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Pancreatic cancer is one of the most common tumors in digestive system, which is characterized by insidious clinical symptoms, strong invasion, easy metastasis and high mortality. In recent years, immunotherapy is a new direction to the treatment of solid tumors, but its applica-tion in pancreatic cancer is limited by tumor microenvironment of pancreatic cancer. The authors systematically analyze the tumor microenvironment of pancreatic cancer, summarize the clinical researches related to pancreatic cancer immunotherapy, and discuss the prospect of pancreatic cancer immunotherapy.
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Objective:To evaluate surgical therapy for patients of hepatocellular carcinoma(HCC) with bile duct tumor thrombi(BDTT).Methods:A retrospective analysis was made on 66 patients with HCC and BDTT undergoing surgical treatment at the First Affiliated Hospital of Hunan Normal University from Jan 2011 to Dec 2016.Results:The overall median survival time of the patients was 31 months. The 1, 3, and 5-year survival rates were 87.9%, 45.5%, and 13.6%, respectively. Univariate analysis showed hepatitis B virus, liver cirrhosis and history of drinking, AFP≥200 ng/ml, tumor resection combined with biliary incision to remove tumor thrombus, tumor undifferentiated/poorly differentiated, tumor diameter ≥50 mm, AJCC 8th stage Ⅲ/Ⅳ and number of lesions ≥ 2 were risk factors for postoperative survival (all P<0.05). Multivariate analysis showed that drinking history, undifferentiated/poorly differentiated tumor, tumor diameter ≥50 mm, and AJCC 8th Ⅲ/Ⅳ stage were independent risk factors (all P<0.05). Conclusion:Surgical resection of HCC combined with BDTT can achieve a satisfactory survival and prognosis.
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Objective:To investigate the feasibility of ventral-combined-dorsal exposure of middle hepatic vein via caudal approach in laparoscopic anatomic hemihepatectomy of liver cancer.Methods:A retrospective analysis was performed on the clinical data of 44 patients undergoing laparoscopic antecedent hemihepatectomy with the ventral-combined-dorsal exposure of middle hepatic vein via caudal approach in the Department of Hepatobiliary Surgery, the First Affiliated Hospital of Hunan Normal University (Hunan Provincial People's Hospital) from January 2021 to September 2021. Among the 44 patients, there were 24 male and 20 female patients, aged 56-66 (61±5) years. The operative time, intraoperative blood loss, occlusion time of the first hilum hepatis, postoperative complications and postoperative hospital stay were analyzed.Results:All 44 patients underwent the surgery successfully. The average operation time was (259.3±33.4) min. Intraoperative blood loss was (113.8±31.0) ml, and no intraoperative blood transfusion was performed. The mean intraoperative occlusion time of the first hilum was (56.1±7.1) min. No postoperative hemorrhage and biliary fistula and other complications occurred. The mean postoperative hospital stay is (9.3±1.4) days. Pathological examination confirmed hepatocellular carcinoma in 36 cases and intrahepatic cholangiocarcinoma in 8 cases.Conclusion:The ventral-combined-dorsal exposure of middle hepatic vein via caudal approach benefits exposure of middle hepatic vein in laparoscopic anatomic hemihepatectomy, reducing intraoperative accidental bleeding and ensuring surgical safety.
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Objective:To evaluate partial ventral hepatectomy in the treatment of patients with complicated iatrogenic high bile duct injury.Methods:The clinical data of 8 cases of complicated iatrogenic high bile duct injury treated with the assistance of hepatic ventral segmentectomy from Mar 2013 to May 2020 at Hunan Provincial People's Hospital was retrospectively analyzed.Results:Among the 8 patients, 5 patients underwent partial Ⅳb lobectomy, and 3 patients received partial Ⅳb and Ⅴ segmentectomy of the liver. All the operation was successful without death in hospital. One case developed subphrenic infection and seroperitoneum, which was healed by anti-infection treatment and abdominocentesis. The postoperative follow-up time was 5-90 months, and all of patients are doing well. There was no stenosis in intrahepatic bile duct by postoperative cholangiography or MRI.Conclusions:Quadrate lobe hepatectomy provides a wide view for the treatment of complicated iatrogenic high bile duct injury by fully opening the first porta hepatis and exposing the primary and secondary bile duct branch helping establish a wide patent tension free bile duct-jejunostomy.
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Objective:To analyze the causes of postoperative stricture of biliary-enteric anastomotic for congenital choledochal cysts.Methods:These 28 patients underwent salvage operation on an average 15 years (0.2-25 years) after initial surgeries at the Department of Hepatobiliary Surgery, Hunan Provincial People's Hospital from Jan 2014 to Jun 2018.Results:In 26 patients the biliary-enteric anastomotic stenosis was benign, and in 2 the stricture was caused by cancerration. In 26 cases the Roux-en-Y hepaticojejunostomy was redone,among them 8 cases underwent concurrent hepatectomy for a better exposure of the intrahepatic bile duct. In 2 cases the anastomotic stenosis was found to be caused by canceration with extensive intraabdominal metastasis ,an external drainage was adopted. There were no inhospital deaths, and no serious complications. The postoperative follow-up time was 6-67 months. Two cancerated patients died within half a year, and the remaining patients had no long-term complications.Conclusions:Biliary-enteric anastomotic stenosis is one of the serious complications in postoperative patients for congenital choledochal cysts. Hence a wide, tension free biliary-enteric anastomosis performed by a experienced hand is necessary.
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Objective:To study the safety and efficacy of laparoscopic cholecystectomy (LC) in treatment of T2a and lower stages of gallbladder carcinoma.Methods:A retrospective study was performed on patients who were diagnosed with gallbladder cancer and underwent surgical treatment from January 2016 to January 2021 at Hunan Provincial People's Hospital. These patients were divided into the simple treatment group and the radical treatment group based on the surgical methods used. The simple treatment group consisted of 64 patients who underwent LC for accidental gallbladder cancers. The radical treatment group consisted of 30 patients who underwent laparoscopic radical cholecystectomy (LRC). The baseline characteristic of the two groups of patients were matched in a 1∶1 ratio using propensity score matching. After matching, there were 26 patients in each of the 2 groups. There were 7 males and 19 females in the simple group, with mean ± s. d. age of (60.6±9.6) years. There were 8 males and 18 females, with mean ± s. d. age (60.9±9.1) years in the radical treatment group. Blood loss, operation time, postoperative hospital stay, biliary leakage, acute pulmonary embolism, and incisional infection were compared between the two groups.Results:In the simple group, the operative time was (78.7±62.9) min, intraoperative blood loss was (10.7±11.6) ml and postoperative hospital stay was (4.4±2.6) d. These results were significantly better than those in the radical group with operative time (298.7±101.3) min, intraoperative blood loss (161.9±96.7) ml and postoperative hospital stay (9.9±4.0) d (all P<0.05). There were no significant difference in the postoperative complications and disease free survival rates between the two groups (both P>0.05). Conclusion:LC was safe and effective for treatment of T2a and lower stages of gallbladder cancer, and it could achieve a similar disease-free survival rate as LRC.
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Objective:To study and analyse the results of postoperative hemorrhage after laparoscopic pancreaticoduodenectomy (LPD).Methods:The clinical data of patients who underwent LPD from May 2011 to December 2019 at Hunan Provincial People's Hospital were retrospectively analyzed. The clinical characteristics of patients, onset time of postoperative hemorrhage, location of postoperative hemorrhage, postoperative biliary fistula, pancreatic fistula, infection and other short-term complications, reoperation and mortality rates were analyzed.Results:Of 356 patients who underwent LPD in this study, there were 200 males and 156 females, aged (58.0±10.5) years. The postoperative complication rate was 33.1% (118/356), the reoperation rate was 6.5% (23/356), and the mortality rate was 2.5% (9/356). The most common complications were postoperative hemorrhage [15.2% (54/356)], pancreatic fistula [14.6%(52/356)] and abdominal infection [13.8%(49/356)]. The onset time of postoperative hemorrhage was usually in the 1st - 14th day, and the highest rate of postoperative hemorrhage was 3.9% (14/356) on the first day after surgery. The postoperative hemorrhage rate then showed a downward trend, but increased again on the 7th day. The extraluminal hemorrhage locations were relatively widely distributed, and the incidence of gastrointestinal anastomotic hemorrhage in patients with intraluminal hemorrhage was the highest [67.9%(19/28)]. Of the 9 patients who died, 7 were related to postoperative bleeding.Conclusions:LPD resulted in a high incidence of complications. Postoperative hemorrhage was a complication that had the greatest impact on short-term recovery of patients. It was also an important cause of reoperation and death. In addition to postoperative bleeding caused by pancreatic fistula, gastrointestinal anastomotic bleeding was also clinically important.
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Objective:To explore the risk factors for overall complications after laparoscopic pancreaticoduodenectomy(LPD) and to establish postoperative pancreatic fistula prediction model for LPD.Methods:The clinical data of 176 patients undergoing LPD from Jan 2014 to Mar 2018 were retrospectively analyzed.Results:One died within 30 days. Five patients underwent reoperation. Seventy-three patients (41%) had complications including pancreatic fistula in 30 cases(17.0%), postoperative hemorrhage in 16 (9.1%); bile leakage in 10 (5.7%); abdominal infection in 6 (3.4%); wound infection in 4 (2.2%); pulmonary infection in 4 (2.2%); gastric emptying disorder in 3 (1.7%). Age, intraoperative blood loss, diabetes mellitus were risk factors for overall postoperative complications of LPD(all P<0.05); Age, male gender, pancreatic duct diameter, pancreas texture, lesion size were risk factors for pancreatic fistula after LPD(all P<0.05). Conclusions:Age, intraoperative blood loss, diabetes mellitus were risk factors for overall postoperative complications of LPD; Age, male gender, pancreatic duct diameter, pancreas texture, and lesion size were risk factors for pancreatic fistula after LPD.
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Objective To investigate the causes and countermeasures of reoperation following laparoscopic pancreatoduodenectomy.Methods The causes,approaches and outcome of reoperation were retrospectively analyzed in 10(4.0％,10/250) patients undergoing reoperations following pancreaticoduodenectomy with various complications in Hunan Provincial People's Hospital from April 2014 to April 2018.Results The causes of the 10 patients including intra-abdominal bleeding of seven cases (2 cases combined with pancreatic fistula,1 case with pancreatic and biliary fistula),1 patient with gastrointestinal anastomosis output perforation,1 patient with intra-abdominal abscess,and 1 case with postoperative pancreatitis.The time of reoperation was one day to 82 day after the first operation.The main methods of reoperation including suture and hemostasis,rebuilding the digestive tract,gastrostomy and enterostomy combined with abdominal cavity drainage.The mortality of reoperation following laparoscopic pancreatoduodenectomy was 20.0％ (2/10).Conclusions Intra-abdominal hemorrhage,pancreatic fistula and intra-abdominal abscess are the major causes of reoperation after laparoscopic pancreatoduodenectomy.Timely and decisive reoperation is an effective means to reduce postoperative morbidity and mortality after LPD.
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Objective@#To summarize our clinical experience and management of an anomalous proximal bile duct joining the cystic duct in laparoscopic cholecystectomy (LC).@*Methods@#A retrospective study was conducted on 8 patients who had an anomalous right anterior bile duct joining the cystic duct who were treated at the Hunan Provincial People's Hospital from March 2003 to January 2019.@*Results@#All the 8 patients were diagnosed to have gallstones cholecystitis on preoperative CT, MRI and abdominal ultrasound. There were no suggestions of an anomalous bile duct. A total of 6 patients underwent reoperation after LC due to abdominal pain and biliary peritonitis. These 6 patients were treated with drainage and T-tube insertion. In the other 2 patients, the anomalous bile duct opening which joined the cystic duct were detected during LC. There was one patient converted to open laparotomy with preservation of the cystic duct and underwent common bile duct T-tube drainage. The other patients continued with laparoscopic surgery. The cystic duct was partially resected with removal of gallbladder, followed by common bile duct drainage. The average follow-up period was 3.4 years and the results were satisfactory.@*Conclusions@#Biliary duct anomaly is the main cause of iatrogenic proximal bile duct injury during laparoscopic cholecystectomy. It is not uncommon to have the anomaly of insertion of right anterior segmental bile duct to the cystic duct. To avoid iatrogenic biliary tract injury, careful preoperative study of X-ray films, accurate identification of the intraoperative gallbladder triangle anatomical structures. Strict adherence to carry out the three-word procedure of " discrimination, cut, identify" will help to reduce the incidence of biliary tract complications in laparoscopic cholecystectomy.
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Objective@#To explore the new gene mutation and clinical manifestations of Caroli syndrome in 2 blood brother cases.@*Methods@#The clinical data of the 2 brothers with clinical diagnosis of Caroli syndrome were analyzed, and the related genes were detected by second-generation sequencing technology.@*Results@#The PKHD1 gene of both brothers had the mutation of c. 5059A>T(exon32). c. 4358(exon 32)delC shift mutation, neither of which has been reported in OMIM database.@*Conclusion@#After analysis, c. 4358(exon32) delC and c. 5059A>T(exon32) may be the new pathogenic mutation of this disease, with the same mutant genotype but completely different phenotype.
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Objectives@#To propose a novel clinical classification system of gallbladder cancer, and to investigate the differences of clinicopathological characteristics and prognosis based on patients who underwent radical resection with different types of gallbladder cancer.@*Methods@#The clinical data of 1 059 patients with gallbladder cancer underwent radical resection in 12 institutions in China from January 2013 to December 2017 were retrospectively collected and analyzed.There were 389 males and 670 females, aged (62.0±10.5)years(range:22-88 years).According to the location of tumor and the mode of invasion,the tumors were divided into peritoneal type, hepatic type, hepatic hilum type and mixed type, the surgical procedures were divided into regional radical resection and extended radical resection.The correlation between different types and T stage, N stage, vascular invasion, neural invasion, median survival time and surgical procedures were analyzed.Rates were compared by χ2 test, survival analysis was carried by Kaplan-Meier and Log-rank test.@*Results@#Regional radical resection was performed in 940 cases,including 81 cases in T1 stage,859 cases in T2-T4 stage,119 cases underwent extended radical resection;R0 resection was achieved in 990 cases(93.5%).The overall median survival time was 28 months.There were 81 patients in Tis-T1 stage and 978 patients in T2-T4 stage.The classification of gallbladder cancer in patients with T2-T4 stage: 345 cases(35.3%)of peritoneal type, 331 cases(33.8%) of hepatic type, 122 cases(12.5%) of hepatic hilum type and 180 cases(18.4%) of mixed type.T stage(χ2=288.60,P<0.01),N stage(χ2=68.10, P<0.01), vascular invasion(χ2=128.70, P<0.01)and neural invasion(χ2=54.30, P<0.01)were significantly correlated with the classification.The median survival time of peritoneal type,hepatic type,hepatic hilum type and mixed type was 48 months,21 months,16 months and 11 months,respectively(χ2=80.60,P<0.01).There was no significant difference in median survival time between regional radical resection and extended radical resection in the peritoneal type,hepatic type,hepatic hilum type and mixed type(all P>0.05).@*Conclusion@#With application of new clinical classification, different types of gallbladder cancer are proved to be correlated with TNM stage, malignant biological behavior and prognosis, which will facilitate us in preoperative evaluation,surgical planning and prognosis evaluation.
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Objective@#To summarized the experience in laparoscopic duodenum-preserving pancreatic head resection (LDPPHR).@*Methods@#The clinical data of four patients who underwent LDPPHR from February 2017 to June 2018 in Hunan Provincial People’s Hospital were retrospectively analyzed. The Clinical characteristics, operation time, intraoperative blood loss, biliary fistula rate, pancreatic fistula rate and follow-up data were analyzed.@*Results@#The four patients included one patient with a solid pseudopapillary tumor and three patients with a serous cystadenoma. Two patients underwent duodenum-preserving total pancreatic head resection, and two patients underwent duodenum-preserving subtotal pancreatic head resection. The operation time of the four patients was (525.8±121.8) minutes, and the blood loss (250.0±191.5) ml. Biliary duct drainage was carried out in 2 patients: one patient developed biochemical bile leakage, while another had no postoperative complication. The two patients without biliary drainage developed grade B pancreatic leakage, delayed bile leakage, abdominal bleeding and infection. All the three patients who developed postoperative complications were treated conservatively and they recovered well.@*Conclusions@#LDPPHR was designed to better preserve the integrity and function of digestive tract. However, the perioperative complications were high. This operation should only be carried out in large pancreatic centers. Routine biliary drainage is recommended to surgeons with little experience in this operation.
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Objective To summarized the experience in laparoscopic duodenum-preserving pancreatic head resection ( LDPPHR ) . Methods The clinical data of four patients who underwent LDPPHR from February 2017 to June 2018 in Hunan Provincial People' s Hospital were retrospectively analyzed. The Clinical characteristics, operation time, intraoperative blood loss, biliary fistula rate, pancreatic fistula rate and follow-up data were analyzed. Results The four patients included one patient with a solid pseudopapillary tumor and three patients with a serous cystadenoma. Two patients underwent duodenum-preserving total pancreatic head resection, and two patients underwent duodenum-preserving subtotal pancreatic head resection. The operation time of the four patients was (525. 8 ± 121. 8) minutes, and the blood loss (250. 0 ± 191. 5) ml. Biliary duct drainage was carried out in 2 patients: one patient developed biochemical bile leakage, while another had no postoperative complication. The two patients without biliary drainage developed grade B pancreatic leakage, delayed bile leakage, abdominal bleeding and infection. All the three patients who developed postoperative complications were treated conservatively and they recovered well. Conclusions LDPPHR was designed to better preserve the integrity and function of digestive tract. However, the perioperative complications were high. This operation should only be carried out in large pancreatic centers. Routine biliary drainage is recommended to surgeons with little experience in this operation.
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Objective To explore the new gene mutation and clinical manifestations of Caroli syndrome in 2 blood brother cases.Methods The clinical data of the 2 brothers with clinical diagnosis of Caroli syndrome were analyzed,and the related genes were detected by second-generation sequencing technology.Results The PKHD1 gene of both brothers had the mutation of c.5059A ＞ T (exon32).c.4358 (exon 32)delC shift mutation,neither of which has been reported in OMIM database.Conclusion After analysis,c.4358 (exon32) delC and c.5059A ＞ T(exon32) may be the new pathogenic mutation of this disease,with the same mutant genotype but completely different phenotype.
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Objective To study the coordination and function of a laparoscopic assistant in laparoscopic pancreaticoduodenectomy (LPD).Methods A retrospective analysis was conducted on 101 patients who underwent LPD at the Department of Hepatobiliary Surgery,Hunan Provincial People's Hospital,from January 2014 to March 2017.The study aimed to study the coordination and function of a laparoscopic assistant.Results LPD was successfully completed in all the 101 patients.There was no conversion to open surgery.The operation time was (326.0 ± 55.6) min,and the resection time was (174.4 ± 42.5) min.The digestive tract reconstruction time was (101.0 ± 21.4) min.The time of pancreaticojejunostomy was (40.5 ± 8.7) min.The time of gastrointestinal anastomosis was:(26.3 ± 5.5) min.The time of biliary anastomosis was (24.4 ± 6.5) min.The intraoperative bleeding was (175.6 ± 41.1) ml.Postoperative pathological data showed that 27 patients (26.7％) had distal common bile duct cancer,23 patients (22.8％)ampullary carcinoma,39 patients (38.6％) duodenal papillary carcinoma,and 12 patients (11.9％) pancreatic ductal adenocarcinoma.The tumor diameter was (2.3 ± 1.3) cm,and the number of resected lymph nodes was (16.7 ±4.2).The number of positive lymph nodes was 1.3 ± 1.1.The length of postoperative hospital stay was 14.8 (8 ～ 29) d.Twenty-three patients developed postoperative pancreatic fistula,including 17 patients (16.8％) with a biochemical fistula,5 patients (5.0％) with a grade B pancreatic fistula,and 1 patient (1.0％) with a grade C pancreatic fistula.There were 2 patients (3.0％) with bile leakage,7 patients (6.9％) with intra-abdominal bleeding,4 patients (4.0％) with delayed gastric emptying,6 patients (5.9％) with abdominal infection,3 patients (3.0％) with pulmonary infection,2 patients (2.0％)with intestinal obstruction,3 patients (3.0％) required a repeated operation,and 1 patient (1.0％) with death in hospital within 30 days after surgery.Conclusions The laparoscopic assistant should have the perspective of "one axis,two sides and four regions" in LPD,and warn the operator to ensure the safety and fluency of the operation by clearly exposing important blood vessels and organs when performing the Kocher incision and when dissecting the key parts such as the dangerous triangle of the uncinate process.During anastomosis,the laparoscopic assistant should appropriately adjust the distance of vision,clearly reveal the surgical field of the anastomotic area,and help the surgeon in improving the precision of the suture and the quality of the anastomosis.
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Lymph node metastasis is the important survival predictor in patients with distal cholangiocarcinoma.With the application of laparoscopic pancreaticoduodenectomy in radical resection of distal cholangiocarcinoma,it is of great clinical significance to explore lymphadenectomy in laparoscopic radical resection of distal cholangiocarcinoma.The American Joint Committee on Cancer (AJCC) Cancer Staging Manual (8th ed) has became the new global guideline for cancer diagnosis and treatment since January 2018,which provides a new recommendation for lymphadenectomy of distal cholangiocarcinoma.This review provides an overview of the clinical significance of total lymph node count and number of involved lymph nodes,"en-block" procedure in lymphadenectomy,membrane anatomy for lymphadenectomy,experience and skills in lymph node dissection,lymph node sorting after surgery,adjuvant therapy in the treatment of distal cholangiocarcinoma.
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Objective To investigate the clinical effects of laparoscopic pancreaticoduodenectomy (LPD) for distal cholangiocarcinoma.Methods The retrospective cross-sectional study was conducted.The clinicopathological data of 37 patients who underwent LPD for distal cholangiocarcinoma in the Hunan Provincial People's Hospital between January 2013 and November 2016 were collected.LPD for distal cholangiocarcinoma was performed using the "en-block" procedure.According to the principle of "one axis,two planes and four zones",anatomy used posterior approach,anterior approach and medial approach,lymph node dissection was performed from carotid sheath outside,and en bloc specimens were resected.Observation indicators:(1) surgical and postoperative recovery situations;(2) postoperative pathological examination;(3) follow-up and survival situations.Follow-up using outpatient examination was performed to detect the patients' recurrence-free survival up to November 2017.Measurement data with normal distribution were represented as (x)±s.The survival curve and rate were drawn and calculated by the Kaplan-Meier method.Results (1) Surgical and postoperative recovery situations:all the 37 patients underwent successful LPD,without conversion to open surgery and perioperative death.The operation time,volume of blood loss and case with intraoperative blood transfusion were (326 ± 55) minutes,(176± 39)mL and 1,respectively.The time to initial exsufflation and time for diet intake were respectively (4.5± 1.6)days and (5.3±2.7)days.Of 37 patients,14 had postoperative complications,including 8 with pancreatic fistula (6 with biochemical fistula and 2 with grade B pancreatic fistula),1 with biliary fistula,3 with postoperative bleeding (2 with intra-abdominal bleeding and 1 with gastrointestinal anastomosis bleeding),2 with delayed gastric emptying (grage A),2 with intra-abdominal infection and 2 with pulmonary infection;the same patients can merge multiple complications.Three patients were in Clavien-Dindo classification ≥ Ⅲ.One patient received reoperation and other patients were improved by symptomatic treatment.Duration of hospital stay of 37 patients was 13.5 days (range,8.0-33.0 days).Eight patients underwent adjuvant chemotherapy of 4-6 cycles by taking orally tegafur or gemcitabine with cisplatin.(2) Postoperative pathological examination:tumor diameter and pancreatic duct diameter of 37 patients were (2.1±1.1)cm and (2.5±1.2) mm,respectively.Of 37 patients,9,13 and 15 were respectively detected in high-differentiated,moderate-differentiated and lowdifferentiated adenocarcinoma.Surgical margins:35 patients received R0 resection and 2 received R1 resection.Number of lymph node dissected,cases with lymph node metastasis and number of positive lymph nodes were respectively 18.5±4.9,16 and 1.7± 1.4.Analysis of lymph node metastasis location showed that the positive rates in 8a,12,13,14 and 17 groups lymph nodes were respectively 5.4％ (2/37),18.9％ (7/37),21.6％ (8/37),8.1％ (3/37) and 10.8％ (4/37);Perineural invasion (PNI),lymphovascular invasion (LVI),pancreatic invasion and duodenal invasion were identified in 14,9,16 and 6 patients,respectively.TNM stage:stage 0,Ⅰ A,Ⅰ B,ⅡA and Ⅱ B were respectively detected in 1,3,5,12 and 16 patients.(3) Follow-up situation:of 37 patients,36 were followed up for 6-45 months,with a median time of 26 months.The median recurrence-free survival time,1-and 3-year recurrence-free survival rates were respectively 28 months,80.6％ and 42.2％.Conclusion LPD is safe and effective for distal cholangiocarcinoma,and "en-block" resection not only helps to optimize the process of LPD for distal cholangiocarcinoma,but also has a significant effect on R0 resection and lymph node dissection.
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Objective To investigate the clinical efficacies of free endoscopic nasobiliary drainage (ENBD) in primary duct closure (PDC) following laparoscopic common bile duct exploration (LCBDE) for choledocholithiasis.Methods The retrospective cohort study was conducted.The clinical data of 312 patients with extrahepatic bile duct stones accompanied with or without cholecystolithiasis who were admitted to the 11 medical centers [86 in the Affiliated Tongji Hospital,Tongji Medical College,Huazhong University of Science and Technology,62 in the Second Affiliated Hospital of Zhejiang University School of Medicine,44 in the West China Hospital of Sichuan University,29 in the First Affiliated Hospital of Xi'an Jiaotong University,27 in the First Hospital Affiliated to Army Medical University (Third Military Medical University),25 in the Hunan Provincial People's Hospital,17 in the Beijing Friendship Hospital of Capital Medical University,10 in the First Affiliated Hospital of Hainan Medical University,5 in the Henan Provincial People's Hospital,4 in the Beijing Tian Tan Hospital of Capital Medical University,3 in the First Affiliated Hospital of Fujian Medical University] from January 2011 to June 2017 were collected.All patients underwent LCBDE+PDC,and 81 and 231 patients with and without ENBD were respectively allocated into the ENBD group and PDC group.Observation indicators:(1) comparisons of operation situations;(2) comparisons of postoperative recovery;(3) comparisons of postoperative complications;(4) follow-up situations.Follow-up using outpatient examination and telephone interview was performed to detect the postoperative complications up to June 2017.Measurement data with normal distribution were represented as x±s.Comparison between groups was analyzed by the t test.Measurement data with skewed distribution were represented M [interquartile range (IQR)],and comparison between groups was analyzed by the nonparametic test.Comparisons of count data were analyzed using the chi-square test and Fisher exact probability.Results (1) Comparisons of operation situations:all the 312 patients underwent successful laparoscopic LCBDE + PDC,without conversion to open surgery,including postoperative death of 1 patient in the PDC group.The common bile duct diameter,cases using interrupted sutures,continuous sutures,absorbable threads and nonabsorbable threads were respectively (1.2±0.4)cm,106,125,195,36 in the PDC group and (1.1±0.5)cm,76,5,79,2 in the ENBD group,with statistically significant differences between groups (t =2.497,x2 =56.706,8.457,P＜0.05).The numbers of stones,stone diameter,cases with common bile duct wall (≤ 3 mm and ＞3 mm),normal and abnormal Oddi sphincter contraction function,volume of intraoperative blood loss and operation time were respectively 2.1±1.7,(1.1-±0.6)cm,148,83,226,5,20 mL (10-45 mL),(116± 49)minutes in the PDC group and 1.9±1.6,(1.0±0.6)cm,49,32,75,6,20 mL (15-30 mL),(113± 23)minutes in the ENBD group,with no statistically significant difference between groups (t =1.021,0.329,x2 =0.329,3.428,Z=1.147,t=0.521,P＞0.05).The further analysis:of 312 patients,cases and time using interrupted sutures and continuous sutures were respectively 182,130 and (133±.49) minutes,(103±34) minutes,with a statistically significant difference between groups (t =-6.605,P＜0.05).The volume of intraoperative blood loss and cases with postoperative complications using interrupted sutures and continuous sutures were respectively 20 mL (15-31 mL),21 and 20 mL (10-45 mL),18,with no statistically significant difference between groups (Z =-0.285,x2 =0.369,P＞ 0.05).Of 312 patients,cases,operation time,volume of intraoperative blood loss and postoperative complications using absorbable threads and non-absorbable threads were respectively 274,(116±44)minutes,20 mL (15-40 mL),33 and 38,(115±35) minutes,18 mL (10-26 mL),6,with no statistically significant difference between groups (Z =0.971,t =0.023,x2 =0.154,P＞ 0.05).(2) Comparisons of postoperative recovery:recovery time of gastrointestinal function,time of abdominal drainage-tube removal,using time of antibiotics and duration of hospital stay were respectively (2.0± 1.5) days,(4.0 ± 2.4) days,(4.0±2.8) days,(5.5±3.0) days in the PDC group and (4.0±1.9) days,(6.9±3.5) days,(10.0± 3.9) days,(11.1±3.7)days in the ENBD group,with statistically significant differences between groups (t =-9.507,-8.258,-15.103,-13.575,P＜0.05).The total expenses of hospital stay in the Affiliated Tongji Hospital,Tongji Medical College of Huazhong University of Science and Technology were respectively (5.1 ±0.6)× 104 yuan in the PDC group and (6.5-±0.5)× 104 yuan in the ENBD group,with a statistically significant difference between groups (t =-9.516,P＜0.05).(3) Comparisons of postoperative complications:incidence of complications in the PDC group was 14.29％ (33/231),including 16 with biliary fistula,11 with biliary tract infection,3 with wound infection,1 with biliary tract bleeding,1 with residual stones of common bile duct and 1 with death;incidence of complications in the ENBD group was 6.17％ (5/81),including 2 with biliary fistula,2 with biliary tract infection and 1 with biliary tract bleeding,showing no statistically significant difference between groups (x2 =3.151,P＞0.05).(4) Follow-up situations:of 312 patients,252 were followed up for 2-67 month,with a median time of 15 months,including 175 in the PDC group and 77 in the ENBD group.During the follow up,there was no occurrence of jaundice,cholangitis and pancreatitis,and stone recurrence and postoperative cholangiostenosis were not detected by abdominal color Doppler ultrasound or CT or magnetic resonanced cholangio-pancreatography.Conclusion On the basis of grasping operative indication strictly,ENBD in PDC following LCBDE for choledocholithiasis is safe and effective.
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Objective To summarize the experience in surgical management of bile duct injury. Methods The clinical data of 683 patients with bile duct injury who were admitted to the Hunan People's Hospital from August 1990 to December 2008 were retrospectively analyzed. Of all the patients, seven received hepatectomy +T tube drainage, two received liver repair + T tube drainage, four received external biliary drainage + hepatectomy,27 received liver repair or hepatectomy + silicone support, 233 received temporary portal triad clamping + gelatin sponge hemostasis, 72 received biliary repair + T tube drainage, 248 received hepatobiliary basin Roux-en-Y anastomosis, 22 received external biliary drainage, 61 received long arm T tube drainage, two received pancreaticoduodenectomy and five received hepatectomy + T tube drainage. The surgical outcomes were evaluated by analyzing the results of the follow-up. Results The surgical outcomes were ranked excellent, good and poor according to the condition of patients and the results of imaging examination. Six hundred and twelve patients were followed up for 8 months to 19 years, and the surgical outcomes were excellent in 337 patients (55.1%), good in 214 patients (35.0%) and poor in 61 patients ( 10.0% ). Conclusion The surgical outcome of bile duct injury could be satisfactory if the approach of the surgery is properly selected.