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BACKGROUND/AIM Computed tomography and positron emission tomography cannot detect all minute distant metastases and fully evaluate extensive vascular invasion in patients with pancreatic ductal adenocarcinoma (PDAC). The aim of this study was to investigate predictors of laparotomy only and palliative surgery in PDAC patients planning surgical resection. PATIENTS AND METHODS We reviewed 239 PDAC patients planning surgical resection. Patients were divided into two groups based on resection status. Multivariate analyses were performed to identify predictors of unresectable disease at laparotomy. RESULTS Twenty-five patients had unresectable disease at laparotomy. Multivariate analysis revealed that anatomical borderline resectable status (yes/no) (HR=5.458, p=0.012), pretreatment CA19-9 (>260/≤260 ng/ml) (HR=4.907, p=0.041), and tumor size (>25/≤25 mm) (HR=21.42, p=0.004) were associated with unresectable disease at laparotomy. CONCLUSION Borderline resectable status, pretreatment CA19-9, and tumor size were closely associated with unresectable disease at laparotomy in PDAC patients planning surgical resection.

Although neoadjuvant chemotherapy (NAC)-gemcitabine plus S-1 (GS) has been reported to have a survival benefit in patients with resectable pancreatic ductal adenocarcinoma (PDAC), optimal candidates for NAC-GS have not been clearly identified.A total of 81 patients with PDAC who underwent pancreatectomy after NAC-GS between 2013 and 2019 were divided into 2 groups based on Evans classification: grade I (10% tumor cell destruction, n = 19) and grades II and III (10% tumor cell destruction, n = 62). Univariate and multivariate analyses using clinical characteristics available before initiation of NAC were performed to predict Evans classification grade I (Evans I).The overall survival in patients with Evans I was significantly lower than that in patients with Evans II and III (P0.001). Multivariate analysis revealed a carcinoembryonic antigen level of3.6 ng/mL (P = 0.001) and C-reactive protein to albumin ratio of0.062 (P = 0.017) as independent predictors for Evans I disease. Seven of 11 patients who met both criteria had Evans I disease.Serum carcinoembryonic antigen and C-reactive protein to albumin ratio are associated with Evans I disease in patients with PDAC who receive NAC-GS. Patients who meet both predictors may not be optimal candidates for NAC-GS.

Recently, the number of patients with pancreatic ductal adenocarcinoma (PDAC) who have received both neoadjuvant chemotherapy (NAC) and adjuvant chemotherapy (AC) has been increasing. However, whether adverse events (AEs) during AC influence the prognosis of patients with resected PDAC who do or do not receive NAC remains uncertain. Patients with PDAC who underwent a pancreatectomy between 2011 and 2019 were divided into two groups: an upfront surgery (UFS) group (n = 72), and an NAC group (n = 77). Patients who received AC were then divided into two groups: an AE grade 0/1/2 group (AE-G-0/1/2) and an AE grade 3/4 group (AE-G-3/4). The relationship between AEs and patient outcome and predictors of AE-G-3/4 were investigated. AC was used in 54 and 65 patients in the UFS and NAC groups, respectively. In the NAC group, the relative dose intensity (RDI) and AC completion rate as well as the overall survival rate of patients with AE-G-3/4 (n = 15) during AC were significantly worse than those of patients with AE-G-0/1/2 (n = 50). However, similar differences were not observed in the UFS group. A multivariate analysis revealed that AE-G-3/4 during NAC, AC agent (gemcitabine), an albumin level

BACKGROUND/AIM An association between the pathological response to neoadjuvant chemotherapy (NAC) and the efficacy of adjuvant chemotherapy (AC) in patients with pancreatic ductal adenocarcinoma (PDAC) remains unknown. PATIENTS AND METHODS A total of 121 patients with PDAC who underwent a pancreatectomy between January 2013 and March 2020 were divided into two groups: an upfront surgery (UFS) group (n=42), and an NAC (gemcitabine plus S-1) group (n=79). In the NAC group, the pathological response was evaluated using the Evans classification. RESULTS The overall survival was significantly higher in patients with an AC relative dose intensity (RDI) ≥80% than in patients with an AC RDI

Background/purpose No effective postoperative adjuvant therapies have been established for patients with hepatocellular carcinoma (HCC). The aim of this study was to investigate the effect of oral administration of branched-chain amino acids (BCAA) on the recurrence-free survival (RFS) after hepatic resection in HCC patients. Methods In this randomized clinical trial, HCC patients undergoing curative resections were randomly assigned in a 1:1 ratio to the BCAA group or surgery-alone group. The BCAA group received BCAA (Livact® ) for up to 4 years. The primary endpoint was RFS. The secondary endpoint was overall survival (OS). Multivariate analysis was performed to detect the clinical characteristics significantly associated with RFS. Results Between January 2010 and October 2014, 156 patients (75 in BCAA group and 81 in surgery-alone group) were enrolled in the study. Of these, two patients were excluded from the efficacy analysis. Comparison of the survival curves by the log rank test demonstrated no significant difference in the RFS (P = .579) or OS (P = .268) between the BCAA and the control group. Multivariate analysis revealed that the RFS was significantly associated with age and number of tumors. A beneficial effect of BCAA on the RFS was found in patients younger than 72 years old with a HbA1c level of Conclusions Oral BCAA supplementation could not reduce the risk of recurrence after hepatic resection in HCC patients; however, the results suggested that BCAA supplementation may be beneficial for selected patients who were younger and had mildly impaired glucose tolerance.

Aim The lymphocyte‐to‐monocyte ratio (LMR) is useful for predicting the prognosis of patients with gastric cancer (GC) and those with colorectal cancer (CRC) undergoing surgery. The relationship between the LMR and postoperative outcome of patients with early‐stage gastrointestinal cancers such as stage I GC and CRC remains unclear. Methods We retrospectively evaluated 323 stage I GC and 152 stage I CRC patients undergoing surgery. Univariate and multivariate analyses using the Cox proportional hazards model were performed to identify the clinical characteristics associated with overall survival (OS), and the cut‐off values of these variables were determined by receiver operating characteristic analysis. The Kaplan–Meier method and log‐rank test were used for postoperative survival comparisons according to the LMR (GC: LMR 75/≤75 years) (HR, 3.511; 95% CI, 1.881‐6.551; P 3.5 g/dL) (HR, 3.040; 95% CI, 1.575‐5.869; P = 0.001), in stage I GC patients. Survival analysis demonstrated a significantly poorer OS in stage I GC patients with a LMR, Relationship between cumulative infectious disease and lymphocyte‐to‐monocyte ratio in patients with early stage gastrointestinal cancer after surgery. (a) Stage I gastric cancer and (b) Stage I colorectal cancer.

Background Evolving surgical technology and medical treatment have led to an expansion of indications to enable resection of large hepatic tumours with involvement of other abdominal structures. Methods Twelve extended liver and abdominal resections, either ex situ with auto-transplantation of the liver remnant or ante situm with veno-venous bypass (VVBP) were performed between 2016 and 2018. We describe our preoperative assessment, compare surgical strategies and assess outcomes. Results The median age of the 10 adult patients was 50.5 years with a majority suffering from sarcoma-like tumours. The two paediatric patients were 3 and 8 years of age, both with hepatoblastoma. Two patients underwent ex situ resections with auto-transplantation of the liver remnant, and nine patients had ante situm tumour removal with the use of VVBP in four. All patients achieved a good immediate liver function. Local infection and acute kidney injury were found in two patients. One patient underwent biliary reconstruction for bile leak. Tumour recurrence was seen in seven patients (58.3%), with four lung metastases. Five patients died from tumour recurrence (41.7%) during the follow-up. Conclusion Extreme liver resections should be performed in experienced centres, where surgical subspecialties are available with access to cardiovascular support. Additionally, experience in split and living-donor liver transplantation is beneficial.

BACKGROUND The prevalent location and incidence of intraductal papillary neoplasm of the bile duct (IPNB) and invasive carcinoma associated with them have varied markedly among studies due to differences in diagnostic criteria and tumor location. METHODS IPNBs were classified into two types: Type 1 IPNB, being histologically similar to intraductal papillary mucinous neoplasm of the pancreas, and Type 2 IPNB, having a more complex histological architecture with irregular papillary branching or foci of solid-tubular components. Medical data were evaluated. RESULTS Among 694 IPNB patients, 520 and 174 had Type 1 and Type 2, respectively. The levels of AST, ALT, ALP, T. Bil, and CEA were significantly higher in patients with Type 2 than in those with Type 1. Type 1 IPNB was more frequently located in the intrahepatic bile duct than Type 2, whereas Type 2 was more frequently located in the distal bile duct than Type 1 IPNB (P

BACKGROUND In context of suboptimal liver utilisation, grafts with various risk factors are under consideration today. For example, impaired vascularity with severe arterial calcifications and modified liver shapes are no longer contraindications and their use depends on the centre policy and experience of the surgical team. Riedel liver lobes represent a tongue-like liver shape with inferior projection in the right liver lobe. Such development modifications were initially described when patients developed a lesion and subsequently presented with symptoms. We here present the first case report in the literature, where such livers with anatomical variations were used for transplantation. CASE SUMMARY We describe here two cases of adult human liver transplantation, where we have accepted two donor livers with modified shape. The technical considerations for transplantation of such livers, found with enlarged right lobes, or Riedel shape, and hypo-trophic left lateral segment are highlighted. Both recipients experienced immediate liver function and overall good outcomes with a minimum follow up of 1 year. We also provide detailed pictures and outcome analysis in combination with a literature review. CONCLUSION The utilisation of donor livers with modified shape, such as Riedel’s Lobe appears safe and will increase the donor pool.

A non-ampullary duodenal mixed adenoneuroendocrine carcinoma (MANEC), consisting of a conventional adenocarcinoma and a neuroendocrine carcinoma (NEC), is exceedingly rare. Moreover, mismatch repair (MMR) deficient tumors have recently attracted attention. The patient, a 75-year-old woman with epigastric pain and nausea, was found to have a type 2 tumor of the duodenum, which was diagnosed on biopsy as a poorly differentiated carcinoma. A pancreaticoduodenectomy specimen showed a well-defined 50 × 48 mm tumor in the duodenal bulb, which was morphologically composed of glandular, sheet-like, and pleomorphic components. The glandular component was a tubular adenocarcinoma, showing a MUC5AC-positive gastric type. The sheet-like component consisted of homogenous tumor cells, with chromogranin A and synaptophysin diffusely positive, and a Ki-67 index of 72.8%. The pleomorphic component was diverse and prominent atypical tumor cells proliferated, focally positive for chromogranin A, diffusely positive for synaptophysin, and the Ki-67 index was 67.1%. The sheet-like and pleomorphic components were considered NEC, showing aberrant expression of p53, retinoblastoma, and p16. Notably, all three components were deficient in MLH1 and PMS2. We diagnosed a non-ampullary duodenal MANEC with MMR deficiency. This tumor has a unique morphology and immunohistochemical profile, and is valuable for clarifying the tumorigenesis mechanism of a non-ampullary duodenal MANEC.

Background Patients with pan-peritonitis (PP) due to colorectal perforation have high mortality rate because colorectal perforation causes septic shock. The association between total steroid intake (TSI) and hospital mortality of such patients is not clear. Methods One hundred forty-two patients who underwent surgery for PP due to colorectal perforation were reviewed. Patients were divided into two groups by 8000 mg of TSI. The cut-off value of TSI was determined using a receiver operating characteristic curve for hospital mortality. Results The cut-off value of TSI for hospital mortality was 8000 mg. Patients with TSI>8000 mg had high rate of hemodialysis, hospital mortality, and elevated neutrophil ratio (>95%) compared with those with TSI≤8000 mg. Multivariate analyses revealed that TSI (>8000/≤8000, mg) (OR, 9.669; 95% CI, 1.011-92.49; P = .049) was significantly associated with hospital mortality as well as bleeding volume (>1000/≤1000, mL) (OR, 26.08; 95% CI, 3.566-190.4; P = .001), lymphocyte ratio (≤4/>4, %) (OR, 7.988; 95% CI, 1.498-42.58; P = .015) and C-reactive protein (≤7.5/>7.5, mg/dL) (OR, 41.66; 95% CI, 4.784-33.33; P = .001). Discussion There was a significant association between TSI and hospital mortality in patients with PP due to colorectal perforation as well as intraoperative bleeding and systemic inflammatory markers.

Telomerase reverse transcriptase (TERT) is reportedly expressed in various types of cancer. However, to the best of our knowledge, the significance of subcellular expression of TERT in hepatocellular carcinoma (HCC) has not been evaluated in detail. The present study evaluated TERT expression in resected HCC tumor tissues using immunohistochemistry. TERT expression was assessed in both the cytoplasm and the nucleus of HCC cells. The associations between TERT expression and clinical characteristics, including expression levels of DNA-dependent protein kinase catalytic unit (DNA-PKcs) and 8-hydroxyganosine (8-OHdG), were investigated. Among the 135 HCCs, TERT expression was positive only in the cytoplasm in 86 tumors (63.7%), was positive only in the nucleus in 3 tumors (2.2%), was positive in both the cytoplasm and the nucleus in 5 tumors (3.7%) and was negative in 41 tumors (30.4%). Similar results were confirmed using another antibody for TERT. Cytoplasmic TERT expression was markedly associated with hepatitis B surface antigen, poor tumor differentiation, and expression levels of DNA-PKcs and 8-OHdG. However, TERT expression in the cytoplasm or in the nucleus was not significantly associated with the overall or recurrence-free survival periods. In conclusion, TERT was mainly expressed in the cytoplasm of HCC tissues. Cytoplasmic TERT expression was closely associated with hepatitis B virus-related HCC and DNA-PKcs expression, as well as oxidative stress.

BACKGROUND/AIM This study aimed to obtain accurate differential diagnosis (DDx) of multicentric carcinogenesis (MC) and intrahepatic metastasis (IM) in recurrent lesions of hepatocellular carcinoma. MATERIALS AND METHODS A total of 79 patients who underwent re-hepatectomy (2000-2013) were examined. PCR was used to analyze 13 chromosomal microsatellite loci by PCR. On the basis of this genetic analysis, the recurrent lesions were diagnosed as IM, MC or not determined (ND). Subsequently, DDx was compared with types of resection and outcome. RESULTS The recurrent lesions were diagnosed as IM in 33 patients, MC in 44, and ND in 2. The anatomical resection group included 14 IM lesions (28%) and 36 MC lesions (72%), while the non-anatomical resection group included 19 IM lesions (70%) and 8 MC lesions (30%) (p

Background Although an inferior vena cava (IVC) filter is used for preventing pulmonary thromboembolism (PTE) in patients with deep vein thrombosis, IVC filter penetration in the duodenum is a rare complication. Case presentation A 35-year-old man had previously undergone retroperitoneal lymph node dissection (RPLND) for testicular cancer and IVC filter placement for prevention of PTE. Esophagogastroduodenoscopy (EGD) for his epigastric pain revealed penetration of the IVC filter in the duodenum. The IVC filter was retrieved through cavotomy, and the duodenal penetration was repaired using EGD clipping. Although it was difficult to mobilize the duodenum due to adhesion resulting from RPLND, the use of a mesenteric approach enabled encircling of the IVC caudal to the duodenum. The mesenteric approach is useful and safe for taping the IVC caudal to the duodenum in cases where it is difficult to mobilize the duodenum. Conclusion IVC taping using the mesenteric approach allowed safe retrieval of the IVC filter after RPLND without postoperative complications.

Highlights • Required inhibitors of all coagulation factors. • After liver resection. • Severe bleeding. • Benefits of using steroid., Introduction Acquired inhibition of coagulation factors is a rare disease, and the diagnosis is often difficult and delayed. We experienced a deficiency in all coagulation factors after hepatobiliary surgery. Case Presentation Extended left liver resection was undertaken and hepaticojejunostomy was performed in a 70-year-old man. He had suffered from a high fever caused by cholangitis for 35 days. The major cause was a narrowing of the hepaticojejunostomy, and reconstruction was carried out. Twenty-four days later, there was a sudden massive bleed from his nose and the surgical site. Steroid pulse therapy was used as a treatment because cross mixing and some blood tests revealed the patient was experiencing an inhibition of all coagulation factors, and consequently the levels of coagulation factors dramatically recovered. Discussion We considered malignancy and surgical damages to be the underlying cause. The reported treatment and examination will help clinicians explore additional reasons for massive bleeding after a severe physical injury. Conclusion We have described the first case of acquired inhibition of all coagulation factors associated with extended left lobectomy.

Highlights • We showed how to manage sever atherosclerosis in liver transplant with special technique. • This case report will help not to discard donated liver graft. • Management of sever artherosclerosis, liver transplantation., Introduction The presence of atherosclerosis of the common hepatic artery (CHA) in donor livers potentially contributes to vascular complications after liver transplantation, thereby most of those organs are traditionally discarded. Herein, we describe the successful outcome of three patients transplanted with grafts that had severe atherosclerosis of the donor CHA up to the level of the gastroduodenal artery (GDA). Presentation of case In all three cases, endarterectomies were performed by dissection between the atheromatous core and the artery intima using a dissecting spatula, allowing to secure the lumen of the vessel. The native CHA/GDA patch was aligned with the corresponding CHA/GDA patch from the graft for the arterial reconstruction. No vascular complications were seen post-operatively. Discussion Endarterectomy and anatomical reconstitution of the arterial tree, without any redundancy or kinking, allowed for the successful transplantation of organs that would be otherwise discarded. Further, the straight alignment of the arteries may enhance flow dynamics, preventing thrombosis. Conclusion This report might guide future studies targeting means to increase the utility of donor livers discarded due to arterial atherosclerosis.

BACKGROUND/AIM The efficacy and feasibility of gemcitabine plus cisplatin (GC) chemotherapy in an adjuvant setting is unclear in patients with biliary tract cancer (BTC) undergoing major hepatectomy. PATIENTS AND METHODS Patients with BTC who underwent major hepatectomy between 2008 and 2018 were included. Patients who received adjuvant chemotherapy (AC) were then divided into two groups: a GC group and a gemcitabine (GEM) alone group. AC-related factors and patient outcomes were investigated. RESULTS Fifty (GC: 28, GEM: 22) patients received AC, and 33 patients did not. No difference in completion rate, relative dose intensity, or adverse events was seen between the two AC groups. Multivariate analysis revealed that AC with GC was an independent predictor of improved survival and reduction of early recurrence. CONCLUSION AC with GC is tolerable and associated with better outcomes in patients with BTC who have undergone major hepatectomy.

Indocyanine green retention rate at 15 min (ICGR15) is a frequently used indicator of liver function. Herein, clinicopathological characteristics of cirrhotic patients with normal ICGR15 value ( 10%) were investigated, as these patients have risk of postoperative liver insufficiency when receiving a major hepatic resection.Patients undergoing hepatectomy for hepatocellular carcinoma were divided into three groups: non-cirrhotic livers (Group A, n = 112): cirrhotic livers with ICGR15 10% (Group B, n = 71): and cirrhotic livers with ICGR15 10% (Group C, n = 296). Background characteristics and surgical outcomes were compared between groups. Functional liver volume (FLV) was computed using total liver volume and signal intensity ratio. Liver parenchymal cell volume ratio was measured in non-cancerous tissue obtained from resected specimens. Univariate and multivariate analyses were performed to detect clinical characteristics correlating with cirrhotic liver pathology with normal ICGR15.There was no significant difference between groups in TLV. FLV was gradually reduced from Group A toward Group C. Liver parenchymal cell volume ratio was also gradually reduced from Group A toward Group C. Multivariate analysis revealed that platelet count ( 12 × 10Our results suggested that cirrhotic liver pathology despite normal liver function was characterized by slightly decreasing liver parenchyma as well as slight degree of fibrosis. Platelet count and PT% are useful for predicting liver cirrhosis with normal ICGR15.

BACKGROUND Serum hyaluronic acid (HA) levels are increased in patients with solid tumors, and may predict outcomes. However, as HA levels also correlate with the degree of liver fibrosis, the prognostic significance of serum HA levels in patients with hepatocellular carcinoma (HCC) is unclear. METHODS A total of 656 consecutive patients who underwent hepatic resection for HCC were divided into two groups by serum HA level (high HA [≥200 ng/mL], n = 248; low HA [

Background The tumor location is the most simple clinical factor and important in liver surgery to make surgical procedure. However, no previous study has investigated the prognostic differences and clinical features of hepatocellular carcinoma showing specific laterality. This study is the first report to focus on the laterality and aimed to lead to more simple and useful predictive factor rather than recent complicated predictive models. Methods Patients who underwent liver resection for the first time for single tumors located within each lobe between 2000 and 2018 were enrolled. We divided them into two groups based on tumor location: a right-sided group and a left-sided group. Univariable and multivariable analyses were performed to assess survival differences in relation to several other factors. Results There were 595 eligible patients; the 5-year survival rates and disease-free survival rates were 49.5% and 19.1% in the left-sided group and 55.6% and 24.5% in the right-sided group, respectively (p = 0.026). Statistical analyses revealed that the following preoperative prognostic factors were independently significant (p < 0.05) in the left-sided group: indocyanine green retention rate at 15 min, alpha fetoprotein, protein induced by vitamin K absence or antagonists-II level, and larger tumor size. Conclusion The left-sided group had a poorer prognosis than the right-sided group. A left-sided tumor location is a significant preoperative factor predictive of poor outcome in patients with hepatocellular carcinoma.

Background/aim Few studies have studied micro hepatic vein invasion in hepatocellular carcinoma (HCC). We explored the correlation between hepatic vein invasion and hepatitis B/C virus infection. Patients and methods Between April 2000 and February 2018, 869 patients underwent liver resection for HCC at a single center. The patients were divided into two groups: those with micro hepatic vein invasion (VV+) and those without (VV-). The clinical data, overall survival (OS) and correlations with the presence of hepatitis B and C viruses were investigated. Results There were 817 VV- patients and 43 VV+ patients. OS was 66.2 months for VV- patients and 9.9 months for VV+ patients (p=0.0010). VV+ patients had significantly higher levels of serum HBV DNA (p=0.016). Conclusion HCC patients with micro hepatic vein invasion showed significantly shorter OS. A higher level of HBV DNA appears to be a risk factor for micro hepatic vein invasion.

Background/aim Although ABO blood group has been reported to be associated with the outcome of patients with pancreatic cancer, little is known about its impact on patients with biliary tract cancer (BTC). We evaluated the prognostic relevance of ABO blood group in patients who had undergone resection of BTC. Patients and methods A total of 154 patients with BTC undergoing pancreatoduodenectomy were retrospectively reviewed. Associations between ABO blood group and patient survival were evaluated by univariate and multivariate analysis. Results The 5-year overall survival rate was higher in group O patients (n=46) than in other blood group patients (n=108) (65.8% vs. 47%, p=0.005). Multivariate analysis revealed that a non-O blood group was an independent risk factor for poor survival (p=0.021). Conclusion ABO blood group is associated with the prognosis of patients with resected BTC; group O patients have a better outcome.

New chemotherapeutic regimens such as S-1 plus docetaxel, S-1 plus oxaliplatin and capecitabine plus oxaliplatin are reported to be effective and safe as postoperative adjuvant chemotherapy (PAC) for advanced gastric cancer (GC) patients. Although the use of these PACs is increasing, it is still unclear how to choose the best regimen for advanced GC patients. Therefore, we aimed to investigate which clinical characteristics are associated with recurrence after curative surgery in patients receiving S-1 as PAC. Thirty-nine patients who received a PAC regimen with S-1 for more than 1 year after curative surgery for advanced GC were enrolled. Univariate and multivariate analyses using the Cox proportional hazard model were performed to detect clinical characteristics that correlated with recurrence. Patients were divided into two groups, recurrence, and non-recurrence, and receiver operating characteristic (ROC) curve analysis was used to identify the cut-off values. Kaplan-Meier analysis and the log-rank test were used for comparison of relapse-free survival (RFS). Fifteen patients had a recurrence after surgery (38.5%, 15/39). Multivariate analysis using clinical characteristics revealed that preoperative C-reactive protein (CRP) (0.3/≤0.3, mg/dL) (HR 10.73;95% C.I., 1.824-63.14;P=0.009) was significantly associated with recurrence. Kaplan-Meier analysis and the log-rank test demonstrated that preoperative CRP (0.3/≤0.3, mg/dL) was also significantly associated with RFS (P0.001). Therefore, preoperative CRP is significantly associated with recurrence and RFS after curative surgery in advanced GC patients receiving S-1 as PAC.

Highlights • An extremely rare early cystic duct carcinoma. • The protruding part was the cause of jaundice. • There is a significant interesting macro findings in the removed sample. • The only small part of the invasive part which reach fibro-muscular layer is revealed by the pathological findings., Introduction Cystic duct carcinoma is a rare disease, and only 33 cases reported worldwide have completely fulfilled the criteria first established by Farrar in 1951. Here we describe an extremely rare case of early cystic duct carcinoma that fulfilled the Farrar criteria, the papillary tumour protruding into the common bile duct, leading to obstructive jaundice. Case presentation A 76-year-old man visited a clinic with icteric conjunctivae, and was referred to our hospital for investigation of suspected obstructive jaundice. He was initially diagnosed as having a distal bile duct carcinoma on the basis of ultrasonography (US), endoscopic retrograde cholangiopancreatography (ERCP), and magnetic resonance cholangiography (MRC), and underwent pancreatoduodenectomy with regional lymphadenectomy. Macroscopic examination showed that the stalk of the papillary tumour originated from the cystic duct, and that the protruding lesion was 50 mm in size. Histopathological examination revealed the tumour to be a papillary adenocarcinoma confined within the fibromuscular layer, with no evidence of lymph node metastasis. Therefore, the final diagnosis was early cystic duct carcinoma. Conclusion To our knowledge, this is the first case report of obstructive jaundice due to early carcinoma of the cystic duct protruding into the bile duct, with characteristics fulfilling the Farrar criteria.

Highlights • An extremely rare case report of hepatic myomatous angiomyolipoma. • Including specific imaging features to diagnose with hepatic angiomyolipoma. • There is a significant interesting imaging findings of hepatic myomatous angiomyolipoma. • Previous reports only revealed the pathological findings and a few imaging findings, however we show two specific features of imaging with rare pathological findings., Introduction Hepatic angiomyolipoma is a rare tumour and is difficult to obtain the accurate diagnosis preoperatively because the imaging features are similar to hepatocellular carcinoma. Presentation of Case We present a case study of an 80-year old woman with a liver tumour measuring 6.2 cm × 6.0 cm. We were able to diagnose the tumour preoperatively as a rare hepatic myomatous angiomyolipoma based on the presence of early venous return evident on angiography and small low-intensity areas corresponding to fat within the tumour revealed by out-of-phase EOB-MRI. The tumour was removed by minimally invasive surgery and our preoperative diagnosis was confirmed by positive immunoreactivity for both angiomyolipoma-specific human melanoma black 45 and smooth muscle cell positivity for melanin. Discussion We consider that the information obtained in this case will be useful for preoperative diagnosis of other hepatic angiomyolipomas, thus facilitating more appropriate and less invasive surgery and improving the overall outcome. Conclusion Hepatic myomatous angiomyolipoma is a rare tumour. We illustrated the two specific imaging features to diagnose it preoperatively.

Intracystic papillary neoplasm (ICPN) is a preinvasive neoplasm of the gallbladder. Preoperative discrimination between ICPN and gallbladder cancer (GC) is difficult. The standard surgical strategy for ICPN has not yet been established. Herein, we report a case of ICPN with an associated invasive adenocarcinoma. A gallbladder tumor was detected by abdominal ultrasonography in an asymptomatic 69-year-old man, and he was referred to our hospital. Although computed tomography (CT), endoscopic ultrasonography, and magnetic resonance imaging findings in the present case were similar to those for GC, positron emission tomography-CT revealed that fluorodeoxyglucose (FDG) did not accumulate within the tumor. These imaging features suggested that patient was suspected to have GC with serosal invasion, and he underwent extended cholecystectomy and D2 lymph node dissection. He did not develop any postoperative complications, and he was discharged on postoperative day 7. There was no evidence of recurrence for 20 months after surgery. Histopathologic examination confirmed ICPN with an associated invasive adenocarcinoma. Because a previous study reported that almost half of ICPNs more than 1.0 cm in size often developed invasive cancer as our case, ICPNs more than 1.0 cm should be suspected of developing invasive carcinoma regardless of positive or negative accumulation of FDG.

Preservation of the future liver remnant (FLR) vascular integrity has always been considered crucial to achieving successful liver growths after major hepatectomies. Most surgeons appeared therefore reluctant to combine stage I of associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) with vascular reconstructions. Here we describe a case series, where we combine parenchymal transection and venous in- or outflow reconstruction of the FLR at stage I of ALPPS. In addition, the cold flush of the FLR or delayed portal vein embolization is applied in selected cases.

Background/aim Little is known about the efficacy of neoadjuvant chemotherapy (NAC) with gemcitabine plus S-1 (GS) for patients with resectable pancreatic ductal adenocarcinoma (R-PDAC). The aim of this study was to investigate differences in the long-term outcome of patients with R-PDAC undergoing pancreatectomy with and without NAC-GS to clarify the clinical significance of NAC-GS. Patients and methods A total of 77 patients with R-PDAC who were scheduled for pancreatectomy between January 2012 and December 2017 were enrolled. Of these patients, 39 received NAC-GS (GS group) and 38 had upfront surgery (UFS group). Results Among the 77 patients, one patient in each group did not undergo pancreatectomy due to intraoperative non-curative factors. Median tumor size and the number of lymph nodes with metastasis were significantly lower in the GS group than in the UFS group (p=0.002 and p=0.017). However, the 5-year overall survival rate was similar in the two groups (26.1% versus 21.5%, p=0.930). Conclusion NAC-GS may not be recommended for patients with R-PDAC since it does not seem to offer any survival benefits.

The concept of intraductal papillary neoplasm of the bile duct (IPNB) has been proposed to be the biliary equivalent of intraductal papillary mucinous neoplasm (IPMN) of the pancreas. While the classification of IPMNs is based on their location of duct involvement, such classification has not been fully evaluated for IPNBs. The aim of this study is to investigate the value of IPNB classification based on its location. A total of 306 consecutive patients who underwent surgical resection with a diagnosis of bile duct tumor were enrolled. Among these patients, 21 were diagnosed as having IPNB. The IPNBs were classified into two groups as follows: extrahepatic IPNB, which located in the distal or perihilar bile duct, and intrahepatic IPNB, which located more peripherally than the hilar bile duct. The clinicopathological features of the two groups were then compared. Extrahepatic IPNB tended to show more invasive characteristics than intrahepatic IPNB (presence of invasive component: 40.0 vs. 9.1%, p = 0.084). Moreover, patients with extrahepatic IPNB showed significantly poorer relapse-free survival (RFS) than those with intrahepatic IPNB [5-year RFS rate (%): 81.8 vs. 16.2, p = 0.014]. Patients with intrahepatic IPNB show more favorable pathological characteristics and postoperative survival outcomes than those with extrahepatic IPNB.

Background and Aim Although the Cancer of the Liver Italian Program (CLIP) score is useful for prognostication of patients with hepatocellular carcinoma (HCC), a previous study has reported that the CLIP score was unable to stratify the postoperative outcomes of HCC patients in whom the score was low (0‐1). Recent studies have reported that the preoperative lymphocyte‐to‐monocyte ratio (LMR) is useful for prognostication of patients with various cancer. Methods We reviewed 329 HCC patients with a low CLIP score (0‐1) undergoing curative resection. This study had the approval of the Institutional Review Board (28068). Multivariate analyses were carried out to detect clinical factors correlating with overall survival (OS). Kaplan‐Meier analysis and the log‐rank test were used for comparison of OS. Results Multivariate analysis showed that LMR (

Although a recent study has shown that the C-reactive protein-to-albumin ratio (CAR) can predict the survival in patients with hepatocellular carcinoma (HCC), it is unclear whether CAR can predict the survival after surgery. To investigate the utility of CAR for prediction of postoperative survival among HCC patients with Child–Pugh class A. We retrospectively reviewed 239 patients with Child–Pugh class A who were newly diagnosed with HCC and received initial liver resection. Univariate and multivariate analyses using the Cox proportional hazard model were performed to detect clinical characteristics that correlated with overall survival (OS), and their cutoff values were identified using receiver operating characteristic curve analyses. The cutoff value of CAR was 0.028. Kaplan–Meier analysis and the log-rank test were used for the comparison of OS and disease-free survival (DFS) between two CAR groups (>0.028/≤0.028). Multivariate analysis using 16 clinical characteristics selected by univariate analyses revealed that CAR (>0.028/≤0.028) (HR, 3.211; 95% CI 1.065–9.680; P = 0.038) was significantly associated with OS, as well as anatomical resection (presence/absence) (HR, 0.275; 95% CI 0.119–0.635; P = 0.275). A significant difference in OS and DFS was observed between patients with low CAR (≤0.028) and patients with high CAR (>0.028). CAR is a useful predictor of postoperative survival among HCC patients with Child–Pugh class A.

Although the globulin-to-albumin ratio (GAR) is useful for prognostication of patients with various cancers, its relationship with hepatocellular carcinoma (HCC) remains unclear. The study aims to investigate the relationship between GAR and postoperative survival among patients with HCC undergoing potentially curative liver resection (LR).We retrospectively reviewed 368 patients with newly diagnosed HCC who underwent initial and potentially curative LR. Univariate and multivariate analyses using the Cox proportional hazard model were performed to detect clinical characteristics that correlated with overall survival (OS). Kaplan-Meier analysis and log-rank test were used to compare OS and disease-free survival (DFS).The result of multivariate analysis using 25 clinical characteristics selected by univariate analysis revealed that the GAR (≥0.918/0.918) was significantly associated with OS (hazard ratio [HR], 2.398; 95% confidence interval [CI], 1.012-5.683; P = 0.047), as well as platelet count (14/≥14, ×10The GAR is a useful predictor of postoperative survival among patients with HCC undergoing potentially curative LR.

BackgroundA 95% CI, 1.824-63.14; P = 0.009) was significantly associated with recurrence. Kaplan-Meier analysis and log-rank test demonstrated that C-reactive protein (>0.3/≤0.3, mg/dL) was also significantly associated with RFS (P Conclusion C-reactive protein is significantly associated with recurrence of GC in patients with PAC using S-1 after curative surgery.