Time to Recurrence After Surgical Resection and Survival After Recurrence Among Patients with Perihilar and Distal Cholangiocarcinomas.

BACKGROUND: The differences between perihilar cholangiocarcinoma (PHCC) and distal cholangiocarcinoma (DCC) regarding recurrence and the factors that affect recurrence after surgery are unclear. This study aims to investigate the differences in recurrence patterns between patients with PHCC and those with DCC after surgical resection with curative intent. It also investigates the risk factors associated with recurrence and survival thereafter. PATIENTS AND METHODS: The postoperative courses of 366 patients with extrahepatic cholangiocarcinomas (EHCCs), including 236 with PHCC and 130 with DCC, who underwent surgical resections were investigated retrospectively. RESULTS: During follow-up, tumors recurred in 143 (60.6%) patients with PHCC and in 72 (55.4%) patients with DCC. Overall survival (OS) after surgery, recurrence-free survival (RFS), and OS after recurrence were similar for the patients with PHCC and those with DCC. The cumulative probability of recurrence declined 3 years after surgery in the patients with PHCC and those with DCC. A multivariable analysis determined that, among the patients with PHCC and those with DCC, regional lymph node metastasis was a significant risk factor associated with RFS. Ten patients with PHCC and eight patients with DCC with two or fewer sites of recurrence in a single organ underwent resections. A multivariable analysis determined that recurrent tumor resection was an independent prognostic factor associated with OS after recurrence in the patients with PHCC and those with DCC. CONCLUSIONS: Postoperative survival did not differ between the patients with PHCC and those with DCC. Frequent surveillances for recurrence are needed for 3 years after surgical resection of EHCCs. In selected patients, surgery for recurrent EHCCs might be associated with improved outcomes.

Intraoperative Real-Time Assessment of Liver Function with Near-Infrared Fluorescence Imaging.

BACKGROUND: Postoperative liver failure is a serious complication after major hepatectomy, and perioperative prediction of its incidence using current technology is still very difficult. Near-infrared (NIR) fluorescence imaging allows quantitative assessment of the fluorescent signal from indocyanine green (ICG) in regions of interest on the liver surface. This method might offer a new promising modality for evaluating regional liver reserve. However, data are lacking regarding the relationship between liver function and fluorescent signals on the liver surface after intravenous ICG injection. This study was conducted to obtain the data necessary to apply NIR fluorescence imaging as a modality for measuring liver function. MATERIALS AND METHODS: This study included 16 patients who underwent open hepatopancreatobiliary surgery between March 2011 and March 2012. After laparotomy, ICG was injected intravenously at 2.5 mg/L of liver volume, then the fluorescence intensity (FI) and signal-to-background ratio (SBR) in the lateral segment of the liver were assessed for 15 min. Intraoperative blood samples were also obtained to measure the plasma clearance rate of ICG (ICGK). Correlations between ICGK, liver volume, and SBR, as well as between ICGK, liver volume, and rate of change of FI were analyzed. RESULTS: The experimental procedure was performed in all 16 patients. The FI of the liver increased rapidly after ICG injection, then became more gradual, reaching a near-plateau after 15 min. A significant correlation was seen between ICGK and the rate of change of FI up to 15 min (|rS| = 0.5725, p < 0.05). CONCLUSION: This is the first report to show a relationship between liver function and fluorescent signals on the liver surface after intravenous ICG injection. Intraoperative NIR fluorescence imaging with ICG may be useful as a new method for assessing liver function.

Near infrared fluorescence light imaging for lymphatic flow toward para-aortic lymph node from the Calot's triangle: A prospective exploratory study.

BACKGROUND: Metastasis to para-aortic lymph nodes (PAN) in hilar malignancies is considered distant metastasis. Fluorescence imaging using near infrared fluorescence light and indocyanine green (ICG-NIR imaging) are widely employed for identifying the sentinel lymph node, which might be an ideal alternative procedure for whole excisional biopsy of PAN. However, there has been no report about ICG-NIR imaging in hilar malignancies. The purpose of this study was to determine the optimal dose for indocyanine green to detect PAN and to reveal the detection rate of ICG-NIR imaging for lymphatic flow toward regional lymph nodes (RLN) or PAN from the Calot's triangle. PATIENTS AND METHODS: We enrolled 62 patients with hepato-pancreatic-biliary malignancies in this study. The dose of ICG was optimized in the first 15 patients and the detection rate for RLN and PAN was evaluated in the remaining 47. We observed that the optimal administered dose of ICG for detecting fluorescent signals in PAN was 5 mg/mL. RESULTS: Using this dose, RLN and PAN fluorescence were detected in 29 of 42 patients. Fluorescent signals were recorded in the lymph nodes (LN) along the bile duct and the posterior surface of the head of the pancreas. We also detected PAN fluorescent signals on the right side of the aorta around the left renal vein. We recommend 5 mg/ml of ICG to visualize lymphatic flow from the hepatoduodenal ligament to PAN using ICG-NIR imaging. However, because detection rate of RLN and PAN were 69%, respectively, further improvement for this procedure will be necessary for clinical application.