SpyGlass in Diagnosis of Hepatocellular Carcinoma with Right Hepatic Duct Tumor Thrombus Hemorrhage: A Case Report.

Hepatocelluar carcinoma presenting as a biliary duct tumor thrombus is a relatively rare entity, with poor prognosis. The primary clinical manifestation of this disease is obstructive jaundice, which can often be misdiagnosed. A 59-year-old female patient was admitted with sudden onset of abdominal pain. Laboratory tests suggested obstructive jaundice, and enhanced magnetic resonance imaging of the upper abdomen did not show obvious biliary dilatation. Endoscopic ultrasound and endoscopic retrograde cholangiopancreatography suggested an occupying lesion in the upper bile duct. SpyGlass and biopsy finally confirmed hepatocellular carcinoma with right hepatic duct tumor thrombus hemorrhage. The SpyGlass Direct Visualization System, as an advanced biliary cholangioscopy device, showed the advantages of single-person operation as well as easy access to and visualization of the lesion.

Robotic Klatskin Type 3A Resection with Biliary Reconstruction: Description of Surgical Technique and Outcomes of Initial Series.

INTRODUCTION: Minimally invasive resection for perihilar cholangiocarcinoma is an emerging technique that requires both mastery in minimally invasive liver resection and biliary reconstruction. Due to technical difficulties in biliovascular dissection, radical portal lymphadenectomy and the need for fine suturing during bilioenteric anastomosis, this type of resection is generally not performed laparoscopically, even at high-volume, liver-surgery centers.1-3 In modern literature, a detailed, operative description of robotic technique for this operation with outcome data is lacking. This video article demonstrates a pure robotic Klatskin Type 3A resection with clinical outcomes of our initial series. VIDEO: A 77-year-old man presented with jaundice and findings of bilateral, intrahepatic, ductal dilation (Right > Left). Radiological imaging showed a type 3A Klatskin tumor with associated thrombosis of the right, anterior portal vein. A further endoscopic evaluation with cholangioscopy confirmed a high-grade Bismuth 3A biliary malignant stricture. Endoscopic drainage was achieved with placement of two, 7-French, 15-cm, plastic, endobiliary stents. A 3-D anatomical liver reconstruction showed a 2-cm mass located in the area of right, anterior, sectoral, Glissonean pedicle with standardized, future, liver-remnant (left hepatic lobe) volume of 50%. The patient was placed supine on the operating table. General endotracheal anesthesia was administered. After exclusion of metastatic peritoneal disease with diagnostic laparoscopy, cholecystectomy and systematic radical portal lymphadenectomy were first completed with a goal to obtain more than six lymph nodes. After appropriate portal lymphadenectomy, the common bile duct was isolated and transected at the level of pancreatic head. The plastic, endobiliary stents were removed, and a distal common bile duct margin was sent for a frozen-section examination to rule out distal extension of the cholangiocarcinoma. A small, accessory, right, hepatic artery lateral to the main portal vein was ligated with locking clips and removed together with the adjacent nodes and lymphatic bearing tissues. The intrapancreatic portion of the distal common bile duct was suture closed once the distal common bile duct margin was confirmed to be negative for neoplasia by the frozen-section examination. The proximal bile-duct dissection commenced cephalad toward the hilar bifurcation. Once the biliary bifurcation has been adequately dissected and detached from the hilar plate, the distal, left, hepatic duct was then transected near the base of the umbilical fissure to gain an R-0 resection margin. A second frozen-section specimen was obtained from the left, hepatic duct cut edge to ensure an absence of infiltrating tumor cells on the future, bile-duct remnant side. Division of short, hepatic veins off the inferior vena cava (IVC) were next completed. Once the line of hepatic-parenchymal transection was confirmed by using indocyanine green administration, the right hepatic artery and portal vein were ligated and clipped. The liver, parenchymal transection began with a crush-clamp technique utilizing robotic, fenestrated bipolar forceps and a vessel-sealing device. Preservation of the middle hepatic vein is always the preferred technique to avoid congestion of the left medial sector of the liver. The entire right hepatic lobe and the caudate lobe were removed en bloc. A large, Makuuchi ligament was isolated and divided by using a robotic, vascular-load stapler once the liver is open-booked. Finally, the root of the right hepatic vein was exposed and transected flush to the IVC by using another load of robotic vascular stapler. The biliary reconstruction then began by creating a 60-cm, roux limb for a hepaticojejunostomy bilioenteric anastomosis. A side-to-side, stapled jejunojejunostomy was created by using two applications for robotic 45-mm, blue load staplers. The common enterotomy was closed with running barbed sutures. The roux limb was then transposed retrocolically toward the porta hepatis. A single end-to-side hepaticojejunostomy anastomosis was created with running absorbable 4-0 barbed sutures. Finally, a closed suction abdominal drain was placed before closing. RESULTS: The operative time was approximately 8 hours with 150 ml of blood loss. The postoperative course was unremarkable. The final pathology report confirmed a moderately differentiated perihilar cholangiocarcinoma with negative resection margins. Ten lymph nodes were harvested. No nodal metastasis or lymphovascular invasion was found. Since 2021, we have undertaken robotic resection of Klatskin 3A tumor in four patients with a median age of 70 years. All patients presented with jaundice, and they mainly underwent preoperative biliary drainage using ERCP. The median operative duration was 508 minutes with estimated blood loss of 150 ml. R-0 resection margins were obtained in all patients. One patient suffered from postoperative complications requiring treatment of line sepsis using intravenous antibiotics. We did not find a 90-day mortality in this series. At a median follow-up period of 15 months, all of the patients were alive without any evidence of disease recurrence. CONCLUSIONS: Robotic resection of Type 3A Klatskin tumor is safe and feasible with appropriate experience in robotic hepatobiliary surgery, as demonstrated in this video article.

Sperm protein antigen 17 and Sperm flagellar 1 cancer testis antigens are expressed in a rare case of ciliated foregut cyst of the common hepatic duct.

INTRODUCTION: Ciliated foregut cysts (CFCs) are frequently described in liver, pancreas and gallbladder and generally considered benign although one case of squamous cell metaplasia and five cases of squamous cell carcinoma arising from a ciliated hepatic foregut cyst have been reported. Here we explore two cancer-testis antigens (CTAs), Sperm protein antigen 17 (SPA17) and Sperm flagellar 1 (SPEF1) expression in a rare case of CFC of the common hepatic duct MATERIALS AND METHODS: 3 µm-thick CFC sections were immunohistochemically treated with antibodies raised against human SPA17 or SPEF1. In silico Protein-Protein Interaction (PPI) network and differential protein expression were also investigated RESULTS: Immunohistochemistry revealed SPA17 and SPEF1 in the cytoplasm of ciliated epithelium. SPA17, but not SPEF1, was also detected in cilia. The PPI networks demonstrated that other CTAs are significantly predicted functional partners with SPA17 and SPEF1. The differential protein expression demonstrated that SPA17 was higher in breast cancer, cholangiocarcinoma, liver hepatocellular carcinoma, uterine corpus endometrial carcinoma, gastric adenocarcinoma, cervical squamous cell carcinoma, bladder urothelial carcinoma. SPEF1 expression was higher in breast cancer, cholangiocarcinoma, uterine corpus endometrial carcinoma and kidney renal papillary cell carcinoma CONCLUSIONS: Our study suggests that further characterization of SPA17 and SPEF1 in patients with CFCs might provide significant insights to understand the mechanisms underlying their potential to malignant transformation.

Role of Intraoperative Assessment of Proximal Bile Duct Margin Status and Additional Resection of Perihilar Cholangiocarcinoma: Can Local Clearance Trump Tumor Biology? A Retrospective Cohort Study.

BACKGROUND: The aim of this study was to evaluate the clinical implications of the proximal bile duct margin status in resection of perihilar cholangiocarcinoma (PHCC). Intraoperative frozen section (IFS) analysis to assess the bile duct margin status is commonly used during PHCC resection. However, the impact of additional resection after obtaining a positive margin on the long-term outcome remains unclear. PATIENTS AND METHODS: Among the 257 patients who underwent PHCC resection, 190 patients with a negative distal margin were included and analyzed. IFS analysis of the proximal bile duct margin was performed in all patients. A positive margin was defined by the presence of either invasive cancer, or carcinoma, in situ. RESULTS: IFS analysis revealed an initial positive margin in 69 (36%) patients. Among 20 patients who underwent re-resection, only 11 patients achieved a negative margin (secondary R0). An initial positive margin was associated with poor long-term outcomes: recurrence-free survival (RFS) and overall survival (OS) were 16 and 25 months for patients with an initial positive margin, but 47 and 63 months for patients with an initial negative margin, respectively (p < 0.0001). In contrast, there was no difference in RFS or OS between patients with a secondary R0 margin, and those with a final R1 margin (14 vs. 16 months for RFS, p = 0.98, and 23 versus 25 months for OS, p = 0.63, respectively). CONCLUSION: An IFS-positive proximal hepatic duct margin dictates poor long-term outcomes for patients with resectable PHCC. Additional resection has minimal impact on survival, even when negative margin is achieved.

Biliary Atresia Remnants Revisited: Myogenesis, Hepatic Duct-Like Structures, and Fate of Peribiliary Glands.

PURPOSE AND CONTEXT: Proximal levels of excised remnants from youngest infants may reveal early features of biliary atresia (BA). METHOD: A targeted IHC survey was applied to 34 most proximal 2 levels in 17 BA remnants excised at age 10-74 days including 7 = <30 days old and 6 control hepatic ducts (HD). KEY RESULTS: Severity of inflammation and extent of active fibroplasia do not distinguish proximal remnants in younger (n = 7) and older (n = 10) infants. In 27/34 levels of 14/17 remnants, reactive stroma is focally SM-MHC-2 (+), marking smooth muscle myosin, termed reactive myogenesis (RM), that is absent in controls. RM facilitates identification of 3 novel hepatic duct remnants (HDR): an HD-like collagen collar lined by degenerating cholangiocytes (n = 5); erosion defects in loose reactive stroma (n = 14); solitary foci of hyperplastic squamoid epithelium (n = 4). Peribiliary glands are either hyperplastic or atretic and typically lack RM. CONCLUSION: Minimally inflammed end-stage lesions in BA remnants occur at youngest ages favoring prenatal onset. Three novel HDR are defined. RM, a useful surrogate for HDR, is a prevalent inappropriate stromal reaction in proximal remnants of uncertain biological significance. RM is the source of mature smooth muscle in BA remnants.

The role of extra-hepatic bile duct resection in patients with gallbladder carcinoma with peri-neural invasion: A ten-year experience in China.

BACKGROUND: Peri-neural invasion (PNI) in gallbladder carcinoma (GBC) has been demonstrated as a vital prognostic factor. However, whether PNI in patients with GBC can be regarded as a surgical indication of bile duct resection (BDR) remains controversial. METHODS: GBC patients with pathologically-confirmed PNI between September 2010 and September 2020 were retrospectively reviewed. Comparative analyses were performed in patients with PNI according to the performance of BDR. SPSS 25.0 software and Graph pad PRISMA 7.0 software were used for statistical analyses. RESULTS: A total of 70 patients GBC patients with PNI were incorporated. The results of comparative analyses indicated that patients who received BDR were generally in a more advanced stage and often required a more extended radical cholecystectomy. Higher incidences of preoperative jaundice (48.6% vs 2.9%, P < 0.0001), major hepatectomy (25.7% vs 8.6%, P = 0.055), combined multi-visceral resections (48.6% vs 5.7%, P < 0.0001), combined major vascular reconstruction (22.9% vs 2.9%, P = 0.014), and a lower R0 rate (68.6% vs 88.6%, P = 0.039) were detected in patients who received BDR. Even after propensity score matching (PSM), BDR still had no significant survival advantage but only increased the length of postoperative stay and the frequency of postoperative morbidities. CONCLUSION: BDR seemed to have no significant survival advantage in GBC patients with PNI and was only correlated with a longer postoperative hospital stay and a higher rate of morbidities. PNI should not be regarded as a surgical indication of BDR in patients with GBC.

The role of extra-hepatic bile duct resection in the surgical management of gallbladder carcinoma. A first meta-analysis.

OBJECTIVE: To systematically evaluate the clinicopathological and prognostic value of extra-hepatic bile duct resection (EHBDR) in the surgical management of patients with gallbladder carcinoma (GBC), especially in non-jaundiced patients. METHODS: PubMed, EMBASE and the Cochrane Library were searched up to March 1st 2021 for comparative studies between bile duct resected and non-resected groups. RevMan5.3 and Stata 13.0 software were used for the statistical analyses. RESULTS: EHBDR did not correlate with a better overall survival (OS) (P = 0.17) or disease-free survival (P = 0.27). No survival benefit was also observed in patients with T2N1 (P = 0.4), T3N0 (P = 0.14) disease and node-positive patients (P = 0.75), rather, EHBDR was even harmful for patients with T2N0 (P = 0.01) and node-negative disease (P = 0.02). Significantly higher incidences of recurrent disease (P = 0.0007), postoperative complications (P < 0.00001) and positive margins (P = 0.02) were detected in the bile duct-resected group. The duration of postoperative hospital stay between the two groups was comparable (P = 0.58). Selection bias was also detected in our analysis that a significantly higher proportion of advanced lesions with T3-4 or III-IV disease was observed in the bile duct-resected group (P < 0.00001). EHBDR only contributed to a greater lymph yield (P = 0.01). CONCLUSION: EHBDR has no survival advantage for patients with GBC, especially for those with non-jaundiced disease. Considering the unfairness of comparing OS between jaundiced patients receiving EHBDR with non-jaundiced patients without EHBDR, we could only conclude that routine EHBDR in non-jaundiced patients is not recommended and future well-designed studies with more specific subgroup analyses are required for further validation.

Surgical implications of the confluence patterns of the left intrahepatic bile ducts in right hepatectomy for perihilar cholangiocarcinoma.

BACKGROUND: Although the most important goal in surgery for perihilar cholangiocarcinoma (PHC) is to achieve tumor-free proximal ductal margins, little is known about the implications of confluence patterns of the left intrahepatic bile ducts for the proximal ductal margin status in right hepatectomy (RH) for PHC. METHODS: Of 203 patients who underwent surgical resection for PHC with curative intent, confluence patterns of the left intrahepatic bile duct were evaluated in 94 consecutive patients who underwent RH, and they were classified into the following two types: normal type: the bile duct of segment 4 (B4) drained into the common trunk of the bile ducts of segment 2 (B2) and segment 3 (B3) at the right side of the umbilical portion of the left portal vein to form the left hepatic duct; and hepatic confluence type: B2 entered the common trunk of B3 and B4 at the hepatic confluence or B4 entered the common trunk of B2 and B3 at the hepatic confluence. The proximal ductal margin status following RH was compared between the two types of confluence patterns. RESULTS: Of 94 consecutive patients, 69 (73%) were the normal type, and 25 (27%) were the hepatic confluence type. There were no significant differences in patients' characteristics, surgical characteristics, surgical outcomes, and histopathological features between the two groups. However, in patients with Bismuth-Corlette type II and IIIa PHC, the achievement rates of negative proximal ductal margins at the first dividing line were significantly higher in the hepatic confluence type group than in the normal type group (16/16 [100%] vs 34/52 [65%], respectively; P = .007). CONCLUSIONS: Confluence patterns of the left intrahepatic bile ducts might affect proximal ductal margin status in RH for PHC.

Bsep expression in hilar cholangiocarcinoma of rat model.

Develop a rat model of hilar cholangiocarcinoma for detecting bile salt export pump (Bsep) expression in hilar cholangiocarcinoma tissues, in order to provide a new therapeutic target for the gene therapy of hilar cholangiocarcinoma. Sixty male Wistar rats (body weight, 190 ± 8 g) were randomly divided into three groups (the experimental group, the control group and the sham operation group, n = 20 each) as follows: The three groups were fed a standard diet, the experimental group was injected by cholangiocarcinoma QBC939 cell suspension along the hilar bile duct into the bile duct bifurcation with microsyringe, the control group was injected by normal saline, the sham operation group did not inject anything. Every day assess the rats' mental state, diet, and motion by using Basso-Beattie-Bresnahan and combined behavioral score. At 4 weeks, one rat of the experimental group was sacrificed after it was administered anesthesia, and we recorded changes in hilar bile duct size, texture, and form. This procedure was repeated at 6 weeks. After 6 weeks, hilar cholangiocarcinoma developed only in the experimental group, thereby establishing an experimental model for studying QBC939-induced hilar cholangiocarcinoma. Tumor formation was confirmed by pathological examination, and hilar bile duct tissues were harvested from both the groups. A real-time polymerase chain reaction assay and an immunohistochemical assay were used to analyze the expression of Bsep in hilar bile duct tissues of each group. From the second week, the rats in experimental group began to eat less, and their body mass decreased compared with control group and sham operation group. After 6 weeks, we detected hilar cholangiocarcinoma in the hilar bile duct tissues of 18 rats (90%) in the experimental group. In the experimental group with hilar cholangiocarcinoma, we found that the levels of total cholesterol, total bilirubin, and direct bilirubin were higher compared with those in the control group and sham operation group. Simultaneously, muddy stones emerged from the bile ducts of rats in the experimental group. The Bsep/Gapdh mRNA ratio in hilar cholangiocarcinoma, control group and sham operation group differed markedly. Light microscopy revealed a granular pattern of Bsep protein expression which reacted with the anti-Bsep antibody. Each section was randomly divided into six regions, with 80 cells were observed in every region. Sections with > 10% positive cells were designated positive, Sections with < 10% positive cells were designated negative. Each group included 4800 cells. In the experimental group, 1200 cells (25%) were positive, in the control group, 3648 cells (76%) were positive and in the sham operation group 3598 cells (75%) were positive, and this difference was statistically significant. Bsep expression significantly decreased in hilar cholangiocarcinoma of rats than those in control group and sham operation group, suggesting that drugs targeting Bsep are a new strategy for hilar cholangiocarcinoma.

Shh-Yap signaling controls hepatic ductular reactions in CCl4 -induced liver injury.

Carbon tetrachloride (CCl4 ) exposure can induce hepatic ductular reactions. To date, however, the related mechanism remains largely unknown. Sonic hedgehog (Shh) and Yes-associated protein (Yap) signaling are correlated with liver injury and regeneration. Herein, we investigated the role of Shh and Yap signaling in the fate of ductular reaction cells in CCl4 -treated livers and the possible mechanisms. Wild-type and Shh-EGFP-Cre male mice were exposed to CCl4 (2 mL/kg), and then treated with or without the Shh signaling inhibitor Gant61. The level of liver injury, proliferation of ductular reaction cells, and expression levels of mRNA and protein related to the Shh and Yap signaling components were assessed. Results showed that CCl4 treatment induced liver injury and promoted activation and proliferation of ductular reaction cells. In addition, CCl4 induced the expression of Shh ligands in hepatocytes, accompanied by activation of Shh and Yap1 signaling in the liver. Furthermore, administration of Gant61 ameliorated liver regeneration, inhibited hepatic ductular reactions, and decreased Shh and Yap1 signaling activity. Thus, Shh-Yap1 signaling appears to play an integral role in the proliferation of ductular reaction cells in CCl4 -induced liver injury. This study should improve our understanding of the mechanism of CCl4 -induced liver injury and ductular reactions and provide support for future investigations on liver disease therapy.

Dilemma of the differential diagnosis of hilar cholangiocarcinoma and benign diseases: a single-center retrospective study.

Hilar cholangiocarcinoma (HCCA), which lacks specific clinical manifestations, remains very difficult to distinguish from benign disease. This distinction is further complicated by the complex hilar anatomy. We conducted the present study to evaluate the differential diagnosis of these conditions. Sixty-five patients underwent resection surgery for suspected HCCA between January 2011 and October 2018. Institutional Review Board of Shengjing hospital agreed this study and all participants sign an informed consent document prior to participation in a research study. Following a postoperative pathology analysis, all patients were divided into two groups: malignant group (54 patients with HCCA) and benign group (11 cases with benign lesions). Compared with the benign group, the malignant group had a significantly higher median age and serum CA19-9, CEA, ALT, BILT and BILD levels (P < 0.05). In contrast, the groups did not differ significantly in terms of the sex distribution, clinical manifestations, serum levels of AST and ALKP, and imaging findings. In a receiver operating characteristic curve analysis, we identified a CA19-9 cutoff point of 233.15 U/ml for the differential diagnosis and CEA cutoff point of 2.98 ng/ml for the differential diagnosis. The differential diagnosis of HCCA and benign hilar lesions remains difficult. However, we found that patients with HCCA tended to have an older age at onset and higher serum levels of CA19-9, CEA, BILT, ALT and BILD. Furthermore, patients with a serum CA19-9 level >233.15 U/ml and CEA level >2.98 ng/ml are more likely to have malignant disease.

Reassessing the role of surgery in the elderly or chronically sick with proximal extrahepatic cholangiocarcinoma.

BACKGROUND: Most data on postoperative outcomes among patients with proximal extrahepatic cholangiocarcinoma are reported by single institutions. The purpose of this study was to analyze postoperative outcomes stratified by age and comorbidities. METHODS: Patients with proximal extrahepatic cholangiocarcinoma who underwent a resection were identified in the National Cancer Database. Pathologic, postoperative, and survival outcomes were compared based on age and Charlson-Deyo comorbidity index. RESULTS: Among the 1,579 patients, the average age was 66 years, and 9.4% of patients were older than 80 years. Most patients had a Charlson-Deyo score of 0 (72.4%), with the minority having scores of 1 (20.5%) or ≥2 (7.1%). Patients ≥80 years had a higher 90-day mortality rate compared with patients 65 to 79 and <65 years (21.3% vs 12.0% vs 7.4%, P < .001). Patients with a Charlson-Deyo score ≥2 had longer duration of stay, greater likelihood of requiring an unplanned readmission, and a higher 90-day mortality rate compared with patients with a lower comorbidity index. Median survival of patients <65, 65 to 79, and ≥80 years was 31, 24, and 17 months, respectively. A similar trend was seen with increasing Charlson-Deyo score (0: 27 months, 1: 25 months, ≥2: 20 months). On multivariable analysis, age ≥80 years (hazard ratio = 1.52, P = .01) and Charlson-Deyo score ≥2 (hazard ratio = 1.45, P = .01) were associated with poor survival. CONCLUSION: In patients with proximal extrahepatic cholangiocarcinoma, age ≥80 years and greater comorbidity index are associated with increased risk of 90-day mortality and poor overall survival. This suggests that resections in high-risk patient populations should be approached with caution.

Perihilar clear cell cholangiocarcinoma: an often-diagnostic challenge.

Cholangiocarcinomas are rare and often diagnosed late. Clear cell histology is a rare variant of such cancers. We report one such case of a man in his late 60s, with a history of excess alcohol intake, who was found to have deranged liver biochemical tests incidentally during an admission for an allergic reaction. Subsequent imaging to investigate this suggested a diagnosis of perihilar cholangiocarcinoma (ultrasound, CT, MRI, cholangiogram). Biopsy confirmed this to be of clear cell type on histology and immunohistochemistry. Diagnosis and further management of this rare entity was conducted in multidisciplinary meetings with the regional hepatobiliary centre. The patient was deemed unsuitable for surgical resection, underwent chemotherapy but died 1 year later.

Primary neuroendocrine tumour of the common hepatic duct: An unexpected Klatskin-like lesion.

The biliary system is an uncommon location for neuroendocrine tumours (NETs), and within this system, the common hepatic duct is an even more rare site for NETs. Clinical and radiological presentations are challenging because these tumours may be preoperatively confused with Klatskin-like lesions. Here we report a well-differentiated grade 2 NET arising from the common hepatic duct in a 64-year-old female. Curative surgery was performed, and no evidence of recurrent disease was observed at the 2-months follow-up.

Current status of laparoscopic radical hilar cholangiocarcinoma in Mainland China.

Our purpose was to explore the status of laparoscopic radical resection of hilar cholangiocarcinoma (LRRHcca) in Mainland China. Studies published before February 2020 were retrieved from CNKI database, Pubmed database and Wanfang database. Search terms included "hilar cholangiocarcinoma", "Klatskin tumor", "laparoscopy", "radical operation". Relevant articles regarding LRRHcca in Mainland China were also retrieved. 13 articles were included in this study, with a total of 189 cases. The operation time was 354 min (weighed average, WA), and the mean intraoperative blood loss was 324 mL (WA). The rate of negative margin (R0 rate) was 95.2%, and the number of lymph nodes received was 9.5 (WA). 2.6% of cases were converted to laparotomy. The incidence of postoperative complications was 21.2%, with 3.2% for those classified as Clavien-Dindo ≥ 3, 12.2% for bile leakage, 1.6% for postoperative abdominal hemorrhage, 1.6% for liver insufficiency, and 1.1% for abdominal infection. In-hospital mortality was 0.5%, with mean postoperative hospital stay of 15 days (WA), and the rate of reoperation was 1.1%. The mean postoperative follow-up time was 16 months (WA), and 1-year overall survival rate was 84.5%. In conclusions, laparoscopic radical hilar cholangiocarcinoma is safe and feasible in experienced hands after careful selection of HCCA cases.

Differences in Prognostic Factors and Recurrence Patterns After Curative-Intent Resection of Perihilar and Distal Cholangiocarcinomas.

BACKGROUND: Perihilar cholangiocarcinoma and distal cholangiocarcinoma arise from the same tissue but require different surgical treatment methods. It remains unclear whether these cholangiocarcinoma types have different outcomes, prognostic factors, and/or recurrence patterns. METHODS: This retrospective study evaluated patients who underwent curative-intent resection for perihilar cholangiocarcinoma or distal cholangiocarcinoma at a tertiary academic hospital during 2000-2015. Survival and prognostic factors were identified using Kaplan-Meier and Cox regression analyses. RESULTS: The 90-day mortality rates were 0% for perihilar cholangiocarcinoma (36 patients) and 4% for distal cholangiocarcinoma (47 patients). There were no significant differences between perihilar cholangiocarcinoma or distal cholangiocarcinoma in median overall survival (30.9 vs 40.4 months) or median disease-free survival (14.2 vs 21.4 months). Among perihilar cholangiocarcinoma patients, age > 65 years was an independent predictor of poorer overall survival (hazard ratio: 2.45, 95% confidence interval: 1.07-5.64), while requiring bile duct re-resection was an independent predictor of disease-free survival (hazard ratio: 2.76, 95% confidence interval: 1.01-7.51). Among distal cholangiocarcinoma patients, a pN1 category independently predicted poorer overall survival (hazard ratio: 3.40, 95% confidence interval: 1.14-10.11), while preoperative CA19-9 levels >30 U/mL (hazard ratio: 2.51, 95% confidence interval: 1.09-5.79) and pN1 category (hazard ratio: 2.51, 95% confidence interval: 1.09-5.79) predicted a shorter disease-free survival. Local recurrence was more common with perihilar cholangiocarcinoma (50% of recurrences), while multiple synchronous sites were more common for distal cholangiocarcinoma (41% of recurrences). CONCLUSION: Perihilar cholangiocarcinoma and distal cholangiocarcinoma patients have similar survival outcomes. However, local control appears to be more prognostic for perihilar cholangiocarcinoma patients, while positive lymph nodes are critical prognostic factor for distal cholangiocarcinoma patients.

Perihilar Hepatectomy for Hepatolithiasis with Compressed Hilar Bile Duct Induced by Perihilar Hyperplasia of Liver.

Background: Stone recurrence is a major problem limiting the effects of surgical treatment for hepatolithiasis. It was showed that hyperplasia of perihilar liver may compress the hepatic portal and cause deficient bile flow because of compressed hilar bile duct, thereby leading to the formation of bile stasis and precipitating stone recurrence. This retrospective study aimed to evaluate the efficiency of perihilar hepatectomy for hepatolithiasis with compressed hilar bile duct induced by perihilar hyperplasia of liver. Methods: 135 patients with compressed hilar bile duct induced by hypertrophied perihilar liver were included in this study from January 2011 to July 2016. Among these patients, 77 underwent conventional operation procedure (control group) and 58 underwent conventional operation procedure added by perihilar hepatectomy (perihilar hepatectomy group). Clinical data containing preoperative data, intraoperative data, operation complications, and short-term and long-term outcomes were collected. Results: The demographic and disease-related characteristics of the two groups were comparable. The two groups were not remarkably different in operation-related characteristics. The incidence of bile leakage in the perihilar hepatectomy group was substantially higher than that in the control group. Other postoperative complications were not remarkably different between the two groups. In the long-term postoperative follow-up period, the incidence of the recurrence of stones and cholangitis in the control group was considerably higher than that in the perihilar hepatectomy group. Conclusions: Based on conventional operation procedure, additional perihilar hepatectomy is a reliable intervention with definite clinical effects for hepatolithiasis with compressed hilar bile duct induced by hypertrophied perihilar liver.