The Status of Liver Margin in Perihilar Cholangiocarcinoma: A Multicenter Study.

OBJECTIVE: This study aimed to investigate the prevalence and distribution of carcinoma in the liver margin (LM) of resected perihilar cholangiocarcinoma (pCCA) and establish a method for LM examination. BACKGROUND: LM is the largest margin in resected pCCA with undefined status and assessment method. METHODS: 227 pCCA cases underwent major hepatectomy were divided into a discovery cohort (n=101) assessed using serial whole-mount digital large sections (WDLS) combined with small sections, and a control cohort (n=126) assessed using only small sections. RESULTS: The LM R1 resection rate was 38.6% (39/101) in the discovery cohort and 5.6% (7/126) in the control cohort. WDLS identified more LM R1 cases compared to the small section in the discovery cohort (38.6% vs. 5.9%, P<0.001). R0 patients in the discovery cohort had better overall survival and recurrence-free survival than those in the control cohort (both P<0.05). Additionally, 95% of carcinoma was found within 20 mm of the proximal ductal margin (DM). A proximal DM distance of<5 mm was an independent risk factor for LM R1 resection. Patients with which are more likely to experience R1 compared to those with ≥ 5 mm (P<0.001). CONCLUSIONS: Positive LM was the significant cause for R1 resection of pCCA and the utilization of WDLS improved the diagnostic accuracy of LM. An examination methodology was established, highlighting the necessity of examining LM within a 20 mm radius around the proximal DM, especially in patients with a proximal DM of<5 mm.

Pattern and extent of intrahepatic infiltration of perihilar cholangiocarcinoma - A case-control study based on liver panoramic digital pathology.

BACKGROUND: The extent of intrahepatic infiltration of perihilar cholangiocarcinoma (PHCC) remains unclear. This research aimed to explore the pattern and extent of intrahepatic infiltration of PHCC to guide surgical treatment and pathological research. MATERIALS AND METHODS: This study included 62 patients diagnosed with PHCC who underwent major hepatectomy. A whole-mount digital liver pathology system (WDLPS) for hepatectomy specimens greater than 10 × 10 cm was used to panoramically assess the intrahepatic infiltration extent of PHCC. RESULTS: The distal intrahepatic infiltration (DIHI) and radial liver invasion (RLI) were important parts of intrahepatic infiltration for PHCC explored by WDLPS. The study confirmed that 75.8% of PHCCs had RLI and the infiltration distance in all patients were within 15,000 µm, 62.9% of PHCCs had DIHI greater than 1 cm away from the main tumor in liver parenchyma. The recurrence-free survival rates and overall survival rates of patients with DIHI were poorer than the patients without DIHI (P＜0.0001, P=0.0038). Arterial invasion on the resected side could be an excellent predictor. A total of 105 liver lobes were resected from 62 PHCC patients. The invasion rates of the left lateral, left medial, right anterior, and right posterior lobe of PHCC were 79%, 100, 100%, and 69% respectively. CONCLUSION: The presence of DIHI in most PHCCs was a significant predictor of poor postoperative recurrence and survival. Based on the extent of intrahepatic infiltration, minor hepatectomy was not suitable as the curative surgery for PHCC. Major hepatectomy and liver transplantation were the ideal radical treatment.

Safety and benefit of modified mesohepatectomy in the treatment of bilobar involvement congenital biliary dilatation.

BACKGROUND: The diseased bile duct in bilobar congenital biliary dilatation is extensive and often requires major hepatectomy or liver transplantation associated with a higher risk. We aimed to evaluate the safety and benefit of modified mesohepatectomy, in comparison with trisectionectomy, to treat bilobar congenital biliary dilatation. METHODS: This study included 28 patients with type IV and V bilobar congenital biliary dilatation. An innovative mesohepatectomy comprising the hepatectomy technique beyond the P/U point and bile duct shaping was applied to 14 patients to address the extensively diseased bile duct and difficulty in hepaticojejunostomy. Another 14 patients received trisectionectomy. The perioperative and long-term outcomes of these patients were compared. RESULTS: The ratio of residual liver volume to standard liver volume in the mesohepatectomy group was higher (78.68% vs. 40.90%, p = 0.005), while the resection rate of the liver parenchyma was lower (28.25% vs. 63.97%, p = 0.000), than that in trisectionectomy group. The mesohepatectomy group had a lower severe complication (>Clavein III, 0% vs. 57.70%, p = 0.019) and incidence of posthepatectomy liver failure (7.14% vs. 42.86%, p = 0.038). No significant difference was observed in blood loss and bile leakage (p > 0.05). All the patients in the mesohepatectomy group achieved optimal results in the long-term follow-up. CONCLUSIONS: mesohepatectomy provides an efficient treatment option for bilobar congenital biliary dilatation and can achieve radical resection, retain more liver parenchyma, and reduce the difficulty of hepaticojejunostomy, especially for patients that are not eligible for major hepatectomy and liver transplantation.

Predicting the occurrence of antagonism within ternary guanidine mixture pollutants based on the concentration ratio of components.

The widespread prevalence and coexistence of diverse guanidine compounds pose substantial risks of potential toxicity interactions, synergism or antagonism, to environmental organisms. This complexity presents a formidable challenge in assessing the risks associated with various pollutants. Hence, a method that is both accurate and universally applicable for predicting toxicity interactions within mixtures is crucial, given the unimaginable diversity of potential combinations. A toxicity interaction prediction method (TIPM) developed in our past research was employed to predict the toxicity interaction, within guanidine compound mixtures. Here, antagonism were found in the mixtures of three guanidine compounds including chlorhexidine (CHL), metformin (MET), and chlorhexidine digluconate (CDE) by selecting Escherichia coli (E. coli) as the test organism. The antagonism in the mixture was probably due to the competitive binding of all three guanidine compounds to the anionic phosphates of E. coli cell membranes, which eventually lead to cell membrane rupture. Then, a good correlation between toxicity interactions (antagonisms) and components' concentration ratios (pis) within binary mixtures (CHL-MET, CHL-CDE, MET-CDE) was established. Based on the correlation, the TIPM was constructed and accurately predicted the antagonism in the CHL-MET-CDE ternary mixture, which once again proved the accuracy and applicability of the TIPM method. Therefore, TIPM can be suggested to identify or screen rapidly the toxicity interaction within ternary mixtures exerting potentially adverse effects on the environment.

The key constituents underlying the combined toxicity of eight cosmetic contaminants towards Vibrio qinghaiensis.

Cosmetic additives (ADDs) and packaging plasticizers (PLAs) probably present potential risks and dangers to the environment and human body as emerging pollutants. To investigate their potential risks and dangers, five ADDs including methyl paraben (MET), ethyl paraben (ETH), propyl paraben (PRO), butyl-hydroxy anisole (BHA), and salicylic acid (SAL), as well as three PLAs including bisphenol A (BPA), bisphenol S (BPS) and tris(2-butoxyethyl) phosphate (TBEP) were selected as research objects, and ten mixture rays (R1-R10) composed of the eight components were designed by the uniform design ray (UD-Ray) method. The toxicities of the eight cosmetic pollutants and their eight-component mixture system towards Vibrio qinghaiensis sp.-Q67 (Q67) were systematically determined by the time-dependent microplate toxicity analysis (t-MTA) method. The three-dimensional (3D) surface of deviation from the concentration addition model (dCA) was utilized to qualitatively and quantitatively analyse the toxicity interaction of the mixtures and the correlation between toxicity interaction and the components' concentration ratios. Finally, eight individual pollutants and representative rays with significant inhibitory and interactive effects were selected to analyse DNA and soluble proteolysis as well as the microstructure and morphology of Q67 after treatment with single chemicals and their mixtures. The results showed that the eight cosmetic pollutants had conspicuous concentration-dependent toxicity and acute toxicity, and none of them, except BPS, BPA and ETH, had time-dependent toxicity. All rays had time/concentration-dependent toxicity and acute toxicity. At the same time, the toxicity interaction of these mixture rays was predominantly antagonism and the strongest antagonism appeared at high concentrations at 12 h. Nevertheless, the components' concentration ratio (pi) was the decisive factor for the type of mixture interaction. The correlation analysis revealed a significant positive linear correlation between mixture toxicity and pETH and pBPA, which indicated that ETH and BPA were the key components of the toxic effects. However, there was a significant negative linear correlation between the antagonism intensity and pBPA and pTBEP, which demonstrated that BPA and TBEP were the key components of the antagonism intensity. Pollutants and their mixtures can also damage cellular structures, and mixtures can exacerbate the dissolution of DNA and soluble proteins.

Patterns of Caudate Lobe Invasion of Hilar Cholangiocarcinoma: A Panoramic Histologic Study of Liver.

BACKGROUND: At present, caudate lobectomy (CL) in hilar cholangiocarcinoma (HCCA) was controversial. Our study was designed to investigate the features of caudate lobe invasion (CLI) by whole-mount histologic large sections (WHLS). METHODS: A total of 46 HCCA patients underwent hemihepatectomy or trisectionectomy combined with CL were included. Serial WHLS (120 mm × 100 mm) were collected, and the relationship between caudate lobe and tumor was retained to determine the incidence of CLI. Hematoxylin and eosin (HE) and immunohistochemical (IHC) staining were completed to further explore the pathway of CLI. RESULTS: The whole region of the Glisson system in caudate lobe and hilar area can be clearly displayed by WHLS, and 32 (32/46 69.6%) patients were identified with CLI. There were three different pathways of CLI with panoramic IHC staining. The most common pathway is through the fibrous connective tissue along Glisson system (20/32 62.5%, without carcinoma in bile ducts). The Bismuth type, tumor size, vascular invasion, pathological type, and hepatic invasion were related to the CLI (p < 0.05). CONCLUSIONS: The incidence and distribution of CLI provided histologic evidence for CL in HCCA. Based on the invasion pathway, it is necessary to assess the fibrous connective tissue in Glisson system of caudate lobe in pathological research and practice.

Impact of the COVID-19 Pandemic on ST-Elevation Myocardial Infarction Management in Hunan Province, China: A Multi-Center Observational Study.

Background: This study aimed to investigate the impact of the COVID-19 pandemic on ST-segment elevation myocardial infarction (STEMI) care in China. Methods: We conducted a multicenter, retrospective cohort study in Hunan province (adjacent to the epidemic center), China. Consecutive patients presenting with STEMI within 12 h of symptom onset and receiving primary percutaneous coronary intervention, pharmaco-invasive strategy and only thrombolytic treatment, were enrolled from January 23, 2020 to April 8, 2020 (COVID-19 era group). The same data were also collected for the equivalent period of 2019 (pre-COVID-19 era group). Results: A total of 610 patients with STEMI (COVID-19 era group n = 286, pre-COVID-19 era group n = 324) were included. There was a decline in the number of STEMI admissions by 10.5% and STEMI-related PCI procedures by 12.7% in 2020 compared with the equivalent period of 2019. The key time intervals including time from symptom onset to first medical contact, symptom onset to door, door-to-balloon, symptom onset to balloon and symptom onset to thrombolysis showed no significant difference between these two groups. There were no significant differences for in-hospital death and major adverse cardiovascular events between these two groups. Conclusion: During the COVID-19 pandemic outbreak in China, we observed a decline in the number of STEMI admissions and STEMI-related PCI procedures. However, the key quality indicators of STEMI care were not significantly affected. Restructuring health services during the COVID-19 pandemic has not significantly adversely influenced the in-hospital outcomes.

Characteristic of Perineural Invasion in Hilar Cholangiocarcinoma Based on Whole-Mount Histologic Large Sections of Liver.

Background & Objective: Perineural invasion is an important biological feature of hilar cholangiocarcinoma (HCCA). We developed a whole-mount histologic large sections (WHLS) of the liver to evaluate peripheral nerve invasion (PNI) of HCCA. Methods: Using sampling, fixation, dehydration, embedding, sectioning, hematoxylin and eosin (H&E) and immunohistochemical (IHC) staining, and scanning, the characteristics of intrahepatic and extrahepatic PNI in 20 patients with Bismuth type III and type IV HCCA were analyzed with WHLS. Correlation between the characteristics of nerve invasion and tumor size, vascular invasion (artery, portal vein), degree of differentiation, microvascular invasion (MVI), carbohydrate antigen19-9 (CA19-9), and differentiation degree of HCCA was statistically evaluated. Results: The WHLS of the liver was successfully established, which enabled us to observe intrahepatic and extrahepatic distribution of HCCA and whether surrounding tissues including nervous, blood, and lymph vessels were infiltrated. Extrahepatic and intrahepatic PNI were identified in 20 (100%) patients and 1 (5.0%) patient, respectively. Vessel density decreased in most invaded nerves presented by CD-34, which correlated with 100% of poorly differentiated and 83% of moderately differentiated tumors (P<0.008). Conclusion: This study established a WHLS of the liver that can be used for clinical diagnosis and research, and confirmed that extrahepatic PNI is prevalent, but intrahepatic nerve invasion is rare and does not accompany the invasion scope of bile ducts in types III and IV HCCA. In addition, moderately and poorly differentiated malignant tumors are more prone to PNI, independent of blood supply.

Clinical Features and Temporal Lung Radiographic Changes in 25 Patients Recovering from COVID-19 Pneumonia: A Retrospective Case-Control Study.

BACKGROUND Little is known of the changes in lung radiographic characteristics over time in patients recovering from COVID-19. This study analyzed the clinical features and temporal lung radiographic changes in patients with moderate and severe COVID-19 pneumonia who did not require invasive mechanical ventilation during the acute and convalescent periods. MATERIAL AND METHODS The data of 25 patients with COVID-19 pneumonia from January 29, 2020, to November 24, 2020, who did not require invasive mechanical ventilation and who were followed up were retrospectively collected. The 25 patients were divided into severe and moderate groups. Clinical characteristics and computed tomography (CT) manifestations were compared. A total of 121 consecutive thin-slice CT scans were collected at 4 weeks, 2 months, and 5 months after admission to evaluate lung abnormalities in the patients. The CT score was used to assess disease severity. RESULTS The severe group had a lower rate of nucleic acid conversion within 10 days of admission and higher D-dimer, creatine kinase, and lactate dehydrogenase values. In the severe group, hospital stay was longer and hospitalization costs were higher. The average CT score of the severe group peaked in the second week, while the moderate group peaked in the first week and then decreased over time. There were no statistically significant differences in the average CT score between the 2 groups at the 5-month follow-up. CONCLUSIONS The pulmonary lesions of patients recovering from COVID-19 and who do not require invasive mechanical ventilation were gradually absorbed and resolved over time.

Extrahepatic bile duct reconstruction in pigs with heterogenous animal-derived artificial bile ducts: A preliminary experience.

BACKGROUND: Extrahepatic biliary duct injury (BDI) remains a complicated issue for surgeons. Although several approaches have been explored to address this problem, the high incidence of complications affects postoperative recovery. As a nonimmunogenic scaffold, an animal-derived artificial bile duct (ada-BD) could replace the defect, providing good physiological conditions for the regeneration of autologous bile duct structures without changing the original anatomical and physiologic conditions. AIM: To evaluate the long-term feasibility of a novel heterogenous ada-BD for treating extrahepatic BDI in pigs. METHODS: Eight pigs were randomly divided into two groups in the study. The animal injury model was developed with an approximately 2 cm segmental defect of various parts of the common bile duct (CBD) for all pigs. A 2 cm long novel heterogenous animal-derived bile duct was used to repair this segmental defect (group A, ada-BD-to-duodenum anastomosis to repair the distal CBD defect; group B, ada-BD-to-CBD anastomosis to repair the intermedial CBD defect). The endpoint for observation was 6 mo (group A) and 12 mo (group B) after the operation. Liver function was regularly tested. Animals were euthanized at the above endpoints. Histological analysis was carried out to assess the efficacy of the repair. RESULTS: The median operative time was 2.45 h (2-3 h), with a median anastomosis time of 60.5 min (55-73 min). All experimental animals survived until the endpoints for observation. The liver function was almost regular. Histologic analysis indicated a marked biliary epithelial layer covering the neo-bile duct and regeneration of the submucosal connective tissue and smooth muscle without significant signs of immune rejection. In comparison, the submucosal connective tissue was more regular and thicker in group B than in group A, and there was superior integrity of the regeneration of the biliary epithelial layer. Despite the advantages of the regeneration of the bile duct smooth muscle observed in group A, the effect on the patency of the ada-BD grafts in group B was not confirmed by macroscopic assessment and cholangiography. CONCLUSION: This approach appears to be feasible for repairing a CBD defect with an ada-BD. A large sample study is needed to confirm the durability and safety of these preliminary results.

Clinical significance of diabetes on symptom and patient delay among patients with acute myocardial infarction-an analysis from China Acute Myocardial Infarction (CAMI) registry.

BACKGROUND: Diabetes is frequently associated with poor prognosis among acute myocardial infarction (AMI) patients. Patients with these comorbidities often have atypical symptoms and subsequent delay in treatment. Few studies have reported detailed AMI symptoms in patients with diabetes. This study compared AMI symptoms and presentation characteristics between diabetics and non-diabetics. METHODS: We included patients from the China AMI registry diagnosed with AMI between January 2013 and September 2014. Baseline characteristics, symptomology, and delay in treatment were compared between diabetics and non-diabetics. Multivariable logistic regression analysis was used to explore independent predictors of atypical symptoms. RESULTS: A total of 4450 (20.2%) patients had diabetes. They were older, more often women, higher in body mass index, and more likely to have non-ST segment elevation myocardial infarction. Fewer diabetic patients presented with persistent precordial chest pain (63.1% vs. 68%, P < 0.0001), diaphoresis (60.1% vs. 65.6%, P < 0.0001), fatigue (16.7% vs. 18.3%, P = 0.0123), and incontinence (0.4% vs. 0.7%, P = 0.0093). Time to hospital presentation was longer among patients with diabetes than those without. In multivariable analysis, diabetes was identified as an independent predictor of atypical symptoms (OR: 1.112, 95% CI: 1.034-1.196). CONCLUSIONS: Our study is the first large-scale study providing evidence that diabetics are less likely to present with typical chest pain and more likely to experience treatment delay when suffering from an AMI. Our results may increase clinician awareness of recognizing AMI patients rapidly to reduce diagnosis and treatment delay, particularly in the context of diabetes.

Augmented reality technology for preoperative planning and intraoperative navigation during hepatobiliary surgery: A review of current methods.

BACKGROUND: Augmented reality (AR) technology is used to reconstruct three-dimensional (3D) images of hepatic and biliary structures from computed tomography and magnetic resonance imaging data, and to superimpose the virtual images onto a view of the surgical field. In liver surgery, these superimposed virtual images help the surgeon to visualize intrahepatic structures and therefore, to operate precisely and to improve clinical outcomes. DATA SOURCES: The keywords "augmented reality", "liver", "laparoscopic" and "hepatectomy" were used for searching publications in the PubMed database. The primary source of literatures was from peer-reviewed journals up to December 2016. Additional articles were identified by manual search of references found in the key articles. RESULTS: In general, AR technology mainly includes 3D reconstruction, display, registration as well as tracking techniques and has recently been adopted gradually for liver surgeries including laparoscopy and laparotomy with video-based AR assisted laparoscopic resection as the main technical application. By applying AR technology, blood vessels and tumor structures in the liver can be displayed during surgery, which permits precise navigation during complex surgical procedures. Liver transformation and registration errors during surgery were the main factors that limit the application of AR technology. CONCLUSIONS: With recent advances, AR technologies have the potential to improve hepatobiliary surgical procedures. However, additional clinical studies will be required to evaluate AR as a tool for reducing postoperative morbidity and mortality and for the improvement of long-term clinical outcomes. Future research is needed in the fusion of multiple imaging modalities, improving biomechanical liver modeling, and enhancing image data processing and tracking technologies to increase the accuracy of current AR methods.

A novel laparoscopic transcystic approach using an ultrathin choledochoscope and holmium laser lithotripsy in the management of cholecystocholedocholithiasis: An appraisal of their safety and efficacy.

BACKGROUND: Although laparoscopic transcystic common bile duct exploration (LTCBDE) is the preferred approach for CBD stone clearance, the success rate can vary between 55% and 85%. This study evaluated if ultrathin choledochoscope and holmium laser lithotripsy could improve the success rate of LTCBDE. METHODS: Records of 126 patients (average age, 46.1 ± 13.8 years) with cholecystocholedocholithiasis treated with laparoscopic cholecystectomy (LC) and LTCBDE were retrospectively reviewed. RESULTS: LC+LTCBDE was performed successfully in 118 of 126 patients, with a surgical success rate of 93.7%. An ultrathin choledochoscope was used in 75 (63.5%) patients, and holmium lithotripsy was performed in 38 (32.2%) patients. The stone clearance rate was 99.2% (117/118). No significant complications occurred. One hundred (84.7%) patients had excellent and 13 (11%) had good outcomes for an overall success rate (excellent plus good) of 95.7%. CONCLUSION: Ultrathin choledochoscope and holmium laser lithotripsy can improve the surgical outcomes of LC+LTCBDE with minimal complications.

Cholesterol polyps in the distal common bile duct: a case report.

RATIONALE: Cholesterol polyps are rare in the common bile duct and difficult to diagnose. PATIENT CONCERNS: The small polypoid lesions often go undetected when using routine imaging methods, such as ultrasonography. DIAGNOSES: We treated a patient with cholesterol polyps in the common bile duct. After failing to detect choleliths using ultrasonography, magnetic resonance cholangiopancreatography revealed mild dilation of the common bile duct. Choledochoscopy was performed during laparoscopic cholecystectomy, which revealed yellowish-white polyps circumferentially distributed across the luminal surface of the distal common bile duct. Histological examination of biopsy specimens indicated cholesterol polyps with characteristic foamy cells. INTERVENTIONS: The patient was treated with ursodeoxycholic acid, and the number of polyps was found to have been reduced at the 6-week follow-up based on T-tube choledochoscopic examination. OUTCOMES: Recovery was unremarkable, and the ursodeoxycholic acid treatment was discontinued at the 6-month follow-up. LESSONS SUBSECTIONS: Our findings suggest that this rare condition can be treated pharmacologically to avoid potential postsurgical complications following resection of the distal common bile duct.

Ultrathin choledochoscope improves outcomes in the treatment of gallstones and suspected choledocholithiasis.

BACKGROUND: We aimed to compare laparoscopic cholecystectomy (LC) and simultaneous laparoscopic transcystic common bile duct exploration (LTCBDE) using an ultrathin choledochoscope with LC followed by endoscopic retrograde cholangiopancreatography (ERC) and endoscopic sphincterotomy (ES) when indicated. METHODS: We retrospectively reviewed the records of patients seen between 2004 and 2014 and treated with LC+LTCBDE or LC for gallstones and suspected choledocholithiasis. Postoperative complications and surgical outcomes were compared using t-test, Mann-Whitney U test, or chi-square test. RESULTS: 115 patients underwent successful LC+LTCBDE and 112 LC; follow-up data was available for 103 and 106 patients, respectively. Seventeen patients (16.5%) in the LC+LTCBDE group and 10 (28.6%) in the LC+ERC+ES group developed complications (P = 0.114). The LC+LTCBDE group had a significantly higher rate of satisfactory biliary function outcomes than the LC+ERC+ES group (98.1% vs. 85.7%, respectively) (P = 0.017). CONCLUSIONS: Single-step LC+LTCBDE using an ultrathin choledochoscope may provide better outcomes in patients with gallstones and suspected choledocholithiasis.

The ubiquitin ligase RNF43 downregulation increases membrane expression of frizzled receptor in pancreatic ductal adenocarcinoma.

RNF43 is a novel tumor suppressor protein and known to be expressed in a multitude of tissue and dysregulated in cancers of these organs including ovarian and colorectal tissues. RNF43 expression has been shown to be expressed in mutated forms in several pancreatic cell lines. RNF43, by virtue of being an ubiquitin ligase, has the potential to ubiquitinylate membrane receptors like frizzled that subserves sensing Wnt soluble signals at the cell membrane. Thus, normally, RNF43 downregulates Wnt signaling by removing frizzled receptor from the membrane. In the present study, the expression of the tumor suppressor RNF43 was examined in human patient samples of pancreatic ductal adenocarcinoma (PDAC). Reduced levels of expression of RNF43 in PDAC were demonstrated by Western blotting. We incorporated membrane biotinylation assay to examine the expression of frizzled6 receptor in the membrane and demonstrated that it is significantly increased in PDAC tissues. This may be responsible for enhanced Wnt/beta-catenin signaling and provides the first level of evidence of a possible role of this well-known pathway in pancreatic exocrine carcinogenesis. We have utilized appropriate controls to ensure the true positivity of the findings of the present study. The contribution of Wnt/beta-catenin/RNF43 pathway in pancreatic carcinogenesis may provide for utilization of pharmacologic resources for precision-based approaches to treat pancreatic ductal adenocarcinoma.

Treatment and outcomes of adults with remnant intrapancreatic choledochal cysts.

BACKGROUND: The purpose of this study is to report our experience with the treatment of remnant intrapancreatic choledochal cysts (CCs) in adults. METHODS: We reviewed retrospectively the records of patients with intrapancreatic remnant CCs who underwent reoperation by our surgical team from January 2000 to December 2012. Postoperative complications, surgical outcomes, and rate of malignancy were noted. RESULTS: A total of 41 patients were included: 35 without malignant transformation after the primary operation and 6 with malignant transformation. After the primary operation, all patients experienced cholangitis, and more than one-half had cholangiolithiasis (66%), pancreatitis (51%), and vomiting (51%). The mean age of the 35 patients (9 males and 26 females) was 49 years (range, 27-69), and the majority had originally a Todani type I cyst (74%). Most patients (74%) had undergone previously subtotal extrahepatic cyst excision and Roux-en-Y hepaticochojejunostomy. After excision of the remnant cyst, the rate of an excellent or good outcome was obtained in 91% of patients. The mean age of the patients with malignant transformation was 51 years (range, 35-70), and the rate of malignancy was 15% (6/41). The average time between the original incomplete CC excision and the diagnosis of malignancy was 140 months (range, 52-265). Four patients underwent pancreatoduodenectomy, and 2 underwent palliative surgery because the lesions were invading adjacent tissues. Five patients died of their disease within 37 months after reoperation. CONCLUSION: Complications seem to be common after incomplete resection of a CC with remnant intrapancreatic CCs, and the malignancy rate is relatively high. To improve outcomes, all attempts at complete resection of the intrapancreatic portion of CCs should be made at the time of the primary operation.

Sphincter of Oddi Dysfunction and the Formation of Adult Choledochal Cyst Following Cholecystectomy: A Retrospective Cohort Study.

To determine the causes underlying the formation of adult choledochal cyst.Anomalous pancreaticobiliary junction is the most widely accepted theory regarding the etiology of choledochal cyst. However, choledochal cysts have been found in patients in the absence of this anomaly. Because the number of adult patients with choledochal cyst is increasing, it is important to address this controversy.Bile amylase levels in the cysts of 27 patients (8 males and 19 females) who had undergone cholecystectomy were retrospectively evaluated.The average age of the 27 patients was 45.8 ± 10.1 years and the majority (85.2%) were diagnosed with Todani type I cysts. None of the patients had dilatation of the common bile duct prior to surgery. There were 6 (22.2%) patients with anomalous pancreaticobiliary junction. However, amylase levels did not significantly differ between patients with and without this anomaly (P = 0.251). According to bile amylase levels, pancreatobiliary reflux was present in 21 (77.8%) patients. The mean amylase level significantly differed in patients with pancreatobiliary reflux (23,462 ± 11,510 IU/L) and those without (235 ± 103 IU/L) (P < 0.001). In patients with pancreatobiliary reflux, only 4 patients had anomalous pancreaticobiliary junction. That is, the majority of patients (17/21, 81%) having pancreatobiliary reflux did not have an anomalous junction of the pancreatic and biliary ducts.Since the only explanation for pancreatobiliary reflux in patients with a normal pancreaticobiliary junction is sphincter of Oddi dysfunction, we proposed that the formation of adult choledochal cyst is mainly due to sphincter of Oddi dysfunction.

Role of the Surgical Method in Development of Postoperative Cholangiocarcinoma in Todani Type IV Bile Duct Cysts.

Background. Our purpose was to investigate the association between the surgical approach for Todani type IV cysts and subsequent malignancy rate. Methods. The records of patients who received cyst excision from 1994 to 2013 were analyzed retrospectively for the following data: demographics, presenting symptoms, postoperative outcomes, malignant transformation, and follow-up reexaminations, including imaging, laboratory, and tumor marker tests. Results. Seven of the 196 patients initially treated at our hospital developed postoperative biliary malignancy, and the surgical approaches were extrahepatic bile duct cyst resection combined with hilar cholangioplasty and Roux-en-Y cystojejunostomy (n = 5), and intra- and extrahepatic bile duct cyst resection and Roux-en-Y hepaticojejunostomy (n = 2). The overall malignancy rate was 3.6% (7/196). Forty-eight patients initially treated at other hospitals developed malignancy postoperatively: 15 (31.2%) remained untreated and 33 (68.8%) had undergone incomplete resection procedures. Because Todani type IV cysts were seen in 268 patients, the postoperative malignancy rate of this group of patients was 12.3% (33/268). Conclusions. Radical resection of both intra- and extrahepatic cysts combined with hepatic resection and Roux-en-Y hepaticojejunostomy is associated with a reduced risk of subsequent cancer development. Procedures in which radical cyst excision is not performed are associated with a greater risk of subsequent malignancy.