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Objective:To investigate the application value of dynamic scintigraphy single-photonemission computed tomography (SPECT) 99m-technetium-galactosyl human serum albumin diethy-lenetriamine pentaacetic ( 99Tc m-GSA) scintigraphy in assessing liver function of perihilar cholangio-carcinoma after portal vein embolization (PVE). Methods:The retrospective and descriptive study was conducted. The clinicopathological data of 16 patients with perihilar cholangiocarcinoma who underwent 99Tc m-GSA scintigraphy after PVE in Beijing Tsinghua Changgung Hospital Affiliated to Tsinghua University from October 2019 to January 2021 were collected. There were 8 males and 8 females, aged from 46 to 78 years, with a median age of 64 years. Observation indicators: (1) liver volume after PVE; (2) liver function after PVE; (3) typical case analysis. Measurement data with normal distribution were represented as Mean± SD. Count data were represented as absolute numbers or percentages. Comparison of data of the same patient was analyzed using the paired t test. Results:(1) Liver volume after PVE:the morphological liver volume and functional liver volume for the 16 patients were (1 420±211)mL and (389±112)mL. The morphological liver volume and functional liver volume were (636±143)mL and (234±106)mL of planning reserved lobe, (784±210)mL and (151±106)mL of planning resection lobe, respectively. The functional liver density (FLD) of planning reserved lobe and planning resection lobe were 0.36±0.12 and 0.19±0.11, showing a significant difference between them ( t=3.794, P<0.05). The planning resection rate of morpholo-gical liver volume and functional liver volume were 37.8%±0.6% and 54.8%±0.2%, showing a significant difference between them ( t=?3.720, P<0.05). (2) Liver function after PVE: 13 of 16 patients completed the indocyanine green (ICG) test, and 3 patients didn't complete the ICG test due to intolerance. For the 13 patients undergoing ICG test, the total ICG-K value was (0.15±0.03)/minutes, and the ICG-K value of planning reserved lobe was (0.07±0.02)/minutes. The total GSA-K value of 16 patients was (0.14±0.10)/minutes, and the GSA-K value of planning reserved lobe was (0.08±0.06)/minutes. (3) Typical case analysis: a 46-year-old male patient with type Bismuth Ⅲa perihilar cholangiocarcinoma was planned to perform perihilar hepatectomy combined with right hepatectomy. The imaging evaluation showed that the volume of reserved liver lobe accounted for 27% of the total liver volume. The serum total bilirubin was 256 μmol/L when admitted and decreased to 118 μmol/L on the day 5 after percutaneous transhepatic biliary drainage. The right anterior and right posterior branches of PVE was performed. SPECT 99Tc m-GSA examination was performed on the day 37 after PVE. The morphological liver volume was 559 mL of planned reserved lobe and 1 461 mL of the whole liver. The planned morphological liver volume resection rate was 61.7%. ICG-K was 0.12/minutes of the whole liver, and 0.04/minutes of planned reserved lobe. The functional liver volume was 134 mL of planned reserved lobe and 309 mL of the whole liver. The planned resection rate of functional liver volume was 56.6%. The GSA-K was 0.20/minutes of the whole liver and 0.09/minutes of planned reserved lobe. R 0 resection was achieved in perihilar hepatectomy combined with right hepatectomy and no liver failure occurred. The survival time of patients was 11 months. Conclusion:Dynamic SPECT 99Tc m-GSA scintigraphy can effectively evaluate the regional function of the reserved liver lobe in patients with perihilar cholangiocarcinoma after PVE.
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Intrahepatic cholangiocarcinoma has low resectability rate, high recurrence and short survival. It is very important to formulate and optimize the strategy of surgical treatment. The only potentially effective treatment for intrahepatic cholangiocarcinoma is surgical resection. Liver transplantation also has some application prospects. Intrahepatic cholangiocarcinoma can be divided into four types: mass forming type, intraductal growth type, periductal infiltration type, mass forming + periductal infiltration(mixed)type. Clinically, the treatment strategy is mainly determined according to the general classification. The application of methods such as preoperative portal vein embolism, neoadjuvant therapy and lymph node dissection make it possible for more patients to undergo surgical resection and improve the surgical effect. Adjuvant treatment including chemotherapy and radiotherapy can significantly improve the prognosis of the patients. The rapid development of molecular targeted therapy and immunotherapy is gradually changing the clinical treatment of intrahepatic cholangiocarcinoma.
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At present,it is not uncommon for patients with biliary dilatation who have failed to undergo multiple operations in clinic.Dong's classification has a definite guiding significance for choosing appropriate surgical methods.Active hepatectomy with "tailor-made" treatment can cure refractory biliary dilatation involving intrahepatic bile ducts.At present,there are still some controversies about the range of hepatectomy and the management of type D lesions in children.At the same time,we should pay close attention to the long-term complications after dilated bile duct resection.
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The annual congress of Japan Surgical Society is a famous academic event in the field of surgery,and the participants can learn from the latest research results of all the major surgical disciplines.The authors selected topics of the ll8th annual congress in 2018,including the latest research results and progresses of laparoscopic hepatectony,liver transplantation,extrahepatic bile duct carcinoma and pancreatic surgery.The purpose of this study is to provide new information and reference for optimizing the diagnosis and treatment of hepatobiliary and pancreatic diseases.
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Objective To investigate the application value of dynamic single-photon emission computed tomography (SPECT) 99m-technetium galactosyl human serum albumin diethylenetriamine pentaacetic acid injection (99 Tcm-GSA) scintigraphy assessing regional liver function changes before and after portal vein embolization (PVE).Methods The retrospective cross-sectional study was conducted.The clinical data of 11 patients with Bismuth Ⅲ a hilar cholangiocarcinoma who were admitted to the General Hospital of People's Liberation Army (10 patients) and Beijing Tsinghua Changgung Hospital (1 patient) from October 2010 to October 2016 were collected.B ultrasound-guided percutaneous transhepatic ipsilateral exbolization was performed before radical resection of hilar cholangiocarcinoma.Dynamic SPECT 99 Tcm-GSA scintigraphy was performed to calculate and compare the changes of functional liver volume (FLV),morphological liver volume (MLV) and functional liver density (FLD) in embolized lobe and non-embolized lobe before PVE and 2 weeks after PVE.Observation indicators:(1) the changes of serum indexes in 2 weeks before and after PVE;(2) the changes of FLV,MLV and FLD in the whole liver,embolized and non-embolized lobes in 2 weeks before and after PVE;(3) surgical and postoperative situations of hilar cholangiocarcinoma;(4) follow-up and survival situations.Follow-up using outpatient examination and telephone interview was performed to detect postoperative serum toal bilirubin (TBil) level,with or without peritoneal effusion and survival up to June 2017.Measurement data with normal distribution were represented as x-±s.The comparisons of pre-and post-operative data were analyzed by the paired t test.Results (1) The changes of serum indexes in 2 weeks before and after PVE:11 patients underwent successful right PVE.The alanine aminotransferase (ALT),TBil,albumin (Alb),Platelets (PLT) and prothrombin time (PT) were respectively (113±20) U/L,(73± 8) μmol/L,(35.0±2.5) g/L,(209±58) × 109/L,(11.4±0.7) seconds in 2 weeks before PVE and (120± 18) U/L,(36± 7) μmol/L,(34.4± 3.2) g/L,(224± 82) × 109/L,(11.2±0.8)seconds in 2 weeks after PVE,with a statistically significant difference in TBil level (t=-10.592,P＜0.05) and no statistically significant difference in ALT,Alb,PLT and PT (t=0.981,-0.350,-0.591,0.533,P＞0.05).(2) The changes of FLV,M LV and FLD in the whole liver,embolized and nonembolized lobes in 2 weeks before and after PVE:the FLV,MLV and FLD of the whole liver were respectively (894±255) mL,(1 552±504) mL,0.59±0.14 in 2 weeks before PVE and (812±206) mL,(1 521±422) mL,0.55±0.16 in 2 weeks after PVE,with no statistically significant difference (t =1.569,0.666,1.980,P＞ 0.05).The FLV,MLV and FLD of the embolized lobe were respectively (623±275) mL,(1 047± 394) mL,0.62±0.14 in 2 weeks before PVE and (375±240) mL,(865±337) mL,0.44±0.24 in 2 weeks after PVE,with statistically significant differences (t =5.909,3.736,3.359,P ＜ 0.05);the descending percentages were respectively 38.1％,9.8％ and 24.6％.The FLV,MLV and FLD of the non-embolized lobe were respectively (274±152)mL,(530±176)mL,0.52±0.21 in 2 weeks before PVE and (436±149) mL,(656±133)mL,0.68± 0.24 in 2 weeks after PVE,with statistically significant differences (t =-6.019,-6.345,-3.933,P＜0.05);the elevated percentages were respectively 80.1％,19.9％ and 23.8％.(3) Surgical and postoperative situations of hilar cholangiocarcinoma:of 11 patients,10 received successful peri-hilar right hemihepatectomy,the right hepatic atrophy and an obvious demarcation line between left and right liver were found intraoperatively;1 stopped operation due to detect intraoperatively peritoneal metastasis of tumor.The operation time,volume of intraoperative blood loss and time of postoperative abdominal drainage-tube removal were respectively (585± 194)minutes,(472± 274)mL and (8±5)days.Of 10 patients undergoing operations,2 were complicated with massive peritoneal effusion at 2 days postoperatively,volume of peritoneal effusion remained more than 500 mL up to 7 days after drainage,and were improved by 1-month conservative treatment;other 8 patients were not complicated with hepatic dysfunction.Duration of hospital stay of 11 patients was (16± 4) days.(4) Follow-up and survival situations:10 patients were followed up for 4-72 months,with a median time of 39 months.During the follow-up,there was no evaluated TBil level and peritoneal effusion in 10 patients.The median survival time,1-,3-and 5-year overall survival rates were 88.8％,74.6％ and 36.8％,respectively.Conclusions The dynamic SPECT 99Tcm-GSA scintigraphy can effectively evaluate liver function changes of embolized and non-embolized lobes before and after PVE.The increased rate of FLV of non-embolized lobe is higher than that of MLV.
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The 8th Japan-China Hepato-Pancreato-Biliary Symposium was held in Tokyo,Japan from 22nd to 23rd November 2018.The meeting was convened coincidently with the 80th Annual Congress of Japanese Surgical Association,which attracted the participation of Chinese and Japanese hepatobiliary and pancreatic surgeons.The symposium aimed to explore the latest achievements and clinical issues of diagnosis and treatment for hepato-pancreato-biliary diseases.In this article,authors reviewed the up-to-date research information in order to share the experience,achievements and new information in the field of hepatobiliary and pancreatic diseases with colleagues.
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Congenital bile duct dilatation may occur in any part of the biliary tree,and the diagnosis and treatment of lesions involving the intrahepatic bile duct is the most challenging issue.Surgical operation plays a dominant role in the management of congenital bile duct dilatation,with the purposes of relieving symptoms and preventing disease progression and malignant transformation.Surgical principles are radical resection of lesions and reconstruction of unobstructed bile drainage.Hepatectomy is the main surgical procedure for congenital bile duct dilatation with involvement of the intrahepatic bile duct,and liver transplantation can be used for diffuse lesions.Therefore,we believe that hepatectomy and early intervention will maximize patients' benefits.
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Objective To explore clinical efficacy of new types of operation based on perihilar resection to cure hilar cholangiocarcinoma.Methods The retrospective descriptive study was conducted.The clinicopathological data of 4 patients with different Bismuth type of hilar cholangiocarcinoma who were admitted to the Beijing Tsinghua Chunggung Hospital from December 2014 to June 2016 were collected.After preoperative examinations and evaluations,single perihilar resection or combined with central liver segmentectomy were performed.Observation indicators included:(1) intraoperative situations;(2) postoperative pathological examinations;(3) postoperative situations;(4) follow-up.Patients were followed up using outpatient examination up to June 2017.Follow-up included abdominal pain,fever,routine blood test,tumor marker test and imaging examination which detected tumor recurrence and metastasis.Measurement data were represented as average (range).Results (1) Intraoperative situations:4 patients received successful operations,with an average operation time of 512 minutes (range,300-620 minutes).Portal vein was blocked continuously,with an average occlusion time of 70 minutes (range,57-80 minutes),an average volume of intraoperative blood loss was 537 mL (range,200-1 000 mL).Two patients received transfusion of 2 U plasma,4 U plasma + 4 U red blood cell (RBC),respectively.(2) Postoperative pathological examinations:results of postoperative pathological examinations in 4 patients showed that tumor size was respectively 1.5 cm× 1.2 cm× 1.1 cm,1.3 cm× 1.1 cm× 1.0 cm,2.0 cm× 1.7 cm× 1.5 cm and 2.0 cm×2.0 cm× 1.5 cm.Tumor differentiation:1 and 3 patients were respectively detected in moderate-differentiated cholangiocarcinoma and low-differentiated cholangiocarcinoma.Positive nerve plexus invasion was found in all 4 patients and 3 patients had regional lymph node metastasis.Four patients received R0 resection.TNM staging:T2aN1M0 and T2bN1M0 were found in 1 and 3 patients,respectively.(3) Postoperative situations:of 4 patients,1 complicated with biliary leakage was cured by conservative treatment and then discharged from hospital at 67 days;3 had good recovery and then discharged from hospital at day 21,14 and 14,respectively.Patients didn't receive postoperative adjuvant treatment,such as chemoradiotherapy.(4) Follow-up:4 patients were followed up for 12-31 months.During follow-up,4 patients were in good condition,and 1 with transient fever was relieved by conservative treatment.Levels of tumor marker in 4 patients were normal,results of enhanced CT scan showed no signs of tumor recurrence and intrahepatic bile duct dilatation.Conclusion After precisely evaluating the tumor extension among segmental bile duct,single perihilar resection or combined with central segmentectomy can effectively cure hilar cholangiocarcinoma.
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Objective To explore clinical efficacy of new types of operation based on perihilar resection to cure hilar cholangiocarcinoma.Methods The retrospective descriptive study was conducted.The clinicopathological data of 4 patients with different Bismuth type of hilar cholangiocarcinoma who were admitted to the Beijing Tsinghua Chunggung Hospital from December 2014 to June 2016 were collected.After preoperative examinations and evaluations,single perihilar resection or combined with central liver segmentectomy were performed.Observation indicators included:(1) intraoperative situations;(2) postoperative pathological examinations;(3) postoperative situations;(4) follow-up.Patients were followed up using outpatient examination up to June 2017.Follow-up included abdominal pain,fever,routine blood test,tumor marker test and imaging examination which detected tumor recurrence and metastasis.Measurement data were represented as average (range).Results (1) Intraoperative situations:4 patients received successful operations,with an average operation time of 512 minutes (range,300-620 minutes).Portal vein was blocked continuously,with an average occlusion time of 70 minutes (range,57-80 minutes),an average volume of intraoperative blood loss was 537 mL (range,200-1 000 mL).Two patients received transfusion of 2 U plasma,4 U plasma + 4 U red blood cell (RBC),respectively.(2) Postoperative pathological examinations:results of postoperative pathological examinations in 4 patients showed that tumor size was respectively 1.5 cm× 1.2 cm× 1.1 cm,1.3 cm× 1.1 cm× 1.0 cm,2.0 cm× 1.7 cm× 1.5 cm and 2.0 cm×2.0 cm× 1.5 cm.Tumor differentiation:1 and 3 patients were respectively detected in moderate-differentiated cholangiocarcinoma and low-differentiated cholangiocarcinoma.Positive nerve plexus invasion was found in all 4 patients and 3 patients had regional lymph node metastasis.Four patients received R0 resection.TNM staging:T2aN1M0 and T2bN1M0 were found in 1 and 3 patients,respectively.(3) Postoperative situations:of 4 patients,1 complicated with biliary leakage was cured by conservative treatment and then discharged from hospital at 67 days;3 had good recovery and then discharged from hospital at day 21,14 and 14,respectively.Patients didn't receive postoperative adjuvant treatment,such as chemoradiotherapy.(4) Follow-up:4 patients were followed up for 12-31 months.During follow-up,4 patients were in good condition,and 1 with transient fever was relieved by conservative treatment.Levels of tumor marker in 4 patients were normal,results of enhanced CT scan showed no signs of tumor recurrence and intrahepatic bile duct dilatation.Conclusion After precisely evaluating the tumor extension among segmental bile duct,single perihilar resection or combined with central segmentectomy can effectively cure hilar cholangiocarcinoma.
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Continuous progress of medicine and related areas are initiating and motivating a paradigm transformation of traditional surgery to precise surgery,which is characterized by precision in decision making and surgical intervention.The strategy of precise surgery is to seek a balance of maximized lesion removal,maximized organ sparing and minimal surgical invasiveness.Due to the special location and biological characteristics,the therapy of hilar cholangiocarcinoma is still challenging.To meet the demand of precise surgery,the knowledge of anatomy,biological characteristics and liver functional reserve is needed and the technical aspects of pre-surgical intervention,liver resection and reconstruction of vessels are also very important.
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Since the 1980s, indications for resection of hilar cholangiocarcinoma have progressively improved. Operation is superior to any other therapeutic modalities with regard to survival rate and quality of life. Currently, hepatic lobectomy, extended hepatic lobectomy, extrahepatic bile duct resection, regional lymphadenectomy and Roux-en-Y hepatoenteric jejunos-tomy are recommended as the treatment of choice for most patients with hilar cholangiocarcinoma. However, controversy still remains regarding the diagnosis and treatment of hilar cholangiocarcinoma, including the assessment of longitudinal tumor extension, the evaluation of hepatic reserve function, the value of biliary drainage, the indication of portal vein emboliza-tion, the range of hepatic resection, the contribution of com-bined vascular resection, and the effectiveness of liver transplan-tation. This article summarizes these main issues requiring further investigation.
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The clinical value of applying portal vein resection and reconstruction in left trisectionectomy for treating advanced hilar cholangiocarcinoma is approved, while it is still a big challenge for clinicians. One female patient suffering from abdominal pain and jaundice received treatment in the General Hospital of PLA in July, 2009. She was prelimiarily diagnosed with Bismuth type Ⅲ a hilar cholangiocarcinoma. A tube was inserted in the left lateral inferior bile duct to carry out percutaneous transhepatic biliary drainage (PTBD). After the anatomic variation of the left bile duct was found, the diagnosis was revised as Bismuth type Ⅳ. A left trisectionectomy was proposed, and another PTBD tube was inserted in the right posterior bile duct.Combined portal vein resection and reconstruction and left trisectionectomy was successfully performed. The postoperation course was uneventful, except for the transient liver dysfunction and biliary-enteric anastomotic leakage.
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65 years) with acute cholecystitis treated by PTGBD in this hospital between January 2001 and December 2005. All the patients were not symptomatically relieved after conservative therapy and/or had severe accompanying co-morbidities. Results A successful tube insertion was achieved in 29 patients, whereas insertion failure was encountered in 1 patient because the gallbladder was full of stones, in which a bile aspiration was performed. The dislodgement of drainage tube occurred in 2 patients (one patient underwent a re-insertion and the other was symptomatically relieved without insertion). Exacerbation of the condition developed in 1 patient after the treatment, and an open cholecystostomy with abdominal irrigation and drainage was performed. Twenty-seven patients were discharged from hospital with the drainage tube intact. Of them, the drainage tube was removed 3 weeks after PTGBD in 25 patients, was maintained for 8 weeks until surgery in 1 patient, and was dislodged in 1 patient. Twenty-eight patients with calculous cholecystitis underwent a delayed surgery, including LC in 25 patients, stone removal by choledochofiberscope in 2 patients, and open surgery in 1 patient because of accompanying choledocholithiasis and retroperitoneal mass (adrenal tumor). In another 4 patients with choledocholithiasis, an intraoperative choledochofiberscopy during LC was performed in 2 patients, and endoscopic sphincterotomy after LC was conducted in 2. No surgery related deaths or bile duct injuries occurred. Conclusions Combined use of PTGBD and delayed LC in elderly patients with acute cholecystitis is safe and effective.
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Objective To assess the clinical efficacy of percutaneous transhepatic portal embolization (PTPE) before the extended right hemihepatectomy for the treatment of hilar cholangiocarcinoma. Methods We successfully carried out a percutaneous transhepatic portal embolization in a patient with hilar cholangiocarcinoma and liver cirrhosis. Hepatic hemodynamics, liver volume,liver functions, and pathological changes were recorded after the procedure. Results After PTPE, the patient developed an inflammatory response manifested by a transient fever (39.2 ℃ at peak on the 5th postoperative day) and a mild abdominal pain. There were no other complications such as nausea, vomitting, hemorrhage, or bile leakage. The volume of the left lobe increased from 417.0 ml to 522.4 ml (enlargement rate, 125.2%); the volume of the right lobe decreased from 1041.3 ml to 1017.4 ml (diminishment rate, 97.7%). The ratio of the left lobe to the whole liver increased from 28.6% to 33.9%. The velocity of blood flow of the left portal vein increased by 100% and 39% on the day of operation and the 6th day after operation, respectively (from 12.8 ml/s preoperatively to 23.2 ml/s and 17.1 ml/s). The values of ICG R15 and ICG-K returned to normal levels. On the 17th day after PTPE, the quantity of bile drainage from the left lobe exceeded that from the right lobe. The extended right hemihepatectomy was performed 34 days after PTPE. During operation, an obvious hypertrophy of the left lobe and a distinct demarcation line between the segment 5, 6, and 7 (S5,6,7) and other segments were observed. Postoperative recovery was uneventful. The pathological examination found stenosis and embolization of the portal vein, as well as the degeneration, necrosis, and apotosis of the liver cells in the embolized lobe. Conclusions Portal vein embolization can effectively induce the hypertrophy of the unembolized lobe, which increases the safety level of following extended hemihepatectomy in patients with impared liver functions.