ABSTRACT
Hilar cholangiocarcinoma is a highly intractable malignancy, and most patients with this disease were diagnosed as a locally advanced stage at their initial presentation. Surgical resection remains as the only curative treatment for hilar cholangiocarcinoma. Hepatic surgeons focus on how to perform radical resection safely and effectively. For locally advanced hilar cholangio-carcinoma, aggressive surgical approach substantially increases the resectability of tumors which were initially regarded as unresectable. Hemihepatectomy or trisectionectomy combined with caudate lobectomy is the standard operation for radical resection of hilar cholangiocarcinoma, vascular resection and lymphadenectomy can be performed selectively. The safety and success of surgical approach is guaranteed by meticulous preoperative management such as preoperative biliary drainage and portal vein embolization, which prevent fatal postoperative complications. Multidisciplinary approach is required for the treatment of hilar cholangiocarcinoma. The combina-tion of aggressive surgical approach and adjuvant therapy remain a promising approach for further improving the resectability of tumors and the survival of patients.
ABSTRACT
Objective To investigate the application value of three-dimensional (3D) reconstruction virtual surgery planning in the surgical treatment of hilar cholangiocarcinoma.Methods The retrospective crosssectional study was conducted.The clinical data of 36 patients with hilar cholangiocarcinoma who were admitted to the First Affiliated Hospital of Fujian Medical University between January 2014 and September 2017 was collected.Before operation,images of 3D virtual surgery planning were respectively reconstructed and determined using IQQA-Liver imaging analysis system,and then precise resection of tumor was performed based on results of virtual surgical planning and intraoperative conditions.Observation indicators:(1) virtual surgical planning;(2) surgical and postoperative situations;(3) follow-up and survival.Follow-up using outpatient examination and telephone interview was performed to detect postoperative survival and tumor recurrence or metastasis up to November 2017.Measurement data with normal distribution were represented as (x)±s.Comparison between indicator of preoperative virtual surgical planning and surgical indicators was analyzed by the t test.The postoperative survival time was calculated by the Kaplan-Meier method.Results (1) Virtual surgical planning:36 patients accomplished 3D visualization reconstruction and virtual surgical planning.Three D visualization reconstruction clearly showed adjacent relationship between tumor size and surrounding vessels or bile duct space.Type Ⅱ,Ⅲ a,Ⅲb and Ⅳ of Bismuth-Corlette Classification were detected in 2,13,14 and 7 patients by 3D visualization system,respectively.The tumor volume,whole liver volume,predicted liver resection volume and remnant liver volume were respectively (76± 26) mL,(1 319± 306) mL,(588± 128) mL and (731± 269) mL.(2) Surgical and postoperative situations:of 36 patients,16,12,5 and 3 patients underwent left hemigepatectomy,right hemigepatectomy,extended left hemigepatectomy and extended right hemigepatectomy,respectively,and all of them were combined with caudate lobectomy of liver.Combined resection and reconstruction of hepatic artery,combined wedge resection and repair of the portal vein and combined end-to-end anastomosis after resection of the portal vein were detected in 1,2 and 1 patients,respectively.Operation time and volume of intraoperative blood loss of 36 patients were respectively (368± 134)minutes and (474±288)mL.Thirty-six patients with postoperative complications were cured by conservative treatment,including 3 with pulmonary infection,3 with intra-abdominal infection and 2 with intra-abdominal lymphatic fistula.Duration of hospital stay of 36 patients was (19±7) days.Type Ⅱ,Ⅲ a,Ⅲ b and Ⅳ of postoperative Bismuth-Corlette Classification were detected in 2,11,13 and 10 patients,respectively.Accuracy of tumor classification through 3D visualization reconstruction was 91.7％ (33/36).Actual liver resection volume of 36 patients was (551± 141)mL,and was not significantly different from predicted liver resection volume (t =1.148,P＞0.05).(3) Follow-up and survival:31 of 36 patients were followed up for 2-39 months after surgery,with a median time of 16 months.The postoperative median survival time was 13 months,and 9 patients had tumor recurrence or metastasis during the follow-up.Conclusion The 3D reconstruction virtual surgery planning can accurately complete the preoperative evaluation,meanwhile,it can also provide important reference for the surgical therapy of hilar cholangiocarcinoma.
ABSTRACT
Digital medicine underwent the conversion from "digital human" to digital medical technology and has been widely used in all aspects of clinical medicine in recent 10 years,especially in hilar cholangiocarcinoma (HCCA).It is difficult to accurately evaluate the longitudinal and vertical tumor invasion by preoperative conventional imaging assessment (CT,MRI,etc.) due to the complexity of this operation.Three-dimensional (3D) visualization can see more comprehensively,more clearly and more accurately on the basis of organs and lesions indicated by CT and MRI.Three-dimensional visualization digital medical technology can accurately,intuitively and stereoscopically display the situation of tumor invasion of the adjacent important vessels as well as the variation of vessels.It plays an important role in the aspects of preoperative evaluation,surgical planning,improving the success rate of operation and reducing complications for HCCA.It also transforms the past model of "crossing the river by feeling the stone" to now "crossing the river by watching the stone".Therefore,it is known as the paradigm of translational medicine.
ABSTRACT
Because of the special anatomical position of hilar cholangiocarcinoma and its characteristics of longitudinal and vertical invasion,it is difficult to obtain satisfactory effect by surgical resection.More and more researchers have realized that the treatment of the hilar cholangiocarcinoma should take biological characteristics of the tumor.Precise medicine using of frontier technologies and omics technologies such as proteomics and genomics,can accurately diagnose diseases at molecular level and may provide a new model for the treatment of hilar cholangiocarcinoma.The gene mutation rate of the hilar cholangiocarcinoma is higher,and the most common mutation genes are KRAS and TP53,following other genes such as CDKN2A,SMAD4,ERBB2,PTEN,APIK3CA,ARID1A,MLL3,ROBO2,RNF43,and PEG3,GNAS,etc.Such frequent,important functional mutations suggest that hilar cholangiocarcinoma may have potential therapeutic targets for molecular targeted drugs.However,due to the complex pathogenesis of the bile duct cancer,the clinical trials of most targeted drugs have not been able to achieve breakthrough progress.Surgical resection should still remain the dominant treatment.The appropriate extent of hepatectomy should be determined individually,and the minor resection is enough for most hilar cholangiocarcinoma.