Metal or plastic stents for preoperative biliary drainage in resectable pancreatic cancer.

INTRODUCTION: In pancreatic cancer, preoperative biliary drainage (PBD) increases complications compared with surgery without PBD, demonstrated by a recent randomised controlled trial (RCT). This outcome might be related to the plastic endoprosthesis used. Metal stents may reduce the PBD-related complications risk. METHODS: A prospective multicentre cohort study was performed including patients with obstructive jaundice due to pancreatic cancer, scheduled to undergo PBD before surgery. This cohort was added to the earlier RCT (ISRCTN31939699). The RCT protocol was adhered to, except PBD was performed with a fully covered self-expandable metal stent (FCSEMS). This FCSEMS cohort was compared with the RCT's plastic stent cohort. PBD-related complications were the primary outcome. Three-group comparison of overall complications including early surgery patients was performed. RESULTS: 53 patients underwent PBD with FCSEMS compared with 102 patients treated with plastic stents. Patients' characteristics did not differ. PBD-related complication rates were 24% in the FCSEMS group vs 46% in the plastic stent group (relative risk of plastic stent use 1.9, 95% CI 1.1 to 3.2, p=0.011). Stent-related complications (occlusion and exchange) were 6% vs 31%. Surgical complications did not differ, 40% vs 47%. Overall complication rates for the FCSEMS, plastic stent and early surgery groups were 51% vs 74% vs 39%. CONCLUSIONS: For PBD in pancreatic cancer, FCSEMS yield a better outcome compared with plastic stents. Although early surgery without PBD remains the treatment of choice, FCSEMS should be preferred over plastic stents whenever PBD is indicated. TRIAL REGISTRATION NUMBER: Dutch Trial Registry (NTR3142).

Prospective enteroscopic evaluation of jejunal polyposis in patients with familial adenomatous polyposis and advanced duodenal polyposis.

Duodenal cancer originating from duodenal adenomas is an important cause of death in patients with familial adenomatous polyposis (FAP). Small intestinal adenomas also occur distal to the duodenum, and literature suggests that they mainly occur in the proximal jejunum in patients with severe duodenal polyp burden. We recently reported on 3 FAP-patients with a jejunal adenocarcinoma, all also harbouring advanced duodenal polyposis. Therefore we questioned whether FAP patients should also be submitted to endoscopic surveillance of the jejunum. The aim of this study was to determine the incidence and burden of jejunal adenomas in patients with FAP and advanced duodenal disease. All patients with FAP and advanced duodenal polyposis (Spigelman stage IV) at our academic centre were invited to undergo antegrade single balloon enteroscopy (Olympus SIF-Q180) with propofol-sedation. Patient characteristics, procedural characteristics (success, depth of insertion) and enteroscopic findings (number, size and pathology) are described. We identified 18 patients with FAP and duodenal polyposis Spigelman stage IV. Thirteen participated in the study with a mean age of 54 (30-64) years. SBE was successfully performed in 10 patients, with a mean depth of insertion of 72 cm beyond the ligament of Treitz. Adenomatous polyps were detected in 9 patients. Only one of them had extensive polyposis beyond Treitz, with large polyps covering up to one-third of the jejunal circumference. No cancers or adenomas with high-grade dysplasia were detected. Clinically significant jejunal polyposis in FAP is rare, even in high-risk patients with advanced duodenal disease. Routine jejunoscopy does not seem warranted in patients with FAP.

Systematic review and meta-analysis of somatostatin analogues for the treatment of pancreatic fistula.

BACKGROUND: Somatostatin analogues are used for the treatment of pancreatic fistula, with the aim of achieving fistula closure or reduction of output. METHOD: MEDLINE, Embase and Cochrane databases were searched systematically for relevant articles followed by hand-searching of reference lists. Data on patient recruitment, intervention and outcome were extracted and meta-analysis performed where reasonable. RESULTS: Seven randomized clinical trials met the inclusion criteria and included a total of 297 patients with fistulas of the gastrointestinal tract; of these, 102 patients had fistulas of pancreatic origin. Pooling of closure rates showed no significant difference between patients treated with somatostatin analogues compared with controls: odds ratio 1·52 (95 per cent confidence interval 0·88 to 2·61). Owing to inconsistent descriptions, pooling of results was not possible for other endpoints, such as time to fistula closure. CONCLUSION: There is no solid evidence that somatostatin analogues result in a higher closure rate of pancreatic fistula compared with other treatments.

What an endoscopist should know about immunoglobulin-G4-associated disease of the pancreas and biliary tree.

Autoimmune pancreatitis (AIP) and IgG4-associated cholangitis (IAC) are the recently recognized pancreatobiliary manifestations of IgG4-associated systemic disease (ISD). Clinically, ISD of the pancreas and/or biliary tree may mimic pancreatic cancer, sclerosing cholangitis, or cholangiocarcinoma. Patients often present with abdominal pain, weight loss, jaundice, itch, and biochemical signs of pancreatitis and cholestasis. Tomography may reveal enlargement of the pancreas or may mimic malignant pancreatic lesions, and cholangiopancreatography may disclose irregularities of the pancreatic duct and stenoses of the distal and/or proximal common bile duct and intrahepatic bile ductules. Serum immunoglobulin G4 (IgG4) is elevated in most patients but, unlike tissue IgG4-loaded plasma cell infiltrates, is not diagnostic of the disease. The application of consensus diagnostic criteria for laboratory investigations, imaging, and histologic findings can identify patients who qualify for corticosteroid treatment. The excellent response to immunosuppressive therapy suggests an immune-mediated etiology of the disease, but the exact pathophysiological mechanisms are still under investigation. Relapse may occur after tapering down of corticosteroids, which supports the rationale of maintenance immunosuppression after remission has been induced.

A new partially covered nitinol stent for palliative treatment of malignant bile duct obstruction: a multicenter single-arm prospective study.

BACKGROUND AND STUDY AIMS: Covered self-expanding metal stents (SEMSs) have proven effective for managing malignant bile duct strictures and may reduce risk of tumor ingrowth. A new nitinol partially covered biliary SEMS was prospectively evaluated. PATIENTS AND METHODS: 70 patients with inoperable extrahepatic biliary obstructions were enrolled in a prospective multicenter trial, and followed up to 6 months or death, whichever came first. Primary endpoint was adequate palliation defined as absence of recurrent biliary obstruction from partly covered SEMS placement to end of follow-up. RESULTS: Mean age of the patients was 69 years and 52 % were men. Pancreatic carcinoma was present in 68 %. One stent was placed in 67 patients, two patients received two, and in one patient a guide wire could not traverse the stricture. In 55 % of patients the SEMS was inserted de novo and in 45 % for exchange with a plastic stent. Technical success was 97 %. At 6 months, 62 % of patients were free of obstructive symptoms; compared with baseline the mean number of symptoms per patient was significantly reduced (3.1 at baseline, 0.6 at 6 months; P < 0.0001) and total bilirubin levels dropped by 73 %. There were four cases of recurrent biliary obstruction, due to stent migration (2), tumor overgrowth (1), and sludge formation (1). Device-related complications included cholecystitis (3), right upper quadrant pain (1), and moderate pancreatitis (1). No tumor ingrowth was reported. CONCLUSIONS: This new partially covered nitinol SEMS is easily inserted, and safe and effective in the palliation of biliary obstruction secondary to malignant bile duct strictures.

Multidisciplinary management of hilar cholangiocarcinoma (Klatskin tumor): extended resection is associated with improved survival.

BACKGROUND: Effective diagnosis and treatment of patients with hilar cholangiocarcinoma (HCCA) is based on the synergy of endoscopists, interventional radiologists, radiotherapists and surgeons. This report summarizes the multidisciplinary experience in management of HCCA over a period of two decades at the Academic Medical Center in Amsterdam, with emphasis on surgical outcome. METHODS: From 1988 until 2003, 117 consecutive patients underwent resection on the suspicion of HCCA. Preoperative work-up included staging laparoscopy, preoperative biliary drainage, assessment of volume/function of future remnant liver and radiation therapy to prevent seeding metastases. More aggressive surgical approach combining hilar resection with extended liver resection was applied as of 1998. Outcomes of resection including actuarial 5-year survival were assessed. RESULTS: Eighteen patients (15.3%) appeared to have a benign lesion on microscopical examination of the specimen, leaving 99 patients with histologically proven HCCA. These 99 patients were analysed according to three 5-year time periods of resection, i.e. period 1 (1988-1993, n=45), 2 (1993-1998, n=25) and 3 (1998-2003, n=29). The rate of R0 resections increased and actuarial five-year survival significantly improved from 20±5% for the periods 1 and 2, to 33±9% in period 3 (p<0.05). Postoperative morbidity and mortality in the last period were 68% and 10%, respectively. CONCLUSION: Extended surgical resection resulted in increased rate of R0 resections and significantly improved survival. Candidates for resection should be considered by a specialized, multidisciplinary team.

Validation of a cholangiographic prognostic model in primary sclerosing cholangitis.

BACKGROUND AND STUDY AIMS: We previously developed a prognostic model for primary sclerosing cholangitis (PSC), which was primarily based on a cholangiographic classification of the intra- and extrahepatic biliary tree lesions. The aim of the present study was to validate the performance of this model in an external cohort. PATIENTS AND METHODS: The validation dataset consisted of patients with PSC from a single referral center in Oslo, Norway. The patients' cholangiograms were scored according to the Amsterdam classification. We then examined whether adjusting the value of the original coefficients of the predictors or adding new predictors would improve the fit of the original model in the validation cohort. In addition, we evaluated calibration (closeness between observed and expected survival) and discrimination using the concordance index. RESULTS: A total of 111 patients (mean age 35 +/- 13 years; 76 % male) were included in the validation study. Baseline clinical characteristics were comparable between the two cohorts. None of the coefficients that were re-estimated in the validation cohort differed significantly from the values of the original model. Observed and expected survival curves were in close agreement across different risk groups. Discrimination of the original model was preserved in the validation cohort: the concordance index was the same in both cohorts. CONCLUSIONS: The prognostic model showed adequate performance in an independent series of patients. Therefore, we updated the model using the data from both cohorts to provide more robust estimates of transplant-free survival for individual patients. A nomogram was constructed, which can be used to predict medium- and long-term prognosis in individual patients with PSC.

Helicobacter pylori eradication and gastric cancer: when is the horse out of the barn?

Helicobacter pylori infection is a major risk factor for gastric cancer development. Therefore, H. pylori eradication may be an important approach in the prevention of gastric cancer. However, long-term data proving the efficacy of this approach are lacking. This report describes two patients who developed gastric cancer at, respectively, 4 and 14 years after H. pylori eradication therapy. These patients were included in a study cohort of H. pylori-infected subjects who received anti-H. pylori therapy during the early years of development of H. pylori eradication therapy and underwent strict endoscopic follow-up for several years. In both patients, gastric ulcer disease and premalignant gastric lesions, i.e., intestinal metaplasia at baseline and dysplasia during follow-up, were diagnosed before gastric cancer development. These case reports demonstrate that H. pylori eradication does not prevent gastric cancer development in all infected patients after long-term follow-up. In patients with premalignant gastric lesions, in particular in patients with a history of gastric ulcer disease, adequate endoscopic follow-up is essential for early detection of gastric neoplasia.

Is endoscopic retrograde cholangiopancreatography valuable and safe in children of all ages?

OBJECTIVE: To evaluate indications, findings, therapies, safety, and technical success of endoscopic retrograde cholangiopancreatography (ERCP) in children of the Emma Children's Hospital Academic Medical Centre in Amsterdam, the Netherlands. DESIGN: Descriptive. Retrospective analysis by medical records. PATIENTS AND METHODS: Information was obtained by chart review of patients between 0 and 18 years who underwent ERCP from 1995 to 2005 in our center. The following data were analyzed: indications, findings, therapies, safety, and technical success. Success was defined as obtaining accurate diagnostic information or succeeding in endoscopic therapy. RESULTS: Sixty-one children (age 3 days to 16.9 years, mean age 7.0 years) underwent a total of 99 ERCPs. Of those patients, 51% (31/61) were younger than 1 year, 84% had biliary indications, and 16% had pancreatic indications for the performance of ERCP. The complication rate was 4% (4/99) and included substantial pancreatitis and mild irritated pancreas. No complications occurred in children younger than 1 year. CONCLUSIONS: ERCP is a safe and valuable procedure for children of all ages with suspicion of pancreaticobiliary diseases. Indications for ERCP are different for children and adults. A laparotomy could be prevented in 12% of children with suspicion of biliary atresia. Further research is required to determine the role of MRCP versus ERCP.

Staging of cholangiocarcinoma: the role of endoscopy.

The main question for staging is resectability, which is reliant on vascular, longitudinal, and metastatic spread. Today, accurate staging of perihilar tumors is achieved by non-invasive diagnostic investigations. Direct cholangiography has been the gold standard as a diagnostic procedure in recent decades. Endoscopic retrograde cholangiopancreaticography (ERCP) often only shows the ducts below the obstruction, and visualization of an obstructed part of the biliary tree is often not possible. Direct cholangiography reveals no information about local tumor extension, lymph nodes, or vascular involvement. Because of the given limitations, potential complications (cholangitis, sepsis) associated with direct cholangiography and reduction of the accuracy of subsequent cross-sectional imaging studies, these invasive techniques should only be used in the case of palliative interventions. Endoscopic ultrasonography-guided fine-needle aspiration (EUS-FNA) can be used to assess the nature of biliary strictures and to derive information about the extent of periductal disease and the presence of lymph node metastases. In a study by Fritscher-Ravens, 44 patients with hilar strictures underwent EUS-FNA. The overall diagnostic accuracy, sensitivity, specificity, positive and negative predictive values were 91% (95% CI, 78.4-96.3%), 89% (95% CI, 73.3-96.8%), 100% (95% CI, 63.1-100%), 100% (95% CI, 88.8-100%), and 67% (95% CI, 34.9-90%), respectively. The planned surgical approach was changed in 27 of 44 patients. In 15-20% of cholangiocarcinoma, patients with unremarkable abdominal imaging studies have metastatic lymph node involvement according to EUS evaluation. Due to the risk of peritoneal seeding, however, EUS with FNA is not recommended in patients still with a potential curative tumor.

Removable fully covered self-expandable metal stents in the treatment of common bile duct strictures due to chronic pancreatitis: a case series.

The aim of this study was to test the removability of fully covered self-expandable metal stents (FCSEMS) in patients with a benign common bile duct (CBD) stricture. A FCSEMS was inserted in six patients with a CBD stricture due to chronic pancreatitis who were considered to be unfit for surgery, and stent removal was attempted after predefined intervals of 4 and 6 months. FCSEMS were successfully placed in all patients (100 % placement success) and stent extraction was accomplished in four patients (66 % removal rate), all of whom achieved stricture resolution (66 % resolution rate). In one patient a recurrent stenosis developed after 6 months (recurrence rate 25 %). Proximal stent migration occurred in two patients. In conclusion, FCSEMS removal was possible in the majority of patients and results regarding stricture dilation were promising. Nevertheless, before FCSEMS can become an acceptable treatment option for benign CBD strictures, innovative stent design modifications are necessary and removability must be ascertained.

Impact of bile duct injury after laparoscopic cholecystectomy on quality of life: a longitudinal study after multidisciplinary treatment.

BACKGROUND AND STUDY AIMS: Bile duct injury (BDI) is associated with increased morbidity and poor survival. The aim of the present study was to compare quality of life (QoL) between patients with BDI and those without after laparoscopic cholecystectomy. A longitudinal assessment was performed and risk factors for poor QoL were determined. PATIENTS AND METHODS: In March 2005 a survey was performed of 403 eligible patients with BDI who were referred to a tertiary center for multidisciplinary treatment by gastroenterologists, radiologists, and surgeons. A longitudinal quality-of-life study was performed to determine changes in outcome after a mean of 5.5 and 11 years' follow-up. RESULTS: Of the eligible 403 patients with BDI, 278 (69 %) responded to the survey after a mean follow-up of 5.9 years. The quality-of-life outcome of injured patients was significantly lower in three of the eight domains compared to patients who underwent cholecystectomy without an injury ( P < 0.05). In seven of the eight QoL domains injured patients scored significantly worse than the healthy population norms ( P < 0.05). The longitudinal assessment after another 5.5 years of follow-up did not show improvement in QoL. Clinical characteristics such as the type of injury and the type of treatment did not affect outcome. Nineteen percent of the patients (n = 53) filed a malpractice claim after BDI. These patients reported better QoL (effect size = 0.6, P = 0.02) when the claim was resolved in their favor than when the claim was rejected. CONCLUSIONS: BDI has a detrimental effect on long-term QoL. QoL in patients with BDI is poor and does not improve during follow-up. The outcome of a malpractice litigation claim is associated with QoL.

[Dutch study on the optimal treatment strategy for patients with a first or second occurrence of gastro-oesophageal variceal bleeding: the TIPS-TRUE trial]. / Nederlandse studie naar de beste behandelstrategie bij patiënten met een eerste of tweede oesofagus- of maagvaricesbloeding: de TIPS-TRUE-trial.

The main options for secondary prevention of gastrooesophageal variceal bleeding are endoscopic therapy and treatment with propranolol. Creation ofa transjugular intrahepatic portosystemic shunt (TIPS) is currently considered a valuable secondary 'rescue' treatment when other therapies fail. Recent data suggest that the use of covered stents markedly increases the efficacy of TIPS, compared with conventional uncovered stents. Therefore, a multicentre randomised trial was designed to compare the effects of TIPS using covered stents with those of endoscopic therapy plus propranolol in patients with a first or second episode ofgastro-oesophageal variceal bleeding. TIPS will be performed in 4 university centres with relevant expertise. The trial will hopefully gain nationwide support, and all centres in The Netherlands are cordially invited to participate.

Immunoglobulin G4-related sclerosing cholangitis in patients resected for presumed malignant bile duct strictures.

BACKGROUND: Immunoglobulin (Ig) G(4)-related lymphoplasmacytic sclerosing pancreatitis has been described in the context of autoimmune pancreatitis mimicking distal cholangiocarcinoma. The aim of this study was to assess the occurrence of this entity in benign bile duct strictures in patients resected for presumed hilar cholangiocarcinoma. METHODS: Of 185 patients who had undergone resection of proximal bile ducts on suspicion of hilar cholangiocarcinoma between January 1984 and June 2005, 32 (17.3 per cent) had a benign bile duct stricture on histopathological examination. After re-evaluation, further immunohistochemical analysis was performed on specimens from patients with features of autoimmune-like disease. RESULTS: The periductal stroma in 15 patients showed features of autoimmune-like disease (diffuse, moderate to severe lymphoplasmacytic infiltration with marked fibrosis). Abundant IgG(4)-positive plasma cell infiltration around the bile duct lesions was seen in two of these. Although not significant, patients with features of autoimmune-like disease on histological changes showed a higher incidence of recurrent biliary complications than those without (P = 0.250). CONCLUSION: Features of autoimmune-like bile duct disease were seen in almost half (15 of 32) of patients with benign hilar strictures resected for presumed hilar cholangiocarcinoma. Frank IgG(4)-related sclerosing disease was found in only two of the 15 patients with autoimmune-like bile duct disease.

Incidence and management of bile leakage after partial liver resection.

BACKGROUND/AIMS: Bile leakage after partial liver resection still is a common complication and is associated with substantial morbidity and even mortality. METHODS: A total of 234 consecutive liver resections without biliary reconstruction, performed between January 1992 and December 2004, were analyzed for postoperative bile leakage. RESULTS: Postoperative bile leakage occurred in 6.8% of patients (16/234). In univariate analysis, male gender (p = 0.037), major liver resection (p = 0.004), right-sided hepatectomy (p = 0.005), prolonged operation time (p = 0.001), intraoperative blood loss >500 ml (p = 0.009), red cell transfusion (p = 0.02), tumor size (p = 0.026), duration of vascular occlusion (p = 0.03) and surgical irradicality (p = 0.001) were risk factors. No independent risk factors were associated with bile leakage after liver resection. Bile leakage originated from the resection plane in 10 patients (63%). Endoscopic biliary decompression was performed in 9 patients as initial treatment, and percutaneous drainage of the bile collection was used in 4 patients. Bile leakage resolved spontaneously in 3 patients. CONCLUSIONS: Bile leakage is a persisting complication and in this study occurred in 6.8% of patients after partial liver resection. Percutaneous drainage of bile collection with or without endoscopic biliary decompression are effective interventions in the management of most cases of bile leakage.

[Surgical drainage of the pancreatic duct in patients with chronic pancreatitis is more effective than endoscopic drainage: randomized trial]. / Chirurgische drainage van de ductus pancreaticus bij patiënten met chronische pancreatitis effectiever dan endoscopische drainage: gerandomiseerde trial.

OBJECTIVE: To compare endoscopic and surgical drainage of the pancreatic duct for ductal decompression in patients with severe pain due to chronic pancreatitis and a dilated pancreatic duct. DESIGN: Randomized clinical trial. METHOD: All symptomatic patients with chronic pancreatitis and a distal obstruction of the pancreatic duct, but without an inflammatory mass, were eligible for this study. Patients were randomized to endoscopic transampullary pancreatic duct drainage or to operative pancreaticojejunostomy. The primary end point was the average Izbicki pain score, measured during 2 years of follow-up. The secondary endpoints were pain relief at the end of follow-up, physical and mental health, morbidity, mortality, hospital stay and number of procedures performed. RESULTS: Of 118 patients who were evaluated between January 2000-October 2004 39 patients were randomized; 19 were treated endoscopically (16 of whom underwent lithotripsy) and 20 by operative pancreaticojejunostomy. During 24 months of follow-up, compared with endoscopic drainage, surgery was associated with lower Izbicki pain scores (51 versus 25; p < 0.001) and better SF-36 physical health summary scores (p = 0.003). Furthermore, at the end of follow-up, pain relief was achieved in 32% of patients randomized to endoscopic drainage and 75% of patients randomized to surgical drainage (p = 0.007). Complication rates and hospital stay were similar, but endoscopic treatment required more procedures (median 8 versus 3; p < 0.001).

[Claims for damages as a result of bile-duct injury during (laparoscopic) cholecystectomy]. / Letselschadeclaims als gevolg van galwegletsel bij een (laparoscopische) cholecystectomie.

OBJECTIVE: To evaluate the frequency of claims for damages initiated by patients referred to a tertiary centre for the treatment of bile-duct injury after a (laparoscopic) cholecystectomy. To determine the relationship between patient characteristics and the initiation of a claim procedure. DESIGN: Descriptive. METHOD: Between 1 January 1990 and 31 December 2005, 500 patients with a bile-duct injury were referred to the Academic Medical Centre, Amsterdam, 454 of whom in the period up to 31 December 2004. Of these, 403 received a mailed questionnaire about the initiation of legal claims for damages. RESULTS: The questionnaire was completed and returned by 278 patients (69%), a representative cohort ofthe 500. Of these, 53 (19%) had submitted a claim for damages. The percentage of claims did not increase over the periods 1991-1995 (19%), 1996-2000 (18%) and 2001-2005 (20%). In the univariate analysis, factors associated with the initiation of a claim procedure were: younger age, the severity of the injury, surgical treatment, being employed at the time of the initial cholecystectomy, and having been placed on sick leave. A complete transection of the common bile duct was the only independent predictive factor for starting a claim procedure (odds ratio: 7.5; 95% CI: 1.9-30.6).

Long-term results of a primary end-to-end anastomosis in peroperative detected bile duct injury.

The management of a bile duct injury detected during laparoscopic cholecystectomy is still under discussion. An end-to-end anastomosis (with or without T-tube drainage) in peroperative detected bile duct injury has been reported to be associated with stricture formation of the anastomosis area and recurrent jaundice. Between 1991 and 2005, 56 of a total of 500 bile duct injury patients were referred for treating complications after a primary end-to-end anastomosis. After referral, 43 (77%) patients were initially treated endoscopically or by percutaneous transhepatic stent placement (n = 3; 5%). After a mean follow-up of 7 +/- 3.3 years, 37 patients (66%) were successfully treated with dilatation and endoscopically placed stents. One patient died due to a treatment-related complication. A total of 18 patients (32%) underwent a hepaticojejunostomy. Postoperative complications occurred in three patients (5%) without hospital mortality. These data confirm that end-to-end anastomosis might be considered as a primary treatment for peroperative detected transection of the bile duct without extensive tissue loss. Complications (stricture or leakage) can be adequately managed by endoscopic or percutaneous drainage the majority of patients (66%) and reconstructive surgery after complicated end-to-end anastomosis is a procedure with relative low morbidity and no mortality.

Original article: New surgical approaches to the Klatskin tumour.

BACKGROUND: Surgical treatment of hilar cholangiocarcinoma (Klatskin tumours) is difficult because of its central location in the liver hilum. Recent developments in surgical techniques have improved the outcome after resection. AIM: To describe the surgical approaches currently applied in our centre and the impact of these strategies on outcome and criteria for resection. METHODS: From 1988 to 2003, 99 consecutive patients underwent resection for hilar cholangiocarcinoma. Patients were analysed for rate of R0 resections in relation with Bismuth classification. Morbidity, mortality and survival were assessed. RESULTS: The rate of hilar resections in combination with (extended) liver resections for type III and IV tumours increased from 24% to 95% in the last 5 years of the study period. Eight patients (8%) had Bismuth type IV tumours. Four of these patients underwent palliative local excisions of the hepatic duct confluence whereas the other four patients underwent hilar resection in combination with partial liver resection, resulting in microscopically radical resections. There was no mortality in this group. Overall postoperative morbidity and mortality were 68% and 10%, respectively. CONCLUSIONS: An aggressive surgical approach consisting of hilar resections combined with partial liver resections including segments 1 and 4, resulted in a higher rate of R0 resections. Even Bismuth type IV tumours may be resectable depending on the biliary anatomy of the hepatic duct confluence.

Photodynamic therapy and Klatskin tumour: an overview.

The prognosis of patients with an unresectable bile duct cancer is poor. In 60-70% of patients, cholangiocarcinoma is located in the hepatic duct bifurcation and known as Klatskin tumour. Surgical resection offers the only chance for 5-year survival, but less than 20% are surgical candidates. Patients with unresectable cholangiocarcinoma are treated with biliary drains, but commonly die of liver failure or cholangitis due to biliary obstruction within 6 to 12 months. Chemotherapy and/or radiotherapy have not been evaluated in randomized, controlled trials. Photodynamic therapy (PDT) is a new and promising locoregional treatment, the aim of which is to destroy tumour cells selectively. PDT involves the injection of a photosensitizer followed by percutaneous or endoscopic direct illumination of the tumour with light of a specific wavelength. In recent non-randomized studies of small numbers of patients with unresectable cholangiocarcinoma, PDT induced a decrease in serum bilirubin levels, improved quality of life and a slightly better survival. Other non-randomized trials failed to show clinical benefits. Recently, the first prospective, randomized controlled study with PDT in a selected group of non-resectable cholangiocarcinoma patients was stopped prematurely. The improvement in survival in the PDT-randomized patients was so impressive that it was considered to be unethical to continue randomization. However, further studies are awaited in unselected patients with unresectable cholangiocarcinoma before PDT can be considered as the standard adjuvant therapy.