Surgical treatment of proximal bile duct tumors

A new classification of proximal bile duct tumors mainly based on endo- and exobiliary neoplastic invasion, indicating radical or palliative surgery is proposed. Fifty-eight patients underwent radical (12) or palliative (46) surgery. The 5-year survival rate of patients treated radically is 40% compared to 0% in patients treated palliatively; all the patients of this latter group died within 22 months. The authors stress the need for a standard anatomical classification for proximal bile duct tumors.     

Surgical therapy of proximal extrahepatic bile duct tumors (Klatskin tumors)

Due to their anatomical position, the tendency of early infiltrative growth and their poor prognosis without treatment, klatskin tumors are challenging concerning diagnosis and therapy. In contrast to other tumors of the gastrointestinal tract, for which exact diagnostic and stage dependent therapeutic guidelines could be formulated, clear recommendations for klatskin tumors are missing. Thus, survival rates after local resection, e. g. resection of the bile duct bifurcation alone, show high rates of R1/2 resection and early tumor recurrence. With an additional hepatic resection formally curative resections and long-term survival can be improved. Extended liver resections including the portal vein provide the highest rates of R0 resections for hilar carcinomas of the extrahepatic bile duct. Survival rates after liver transplantation for klatskin tumors are not yet convincing. Promising first results have been reported for the combination of neoadjuvant treatment and liver transplantation and might show future perspectives for the treatment of klatskin tumors.     

Surgical treatment of hilar bile duct carcinoma

Carcinoma of the bile duct at the hepatic hilar region is not a rare condition but with a low resectability rate. The incidence of this disease seems to be on increasing. In a previous report, 60 cases were explored surgically from 1975 to 1985, but resection was only possible in 5 cases (9.1%); while in the recent years from June, 1986 to June 1989, 24 cases were explored in the Surgical Department of General Hospital of PLA, 16 cases were resected, with a resectability rate of 66%. The increase of resectability rate was due to earlier recognition of this condition and the extension of surgery, including major resection of liver as well as radical dissection of the hepato-duodenal ligament and reparative operations on the blood vessels. Among these 16 cases, major hepatic resection was performed in 10 cases, in which, 3 cases of resections of the middle lobe of the liver were done instead of right or extended right lobectomy. No operative mortality in the 30 days' postoperative period, but the postoperative morbidity rate was still high and most of the complications were related to biliary leakage and infect ion. Three patients died in the postoperative follow up period at 6.14 and 15 months respectively. All of them died from biliary infection. The remaining 13 patients were still living, the longest being 40 months and the average living time was 16.1 months. Probably, lowering of the operative mortality rate and morbidity rate are still the most important considerations in the surgical treatment of hilar carcinoma at the present time.(ABSTRACT TRUNCATED AT 250 WORDS)     

Surgical treatment of cholangiocellular carcinoma

Intrahepatic cholangiocellular carcinoma (CCC) is known to be associated with severe symptoms and a particularly poor prognosis. Nonsurgical methods have failed to change this situation up to now. Surgical therapy, so far, is the only chance for effective treatment, but it has had limited success. The relative infrequency of this tumor does not allow extensive statistics and limits our present knowledge. In this contribution the outcome of 50 patients who underwent liver resection or liver transplantation in our institution is reported. Their courses have been reevaluated according to pathohistologic classification and TNM tumor staging. The median survival rates were 12.8 months in the group of patients after liver resection (n=32) and 5.0 months after liver transplantation (n=18). Liver transplantation, however, was performed only in patients with unresectable tumors. The longest survival after transplantation was 25 months; after resection four patients survived more than 5 years. In the resection group and the transplantation group survival rates correlated with tumor size and tumor stages according to TNM, although the differences were not statistically significant. Liver resection thus has its place in resectable situations. Liver transplantation for unresectable lesions of this tumor type—always deemed critically in the past—seems not to be indicated with our present stage of knowledge, unless adjuvant protocols appear promising and are tested.

---

Resumen El carcinoma colangiocelular intrahepático (CCC) se caracteriza por severa sintomatología y muy mal pronóstico. Hasta el presente, los métodos terapéuticos no quirúrgicos han demostrado incapacidad de modificar tal situación. El tratamiento quirúrgico aun constituye la única modalidad eficaz, pero con éxito limitado. La rareza de este tumor no ha permitido acumular estadísticas numerosas, limitando nuestro conocimiento de la enfermedad. En este trabajo se presentan los resultados en 50 pacientes sometidos a resección hepática o a trasplante de hígado en nuestra institución, valorándolos según clasificación histopatológica y estadificación TNM del tumor. Las tasas medias de sobrevida fueron 12.8 meses en el grupo de pacientes con resección hepática (n=32) y 5.0 meses después de trasplante de hígado (n=18). El trasplante de hígado, sin embargo, fue realizado únicamente en situaciones de irresecabilidad. La myor supervivencia luego de trasplante fue 25 meses; entre los sometidos a resección, 4 pacientes sobrevivieron más de 5 años. Las tasas de sobrevida se correlacionaron, tanto en el grupo de resección como en el de trasplante, con el tamaño del tumor y con la estadificación TNM, aunque las diferencias no fueron estadísticamente significativas. La resección hepática, incluyendo cirugía mayor, tiene indicación en pacientes con tumores resecables. El trasplante en los pacientes con tumores no resecables no parece estar indicado, a la luz del conocimiento actual, a menos que protocolos coadyuvantes, debidamente probados, aporten resultados promisorios.

---

Résumé Le cholangiocarcinome donne des symptômes sévères et est associé à un prognostic particulièrement mauvais. Le traitement non chirurgical est inopérant. La chirurgie, jusqu'à présent, est la seule chance de traitement efficace quoi que les succès sont très limités. La faible fréquence de cette tumeur ne permet pas d'accumuler des statistiques valables, et ceci limite l'état de nos connaissances actuelles. L'évolution chez 50 patients ayant eu une résection ou une transplantation a été analysée en fonction de leur classifications anatomopathologique et TNM. La survie médiane était de 12.8 mois chez le groupe de patients ayant eu une résection (n=32) et de 5.0 mois après la transplantation hépatique (n=18). La transplantation cependant, a été réalisée chez les patients où la résection était impossible. La survie la plus longue après transplantation a été de 25 mois. Quatre patients ont survécu plus de 5 ans après résection. La survie était corrélée avec la taille de la tumeur et le stade TNM, mais sans signification statistique. La résection hépatique est donc valable pour ces tumeurs. En cas de lésion non résequable, la transplantation ne semble pas être une solution valable.

     

Surgical management of proximal bile duct cancers

INTRODUCTION: Tumors arising from the proximal biliary tree remain particularly challenging with respect to their evaluation and treatment. Complete resection with negative histologic margins is the most effective treatment modality. RESULTS: However, the majority of patients are not candidates for surgery. Over the last decades, advances have evolved to improve resectability and morbidity after major liver and bile duct resection. However, these disease processes still pose a management challenge. Herein, we provide an overview of proximal bile duct cancers, hilar cholangiocarcinoma (HCCa) and intrahepatic cholangiocarcinoma (ICCa).     

Surgical treatment of iatrogenic lesions of the proximal common bile duct

Between January 1979 and September 1999 a series of 96 patients were operated on at our institution for iatrogenic biliary injuries, and among them 62 involved the proximal biliary tract. Injuries, according to the Strasberg classification, were type E2 in 18 patients, type E3 in 29 patients, and type E4 in 15 patients. The most frequent primary surgical procedures were laparoscopic cholecystectomy in 27 of the 62 patients (43.6%) and open cholecystectomy in 30 patients (48.3%). Previous repair had been attempted in 25 patients (40.3%). A total of 58 cholangiojejunostomies were performed. Repair had been performed directly, and a T-tube had been left in the main bile duct in four patients with E2 Strasberg lesions. Postoperative death occurred in four patients (6.4%). Outcome was graded as excellent, good, or poor depending on clinical symptoms, liver function tests, and the need for reintervention due to anastomotic stricture. The final outcome was evaluated in 54 patients. The mean follow-up was 5.9 ± 0.3 years, with the longest follow-up 10.2 years. Following our first repair 49 of the 54 patients (90.7%) had excellent results, 1 (1.9%) had good results, and 4 (7.4%) had poor results. None of the patients who underwent immediate or early repair had complications. Diagnostic and therapeutic courses are given on the basis of the type of lesion and the timing of repair. We emphasize the importance of timing (i.e., carrying out surgical repair as soon as possible) and of cholangiojejunostomy reconstruction in respect to defined technical principles. Moreover, we believe that repair treatment at a hepatobiliary center with multidisciplinary competence greatly influences the final long-term outcome.     

Surgical treatment for carcinoma of the extrahepatic bile duct

Eighty-six patients with primary extrahepatic bile duct carcinoma operated on in the Second Department of Surgery at Nagasaki University Hospital during a recent 13.5-year period were reviewed. The patients were divided into five groups depending upon the site of the tumor. The operative mortality, resectability, postoperative survival period, and five-year survival rate in each group were studied. The lower third group had the highest resectability, lowest operative mortality and longest post operative survival period. The hepatic duct, the upper third and the extended groups, however, showed extremely poor results. The pathological features of these three groups are discussed here and an operative procedure for resection of the tumor is proposed. We emphasize that the development of methods of early diagnosis is necessary, and recommend aggressive surgical treatment for tumors of the hepatic duct, upper third, and extended groups.     

Surgical treatment for carcinoma of the extrahepatic bile duct

Eighty-six patients with primary extrahepatic bile duct carcinoma operated on in the Second Department of Surgery at Nagasaki University Hospital during a recent 13.5-year period were reviewed. The patients were divided into five groups depending upon the site of the tumor. The operative mortality, resectability, postoperative survival period, and five-year survival rate in each group were studied. The lower third group had the highest resectability, lowest operative mortality and longest post operative survival period. The hepatic duct, the upper third and the extended groups, however, showed extremely poor results. The pathological features of these three groups are discussed here and an operative procedure for resection of the tumor is proposed. We emphasize that the development of methods of early diagnosis is necessary, and recommend aggressive surgical treatment for tumors of the hepatic duct, upper third, and extended groups.     

Surgical treatment in proximal bile duct cancer. A single-center experience.

OBJECTIVES: The authors evaluated the experience and results of a single center in surgical treatment of proximal bile duct carcinoma. SUMMARY BACKGROUND DATA: Whenever feasible, surgery is the appropriate treatment in proximal bile duct carcinoma. To improve survival rates and with special regard to liver transplantation, the extent of surgical radicalness remains an open issue. PATIENTS AND METHODS: Retrospective analysis of 249 patients who underwent surgery for proximal bile duct carcinoma via the following procedures: resection (n = 125), liver transplantation (n = 25), and exploratory laparotomy (n = 99). Survival rates were calculated according to the Kaplan-Meier method, uni- and multivariate analysis of prognostic factors, and log rank test (p < 0.05). RESULTS: Survival rates after resection and liver transplantation are correlated with international Union Against Cancer (UICC) tumor stage (resection: overall 5-year, 27.1%; stage I and II, 41.9%; stage IV, 20.7%; liver transplantation: overall 5-year, 17.1%; stage I and II, 37.8%; stage IV, 5.8%). Significant univariate prognostic factors for survival after liver resection were lymph node involvement (N category), tumor stage, tumor-free margins, and vascular invasion; for transplantation, they were local tumor extent, N category, tumor stage, and infiltration of liver parenchyma. For resection and transplantation, a multivariate analysis showed prognostic significance of tumor stage and tumor-free margins. CONCLUSION: Resection remains the treatment of choice in proximal bile duct carcinoma. Whenever possible, decisions about resectability should be made during laparotomy. With regard to the observation of long-term survivors, liver transplantation still can be justified in selected patients with stage II carcinoma. It is unknown whether more radical procedures, such as liver transplantation combined with multivisceral resections, will lead to better outcome in advanced stages. With regard to palliation, surgical drainage of the biliary system performed as hepatojejunostomy can be recommended.     

胆管损伤的外科处理

胆管损伤的治疗一直是胆道外科的重要课题.胆管损伤若处理不当,可继发胆管狭窄和复发性胆管炎,远期可导致胆汁性肝硬化和门静脉高压,患者将陷于无尽的痛苦之中.患者常需反复进行胆道狭窄修复手术,成为胆道外科最棘手的难题之一.分析我们治疗的近三百例胆道损伤性狭窄病例提示,原先处理失败的原因大多数与胆道损伤后再次手术时机不合适,治疗未遵循胆道外科原则,手术方法选择不当,或未重视胆道重建的技术细节等因素有关.本文就上述这几个方面,结合我们的临床经验,对损伤性胆管狭窄的外科处理进行探讨.     

胆管壁坏死的手术处理

目的 探讨胆管壁坏死外科手术处理.方法 回顾性分析了1990年5月至2008年12月收治的94例胆管壁坏死病人的临床资料.结果 无手术病死、无胆瘘、大出血等严重并发症.结论 根据胆管壁坏死的特点采用相应的手术方式.

Abstract：

Objective To explore the surgical treatment of bile duct necrosis.Methods Clinical data of 94 cases of bile duct necrosis treated in this hospital from May1990 to December 2008 were retrospectively analyzed.Results There were no death or severe complications such as biliary fistula and massive hemorrhage in these patients.Conclusion Bile duct necrosis should be treated with a proper surgical approach based on its features.     

高位胆管损伤性狭窄的外科处理

由于外伤、医疗相关操作或其他任何原因破坏了胆道系统的完整性和通畅性,即为胆管损伤.当这种损伤发生在左、右肝管汇合部或以上引起胆管狭窄,称为高位胆管损伤性狭窄.由于其位置深、解剖复杂,且常由于经历过手术治疗,局部粘连严重,外科处理时需要一定的技术和经验.     

损伤性胆管狭窄的外科治疗

目的 评价损伤性胆管狭窄的外科治疗效果。方法 总结了近8年来收治的56例医源性胆管狭窄病例，其中男性26例，女性30例。行开腹胆囊切除术致伤者36例，占64.29％．腹腔镜胆囊切除术损伤4例，胆总管探查术损伤14例。损伤后距来我院的时间以半年至2年为最多。治疗多已属后期，且胆管狭窄部位高。56例病人在我院进行了胆肠通路的重建手术或胆管狭窄的修复手术。结果 随访率(51／56)为91．07％．50例随访时间超过2年。3例因狭窄复发再次手术。疗效，优良率为90％。本组无手术死亡。结论 研究表明Roux-en-Y胆肠吻合术是治疗胆管狭窄尤其部位较高。狭窄段较长的胆管狭窄的有效方法。利用带蒂胆囊瓣。空肠瓣和胃壁瓣修复胆管也取得了良好疗效。同时进行胆管内支撑有助于提高疗效，防止胆管再狭窄。     

Current status in the management of proximal bile duct carcinoma

The confluence of the biliary duct constitutes the most common location of the bile duct neoplasms. Resection of the tumor is the only procedure which has met with long-term survival rates (more than 5 years). An enhanced exposure of the tumor in surgical intervention contributes to increasing the number of resectable cases. The transhepatic approach through the principal incision offers the best possibility to explore the tumors of the proximal bile duct confluence, using this approach the resection rate is higher than that of other routes. The surgical management of confluence biliary duct carcinoma can be curative if the diagnosis is made in early stages of the disease and if at that time resection is possible.     

Surgical treatment of hilar bile duct carcinoma: Experience with 25 consecutive hepatectomies

To evaluate our recent surgical policy regarding hilar bile duct carcinoma, we evaluated 62 cases treated between 1976 and 1993, and 25 cases treated between 1994 and 2000. In the late period we used percutaneous transhepatic portal vein embolization (PTPE) before extended right hepatectomy; S4a + S5 + S1 hepatectomy for elderly patients and those with poor liver function; and routine total caudate lobectomy including the paracaval portion and resection of the inferior portion of the medial segment (S4a). Sixtyfive (74.7%) of the 87 patients underwent hepatectomy: 40 in the early period and 25 in the late period. Bile duct resection alone was performed in 22 patients, all in the early period. Resection was curative in 54.8% in the early period and 88.0% in the late period. The 3- and 5-year survival rates in the early period were 27.1% and 20.2%, respectively, as compared to 59.9% and 49.9% in the late period. Analysis of the 25 hepatectomies in the late period revealed improved survival times compared to patients treated by PTPE with extended right hepatectomy. No complications occurred after extended left hepatectomy or S4a + S5 + S1 hepatectomy, but four patients (16%) who underwent extended right hepatectomy plus PTPE died postoperatively. Our policy has resulted in improved outcome in patients with hilar bile duct carcinoma.     

原发性肝癌伴胆管癌栓的外科治疗

目的　探讨伴胆管癌栓的原发性肝癌 (HCC)外科治疗方式的选择及对预后的影响。方法　回顾性分析 1994～ 2 0 0 1年 15例HCC伴胆管癌栓的外科治疗情况。　结果　肝癌切除加胆管癌栓清除术 7例 ,肝癌切除加肝外胆管切除术 4例 ,单纯胆总管切开取栓术 3例 ,背驮式肝移植 1例。术后 1年生存率为 73 3%,3年生存率为 40 %,其中有 2例生存已超过 5年。门静脉侵犯者的生存率显著低于未侵犯者 (P <0 0 5 )。　结论　原发性肝癌伴胆管癌栓行外科治疗是一种积极有效的治疗方法。复发后选择适当病例再次手术 ,仍可取得较好疗效。肝移植作为一种崭新的手术方式值得探讨。