Margin-negative (R0) resection of liver and/or pancreas with combined vascular resection has contributed to the evolution of treatment of biliary tract cancers. However, aggressive hepatic resection or pancreatic resection impairs patients' quality of life (QOL). Thus, both R0 resection and QOL are important factors in the treatment.

Four hundred and seventy-seven consecutive patients with biliary tract cancers; intrahepatic cholangiocarcinoma (n=77), perihilar cholangiocarcinoma (n=65), distal cholangiocarcinoma (n=126), gall-bladder carcinoma (n=112), and ampullary carcinoma (n=97) who underwent surgical resection at the Tokai University Hospital between 2000 and 2020 were retrospectively analyzed.

The 5-year survival rate for patients with intrahepatic cholangiocarcinoma, perihilar cholangiocarcinoma, distal cholangiocarcinoma, gall-bladder carcinoma, and ampullary carcinoma after R0 resection were 55%, 46%, 60%, 63%, 64%, respectively. The 5-year survival rate for patients with those carcinomas after R1 resection were 22%, 10%, 16%, 6%, 0%, respectively. There was a significant difference in survival between patients after R0 resection and those after R1 resection. Eight patients (1.7%) postoperatively died in hospital. In conclusion, better survival results could be achieved by R0 resection in patients with biliary tract cancers.

Lithotripsy treatment using Spy-Glass™ DS (Spy-DS)-guided electronic hydraulic lithotripsy (EHL) is useful for difficult bile duct stones to remove such as giant piled stones and intrahepatic stones. Since 2017, we have been treating stones under the Spy-DS. Fourteen patients (8 cases of common bile duct stones and 6 cases of intrahepatic stones) who had undergone Spy-DS-guided EHL for difficult bile duct stones were retrospectively examined since October 2017 to September 2020. The main outcomes were the treatment results (the rate of complete stone removal and total procedure time to complete) and adverse events. The rate of complete stone removal was 100%. The median total procedure time for common bile duct was 72.5 (8-141) minutes, and that for intrahepatic stones was 69.5 (5-138) minutes. The median number of endoscopic sessions for the common bile duct was 2.5 (2-4) times, and that for intrahepatic stones was 2 (1-3) times. Although there was one adverse event after endoscopic large-diameter nipple dilatation (EPLBD), it improved conservatively. The Spy-DS-guided EHL appears useful for complete stone removal of difficult bile duct stones.

Laparoscopic cholecystectomy (Lap-C) has become the standard, while serious complications continue to occur with a certain probability. Vascular bile duct injury due to Lap-C is one of the most avoidable complications and its prognosis is poor. It is important to understand the anatomical structures, so called landmarks for avoiding bile duct injury. The establishment of the Critical View of Safety (CVS) is particularly important for avoiding bile duct injury due to misidentification. In addition, in so-called difficult gallbladder, where it is impossible to establish CVS due to fibrotic scarring of the Calot's triangle because of inflammatory changes such as acute cholecystitis, subtotal cholecystectomy is encouraging procedure. Especially, subtotal fenestrating cholecystectomy should be liberally selected. Understanding the landmarks and liberal use of bailout procedures will lead to the completion of safe Lap-C.

Leukemia presenting as a gallbladder tumor is extremely rare. 70-year-old man who was diagnosed with sternum infectious arthritis was coincidentally found a gallbladder tumor and a left renal tumor by enhanced CT. Preoperative diagnosis was gallbladder carcinoma invading the subserosa. Cholecystectomy accompanied with the gallbladder bed resection and regional lymph node dissection were performed. Histopathological examination revealed that atypical lymphoid cells proliferated diffusely throughout the gallbladder wall, and no atypical cells were found in the gallbladder epithelium. Immunohistochemistry showed TdT (+), CD10 (+), CD79a (+), and Bcl-2 (+). In addition, bone marrow biopsy showed proliferation of atypical cells in about 60% of the tissues, showing an immunostaining pattern similar to that of gallbladder specimens, and the diagnosis was B lymphoblast acute leukemia. PET examination revealed a high accumulation of fluorodeoxyglucose in the bones and left kidney tumors of the whole body, as well as in the para-aortic lymph nodes and uncinate process of pancreas. One course of chemotherapy (HyperCVAD+MA) was performed and a complete metabolic response was obtained. At 15 months after the three courses of chemotherapy, a PET scan showed recurrence of the disease in the bone.

The patient was a 71-year-old male with a chief complaint of itching and jaundice. Detailed physical examinations revealed that his condition was diagnosed as laterally advanced extrahepatic cholangiocarcinoma. To obtain the R0 resection, right or left trisectionectomy with pancreatoduodenectomy was needed. We informed him of the treatment strategy such as resection, chemotherapy and second opinion, he selected chemotherapy. Chemotherapy using gemcitabine and cisplatin was initiated and computed tomography after 4 cycles revealed that the tumor had decreased. After 13 cycles, right hepatectomy with caudate lobectomy and extrahepatic bile duct resection was performed as conversion surgery. As a result, a pathological complete response was achieved in the primary tumor. Although he did not receive any further adjuvant chemotherapy, no recurrent lesions have been detected for 28 months after the surgery.

A 76-year-old woman was admitted to our hospital with epigastric pain and was diagnosed with gallbladder and common bile duct stones associated with complete visceral inversion (situs inversus) by an abdominal CT examination. After removal of choledocholithiasis endoscopically, laparoscopic cholecystectomy was planned. Preoperative abdominal CT examination showed that the gallbladder was associated with an anatomical malposition. It was attached to the right side of hepatic round ligament. Therefore, in addition to adjusting the port position, dome down method was performed to resect the gallbladder. Situs inversus is a congenital developmental abnormality in which the organs are mirror images of the left and right, and the probability of having comorbid malformations in the digestive system, cardiovascular system, and urinary system, etc. Laparoscopic cholecystectomy in a patient with complete visceral inversion and malposition of gallbladder was safely performed after careful preoperative image evaluation and surgical planning.

Various aspects of improvement have been achieved in biliary tract cancer surgery. First, extended procedures have been aggressively indicated to increase resectability, and lower operative mortality resulting from refinement of perioperative patient management has elucidated survival benefit of extended resections. Thus, acceptable surgical and survival outcomes following combined hepatic artery resection have increased resectability in patients with advanced perihilar cholangiocarcinoma in a recent report. Second, several prospective studies are ongoing to validate the efficacy of adjuvant and neoadjuvant therapy, and selected patients with initially unresectable disease undergo resection after confirming favorable response to powerful chemotherapeutic regimens.

Third, minimum invasive surgeries (MIS) have been increasingly indicated and their acceptable surgical outcomes have shown the safety of the procedures. The oncological and survival benefit of such procedures need to be evaluated with large series data.