Objective To explore primary surgical treatment experience of typeⅣ hilar cholangiocarcinoma. Methods From April 2008 to April 2011，20 patients with type Ⅳ hilar cholangiocarcinoma were enrolled into the same surgical group in Department of Hepatobiliary and Pancreatic Surgery of West China Hospital of Sichuan University.The intra- and post-operative results were analyzed.Results The total resection rate was 75%，which was consisted of 10 cases of radical excision and 5 cases of non-radical excision.Seven patients received left hepatic trisegmentectomy and caudate lobe resection including anterior and posterior right hepatic duct reconstruction，hepatojejunostomy，and Roux-en-Y jejunojejunostomy.Six patients received enlarged left hepatic trisegmentectomy and caudate lobe resection including left intrahepatic and extrahepatic duct reconstruction，hepatojejunostomy，and Roux-en-Y jejunojejunostomy. Two patients received quadrate lobe resection including two cholangioenterostomies after anterior and posterior right hepatic duct reconstruction，and left intrahepatic and extrahepatic duct reconstruction.After percutaneous transhepatic cholangial drainage （PTCD） and portal vein embolization （PVE），two patients with total bilirubins ＞400 mmol/L received radical excision and non-radical excision，respectively.Three patients only received PTCD during operation due to wide liver and distant metastasis，and two patients received T tube drainage during operation and postoperative PTCD due to left and right portal vein involvement. All 15 patients who received lesion resection survived more than one year， whereas another five patients whose lesions can not been resec ted only survived from 3 to 6 months with the mean of 4.2 months.No death occurred during the perioperative period. Conclusions For patients with type Ⅳ hilar cholangiocarcinoma， preoperative evaluation and tumor resection shall conducted so as to relieve obstruction of biliary tract，otherwise PTCD and PVE prior to the final lesion resection shall be performed.
【Abstract】ObjectiveTo investigate whether abnormal expression of β-catenin and high expression of c-myc have played a possible role in hilar cholangiocarcinoma carcinogenesis.MethodsBy using immunohitochemical staining (SP method), the authors detected the expression of β-catenin and c-myc in 42 paraffin-embedded samples of hilar cholangiocarcinoma and 10 benign bile duct disease tissue, and then analyzed the relationship of them with clinical data. Resultsβ-catenin was normally expressed in 10 benign bile duct disease tissue, while expression of c-myc was negtive. In hilar cholangiocarcinoma tissue, the positive expression rate of β-catenin （71.4%） was significantly correlated to the lymphoid node metastasis of hilar cholangiocarcinoma (χ2=4.75，P＜0.05),but was not statistically correlated to the tumor size，the extent of differentiation and infiltration (χ2=3.35，3.45，4.32，Pgt;0.05); the expression rate of c-myc (76.2%) was correlated with the extent of differentiation(χ2=4.87, P＜0.05),but not with the size, infiltration, lymphoid metastasis（χ2= 3.47，4.12，2.76， Pgt;0.05). The abnormal expression of β-catenin had relevance to the high expression of c-myc with hilar cholangiocarcinoma （r=0.324,P＜0.01）. ConclusionThe expression of beta-catenin and c-myc is significantly altered in hilar cholangiocarcinoma, and correlate with biological features of cholangiocarcinoma.The abnormal expression of beta-catenin is one of the mechanisms for the spread of hilar cholangiocarcinoma.
ObjectiveTo investigate the expression of proapoptosis gene bad in intrahepatic cholangiocarcinoma (ICC) and its relationship to differentiation of the tumor.MethodsThe immunohistochemistry technique by Dako Envision system and rabbit antihuman bad polyclonal antibodies were adopted. The expression of bad was detected in 48 cases of ICC and 25 cases of control tissues.ResultsBad immunoreactivity in 48 cases of ICC was higher than that of bile duct epithelium in 25 cases of control tissues. And contrasted with 21 cases of well differentiated ICC, bad immunoreactivity was higher in 27 cases of middle and poor differentiated ICC.ConclusionThe expression of bad gene may be related to the differentiation of ICC.
ObjectiveTo discuss the effect of palliative drainage operation on the life quality of hilar cholangiocarcinoma. MethodsCholangiocarcinoma data of our hospital in recent 21 years were analysed retrospectively. They were divided into four groups: RouxenY choledochojejunostomy group, bridge internal drainage group, PTCD (or ERBD) internal drainage group, and operative external drainage group. The operative mortality, incidence of postoperative cholangitis and survival period were compared among groups.ResultsThe total perioperative mortality of 193 cases of palliative operation was 9.3%, there was no difference among groups (P＞0.05). The rate of postoperative cholangitis in the bridge internal drainage group (10.0%) was lower than that of RouxenY choledochojejunostomy group (19.4%),P＜0.05, the rate of cholangitis in PTCD (or ERBD) internal drainage group (37.5%) and operative external drainage group (38.1%) were significantly higher than that of RouxenY choledochojejunostomy group (P＜0.01). There was no significant difference between RouxenY choledochojejunostomy group 〔(9.2±1.8) months〕 and PTCD (or ERBD) internal drainage group 〔(8.8±1.9) months〕 in survival period (P＞0.05)，but the survival period of the above groups were significantly higher than that of bridge internal drainage group 〔(6.5±1.6) months〕，P＜0.05, and operative (or PTCD) external drainage group 〔(4.3±2.0) months〕,P＜0.01.ConclusionThe life quality of RouxenY choledochojejunostomy group is better than that of bridge internal drainage group and PTCD (or ERBD) internal drainage group, the life quality of external drainage is worse than that of the other groups.
Objective To investigate the regulatory effect of somatostatin analogue (SMS201995,SMS) on proliferation and apoptosis in human cholangiocarcinoma cell line in vitro. MethodsProliferation curve, flow cytometry, agarose gel electrophoresis, Annexin VFITC and flow cytometric immunofluorescent technique were performed to identify the inhibitory effect on cell proliferation and the induction of apoptosis of human cholangiocarcinoma cells (SKChA1). ResultsSMS significantly reduced the SKChA1 cell growth by serum in long experiments and transiently accumulated it in G0/G1 phase. Dotplot analysis of cells duallabeled with Annexin VFITC and PI confirmed the induction of apoptosis by SMS in SKChA1 cells.AnnexinVFITC labeling was markedly enhanced following treatment with SMS for 24 h. DNA of treated SKChA1 cells appeared a ladder pattern characteristic of apoptosis. Besides, timedependent increase in bax and decrease in bcl2 occured during SMS treatment. Conclusion SMS could inhibit the proliferation activity and induce apoptosis of cholangiocarcinoma cell line SKChA1. The mechanisms of apoptosis might be correlated with the expression of apoptosisregulatory gene bax and bcl2.
Objective To establish perineural invasion xenograft model of hilar cholangiocarcinoma. Methods The cultured cells of cholangiocarcinoma cell line QBC939 were inoculated subcutaneously in the nude mice so as toestablish primary subcutaneous model of cholangiocarcinoma. The primary tumor tissues were inoculated intraperitoneallyaround the liver in the nude mice so as to establish the second generation intraperitoneal xenograft model. The successful xenografted tumor tissues were obtained for anatomical and pathological examinations. Results The tumor formation rate of primary subcutaneous xenograft of hilar cholangiocarcinoma was 100% （5/5）， and no nerve infiltration was observed. The tumor formation rate of the second generation intraperitoneal xenograft was 45% （9/20）， and two mice （2/9， 22%） manifested nerve infiltration. The rate of nerve infiltration was 10% （2/20）， and the tumor cells had different size and diversity， irregular shape， low differentiation， decreased cytoplasm and nucleus karyomegaly， visible atypical and fission phase， and no obvious gland tube structure by pathological examination. Conclusions Hilar cholangiocarcinoma cell has the particular features of perineural invasion， it is a good experiment platform for researching the mode and biological characteristics of perineural invasion of hilar cholangiocarcinoma by applicated QBC939 cell lines to establish the perineural invasion xenograft model of cholangiocarcinoma.
ObjectiveTo summarize the clinical experience of 58 operations for biliary malignant tumor with da Vinci surgical system. MethodsFrom January 2009 to October 2010, 180 patients with hepatopancreaticobiliary and gastrointestinal disease underwent robotic surgeries by using da Vinci surgical system, including 58 patients with biliary malignant tumor. The case distribution, intra and postoperative data were analyzed. ResultsOf 58 patients, 3 patients with intrahepatic bile duct cystadenocarcinoma received wedge resections of liver. In 36 patients with hilar cholangiocarcinoma, anatomical left hemihepatectomies were performed in 3 cases, resection of extrahepatic duct and gallbladder bridge type biliary revascularization in 3 cases, resection of extrahepatic duct and biliary-enteric Roux-en-Y anastomosis in 14 cases, tumor resection and revascularization of hepatic portal bile duct in 1 case, palliative external drainage of intrahepatic bile duct in 5 cases, and Y-internal drainage of hepatic portal in 10 cases. In 10 patients with gallbladder carcinoma, resection of extrahepatic duct and gallbladder and biliaryenteric Roux-en-Y anastomosis in 2 cases, cholecystectmy in 3 cases, cholecystectmy and external drainage of intrahepatic bile duct in 1 case, cholecystectmy and Y-internal drainage by suspension of hepatic portal in 4 cases. A patient with middle bile duct cancer received radical resection of cholangiocarcinoma and biliary-enteric Roux-en-Y anastomosis. Of 8 patients with distal bile duct cancer, Whipple procedure were performed. Of 58 patients, 2 cases converted to hand-assistant procedure (3.4%). For all patients, operation time was (6.18±1.71) h, blood loss was (116.66±56.06) ml, blood transfusion was (85.55±38.28) ml, ambulation time was (9.10±2.91) h, feeding time was (14.95±4.35) h, and hospital stay was (12.81±4.29) d. Postoperative complications occurred in 8 cases (13.8%), including bile leakage (3 cases), wound bleeding (1 case), pancreatoenteric anastomotic leakage (2 cases), pulmonary infection (1 case), and renal failure (1 case). Of these 8 cases, 6 cases recovered smoothly and 2 cases die of severe pulmonary infection and renal failure after conservative treatment (3 or 4 weeks), therefore, the mortality of patients was 3.4%. In 36 patients with hilar cholangiocarcinoma, 19 cases died (on 2 monthes 4 cases, on 6 monthes 5 cases, on 10 monthes 8 cases, and on 12 monthes 2 cases after operation), 11 cases survival well (gt;26 monthes 4 cases, gt;22 monthes 3 cases, and gt;19 monthes 4 cases), and 6 cases required hospitalization. Of 10 patients with gallbladder carcinoma, 7 cases died (on 3 monthes 1 case, on 5 monthes 1 case, on 8 monthes 1 case, on 11 monthes 3 cases, and on 12 monthes 1 case after operation) and 3 cases survival (gt;17 monthes 2 cases, gt;13 monthes 1 case). In 8 cases undergoing pancreatoduodenectomy, 5 cases died (on 4 monthes 2 cases, on 6 monthes 2 cases, and 10 monthes 1 case after operation) and 3 cases survived well over 2 years. Three patients with intrahepatic bile duct cystadenocarcinoma survived over 1 year. Conclusionsda Vinci surgical system can carry out all kinds of surgery for biliary malignant tumor, especially prominent in the complicated surgeries for hepatic portal, which breaks through the restricted area of laparoscope in hepatobiliary malignant tumor.
ObjectiveTo investigate the value of diffusion weighted imaging (DWI) combined with three-dimensional volumetric interpolated breath-hold examination (3D-VIBE) in evaluating metastatic lymph nodes secondary to hilar cholangiocarcinoma. MethodsFrom July 2009 to March 2011, DWI examination was performed in 37 patients with hilar cholangiocarcinoma, which was compared with 3D-VIBE sequences. The morphological characteristics and distribution were analyzed for metastatic and nonmetastatic lymph nodes. Signal intensity (SI) was measured on DWI images and apparent diffusion coefficient (ADC) was calculated for each lymph node. The SI of lymph nodes (SILN） and liver (SIliver) were also measured and the ratio of SI was calculated. The ADC and the ratio of SI were compared between metastatic and nonmetastatic lymph nodes. ResultsThere were fifty-nine groups of lymph nodes in 37 patients with hilar cholangiocarcinoma, fifty-one groups were revealed in both DWI and 3D-VIBE sequences, and eight groups were only demonstrated in one sequence (P=0.070). The short diameters were (1.05±0.42) cm and (0.78±0.22) cm on 3D-VIBE images for metastatic and nonmetastatic lymph nodes, respectively (P=0.030). The ADC value in metastatic lymph nodes was (1.64±0.3)×10-3 mm2/s, which was significantly lower than that in nonmetastatic lymph nodes 〔(2.28±0.79)×10-3 mm2/s〕 on DWI images (P=0.033). There were no significant differences in SILN/SIliver between metastatic and nonmetastatic lymph nodes on images of portal venous phase and 3 min delayed contrast-enhanced phase. ConclusionsDifferences of ADC and short diameter can provide valuable information to differentiate metastatic lymph nodes with nonmetastatic lymph nodes. When combined with 3D-VIBE sequence, DWI is more effective in evaluating metastatic lymph nodes secondary to hilar cholangiocarcinoma.
ObjectiveTo discuss the treatment methods and outcome of hilar cholangiocarcinoma. MethodsFrom January 2002 to December 2008, 81 cases of hilar cholangiocarcinoma were retrospectively analyzed. ResultsAmong 81 patients, there were 55 males and 26 females, ages were from 38 to 72 years with an average age 57.5 years. In BismuthCorlette classification, 5 cases were type Ⅰ, 15 cases type Ⅱ, 14 cases type Ⅲa, 14 cases type Ⅲb, 33 cases type Ⅳ, according to the preoperative results of MRCP, but the classification of 15 cases were not consistent to the preoperative results (5 cases type Ⅱ, 8 cases type Ⅲ, 2 cases type Ⅳ) according to the results of intraoperative exploration. The rates of complications of radical operation, palliative operation, internal biliary drainage, and external biliary drainage were 54.5%(12/22), 58.8%(10/17), 23.8%(5/21), and 66.7%(14/21), respectively. The rate of complications of internal biliary drainage was lower than that of the other three methods (Plt;0.01), there were no significant differences among the other three methods. The 1, 2, 3, and 5year survival rates of 22 patients with radical operation, 17 patients with palliative operation, 21 patients with internal biliary drainage, 21 patients with external biliary drainage were 75.0%, 60.0%, 38.3%, 2.6%; 72.7%, 26.5%, 4.2%, 0; 50.5%, 15.8%, 2.2%, 0; 30.6%, 8.5%, 0, 0, respectively. The median survival time was 29.5 months, 13.8 months, 10.5 months, and 8.3 months, respectively. Survival rate of radical operation was higher than that of palliative operation (χ2=14.20, P=0.000 3), palliative operation was higher than that of internal biliary drainage (χ2=4.50, P=0.040 5), and internal biliary drainage was higher than that of external biliary drainage (χ2=4.45, P=0.040 1). ConclusionsThe BismuthCorlette classification is a guide to the required surgery, but the results of intraoperative exploration decides the final classification and operative method. Radical resection is the main related factors influencing the therapy efficacy of hilar cholangiocarcinona. Basinstyle anastomosis and T type supportingtube is the first choice of palliative operation. External drainage, to the full, is avoided.
Objective To research the effect of γ-ray released from 103Pd radioactive stent on the expression of Fas gene and its relation with apoptosis of cholangiocarcinoma cell and the significances through the establishment of human cholangiocarcinoma model. Methods The model of nude mouse with implanted human cholangiocarcinoma was established. The mice were divided into study group and control group, 37 MBq 103Pd biliary stent was implanted in the study group and the ordinary metal biliary stent was implanted in the control group. The volume of tumor was measured, the cell apoptosis was detected by the TUNEL method and the expression of Fas gene of the cell apoptosis of the induced human cholangiocarcinoma was checked out by immunohistochemistry staining 10 d after the implantation. Results Compared with the control group, the growing speed of the volume of tumor in study group was significantly reduced (Plt;0.05), the expression positive rate of Fas gene was significantly higher (Plt;0.05), and the apoptotic rate of cancer cells was also higher (Plt;0.01). Conclusions The 103Pd radioactive stent can induce the cell apoptosis in nude mouse model with implanted human cholangiocarcinoma inhibit the cell growth of bile duct cancer and may promote the apoptosis of cancer cells by increasing the expression of Fas gene. It may be helpful for the further study of treatment for bile duct cancer using 103Pd radioactive stent.