Tratamiento quirúrgico del colangiocarcinoma extrahepático / Surgical Treatment of Extrahepatic Cholangiocarcinoma

Introducción: El colangiocarcinoma constituye la neoplasia de la vía biliar más frecuente, la cual es responsable de una alta morbimortalidad. Objetivo: Determinar la morbilidad y la mortalidad por colangiocarcinoma extrahepático en el Servicio de Cirugía del Hospital Universitario Manuel Ascunce Domenech. Métodos: Se realizó un estudio descriptivo, prospectivo y observacional de pacientes que ingresaron en el Servicio de Cirugía General con diagnóstico de colangiocarcinoma extrahepático entre septiembre de 2018 y enero del 2022. El universo estuvo conformado por 21 pacientes que cumplieron con los criterios de inclusión. Se utilizaron métodos estadísticos descriptivos y cálculos con valores porcentuales. Resultados: La mayor incidencia de los pacientes fueron del sexo masculino y blancos, con el 71,4 por ciento y el 85,7 por ciento respectivamente. Predominó el adenocarcinoma como variedad histológica con un 85,7 por ciento, así como el colangiocarcinoma proximal y la variante esclerosante de su clasificación. El 71,4 por ciento de los pacientes egresaron vivos y con una cirugía con finalidad curativa. Conclusiones: La mayoría de los pacientes fueron masculinos, de color blanco y de procedencia rural. Los hallazgos más frecuentes fueron la localización proximal y la variante esclerosante. A más de la mitad de los pacientes se les realizó procedimiento de Hess y Whipple con finalidad curativa. La fuga biliar, el adenocarcinoma como tipo histológico y el estado al egreso vivo prevaleció en todos los pacientes(AU)

Introduction: Cholangiocarcinoma is the most frequent biliary tract neoplasm responsible for high morbidity and mortality. Objective: To determine morbidity and mortality due to extrahepatic cholangiocarcinoma in the surgery service of Hospital Universitario Manuel Ascunce Domenech. Methods: A descriptive, prospective and observational study was carried out with patients admitted to the general surgery service with a diagnosis of extrahepatic cholangiocarcinoma between September 2018 and January 2022. The study universe consisted of 21 patients who met the inclusion criteria. Descriptive statistical methods and calculations with percentage values were used. Results: The highest incidence of patients were male and white-skinned, accounting for 71.4 percent and 85.7 percent, respectively. Adenocarcinoma predominated as histological variety, representing 85.7 percent, together with proximal cholangiocarcinoma and the sclerosing variant of its classification. 71.4 percent of the patients were discharged alive and after curative surgery. Conclusions: Most of the patients were male, white-skinned and from rural origin. The most frequent findings were a proximal location and the sclerosing variant. Over half the patients underwent Hess and Whipple procedure with curative purpose. Biliary leakage, adenocarcinoma as histologic type, and the condition of alive at discharge prevailed in all patients(AU)

Serum metabolomics study on benign liver lesions and hepatic malignancies by central carbon pathway metabolites / 药学实践杂志

Objective To screen potential metabolites and significantly altered metabolic pathways of liver lesions by central carbon pathway metabolites. Methods 32 healthy volunteers (HC), 23 patients with biliary cysts (CYST), 19 patients with biliary stones (Stone), 45 patients with hepatocellular carcinoma (HCC), and 50 patients with hilarcholangiocarcinoma (HCCA) were recruited. Their serum samples were collected for UPLC-QQQ-MS analysis and further MPP statistical analysis. Pattern recognition was further used to discovery the differences in metabolome between groups, and to explore the significantly altered metabolic pathway and possible pathogenic mechanism of liver diseases. Results A total of 15, 7, 7, and 3 metabolites and a total of 8, 4, 4, and 1 metabolic pathway that were significantly different in serum between CYST, Stone, HCC, HCCA and healthy controls were identified and enriched through serum metabolomics analysis, respectively. Conclusion According to the above identified differential metabolites and enriched metabolic pathway results, it is shown that liver lesions mainly involved in the energy metabolism and amino acid metabolism & transport, in addition, inositol phosphate metabolism were significantly changed both in CYST, Stone, HCC and HCCA.

The efficacy of the combination of radiofrequency ablation and endoscopic metal stent in the treatment of 44 patients with unresectable cholangiocarcinoma / 中华消化杂志

Objective:To explore the efficacy of the combination of radiofrequency ablation(RFA) and endoscopic metal stent in the treatment of patients with unresectable cholangiocarcinoma.Methods:From January 3, 2012 to June 30, 2019, at the Department of Endoscopic of the Third Affiliated Hospital of Naval Medical University, the clinical data of 44 patients with unresectable cholangiocarcinoma who were treated by the combination of RFA and endoscopic metal stent were retrospectively collected, which included age, gender, location of cholangiocarcinoma(hilar cholangiocarcinoma and distal cholangiocarcinoma), etc. Postoperative evaluation was conducted based on the follow-up, including clinical success rate, postoperative complication rate, time of stent patency and overall survival time (OS). The Kaplan-Meier method and log-rank test were used to analyze the difference of OS between patients with hilar cholangiocarcinoma and distal cholangiocarcinoma. Mann-Whitney U test was used for statistical analysis. Results:The age of the 44 patients with cholangiocarcinoma was (70.3±11.6) years old, with 20 males (45.5%). There were 22 patients (50.0%) with hilar cholangiocarcinoma and 22 patients (50.0%) with distal cholangiocarcinoma. The clinical success rate of 44 patients was 93.2%(41/44). A total of 5 patients(11.4%) had postoperative complications, which were all improved by appropriate treatment. The median time of follow-up of the 44 patient was 9.2 months(ranged from 3.1 to 57.6 months), the median time of stent patency was 7.0 months (ranged from 5.8 to 8.2 months). Thirty-two patients (72.7%) died during the follow-up, and the median OS was 10.9 months(ranged from 9.0 to 12.8 months). The median OS of patients with hilar cholangiocarcinoma was 7.8 months(ranged from 4.6 to 11.0 months) and that of patients with distal cholangiocarcinoma was 12.5 months(ranged from 5.7 to 19.4 months), and there was no statistically significant difference( P>0.05). Conclusion:RFA combined with endoscopic metal stent is safe and effective in the treatment of patients with unresectable cholangiocarcinoma.

Comparison of clinical efficacy between laparoscopic and open radical resection of hilar cholangiocarcinoma / 中华普通外科杂志

Objective:To evaluate the efficacy of total laparoscopic surgery vs. open surgery for hilar cholangiocarcinoma. Methods:The clinical data of 45 patients undergoing laparoscopic radical resection of hilar cholangiocarcinoma and 42 patients by open surgery from Mar 2017 to Mar 2021 were retrospectively analyzed.Results:There was no significant difference in demographics, Bismuth classification and excision extension between the two groups (all P>0.05). The laparoscopic surgery used longer time ( t=-1.366, P<0.05). The intraoperative blood loss, number of lymph node dissection and postoperative hospital stay favored laparoscopic method( t=0.043, t=0.026, t=-1.852, P<0.05). R 0 radical resection rate，postoperative complications were also in favor of laparoscopic surgery ( χ2=3.216, χ2=2.566, all P<0.05). There was no significant difference in postoperative pathology and in hospital expenses (all P>0.05). The 1- and 3-year survival rate of the laparoscopic group was superior (all P<0.05). Conclusions:In spite of longer operational time，patients in laparoscopic hilar cholangiocarcinoma radical resection group have shorter postoperative in hospital stay and longer postoperative survival time.

Clinical effect of liver transplantation on hilar cholangiocarcinoma / 国际外科学杂志

Hilar cholangiocarcinoma(HCCA) is a relatively rare disease with great invasiveness. Traditionally, radical resection has been considered the cornerstone of its treatment. However, only less than 40% of cases can be resected. Surgical resection is complex, risky and difficult to achieve R0 resection and may lead to various postoperative complications. In recent years, the combination of neoadjuvant chemoradiotherapy with liver transplantation(LT) has provided an option for patients with unresectable diseases, and strict patient screening criteria has allowed LT protocol to achieve promising therapeutic effects in PCCA. In order to provide an intellectual background for the choice of LT protocol in the clinical treatment of HCCA patients, this article will review the application standards of LT in HCCA, summarize the application status of LT in patients with different resectability, compare the prognostic effect of resection and LT, and introduce the advantages of LT in the treatment of HCCA associated with primary sclerosing cholangitis(PSC).

Advances in diagnosis and treatment of hilar cholangiocarcinoma / 国际外科学杂志

Hilar cholangiocarcinoma is the most common extrahepatic malignant tumor in clinic, accounting for about 50%-60% of bile duct tumors. Currently, radical surgical resection is regarded as the best treatment for early hepatic hilar cholangiocarcinoma, but, it’s early lesions have no obvious clinical symptoms. Most patients are already in the advanced stage of the disease when they are admitted to hospital. The surgical resection rate is low, and the 5-year survival rate does not exceed 25%. Locally advanced hepatic hilar cholangiocarcinoma are treated with neoadjuvant chemoradiation therapy followed by surgery, it can prolong survival time of the patient. At the same time, the recurrence rate after surgery can reach 50%-70%, and the cancer easily invades microvessels, lymphatic vessels, peripheral nerves and liver, which is one of the most challenging problems in the field of biliary surgery. Therefore, early diagnosis, perioperative management, adequate and accurate preoperative staging assessment, intraoperative standardized resection, postoperative adjuvant therapy of hilar cholangiocarcinoma, it is of great significance to improve the rate of radical surgical resection and prolong the survival time of patients.

Diagnosis and treatment of hilar cholangiocarcinoma / 国际外科学杂志

Hilar cholangiocarcinoma(HCCA) is a hotpot and a difficult point in the field of hepatobiliary surgery. HCCA is the most common type of cholangiocarcinoma and is characterized by atypical early clinical manifestations, rapid progression and poor prognosis. There is no specific marker for HCCA and its preoperative diagnosis and evaluation mainly relies on imaging examination. Surgical treatment is still the main treatment, but most patients have lost the opportunity of surgical resection by the time of treatment. In recent years, a large number of studies have been conducted on the diagnosis and treatment of HCCA at home and abroad, and the efficacy of HCCA has been improved. Perioperative management, including the selection of preoperative drainage and perioperative chemoradiotherapy and others, improved postoperative survival. Among them, the application of preoperative radiotherapy and chemotherapy in the field of liver transplantation has achieved quite good results. Targeted therapy and immunotherapy have provided new treatment methods for HCCA. This paper reviews the diagnosis and multimodal treatment of HCCA.

Discussion on enhanced recovery after surgery of hilar cholangiocarcinoma after operation / 国际外科学杂志

The concept of enhanced recovery after surgery has been widely accepted and applied by clinical medical staff, and has made good progress in the field of hepatobiliary pancreatic surgery in recent years. Hilar cholangiocarcinoma is one of the more complicated operations in hepatobiliary pancreatic surgery. The traditional perioperative management mode is not conducive to the early rehabilitation of patients, and the relative operation risk and the probability of postoperative complications are high. In order to promote the application of enhanced recovery after surgery in patients with hilar cholangiocarcinoma after operation, this paper systematically introduces the measures and experience of accelerated rehabilitation after operation of hilar cholangiocarcinoma from the aspects of postoperative multimodal analgesia, early activity, diet, drainage tube management, discharge and follow-up, based on the relevant literature and combined with own work experience. These measures can reduce the postoperative complications of patients with hilar cholangiocarcinoma and promote their early rehabilitation.

Clinical effect of different plastic biliary stent indwelling methods on managing obstructive jaundice in unresectable hilar cholangiocarcinoma / 中华消化内镜杂志

Objective:To compare the clinical effect of three indwelling methods of plastic biliary stent on relieving obstructive jaundice caused by unresectable hilar cholangiocarcinoma.Methods:A retrospective study was performed on data of 61 patients with obstructive jaundice caused by unresectable hilar cholangiocarcinoma from April 2014 to December 2020 in Cancer Hospital, Chinese Academy of Medical Sciences. Plastic biliary stent placement was used to relieve jaundice, including 18 cases of intragastric indwelling at the end of biliary stent, 31 cases of duodenal papilla indwelling at the end of biliary stent, and 12 cases of horizontal portion of duodenum indwelling at the end of biliary stent. Incidence of fever within 2 weeks, perioperative mortality, 90-day obstruction rate, and median stent patency period were followed up and the results were analyzed.Results:The incidence of fever within 2 weeks of the three groups were significantly different [66.7% (12/18), 58.1% (18/31) and 16.7% (2/12), χ2=7.30, P=0.026]. There were no statistically differences in the perioperative mortality [0 (0/16), 3.2% (1/31) and 0 (0/10), χ2=1.09, P=1.000], 90-day obstruction rate [52.9% (9/17), 48.3% (14/29) and 40.0% (4/10), χ2=1.91, P=0.589], or median stent patency period (66.0 d, 91.5 d and 94.0 d, Z=4.96, P=0.084) among three groups. Conclusion:Patients with biliary plastic stents with ends placed at the horizontal portion of the duodenum show lower incidence of fever within two weeks after implantation, and similar median stent patency period, 90-day obstruction rate and perioperative mortality compared with intragastric indwelling and duodenal papilla indwelling groups. Therefore, biliary plastic stents with ends placed at the horizontal portion of the duodenum should be recommended as the preferred procedure.

Advances in therapies for unresectable hilar cholangiocarcinoma / 国际外科学杂志

Hilar cholangiocarcinoma is the most common malignant tumor of the biliary tract. Surgical resection is the only radical treatment method at present. However, due to its insidious onset and high degree of malignancy, it is usually in the middle or late stage when first diagnosed, most patients have lost the chance of radical surgery and have a very poor prognosis. In recent years, with the continuous progress of medical technology, the optimization and different combination of treatment methods such as chemotherapy, radiotherapy, biliary drainage, photodynamic therapy, nano-knife ablation, intraluminal radiofrequency ablation, liver transplantation, targeted therapy and immunotherapy has significantly improved the prognosis of patients with unresectable hilar cholangiocarcinoma. Chemotherapy, radiotherapy, photodynamic therapy and intraluminal radiofrequency ablation on the basis of biliary drainage can prolong the time of biliary patency. Nano-knife ablation can maximize the elimination of tumor cells on the premise of protecting the structure of the ducts. Liver transplantation offers a possibly curative opportunity for patients with unresectable hilar cholangiocarcinoma. Targeted therapy and immunotherapy provide a breakthrough point for precision therapy and individualized therapy. Based on the literature and the clinical experience of our team, this paper discussed the therapeutic approaches for unresectable hilar cholangiocarcinoma and encountered problems, so as to provide reference for clinical treatment and related research.

Elementos etiopatogénicos y diagnósticos del tumor de Klatskin o colangiocarcinoma hiliar / Etiopathogenetic and Diagnostic Elements of Klatskin's Tumor or Hilar Cholangiocarcinoma

RESUMEN Introducción: El colangiocarcinoma hiliar es un tumor poco frecuente, de mal pronóstico y elevada mortalidad; con un curso silente hasta la fase avanzada de la enfermedad. Objetivo: Describir la etiopatogenia y el diagnóstico por imágenes del colangiocarcinoma hiliar. Métodos: De las bases datos PubMed, SciELO y Latindex, se seleccionaron artículos publicados desde 2005 hasta mayo de 2020, relacionados con el colangiocarcinoma hiliar/ perihiliar: etiopatogenia, diagnóstico clínico, estudios de laboratorio y estudios imaginológicos. Desarrollo: Ictericia obstructiva (90 por ciento), pérdida de peso (60 - 75 por ciento) y dolor abdominal (40 por ciento) constituyen los síntomas de presentación más frecuentes. Los factores predisponentes, genéticos y ambientales, desencadenan respuesta inflamatoria crónica que lesionan el DNA de las células ductales provocando diferenciación celular anómala con el desarrollo de colangiocarcinoma. Las infecciones parasitarias y enfermedad litiásica de las vías biliares, en países orientales y la colangitis esclerosante primaria, en occidente, constituyen los principales factores predisponentes. El trípode para el diagnóstico lo conforman: la ecografía, tomografía axial computarizada y la resonancia magnética nuclear. Conclusiones: El colangiocarcinoma hiliar es una causa de colestasis poco frecuente en la población general, con un predominio sexta década de la vida y en el sexo masculino, siendo la ictericia el motivo de consulta de estos pacientes, donde la ecografía y la tomografía axial computarizada juegan el papel más importante en su diagnóstico y donde la clasificación de Bismuth-Corlette y TNM son esenciales para la correcta planificación del tratamiento(AU)

ABSTRACT Introduction: Hilar cholangiocarcinoma is a rare tumor, with poor prognosis and high mortality, with a silent course until the advanced stage of the disease. Objective: To describe the etiopathogenesis and imaging diagnosis of hilar cholangiocarcinoma. Methods: From the PubMed, SciELO and Latindex databases, articles published from 2005 to May 2020 were selected, insofar they were related to hilar/perihilar cholangiocarcinoma: etiopathogenesis, clinical diagnosis, laboratory studies and imaging studies. Development: Obstructive jaundice (90 percent), weight loss (60-75 percent) and abdominal pain (40 percent) are the most frequent presenting symptoms. Predisposing factors, either genetic and environmental, trigger chronic inflammatory responses that damage the DNA of ductal cells, causing abnormal cell differentiation with the development of cholangiocarcinoma. Parasitic infections and bile duct stone disease in Eastern countries and primary sclerosing cholangitis in the West are the main predisposing factors. The tripod for diagnosis is made up of ultrasound, computerized axial tomography and nuclear magnetic resonance. Conclusions: Hilar cholangiocarcinoma is a rare cause of cholestasis among the general population, with a predominance during the sixth decade of life and among males, jaundice being the reason for consultation of these patients, in which ultrasound and computerized axial tomography play the most important elements for its diagnosis, while the TNM and Bismuth-Corlette classification are essential for the correct planning of treatment(AU)

Tumor de Klatskin (colangiocarcinoma hiliar) su morbimortalidad en un servicio de cirugía / Klatskin's tumor (hilar cholangiocarcinoma) his morbi-mortality in a surgery service

RESUMEN Introducción: El tumor de Klatskin es el colangiocarcinoma, más frecuente de la vía biliar siendo responsable de una alta morbimortalidad en los servicios de cirugía. Objetivo: Determinar la morbilidad y la mortalidad por tumor de Klatskin en el Servicio de Cirugía del Hospital Universitario "Manuel Ascunce Domenech". Métodos: Se realizó un estudio descriptivo, prospectivo y observacional de pacientes que ingresaron en el Servicio de Cirugía General con diagnóstico de tumor de Klatskin, entre septiembre de 2018 y enero del 2020. El universo estuvo conformado por 7 pacientes que cumplieron con los criterios de inclusión. Se utilizaron métodos estadísticos descriptivos y cálculos con valores porcentuales. Resultados: La mayor incidencia de los pacientes fue de sexo masculino y de raza blanca, con un 71,4 por ciento y 85,7 por ciento respectivamente. Predominó adenocarcinoma como variedad histológica con un 85,7 por ciento. Tipo II de la clasificación topográfica, el procedimiento de Hess como operación realizada y la bilirragia como complicación prevaleció con un 42,8 por ciento respectivamente. El 85,7 por ciento de los pacientes egresaron vivos y con una cirugía con finalidad curativa. Conclusiones: La mayoría de los pacientes eran masculinos y de color blanco. Más de la mitad de los pacientes fueron clasificados como tipo I y II según clasificación de Bismuth-Corlette. El proceder de Hess, el adenocarcinoma como forma histológica y el estado del egreso vivo predominó en el total de pacientes(AU)

ABSTRACT Introduction: Klatskin's tumor is cholangiocarcinoma, most frequent to occur in the bile duct, being responsible for high morbidity and mortality in surgery departments. Objective: To determine the morbidity and mortality of Klatskin's tumor at the surgery service of Manuel Ascunce Domenech University Hospital. Methods: We carried out a descriptive, prospective and observational study of patients admitted to the general surgery service with a diagnosis of Klatskin's tumor, between September 2018 and January 2020. The study population consisted of seven patients who met the inclusion criteria. Descriptive statistical methods and calculations with percentage values were used. Results: The highest incidence was represented male and white patients, accounting for 71.4 percent and 85.7 percent, respectively. Adenocarcinoma predominated as a histological variety, accounting for 85.7 percent. There was prevalence of type II of topographic classification, the Hess procedure as the performed operation, and bilirrhagia as a complication, accounting for 42.8 percent, respectively. 85.7 percent of the patients were discharged and received surgery for curative purposes. Conclusions: Most of the patients were male and white. More than half of the patients were classified as types I and II, according to the Bismuth-Corlette classification. The Hess procedure, adenocarcinoma as a histological form, and discharge predominated in all patients(AU)

Analysis of treatment methods and prognostic factors in 354 cases of hilar cholangiocarcinoma: A cohort study

Context: Better management strategies are needed to improve the survival of patients with hilar cholangiocarcinoma (HCCA). Aims: This study was designed to examine the effects of different treatment methods on survival and prognostic factors in HCCA. Settings and Design: We retrospectively analyzed the clinical data of 354 patients with HCCA treated at our institution from 2003 to 2013. Materials and Methods: Patients were divided into three groups according to the treatment: the radical resection group, the nonradical resection group, and the biliary drainage-only group. Statistical Analysis Used: The Kaplan–Meier method was used to compare survival rates between the groups, and the independent prognostic factors were assessed using the Cox proportional hazards model. Results: There were 110 patients in the radical resection group, 93 patients in the nonradical resection group, and 151 patients in the biliary drainage-only group, and they showed differing survival rates: 1-year survival rates of 70.7%, 49.5%, and 31.3%; 2-year survival rates of 62.9%, 24.7%, and 9.0%; 3-year survival rates of 34.7%, 4.0%, and 0%; and median survival of 21.7 months, 13.6 months, and 8.7 months, respectively. The radical resection group had the longest overall survival (P< 0.001). Treatment method, albumin (ALB), total bilirubin (TBIL), postoperative pathological T-stage, and distant metastasis were identified as independent prognostic indicators of survival. Conclusions: Radical resection significantly increases survival in patients with HCCA, and an increase in ALB and a decrease in TBIL improve the prognosis of patients with HCCA

Application of 3D visualization and 3D printing in individualized precision surgery for Bismuth-Corlette type Ⅲ and Ⅳ hilar cholangiocarcinoma / 南方医科大学学报

OBJECTIVE@#To explore the application of 3D visualization and 3D printing in individualized precision surgical treatment of Bismuth-Corlette type Ⅲ and Ⅳ hilar cholangiocarcinoma.@*METHODS@#We retrospectively analyzed the data of 10 patients with hilar cholangiocarcinoma undergoing surgeries under the guidance of 3D visualization and 3D printing in the Department of Hepatobiliary Surgery, Zhujiang Hospital from May 2016 to March 2019. Thin-section CT data of the patients were collected for 3D reconstruction and 3D printing, and the 3D printed models were used for observing the 3D relationship of tumor with the intrahepatic bile duct, hepatic artery, portal vein and hepatic vein system and for performing preoperative simulated surgery and surgical planning. The 3D printed models were subsequently used for real-time intraoperative navigation to guide surgeries in the operating room.@*RESULTS@#3D visualization models were successfully reconstructed for all the 10 patients and printed into 3D models. The 3D visualization types in Bismuth-Corlette classification included type Ⅲa (4 cases), type Ⅲb (4 cases), and type Ⅳ (2 cases); 4 patients showed portal vein variation, 3 had hepatic artery variation, and 2 had both portal vein and hepatic artery variations. Two patients were found to have trifurcation type of portal vein variation, one had "I-shaped" variation, and one showed the absence of the right anterior branch of the portal vein; 3 patients had hepatic artery variations with the left hepatic artery originating from the left gastric artery (1 case) and the right hepatic artery originating from the superior mesenteric artery (2 cases). Four patients with type Ⅲb underwent left hepatectomy; 4 with type Ⅲa received right hepatectomy; 1 patient with of type Ⅳ received peripheral hepatic resection and another underwent left hepatectomy. The results of preoperative 3D reconstruction, 3D printed model and preoperative planning were consistent with the intraoperative findings. The operative time was 452±75.12 min with a mean intraoperative blood loss of 356±62.35 mL and a mean hospital stay of 15 ± 4.61 days in these cases. One patient had bile leakage and 3 patients had pleural effusion postoperatively, and they were discharged after drainage and medications. No liver failure or death occurred in these cases perioperatively.@*CONCLUSIONS@#3D visualization and 3D printing can facilitate accurate preoperative assessment, surgical planning and surgical procedure optimization for Bismuth-Corlette type Ⅲ and Ⅳ hilar cholangiocarcinoma to improve surgical safety and reduce surgical risks especially in cases of intrahepatic vascular variations.

Current status of intraoperative lymph node dissection for hilar cholangiocarcinoma / 中华外科杂志

Lymphatic metastasis is an independent prognostic factor for surgical prognosis of patients with hilar cholangiocarcinoma (HCCA) . Lymph node dissection is an important content of radical resection of HCCA, but there are still many disputes about the definition, scope and dissection numbers of intraoperative lymph node dissection. There has been a lot of research being done at home and abroad in recent years focusing on the above problems, and novel insights have also been proposed.According to the current view, routine skeletal dissection of lymph nodes in the duodenum ligament of liver, the common hepatic artery, and the posterior part of the duodenum of pancreas head (the 12th group, the 8th group and the 13th group) during operation can bring significant survival benefits to patients with HCCA. However, it is still not clear whether the dissection of peripheral lymph node in truncus coeliacus, aorta abdominalis, and venae cava inferior during operation can bring survival benefits to HCCA patients during operation. Properly increasing the number of lymph node dissection during operation can not only significantly improve the survival prognosis of the patients of HCCA with stage N0, but also improve the detection rate of positive lymph nodes and obtain enough information for the stage of the disease. However, the excessive increase of total lymph node count is not only difficult to achieve in practice, but may also lead to an increase in the incidence of postoperative complications. Therefore, further investigation is needed in intraoperative lymph node dissection of HCCA.

Analysis of prognostic factors in the surgical treatment of hilar cholangiocarcinoma / 中华消化外科杂志

Objective To analyze the prognostic factors in the surgical treatment of hilar cholangiocarcinoma.Methods The retrospective case-control study was conducted.The clinicopathological data of 93 patients [61 males and 32 females,age (64±8)years with the range of 43-84 years] with hilar cholangiocarcinoma who underwent surgical treatments in the General Hospital of the Northern Theater from January 2010 to December 2017 were collected.According to preoperative different staging and intraoperative exploration of hilar cholangiocarcinoma,corresponding operations were performed.Observation indicators:(1) surgical treatment situations;(2) tumor typing,staging and degree of differentiation:① tumor typing and staging,② degree of tumor differentiation;(3) follow-up situations;(4) analysis of prognostic factors:① univariate analysis,② multivariate analysis;(5) subgroup analysis.Follow-up using outpatient examination and telephone interview was performed to detect survival time and survival rate of patients up to December 31,2017.Kaplan-Meier method was used to calculate survival time and survival rate and to draw survival curves.Survival situations were analyzed byLog-rank test.The univariate analysis and multivariate analysis were performed using the Log-rank test and COX proportional hazard model respectively.Results (1) Surgical treatment situations:93 patients underwent surgical treatments,including 51 undergoing radical resection,23 undergoing palliative resection,16 undergoing internal biliary drainage or external drainage,3 undergoing abdominal laparotomy and intraoperative biopsy.(2) Tumor typing,staging and degree of differentiation.① Tumor typing and staging:of the 93 patients with hilar cholangiocarcinoma,Bismuth-Corlette type Ⅰ,Ⅱ,Ⅲa,Ⅲb and Ⅳ were detected in 26,22,9,18 and 18 patients.TNM stage Ⅰ,Ⅱ,Ⅲ and Ⅳ were detected in 7,34,22 and 30 patients,Mayo Clinic stage 1,2,3,4 were detected in 20,19,51 and 3 patients.② Degree of tumor differentiation:results of pathological examination showed 16 of 93 patients with highly differentiated adenocarcinoma,35 with moderately differentiated adenocarcinoma,37 with poorly differentiated adenocarcinoma,4 with mucinous adenocarcinoma and 1 with papillary adenocarcinoma.(3) Follow-up situations:93 patients were followed up for 6-36 months,with a median time of 24 months.The survival time of 93 patients was (21.4±2.1)months and the 1-,2-,3-year overall survival rates were 62.2％,34.9％ and 17.1％,respectively.(4) Analysis of prognostic factors:① results of univariate analysis showed that preoperative level of TBil,preoperative level of CA19-9,preoperative level of CA24-2,surgical methods,lymph node metastasis,vascular invasion,TNM staging,Mayo Clinic staging,degree of tumor differentiation were related factors affecting prognosis of patients with hilar cholangiocarcinoma (x2 =6.321,7.357,6.590,22.088,11.173,22.914,23.326,25.966,39.512,P＜0.05).② Results of multivariate analysis showed that preoperative level of TBil,preoperative level of CA 19-9,surgical methods,vascular invasion and degree of tumor differentiation were independent factors affecting prognosis of patients with hilar cholangiocarcinoma (odds ratio=1.002,1.001,2.690,2.626,0.420,95％ confidence interval:1.000-1.004,1.000-1.002,1.474-4.910,1.333-5.134,0.206-0.854,P＜0.05).(5) Subgroup analysis:of the 93 patients,the survival time of 51 undergoing radical resection was (28.0±2.3)months,and the 1-,2-,3-year survival rates were 75.3％,57.5％ and 25.7％,respectively;the survival time of 23 undergoing palliative resection was (14.0±2.4)months and the 1-,2-,3-year survival rates were 60.9％,13.0％,0,respectively;the survival time of 19 undergoing biliary drainage or open exploration was (8.0±2.9) months and the 1-,2-,3-year survival rates were 31.6％,7.9％,0,respectively.The survival of patients undergoing radical resection was significantly different from that of patients undergoing palliative resection,biliary drainage and open laparotomy respectively (x2 =10.939,18.343,P＜0.05).The survival of patients undergoing palliative resection was not statistically significant different from that of patients undergoing biliary drainage or exploration group (x2 =2.803,P＞0.05).Of the 35 patients with vascular invasion,the overall survival time was (7.0±2.0)months and 1-,2-,3-year survival rates were 14.5％,7.3％,0 respectively in 18 with portal vein invasion only,(10.0± 2.1)months and 37.5％,18.8％,and 18.8％ respectively in 8 with hepatic artery invasion,showing no statistically significant difference between the two groups (x2 =0.905,P＞0.05).Conclusions Preoperative level of TBil,preoperative level of CA19-9,surgical procedures,vascular invasion and degree of tumor differentiation are independent prognostic factors for patients with hilar cholangiocarcinoma.Radical resection can prolong the survival time of patients compared with other surgical treatments.

Diagnostic staging laparoscopy in gallbladder carcinoma and hilar cholangiocarcinoma: a meta-analysis / 中华肝胆外科杂志

Objective To analyze the impact of diagnostic staging laparoscopy in gallbladder carcinoma and hilar cholangiocarcinoma.Methods The Medline,Embase,Web of Science,Cochrane library and Google Scholar were searched for literature on staging laparoscopy (SL) in gallbladder carcinoma and hilar cholangiocarcinoma.The sensitivity,specificity and diagnostic accuracy of SL were evaluated.Results Eight studies were included in the meta-analysis.During laparoscopy,unresectable disease was found in 316 of 1 062 patients (29.8％),of whom 32.4％ were patients with suspected hilar cholangiocarcinoma (HC) and 27.6％ were patients with suspected gall-bladder cancer (GBC).The sensitivities were 0.556 (95％ CI:0.495-0.616) for patients with HC and 0.642 (95％ CI:0.579-0.701) for patients with GBC.The pooled specificity for SL was 100％ (95％ CI:0.993-1.000) for all the studies.Conclusion For patients with gallbladder cancer or hilar cholangiocarcinoma,SL combined with intraoperative ultrasound improved the accuracy of diagnosis and avoided unnecessary laparotomy.

Laparoscopic radical resection of hilar cholangiocarcinoma: a report of 32 patients / 中华肝胆外科杂志

Objective To analyze the clinical outcomes and surgical procedures of 32 patients who underwent laparoscopic radical resection of hilar cholangiocarcinoma.Methods From January 2013 to July 2018,32 patients who were diagnosed to have hilar cholangiocarcinoma underwent total laparoscopic treatment in Second Hospital of Hebei Medical University.The clinical data of these patients were recorded,including the general data,Bismuth types,AJCC types,postoperative complications,pathological findings,and follow-up results.Results This study included 20 males and 12 females with a mean age of 60.9±8.8 years and a body mass index of 22.6±3.2 kg/m2.According to the preoperative imaging studies,the Bismuth types Ⅰ,Ⅱ,Ⅲa,Ⅲb,and Ⅳ were found in 12,2,3,4 and 11 patients,respectively.Laparoscopic radical resection of hilar cholangiocarcinoma and bilioenteric anastomosis was performed in 12 patients,with radical resection and external bile drainage in 6 patients,extended hemihepatectomy with caudate lobectomy in 6 patients and concomitant portal vein resection in 2 patients.The mean operative time was 365.6± 121.9min and the median intraoperative blood loss was 300 (75,400) ml.Intraoperative red cell and plasma transfusion were 0-15 U and 400(0,625)ml,respectively.According to the Clavien-Dindo complication classification system,5 of 32 (15.6％) patients developed type Ⅱ morbidity.The postoperative pathological findings revealed bile duct adenocarcinoma in 30 patients and mucinous adenocarcinoma in 2 patients.The median size of cancer was 3.0 (1.0,3.5) cm.According to the 8th AJCC staging system,stage Ⅰ,Ⅱ,Ⅲ,and Ⅳ were found in 6,13,11,and 2 patients,respectively.A negative resection margin was achieved in 24 of 32 patients (75％).Up to August 6,30 of 32 patients (93.8％) were followed up and the overall 1-,2-,and 3-year survival rates for the patients who underwent laparoscopic radical resection for hilar cholangiocarcinoma were 80.0％,53.0％,and 53.3％.The median survival time was 21.8 months.Conclusion Total laparoscopic surgery for hilar cholangiocarcinoma was safe and feasible if performed by an experienced surgeon after accurate preoperative evaluation.

Treatment of hilar cholangiocarcinoma in the era of precision surgery / 中华消化外科杂志

Hilar cholangiocarcinoma (HCCa) is a biliary malignancy that seriously affects the survival of patients.Radical resection is the only cure method for patients to achieve long-term survival.However,due to the low rate of radical resection,its prognosis is poor.In this article,surgical treatment strategies of HCCa in the precision surgery era,3D image evaluation in the curative resection,surgical procedure decision and the preservation of liver parenchyma in the hepatic resection are discussed combined with the research progress at home and abroad.

The new classifications of biliary tract diseases based on actual anatomy / 中华外科杂志

In order to facilitate the treatment strategies for biliary tract injury, hilar cholangiocarcinoma, bile duct tumor thrombus, cholangiocellular carcinoma and bile duct cystic dilatation, many classifications have been made, even more than 10 types for one disease. Each type is represented by numbers or English alphabet, which are not only confusing but also difficult to remember. The Academician Mengchao Wu divided the liver into five sections and four segments base on its anatomy, this classification is very direct and visual, thus had been using till now. In order to overcome those complicated problems, it is considered to develop a new classification based on actual anatomic location similar to that for liver cancer, which is easy to remember and to directly determine the treatment strategy. All kinds of classifications have their own characteristics and advantages and disadvantages. This practical classifications avoid the complexity and may be useful for clinicians.