer recurred with multiple lung metastases after 5 months. Approximately 13 months after the initial diagnosis of recurrence, the lung metastases decreased in size and eventually resolved without any anticancer therapy. The patient remains alive for over 41 months after recurrence. Discussion Based on our case and literature, Hypoxia with hypotension due to hemodialysis can reduce the blood and oxygen supply of the body, which may lead to the spontaneous regression of the metastatic tumors. Conclusion We herein reported a case of spontaneous regression of HCC undergoing dialysis.

Malignant biliary obstruction (MBO) is a life-threatening condition. We aimed to investigate the outcome of salvage percutaneous transhepatic biliary drainage (PTBD) in patients with unresectable MBO due to failure of management by endoscopic retrograde cholangiopancreatography (ERCP) and/or prior surgical bypass.Fifty-two consecutive patients (mean age, 69 years; 44.2% women) underwent salvage PTBD between 2013 and 2020.The median overall survival rate was 4.2 months, with a 95% confidence interval (CI) of 1.9-5.7. The median overall survival (OS) were 11.1 months and 1.9 months for patients who underwent chemotherapy (n=17) and best supportive care (n=35), respectively (p=0.0005). Independent factors predicting poor outcome were best supportive care, with a hazard ratio (HR) of 3.3 (95%CI=1.3-8.5), American Society of Anesthesiologists physical status classification (ASA) with a HR of 13.5 (95%CI=1.3-136.0) and Eastern Cooperative Oncology Group (ECOG) performance status of 4, with a HR of 3.3 (95%CI=1.0-6.2).Salvage PTBD with chemotherapy has the potential to achieve prolonged survival in patients with unresectable MBO, including those with failure of ERCP and/or surgical bypass.

Hepatocellular carcinoma (HCC) shows a high mortality rate. A macrotrabecular (MT) pattern and vessels encapsulating tumor clusters (VETC) pattern have been reported as aggressive histological patterns in HCC. However, their cut-off values have been contentious.Nine hundred eighty-five cases of previously diagnosed HCC were enrolled. The percentage areas of the MT and/or VETC pattern with ≥ 5% at every 10% increment were assessed. Clinicopathological analysis including patients' prognosis was conducted.One hundred fifty-eight and eighty-four cases were accompanied by 5-49% and ≥ 50% MT components, respectively. Two hundred six and twenty-nine cases had 5-49% and ≥ 50% VETC components, respectively. Cases with these histological patterns in common had aggressive characteristics and worse prognosis compared to cases with none of these patterns. The presence of 5-49% VETC pattern was independent worse prognostic factor in overall survival (P = 0.046). HCCs with the MT pattern and the VETC pattern were significantly accompanied by the VETC pattern and the MT pattern (P 0.001), respectively.As even 5% of the MT pattern and/or VETC pattern affected the prognosis of patients with HCC, the amount of these pattern should be described in pathological reports. This information could be useful in expecting patients' prognosis and providing proper post-operative treatments.

BACKGROUND/AIM Recent studies have demonstrated the efficacy of salvage surgery following downstaging of hepatocellular carcinoma (HCC). The aim was to assess the outcomes of salvage surgery after successful downstaging using hepatic arterial infusion chemotherapy (HAIC). PATIENTS AND METHODS Patients whose diagnosis was unresectable locally advanced HCC and who were resected after conversion to a resectable status by HAIC were included. The overall survival (OS) rate, and disease-free survival (DFS) rate were analyzed by stratifying patients into those with Vp3/4, Vv2/3, and those without major vascular invasion (MVI). RESULTS Eighteen patients were censored. Among them, six patients had Vp3/4, four patients had Vv2/3, and eight patients had no MVI. The 5-year OS rates of patients with Vp3/4 and those without MVI were 83% and 73%, respectively, whereas those with Vv2/3 had 0% (p

Background/aim We investigated the anti-proliferative effect of quercetin on liver cancer cell lines. Materials and methods Thirteen liver cancer cell lines were cultured followed by treatment with varying concentrations of quercetin (0-100 μM) or quercetin and 5-FU, and the cell viability was analysed by the MTT assay. Flow cytometry was also used to examine cell cycle progression after treatment with quercetin. Results The addition of quercetin resulted in a dose- and time-dependent suppression of cell proliferation. In some cell lines, treatment with quercetin and 5-FU caused an additional or synergistic effect. Most cell lines displayed cell cycle arrest at different phases of the cell cycle. Conclusion Quercetin inhibits the proliferation of liver cancer cells via induction of apoptosis and cell cycle arrest.

A 71-year-old man who underwent laparoscopic partial liver resection for local recurrence hepatocellular carcinoma (HCC)in segment 4 one year after percutaneous radiofrequency ablation(RFA)for HCC. About 3 years after treatment, the patient showed elevation of serum level of tumor marker and a mass lesion in the round ligament on CT and EOB-MRI. We made a diagnosis of peritoneal dissemination of HCC. Laparoscopic extirpation of peritoneal dissemination using indocyanine green(ICG)imaging was performed and no other tumors were observed in the peritoneal cavity. A lesion was diagnosed as peritoneal dissemination of HCC, and postoperative course was uneventful. This patient underwent repeated RFA and partial resection for recurrence of HCC. The patient was died for intrahepatic multiple recurrence of HCC without peritoneal dissemination 25 months after extirpation of peritoneal dissemination. In the field of hepatobiliary surgery, ICG imaging can be used for the intraoperative real-time visualization of hepatic malignancies. The ICG imaging is restricted to detection of fluorescence for liver tumors 5-10 mm from the liver surface. In the detection of peritoneal dissemination, however, there are no such limitations. Laparoscopic extirpation using ICG imaging is useful for the detection of peritoneal dissemination of HCC and may improve the prognosis in selected patients.

Background The number of patients with fatty liver due to alcohol consumption, the metabolic syndrome, non-alcoholic fatty liver disease, and non-alcoholic steatohepatitis is increasing. Because there is no consensus on the risk of hepatectomy in patients with fatty liver, this study examined the clinical outcomes of hepatectomy in fatty liver patients by evaluation their transaminase levels. Methods Patients (n = 164) who underwent hepatectomy for primary liver tumors from January 2014 to March 2019 were included in the study. They were divided into the steatohepatitis (n = 19), steatosis (n = 20), and viral hepatitis (n = 30) groups. Serum values of aspartate aminotransferase (AST), alanine transaminase (ALT), total bilirubin (TB), white blood cells, and platelets level and the prothrombin time (PT) were compared before and immediately after surgery, and on postoperative days 1–5, 7, and 10. Results Overall, the AST and ALT elevation rates were higher in the control group than in the steatosis and steatohepatitis groups during postoperative days 2–7. There was no difference in postoperative hepatic dysfunction between the steatosis and steatohepatitis groups. Univariate analysis revealed significant differences in liver stiffness, operative time, mobilization, and the Pringle time. Multivariate analysis indicated low liver stiffness and a longer Pringle time as independent risk factors. Postoperative changes in the TB and albumin levels and the PT did not differ between the groups. There was no difference in the postoperative complications and hospital stay length between the groups. Conclusions Fatty liver does not increase the risk of postoperative liver damage following hepatectomy.

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.

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.

Background Intrahepatic cholangiocarcinoma (ICC) is primary cancer of the liver with poor prognosis because of its high potential for recurrence and metastasis. We experienced a rare case of ICC with hematogenous metastasis to the falciform ligament. We aimed to clarify the route of metastasis to the mesentery by increasing the accuracy of preoperative imaging and establish a hepatectomy to control cancer. Case presentation An 85-year-old woman was referred to our hospital for a detailed study of progressively increasing liver tumors. She had no subjective symptoms. Her medical history showed hypertension, aneurysm clipping for cerebral hemorrhage, and gallstones. A detailed physical examination and laboratory data evaluation included tumor markers but did not demonstrate any abnormalities. On computed tomography scan, contrast-enhanced ultrasound, and magnetic resonance imaging with gadolinium ethoxybenzyl diethylenetriamine penta-acetic acid, the tumor appeared to be located in liver segment IV, protruding outside the liver. It appeared to contain two distinct components; we suspected ICC in the intrahepatic tumor component. Laparoscopic observation revealed that the extrahepatic lesion was an intra-falciform ligament mass; laparoscopic left hepatectomy was performed. Microscopically, the main tumor in segment IV was 15 mm in diameter and was diagnosed as moderately and poorly differentiated ICC. The tumor of the intra-falciform ligament was not continuous with the main intrahepatic nodule and was also diagnosed as ICC with extensive necrosis. There were no infiltrates in the round ligament of the liver, and several tumor thrombi were found in the small veins of the falciform ligament. Conclusions To date, there have been a few reports of metastases of primary liver cancer to the falciform ligament. At the time of preoperative imaging and pathological diagnosis, this case was suggestive of considering that the malignant liver tumor might be suspected of metastasizing to the falciform ligament. Our case improves awareness of this pathology, which can be useful in the future when encountered by hepatic specialists and surgeons.

Annular pancreas is a rare congenital anomaly that rarely occurs in parallel with malignancy. We herein report a case of annular pancreas with carcinoma of the papilla of Vater. A 76-year-old woman presented with abdominal pain and was referred to us after gastroduodenal endoscopy showed a tumor of the papilla. Preoperative computed tomography confirmed the presence of an ampullary tumor. During surgery, we found an anomaly consisting of a ring-like band of pancreatic tissue encircling the second part of the duodenum. Transduodenal papillectomy with preservation of the annular pancreas was subsequently performed. The patient was discharged without any postoperative morbidity.

Supplemental Digital Content is available in the text., Background: The success of laparoscopic liver resection (LLR) depends on stable and full exposure of the parenchymal transection plane. We evaluated the efficacy of LLR using a silicone band retraction method for lesions in the anterolateral and posterosuperior segments. Methods: We retrospectively analyzed 189 consecutive patients who had undergone LLR in our hospital between July 2010 and July 2020. They were divided into 2 groups according to whether LLR was performed before (conventional group; n=64) or after (silicone band group; n=125) the introduction of the silicone band retraction method. Results: The silicone band group demonstrated significantly less blood loss than that by the conventional group. The mean operative time and the hospital stay in the silicone band group were obviously shorter than that in the conventional group. The open conversion rate and the major complication rate were significantly lower in the silicone band group than that in the conventional group. Conclusion: The silicone band retraction method is a useful approach that results in a safe LLR.

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.

We investigated the anti-proliferative effect of quercetin on liver cancer cell lines.Thirteen liver cancer cell lines were cultured followed by treatment with varying concentrations of quercetin (0-100 μM) or quercetin and 5-FU, and the cell viability was analysed by the MTT assay. Flow cytometry was also used to examine cell cycle progression after treatment with quercetin.The addition of quercetin resulted in a dose- and time-dependent suppression of cell proliferation. In some cell lines, treatment with quercetin and 5-FU caused an additional or synergistic effect. Most cell lines displayed cell cycle arrest at different phases of the cell cycle.Quercetin inhibits the proliferation of liver cancer cells via induction of apoptosis and cell cycle arrest.

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.

The therapeutic management of simultaneous liver metastasis of colorectal cancer(SCRLM)remains controversial. Although hepatic metastasectomy is the first choice for resectable liver metastasis of colorectal cancer, radiofrequency ablation (RFA)is one of the least invasive application for patients who refuse more invasive treatment such as hepatectomy and longterm systemic chemotherapy or for whom such treatment is not suitable. We report 2 cases of SCRLM treated by surgery combined with intraoperative RFA and adjuvant chemotherapy, raising the possibility of local control in the liver for selected patients.

Background Some literature has reported on endovascular treatment for very early hepatic artery stenosis (HAS; within 2 weeks after liver transplantation, and has deemed endovascular treatment to be a contraindication because out of serious complications associated with the procedure. We report on 2 cases of very early HAS successfully treated with endovascular treatment after living-donor liver transplantation (LDLT). Case 1 A 54-year-old woman underwent LDLT with a left liver graft. The native right gastric artery and left hepatic artery (LHA) of the donor were anastomosed. On postoperative day (POD) 13, HAS was suspected and multidetector computerized tomographic angiography (MDCTA) was performed, which revealed 90% stenosis of the arterial anastomosis and 50% stenosis of the LHA in the graft. We performed percutaneous balloon arterioplasty (PBA) without any complications. The artery was patent with a postoperative follow-up of 60 months without the need for repeat intervention. Case 2 A 67-year-old woman with a history of repeated transarterial chemoembolization for hepatocellular carcinoma underwent LDLT with a left liver graft. The native A4 and LHA of the donor were anastomosed. We performed MDCTA on POD 11, which revealed 70% stenosis of the native hepatic artery. We performed PBA followed by stent placement on POD 11 without complication. The artery was patent with a postoperative follow-up of 40 months without the need for repeated intervention. Conclusions Endovascular treatment has the potential to avoid the need for repeated surgical interventions or retransplantation, and it can be safely performed in carefully selected patients.

A 65-year-old man with sigmoid colon cancer underwent sigmoidectomy, followed by 8 courses of oral S-1 as postoperative adjuvant chemotherapy. Three years and 3 months after surgery, the patient developed liver metastasis, lymphadenopathy at the root of the inferior mesenteric artery, and bilateral hydronephrosis. The left hydronephrosis was believed to be due to invasion by lymph node metastasis at the root ofthe inferior mesenteric artery. The patient underwent laparoscopic partial resection ofsegment 5 ofthe liver, excision ofthe lymph nodes at the root ofthe inferior mesenteric artery(combined resection ofthe left ureter), bilateral ureteral stent placement, and left ureteral reconstruction. The postoperative course was without complications, and he was discharged 12 days after surgery. Follow-up observation without postoperative adjuvant chemotherapy was planned, according to the patient's wishes.

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.

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.

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.

Background Liver is a common location of colorectal metastasis, but intrabiliary growth of liver metastasis is not well recognized. Furthermore, intrabiliary metastasis that discovered over 10 years after excision has rarely been described. Case presentation An 80-year-old man was admitted due to the presence of a liver mass in segment 5 (S5) concomitant with elevated carcinoembryonic antigen (CEA), and carbohydrate antigen (CA) 19–9. He underwent right hemicolectomy for colon cancer 12 years prior. Enhanced computed tomography (CT) showed dilated bile ducts with periductal enhancement in S5; hence, cholangiocarcinoma was suspected. Upon anterior segmentectomy, we observed that the cut surface of the specimen exhibited a yellowish-white tumor within the bile ducts. Histologically, the tumor formed within the papillary process, extended along the lumen, and replaced the normal bile duct epithelium. Immunohistochemical studies showed that the liver tumor and primary colon cancer were negative for cytokeratin (CK) 7 and positive for CK20 and Caudal-type homeobox transcription factor 2 (CDX-2). In addition, both tumors showed a same KRAS mutation. We diagnosed the liver tumor as liver metastasis recurrence from colon cancer. Conclusion Intrabiliary growth type of metastasis (IGM) is difficult to distinguish from cholangiocarcinoma, and sometimes develops long after surgery; thus, careful examination of a patient’s history is needed in such cases.

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.

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.

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.

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.