A 48-year-old man with jaundice was referred to our hospital. Endoscopic retrograde cholangiography showed primary sclerosing cholangitis. Endoscopic biliary drainage was not successful because of highly viscous bile, so we performed percutaneous trans-gallbladder drainage (PTGBD), which was able to reduce the total serum bilirubin level from 8 to 10mg/ml. Subsequently, an indwelling drainage catheter was placed in the gallbladder for 13 months. However, liver atrophy worsened with the gradual progression of hepatic failure. Twelve months later, he complained of dyspnea. Computed abdominal tomography showed that the drainage catheter had perforated the diaphragm and become exposed to the chest cavity. In spite of intensive care, the patient died of liver failure while waiting for a liver transplant. Careful attention should be paid to the possibility of this serious complication in such patients.

Background:Pancreas ductal adenocarcinoma (PDAC) remains the most malignant digestive disease, but several treatment strategies for PDAC have been developed. Here we describe some current topics regarding the treatment of PDACs in Nagasaki, Japan. 1: Prevention of pancreas fistula (PF) after pancreas resection Adjuvant chemotherapy for PDAC was demonstrated to be useful to prolong patients’ survival after the resection of PDAC. To introduce adjuvant chemotherapy for PDAC quickly, it is important to prevent the development of a PF after pancreas resection. We evaluated the safety and efficacy of early drain removal on postoperative day 1 after distal pancreatectomy (DP; n=71), and we found that early drain removal was safe and effective for preventing grade B/C PFs (0% vs. late removal 16%; p<0.001). 2: Laparoscopic surgery for PDAC Laparoscopic distal pancreatectomy (Lap-DP) for low-grade malignant tumors at the left side of the pancreas has been recognized to be safe and feasible, and a few studies have already obtained similar findings for PDAC compared to open DP. We have been performing the Lap-DP for PDACs without invasion beyond the pancreas, and the modified radical antegrade modular pancreatosplenectomy (mRAMPS) is conducted at our institute. The plexus around the celiac artery or superior mesenteric artery is dissected to a limited extent. Histologically, all of our PDAC patients who underwent a Lap-DP (n=5) achieved an R0 resection. 3: Dendritic cell-based therapeutic vaccination for PDAC The treatment of unresectable or recurrent PDAC is not promising. We started administering a dendritic cell-based therapeutic vaccination in such cases along with the use of the anticancer drugs gemcitabine and/or S-1. A total of eight patients received this therapy, and it seemed that the patients with recurrence after resection and those who had strong delayed-type hypersensitivity around the injected lesion had a favorable prognosis, although the results were obtained with a small number of patients. Conclusions: Our recent treatments for PDAC are feasible and useful. It is important to develop various ways to prolong the survival of PDAC patients.

Background:Pancreas ductal adenocarcinoma (PDAC) remains the mostmalignant digestive disease, but several treatment strategies for PDAC have beendeveloped. Here we describe some current topics regarding the treatment ofPDACs in Nagasaki, Japan.1: Prevention of pancreas fistula (PF) after pancreas resectionAdjuvant chemotherapy for PDAC was demonstrated to be useful to prolongpatients’ survival after the resection of PDAC. To introduce adjuvant chemotherapyfor PDAC quickly, it is important to prevent the development of a PF afterpancreas resection. We evaluated the safety and efficacy of early drain removalon postoperative day 1 after distal pancreatectomy (DP; n=71), and we found thatearly drain removal was safe and effective for preventing grade B/C PFs (0% vs.late removal 16%; p<0.001).2: Laparoscopic surgery for PDACLaparoscopic distal pancreatectomy (Lap-DP) for low-grade malignant tumors atthe left side of the pancreas has been recognized to be safe and feasible, and afew studies have already obtained similar findings for PDAC compared to openDP. We have been performing the Lap-DP for PDACs without invasion beyondthe pancreas, and the modified radical antegrade modular pancreatosplenectomy(mRAMPS) is conducted at our institute. The plexus around the celiac artery orsuperior mesenteric artery is dissected to a limited extent. Histologically, all of ourPDAC patients who underwent a Lap-DP (n=5) achieved an R0 resection.3: Dendritic cell-based therapeutic vaccination for PDACThe treatment of unresectable or recurrent PDAC is not promising. We startedadministering a dendritic cell-based therapeutic vaccination in such cases alongwith the use of the anticancer drugs gemcitabine and/or S-1. A total of eightpatients received this therapy, and it seemed that the patients with recurrenceafter resection and those who had strong delayed-type hypersensitivity aroundthe injected lesion had a favorable prognosis, although the results were obtainedwith a small number of patients.Conclusions:Our recent treatments for PDAC are feasible and useful. It is important to developvarious ways to prolong the survival of PDAC patients.