PMC6215962_01
Enhanced CT taken 7 years prior showed the gall bladder (GB) carcinoma (arrow) involving the stomach (S) and right side transverse colon (C), which was resected en bloc.
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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).
Enhanced CT showing extensive cholangiocarcinoma with wall thickening and biliary stenosis (arrow) (a). PTBD cholangiography showed irregularity at the same lesion (arrowhead) (b).
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Enhanced abdominal computed tomography (CT) and PTBD cholangiography showed wide stenosis of the intra- and extra-hepatic bile duct (Fig. 2a and b).
Cholangioscopy showed a narrow, papillary tumor at the stenotic lesion (a). Intra-luminal view showed that the confluence of the anterior and posterior sectorial bile duct was normal. (b). IDUS showed wall thickness at the main mass lesion (c), a thinner wall with dilatation at the confluence of the anterior and posterior sectorial bile duct (d) with no involvement of the RHA (A) (e).
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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).
The origin of PD was placed in front of the SMV (arrow) (a), and PD was completed first (b). P, pancreas burden between head and body; D, duodenum.
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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).
Severe adhesion between the hilar bile duct and RHA was observed (arrowhead) (a), and the anterior sectorial branch was incidentally injured and repaired by micro-surgery (arrow) (b). aRHA, anterior branch of RHA; pRHA, posterior branch.
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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).
Macroscopic findings by HPD showed no remnant cholangiocarcinoma at the transected bile duct and dissected surface. a) Cholangiocarcinoma, b) papillary adenocarcinoma, c) subserosal infiltration of the cancer nest, and d) pancreatic infiltration of the cancer nest.
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Thus, R0 resection was performed without tumor exposure at the dissected plane (Fig. 6).