At present, the application of extended radical surgery in hilar cholangiocarcinoma (hCCA) remained controversial. The author reviewed the relevant literatures published in recent years and combined with his own experience, preliminarily discussed the application value of extended radical surgery in hCCA, and believed that: for some strictly selected cases of hCCA, under the premise of ensuring patient safety, extended radical surgery was an important treatment method for hCCA patients to obtain R0 removal, and the survival status of patients was better than that of palliative surgery, but the indications need to be strictly mastered. For patients with hCCA, whether to adopt extended radical surgery and the specific scope of surgical resection should be based on the scope of lesions and the involved organs, tissues and blood vessels to implement an individualized surgical program on the premise of comprehensive evaluation and full preparation before surgery. Do not blindly carry out extended radical surgery.
ObjectiveTo understand the current situation of surgical treatment of hilar cholangiocarcinoma. MethodThe literature relevant to surgical treatment of hilar cholangiocarcinoma at home and abroad in recent years was reviewed. ResultsThe various surgical treatment schemes of hilar cholangiocarcinoma had advantages and disadvantages. At present, there were still disputes and no unified consensus on preoperative preparation, selection of intraoperative surgical resection range, and applications of laparoscopy and robot, etc. The individualized surgical treatment plan should still be formulated based on the specific condition of the patient and the professional experience of the surgeon. The individualized surgical treatment plan should still be formulated based on the specific condition of the patient and the professional experience of the surgeon. ConclusionIt is believed that accurate preoperative condition evaluation should be carried out for each patient with hilar cholangiocarcinoma, so as to formulate the best surgical treatment plan, achieve individualized accurate treatment and benefit patients.
ObjectiveTo explore the technique of hepatic artery reconstruction in complicated hilar cholangiocarcinoma surgery. MethodThe clinicopathologic data of 3 patients with complicated hilar cholangiocarcinoma with arterial invasion underwent hepatic artery reconstruction in the Department of Hepatopancreatobiliary Center of Beijing Tsinghua Changgung Hospital from March to July 2022 were retrospectively analyzed. ResultsAll 3 patients (case 1–3) were the males, aged 53, 68, and 56 years, respectively, and with hypertension or diabetes; the longitudinal diameters of the tumor were 3.5 cm, 3.0 cm, and 3.2 cm, respectively. All patients had the right hepatic artery invasion. Case 2 and 3 had the arterial stratification. The arterial defects after radical resection were 4.5 cm, 3 cm, and 3 cm, respectively. The right or right posterior hepatic artery was reconstructed by the autotransplantation of right gastroomental artery, the left hepatic artery, and the anterior superior pancreaticoduodenal artery, respectively. After operation, the reconstructed hepatic arteries were unobstructed and free of stenosis, and there were no complications such as bleeding, infection, and thrombosis by Doppler ultrasound and CT angiography. The results of postoperative pathological diagnosis were the hilar cholangiocarcinoma with arterial invasion, and all the incisal edges were negative. ConclusionFrom the preliminary results of 3 cases, it is safe, feasible, and effective to select proper autologous artery (matched in length and caliber) for reconstruction the defective invaded hepatic artery which resected together with hilar cholangiocarcinoma, but the technical difficulty is still relatively high.
ObjectiveTo investigate the feasibility, safety and clinical effect of total laparoscopic radical resection of hilar cholangiocarcinoma.MethodsRetrospectively summarized the 14 patients with hilar cholangiocarcinoma, who underwent total laparoscopic radical resection of hilar cholangiocarcinoma in the Affiliated Hospital of Xuzhou Medical University from April 2016 to June 2018. Collected the clinical data of those patients, including 7 cases of Bismuth type Ⅰ, 5 cases of Bismuth type Ⅱ, and 2 cases of Bismuth type Ⅲb.ResultsTotal laparoscopic radical resection of hilar cholangiocarcinoma were performed successfully in all 14 patients. The operative time was 190–400 min (median time of 285 min) and the amount of intraoperative blood loss was 100–500 mL (median amount of 175 mL). There was no death case during the perioperative period. Postoperative pathological results showed that all cases accorded with bile duct adenocarcinoma, resection margins of them were negative, amount of lymph node was detected 6–15 per case (median amount of 8 per case), and 3 patients were inspected with peritumoral lymph node metastasis. Two patients were combined with postoperative bile leakage, one of whom was complicated with an abdominal infection, and both were cured and discharged after conservative treatment. All patients were followed-up regularly within 3–24 months (median followed-up period of 16 months). One of them recurred within 12 months after the operation. The remaining patients have survived well so far.ConclusionUnder the operation of the experienced surgeon, total laparoscopic radical resection of hilar cholangiocarcinoma is safe, feasible and effective in the short term.
Objective To explore application value of photodynamic therapy (PDT) in treatment of unresectable hilar cholangiocarcinoma. Method The literatures about PDT in the treatment of the unresectable hilar cholangiocarcinoma in the PubMed, MedLine, Embase, CNKI, and Wanfang databases were reviewed. Results The PDT combined with stent or chemotherapy was the main method in the treatment of the unresectable hilar cholangiocarcinoma, which could make the tumor down-staging, obviously reduce the jaundice, improve the quality of life, improve the survival rate, prolong the stent patency and be treated repeatedly. Especially, it was suitable for the patients with elderly, poor health, intolerance of surgery, could partly replace the R1 or R2 operation of hilar cholangiocarcinoma and avoid the risk of surgery and postoperative complications. The therapeutic effective of the PDT was related to the early therapy and times of therapy. However, the shortcomes of the PDT were that the depth of killing tumor was not enough and there was a certain incidence of adverse reaction. Conclusions Therapeutic effect of PDT combine with stent or chemotherapy for unresectable hilar cholangiocarcinoma is better than that of single therapy. It is expected to be a first-line scheme of palliative treatment for unresectable hilar cholangiocarcinoma.
Objective To compare the clinicopathological features of hilar cholangiocarcinoma (HCCA) and hilar benign diseases, and then explore the value of carbohydrate antigen 19-9 (CA19-9) and carcinoembryonic antigen (CEA) in the differential diagnosis between them. Methods Clinical data of 65 patients (54 patients with HCCA and 11 patients with hilar benign diseases) who were diagnosed as HCCA and received treatment from January 2011 to October 2015 in our hospital were retrospectively analyzed. Comparison of clinical data of HCCA patients and patients with hilar benign diseases in age, gender, disease duration, clinical manifestation, laboratory examination, and imaging examination was performed, and the receiver operating characteristic curve (ROC) was used to explore the value of CA19-9 and CEA in differential diagnosis between hilar benign diseases and HCCA. Results The age, levels of serum CA19-9, CEA, alanine aminotransferase (ALT), total bilirubin (BILT), and direct bilirubin (BILD) of HCCA group were significantly higher than that in benign group (P<0.05). However, the gender, disease duration, clinical manifestations (including jaundice, abdominal discomfort, fever, and weight loss), serum aspartate aminotransferase (AST), serum alkaline phosphatase (ALKP), and imaging findings (including hilar mass, intrahepatic bile duct dilatation, thickening of the bile duct wall, lymph node enlargement, vascular invasion, and gallbladder invasion) had no significant difference between the 2 groups (P>0.05). The ROC curve results showed that, when cut-off point for CA19-9 was 233.15 U/mL, the sensitivity was 56% and specificity was 91%; when cut-off point for CEA was 2.98 ng/mL, the sensitivity was 61% and specificity was 90%. Conclusions For the differential diagnosis between HCCA and hilar benign diseases, the elderly patients with high levels of serum transaminase and bilirubin were more likely to be malignant. It is more likely to be malignant when the serum CA19-9>233.15 U/mL or CEA>2.98 ng/mL.
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.
ObjectiveTo explore the value of magnetic resonance diffusion weighted imaging (DWI) in preoperative Bismuth-Corlette classification of hilar cholangiocarcinoma (HCCA). MethodsA total of 53 HCCA patients confirmed by postoperative pathology were retrospectively included. The accuracy of two sequence combinations, namely dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) + magnetic resonance cholangiopancreatography (MRCP) and DCE-MRI + MRCP + DWI, in evaluating the longitudinally involved bile duct segments and Bismuth-Corlette classification of HCCA was compared. Additionally, the correlation between apparent diffusion coefficient (ADC) values and tumor Bismuth-Corlette classification as well as degree of differentiation was analyzed. ResultsThere were 318 bile duct segments in 53 HCCA patients. The accuracy rate of DCE-MRI + MRCP was 93.7% (298/318), the sensitivity was 91.5% (161/176), and the specificity was 96.5% (137/142). The accuracy rate of DCE-MRI + MRCP + DWI was 96.5% (307/318), the sensitivity was 96.0% (169/176), and the specificity was 97.2% (138/142). Receiver operating characteristic (ROC) curve analysis showed that the area under the ROC curve (AUC) of DCE-MRI + MRCP + DWI was 0.966 [95%CI (0.940, 0.983), P＜0.001], and its diagnostic efficacy was superior to that of DCE-MRI + MRCP [AUC=0.940, 95%CI (0.908, 0.963), P＜0.001]. The DeLong test indicated a statistically significant difference in AUC between the two sequences (Z=2.633, P＜0.01). The accuracy rates of preoperative Bismuth-Corlette classification of HCCA evaluated by DCE-MRI + MRCP and DCE-MRI + MRCP + DWI were 86.8% (46/53) and 94.3% (50/53), respectively. After adding the DWI sequence, the consistency between Bismuth-Corlette classification results and surgical pathological classification results (Kappa=0.922, P<0.001) was higher than that of DCE-MRI + MRCP sequence (Kappa=0.820, P<0.001), with a statistically significant difference (χ2=160.370, P<0.001). In addition, the ADC value of HCCA was negatively correlated with tumordegree of differentiation (rs=–0.524, P<0.001), but had no significant correlation with its Bismuth-Corlette classification (rs=–0.058, P=0.682). ConclusionsDCE-MRI + MRCP + DWI sequence can effectively improve the accuracy in preoperative evaluation of the involvement of bile duct segments and Bismuth-Corlette classification of HCCA, which provides guidance for precise preoperative surgical planning in clinical practice. In addition, the ADC value can provide additional information required for non-invasive preoperative prediction of the prognosis of HCCA patients.
Objective To explore favorable factors of reducing incidence of postoperative liver failure after radical resection of Bismuth-Corlette type Ⅳ hilar cholangiocarcinoma in condition of hyperbilirubinemia. Methods All the clinical data of one patient with Bismuth-Corlette type Ⅳ hilar cholangiocarcinoma underwent radical resection in June 2017 in the West China Hospital of Sichuan University were collected. The preoperative total bilirubin level of this patient was 470.3 μmol/L, the patient didn’t receive preoperative biliary drainage. The preoperative jaundice time and cholangitis were calculated accurately. A 3D imaging system for quantitative evaluation of the liver was used to reconstruct the images with contrast-enhanced CT images of this patient. And the total liver volume and the future liver remnant volume (FLRV) were calculated. Finally, 6 months of follow-up were conducted after surgery. Results The exact jaundice time was 20 d and there was no preoperative cholangitis. The postoperative FLRV accounted for about 70%. No postoperative liver failure occurred. No recurrence of tumor and death of patient occurred after 6 months of follow-up. Conclusions Radical resection of hilar cholangiocarcinoma in condition of hyperbilirubinemia is not an absolute contraindication for surgery, but indications should be strictly controlled. For special patient whose jaundice with short duration, no preoperative cholangitis and a high FLRV may be treated with directly radical surgery to prevent for losting the best time of surgery.
Objective To investigate the strategy of treatment and prevention of hemorrhage after radical resection of hilar cholangiocarcinoma. Method Reviewing the related literatures at home and abroad in recent years, to summarize the progress of treatment and prevention of hemorrhage after radical resection of hilar cholangiocarcinoma. Results We should clear the postoperative bleeding time, extent, cause, and location, to help the clinician to choose the appropriate timing of intervention and treatment. The patients with early hemorrhage and mild degree hemorrhage could be treated conservatively. If patients with severe hemorrhage and hemodynamic disorders, surgical intervention must be decisive. Patients with late hemorrhage would have serious consequences, and these patients should receive interventional or surgical treatment as early as possible. Conclusions For patients with hilar cholangiocarcinoma after radical resection, doctors need to do accurate preoperative evaluation, meticulous operation, and intensive management after operation, to reduce the incidence of hemorrhage after radical resection of hilar cholangiocarcinoma. If the postoperative hemorrhage occurs, the cause, location, time, and degree of hemorrhage should be clearly defined to facilitate clinicians to make rapid clinical decisions and to develop treatment programs.