Outcomes of bile duct resection with or without liver resection in management of Klatskin tumor: A 15-year U.S. National Data Review

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Background: Surgical resection can provide an increase in survival for incurable patients with cholangiocarcinoma (CCA); Since outcomes improve significantly with more aggressive intervention liver resection (LR) should be pursued together with common bile duct resection (CBDR). We aimed to analyze the trends of surgical management of hilar CCA also known as Klatskin tumor (KT) across 15 years in the U.S. Methods: We extracted two cohorts of hospitalizations from Nationwide Inpatient Sample (NIS) 2005-2019yy using ICD-9 and ICD-10 diagnosis and procedure codes for KT, CBDR and LR. First group of patients with KT had CBDR performed alone and the second group of KT patients received CBDR and LR during the same hospitalization. We compared mortality, performed socio-demographic analysis stratified by patient and hospital information and used length of stay (LOS) and mean charges (MC) as additional outcomes. Results: We extracted a total of 3,095 hospitalizations with KT that underwent CBDR alone or CBDR with LR. There was a transition in proportion of CBDR alone versus CBDR with LR across years, which we attribute to the change in coding from ICD-9 to ICD- 10, with the combined coding year 2015 demonstrating equalization of proportion of performed procedures prior to the flip in 2016. Since ICD-10 procedure coding was more specific for CBDR and LR, we as a result of this conclude that ICD-10 coding years 2016 and onward are more accurate and the latest trends demonstrate the increasing performance of only CBDR in KT patients rather than CBDR with LR (75% vs. 25% in 2019). Analysis of socio-demographics is presented in the Table. More than 2/3 of the patients were above age 60. Proportionally CBDR alone was more likely to be covered by public insurance than CBDR with LR (Public: 63.7% vs. 57.1%; Private: 34% vs. 40%). Even though it is a more invasive intervention, CBDR with LR had slightly less mean overall charges (MC=$223,903 for CBDR vs. $212,072 for CBDR with LR (P=0.5574)) and similar hospital resource utilization (LOS= 14 days for CBDR vs.14.7 days for CBDR with LR) compared to CBDR alone. Most of the procedures (>94%) were performed in teaching hospitals. Inpatient mortality was 5.5% for CBDR alone vs. 8.7 % for CBDR with LR. Conclusions: Our analysis demonstrated that for KT proportionally, CBDR performance is more prevalent than CBDR with LR in the latest years 2016-2019. Considering the comparable cost and hospital resource utilization with intent to cure, more aggressive surgical management should be pursued. Inpatient mortality was higher for more aggressive surgical management 5.5% for CBDR alone vs. 8.7% for CBDR with LR. Insurance type may play a role in the procedure choice. [Table: see text]

Delayed appearance of mature ganglia in an infant with an atypical presentation of total colonic and small bowel aganglionosis: a case report

Background

Total colonic and small bowel aganglionosis (TCSA) occurs in less than 1% of all Hirschsprung’s disease patients. Currently, the mainstay of treatment is surgery. However, in patients with TCSA, functional outcomes are often poor. A characteristic transition zone in TCSA can be difficult to identify which may complicate surgery and may often require multiple operations.

Case presentation

We present the case of a male infant who was diagnosed with biopsy-proven total colonic aganglionosis with extensive small bowel involvement as a neonate. The patient was diverted at one month of age based on leveling biopsies at 10 cm from the Ligament of Treitz. At 7 months of age, during stoma revision for a prolapsed stoma, intra-operative peristalsis was observed in nearly the entire length of the previously aganglionic bowel, and subsequent biopsies demonstrated the appearance of mature ganglion cells in a previously aganglionic segment.

Conclusions

TCSA remains a major challenge for pediatric surgeons. Our case introduces new controversy to our understanding of aganglionosis. Our observations warrant further research into the possibility of post-natal ganglion maturation and encourage surgeons to consider a more conservative surgical approach.