Protocol for liver transplantation in hilar cholangiocarcinoma / Protocolo de transplante hepático para colangiocarcinoma hilar

ABSTRACT Background: Hilar cholangiocarcinoma represents more than half of all cholangiocarcinoma cases, having poor prognosis and presenting a median overall survival after diagnosis of 12-24 months. In patients who have unresectable tumors with a better prognosis, the proposal to perform liver transplantation emerged for expanding the possibility of free margins by performing total hepatectomy. Aim: To provide a Brazilian protocol for liver transplantation in patients with hilar cholangiocarcinoma. Method: The protocol was carried out by two Brazilian institutions which perform a large volume of resections and liver transplantations, based on the study carried out at the Mayo Clinic. The elaboration of the protocol was conducted in four stages. Result: A protocol proposal for this disease is presented, which needs to be validated for clinical use. Conclusion: The development of a liver transplantation protocol for cholangiocarcinoma aims not only to standardize the treatment, but also enable a better assessment of the surgical results in the future.

RESUMO Racional: O colangiocarcinoma hilar representa mais da metade de todos os casos de colangiocarcinoma; tem prognóstico reservado e sobrevida global mediana de 12- 24 meses após o diagnóstico. A proposta de realizar transplante hepático surgiu para ampliar a possibilidade de margens livres através de hepatectomia total nos portadores de tumoresirressecáveis com melhor prognóstico. Objetivo: Apresentar protocolo brasileiro para realização de transplante hepático em pacientes com colangiocarcinoma hilar. Método: O protocolo foi realizado por duas instituições com grande volume de ressecções e transplantes hepáticos no Brasil, baseado no trabalho realizado pela MayoClinic. A elaboração foi dividida em quatro etapas. Resultado: É apresentada proposta de protocolo para esta doença a ser validada na aplicação clínica. Conclusão: Foi possível elaborar protocolo de transplante hepático para colangiocarcinoma a fim de uniformizar o tratamento e melhor avaliar os resultados cirúrgicos.

Biodegradable biliary stents: a new approach for the management of hepaticojejunostomy strictures following bile duct injury. prospective study / Stent biliar biodegradável: uma nova abordagem para as estenoses hepaticojejunais após lesão do ducto biliar. estudo prospectivo

ABSTRACT Background: Once a biliary injury has occurred, repair is done by a hepaticojejunostomy. The most common procedure is to perform a dilatation with balloon with a success of 70 %. Success rates range using biodegradable stents is from 85% to 95%. Biodegradable biliary stents should change the treatment of this complication. Aim: To investigate the use of biodegradable stents in a group of patients with hepaticojejunonostomy strictures. Methods: In a prospective study 16 biodegradable stents were placed in 13 patients with hepaticojejunostomy strictures secondary to bile duct repair of a biliary surgical injury. Average age was 38.7 years (23-67), nine were female and four male. All cases had a percutaneous drainage before at the time of biodegradable stent placement. Results: In one case, temporary haemobilia was present requiring blood transfusion. In another, pain after stent placement required intravenous medication. In the other 11 patients, hospital discharge was the next morning following stent placement. During the patient´s follow-up, none presented symptoms during the first nine months. One patient presented significant alkaline phosphatase elevation and stricture recurrence was confirmed. One case had recurrence of cholangitis 11 months after the stent placement. 84.6% continued asymptomatic with a mean follow-up of 20 months. Conclusion: The placement of biodegradable stents is a safe and feasible technique. Was not observed strictures caused by the stent or its degradation. It could substitute balloon dilation in strictures of hepaticojejunostomy.

RESUMO Racional: Uma vez que lesão biliar ocorreu, o reparo é feito por hepaticojejunostomia. O procedimento mais comum é efetuar dilatação com balão com sucesso de 70%. As taxas de sucesso utilizando stents biodegradáveis ​​é de 85% a 95%. Stents biliares biodegradáveis ​​devem mudar o tratamento desta complicação. Objetivo: Investigar o uso de stents biodegradáveis em um grupo de pacientes com estenose hepaticojejunal Métodos: Em estudo prospectivo 16 stents biodegradáveis ​​foram colocados em 13 pacientes com estenose de hepaticojejunostomia secundárias usados para reparação do ductos biliares de lesão cirúrgica. A média de idade foi de 38,7 anos (23-67), nove pacientes eram homens e quatro mulheres. Todos os casos tiveram drenagem percutânea antes do momento da colocação de stent biodegradável. Resultados: Em um caso, haemobilia temporária estava presente com necessidade de transfusão de sangue. Em outro, dor após a colocação do stent necessitou de medicação intravenosa. Nos outros 11 pacientes, alta hospitalar foi na manhã seguinte após o procedimento. Durante o seguimento, nenhum apresentou sintomas durante os primeiros nove meses. Um paciente apresentou significativa elevação da fosfatase alcalina por recidiva da estenose. Um caso teve recorrência de colangite 11 meses após a colocação do stent. Continuaram assintomáticos 84,6% com média de acompanhamento de 20 meses. Conclusão: A colocação de stents biodegradáveis ​​é técnica segura e viável. Não foram observadas restrições causadas pelo stent ou pela sua degradação. Stent pode substituir dilatação com balão na estenose de hepaticojejunostomia.

Intraductal malignant tumors in the liver mimicking cholangiocarcinoma: Imaging features for differential diagnosis

No abstract available.

Endoscopic drainage in patients with inoperable hilar cholangiocarcinoma

Hilar cholangiocarcinoma has an extremely poor prognosis and is usually diagnosed at an advanced stage. Palliative management plays an important role in the treatment of patients with inoperable hilar cholangiocarcinoma. Surgical, percutaneous, and endoscopic biliary drainage are three modalities available to resolve obstructive jaundice. Plastic stents were widely used in the past; however, self-expanding metal stents (SEMS) have become popular recently due to their long patency and reduced risk of side branch obstruction, and SEMS are now the accepted treatment of choice for hilar cholangiocarcinoma. Bilateral drainage provides more normal and physiological biliary flow through the biliary ductal system than that of unilateral drainage. Unilateral drainage was preferred until recently because of its technical simplicity. But, with advancements in technology, bilateral drainage now achieves a high success rate and is the preferred treatment modality in many centers. However, the choice of unilateral or bilateral drainage is still controversial, and more studies are needed. This review focuses on the endoscopic method and discusses stent materials and types of procedures for patients with a hilar cholangiocarcinoma.

Risk Factors for Long-term Outcomes after Initial Treatment in Hepatolithiasis

Hepatobiliary complications, such as stone recurrence, recurrent cholangitis, liver abscess, secondary biliary cirrhosis, and cholangiocarcinoma may occur after treatment for hepatolithiasis. However, few previous studies have addressed the risk factors and long-term outcomes after initial treatment. Eighty-five patients with newly diagnosed hepatolithiasis, actively treated for hepatolithiasis, constituted the cohort of this retrospective study. Patients were treated by hepatectomy or nonoperative percutaneous transhepatic cholangioscopic lithotomy. Long-term complications, such as recurrent cholangitis, liver abscess, secondary biliary cirrhosis, and cholangiocarcinoma, and their relationships with clinical parameters were analyzed. The mean follow-up period was 57.4 months. The overall hepatobiliary complication rate after the treatment was 17.6%. Multivariate analysis of suspected risk factors showed that complications were associated with age (HR, 1.046; CI, 1.006-1.089), bile duct stricture (HR, 4.894; CI, 1.295-18.495), and residual stones (HR, 3.482; CI, 1.214-9.981). In conclusion, several long-term hepatobiliary complications occur after hepatolithiasis treatment, and regular observation is necessary in patients with concomitant biliary stricture or residual stones.

Percutaneous endoscopic gastrostomy/jejunostomy combined with percutaneous transhepatic biliary drainage in treating malignant biliary obstruction

To investigate the safety and efficacy of percutaneous endoscopic gastrostomy/jejunostomy [PEG/PEJ] combined with percutaneous transhepatic biliary drainage [PTCD] in treating malignant biliary obstruction. Nine patients [6 males and 3 females, average age 71.3 +/- 5.5 years] with complete obstruction of the biliary tract were treated with PEG/PEJ after PTCD. The PEG/PEJ and PTCD tubes were linked outside of the abdominal wall to direct the externally drained bile back to the jejunum through the PEG/PEJ intestinal tube. Clinical symptoms and liver function were assessed following the treatment. The operations were successfully completed in the 9 patients within 40 min [average 35 +/- 2.9 min]. Clinical symptoms such as jaundice, abdominal distension, stomachache and diarrhea appeared but improved within 7 days of the operation. Serum levels of bilirubin, aspartate aminotransferase and alanine aminotransferase were reduced [p < 0.01] 4 weeks following the treatment. There were no procedural complications. Combined PEG/PEJ and PTCD appeared to be safe and effective in the management of malignant biliary obstruction. Further, larger-scale studies will be needed to verify findings of this report

Major hepatic resection for hilar cholangiocarcinoma without preoperative biliary drainage.

Hilar cholangiocarcinoma is a rare cancer in western countries but very high incidence in the northeast of Thailand. The only chance to cure is surgical resection. Preoperative biliary drainage (PBD) for improving liver function to decrease perioperative morbidity and mortality is claimed to be beneficial. To determine whether liver resection with hilar resection is a safe procedure in obstructive jaundice patients caused by hilar cholangiocarcinoma, the records of 30 consecutive patients undergoing surgery between May 1999 and May 2002 at Srinagarind hospital, Khon Kaen University, were retrospectively analyzed. Two patients died during hospitalization, an operative mortality of 6.7%. Survival was 33% at 1 year, 12% at 2 years,10% at 3 years and 6.7% at 4 years. In our experience, it is safe in most patients with obstructive jaundice due to hilar cholangiocarcinoma to perform liver resection without preoperative biliary drainage (PBD).

Las colangioyeyunoanastomosis centrales y periféricas en el tratamiento de las estenosis altas de las vías biliares: experiencia personal de 164 casos / The central and peripheral cholangiojejunoanastomoses in the treatment of high strictures of the bile ducts: personal experience of 164 cases

Se presenta la experiencia del autor en diferentes técnicas quirúrgicas de colangioyeyunostomías y resecciones hepáticas asociadas a nivel del tercio proximal de la convergencia biliar entre 1988 y el 2004. Análisis de datos obtenidos de la experiencia personal llevada prospectivamente por el autor, en colangioyeyunostomías realizadas a nivel del tercio proximal del hepático común y en la convergencia, entre 1988 y el 2004, referidos al mismo a cuatro diferentes Instituciones: Servicio de Cirugía II del Hospital Ildemaro Salas (IVSS), Servicio de Cirugía Digestiva del Hospital Oncológico "Padre Machado", Servicio de Cirugía III del Hospital "Domingo Luciani" (IVSS) y al Instituto de Clínicas y Urología Tamanaco. Se excluyeron pacientes con estenosis bajas. Se analizaron 164 casos. 64,4 por ciento de las cirugías se hicieron por lesiones intraoperatorias ocurridas durante colecistectomías. El 33,3 por ciento se debieron a enfermedad maligna. 154 (93.9 por ciento) fueron centrales o hiliares y 10 (6,09 por ciento) fueron periféricas. Se efectuaron 32 resecciones hépáticas, 23 (71,7 por ciento) fueron resecciones menores y 9 (28,13 por ciento) fueron mayores. Se realizaron 95 (57,9 por ciento) reintervenciones de las vías biliares: 90 (94.4 por ciento) por patología benigna y 5 (5.2 por ciento) por patología maligna. La morbilidad fue de 21,9 por ciento y la mortalidad fue de 7,9 por ciento (61,5 por ciento sepsis). 88.68 por ciento de los pacientes con lesión de la vía biliar, presentaron buena evolución. Los pacientes con estenosis biliares tratadas con las diferentes técnicas quirúrgicas descritas en el presente estudio mejoraron su calidad de vida en comparación con las condiciones preoperatorias de dichos pacientes.

Palliative surgical bypass versus percutaneous transhepatic biliary drainage on unresectable hilar cholangiocarcinoma.

OBJECTIVE: To compare the survival probability of unresectable hilar cholangiocarcinoma patients who have been managed by palliative surgical bypass versus percutaneous transhepatic biliary drainage (PTBD). MATERIAL AND METHOD: A historical (retrospective) cohort study was performed by retrospective and prospective data collection. From January 1, 2000 to December 31, 2002, all unresectable hilar cholangiocarcinoma patients who received only one type of palliative surgical bypass or PTBD in Srinagarind Hospital, Khon Kaen University were included in the present study. The patients were followed until December 31, 2004. Survival analysis was completed for all of the patients. STATISTIC ANALYSIS: Survival analysis was analyzed with the Kaplan-Meier method, Cox regression analysis, and Log-rank test. A p-value of less than 0.05 was considered significant. RESULTS: During the study period, 83 patients were included. Palliative surgical bypass was performed in 42 patients and PTBD was performed in 41 patients. Demographic data, peri-operative complication rate, and late complication rate were comparable. The median survival time of the palliative surgical bypass group was 160 days,(95% CI: 85.33, 234.67) and 82 days (95% CI: 29.76, 134.24)for PTBD group. Comparing survival experience by Log-rank test gave statistical significant diference (p = 0.0276). Hazard ratio was 0.599 (p = 0.03) CONCLUSION: Survival rate of the palliative surgical bypass group was higher than the PTBD group. The survival rate of both groups was comparable to previous reports.

Estrategia terapéutica en el diagnóstico postoperatorio de lesión de un conducto hepático anómalo / Persistant biliary fistula from annomalous hepatic duct injury postoperative and useful therapeutic strategy

Antecedentes: La presencia de un conducto hepático anómalo derecho (CHA) es un factor de riesgo de lesión quirúrgica ductal en la colecistectomía. Se han descrito distintas alternativas terapéuticas en esta lesión. Objetivo: Analizar la estrategia diagnóstica postoperatoria y las ventajas de un tratamiento combinado percutáneo y quirúrgico. Lugar de aplicación: Hospital público de referencia y nivel terciario. Diseño: Series de casos consecutivos. Población: Cuatro pacientes con lesión de un CHA sobre 4850 colecistectomizados entre marzo de 2000 y marzo de 2005. Método: Evaluación retrospectiva. Resultados: Tres pacientes tuvieron lesión de conductos anómalos de los segmentos VI y VII (dos aberrantes y uno accesorio) y el cuarto una lesión de un conducto aberrante del segmento VI. Tres enfermos presentaron una fístula biliar externa y el cuarto se operó de urgencia por sospecha de perforación visceral bloqueada. En un paciente la fístula biliar cerró espontáneamente a los dos meses; en los otros fracasó el tratamiento endoscópico y fueron operados electivamente previa contemporización biliar percutánea del sector hepático aislado. En ambos pacientes y en el operado de urgencia se reparó el conducto mediante una hepaticoyeyunostomía en Y de Roux. La media de seguimiento fue de 13.5 meses. Todos evolucionaron asintomáticos y sin colestasis. Conclusión: En la fístula biliar persistente por lesión de un CHA y fracaso endoscópico, la contemporización con un drenaje biliar percutáneo y cirugía electiva es una estrategia factible y útil en el pre, intra y postoperatorio

Management of hilar malignant biliary strictures

To determine the etiology of Hilar malignant biliary strictures and the efficacy of hepaticojejunostomy in it's management with or without segmental liver resection. A retrospective study of 33 patients was carried out at Civil Hospital and Lyari General Hospital Karachi. They presented with signs and symptoms of mechanical cholestasis. Study was conducted to find the etiology, level of obstruction and the extent of the disease together with approaches to either cure the disease or to relieve the symptoms. Curative resection was attempted where possible in all 33 patients but decision of curative resection or palliative bypass with or without liver resection was made per operatively after accessing the level of obstruction and extent of local, parenchymal or vascular infiltration. Of the 33 patients studied, 72.73% [n=24] had cholangiocarcinoma and 27.27% [n=9] had gall bladder Ca with local bile duct extension. Four different sites of biliary tree [i] common hepatic duct [CHD], [ii] confluence of common hepatic duct [CCHD], [iii] right and left hepatic duct [R and LHD] separately, and [iv] left hepatic duct [LHD] were anastamosed with jejunum. Normal liver functions with complete relieve from symptoms was achieved where CHD or CCHD was anastamosed whereas only a significant decrease was observed when R and LHD and only LHD were anastamosed with jejunum. Surgical resection of the tumor together with biliary decompression using different approaches of hepaticojejunostomy is an effective way of managing malignant Hilar bile duct obstruction as well as significantly decreasing the severity of symptoms in irresectable tumours

Enfermedad de Caroli: reporte del primer caso diagnosticado en Guatemala / Caroli's disease: report of the first case diagnosed in Guatemala

Los quistes de las vías biliares intrahepáticas constituyen una enfermedad congénita rara, caracterizada por dilataciones saculares segmentarias, cuyas manifestaciones clínicas son debidas a colangitis y litiasis biliar. Esta enfermedad descrita por Jacques Caroli en 1958 ha sido reportada con mas frecuencia gracias a los mejores métodos de diagnóstico actuales. Este reporte clínico describe a una mujer de 38 años de edad con ictericia crónica y daño hepático. La paciente tenía dilataciones quísticas del árbol biliar izquierdo, hepatolitiasis y fibrosis hepática congénita asociada a hipertensión portal secundaria. Por la época en que este caso fue manejado (1976)apenas se habían reportado medio centenar de casos; y cuando fue presentado(Congreso Nacional de Medicina 1981)ya existían 84 casos referidos, pero ninguno en la literatura latinoamericana

Derivaciones biliodigestivas / Biliodigestive shunts

Se muestra la experiencia del Servicio de Cirugía del Hospital de Quilpué en 43 pacientes con derivaciones biliodigestivas realizadas entre enero de 1985 y enero de 1990; se tabula y analiza edad, sexo, antecedentes mórbidos, clínicos y de laboratorio, indicación de la intervención, técnicas usadas, complicaciones inmediatas y tardías, mortalidad y seguimiento. Se concluye que la indicación de la técnica, la predominancia del sexo femenino, la distribución por grupos etarios se ajustan a las cifras presentadas por otros autores. Las complicaciones inmediatas más relevantes fueron infección de herida operatoria (11,6%), cuadros respiratorios (27,8%), siendo la mortalidad operatoria de 6,9%

Hemorragia digestiva: uma complicaçäo tardia das anastomoses hepático jejunais em Y de Roux / Digestive hemorrhage: a late complication of hepaticojejunal Roux-en-Y anastomosis

Estudaram-se dois casos de hemorragia digestiva alta decorrente de sangramento da própria anastomose bilio-digestiva em doentes submetidos a duodenopancreatectomias parciais. O tratamento instituído foi ressutura das anastomoses com controle total do sangramento. Chamam-se a atençäo para esta possibilidade de sangramento digestivo alto, discutindo o diagnóstico e terapêutica destas complicaçöes

Dilataçäo cística das vias biliares intrahepáticas (moléstia de Caroli) / Cystic dilation of the intrahepatic bile ducts (Caroli's disease)

A dilataçäo cística das vias biliares intrahepáticas (DCVBI), conhecida como moléstia de Caroli, é uma afecçäo infreqüente passando muitas vezes desapercebida. Até hoje pouco mais de 100 casos foram descritos; os métodos mais modernos de investigaçäo e diagnóstico têm permitido, porém, a detecçäo mais freqüente desta anomalia. Teve-se oportunidade de tratar nos últimos anos três pacientes com DCVBI; discutem-se os diferentes aspectos concernentes ao diagnóstico e tratamento, confrontando-se seus resultados com as informaçöes na literatura. Em todos os três casos, os sintomas mais precocemente referidos foram dores em cólicas no abdome superior nos primeiros anos de vida. Em um destes pacientes as crises dolorosas estavam associadas à icterícia e febre, sendo que colangite prolongada acabou levando à uma cirrose biliar secundária e ao hipodesenvolvimento somático. No que tange ao tratamento, em dois pacientes foi realizada uma hepático-jejunoanastomose intrahepática e no terceiro uma hepatectomia esquerda. Nos dois pacientes de maior idade havia, por ocasiäo da cirurgia, cálculos no interior da via biliar dilatada

Anastomoses biliodigestivas intra-hepáticas / Intrahepatic bilio-digestive anastomoses

Os autores abordam o problema da obstruçäo da via biliar alta, tanto de origem benigna quanto maligna. Mostram quais os exames complementares para se chegar ao diagnóstico e as indicaçöes cirúrgicas. Finalmente mostram as principais cirurgias utilizadas para alívio da obstruçäo alta, lembrando que os cirurgiöes devem ficar atentos para a necessidade do uso de uma delas em uma parcela significativa de pacientes com icterícia obstrutiva