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Objective To investigate clinical efficacy and prognostic factors of hilar cholangiocarcinoma.Methods The retrospective case-control study was conducted.The clinicopathological data of 322 patients with hilar cholangiocarcinoma who were admitted to the Xiangya Hospital of Central South University between December 2005 and November 2015 were collected.Preoperative staging and classification of tumor and treatment planning were carried out according to the results of laboratory and imaging examinations.Observation indexes:(1) clinical features and results of assisted examinations;(2) treatments and results of pathological examination;(3) followup and survival;(4) prognostic factors analysis:gender,age,preoperative highest total bilirubin (TBil),preoperative carcinoembryonic antigen (CEA),preoperative CA19-9,preoperative CA242,preoperative CA125,treatment methods and TNM staging.The follow-up of outpatient examination and telephone interview was perfornmed to detect patients' survival up to November 2016.Survival curve was drawn using the Kaplan-Meier method.Survival and univariate analyses were done using the Log-rank test,and multivariate analysis was done using the Cox proportional hazard model.Results (1) Clinical features and results of assisted examinations:among the 322 patients,there were 301 patients with a chief complaint of jaundice.Of the 322 patients,the preoperative highest levels of TBil,DBil,ALT and AST in 322 patients were 3.9-785.2 μmol/L,1.6-410.2 μ mol/L,14.8-484.5 U/L and 21.4-539.8 U/L,respectively.Levels of ALP and GGT in 272 patients were 93.8-1 890.0 U/L and 2.0-1 832.8 U/L,respectively.Seventy-seven of 292 patients had an elevated CEA level,272 of 298 patients had an elevated CA19-9 level,153 of 260 patients had an elevated CA242 level and 86 of 260 patients had an elevated CA125 level.According to Bismuth-Corlette type,24 patients were detected in type Ⅰ,115 in type Ⅱ,55 in type Ⅲa,63 in type Ⅲb and 65 in type Ⅳ.(2) Treatments and results of pathological examination:Of the 322 patients,104 patients underwent radical resection,including 79 with hilar bile duct resection (9 combined with vascular resection and reconstruction) and 25 with extended hepatic lobectomy (16 combined with caudate lobectomy),and 218 patients underwent palliative treatments,including 134 with external biliary drainage and 84 with internal biliary drainage.Five patients were dead in the perioperative period,of which 2 died of acute liver failure,1 died of systemic infection and multiple organ failure,1 died of acute renal failure and 1 died of acute suppurative cholangitis,septic shock and disseminated intravascular coagulation.Of 263 patients receiving pathological examination,adenocarcinoma was detected in 253 patients (12 with high-differentiated adenocarcinoma,85 with moderate-differentiated adenocarcinoma,33 with low-differentiated adenocarcinoma and 123 with indefinite differentiation),mucinous adenocarcinoma in 5 patients,cholangiocarcinoma in 3 patients and neuroendocrine carcinoma in 2 patients.TNM staging of 322 patients:stage Ⅰ was detected in 8 patients,stage Ⅱ in 53 patients,stage Ⅲ in 132 patients,stage Ⅳ in 96 patients and indefinite stage in 33 patients.(3) Follow up and survival:among the 322 patients,296 were followed up for 12-132 months,with a median follow-up time of 65 months,including 94 with radical resection and 202 with palliative treatments.Among the 296 patients,the median survival time and 1-,3-,5-year survival rates were 10 months,47.1％,20.2％ and 9.5％,respectively.0f296 patients with follow-up,median survival time and 1-,3-,5-year survival rates were 31 months,84.0％,46.2％,25.0％ in 94 patients receiving radical resection and 7 months,29.9％,8.1％ and 2.3％ in 202 patients receiving palliative treatment,respectively,with a statistically significant difference between the 2 groups (x2=78.777,P＜ 0.05).Among the 94 patients receiving follow-up and radical resection,the median survival time and 1-,3-,5-year survival rates were 31 months,82.1％,45.1％,25.7％ in 73 patients undergoing hilar bile duct resection and 35 months,90.5％,49.8％,22.1％ in 21 patients undergoing hepatic lobectomy,respectively,with no statistically significant difference (x2=0.186,P＞0.05).Among the 73 patients undergoing hilar bile duct resection,median survival time and 1-,3-,5-year survival rates were 16 months,57.1％,0,0 in 7 patients combined with vascular resection and reconstruction and 34 months,84.6％,49.5％,27.5％ in 66 patients undergoing simplex hilar bile duct resection,respectively,showing a statistically significant difference (x2 =11.977,P＜ 0.05).(4) Prognostic factors analysis:results of univariate analysis showed that preoperative highest TBil,preoperative CEA,preoperative CA242,preoperative CA125,treatment methods and TNM staging were related factors affecting prognosis of patients with hilar cholangiocarcinoma (x2=25.009,18.671,9.359,33.628,94.729,77.136,P＜0.05).Multivariate analysis showed that preoperative highest TBil ≥ 342.0 μmol/L,preoperative CEA ≥ 5.00 μg/L,palliative treatments,TNM stage Ⅲ and Ⅳ were the independent risk factors affecting the poor prognosis of patients with hilar cholangiocarcinoma (HR =2.270,2.147,3.166,2.351,95％ confidence interval:1.587-3.247,1.446-3.188,2.117-4.734,1.489-3.712,P＜0.05).Conclusions Prognosis of hilar cholangiocarcinoma is still unsatisfactory.The R0 resection is the key in radical surgery.Preoperative highest TBil≥342.0 μmol/L,preoperative CEA ≥ 5.00 μg/L,palliative treatments,TNM stage Ⅲ-Ⅳ are independent risk factors affecting the poor prognosis of patients with hilar cholangiocarcinoma.
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Objective To systematically evaluate the safety and effectiveness of combined portal vein resection and reconstruction in the resection of hilar cholangiocarcinoma.Methods Literatures were researched using Cochrane Library,PubMed,Embase,China Biology Medicine disc,China National Knowledge Infrastructure,Wanfang database,VIP database from January 31,2006 to January 31,2016 with the key words including “hilar cholangiocarcinoma”“Klatskin tumor”“Bile duct neoplasm”“Vascular resection”“portal vein resection”“肝门部胆管癌”“血管切除”“门静脉切除”.The clinical studies of resection of hilar cholangiocarcinoma with portal vein resection and construction and without vascular resection and construction were received and enrolled.Two reviewers independently screened literatures,extracted data and assessed the risk of bias.Patients who underwent resection of hilar cholangiocarcinoma combined with portal vein resection and reconstruction were allocated into the portal vein resection group and patients who didn't undergo vascular resection were allocated into the no vascular resection group.Analysis indicators included (1) results of literature retrieval;(2) results of Meta-analysis:① incidence of postoperative complications (hepatic failure,biliary fistula,intra-abdominal hemorrhage),② postoperative mortality,③ patients' prognosis,④ related indicators of postoperative pathology (lymph node metastasis rate,moderate-and low-differentiated rate,nerve invasion rate,negative rate of resection margin).The heterogeneity of the studies was analyzed using the I2 test.The hazard ratio (HR) and 95％ confidence interval (CI) were used for assessing the prognostic indicators.The incidence of complications,mortality and pathological indicators were evaluated by the odds ratio (OR) and 95％ CI.Results (1) Results of literature retrieval:13 retrospective studies were eurolled in the meta-analysis,and the total sample size was 1 668 cases including 437 in the portal vein resection group and 1 231 in the no vascular resection group.(2) Results of Meta-analysis:① incidence of postoperative complications was respectively 39.86％ in the portal vein resection group and 35.27％ in the no vascular resection group,with no statistically significant difference between the 2 groups (OR =1.12,95％ CI:0.82-1.53,P ＞0.05).The results of subgroup analysis showed that hepatic failure,biliary fistula and intra-abdominal hemorrhage were postoperative main complications,and the incidences were 17.09％,8.79％,6.25％ in the portal vein resection group and 10.62％,9.69％,2.51％ in the no vascular resection group,respectively,with no statistically significant difference between the 2 groups (OR =0.48,1.13,0.82,95％ CI:0.23-1.02,0.45-2.83,0.21-3.12,P ＞ 0.05).② Postoperative mortality was respectively 5.38％ in the portal vein resection group and 3.88％ in the no vascular resection group,with no statistically significant difference between the 2 groups (OR =1.16,95％ CI:0.62-2.14,P ＞ 0.05).③ There was statistically significant difference in patients' prognosis between the 2 groups (HR =1.81,95％ CI:1.52-2.16,P ＜ 0.05).④ The related indicators of postoperative pathology:lymph node metastasis rate,moderate-and low-differentiated rate and negative rate of resection margin were 41.55％,76.42％,63.74％ in the portal vein resection group and 33.42％,66.75％,64.29％ in the no vascular resection group,respectively,with no statistically significant difference between the 2 groups (OR =1.45,1.59,0.67,95％ CI:0.95-2.21,0.97-2.61,0.37-1.20,P ＞ 0.05).The nerve invasion rate was 83.47％ in the portal vein resection group and 64.90％ in the no vascular resection group,with a statistically significant difference between the 2 groups (OR =2.61,95 ％ CI:1.45-4.70,P ＜ 0.05).Conclusion Combined portal vein resection and reconstruction is safe and feasible in the treatment of hilar cholangiocarcinoma,and the prognosis of patients with portal vein invasion is worse than that without portal vein invasion.
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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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Objective To investigate the surgical method and clinical efficacy of hilar cholangio carcinoma in Bismuth type Ⅳ.Methods The retrospective descriptive study was adopted.The clinical data of 1 patient with hilar cholangiocarcinoma in Bismuth type Ⅳ who was admitted to the Renji Hospital affiliated to Shanghai Jiaotong University in October 2014 were collected.The patient had complaint about right upper abdominal pain for half month.Enhanced CT scan showed soft-tissue mass at hepatic hilum.After accurate assessment,the patient underwent radical resection of hilar cholangiocarcinoma + right hemihepatectomy + perihilar resection + right caudate hepatectomy + Roux-en-Y hepaticojejunostomy.The operation time,volume of intraoperative blood loss,results of pathological examination,postoperative complications,time of drainage tube removal,discharge time and follow-up were observed.The follow-up was performed to detect the life quality and tumor recurrence by outpatient examination and telephone interview up to July 2015.Results The patient received successful radical resection of hilar cholangiocarcinoma + right hemihepatectomy + perihilar resection + right caudate hepatectomy + Roux-en-Y hepaticojejunostomy.Operation time and volume of intraoperative blood loss were 480 minutes and 300 mL,respectively.The result of pathological examination showed that the size of hilar bile duct was 4 cm× 3 cm × 2 cm and poor-differentiated adenocarcinoma infiltrated through bile duct into liver tissues and right branch of portal vein.Two lymph nodes in the 8th group,1 in the 12a group and 3 in the 12p group were positive by detection,showing the metastasis of cancer cells.The resection margins of liver and bile ducts were negative,achieving a R0 resection.The patient had a removal of negative pressure drainage tube at postoperative day 7 and discharged from hospital at postoperative day 12,with a good recovery and without the complications of biliary fistula,abdominal infection and hepatic failure.During the 9-month follow-up,there was a good life quality and no tumor recurrence.Conclusion The radical resection rate of Bismuth type Ⅳ tumor can be increased by accurate preoperative evaluation,rational surgical approach,individualized surgical planning and precise intraoperative procedures.
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The management of hilar cholangiocarcinoma was challenging to the surgeons due to difficult operations and low resection rate.Recently,a new mode of multidisciplinary team (MDT) is applied to the diagnosis and treatment of hilar cholangiocarcinoma,which leads to significant changes and development of the diagnosis and treatment for hilar cholangiocarcinoma.In this article,the authors first introduced the recent application of MDT treatment for hilar cholangiocarcinoma on diagnostic methods,staging systems,evaluation for resectability,radical resection,application of liver transplantation and other systematic therapies.Considering the complexity of hilar cholangiocarcinoma,a surgery-centered MDT for hilar cholangiocarcinoma is important and should be promoted.
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Objective To investigate the efficacy of different radical surgical procedures for the treatment of hilar cholangiocarcinoma.Methods The clinical data of 207 patients with hilar cholangiocarcinoma who were treated at the Southwest Hospital from June 2007 to June 2012 were retrospectively analyzed.Local resection or hemihepatectomy combined with caudate lobectomy was applied to patients with Bismuth type Ⅰ hilar cholangiocarcinoma; dumbbell type radical resection was applied to patients with Bismuth type Ⅱ hilar cholangiocarcinoma or some patients with type Ⅲ a,Ⅲ b and Ⅳ hilar cholangiocarcinoma; hemihepatectomy or extended hemihepatectomy combined with caudate lobectomy was applied to patients with Bismuth type Ⅲ a,Ⅲ b and Ⅳ hilar cholangiocarcinoma.The patients were followed up every 3 months postoperatively till December 2012.All data were analyzed using the chi-square test or Fisher exact probability test,the survival curve was drawn by Kaplan-Meier method,and the survival was analyzed using the Log-rank test.Results Of the 207 patients,124 received radical resection,including 14 received local resection,23 received dumbbell type resection,87 received lobectomy + caudate lobectomy,49 received palliative resection; 34 received biliary drainage.Four patients died perioperatively.The incidences of complications of dumbbell type radical resection,left hemihepatectomy + caudate lobectomy,right hemihepatectomy + caudate lobectomy were 21.7％ (5/23),46.6％ (27/58) and 48.3％ (14/29),respectively.The incidence of complications after dumbbell type radical resection was significantly lower than left hemihepatectomy + caudate lobectomy and right hemihepatectomy + caudate lobectomy (x2 =4.42,3.90,P ＜ 0.05).One hundred and seventy patients were followed up.The median survival time of the 112 patients who received radical radical resection was 26.5 months,and the 1-,3-,5-year survival rates were 75.9％ (85/112),42.9％ (24/56) and 28.9％ (11/38),respectively.The median survival time of the 38 patients who received palliative resection was 8.5 months,and the 1-,3-year survival rates were 31.6％ (12/38) and 0.The survival time of 20 patients who received biliary drainage was 4.0 months,and the l-year survival rate was 0.The survival rate of patients who received radical resection was significantly higher than those who received palliative resection (x2=65.32,P ＜ 0.05).There was a significant difference in the survival rate between patients who received surgical treatment and those who received biliary drainage (x2=99.97,P ＜ 0.05).Of the 112 patients who received radical resection,the median survival time of 10 patients who received local resection of tumor was 47.0 months,the 1-year survival rate was 10/10,and 4 patients survived at the end of the follow-up; the median survival time of 23 patients who received dumbbell type radical resection was 32.0 months,and the 1-,3-year survival rates were 95.7％ (22/23) and 7/15,and the survival time of 6 patients was longer than 5 years; the median survival time of 54 patients who received left hemihepatectomy or extended left hemihepatectomy + caudate lobectomy was 27.6 months,and the 1-,3-year survival rates were 42.1％ (24/57) and 38.7％ (12/32),and the survival time of 9 patients was longer than 5 years,3 patients survived at the end of the follow-up ; the median survival time of 25 patients who received right hemihepatectomy or extended right hemihepatectomy + caudate lobectomy was 28.3 months,and the 1-,3-year survival rates were 45.8％ (11/24) and 6/15,and the survival time of 6 patients was longer than 5 years,2 patients survived at the end of follow-up.The median survival time of 35 patients (patients with Bismuth type Ⅰ,Ⅱ hilar cholangiocarcinoma and Bismuth Ⅲ a and Ⅲ b hilar cholangiocarcinoma which did not invade the secondary bile duct) who received hemihepatectomy + caudate lobectomy was 32.0 months,and the 1-,3-,5-year survival rates were 91.4％ (32/35),45.8％ (11/24) and 5/16,which were not different from the survival rate of patients who received dumbbell type radical resection (x2 =0.17,P ＞ 0.05).The 5-year survival rate of patients with lymph node metastasis was 4/19,which was significantly lower than 30.4％ (7/23) of patients without lymph node metastasis (x2 =23.40,P ＜ 0.05).Conclusion Joint lobectomy and standardized lymph node dissection could help to improve the efficacy of surgical treatment for patients with hilar cholangiocarcinoma.
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Objective To investigate the value of modified T staging system in the diagnosis and treatment of hilar cholangiocarcinoma (HCCA).Methods The clinical data of 95 patients with HCCA who were admitted to the Memorial Sun Yat-Sen Hospital from December 1995 to January 2010 were retrospectively analyzed.Based on the results of imaging examination,preoperative staging was determined according the modified T staging system.The prognosis of the patients in difference T stages were compared.The data were analyzed by using the chi-square test and Fisher exact test.The survival curve was drawn by Kaplan-Meier method and the survival rate was compared by using the Log-rank test.Results The diagnostic rates of ultrasound + magnetic resonance cholangiopancreatography (MRCP),ultrasound + computed tomography (CT) or spiral CT were 93％ (37/40) and 66％ (23/35),respectively.The diagnostic rates of ultrasound + CT or spiral CT and endoscopic retrograde cholangiopancreatography (ERCP),ultrasound + CT or spiral CT and MRCP were 14/15 and 15/15,respectively.Of the 95 patients,44 received operation (including 28 cases of radical resection and 16 cases of palliative resection),16 received exploratory laparotomy,and 35 received simple internal or external drainage.For patients in T1,T2 and T3 stages,the resection rates were 71％ (30/42),50％ (12/24) and 7％ (2/29),respectively,with significant differences (x2 =30.182,P ＜0.05).The negative rates of the resection margins of patients in T1 and T2 stages were 77％ (23/30) and 5/12,respectively,2 patients in T3 stage were found with tumor residuals at the resection margin.There was a significant difference in the radical resection rate among patients in different T stages (x2 =8.204,P ＜ 0.05).Of the 44 patients who received surgical treatment,30 (68％) received concomitant partial hepatectomy.The ratios of patients in T1 and T2 stages who received concomitant partial hepatectomy were 70％ (21/30) and 9/12,respectively,with no significant difference (x2 =0.101,P ＞ 0.05).Fourteen (32％) patients received tumor resection.The incidences of complications and perioperative mortalities were 53％ (16/30) and 10％ (3/30) for patients who received concomitant partial hepatectomy,and 5/14 and 1/14 for patients who received tumor resection,with no significant differences between the 2 groups (x2 =1.188,0.094,P ＞ 0.05).The median survival time of patients who received concomitant partial hepatectomy was 29 months,which was significantly longer than 19 months of patients who received tumor resection (x2 =11.317,P ＜0.05).Eighty-six patients were followed up,and the median time of follow up was 15.6 months (range,3-70 months).The 1-year cumulative survival rates of patients in T1,T2 and T3 stages were 73.8％,58.0％ and 9.2％,respectively,and the 3-year cumulative survival rates of patients in T1,T2 and T3 stages were 33.5％,12.1％ and 0,respectively.The median survival time of patients in T1,T2 and T3 stages were 24,16 and 7 months,respectively.The prognosis of patients was getting poor as the increase of the T stages (x2 =37.07,P ＜ 0.05).Conclusions The modified T-staging system is beneficial to preoperative evaluation of patients with HCCA.Concomitant partial hepatectomy could improve the radical resection rate and prolong the median survival time of HCCA patients.