Bridging metallic stent placement in acute obstructed left sided malignant colorectal cancer: optimal time for surgery.

BACKGROUND: Colonic stenting is now the preferred treatment either for palliation or as a bridge to surgery for obstructed colorectal cancer. It reduces complications from emergency surgery and the need for colostomy formation. However, stent perforation can lead to peritoneal tumor spillage, a higher rate of infection and changing the risk of a potentially curable disease to an incurable one. Therefore, it is important to study the optimum time for operation after stent insertion. MATERIAL AND METHOD: From January 2006 to January 2012, 30 cases of acute left-sided malignant colorectal obstruction were managed by expandable metallic stent (SEMS) as a bridge to surgery. In all, 19 males and 11 females with mean age of 60.07±12.19 years (range 40-80 years) were included in the study. The obstructed locations were 1 case at the transverse colon, 6 cases at the descending colon, 13 cases at the sigmoid colon, 5 cases at the upper third at the rectum and 5 cases involving the middle third of the rectum. RESULTS: The perforation of SEMS was founded in 11 cases (36.67%). The mean bridging time before operation in the nonperforated group was 5.54 (±1.29) days shorter than in the perforated group, 10.54 (±4.82) days (p<0.001). All of the subjects in the perforated group reported clinical lower abdominal pain without sign of peritonitis, developed in an average 4.5 days (3-7 days). CONCLUSION: The optimum bridging time for surgery should be within 5 days.

Incidence of primary colorectal cancer from colonoscopy examinations in patients presenting with liver mass.

BACKGROUND: An in-patient presented with atypical primary liver mass and was suspected of having liver metastasis. One method of investigation is colonoscopy; however, there are currently no clear guidelines to indicate when this procedure should be performed. MATERIAL AND METHOD: This was a retrospective review of 6 years' data from the surgical endoscopic unit in Rajavithi Hospital. The inclusion criteria were: (1) patient presented with liver mass, (2) radiological findings (mainly from CT scan or MRI) were not typicalfor hepatocellular carcinoma (HCC), intrahepatic cholagiocarcinoma (ICGC) and other primary liver tumors. The exclusion criteria were: (1) patients did not undergo the operation in Rajavithi Hospital, (2) there was loss of patient data during the follow-up period. RESULT: A total of 1,532 cases underwent colonoscopy, of which 109 met the inclusion criteria. There were 24 cases of positive primary colorectal cancer and the incidence was 22% (95% CI 14.1-29.9), and 1 case of terminal ileum cancer. The final results after operation showed 40 cases of HCC, and 21 cases of intrahepatic cholangiocarcinoma. Risk factors for testing positive for colorectal cancer were: presenting with GI symptoms; abnormal CEA levels; and positive family history of colorectal cancer CONCLUSION: To increase the incidence of positive results for colorectal cancer and reduce unnecessary colonoscopy in patients who present with liver mass, the factors which indicate colonoscopy should be patients who present with GI symptom, abnormal CEA level, and whose family history raises concern.

Prognostic relevance of circulating CK19 mRNA in advanced malignant biliary tract diseases.

AIM: To determine the role of circulating tumor cells (CTCs) in prediction of the overall survival of patients with advanced malignant biliary tract obstruction. METHODS: We investigated the prognostic value of CTCs by examining two markers, cytokeratin (CK) 19 and human telomerase reverse transcriptase (hTERT) mRNA, in 40 patients diagnosed with advanced malignant biliary tract diseases. Quantitative real-time reverse transcription polymerase chain reaction was used to detect CK19 and hTERT mRNA in the peripheral blood of these patients. Overall survival was analyzed using the Kaplan-Meier method and Cox regression modeling. RESULTS: Positive CK19 and hTERT mRNA expression was detected in 45% and 60%, respectively, of the 40 patients. Univariable analysis indicated that positive CK19 mRNA expression was significantly associated with worse overall survival (P = 0.009). Multivariable analysis determined that positive CK19 mRNA expression, patient's age and serum bilirubin were each independently associated with overall survival. CONCLUSION: CK19 mRNA expression levels in peripheral blood appear to provide a valuable marker to predict the overall survival of patients with advanced malignant biliary tract obstruction.

Serum NGAL to Clinically Distinguish Cholangiocarcinoma from Benign Biliary Tract Diseases.

Aim. To determine whether the serum level of NGAL can discriminate cholangiocarcinoma from benign biliary tract disease in patients. Methods. This study was performed according to a prospective-specimen-collection, retrospective-blinded-evaluation (PRoBE) design. A total of 50 cholangiocarcinoma and 50 benign biliary tract disease cases were randomly selected from a cohort of consecutive cases of biliary tract diseases. Their sera were measured for the levels of NGAL and the widely used serum cholangiocarcinoma marker, carbohydrate antigen 19-9 (CA19-9). Results. The serum CA19-9 and NGAL levels were significantly elevated in cholangiocarcinoma patients (CA19-9: P < .001, NGAL: P < .001). The area under the curve (AUC) of a receiver operating characteristic (ROC) curve analysis for the diagnosis of cholangiocarcinoma of CA19-9 and NGAL was 0.81 and 0.79, respectively. Conclusion. The diagnostic accuracy of serum NGAL and CA19-9 makes them good candidates for use as biomarkers to discriminate cholangiocarcinoma patients from benign biliary tract disease patients.

Prospective study of MMP7 serum levels in the diagnosis of cholangiocarcinoma.

AIM: To determine whether the serum level of matrix metalloproteinase-7 (MMP7) has the potential to diagnosis cholangiocarcinoma from benign biliary tract diseases. METHODS: This study was performed according to the PRoBE (a prospective-specimen-collection, retrospective-blinded-evaluation) design. A total of 187 patients with obstructive jaundice were consecutively enrolled. After the diagnostic status of these patients was ascertained, their levels of serum MMP7 were assayed and compared with serum carbohydrate antigen 19-9 (CA19-9). This was conducted in a blinded case (cholangiocarcinoma)-control (benign biliary tract disease) setup. RESULTS: MMP7 and CA19-9 serum levels were significantly elevated in cholangiocarcinoma patients (P < 0.001). The area under the curve (AUC) from a receiver operating characteristic (ROC) curve analysis for the diagnosis of cholangiocarcinoma, using MMP7 was more accurate than CA19-9 (AUC = 0.84, 95% CI: 0.778-0.903 for MMP7 and AUC = 0.79, 95% CI: 0.708-0.868 for CA19-9). The sensitivity and specificity of serum MMP7 (cut-off value of 5.5 ng/mL) was 75% and 78%, respectively, while the sensitivity and specificity of serum CA19-9 (cut-off value of 100 U/mL) was 68% and 87%, respectively. CONCLUSION: Serum values of MMP7 and CA19-9 appear to be useful biomarkers for differentiating cholangiocarcinoma from benign biliary tract obstructive diseases.

Cholangiocarcinoma in a 24-year-old woman with hepatolithiasis.

Hepatolithiasis is well known to represent an etiology of cholangiocarcinoma. The average age of patients with a diagnosis of cholangiocarcinoma that occurs as a complication of hepatolithiasis is about 62-year-old. Here, the authors present a case of cholangiocarcinoma that occurred in a 24-year-old woman who presented with the recurrent cholangitis from hepatolithiasis. Left hepatectomy with hepaticojejunostomy was performed because she had multiple stones in an atrophic left lobe of the liver. Histopathological examination revealed that it was cholangiocarcinoma located in the inflammatory left hepatic duct.

Detection of serum MMP-7 and MMP-9 in cholangiocarcinoma patients: evaluation of diagnostic accuracy.

BACKGROUND: Cholangiocarcinoma is an aggressive tumor with a tendency for local invasion and distant metastases. Timely diagnosis is very important because surgical resection (R0) remains the only hope for a cure. However, at present, there is no available tumor marker that can differentiate cholangiocarcinoma from benign bile duct disease. Previous studies have demonstrated that matrix metalloproteinase (MMP)-7 and MMP-9 are frequently expressed in cholangiocarcinoma specimens. METHODS: This study was designed to determine whether the serum levels of MMP-7 and MMP-9 can discriminate cholangiocarcinoma patients from benign biliary tract disease patients in comparison to carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA19-9). We measured the level of CEA, CA19-9, MMP-7 and MMP-9 in the serum of 44 cholangiocarcinoma and 36 benign biliary tract diseases patients. RESULTS: Among the serum levels of CEA, CA19-9, MMP-7 and MMP-9, only the serum MMP-7 level was significantly higher in the patients with cholangiocarcinoma (8.9 +/- 3.43 ng/ml) compared to benign biliary tract disease patients (5.9 +/- 3.03 ng/ml) (p < 0.001). An receiver operating characteristic (ROC) curve analysis revealed that the detection of the serum MMP-7 level is reasonably accurate in differentiating cholangiocarcinoma from benign biliary tract disease patients (area under curve = 0.73; 95% CI = 0.614-0.848). While the areas under the curve of the ROC curves for CEA, CA19-9 and MMP-9 were 0.63 (95% CI = 0.501-0.760), 0.63 (95% CI = 0.491-0.761) and 0.59 (95% CI = 0.455-0.722), respectively. CONCLUSION: Serum MMP-7 appears to be a valuable diagnostic marker in the discrimination of cholangiocarcinoma from benign biliary tract disease. Further prospective studies for serum MMP-7 measurement should be carried out to further investigate the potential of this molecule as a biomarker of cholangiocarcinoma.

Role of ciprofloxacin in patients with cholestasis after endoscopic retrograde cholangiopancreatography.

AIM: To determine the role of ciprofloxacin in reducing cholangitis in cholestatic patients with adequate biliary drainage after endoscopic retrograde cholangiopancreatography (ERCP). METHODS: A randomized, controlled trial was performed in 48 cholestatic patients at Rajavithi Hospital (Tertiary Referral Center for ERCP: 600 cases per year). All the 48 patients received 200 mg ciprofloxacin intravenous injection for 30 min before starting any procedures, and then were randomly divided in two groups. Twenty-two patients in study group continually received ciprofloxacin until 48 h after ERCP. Causes of biliary obstruction, bacteriology of bile and blood (in cholangitis) and clinical cholangitis were recorded. RESULTS: Forty-eight patients were enrolled and divided into continuous ciprofloxacin treatment group (n = 22) and discontinuous ciprofloxacin treatment group (n = 26). During ERCP, stones were found in 22 patients, malignant diseases in 24 patients and other pathologic lesions in 5 patients. One (4.5%) of the 22 patients who received ciprofloxacin and 2 (6.3%) of the 26 patients who discontinued ciprofloxacin after ERCP developed cholangitis (relative risk = 0.71; 95% CI = 0.14-3.65; P = 0.88). Bacterobilia was found in 27 (56.3%) out of 48 patients. E. coli and Streptococcus viridans were the most common organisms. CONCLUSION: Continual use of ciprofloxacin in patients with cholestasis after adequate biliary drainage procedures plays no role in reducing cholangitis.

Circulating hTERT mRNA as a tumor marker in cholangiocarcinoma patients.

AIM: To investigate human telomerase reverse transcriptase (hTERT) mRNA in the serum of cholangiocarcinoma patients. METHODS: The serum of thirty three cholangiocarcinoma patients, forty one benign biliary tract disease patients and ten healthy volunteers were collected and analyzed for the expression of hTERT mRNA by real-time reverse transcriptase-polymerase chain reaction (RT-PCR). We then examined the correlation between values of serum hTERT mRNA and the pathological staging of cholangiocarcinoma. RESULTS: hTERT mRNA was detected in 28 of 33 (84.85%) of serum obtained from cholangiocarcinoma patients and 9 of 41 (21.9%) of serum obtained from benign biliary tract disease patients. hTERT mRNA was not detected in any serum obtained from healthy volunteers. on the other hand the common tumor marker, CA19-9 was detected in 20 of 33 (60.6%) of serum obtained from cholangiocarcinoma patients and 8 of 41 (19.5%) of serum obtained from benign biliary tract disease patients. However, no correlation was found between the present of serum hTERT mRNA and tumor staging. CONCLUSION: These results indicate that the detection of circulating hTERT mRNA was identified in almost all cholangiocarcinoma patients. It offers a novel tumor marker, which can be used as a complementary study for diagnosis of cholangiocarcinoma.