Value of Multidetector-row Computed Tomography in Diagnosis of Portal Vein Invasion by Perihilar Cholangiocarcinoma

Clinical features and prediction of long-term survival after surgery for perihilar cholangiocarcinoma

INTRODUCTION

The treatment of perihilar Cholangiocarcinoma (pCCA) poses specific challenges not only due to its high perioperative complication rates but also due its dismal long-term prognosis with only a few long-term survivors (LTS) among the patients. Therefore, in this analysis characteristics and predictors of LTS in pCCA patients are investigated.

MATERIAL AND METHODS

In this single center analysis, patients undergoing curative-intent liver resection for pCCA between 2010 and 2022 were categorized into long-term and short-term survivors (STS) excluding perioperative mortality. Binary logistic regression was used to determine key differences between the groups and to develop a prognostic composite variable. This composite variable was subsequently tested in the whole cohort of surgically treated pCCA patients using Cox Regression analysis for cancer-specific survival (CSS).

RESULTS

Within a cohort of 209 individuals, 27 patients were identified as LTS (median CSS = 125 months) and 55 patients as STS (median CSS = 16 months). Multivariable analysis identified preoperative portal vein infiltration (OR = 5.85, p = 0.018) and intraoperative packed red blood cell (PRBC) transfusions (OR = 10.29, p = 0.002) as key differences between the groups. A prognostic composite variable based on these two features was created and transferred into a Cox regression model of the whole cohort. Here, the composite variable (HR = 0.35, p<0.001), lymph node metastases (HR = 2.15, p = 0.001) and postoperative complications (HR = 3.06, p<0.001) were identified as independent predictors of CSS.

CONCLUSION

Long-term survival after surgery for pCCA is possible and is strongly negatively associated with preoperative portal vein infiltration and intraoperative PRBC transfusion. As these variables are part of preoperative staging or can be modulated by intraoperative technique, the proposed prognostic composite variable can easily be transferred into clinical management to predict the oncological outcome of patients undergoing surgery for pCCA.

Utility of modified pancreaticoduodenectomy (Hi-cut PD) for middle-third cholangiocarcinoma: an alternative to hepatopancreaticoduodenectomy

BACKGROUND

The standard procedure for middle-third cholangiocarcinoma (MCC) is pancreaticoduodenectomy (PD); hepatopancreaticoduodenectomy (HPD) is often performed despite its high risk. There is no clear selection guidance for these procedures.

METHODS

Patients with MCC who underwent HPD or PD were retrospectively evaluated. The conventional PD was modified (mPD) to transect the bile duct beyond or close to the cranial level of the portal bifurcation.

RESULTS

The mPD group (n = 55) was characterized by older age, shorter operation time, less blood loss, and less frequent complications than were observed in the HPD group (n = 34). The median grossly tumor-free margin of the proximal bile duct (GM) was 13 mm vs 20 mm (P = 0.006). Overall survival did not differ significantly between groups (48% vs 53% at 5 years, P = 0.399). Multivariate analysis identified positive surgical margin as a sole independent prognostic factor (hazard ratio, 1.89; P = 0.043), which was statistically associated with GM length. Five-year survival for mPD patients with GM ≥15 mm was significantly better than that for those who had GM <15 mm (69% vs 33%, P = 0.011) and comparable to that of HPD patients (53%, P = 0.450).

CONCLUSION

The mPD may be recommended in patients with MCC, provided that GM ≥15 mm is expected from the preoperative radiological imaging. Otherwise, HPD should be considered.

The Short- and Long-Term Surgical Results of Consecutive Hepatopancreaticoduodenectomy for Wide-Spread Biliary Malignancy

BACKGROUND

Cancer-free resection (R0) is one of the most important factors for the long-term survival of biliary carcinoma. For some patients with widespread invasive cancer located between the hilar and intrapancreatic bile duct, hepatopancreaticoduodenectomy (HPD) is considered a radical surgery for R0 resection. However, HPD is associated with high morbidity and mortality rates. Furthermore, previous reports have not shown lymph node metastasis (LNM) status, such as the location or number, which could influence the prognosis after HPD. In this study, first, we explored the prognostic factors for survival, and second, we evaluated whether the LNM status (number and location of LNM) would influence the decision on surgical indications in patients with widely spread biliary malignancy.

METHODS

We retrospectively reviewed the medical records of 54 patients who underwent HPD with hepatectomy in ≥2 liver sectors from January 2003 to December 2021 (HPD-G). We also evaluated 54 unresectable perihilar cholangiocarcinoma patients who underwent chemotherapy from January 2010 to December 2021 (CTx-G).

RESULTS

R0 resection was performed in 48 patients (89%). The median survival time (MST) and 5-year overall survival rate of the HPD-G and CTx-G groups were 36.9 months and 31.1%, and 19.6 months and 0%, respectively. Univariate and multivariate analyses showed that pathological portal vein involvement was an independent prognostic factor for survival (MST: 18.9 months). Additionally, patients with peripancreatic LNM had worse prognoses (MST: 13.3 months) than CTx-G.

CONCLUSIONS

Patients with peripancreatic LNM or PV invasion might be advised to be excluded from surgery-first indications for HPD.

Efficacy of Extended Modification in Left Hemihepatectomy for Advanced Perihilar Cholangiocarcinoma: Comparison Between H12345'8'-B-MHV and H1234-B

OBJECTIVE

The aim of this study was to verify the prognostic impact of the tumor exposure at the liver transection margin (LTM) in left-sided perihilar cholangiocarcinoma and the impact of middle hepatic vein (MHV) resection on this exposure.

BACKGROUND

In perihilar cholangiocarcinoma, tumors are unexpectedly exposed at the LTM during left hemihepatectomy (LH).

METHODS

Patients who underwent LH for perihilar cholangiocarcinoma during 2002 to 2018 were retrospectively evaluated. LH was classified into conventional and extended types, which preserved and resected the MHVs, respectively. Positive LTM was defined as the involvement of invasive carcinoma at the liver transection plane and/or the adjacent Glissonean pedicle exposed. The clinicopathologic features and survival outcomes were compared between procedures.

RESULTS

Among 236 patients, conventional and extended LHs were performed in 198 and 38 patients, respectively. The LTM was positive in 31 (13%) patients, with an incidence of 14% versus 8% ( P = 0.432) and 24% versus 0% in advanced tumors ( P = 0.011). Tumor size ≥ 18 mm ( P = 0.041), portal vein invasion ( P = 0.009), and conventional LH ( P = 0.028) independently predicted positive LTM. In patients with negative LTM, the survival was comparable between the two groups: 60.4% versus 59.2% at 3 years ( P = 0.206), which surpassed 17.7% for those with positive LTM in the conventional group ( P < 0.001). Multivariable analysis demonstrated that LTM status was an independent prognostic factor ( P = 0.009) along with ductal margin status ( P = 0.030).

CONCLUSIONS

The LTM status is an important prognostic factor in perihilar cholangiocarcinoma. Extended LH reduced the risk of tumor exposure at the LTM with a subsequent improvement in the survival, particularly in advanced tumors.

Endoscopic management of perihilar cholangiocarcinoma

Endoscopic management for perihilar cholangiocarcinoma (PHCC) is evolving toward more accurate diagnosis and safer drainage. In imaging, it is important to diagnose the entire lesion using multidetector-row computed tomography to determine resectability and optimal surgical planning, followed by local diagnosis using endoscopic retrograde cholangiopancreatography. Video peroral cholangioscopy and probe-based confocal laser endomicroscopy have been newly introduced as diagnostic imaging methods and are being applied clinically. In transpapillary forceps biopsy for PHCC diagnosis, the location in the bile duct (for mapping biopsy) and the number of biopsy samples should be determined depending on resectability, the morphological type, and future surgical planning. Preoperative drainage has shifted from percutaneous transhepatic biliary drainage to endoscopic nasobiliary drainage given the possibility of seeding metastasis. In addition, considering potential patient discomfort from a nasal tube, the usefulness of the placement of a plastic stent above the papilla (inside stent) as a bridging therapy for surgery has been reported. For drainage of unresectable PHCC, the improved prognosis due to advances in chemotherapy has necessitated a strategy that accounts for reintervention. Thus, in addition to uncovered self-expandable metallic stents (SEMS), exchangeable slim fully covered SEMS and inside stents have started to be used. In addition to the conventional transpapillary approach, an endoscopic ultrasonography-guided approach has been introduced, and a combination of both methods has also been proposed. To improve the quality of life and prognosis of PHCC patients, endoscopists need to understand and be able to use the various methods of endoscopic management for PHCC.

Multidetector CT of Extrahepatic Bile Duct Cancer: Diagnostic Performance of Tumor Resectability and Interreader Agreement

Background In extrahepatic bile duct (EHD) cancer, accurate assessment of resectability is essential for curative surgery, but pertinent guidelines from the perspectives of radiologists are yet to be developed. Purpose To investigate the performance of multiphasic CT in the assessment of longitudinal tumor extent, vascular invasion, and resectability of EHD cancer according to the Korean Society of Abdominal Radiology consensus recommendation and to evaluate the interreader agreement. Materials and Methods This retrospective study included patients with EHD cancer who underwent multiphasic CT examinations with section thickness of 3 mm or less before surgery from January 2016 to December 2018. Four abdominal radiologists independently evaluated the overall and biliary segment-wise longitudinal tumor extent, the presence of hepatic artery and/or portal vein invasion, and the resectability according to the Korean Society of Abdominal Radiology recommendations. The diagnostic performance was assessed with sensitivity, specificity, accuracy, and area under the receiver operating characteristic curve. Interreader agreement was determined using κ statistics. Results A total of 112 patients (mean age ± SD, 61 years ± 11; 73 men) were evaluated. The accuracy of the overall longitudinal tumor extent assessment ranged from 56.3% (63 of 112 patients) to 74.1% (83 of 112 patients). The sensitivity for detecting secondary confluence involvement (n = 62) was lower than that for the primary confluence or intrapancreatic duct (n = 115; 38.5%-75% vs 72.1%-96.3%, respectively). Vascular invasion (n = 17) had moderate sensitivity (28.6%-71.4%) and high specificity (77.5%-99.0%). For predicting negative-margin (R0) resection (n = 85), the sensitivity and specificity ranged from 71.8% to 96.5% and from 11.1% to 66.7%, respectively, and the areas under the receiver operating characteristic curve ranged from 0.69 to 0.80. Interreader agreements for tumor extent, vascular invasion, and resectability had κ values of 0.65-0.89, 0.21-0.64, and 0.35-0.56, respectively. Conclusion For the preoperative evaluation of extrahepatic bile duct cancer, the Korean Society of Abdominal Radiology consensus recommendation enabled systematic assessment of longitudinal tumor extent and vascular invasion with acceptable performance in predicting negative-margin resection with use of multiphasic CT and with fair to good interreader agreement. © RSNA, 2022 Online supplemental material is available for this article.

Major hepatectomy with combined vascular resection for perihilar cholangiocarcinoma

Background

Hepatectomy with vascular resection (VR) for perihilar cholangiocarcinoma (PHCC) is a challenging procedure. However, only a few reports on this procedure have been published and its clinical significance has not been fully evaluated.

Methods

Patients undergoing surgical resection for PHCC from 2002–2017 were studied. The surgical outcomes of VR and non-VR groups were compared.

Results

Some 238 patients were included. VR was performed in 85 patients. The resected vessels were hepatic artery alone (31 patients), portal vein alone (37 patients) or both (17 patients). The morbidity rates were almost the same in the VR (49.4 per cent) and non-VR (43.8 per cent) groups (P = 0.404). The mortality rates of VR (3.5 per cent) and non-VR (3.3 per cent) were also comparable (P > 0.999). The median survival time (MST) was 45 months in the non-VR group and 36 months in VR group (P = 0.124). Among patients in whom tumour involvement was suspected on preoperative imaging and whose carbohydrate antigen 19-9 (CA19-9) value was 37 U/ml or less, MST in the VR group was significantly longer than that in the non-VR group (50 versus 34 months, P = 0.017). In contrast, when the CA19-9 value was greater than 37 U/ml, MST of the VR and non-VR groups was comparable (28 versus 29 months, P = 0.520).

Conclusion

Hepatectomy with VR for PHCC can be performed in a highly specialized hepatobiliary centre with equivalent short- and long-term outcomes to hepatectomy without VR.

Current Status and Recent Update of Imaging Evaluation for Peri-Hilar Cholangiocarcinoma

간문주변부의 해부학적 복잡성으로 인해 간문주변부 담관암은 그 진단과 치료가 어려운 질환으로 알려져 있다. 간문주변부 담관암이 의심되는 환자에 있어서, 영상 검사는 이상 소견의 발견 및 감별 진단, 종양의 종축 침범 부위의 파악, 인접 혈관 침범과 원격 전이 유무의 파악, 그리고 최종적으로 수술적 절제 가능 유무의 평가에 있어 핵심적인 역할을 하고 있다. 이 종설에서는 간문주변부 담관암의 분류 및 종양의 평가를 위해 권고되는 표준 영상 검사의 기법과 간문주변부 담관암의 전형적인 영상 소견에 대해 기술할 예정이다. 종축 방향의 종양 침범 파악, 인접 혈관 침범 및 원격 전이 유무의 평가에 있어서 각 영상 검사 소견과 그 진단능에 대해 논의할 예정이다. 이후 전통적인 절제 가능성 평가의 개념에 대해 고찰하고, 최근의 경향을 소개한다.

Clinical practice guidelines for the management of biliary tract cancers 2019: The 3rd English edition

BACKGROUND

The Japanese Society of Hepato-Biliary-Pancreatic Surgery launched the clinical practice guidelines for the management of biliary tract cancers (cholangiocarcinoma, gallbladder cancer, and ampullary cancer) in 2007, then published the 2nd version in 2014.

METHODS

In this 3rd version, clinical questions (CQs) were proposed on six topics. The recommendation, grade for recommendation, and statement for each CQ were discussed and finalized by an evidence-based approach. Recommendations were graded as Grade 1 (strong) or Grade 2 (weak) according to the concepts of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system.

RESULTS

The 31 CQs covered the six topics: (a) prophylactic treatment, (b) diagnosis, (c) biliary drainage, (d) surgical treatment, (e) chemotherapy, and (f) radiation therapy. In the 31 CQs, 14 recommendations were rated strong and 14 recommendations weak. The remaining three CQs had no recommendation. Each CQ includes a statement of how the recommendations were graded.

CONCLUSIONS

This latest guideline provides recommendations for important clinical aspects based on evidence. Future collaboration with the cancer registry will be key for assessing the guidelines and establishing new evidence.

Combined Vascular Resection for Locally Advanced Perihilar Cholangiocarcinoma

OBJECTIVE

To evaluate the efficacy and safety of combined vascular resection (VR) in advanced perihilar cholangiocarcinoma (PHC).

SUMMARY OF BACKGROUND DATA

Hepatectomy combined with portal vein resection (PVR) and/or hepatic artery resection (HAR) is technically demanding but an option only for tumor eradication against PHC involving the hilar hepatic inflow vessels; however, its efficacy and safety have not been well evaluated.

METHODS

Patients diagnosed with PHC during 2001-2018 were included. Patients who underwent resection were divided according to combined VR. Patients undergoing VR were subdivided according to type of VR. Postoperative outcomes and OS were compared between patient groups.

RESULTS

Among the 1055 consecutive patients, 787 (75%) underwent resection (without VR: n = 484, PVR: n = 157, HAR: n = 146). The incidences of postoperative complications and mortality were 49% (without VR vs with VR, 48% vs 50%; P= 0.715) and 2.1% (without VR vs with VR, 1.2% vs 3.6%; P= 0.040), respectively. The OS of patients who underwent resection with VR (median, 30 months) was shorter than that of those who underwent resection without VR (median, 61 months; P < 0.0001); however, it was longer than that of those who did not undergo resection (median, 10 months; P < 0.0001). OS was not significantly different between those who underwent PVR and those who underwent HAR (median, 29 months vs 34 months; P = 0.517).

CONCLUSION

VR salvages a large number of patients from having locally advanced PHC that is otherwise unresectable and is recommended if the hilar hepatic inflow vessels are reconstructable, providing acceptable surgical outcomes and substantial survival benefits.

Radiologic Evaluation and Structured Reporting Form for Extrahepatic Bile Duct Cancer: 2019 Consensus Recommendations from the Korean Society of Abdominal Radiology

Radiologic imaging is important for evaluating extrahepatic bile duct (EHD) cancers; it is used for staging tumors and evaluating the suitability of surgical resection, as surgery may be contraindicated in some cases regardless of tumor stage. However, the published general recommendations for EHD cancer and recommendations guided by the perspectives of radiologists are limited. The Korean Society of Abdominal Radiology (KSAR) study group for EHD cancer developed key questions and corresponding recommendations for the radiologic evaluation of EHD cancer and organized them into 4 sections: nomenclature and definition, imaging technique, cancer evaluation, and tumor response. A structured reporting form was also developed to allow the progressive accumulation of standardized data, which will facilitate multicenter studies and contribute more evidence for the development of recommendations.

New method for the assessment of perineural invasion from perihilar cholangiocarcinoma

PURPOSE

Perineural invasion (PN) is often found in perihilar cholangiocarcinoma. New procedure was developed to assess PN around the right hepatic artery (RHA) using dual-energy computed tomography (DECT).

METHODS

Thirty patients with perihilar cholangiocarcinoma who underwent DECT before biliary drainage were retrospectively reviewed. Mask images, i.e., the periarterial layer (PAL) around the RHA and superior mesenteric artery (SMA), were made from late arterial phase DECT. The mean CT number of the PAL was measured.

RESULTS

Twenty patients with PN around the RHA were classified into the PN (+) group. The remaining 10 patients without PN and other 26 patients with other diseases that are never accompanied with PN were classified into the PN (-) group. The PAL ratio (the CT number of the PAL around the RHA relative to that around the SMA) was calculated. Both the mean CT number of the PAL around the RHA and the PAL ratio were significantly higher in the PN (+) group than in the PN (-) group. According to an ROC analysis, the predictive ability of the PAL ratio was superior. Using the cutoff value of the PAL ratio 1.009, a diagnosis of PN around the RHA was made with approximately 75% accuracy.

CONCLUSIONS

Assessment with CT number of the PAL reconstructed from DECT images is an easy and objective method to diagnose PN.

Fifty-year history of biliary surgery

There has been enormous progress in the surgical treatment of biliary tract cancers in the past 50 years. In preoperative management, biliary drainage methods have changed from percutaneous transhepatic biliary drainage to endoscopic nasobiliary drainage, while the advent of multidetector-row computed tomography in imaging diagnostics now enables visualization of three-dimensional anatomy, extent of cancer progression, and hepatic segment volume. Portal vein embolization has also greatly improved the safety of extended hepatectomy, and indication of extended hepatectomy can now be objectively determined with a combination of the indocyanine green test and computed tomography volumetry. In terms of surgery, combined resection and reconstruction of the portal vein and/or hepatic artery can now be safely carried out at specialized centers. Further, long-term survival can be attained with combined vascular resection if R0 resection can be achieved, even in locally advanced cancer. Hepatopancreatoduodenectomy, combined major hepatectomy with pancreatoduodenectomy, should be aggressively carried out for laterally advanced cholangiocarcinoma, whereas its indication for advanced gallbladder cancer should be carefully evaluated. Japanese surgeons have made a significant contribution to the progression of extended surgeries such as combined vascular resection and hepatopancreatoduodenectomy for biliary tract cancer.

Survey of preoperative management protocol for perihilar cholangiocarcinoma at 10 Japanese high-volume centers with a combined experience of 2,778 cases

BACKGROUND

In Japan, strategies for preoperative management of perihilar cholangiocarcinoma (PHC) have evolved over the last decade; the operative mortality has significantly reduced to <5%.

METHODS

A questionnaire was sent to 10 institutions based on their case volume. Questionnaire was based on: (1) preoperative biliary drainage, (2) bile replacement, (3) role of synbiotics, (4) remnant liver volume enhancement, (5) predicted remnant liver function, (6) imaging, (7) nutrition, and (8) role of Inchinkoto.

RESULTS

The median case volume was 226 (range 105-889) cases, respectively. Eight institutions preferred endoscopic nasobiliary drainage and two preferred endoscopic biliary stenting for biliary drainage. Nine used bile replacement within 2-3 days of biliary drainage. Four used synbiotics preoperatively. The median cutoff value for future remnant liver volume and serum total bilirubin, at which portal vein embolization (PVE) is done, is <40% and <4 mg/dl. The median interval between PVE and surgery was 3-4 weeks. To predict remnant liver function, indocyanine green retention (n = 8) and clearance rate (n = 2) were mainly used. Five used Inchinkoto to improve liver function. Nine used multidetector computed tomography and direct cholangiography for surgical planning.

CONCLUSION

With appropriate preoperative management of PHC, surgical morbidity and mortality can be reduced. This survey can provide recommendations to improve PHC perioperative outcomes.

Comparison Between Multidetector CT and High-Field 3T MR Imaging in Diagnostic and Tumour Extension Evaluation of Patients with Cholangiocarcinoma

PURPOSE

To compare multidetector computed tomography (MDCT) and magnetic resonance imaging (MRI) with cholangiopancreatography (MRCP) findings in the diagnostic evaluation of patients with cholangiocarcinoma (CCA) to establish tumour resectability.

METHODS

Thirty patients (22 M, 8 F) with pathologically proven CCA by post-surgical specimens (n = 20), core biopsy (n = 6) or cytology (n = 4) underwent both MDCT and MRI with MRCP. CCA lesions were classified on the basis of anatomical locations in intra-hepatic (iCCA), peri-hilar (pCCA) and distal (dCCA) tumours. Morphological tumour pattern, lesion size, biliary dilatation, tumour contrast enhancement type, lymph node involvement and vascular infiltration were directly compared between MDCT and MRI with MRCP. As a rule, a tumour resectability judgement for each patient was formulated by both imaging techniques comparing imaging results with direct surgical assessment (n = 20) or interventional procedures (n = 10).

RESULTS

In terms of anatomical location, 14 iCCA, 8 pCCA and 8 dCCA were observed; both imaging techniques were concordant about the identification and morphological characterization of tumour lesions and in the evaluation of tumour features (lesion size, contrast enhancement pattern, capsular retraction, biliary dilatation, lymph node involvement and vascular infiltration) as well as in assessing lesion resectability; an excellent agreement (k = 1) for the assessment of all the parameters included in imaging analysis was observed.

CONCLUSIONS

The comparative concordant results of our study suggest that MRI with MRCP represents a valid alternative to MDCT for the diagnostic evaluation of patients with CCA to establish tumour resectability providing multiplanar scanning of high-contrast imaging quality; MDCT should be preferred in uncooperative patients, in the presence of biliary stents or when MRI is absolutely contraindicated for incompatible medical devices.

Left Hepatectomy with Combined Resection and Reconstruction of Right Hepatic Artery for Bismuth Type I and II Perihilar Cholangiocarcinoma

BACKGROUND

Right hepatectomy with caudate lobectomy (RHx) is considered an appropriate procedure for Bismuth type I/II perihilar cholangiocarcinoma in terms of its anatomical and oncological aspect. However, validity of left hepatectomy with caudate lobectomy (LHx) concomitant with arterial resection and reconstruction (AR) is not fully evaluated.

METHODS

The patients who underwent surgical resection for Bismuth type I/II perihilar cholangiocarcinoma between 2002 and 2013 were studied. The standard procedure for Bismuth type I/II cholangiocarcinoma in the institute was RHx, while in patients who had insufficient functional reserve of the left liver, LHx was selected, irrespective of the necessity of AR. The clinicopathologic and perioperative outcomes after LHx + AR were compared with those after RHx.

RESULTS

The surgical procedures comprised LHx + AR in 12 and RHx in 24. The left liver volume and left liver functional reserve were significantly lower with LHx + AR than with RHx (left liver volume: 28.0 vs. 33.7%, p = 0.026; estimated indocyanine green clearance of the left liver: 0.036 vs. 0.046, p < 0.001). The rate of surgical morbidity was almost identical between the two procedures. No arterial reconstruction-related complications occurred. The overall 3- and 5-year survival rates and median survival time were 66.7%, 41.7% and 44 months for LHx + AR and 70.8%, 49.0% and 57 months for RHx (p = 0.640).

CONCLUSION

LHx + AR for Bismuth type I/II perihilar cholangiocarcinoma is considered to be a valid alternative to RHx in patients with an insufficient left liver functional reserve.

Preoperative neutrophil-lymphocyte and platelet-lymphocyte ratios as independent predictors of T stages in hilar cholangiocarcinoma

Background: The purpose of this study was to evaluate the relationship between preoperative inflammatory markers (neutrophil–lymphocyte ratio (NLR) and platelet–lymphocyte ratio (PLR)) and different American Joint Committee on Cancer (AJCC) T stages in patients with hilar cholangiocarcinoma.

Methods: A total of 101 patients who underwent surgical treatment for hilar cholangiocarcinoma between 2003 and 2014 in Peking Union Medical College Hospital were retrospectively analyzed. Receiver-operating curves were used to calculate optimal cutoff values for the NLR and the PLR. Univariate and multivariate analyses were used to identify whether the NLR and PLR can independently predict different AJCC T stages.

Results: Multivariate analysis showed that higher NLR and PLR independently predicted advanced AJCC T stages (OR 3.74, 95% CI 1.09–12.83, P=0.036; and OR 7.86, 95% CI 2.25–27.43, P=0.001, respectively). At a threshold of 2.75, the NLR was 75.9% sensitive and 66.7% specific for different AJCC T stages; at a threshold of 172.25, the PLR was 65.5% sensitive and 80.6% specific.

Conclusion: Preoperative NLR and PLR can be used as independent predictors of different AJCC T stages in patients with hilar cholangiocarcinoma.

Cholangiographic Tumor Classification for Simple Patient Selection Prior to Hepatopancreatoduodenectomy for Cholangiocarcinoma

BACKGROUND

Hepatopancreatoduodenectomy (HPD) is employed for patients with laterally advanced cholangiocarcinoma. However, the survival benefit of this extended approach remains controversial. The aim of this study is to identify a tumor feature benefiting from HPD from the standpoint of long-term survival.

PATIENTS AND METHODS

Patients with cholangiocarcinoma who underwent HPD with curative intent between 2001 and 2017 were retrospectively analyzed. Tumors were radiologically classified by preoperative cholangiogram. Diffuse type was defined as significant tumor/stricture located from the hilar to intrapancreatic duct; localized type was defined as tumor otherwise. Univariable and multivariable analyses were performed to identify prognostic indicators.

RESULTS

Of 100 study patients, 28 (28%) patients had diffuse tumor type, while the remaining 72 (72%) patients had localized tumors. The former group showed significantly longer lateral length (43 versus 22 mm, P < 0.001) and more frequent pancreatic invasion (50% versus 32%, P = 0.110), advanced T classification (64% versus 49%, P = 0.185), and nodal metastasis (57% versus 47%, P = 0.504), compared with the latter group. The survival for patients with diffuse tumor type was significantly worse than that for patients with localized tumor type, with 5-year survival rates of 59.0% versus 26.3%, respectively (P = 0.003). Multivariable analysis identified four independent factors deteriorating long-term survival: cholangiographic diffuse tumor (P = 0.021), higher age (P = 0.020), percutaneous biliary drainage (P = 0.007), and portal vein resection (P = 0.007).

CONCLUSIONS

Presurgical cholangiographic classification, diffuse or localized type, is a tumor-related factor closely associated with survival probability; therefore, it may be a useful feature for patient selection prior to HPD for cholangiocarcinoma.

Diagnosis by 64-Row Multidetector Computed Tomography for Longitudinal Superficial Extension of Distal Cholangiocarcinoma

BACKGROUND

This study aimed to demonstrate the diagnostic ability of 64-row multidetector computed tomography (64-row MDCT) for longitudinal superficial extension of distal cholangiocarcinoma (LSEDC).

METHODS

Twenty-seven patients with distal cholangiocarcinoma (DC) underwent preoperative 64-row MDCT without drainage tubes. LSEDC was diagnosed using curved planar reconstruction images reconstructed from 64-row MDCT, which were compared with pathologic findings.

RESULTS

LSEDC was observed in 13 patients (48%). Ten patients (37%) had enhancing nonthickened bile ducts extending continuously from the main tumor (type 1). These coincided with pathologic findings of high-grade dysplasia (HGD) in 90.0% of cases; that is, a positive predictive value (9/10). Fourteen patients (52%) had only wall thickening of the main tumor with or without enhancement (type 2). Four patients with HGD in this group were difficult to diagnose. Three patients (11%) had enhancing nonthickened bile ducts not in continuity with the main tumor (type 3). This finding revealed an inflammatory change instead of a carcinoma in the pathologic findings. The sensitivity and specificity of detecting HGD were 75% and 93% on the liver side, 33% and 100% on the duodenal side, respectively. Four patients (67%) with HGD on the liver side were overdiagnosed, and one patient (17%) was underdiagnosed. Most of the patients overdiagnosed on the liver side (3/4 or 75%) had drainage tubes inserted before the MDCT.

CONCLUSIONS

For DC patients without drainage tubes, the 64-row MDCT technique may be useful for diagnosing HGD depicted as LSEDC on the liver side but not as useful on the duodenal side.

Modification and establishment of CT criteria in preoperative assessment of portal venous invasion by hilar cholangiocarcinoma

BACKGROUND

To compare the diagnostic performance of CT criteria and to establish a new model in evaluating portal venous invasion by hilar cholangiocarcinoma.

METHODS

CT images of 67 patients with hilar cholangiocarcinoma were retrospectively reviewed. Modified Loyer's, Lu's and Li's standard introduced from pancreatic cancer were used to evaluate portal venous invasion with the reference of intraoperative findings and/or postoperative pathological diagnosis. A new model was constructed with modified Lu's standard and contact length between portal vein and tumor.

RESULTS

The modified Loyer's standard, modified Lu's standard and Li's standard showed a sensitivity of 86.7%, 83.3%, 70.0%, a specificity of 89.4%, 95.7%, 95.7% and an accuracy of 88.6%, 92.0%, 88.1%, respectively. CT criteria performed better in evaluating left branch. The new model performed significantly better than any CT criterion or contact length, with a sensitivity of 95.0%, a specificity of 96.5% and an accuracy of 96.0%.

CONCLUSIONS

Modified Lu's standard performed best in evaluating portal venous invasion by hilar cholangiocarcinoma among three CT criteria. The left branch invasion could be evaluated by CT criteria better than the right branch and the trunk of portal vein. The new mode significantly improved the diagnostic performance of portal venous invasion by hilar cholangiocarcinoma.

Impact of Biliary Drainage on Multidetector-Row Computed Tomography on R0 Resection of Perihilar Cholangiocarcinoma

BACKGROUND

Although multidetector-row computed tomography (MDCT) before biliary drainage is useful for the assessment of the resectability of perihilar cholangiocarcinoma (PHC), the impact of biliary drainage on MDCT images before surgical resection for PHC has been poorly studied, and its possible consequences for R0 resection of PHC remain unclear. This study was performed to compare the surgical outcomes of patients with PHC who underwent MDCT before versus after biliary drainage.

METHODS

All consecutive patients who underwent major hepatectomy extending to segment 1 with extrahepatic bile duct resection for PHC from 2009 to 2016 were retrospectively evaluated. R0 resection was defined as no residual cancer at all surgical margins. Patients with pathological stage IV PHC were excluded.

RESULTS

Of 142 patients who underwent major hepatectomy, 108 were eligible for this study. Of these 108 patients, 64 (59%) and 44 (41%) underwent MDCT before and after biliary drainage, respectively. The total bilirubin concentration at presentation was lower in patients who underwent MDCT before than after biliary drainage (4.1 ± 5.9 vs. 8.0 ± 7.1 mg/ml, respectively; p = 0.002). Although there were no significant differences in the surgical characteristics or pathological stages between the two groups, R0 resection was more frequently achieved in patients who underwent MDCT before than after biliary drainage [46/64 (72%) vs. 22/44 (50%), respectively; p = 0.03]. On multivariate analysis, MDCT before biliary drainage was independently associated with R0 resection of PHC (risk ratio: 2.38, 95% CI 1.05-5.41; p = 0.04).

CONCLUSIONS

In selected patients, MDCT should be performed before biliary drainage to achieve R0 resection of PHC.

Effectiveness of a modified 6-Fr endoscopic nasobiliary drainage catheter for patients with preoperative perihilar cholangiocarcinoma

BACKGROUND AND STUDY AIMS

To decrease complications associated with preoperative endoscopic nasobiliary drainage (ENBD) for perihilar cholangiocarcinoma patients, we developed a modified 6-Fr ENBD catheter with multiple side holes (m-ENBD). The aim of this retrospective study was to compare the m-ENBD catheter with a conventional 7-Fr ENBD catheter (c-ENBD).

PATIENTS AND METHODS

This study involved 371 patients with suspected perihilar cholangiocarcinoma who underwent ENBD using a c-ENBD catheter or an m-ENBD catheter. The effectiveness of each catheter and the incidence of complications were evaluated. Univariate and multivariate analyses followed by propensity score matching were performed.

RESULTS

In 145 patients with total bilirubin levels ≥ 2.0 mg/dL prior to drainage, these levels decreased to < 2.0 mg/dL after ENBD in 81.1 % of the c-ENBD patients and in 74.0 % of the m-ENBD patients ( P  = 0.325). Post-ENBD cholangitis occurred in 24.9 % of the c-ENBD patients and in 12.4 % of the m-ENBD patients ( P  = 0.006). After propensity score matching, the rate of post-ENBD cholangitis ( P  = 0.007) and the number of patients requiring subsequent or additional drainage ( P  = 0.030) were significantly lower in the m-ENBD group.

CONCLUSION

The modified 6-Fr ENBD catheter was associated with a lower incidence of post-ENBD cholangitis than the conventional 7-Fr ENBD catheter, and the incidence of subsequent or additional drainage procedures was also decreased.

The development of an automatically produced cholangiography procedure using the reconstruction of portal-phase multidetector-row computed tomography images: preliminary experience

PURPOSE

Fusion angiography using reconstructed multidetector-row computed tomography (MDCT) images, and cholangiography using reconstructed images from MDCT with a cholangiographic agent include an anatomical gap due to the different periods of MDCT scanning. To conquer such gaps, we attempted to develop a cholangiography procedure that automatically reconstructs a cholangiogram from portal-phase MDCT images.

METHODS

The automatically produced cholangiography procedure utilized an original software program that was developed by the Graduate School of Information Science, Nagoya University. This program structured 5 candidate biliary tracts, and automatically selected one as the candidate for cholangiography. The clinical value of the automatically produced cholangiography procedure was estimated based on a comparison with manually produced cholangiography.

RESULTS

Automatically produced cholangiograms were reconstructed for 20 patients who underwent MDCT scanning before biliary drainage for distal biliary obstruction. The procedure showed the ability to extract the 5 main biliary branches and the 21 subsegmental biliary branches in 55 and 25 % of the cases, respectively. The extent of aberrant connections and aberrant extractions outside the biliary tract was acceptable. Among all of the cholangiograms, 5 were clinically applied with no correction, 8 were applied with modest improvements, and 3 produced a correct cholangiography before automatic selection.

CONCLUSIONS

Although our procedure requires further improvement based on the analysis of additional patient data, it may represent an alternative to direct cholangiography in the future.

Surgical and Radiological Studies on the Length of the Hepatic Ducts

BACKGROUND

Right-sided hepatectomy is often selected for perihilar cholangiocarcinoma, due to the anatomic consideration that "the left hepatic duct is longer than that of the right hepatic duct". However, only one study briefly mentioned the length of the hepatic ducts. Our aim is to investigate whether the consideration is correct.

METHODS

In surgical study, the lengths of the resected bile duct were measured using pictures of the resected specimens in 475 hepatectomized patients with perihilar cholangiocarcinoma. In radiological study, the estimated lengths of the bile duct to be resected were measured using cholangiograms reconstructed from computed tomography images in 61 patients with distal bile duct obstruction.

RESULTS

In surgical study, the length of the resected left hepatic duct was 25.1 ± 6.4 mm in right trisectionectomy (n = 37) and 14.9 ± 5.7 mm in right hepatectomy (n = 167). The length of the right hepatic duct was 14.1 ± 5.7 mm in left hepatectomy (n = 149) and 21.3 ± 6.4 mm in left trisectionectomy (n = 122). In radiological study, the lengths of the bile duct corresponding to the surgical study were 34.1 ± 7.8, 22.4 ± 7.1, 20.8 ± 4.8, and 31.6 ± 5.3 mm, respectively. Both studies determined that the lengths of the resected bile ducts were (1) similar between right and left hepatectomies, (2) significantly shorter in right hepatectomy than in left trisectionectomy, and (3) the longest in right trisectionectomy.

CONCLUSIONS

The aforementioned anatomical assumption is a surgeon's biased view. Based on our observations, a flexible procedure selection is recommended.

Major hepatopancreatoduodenectomy with simultaneous resection of the hepatic artery for advanced biliary cancer

BACKGROUND

Major hepatopancreatoduodenectomy (HPD) with simultaneous resection of the hepatic artery (HA) for biliary cancer is the most extended surgery for obtaining curative resection, and its clinical significance is unclear. The aim of this study was to appraise the clinical value of this extended procedure as a treatment for biliary cancer.

METHODS

We retrospectively reviewed the medical records of 38 patients with biliary cancer who underwent major HPD from 1994 to 2014. Clinicopathological factors and survival following HPD were compared between patients with and without simultaneous resection of the HA.

RESULTS

Of the 38 study patients, 12 patients (32 %) underwent major HPD with HA. There was no significant difference in major complications between the two groups. The overall 2-year survival rate and the median survival time following major HPD with HA were 71 % and 42.3 months. The survival of the patients with gallbladder cancer was significantly worse than that of the patients with bile duct cancer (p = 0.001).

CONCLUSIONS

Major HPD with simultaneous resection of the HA can be a preferable treatment option for bile duct cancer that offers acceptable perioperative morbidity and mortality, as well as long-term survival. However, this procedure for gallbladder cancer should not be performed.

Prognostic impact of the site of portal vein invasion in patients with surgically resected perihilar cholangiocarcinoma

BACKGROUND

The aim of this study was to determine the impact of the site of portal vein invasion on survival after hepatectomy for perihilar cholangiocarcinoma.

METHODS

This study classified 168 patients undergoing resection for perihilar cholangiocarcinoma histologically as without portal vein resection or tumor invasion to the portal vein (PV0), with tumor invasion to unilateral branches of the portal vein (PVt3), or with tumor invasion to the main portal vein or its bilateral branches, or to unilateral second-order biliary radicals with contralateral portal vein involvement (PVt4). Patients in PVt4 were subclassified into the A-M group (cancer invasion limited to the tunica adventitia or media) or the I group (cancer invasion reaching the tunica intima).

RESULTS

Of the patients, 121 were in PV0, 21 were in PVt3, and 26 were in PVt4. There was no difference in survival between the PV0 and PVt3 groups (P = .267). The PVt4 group had a worse prognosis than the PVt3 group (P = .046). In addition, the A-M (n = 19) and I subgroups (n = 7) of PVt4 had worse prognoses than the PV0 or PVt3 groups (P = .005 and < .001, respectively). All patients in the I subgroup of PVt4 died within 9 months after resection. On multivariate analysis, PVt4 (P = .029) was identified as an independent prognostic factor.

CONCLUSIONS

In perihilar cholangiocarcinoma, postoperative survival was no different between patients with and without ipsilateral portal vein invasion, although patients with tumor invasion to the main or contralateral branches of the portal vein, especially with tunica intima invasion, had extremely poor prognoses.

Central hepatectomy with pancreatoduodenectomy for diffusely spread bile duct cancer

BACKGROUND

Major hepatectomy with concomitant pancreatoduodenectomy (major-HPD) is the only procedure that provides a curative resection for diffusely spread extrahepatic bile duct cancer (DSEBDC). We sometimes encounter patients who cannot undergo major-HPD because of a poor functional hepatic reserve. The aim of the present study was to assess the feasibility of central hepatectomy with pancreatoduodenectomy (central-HPD) for patients with DSEBDC as an alternative to major-HPD.

METHODS

Between 2002 and 2010, six patients with DSEBDC underwent central-HPD. The hepatectomy procedures for central-HPD included central bisectionectomy with S1 resection (S1r) and right anterior sectionectomy with S1r.

RESULTS

The estimated resection liver volume was decreased from 77.5% to 46.6% by the application of central-HPD. The median operative duration was 929 min, and the median blood loss was 2568 ml. Postoperative complications were observed in five patients. The proximal ductal stump was histologically positive with non-invasive cancer in three patients and positive with invasive cancer in one. The overall survival of the six patients was 62.5% at 5 years after surgery.

CONCLUSIONS

While central-HPD was a technically complicated procedure associated with a high morbidity rate, it offered a favorable overall survival and might be an alternative option for DSEBDC patients with a poor hepatic functional reserve.

Surgical technique of hepatectomy combined with simultaneous resection of hepatic artery and portal vein for perihilar cholangiocarcinoma (with video)

Perihilar cholangiocarcinomas often involve the bifurcation of the portal vein and the hepatic artery at initial presentation. Previously, vascular invasion was a major obstacle for R0 resection; therefore, such tumors were regarded as locally advanced, unresectable disease. Recently, in leading centers, these tumors have been resected using a specific technique, vascular resection and reconstruction. Vascular resection is classified into three types: portal vein resection alone, hepatic artery resection alone, and simultaneous resection of both the portal vein and hepatic artery. Of these, portal vein resection is widely performed, whereas hepatic artery resection remains controversial. Therefore, hepatectomy combined with simultaneous resection of the portal vein and hepatic artery represents one of the most complicated and challenging procedures in hepatobiliary surgery. The survival benefit of this extended procedure remains unproven, and there is only a single study reporting an unexpectedly favorable outcome in 50 patients. Considering the dismal survival in patients with unresectable disease, hepatic artery resection and/or portal vein resection may be a promising option of choice. However, the technique is highly demanding and has not been standardized. Therefore, this extended surgery may be allowed only in selected hepatobiliary centers.

A review of the clinical diagnosis and therapy of cholangiocarcinoma

Cholangiocarcinoma (CCA) is the second most common primary hepatic malignancy worldwide. The incidence of intrahepatic CCA is increasing, whereas that of extrahepatic CCA is decreasing. This review looks at the new advances that have been made in the management of CCA, based on a PubMed and Science Citation Index search of results from randomized controlled trials, reviews, and cohort, prospective and retrospective studies. Aggressive interventional approaches and new histopathological techniques have been developed to make a histological diagnosis in patients with high risk factors or suspected CCA. Resectability of the tumour can now be assessed using multiple radiological imaging studies; the main prognostic factor after surgery is a histologically negative resection margin. Biliary drainage and/or portal vein embolization may be performed before extended radical resection, or liver transplantation may be undertaken in combination with neoadjuvant chemotherapy or chemoradiotherapy. Though many advances have been made in the management of CCA, the standard modality of treatment has not yet been established. This review focuses on the clinical options for different stages of CCA.

Assessing resectability in cholangiocarcinoma

Assessment of surgical resectability in cholangiocarcinoma is more complicated than other gastrointestinal malignancies and remains unestablished. According to the primary origin and tumor extent, the applied surgical procedure varies from extrahepatic bile duct resection to right or left trisectionectomy concomitant with pancreatoduodenectomy. Portal vein resection and reconstruction during hepatectomy has been feasible. Thanks to the availability of new microscopic surgical techniques, hepatic arterial resection and reconstruction have also come to be applied for locally advanced cholangiocarcinoma cases. These vascular surgical techniques can expand surgical indications for advanced cholangiocarcinoma. On the other hand, determination of the tumor extent or staging still remains difficult and imprecise. The endoscopic approach has come to play significant roles both for preoperative biliary drainage and tumor staging. Estimation of the functional reserve of future remnant liver in cholestatic patients still remains unresolved. Hepatobiliary surgeons should carefully estimate the safety of the surgical procedure in each individual patient requiring extensive hepatobiliary resection. Early establishment of the measurement methods of the functional capacity of future remnant liver is an important and urgent issue for assessing safer surgical resectablity of cholangiocarcinoma.

Evolution of surgical treatment for perihilar cholangiocarcinoma: a single-center 34-year review of 574 consecutive resections

OBJECTIVE

To review our 34-year experience with 574 consecutive resections for perihilar cholangiocarcinoma and to evaluate the progress made in surgical treatment of this disease.

BACKGROUND

Few studies have reported improved surgical outcomes for perihilar cholangiocarcinoma; therefore, it is still unclear whether surgical treatment of this intractable disease has progressed.

METHODS

Between April 1977 and December 2010, a total of 754 consecutive patients with perihilar cholangiocarcinoma were treated, of whom 574 (76.1%) underwent resection. The medical records of these resected patients were retrospectively reviewed.

RESULTS

The incidence of major hepatectomies has increased, and limited resections, including central hepatectomies and bile duct resections, were rarely performed. Combined vascular resection was being used more often. Operative time has become shorter, and intraoperative blood loss has also decreased significantly. Because of refinements in surgical techniques and perioperative management, morbidity decreased significantly but was still high, with a rate of 43.1% in the last 5 years. Mortality rate has also decreased significantly (P < 0.001) from 11.1% (8/72) before 1990 to 1.4% (3/218) in the last 5 years. The ratio of advanced disease defined as pStage IVA and IVB has increased significantly from 49.4% before 2000 to 61.4% after 2001. The disease-specific survival for the 574 study patients (including all deaths) was 44.3% at year 3, 32.5% at year 5, and 19.9% at year 10. The survival was significantly better in the later period of 2001 to 2010 than in the earlier period of 1977 to 2000 (38.1% vs 23.1% at year 5, P < 0.001). For pM0, R0, and pN0 patients (n = 243), the survival in the later period was good with 67.1% at year 5, which was significantly better than that of the earlier period (P < 0.001). For pM0, R0, and pN1 patients (n = 142), however, the survival in the later period was similar to that of the earlier period (22.1% vs 14.6% at year 5, P = 0.647). Multivariate analysis revealed that lymph node metastasis was the strongest prognostic indicator.

CONCLUSIONS

Surgical treatment of perihilar cholangiocarcinoma has been evolving steadily, with expanded surgical indication, decreased mortality, and increased survival. Survival for R0 and pN0 patients was satisfactory, whereas survival for pN1 patients was still poor, suggesting that establishment of effective adjuvant chemotherapy is needed.

Advances in diagnosis and treatment of hilar cholangiocarcinoma -- a review

Hilar cholangiocarcinoma (HC) is a rare tumor that causes devastating disease. In the late stages, this carcinoma primarily invades the portal vein and metastasizes to the hepatic lobes; it is associated with a poor prognosis. HC is diagnosed by its clinical manifestation and results of imaging techniques such as ultrasound, computed tomography, magnetic resonance cholangiopancreatography, endoscopic retrograde cholangiography, and percutaneous transhepatic cholangiography. Preoperative hepatic bile drainage can improve symptoms associated with insufficient liver and kidney function, coagulopathy, and jaundice. Surgical margin-negative (R0) resection, including major liver resection, is the most effective and potentially curative treatment for HC. If the tumor is not resected, then liver transplantation with adjuvant management can improve survival. We conducted a systematic review of developments in imaging studies and major surgical hepatectomy for HC with positive outcomes regarding quality of life.

Preoperative endoscopic nasobiliary drainage in 164 consecutive patients with suspected perihilar cholangiocarcinoma: a retrospective study of efficacy and risk factors related to complications

OBJECTIVE

To assess the clinical benefits of preoperative endoscopic nasobiliary drainage (ENBD) in patients with perihilar cholangiocarcinoma.

BACKGROUND

The advantages of ENBD have been previously reported. However, no studies to date have examined a large number of patients, including those with Bismuth-Corlette (B-C) type III to IV tumors. In addition, sufficient data on the risk factors associated with ENBD complications are not available.

METHODS

This study involved 164 consecutive patients with suspected perihilar cholangiocarcinoma (128 patients with B-C type III-IV tumors) who had undergone unilateral ENBD between January 2007 and December 2010. The success and efficacy of this procedure and the risk factors for post-ENBD cholangitis and pancreatitis were retrospectively evaluated.

RESULTS

The ENBD procedure was successful in 153 (93.3%) of the 164 patients. Of these 164 patients, 65 had serum total bilirubin (TB) levels of 2.0 mg/dL or more before the drainage. The first unilateral ENBD was successfully performed in 60 of the 65 patients, and the TB level decreased to less than 2.0 mg/dL after ENBD in 50 of these 60 patients (83.3%). The significant predictive factors for ENBD efficacy included the pre-ENBD TB level (P = 0.032; 95% confidence interval [CI], 1.01-1.23) and post-ENBD cholangitis (P = 0.012; 95% CI, 1.61-43.2). Post-ENBD cholangitis occurred in 47 (28.8%) of the 163 patients, and a previous endoscopic sphincterotomy (EST) was found to be a significant risk factor for post-ENBD cholangitis (P = 0.008; 95% CI, 1.30-5.46). Post-ENBD pancreatitis occurred in 33 (20.1%) of the 164 patients (26 grade 1 patients, 4 grade 2 patients, and 3 grade 3 patients). The significant risk factors included undergoing pancreatography (P < 0.001; 95% CI, 2.44-31.1) and the absence of previous EBS or ENBD (P < 0.001; 95% CI, 3.03-29.2).

CONCLUSIONS

Unilateral ENBD of the future remnant lobe(s) exhibited a high success rate, suggesting that it is an effective and suitable preoperative drainage method for perihilar cholangiocarcinoma even in patients with B-C type III to IV tumors. To reduce the postprocedural complications, ENBD should be performed without EST or pancreatography.

Salvage hepatectomy for perihilar malignancy treated initially with biliary self-expanding metallic stents

BACKGROUND

A salvage hepatectomy for an "inoperable" advanced perihilar tumor initially treated with a self-expanding metallic stent (SEMS) is challenging, and its safety and survival benefits remain unclear. The aim of this study was to report our experiences with this difficult resection.

METHODS

This study involved 10 consecutive patients with suspected perihilar cholangiocarcinoma who underwent SEMS placement at a local hospital and were referred to our clinic for possible resection as their last option. Their medical records were analyzed retrospectively.

RESULTS

Tumor extent was first reevaluated using multidetector-row computed tomography. Of the 10 patients, 4 were diagnosed as inoperable owing to locally advanced tumors (n = 3) or poor physical condition (n = 1). In the remaining 6 patients, after additional biliary drainage, a salvage hepatectomy was performed, including a right hepatectomy with a caudate lobectomy in 5 patients and a central bisectionectomy with a caudate lobectomy in 1. A combined portal vein resection was required in 3 patients, and a combined pancreatoduodenectomy was performed in 2 patients. R0 resection was achieved in 5 patients, and all patients tolerated the resection. Three patients died of recurrence, and the remaining 3 were alive without recurrence at the time of publication, 1 of whom has survived >10 years.

CONCLUSION

Pre-resection SEMS placement does not preclude a subsequent hepatectomy for patients with advanced perihilar tumors. Salvage hepatectomy, although technically demanding, is feasible and can revise the palliative scenario and benefit selected patients treated initially with an SEMS.

Radiological staging in patients with hilar cholangiocarcinoma: a systematic review and meta-analysis

OBJECTIVE

To obtain diagnostic performance values of CT, MRI, ultrasound and 18-fludeoxyglucose positron emission tomography (PET)/CT for staging of hilar cholangiocarcinoma.

METHODS

A comprehensive systematic search was performed for articles published up to March 2011 that fulfilled the inclusion criteria. Study quality was assessed with the quality assessment of diagnostic accuracy studies tool.

RESULTS

16 articles (448 patients) were included that evaluated CT (n=11), MRI (n=3), ultrasound (n=3), or PET/CT (n=1). Overall, their quality was moderate. The accuracy estimates for evaluation of CT for ductal extent of the tumour was 86%. The sensitivity and specificity estimates of CT were 89% and 92% for evaluation of portal vein involvement, 83% and 93% for hepatic artery involvement, and 61% and 88% for lymph node involvement, respectively. Data were too limited for adequate comparisons of the different techniques.

CONCLUSION

Diagnostic accuracy studies of CT, MRI, ultrasound or PET/CT for staging of hilar cholangiocarcinoma are sparse and have moderate methodological quality. Data primarily concern CT, which has an acceptable accuracy for assessment of ductal extent, portal vein and hepatic artery involvement, but low sensitivity for nodal status.

Perihilar cholangiocarcinoma: a surgeon's viewpoint on current topics

Perihilar cholangiocarcinomas are defined anatomically as "tumors that are located in the extrahepatic biliary tree proximal to the origin of the cystic duct". However, as the boundary between the extrahepatic and intrahepatic bile ducts is not well defined, perihilar cholangiocarcinomas potentially include two types of tumors: one is the "extrahepatic" type, which arises from the large hilar bile duct, and the other is the "intrahepatic" type, which has an intrahepatic component with the invasion of the hepatic hilus. The new TNM staging system published by the International Union Against Cancer (UICC) has been well revised with regard to perihilar cholangiocarcinoma, but it still lacks stratification of patient prognosis and has little applicability for assessing the feasibility of surgical treatment; therefore, further refinement is essential. Most patients with perihilar cholangiocarcinomas present with jaundice, and preoperative biliary drainage is mandatory. Previously, percutaneous transhepatic biliary drainage was used in many centers; however, it is accepted that endoscopic naso-biliary drainage is the most suitable method of preoperative drainage. Portal vein embolization is now widely used as a presurgical treatment for patients undergoing an extended hepatectomy to minimize postoperative liver dysfunction. The surgical resection of a perihilar cholangiocarcinoma is technically demanding and continues to be the most difficult challenge for hepatobiliary surgeons. Because of advances in diagnostic and surgical techniques, surgical outcomes and survival rates after resection have steadily improved. However, survival, especially for patients with lymph node metastasis, is still unsatisfactory, and the establishment of adjuvant chemotherapy is necessary. Further synergy of endoscopists, radiologists, oncologists, and surgeons is required to conquer this intractable disease.

The Blumgart preoperative staging system for hilar cholangiocarcinoma: analysis of resectability and outcomes in 380 patients

BACKGROUND

Complete resection of hilar cholangiocarcinoma (HCCA) is a critical determinant of long-term survival. This study validates a previously reported preoperative clinical T staging system for determining resectability of HCCA.

STUDY DESIGN

Consecutive patients with confirmed HCCA treated over an 18-year period were included. Patient demographics, preoperative imaging studies, resection type, margin status, lymph node status, histopathologic findings, morbidity, and outcomes were entered prospectively and analyzed retrospectively; changes in these variables over time were assessed. All patients were placed into 1 of 3 stages based on the extent of ductal involvement by tumor, portal vein compromise, or lobar atrophy.

RESULTS

From March 1991 through December 2008, 380 patients were evaluated. Eighty-five patients had unresectable disease; 295 patients underwent exploration with curative intent. One hundred fifty-seven patients underwent resection: 129 (82.2%) had a concomitant hepatic resection and 120 (76.4%) had an R0 resection. Of the 32 actual 5-year survivors (120 at risk), 30 patients (93.8%) had a concomitant hepatic resection. In patients who underwent an R0 resection, concomitant partial hepatectomy, well-differentiated histology, and negative lymph nodes were independent predictors of long-term survival. In the 376 patients whose disease could be staged, the preoperative clinical T staging system predicted resectability (p < 0.001), metastatic disease (p < 0.001), and R0 resection (p = 0.007).

CONCLUSIONS

The preoperative clinical T staging system of Blumgart, defined by the radial and longitudinal tumor extent, accurately predicts resectability of HCCA. The full outcomes benefit of resection is realized only if a concomitant partial hepatectomy is performed.

Diagnostic ability of MDCT to assess right hepatic artery invasion by perihilar cholangiocarcinoma with left-sided predominance

BACKGROUND/PURPOSE

There have been few reports on the diagnostic ability of multidetector-row computed tomography (MDCT) to assess invasion of the hepatic artery. The aim of this study was to assess the diagnostic ability of MDCT for right hepatic artery (RHA) invasion.

METHODS

From August 2006 to October 2010, 103 consecutive patients with left-sided predominance perihilar cholangiocarcinoma underwent left-sided hepatectomy; all patients received MDCT as a preoperative workup. Three-dimensional volume-rendered and multiplanar reformation (MPR) images were retrospectively examined for evidence of RHA invasion, and the agreement between intraoperative macroscopic and histologic findings was assessed.

RESULTS

No macroscopic evidence of RHA invasion was found in any of the 50 patients presenting visible low-density planes on MPR images between the RHA and adjacent tumor. Of the remaining 53 patients without visible low-density planes, 38 patients presented macroscopic evidence of RHA invasion and underwent combined RHA resection; the other 15 patients did not exhibit RHA invasion. The RHA contact length, as measured on MDCT images by curved planar reformations, was significantly longer in the former 38 patients than in the latter 15 patients (24.3 ± 16.9 vs. 8.6 ± 3.0 mm, respectively, P = 0.001). Histologic cancer infiltration of the resected RHA was found in 18 (47.4%) of the 38 patients who underwent RHA resection. Diagnosis of macroscopic RHA invasion based on the presence or absence of a low-density plane had an accuracy of 85.4%.

CONCLUSIONS

We conclude that MDCT is useful for assessing RHA invasion by perihilar cholangiocarcinoma.

Serum CA19-9 is a significant predictor among preoperative parameters for early recurrence after resection of pancreatic adenocarcinoma

OBJECTIVE

To evaluate the preoperative factors predictive of postoperative early recurrence in patients with resected pancreatic cancer focusing on the serum CA19-9 value.

METHODS

One hundred fifty-four patients undergoing surgical resection for pancreatic cancer were enrolled in this study. Univariate and multivariate analyses were performed to determine the predictors of early recurrence which was defined as relapse within 6 months after surgery.

RESULTS

On ROC curve analysis, the cutoff value of CA19-9 was determined to be 100 U/ml. Of 73 patients with CA19-9 value ≥ 100 U/ml, 39 (53 %) had early recurrence. In contrast, only 9 of 81 patients (11 %) with CA19-9 value < 100 U/ml developed a recurrence at an early period (p < 0.001). Multivariate analysis revealed that CA19-9 value ≥ 100 U/ml (odds ratio, 11.2) were significant predictors of early recurrence. The overall 3- and 5-year survival rates and median survival times were 47.3 %, 40.1 %, and 31 months in patients with CA19-9 value < 100 U/ml and 21.2 %, 9.4 %, and 16 months in patients with CA19-9 value ≥ 100 U/ml (p < 0.001).

CONCLUSIONS

A preoperative CA19-9 value ≥ 100 U/ml was a significant predictor of early recurrence and a poor prognosis after resection for pancreatic adenocarcinoma.

Gallbladder cancer involving the extrahepatic bile duct is worthy of resection

OBJECTIVE

To clarify the value of resection of gallbladder cancer involving the extrahepatic bile duct.

BACKGROUND

: Several recent studies have proven that jaundice and extrahepatic biliary involvement are independent predictors of a poor outcome. Only a few authors recommend resection of such advanced disease.

METHODS

One hundred patients with pT3/4, pN0/1, M0 disease were the subjects of this study. Mortality and long-term outcome were analyzed using a prospectively collected database.

RESULTS

The only factor associated with mortality in univariate and multivariate analyses was intraoperative blood loss. The 5-year survival rate and median survival time were 23% and 1.5 years for patients with pathologic extrahepatic biliary invasion (pEBI), and 54% and 15.4 years for patients without pEBI. Twelve patients with pEBI survived beyond 5 years. Multivariate analysis revealed that R1/2 resection and combined resection of adjacent organs other than the liver and extrahepatic bile duct (CRAO) were independent predictors of poor outcome. Five-year survival rate and median survival time after R0 resection without CRAO were 36% and 3.8 years even in patients with pEBI. In contrast, after R0 resection with CRAO 5-year survival and median survival time were 16% and 0.8 years, respectively.

CONCLUSIONS

Patients with advanced gallbladder cancer with pEBI are candidates for resection when distant metastases are absent and R0 resection is achievable. When CRAO is unnecessary, surgical resection should be aggressively planned.

Hepatectomy with simultaneous resection of the portal vein and hepatic artery for advanced perihilar cholangiocarcinoma: an audit of 50 consecutive cases

OBJECTIVE

To outline our experience with hepatectomy with simultaneous resection of the portal vein and hepatic artery for advanced perihilar cholangiocarcinoma, and to discuss the clinical significance of this challenging hepatectomy.

SUMMARY BACKGROUND DATA

Only a few authors reported negative results for this surgery in a very limited number of patients.

METHODS

We retrospectively reviewed medical records of 50 patients with advanced cholangiocarcinoma who underwent hepatectomy (left trisectionectomy in 26, left hepatectomy in 23, and right hepatectomy in 1) with simultaneous resection and reconstruction of the portal vein and hepatic artery, focusing on surgical outcome and survival.

RESULTS

The operative time was 776 +/- 191 minutes, and blood loss was 2593 +/- 1890 mL. Time of vessel resection and reconstruction was 25 +/- 19 minutes for the portal vein and 119 +/- 56 minutes for the hepatic artery. A total of 27 (54.0%) patients developed several kinds of complications, including intra-abdominal abscess (n = 13), wound infection (n = 9), bile leakage from liver stump (n = 9), and liver failure (n = 7). Relaparotomy was necessary in 5 (10.0%) patients. One (2.0%) patient died of a postoperative complication. Microscopic cancer invasion of the resected portal vein was found in 44 (88.0%) patients, while that of the resected hepatic artery was found in 27 (54.0%). The distal bile duct margin, proximal bile duct margin, and radial margin were positive for cancer in 2 (4.0%), 4 (8.0%), and 17 (34.0%) patients, respectively. Consequently, R0 resection was achieved in 33 (66.0%) patients. The 1-, 3-, and 5-year survival rates were 78.9%, 36.3%, and 30.3%, respectively. Survival for 30 patients with pM0 disease who underwent R0 resection was better, being 40.7% at the 3- and 5-year time points.

CONCLUSION

Major hepatectomy with simultaneous resection and reconstruction of the portal vein and hepatic artery is technically demanding. However, this surgery can be performed with acceptable mortality by an experienced surgeon and offers a better chance of long-term survival in selected patients.

Surgical treatment of hilar cholangiocarcinoma in the "new era": the Nagoya University experience

OBJECTIVE

To review our surgical experience with hilar cholangiocarcinoma in the "new era."

METHODS

The medical records of 428 patients with hilar cholangiocarcinoma who underwent treatment between 2001 and 2008 at the First Department of Surgery, the Nagoya University Hospital, were retrospectively reviewed.

RESULTS

Of the 428 patients, 298 (70%) underwent surgical resection (R0, n = 220; R1, n = 70; R2, n = 8). Portal vein resection was performed in 111 (37%) patients, and hepatic artery resection was performed in 53 (18%) patients. Several different types of postoperative complications occurred in a total of 129 (43%) patients and led to 6 (2%) deaths. Of the 298 resected tumors, 206 (69%) were extrahepatic type tumors, and the remaining 92 (31%) were intrahepatic type tumors. Using the Bismuth classification criteria, we identified 15 (5%) type I, 21 (7%) type II, 120 (40%) type III, and 142 (48%) type IV tumors. The overall 1-, 3-, and 5-year survival rates for all 298 patients were 77, 49, and 42%, respectively. The survival rates were highest among the 197 patients with pM0 disease who underwent R0 resection. Patients in this subgroup had a 5-year survival rate of 52%. The 5-year overall survival rate for the 55 patients with pM0 disease who underwent R1 resection was 32%. The survival rate for patients who had pM1 disease and/or underwent R2 resection was the worst of all the subgroups, but was nonetheless significantly better than that of patients with unresectable tumors. The survival rate for patients who underwent vascular resection and reconstruction was unexpectedly better, with 5-year survival of >20%.

CONCLUSIONS

The surgical approach to hilar cholangiocarcinoma has become more challenging in the new era. Nevertheless, surgical outcomes have been improved, with decreased morbidity and mortality rates being observed. Long-term survival has also steadily improved. These findings indicate that biliary surgeons should use an aggressive surgical strategy to treat this intractable disease.

Value of multidetector row CT in the assessment of longitudinal extension of cholangiocarcinoma: correlation between MDCT and microscopic findings

BACKGROUND

A few authors have reported the value of multidetector row CT (MDCT) for evaluating the longitudinal extent of cholangiocarcinoma. They have not focused on CT attenuation of a tumor and actual tumor extent along the bile ducts. We designed the present study to analyze attenuation.

METHODS

Between January 2003 and July 2005, 113 consecutive patients with cholangiocarcinoma underwent a surgical resection following MDCT. Of these MDCT studies, 73 (perihilar cholangiocarcinoma, n = 62; middle and distal cholangiocarcinoma, n = 11) were suitable for analysis, and the patients were enrolled in the study. Patients were divided according to tumor hypoattenuation and hyperattenuation on MDCT. Histologic differentiation, desmoplastic reaction, and vascular density were microscopically compared with the tumor attenuation to differentiate the characteristics of the attenuation. The extent of cancer along the bile duct diagnosed by MDCT was compared with the actual extent determined by the microscopic findings.

RESULTS

Hyperattenuated tumor was observed in 40 patients. There was no difference in histologic differentiation, desmoplastic reaction, or vascular density between the hyperattenuated and hypoattenuated cholangiocarcinomas. Neither the proximal nor the distal borders between the normal and thickened bile duct wall could be determined in the 33 patients with hypoattenuated tumor; in contrast, an accurate assessment of extent of tumor was obtained in 76% of the proximal borders and 82% of the distal borders in the 40 patients with hyperattenuated tumor.

CONCLUSIONS

Although the cause of the difference between the hyperattenuated and hypoattenuated cholangiocarcinoma still is unclear, MDCT can be an alternative to direct cholangiography in selected patients with hyperattenuated cholangiocarcinoma.