A 61-year-old woman was admitted to a hospital due to obstructive jaundice. Extensive EC was found by diagnostic imaging, and she was subsequently scheduled for brachytherapy since the tumor was found to be unresectable. Seven years prior at the same hospital, she underwent multi-organ en bloc resection for advanced gall bladder (GB) carcinoma involving the distal stomach and right side transverse colon (Fig. 1). Extended cholecystectomy, distal gastrectomy, and right hemi-colectomy with loco-regional lymphadenectomy were also performed. Despite not receiving adjuvant chemotherapy, she had remained without tumor relapse. She was referred to our institute for a second opinion.
Obstructive jaundice was resolved by percutaneous transhepatic biliary drainage (PTBD) via the left lateral sector of the liver at the previous hospital. Enhanced abdominal computed tomography (CT) and PTBD cholangiography showed wide stenosis of the intra- and extra-hepatic bile duct (Fig. 2a and b). Cholangioscopy and intraductal ultrasonography (IDUS) showed a papillary tumor with wall thickness and stenosis with no involvement of the adjacent right hepatic artery (RHA) (Fig. 3a and b). Endoscopic biopsy performed at the stenotic lesion and non-stenotic bile duct at the confluence of the anterior and posterior sectional branches was negative. Although invasive adenocarcinoma was diagnosed, cancer infiltration was not observed at the non-stenotic bile duct epithelium. Since neither distant nor node metastasis was observed and liver function reserve was sufficient for hemi-hepatectomy, we planned for HPD despite the possibility of tumor recurrence from GB cancer.
There was no peritoneal dissemination, liver metastasis, or distant node metastasis by laparotomy. Although there was a postoperative adhesion in the upper abdomen, the front of a superior mesenteric vein (SMV) was found and pancreaticoduodenectomy (PD) was performed (Fig. 4a and b). During exfoliation of the hilar bile duct, adhesion to the surrounding main vessels became severe, particularly in the neighboring RHA (Fig. 5a); however, this was considered non-tumor invasion by macroscopic findings. The anterior sectorial arterial branch was partially injured and was repaired with 8-0 polypropylene sutures (Fig. 5b). After anastomosis, arterial flow increased compared with dissection. Left hepatectomy with transection of the right hepatic duct was also performed at the lesion. Thus, R0 resection was performed without tumor exposure at the dissected plane (Fig. 6). Pancreatojejunostomy, hepaticojejunostomy, and jejuno-jejunostomy were also performed. The total operating time was 685 min (including 45 min for arterial repair), and blood loss was 1200 mL, which did not require blood transfusion.
Microscopic findings showed papillary adenocarcinoma with stromal and pancreatic invasions that did not extend to the dissected surface. Lymph node metastasis was found on the pancreatic surface. R0 resection was also histologically confirmed. The postoperative course was uneventful without severe damage to the liver, and the patient was discharged at day 14. Four months after HPD, she remains without tumor recurrence or complications.