New criteria of resectability for pancreatic cancer: A position paper by the Japanese Society of Hepato-Biliary-Pancreatic Surgery (JSHBPS).

The symposium "New criteria of resectability for pancreatic cancer" was held during the 33nd meeting of the Japanese Society of Hepato-Biliary-Pancreatic Surgery (JSHBPS) in 2021 to discuss the potential modifications that could be made in the current resectability classification. The meeting focused on setting the foundation for developing a new prognosis-based resectability classification that is based on the tumor biology and the response to neoadjuvant treatment (NAT). The symposium included selected experts from Western and Eastern high-volume centers who have discussed their concept of resectability status through published literature. During the symposium, presenters reported new resectability classifications from their respective institutions based on tumor biology, conditional status, pathology, and genetics, in addition to anatomical tumor involvement. Interestingly, experts from all the centers reached the agreement that anatomy alone is insufficient to define resectability in the current era of effective NAT. On behalf of the JSHBPS, we would like to summarize the content of the conference in this position paper. We also invite global experts as internal reviewers of this paper for intercontinental cooperation in creating an up-to-date, prognosis-based resectability classification that reflects the trends of contemporary clinical practice.

Massive cerebral air embolism following percutaneous transhepatic biliary drainage: A case report.

RATIONALE: Cerebral air embolism from portal venous gas rarely occurs due to invasive procedures (e.g., endoscopic procedures, liver biopsy, or percutaneous transhepatic biliary drainage) that disrupt the gastrointestinal or hepatobiliary structures. Here, we report a rare case of fatal cerebral air embolism following a series of percutaneous transhepatic biliary drainage tube insertions. PATIENT CONCERNS: A 50-year-old woman with a history of cholecystectomy, liver wedge resection, and hepaticojejunostomy for gallbladder cancer presented with altered mental status 1 week after percutaneous transhepatic biliary drainage tube placement. DIAGNOSES: Extensive cerebral air embolism and acute cerebral infarction. INTERVENTIONS: Brain computed tomography and magnetic resonance imaging, hyperbaric oxygen therapy, medical therapy. OUTCOMES: Despite the use of hyperbaric oxygen therapy and medical treatment including vasopressors, the patient eventually died due to massive systemic air embolism. LESSONS: To date, there have been no reports of cerebral air embolism due to percutaneous transhepatic biliary drainage with pronounced radiologic images. We reviewed previously reported fatal cases associated with endoscopic hepatobiliary procedures and assessed the possible mechanisms and potential causes of air embolism.

Clinical Benefit of Preoperative Exercise and Nutritional Therapy for Patients Undergoing Hepato-Pancreato-Biliary Surgeries for Malignancy.

BACKGROUND: The impact of prehabilitation on physical fitness and postoperative course after hepato-pancreato-biliary (HPB) surgeries for malignancy is unknown. The current study aimed to investigate the effect of preoperative exercise and nutritional therapies on nutritional status, physical fitness, and postoperative outcomes of patients undergoing an invasive HPB surgery for malignancy. METHODS: Patients who underwent open abdominal surgeries for HPB malignancies (major hepatectomy, pancreatoduodenectomy, or hepato-pancreatoduodenectomy) between 2016 and 2017 were subjected to prehabilitation. Patients before the introduction of prehabilitation were included as historical control subjects for 1:1 propensity score-matching (no-prehabilitation group). The preoperative nutritional status and postoperative course were compared between the two groups. RESULTS: The prehabilitation group consisted of 76 patients scheduled to undergo HPB surgeries for malignancy. An identical number of patients were selected as the no-prehabilitation group after propensity score-matching. During the waiting period, serum albumin levels were significantly deteriorated in the no-prehabilitation group, whereas this index did not deteriorate or even improved in the prehabilitation group. By performing prehabilitation, a 6-min walk distance and total muscle/fat ratio were significantly increased during the waiting period. Although the overall incidence of postoperative complications did not differ between the two groups, the postoperative hospital stay was shorter in the prehabilitation group than in the no-prehabilitation group (median, 23 vs 30 days; p = 0.045). CONCLUSION: The introduction of prehabilitation prevented nutritional deterioration, improved physical fitness before surgery, and shortened the postoperative hospital stay for the patients undergoing HPB surgeries for malignancy.

Predictors of Failed Transcystic Laparoscopic Common Bile Duct Exploration: Analysis of Multicenter Integrated Health System Database.

BACKGROUND: The aim of this study is to report our experience with laparoscopic common bile duct exploration (LCBDE) and validate the experts' opinion about anatomical predictors of failed transcystic LCBDE (TLCBDE) approach. METHODS: Patients undergoing LCBDE at Kaiser Permanente Southern California hospitals (2005-2015) were included. Predictors of failed TLCBDE were identified using bivariate analysis. RESULTS: Of 115 LCBDE, 89.6% were TLCBDE and 10.4% through choledochotomy. Success rate, morbidity, and length of hospital stay were 83.5%, 6.1%, and 3.8 days respectively. Only stone size:cystic duct ratio >1 (35% versus 63%, P = .044) was associated with failure of TLCBDE. In accordance with experts' opinion, there was a suggestive association of stone size ≥6 mm, cystic duct ≤4 mm, multiple stones, and proximal stone location with failure; however, these did not reach statistical significance. CONCLUSION: LCBDE is an effective and safe mean of clearing common bile duct stones at community hospitals of an integrated health system. Previously cited contraindications for TLCBDE are not absolute, but rather predictors of failure.

[Effect of Xuebijing injection on postoperative inflammatory response in patients after hepatobiliary and pancreatic surgeries: a retrospective cohort study].

OBJECTIVE: To analyze the effect of Xuebijing injection on inflammatory response in patients after hepatobiliary and pancreatic surgeries, and to evaluate its safety and clinical value. METHODS: A retrospective cohort study was conducted. 708 patients received hepatobiliary and pancreatic surgeries of Nanfang Hospital, Southern Medical University from January 2015 to September 2017 were enrolled and divided into Xuebijing treatment group and conventional treatment group according to whether they were treated with Xuebijing injection or not. The inflammatory response indexes included white blood cell count (WBC), neutrophil (NE), C-reactive protein (CRP), body temperature, which were compared between the two groups at 1, 3, and 5 days after operation. The incidence of adverse reactions, the length of postoperative hospital stays and hospitalization costs were compared. RESULTS: A total of 209 patients were prescribed with Xuebijing injection, and 499 patients were allocated into conventional treatment group. The two groups were stratified by liver, biliary and pancreatic surgery types, and further 1:1 propensity score matching was performed. After propensity score match, 189 patients were included in each group, with 101, 46, and 42 patients undergoing liver, biliary, and pancreas surgery, respectively. There were no significant differences in baseline data such as gender, age and inflammatory response indexes before surgery between the two groups. In both groups, the WBC and NE showed a gradual decline after operation, CRP were increased gradually and then decreased after 3 days. Compared with the conventional treatment group, Xuebijing treatment group showed obvious anti-inflammatory effect from 3 days after operation [WBC (×109/L): 10.1±4.0 vs. 11.0±3.5, NE: 0.71±0.10 vs. 0.76±0.12, CRP (mg/L): 73.1±38.7 vs. 82.2±41.8, all P < 0.05]. On the 5th day, it still showed a strong anti-inflammatory trend [WBC (×109/L): 7.0±2.8 vs. 7.9±2.6, NE: 0.62±0.10 vs. 0.68±0.12, CRP (mg/L): 43.4±31.0 vs. 50.9±25.3, all P < 0.05]. The cases of postoperative fever in the Xuebijing treatment group were significantly less than that in the conventional treatment group (cases: 98 vs. 119, χ2 = 4.711, P = 0.029). There was no significant different in the total incidence of adverse drug reactions such as rash, nausea and vomiting (5.0% vs. 3.2%), the length of postoperative hospital stays [days: 9.3 (6.1, 13.5) vs. 9.1 (5.5, 13.3)] and hospitalization costs [wanyuan: 5.8 (3.6, 9.5) vs. 5.7 (3.5, 9.8)] between Xuebijing treatment group and conventional treatment group (all P > 0.05). CONCLUSIONS: Xuebijing injection has a good anti-inflammatory effect on patients undergoing hepatobiliary and pancreatic surgeries. Xuebijing injection has good safety and can be applied to the prevention and treatment of excessive inflammatory reaction after hepatobiliary and pancreatic surgeries.

Treatment of pancreatic head cancer with obstructive jaundice by endoscopy ultrasonography-guided gastrojejunostomy: A case report and literature review.

RATIONALE: Ultrasonography-guided gastrojejunostomy (EUS-GJ) might be a safe, innovative and minimally invasive interventional treatment for patients with gastric outlet obstruction (GOO) as an alternative to the surgical approach. To date, few cases have been reported in the literature. PATIENT CONCERNS: A case of pancreatic head carcinoma with obstructive jaundice occurred in a 78-year-old man with a prior history of pancreatic head cancer. Biliary stent placement was conducted 1 year earlier. DIAGNOSES: The patient was diagnosed with pancreatic cancer, pulmonary infection, pyloric obstruction, and biliary stent implantation. INTERVENTIONS: EUS-GJ was performed. The wire and a double-balloon catheter reached the position of stenosis, then a double mushroom head bracket was released under EUS. The position was confirmed via X-ray. OUTCOMES: The symptoms of obstruction were alleviated. No recurrence of obstruction, bleeding, perforation, and other complications occurred for the following 1.5 months while he died because of whole body spread of pancreatic cancer. LESSONS: EUS-GJ may be reliable and effective for patients with GOO.

Treatment of pancreatic cancer with intravenous vitamin C: a case report.

Pancreatic ductal adenocarcinoma (PDA) has a dismal prognosis and is often discovered at an advanced stage with few therapeutic options. Current conventional regimens for PDA are associated with significant morbidity, decreased quality of life, and a considerable financial burden. As a result, some patients turn to integrative medicine therapies as an alternate option after a diagnosis of PDA. Intravenous pharmacologic ascorbic acid (PAA) is one such treatment. The use of PAA has been passionately debated for many years, but more recent rigorous scientific research has shown that there are significant blood concentration differences when ascorbic acid is given parenterally when compared to oral dosing. This pharmacologic difference appears to be critical for its role in oncology. Here, we report the use of PAA in a patient with poorly differentiated stage IV PDA as an exclusive chemotherapeutic regimen. The patient survived nearly 4 years after diagnosis, with PAA as his sole treatment, and he achieved objective regression of his disease. He died from sepsis and organ failure from a bowel perforation event. This case illustrates the possibility of PAA to effectively control tumor progression and serve as an adjunct to standard of care PDA chemotherapy regimens. Our patient's experience with PAA should be taken into consideration, along with previous research in cell, animal, and clinical experiments to design future treatment trials.

High expression of MMP-9 is associated with better prognosis in extrahepatic bile duct cancer patients.

PURPOSE: To evaluate the prognostic value of matrix metalloproteinase-9 (MMP-9) in patients with extrahepatic bile duct (EHBD) cancer undergoing surgical resection and adjuvant radiotherapy. METHODS: Between January 2000 and August 2006, patients who underwent complete resection followed by adjuvant radiotherapy for EHBD cancer were enrolled in this study. The expression of MMP-9 was assessed with immunohistochemical staining. The prognostic values of the MMP-9 expression and other clinicopathologic factors were evaluated in univariate and multivariate analyses. RESULTS: Sixty-six patients were included in this study. All received radiotherapy with a median dose of 40 Gy (range, 40-56), and 61 patients received concomitant fluoropyrimidine chemotherapy. MMP-9 was highly expressed in 33 patients (50.0%). MMP-9 expression was significantly associated with locoregional recurrence-free survival (LRRFS) and overall survival (OS) but not with distant metastasis-free survival (DMFS). The 5-year LRRFS and OS rates were 50.8% versus 86.5% (p = .0281), and 23.3% versus 68.1% (p = .0087) in patients with low and high expression of MMP-9, respectively. Among the clinicopathologic factors, tumor location was associated with DMFS and OS (p = .0292 and .0003, respectively). Nodal stage and histologic differentiation showed significant association with DMFS (p = .0277 and .0060, respectively). Based on multivariate analysis for OS, tumor location was the only significant prognostic factor (p = .0021), while MMP-9 expression showed marginal significance (p = .0633). CONCLUSION: MMP-9 expression is a useful prognostic factor for predicting LRRFS and OS in patients with EHBD cancer after surgical resection and adjuvant radiotherapy.

Long-term outcomes of six patients after partial internal biliary diversion for progressive familial intrahepatic cholestasis.

BACKGROUND: Partial internal biliary diversion (PIBD) is an alternative approach for the treatment of devastating pruritus in patients with progressive familial intrahepatic cholestasis (PFIC). In these patients quality of life can be improved and progression of liver disease can be delayed while waiting for liver transplantation. The aim of our study was to evaluate six patients with PFIC who have undergone PIBD in long-term follow-up. METHODS: Retrospective review of the records of six patients who underwent PIBD for PFIC between 2008 and 2010 was conducted to evaluate age, growth, clinical and laboratory studies for long-term outcome. RESULTS: Serum postoperative bile acid levels were reduced from a mean 340.1µmol/L (range 851-105) preoperatively to a mean of 96.3µmol/L at postoperative fifth year. The difference between pre- and postoperative bile acid levels was statistically significant (p=0.018). AST decreased from 79.1U/L (range 43-150U/L) to 64.6U/L (range 18-172U/L), ALT decreased from 102.8U/L (range 35-270U/L) to 84.6U/L and total bilirubin decreased from 2.9µmol/L (range 0.35-6.4µmol/L) to 1.53µmol/L (range 0.3-2.4). Again, the decrease in total bilirubin levels was significant (p=0.043). Pruritus was diminished from a mean of +4 (range 4-4) preoperatively to a mean of +2 (4-0). One patient who underwent liver transplantation owing to relapsing pruritus died from postoperative sepsis in the early postoperative period at the fifth year after PBID. Five symptom-free patients have not required liver transplantation at a mean period of 6.1±0.83years (5.1-7.0years) follow-up. CONCLUSION: PBID is an effective surgical procedure in the long-term and can delay the need for liver transplantation in children with PFIC by reducing jaundice and pruritus.

Hemobilia: An Uncommon But Notable Cause of Upper Gastrointestinal Bleeding.

GOAL AND BACKGROUND: A literature review to improve practitioners' knowledge and performance concerning the epidemiology, diagnosis, and management of hemobilia. STUDY: A search of Pubmed, Google Scholar, and Medline was conducted using the keyword hemobilia and relevant articles were reviewed and analyzed. The findings pertaining to hemobilia etiology, investigation, and management techniques were considered and organized by clinicians practiced in hemobilia. RESULTS: The majority of current hemobilia cases have an iatrogenic cause from either bile duct or liver manipulation. Blunt trauma is also a significant cause of hemobilia. The classic triad presentation of right upper quadrant pain, jaundice, and upper gastrointestinal bleeding is rarely seen. Computed tomography and magnetic resonance imaging are the preferred diagnostic modalities, and the preferred therapeutic management includes interventional radiology and endoscopic retrograde cholangiopancreatography. Surgery is rarely a therapeutic option. CONCLUSIONS: With advances in computed tomography and magnetic resonance imaging technology, diagnosis with these less invasive investigations are the favored option. However, traditional catheter angiography is still the gold standard. The management of significant hemobilia is still centered on arterial embolization, but arterial and biliary stents have become accepted alternative therapies.

Clinical Variability After Partial External Biliary Diversion in Familial Intrahepatic Cholestasis 1 Deficiency.

OBJECTIVES: Familial intrahepatic cholestasis 1 (FIC1) deficiency is caused by a mutation in the ATP8B1 gene. Partial external biliary diversion (PEBD) is pursued to improve pruritus and arrest disease progression. Our aim is to describe clinical variability after PEBD in FIC1 disease. METHODS: We performed a single-center, retrospective review of genetically confirmed FIC1 deficient patients who received PEBD. Clinical outcomes after PEBD were cholestasis, pruritus, fat-soluble vitamin supplementation, growth, and markers of disease progression that included splenomegaly and aspartate aminotransferase-to-platelet ratio index. RESULTS: Eight patients with FIC1 disease and PEBD were included. Mean follow-up was 32 months (range 15-65 months). After PEBD, total bilirubin was <2 mg/dL in all patients at 8 months after surgery, but 7 of 8 subsequently experienced a total of 15 recurrent cholestatic events. Subjective assessments of pruritus demonstrated improvement, but itching exacerbation occurred during cholestatic episodes. High-dose fat-soluble vitamin supplementation persisted, with increases needed during cholestatic episodes. Weight z scores improved (-3.4 to -1.65, P < 0.01). Splenomegaly did not worsen or develop and 1 patient developed an aminotransferase-to-platelet ratio index score of >0.7 suggesting development of fibrosis 24 months after PEBD. CONCLUSIONS: Clinical variability is evident among genetically defined FIC1 deficient patients after PEBD, even among those with identical mutations. Recurrent, self-limited episodes of cholestasis and pruritus are reminiscent of the benign recurrent intrahepatic cholestasis phenotype. Despite diversion of bile from the intestinal lumen, weight gain improved while fat-soluble vitamin requirements persisted. Significant progression of liver disease was not evident during follow-up.

Role of preoperative biliary stents, bile contamination and antibiotic prophylaxis in surgical site infections after pancreaticoduodenectomy.

BACKGROUND: The routine use of preoperative biliary drainage before pancreaticoduodenectomy (PD) remains controversial. This observational retrospective study compared stented and non-stented patients undergoing PD to assess any differences in post-operative morbidity and mortality. METHODS: A total of 180 consecutive patients who underwent PD and had intra-operative bile cultures performed between January 2010 and February 2013 were retrospectively identified. All patients received peri-operative intravenous antibiotic prophylaxis, primarily cefazolin. RESULTS: Overall incidence of post-operative surgical complications was 52.3 %, with no difference between stented and non-stented patients (53.4 % vs. 51.1 %; p = 0.875). However, stented patients had a significantly higher incidence of deep incisional surgical site infections (SSIs) (p = 0.038). In multivariate analysis, biliary stenting was confirmed as a risk factor for deep incisional SSIs (p = 0.044). Significant associations were also observed for cardiac disease (p = 0.010) and BMI ≥25 kg/m(2) (p = 0.045). Enterococcus spp. were the most frequent bacterial isolates in bile (74.5 %) and in drain fluid (69.1 %). In antimicrobial susceptibilty testing, all Enterococci isolates were cefazolin-resistant. CONCLUSION: Given the increased risk of deep incisional SSIs, preoperative biliary stenting in patients underging PD should be used only in selected patients. In stented patients, an antibiotic with anti-enterococcal activity should be chosen for PD prophylaxis.

CD24 expression predicts distant metastasis in extrahepatic bile duct cancer.

AIM: To evaluate the prognostic significance of CD24 expression in patients undergoing adjuvant chemoradiotherapy for extrahepatic bile duct (EHBD) cancer. METHODS: Eighty-four patients with EHBD cancer who underwent curative resection followed by adjuvant chemoradiotherapy were enrolled in this study. Postoperative radiotherapy was delivered to the tumor bed and regional lymph nodes up to a median of 40 Gy (range: 40-56 Gy). All patients also received fluoropyrimidine chemotherapy for radiosensitization during radiotherapy. CD24 expression was assessed with immunohistochemical staining on tissue microarray. Clinicopathologic factors as well as CD24 expression were evaluated in multivariate analysis for clinical outcomes including loco-regional recurrence, distant metastasis-free and overall survival. RESULTS: CD24 was expressed in 36 patients (42.9%). CD24 expression was associated with distant metastasis, but not with loco-regional recurrence nor with overall survival. The 5-year distant metastasis-free survival rates were 55.1% and 29.0% in patients with negative and positive expression, respectively (P = 0.0100). On multivariate analysis incorporating N stage, histologic differentiation and CD24 expression, N stage was the only significant factor predicting distant metastasis-free survival (P = 0.0089), while CD24 expression had borderline significance (P = 0.0733). In subgroup analysis, CD24 expression was significantly associated with 5-year distant metastasis-free survival in node-positive patients (38.4% with negative expression vs 0% with positive expression, P = 0.0110), but not in node-negative patients (62.0% with negative expression vs 64.0% with positive expression, P = 0.8599). CONCLUSION: CD24 expression was a significant predictor of distant metastasis for patients undergoing curative resection followed by adjuvant chemoradiotherapy especially for node-positive EHBD cancer.

History of biliary surgery.

Since ancient times biliary surgery has been one of the major interests of doctors and other scientists around the world. From the ancient Greeks and Egyptians to the greatest scientists of modern times biliary surgery has advanced remarkably. Especially during the last century huge progress has been made in this field. Minimally invasive surgical techniques have been developed and combined with general anesthesia and antisepsis that have made biliary surgery particularly safe for every patient and have made cholecystectomy one of the most common operations in the world today.

[Treatment and prophylaxis of infectious complications in hepatobiliary surgery].

The results of application of the antibacterial chinolone preparation maxicine in hepatobiliary surgery and gynecology in 28 patients were analyzed. In 6 patients the preparation was applied after reconstructive operations on biliary tructs (high hepaticojejunostomy for cicatricial stricture of biliary ducts), in 22--after laparoscopic operations (cholecystectomy, choledocholithotomy, excision of suppurated ovarian cysts). The spectrum of causative agents was presented. There was proved a high efficacy of the preparation for prophylaxis and treatment of the diseases and postoperative complications after interventions on the hepatobiliary zone organs and the ovarian cystic affection.

[Partial external biliary diversion: a therapeutic alternative for Alagille syndrome. First case in Argentina]. / Derivación biliar externa parcial: alternativa terapéutica en el síndrome de Alagille. Primer caso en la Argentina.

BACKGROUND: Alagille 's syndrome is the main syndromic chronic intrahepatic cholestasis characterized by hypoplasia of the intrahepatic bile ducts. It is a multisystem disorder of autosomal dominant inheritance with involvement of multiple organs. Usually it becomes apparent in the neonatal period, presenting as subclinical cases or severe degrees of the disease with the consequent development of liver cirrhosis and subsequent liver failure associated with multiple abnormalities: defects in the vertebral arches, typical facies, pulmonary stenosis, mental retardation and hypogonadism. OBJECTIVE: To present the first case of partial external biliary diversion in Argentina, showing the surgical technique and the improvement in the quality of life, as an alternative to be considered in patients with Alagille's syndrome before the development of cirrhosis. RESULTS: It has been shown that partial external biliary diversion can stop the process of liver fibrogenesis, halting the progression of the disease and avoiding the need for transplantation in some types of intrahepatic cholestasis when cirrhosis has not been established. DISCUSSION: This surgical technique can improve the quality of life and morbidity associated with hypercholesterolemia in patients with Alagille's syndrome, delaying and maybe avoiding the need for liver transplantation.

[A clinical study of bile cultures and antibiotic susceptibility test in the patients with operation on biliary tract].

OBJECTIVE: To illustrate the bacteriology and their susceptibility to antibiotics in patients with biliary tract diseases and provide information for antibiotic choices. METHODS: The bile specimens were cultured and pathogens' susceptibility to antibiotics was obtained intraoperatively from 195 patients undergoing operations on biliary tract and 24 healthy liver donors from June 2007 to March 2008. RESULTS: Among 195 bile specimens collected from the patients intraoperatively, 44 ones were found bacterial growth by culture (22.6%), in which 11 ones were mixed infections (25.0%). Fifty-five bacterial strains belonging to 16 species were identified from these bile specimens. They included 34 Gram negative strains (61.8%), 19 Gram positive strains (34.6%) and 2 fungal strains (3.6%). The commonest pathogens were Escherichia coli (27.3%), Enterobacter cloacae (12.7%), Enterococcus faecalis (12.7%) and Enterococcus faecium (10.9%). Among 24 bile specimens collected from the healthy liver donors, one was found Escherichia coli growth by culture (4.2%). The results of susceptibility test showed that the resistant rates of Gram negative strains to Meropenem was 2.8%, followed by Imipenem (5.6%), Sulperazone (22.8%) and Amikacin (28.7%). In this study Gram negative strains were highly resistant to Penicillins, Quinolones, some third generation Cephalosporins and so on (>50.0%). None of Gram positive strains were resistant to Vancomycin and Teicoplanin. They were highly resistant to Penicillins, Quinolones, Clindamycin and so on (>40.0%). CONCLUSIONS: (1) Gram negative strains remain the commonest pathogens in biliary tract infection in Renji Hospital and the commonest pathogen is Escherichia coli. The infection of enterococcus is going up. The mixed infection cases happen mostly in acute biliary infection. (2) To treat biliary infection the broad-spectrum antibiotics which are effective to Escherichia coli are optimal choices. Ceftazidime or Ciprofloxacin may be used in mild biliary infection. Sulperazone or Amikacin may be used in severe biliary infection. Imipenem and Vancomycins may be used as second choice to treat the infection which other drugs are ineffective to.

Prognostic factors in patients with advanced cholangiocarcinoma: role of surgery, chemotherapy and body mass index.

AIM: To study the factors that may affect survival of cholangiocarcinoma in Lebanon. METHODS: A retrospective review of the medical records of 55 patients diagnosed with cholangio-carcinoma at the American University of Beirut between 1990 and 2005 was conducted. Univariate and multivariate analyses were performed to determine the impact of surgery, chemotherapy, body mass index, bilirubin level and other factors on survival. RESULTS: The median survival of all patients was 8.57 mo (0.03-105.2). Univariate analysis showed that low bilirubin level (< 10 mg/dL), radical surgery and chemotherapy administration were significantly associated with better survival (P = 0.012, 0.038 and 0.038, respectively). In subgroup analysis on patients who had no surgery, chemotherapy administration prolonged median survival significantly (17.0 mo vs 3.5 mo, P = 0.001). Multivariate analysis identified only low bilirubin level < 10 mg/dL and chemotherapy administration as independent predictors associated with better survival (P < 0.05). CONCLUSION: Our data show that palliative and postoperative chemotherapy as well as a bilirubin level < 10 mg/dL are independent predictors of a significant increase in survival in patients with cholangiocarcinoma.

Inchin-ko-to prevents medium-term liver fibrosis in postoperative biliary atresia patients.

The oriental herbal formulation inchin-ko-to (ICKT) inhibits liver cell apoptosis induced by transforming growth factor-beta 1 (TGF-beta1). This study evaluated the effect of ICKT on serum markers of liver function and liver fibrosis in postoperative biliary atresia (BA) patients. Twenty-one postoperative BA patients with elevated GOT, GPT and gamma-GTP, but normal serum total bilirubin levels, were divided into two groups arbitrarily; an ICKT group (n = 12), and a no-ICKT group (n = 9). Serum markers of liver function [GOT, GPT, gamma-GTP, total bile acids (TBA)], and serum markers of liver fibrosis [hyaluronic acid (HA), type IV collagen (C-IV)], were measured in both groups at the beginning of the study, and at 1, and 3 years after the beginning of the study and the results compared statistically. All patients tolerated ICKT well, and there were no side effects. In the ICKT group, mean serum HA levels were significantly decreased at 1 year (P < 0.012), and at 3 years, both mean serum HA and C-IV were significantly decreased (P < 0.001 and P < 0.003, respectively). However, mean serum levels of GOT, GPT, gamma-GTP, and TBA did not change significantly following ICKT use for any length of time (all P > 0.05). Administration of ICKT in postoperative BA patients appears to lower the serum levels of markers of fibrosis in the medium-term. Whether this in fact correlates with prevention cannot be determined from this paper, but ICKT would appear to protect against liver fibrosis. Long-term studies are required to determine the exact role ICKT plays in prognosis of BA patients.