Valoración de la linfadenectomía en una serie consecutiva de pacientes tratados por cáncer biliar / Evaluation of lymphadenectomy in a consecutive series of patients treated for biliary cancer

Resumen Introducción: Si bien actualmente la 8a edición de la clasificación del AJCC para cáncer biliar, recomienda una linfadenectomía con 6 o más GL, su aplicación es escasa. Objetivo: Analizar la aplicabilidad y los resultados de la linfadenectomía en pacientes resecados con fines curativos por cáncer biliar. Materiales y Método: Análisis retrospectivo de pacientes operados por cáncer biliar de 2001 a 2018. Se analizaron variables perioperatorias referidas a la linfadenectomía (número de GL, GL+, morbilidad), comparando supervivencia en pacientes con < 6 y ≥ 6 GL resecados. Resultados: en 72 pacientes resecados por cáncer biliar (46 CaV, 26 CC), se realizaron 66 (91.7%) linfadenectomías N1. En 62.1% (n = 41) se obtuvieron < 6 GL y en el 37.9% (n = 25) ≥ 6 GL. El promedio de GL resecados fue de 5. En 16 (24,2%) linfadenectomías se hallaron GL+ sin diferencias entre ambos grupos. La morbimortalidad global fue de 30,3%, con una mortalidad del 4.5% sin diferencias. Con un seguimiento de 36.9 meses, la supervivencia a 5 años fue 43,7% (n = 17), 7 pacientes con ≥ 6 GL, y 10 pacientes con < 6 GL (p = NS). La supervivencia media en pacientes con GL+ fue 15 meses (6-34 meses). Conclusión: la linfadenectomía ocupa un rol primordial en la cirugía curativa del cáncer biliar, tanto para definir una estadificación y un pronóstico adecuados como para optimizar los resultados de la resección curativa en esta entidad. Su indicación debe ser sistemática con la obtención de un número adecuado de GL acorde a las recomendaciones actuales.

Introduction: Currently the 8th edition of the AJCC classification recommends the resection of 6 or more lymph nodes (LN) in gallbladder cancer and cholangiocarcinoma. However, its implementation is universally scarce. Aim: The goal is to analyze the applicability and results of lymphadenectomy in patients resected with curative purposes in biliary cancer. Materials and Method: a retrospective analysis of patients with biliary cancer (gallbladder carcinoma, intrahepatic and hilar cholangiocarcinoma) treated by curative resection from 2001 to 2018 was performed. Perioperative variables related to lymphadenectomy (LN number, LN positive, related morbidity) were analyzed, comparing survival in patients with < 6 and ≥ 6 resected LN. Results: 72 patients resected for biliary cancer (46 gallbladder cancer, 26 cholangiocarcinoma) were included with 66 (91.7%) N1 lymphadenectomies corresponding to the hepatoduodenal ligament nodes performed. In 62.1% (n = 41) < 6 LN and in 37.9% (n = 25) ≥ 6 LN were resected. Average LN count was 5. In 16 (24.2%) patients positive LN were found, 7 in the group with ≥ 6 LN (28%) vs. 9 in the group with < 6 LN (22%) (p = NS). Overall morbimortality was 30.3% (n = 20). Average follow-up was 36.9 months. Survival at 5 years was 43.7% (n = 17), 7 patients with lymphadenectomy ≥ 6 LN, and 10 patients with < 6 LN (p = NS). Survival mean in patients who had positive LN was 15 months. Conclusión: Lymphadenectomy has a primary role in the radical resection with curative intention for biliary cancer. Systematic indication of lymphadenectomy should be prioritized, with the achievement of an adequately number of LN according to the actual recommendations. Lymphadenectomy is crucial for an adequate staging and prognosis, as well as to optimize the results of curative resection in this entity.

Significance of combination of targeted therapy and immunotherapy in conversion therapy of biliary tract cancer / 中华外科杂志

Biliary tract cancer has insidious onset and high degree of malignancy, and radical resection is often impossible when it is diagnosed.Conversion therapy can achieve tumor downgrading, so that patients who were initially unresectable have a chance to achieve R0 resection.However, due to the high heterogeneity and complex immune microenvironment of biliary tract cancer, conversion therapy is still in the stage of active exploration.As a new type of conversion therapy, combination of targeted therapy and immunotherapy is of great significance to effectively improve the efficiency of conversion therapy.Further exploration of combination mechanism and improvement of immune microenvironment are expected to become the future direction of combination of targeted therapy and immunotherapy.

The largest western experience with hepatopancreatoduodenectomy: lessons learned with 35 cases / A maior experiência ocidental com hepatopancreatoduodenectomia: lições aprendidas com 35 casos

Background : Hepatopancreatoduodenectomy is one of the most complex abdominal operations mainly indicated in advanced biliary carcinoma. Aim : To present 10-year experience performing this operation in advanced malignant tumors. Methods : This is a retrospective descriptive study. From 2004 to 2014, 35 hepatopancreatoduodenectomies were performed in three different institutions. The most common indication was advanced biliary carcinoma in 24 patients (68.5%). Results: Eighteen patients had gallbladder cancer, eight Klatskin tumors, five neuroendocrine tumors with liver metastasis, one colorectal metastasis invading the pancreatic head, one intraductal papillary mucinous neoplasm with liver metastasis, one gastric cancer recurrence with liver involvement and one ocular melanoma with pancreatic head and right liver lobe metastasis. All patients were submitted to pancreatoduodenectomy with a liver resection as follows: eight right trisectionectomies, five right lobectomies, four left lobectomies, 18 central lobectomies (IVb, V and VIII). The overall mortality was 34.2% (12/35) and the overall morbidity rate was 97.4%. Conclusion : Very high mortality is seen when major liver resection is performed with pancreatoduodenectomy, including right lobectomy and trisectionectomy. Liver failure in combination with a pancreatic leak is invariably lethal. Efforts to ensure a remnant liver over 40-50% of the total liver volume are the key to obtain patient survival.

Racional : Hepatoduodenopancreatectomia é uma das operações abdominais mais complexas indicadas principalmente no carcinoma biliar avançado. Objetivo : Apresentar experiência de 10 anos executando esta operação em tumores malignos avançados. Métodos : Trata-se de estudo descritivo e retrospectivo. De 2004 a 2014, 35 hepatopancreatoduodenectomias foram realizadas em três diferentes instituições. A indicação mais comum foi carcinoma biliar avançado em 24 pacientes (68,5%). Resultados : Dezoito tinham câncer de vesícula biliar, oito tumores de Klatskin, cinco tumores neuroendócrinos com metástase hepática, uma metástase colorretal invadindo a cabeça do pâncreas, uma neoplasia mucinosa papilar intraductal com metástase hepática, uma recorrência do câncer gástrico com comprometimento hepático e um melanoma ocular com metástase na cabeça do pâncreas e no lobo direito do fígado. Todos os pacientes foram submetidos a duodenopancreatectomia com ressecção hepática da seguinte forma: oito triseccionectomias direitas, cinco lobectomias direitas, quatro lobectomias esquerdas, e 18 lobectomias centrais (IVb, V e VIII). A mortalidade global foi de 34,2% (12/35) e a taxa de morbidade global foi de 97,4%. Conclusão : Alta mortalidade é vista quando grande ressecção hepática é realizada junto à duodenopancreatectomia, incluindo lobectomia e triseccionectomia direita. Insuficiência hepática em combinação com deiscência do pâncreas é invariavelmente letal. Esforços para garantir fígado remanescente em 40-50% do volume total são a chave para obter sobrevida.

Percutaneous Unilateral Biliary Metallic Stent Placement in Patients with Malignant Obstruction of the Biliary Hila and Contralateral Portal Vein Steno-Occlusion

OBJECTIVE: To investigate the outcomes of percutaneous unilateral metallic stent placement in patients with a malignant obstruction of the biliary hila and a contralateral portal vein steno-occlusion. MATERIALS AND METHODS: Sixty patients with a malignant hilar obstruction and unilobar portal vein steno-occlusion caused by tumor invasion or preoperative portal vein embolization were enrolled in this retrospective study from October 2010 to October 2013. All patients were treated with percutaneous placement of a biliary metallic stent, including expanded polytetrafluoroethylene (ePTFE)-covered stents in 27 patients and uncovered stents in 33 patients. RESULTS: A total of 70 stents were successfully placed in 60 patients. Procedural-related minor complications, including self-limiting hemobilia (n = 2) and cholangitis (n = 4) occurred in six (10%) patients. Acute cholecystitis occurred in two patients. Successful internal drainage was achieved in 54 (90%) of the 60 patients. According to a Kaplan-Meier analysis, median survival time was 210 days (95% confidence interval [CI], 135-284 days), and median stent patency time was 133 days (95% CI, 94-171 days). No significant difference in stent patency was observed between covered and uncovered stents (p = 0.646). Stent dysfunction occurred in 16 (29.6%) of 54 patients after a mean of 159 days (range, 65-321 days). CONCLUSION: Unilateral placement of ePTFE-covered and uncovered stents in the hepatic lobe with a patent portal vein is a safe and effective method for palliative treatment of patients with a contralateral portal vein steno-occlusion caused by an advanced hilar malignancy or portal vein embolization. No significant difference in stent patency was detected between covered and uncovered metallic stents.

Biliary bypass surgery - Analysis of indications and outcome of different procedures

This study reports the indications and outcome of various biliary bypass surgical procedures from a single centre over a period of 10 years. This is a prospective observational study conducted over a period of 10 years [January 2001-december 2010]. A total of 1500 patients were included, who underwent pancreatico-biliary surgery due to common bile duct [CBD] stones, congenital anomalies of biliary tree, unoperable pancreatico-biliary malignancies, CBD strictures and cases who developed iatrogenic biliary injuries during cholecystectomy [both open and laproscopic] during this period of time. The patients who required biliary bypass surgery were further analysed for indications and outcome. Out of 1500 patients 83 [5.53%] required biliary bypass surgical procedures. The CBD stones were observed as the most common indication [25.3%], followed by CBD injuries after open [10.84%] or laproscopic-cholecystectomy [14.46%], carcinoma head of pancreas [12.05%] and CBD obstruction [14.46%] either due to CBD strictures or unknown distal obstruction. Roux-en-Y-hepatico-jejunostomy [26.51%] was the most frequently performed procedure, followed by choledochoduodenostomy and Roux-en-Y choledocho-jejunostomy [i.e. 25.3% and 12.05% respectively]. Roux-en-Y biliary bypass procedure was observed to be associated with better outcome in terms of rate of complications as well duration of hospital stay. Biliary bypass surgical procedures are the better options to restore the continuity of biliary system in patients with iatrogenic biliary tree injuries and un-operable pancreatico-biliary malignancy. Roux-en-Y biliary bypass procedure is safe and problem solving method in these cases

Preoperative portal vein embolization in hepatobiliary tract malignancy: an experience at King Chulalongkorn Memorial Hospital.

BACKGROUND: Major hepatic resections are increasingly performed for both primary and secondary liver cancers nowadays. However, morbidity from these operations is still high. One of the dreadful complications, sometimes lead to fatality, is postoperative liver failure. There are many factors which are associated with this complication such as chronic liver disease, low residual liver volume after resection. Portal vein embolization (PVE) is the procedure which increases the liver volume of the non-embolized lobe. Now, PVE has gained acceptance in many centers to overcome or reduce this complication. This report described the authors' experiences of PVE since 2001 at King Chulalongkorn Memorial Hospital. MATERIAL AND METHOD: The records of 10 patients who had PVE were reviewed CT volumetry of the liver was done before and after procedure. The authors calculated future liver remnant from CT volumetry and compared this volume to standard liver volume. The postoperative complications and hospital courses of these patients were also recorded. RESULTS: Mean growth of future liver remnant (FLR) ratio after PVE was 13.7 +/- 6.2% (median 13, range 4-25). There was no major complication after PVE. Six patients underwent liver resection and there was no major complication or mortality. No one had persistent hyperbilirubinemia 2 weeks after operation. CONCLUSION: The PVE is the useful and safe optional procedure to increase future liver remnant volume. It not only reduces the postoperative liver failure but increases the chance for curative resection.

Pancreatogastroanastomosis / Pancreaticogastrostomy

Desde 1991, hemos realizado 17 duodenopancreatectomías y reconstruimos con la pancreatogastroanastomosis en 11 oportunidades. La mortalidad fue del 0 por ciento, y la morbilidad alcanzó el 52,94 por ciento. En esta presentación proponemos nuestra técnica

Carcinoma da junçäo do ducto hepático principal / Carcunoma of the junction of the duct hepatic

Os autores apresentam um caso de colangiocarcinoma da junçäo dos ductos hepáticos principais (tumor de Klatskin), que fora tratado com drenagem biliar externa. Discutem os aspectos do diagnóstico e tratamento.

Utilidad de las endoprótesis en el manejo de la obstrucción biliar benigna y maligna: resultados en 17 pacientes / Usefulnes of stents in patients with bening and malignant biliary obstruction. Results in 17 patients

Se informan los resultados obtenidos de la colocación de diferentes endoprótesis biliares en 17 pacientes, durante el período de junio de 1991 a junio de 1993. Se utilizaron prótesis plástica de poliuretano en cinco pacientes y en el resto se colocaron prótesis metálicas de diferente tipo, Wallstent en seis Strecker en cinco y Palmaz en uno. La indicación fue por patología maligna en 12 pacientes y en los cinco restantes por obstrucción benigna posquirúrgica (estenosis de derivación biliodigestiva). El resultado y evolución fueron satisfactorios en 13 pacientes (76 por ciento), mientras que en cuatro pacientes se presentaron diferentes complicaciones como obstrucción prematura de la prótesis en tres pacientes, dos de ellos con colangitis asociada y fístula bilioportal en uno y que requirieron procedimientos secundarios para solucionar dichas complicaciones. El uso de endoprótesis metálicas en las vías biliares representa un importante avance el manejo de la obstrucción benigna o maligna, ya que se instalan percutáneamente con mayor facilidad y menor trauma, logrando un mayor diámetro que con las de tipo plástico

Neoplasias malignas de vesícula y vias biliares extra-hepáticas. Revisión clínico- Patológica de 81 casos / Malignancies of gallbladder and extrahepatic bile ducts

Se revisan los aspectos clínicos, quirúrgicos y anátomopatológicos de 81 pacientes con neoplasias de vesícula y vías biliares extrahepáticas dividiéndose en cuatro grupos según la localización. Predominó el sexo femenino, la edad promedio fue de 57.05 años, con mayor incidencia entre la quinta y sexta década de la vida. Podemos concluir que los signos y síntomas no son contributorios, al igual que los éxamenes auxiliares. El tipo histológico más frecuente fue el adenocarcinoma, el pronóstico es pésimo ya que la mayoría de los cánceres del sistema hepatobiliar han crecido mas allá de los límites de una resección curativa al momento en que se hacen clínicamente evidentes. Es de hacer notar que más del 80 por ciento de las neoplasias de vesícula biliar tiene litiasis concomitante

La Cirugía biliar y el papel de la citología en el diagnostico y detección de neoplasias de la vía biliar / Biliary surgery and the cytology in diagnosis and neoplasms detection in the pathways biliar

Se realiza el estudio prospectivo de 100 casos consecutivos de bilis vesicular y coledociana tomadas durante el acto operatorio electivo de vías biliares que ingresaron al quirófano con el diagnóstico de colecistitis crónica calculosa. Se obtuvo 3 por ciento de positividad sin falsos positivos. Los PAP que resultaron negativo pero que después se demostró tumor, se trató de neoplasias que no estaban en contacto con bilis. La alta confiabilidad de este procedimiento, hace surgir su utilización rutinaria junto con la metodología de investigación de la pieza operatoria como lo hace la escuela japonesa. El trabajo en equipo multidisciplinario es fundamental.

Tumores malignos de los conductos biliares extrahepáticos: análisis de 31 observaciones / Malignant tumors of the extrahepatic bile ducts: analysus of 31 observations

Se presentan 31 pacientes operados por cáncer de la vía biliar principal, comentando los resultados obtenidos. Se efectúa un análisis de las posibiloidades quirúrgicas de acuerdo a loa localización, considernado las ventajas e inconvenientes de la cirugía resectiva y derivativa

Cáncer de la vía biliar: análisis sobre 52 casos / Biliary duct cancer: analysis of 52 cases

Tras un breve resumen de la epidemiología, anatomía patológica, clínica, métodos auxiliares del diagnóstico y de sentar las bases del tratamiento, se expone la experiencia obtenida en el tratamiento de 52 pacientes portadores de cáncer en las vías biliares. Se hace referencia a la topografía de los casos registrados, su relación edad/sexo, sus síntomas y signos, poniendo énfasis en el excesivo tiempo promedio demandado para efectuar el diagnóstico de certeza (25,9 días). Asimismo se comprueban las alteraciones de laboratorio propias de todo síndrome coledociano y se clasifican los informes de anatomía patológica que se hicieron en todos los pacientes. Se analizan los tipos de operación que se efectuaron y los resultados postoperatorios relacionándolos con la topografía lesional

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