Clinical features of pancreaticobiliary maljunction: update analysis of 2nd Japan-nationwide survey

Introduction

Pancreaticobiliary maljunction (PBM) is a congenital anomaly, which can be defined as a union of the pancreatic and biliary ducts located outside off the duodenal wall. We herein investigate clinical features of PBM including as the 2nd report of a Japanese nationwide survey.

Patients and methods

During a period of 18 years (from 1990 to 2007), 2,561 patients with PBM were registered at 141 medical institutions in Japan. Among them, eligible patients (n = 2,529) were divided into two groups: adult (n = 1,511) and pediatric patients (n = 1,018). Comparisons of clinical features including associated biliary cancers were performed according to the biliary dilatation (BD), age factor, and time era.

Results

Only one case in pediatric patients with BD combined with a bile duct cancer (0.1 %). In adult patients, the bile duct cancer and the gallbladder cancer was seen in 6.9 and 13.4 % patients with BD and in 3.1 and 37.4 % patients without BD, respectively. In adult patients with BD, the occurrence rates of biliary cancers were increased in latter period (00’–07’) compared with former period (90’–99’). The ratio of biliary cancer localization was changed between former and latter period, and the bile duct cancer was increased in latter period (from 5.5 to 9.3 %).

Conclusions

The largest series of PBM were evaluated to clarify the clinical features including the associated biliary cancer in this Japan-nationwide survey. This report could be widely used in the future as a reference data for diagnosis and treatment of PBM.     

Hilar cholangioplasty using omentum for ductal defect in biliobiliary fistula

Background/purpose

A non-circumferential defect of the biliary system is occasionally faced at surgery for biliobiliary fistula. The condition represents an uncommon but important complication of gallstone disease. Although direct closure and patch repair using the gallbladder cuff are recommended as first-line treatments, these procedures are sometimes technically difficult in the presence of severe inflammation. The authors, herein, present a novel procedure denoted as hilar cholangioplasty, which utilizes the pedicled omentum.

Methods

An 80-year-old man was referred to our hospital because of cholangitis. Endoscopic retrograde cholangiography demonstrated a large gallstone astride the common hepatic duct with upstream biliary dilation, indicating biliobiliary fistula. Upon laparotomy, a 2 × 3 cm ductal defect was found just under the hepatic bifurcation, after removal of the gallstones and the gallbladder. The surrounding tissue, as well as the bile duct, was extensively inflamed with dense fibrosis, such that first-line repair methods could not be performed. As an alternative method, the pedicled omentum was used for cholangioplasty.

Results

Postoperative cholangioscopy showed a yellow polypoid mass without constriction. Histologically, ordinary biliary epithelium overlaid the surface of the grafted omentum. The patient has remained well at 3-year follow-up.

Conclusion

The present method is simple and could be a promising option when standard repair methods cannot be applied.     

Gallbladder Stent Placement for Prevention of Cholecystitis in Patients Receiving Covered Metal Stent for Malignant Obstructive Jaundice: A Feasibility Study

Purpose

Covered self-expanding metal stents (CSEMS) have been used for palliation of malignant distal biliary strictures. Occlusion of the cystic duct by CSEMS may be complicated by cholecystitis. This potentially could be prevented by placement of a transpapillary gallbladder stent (GBS).

Patients and Methods

Between 11/2006 and 10/2007, a total of 73 patients (50 male) aged 65 ± 14 years underwent CSEMS placement for palliation of malignant obstructive jaundice. In cases where CSEMS placement caused occlusion of the cystic duct, a 7 French transpapillary pigtail gallbladder stent (GBS) was inserted to prevent cholecystitis.

Results

Of the 73 patients, 18 had a prior cholecystectomy; 34 had the CSEMS placed below the cystic duct insertion. In 19 out of the 21 patients who had a CSEMS covering the cystic duct ostium, GBS placement was attempted, which was successful in 11 individuals (58%). An attempt to access the gallbladder was complicated by wire perforation of the cystic duct in three patients; one patient requiring emergent cholecystostomy tube placement. None of the patients who underwent successful GBS placement developed cholecystitis. One GBS dislodged and was repositioned. Cholecystitis occurred in two (20%) of the ten patients without transpapillary gallbladder decompression who had a CSEMS covering the cystic duct.

Conclusions

The ideal placement of a CSEMS is below the cystic duct insertion. Should the cystic duct ostium be occluded, placement of a GBS should be considered to minimize the risk of cholecystitis.     

Sonographic demonstration of wall thickness of the gallbladder in pediatric patients with pancreatico-biliary maljunction

Background

Sonographic demonstration of extramural and intrapancreatic junction of the pancreatic and bile ducts, pathognomonic for pancreatico-biliary maljunction (PBM), is not easy in pediatric patients. We measured sonographic thickness of the gallbladder (GB) and retrospectively examined correlation of it with PBM.

Methods

Twenty-seven children with PBM were examined with conventional ultrasonography (US). All patients underwent hepaticojejunostomy, and resected GB were studied in histological examination. Preoperative extracorporeal US measured gallbladder wall thickness, and abnormal GB wall was defined 3?mm or more in thickness.

Results

They consisted of 8 males and 19 females, ranging in age from 2?months to 11?years. The thickness of the GB wall was more than 3?mm in 18: 10 with smooth thickness and 8 with non-uniform thickness. The thickness of GB wall was found in 16 (84.2%) of the 19 patients more than 1?year of age. The difference between sonographic and macroscopic measurements of the wall thickness was less than 1?mm in 24 (89%) of the 27 patients.

Conclusion

US measurement of gallbladder wall thickness can be a screening test more than 1?year of age for PBM.     

Clinical and pathological features of primary carcinoma of the cystic duct

Background

According to Farrar’s criteria, a tumor restricted to the cystic duct is defined as cystic duct carcinoma, but this definition excludes advanced carcinoma originating from the cystic duct.

Patients and methods

For the purpose of this study, primary cystic duct carcinoma was defined as a tumor originating from the cystic duct. We investigated the clinicopathological features of 15 cystic duct carcinomas, including 13 that did not fit Farrar’s criteria, and compared them with those of 52 cases of gallbladder carcinoma and 161 cases of extrahepatic bile duct carcinoma.

Results

The incidence of primary cystic duct carcinoma was 6.6% among all malignant biliary tumors. The main symptom was jaundice in 67% of cases. The operative procedures employed ranged from cholecystectomy to hepatopancreatoduodenectomy. The cases of cystic duct carcinoma and bile duct carcinoma showed a high frequency of perineural infiltration. The overall 5-year survival rate of the 15 patients was 40%.

Conclusion

Patients with advanced cystic duct carcinoma show a high frequency of jaundice and perineural infiltration. Our data suggest that cystic duct carcinoma may be considered a distinct subgroup of gallbladder carcinoma. Radical surgery is necessary for potentially curative resection in patients with advanced cystic duct carcinoma.     

Recent advances in pancreaticobiliary maljunction

The purpose of this review is to evaluate our current knowledge of the embryologic etiology of pancreaticobiliary maljunction (PBM), its diagnosis, clinical aspects, and treatment, and to clarify the mechanisms of PBM involvement in carcinogenesis. Although the embryologic etiology of PBM still awaits clarification, an arrest of the migration of the common duct of the biliary and pancreatic ducts inwards in the duodenal wall has hitherto been speculated to result in a long common channel in PBM. However, we propose the hypothesis that the etiology of PBM is caused by a disturbance in the embryonic connections (misarrangement) of the choledochopancreatic duct system in the extremely early embryo. That is, PBM is an anomaly caused by a misarrangement whereby the terminal bile duct joins with a branch of the ventral pancreatic duct system, including the main pancreatic duct. PBM is frequently associated with congenital bile duct cyst (CCBD). However, these two anomalies are thought to have different embryonic etiologies. The diagnostic criteria for PBM are the radiological and anatomical detection of the extramural location of the junction of the pancreatic and biliary ducts in the duodenal wall. However, in PBM patients with a short common duct (less than 1 cm in length), detection of the extramural location is difficult. The clinical features of PBM are intermittent abdominal pain, with or without elevation of pancreatic enzyme levels; and obstructive jaundice, with or without acute pancreatitis, while the clinical features of PBM patients with CCBD are primary bile duct stone and acute cholangitis. The optimum approach for the treatment of PBM is the prevention of the reciprocal reflux of bile and pancreatic juice in the pancreas and the bile duct system. To achieve these aims, the surgical approach is most effective, and complete biliary diversion procedures with bile duct resection (for example, choledochoduodenostomy or choledochojejunostomy of the Roux‐en‐Y type) are most useful. Recently, it has been recognized that the development of biliary ductal carcinoma is associated with PBM. That is, the development of gallbladder cancer occurs frequently in PBM patients without CCBD, and bile duct cancer originating from the cyst wall also occurs in PBM patients with CCBD. It is speculated that the pathogenesis of the bile duct or gallbladder cancer in PBM patients involves the reciprocal reflux of bile and pancreatic juice. Investigations of epithelial cell proliferation in the gallbladder of PBM patients, and of K‐ras mutations andp53 suppressor gene mutations, loss of heterozygosity ofp53, and overexpression of thep53 gene product in gallbladder cancer and noncancerous lesions in PBM patients have been carried out in various laboratories around the world. The results support the conclusion that PBM is a high risk factor for the development of bile duct carcinoma.     

Biliary tract cancer treatment: 5,584 results from the Biliary Tract Cancer Statistics Registry from 1998 to 2004 in Japan

Background/Purpose

The results from the Japanese Biliary Tract Cancer Statistics Registry from 1988 to 1998 were reported in 2002. In the present study, we report here selectively summarized data as an overview of the 2006 follow-up survey of the registered cases from 1998 to 2004 for information bearing on problems with the treatment of cancer of the biliary tract.

Methods

A total of 5,584 patients were registered from 1998 to 2004. The site of cancer was the bile duct in 2,732 patients, the gallbladder in 2,067, and the papilla of Vater in 785. Those cases were analyzed with regard to patient survival according to the extent of tumor invasion (pT), the extent of lymph node metastasis (pN) and the stage.

Results

The five-year survival rate after surgical resection was 33.1% for bile duct cancer, 41.6% for gallbladder cancer, and 52.8% for cancer of the papilla of Vater. For hilar or superior bile duct cancer, the 5-year survival rate was lower with an increase in the pT, pN and f stage, except pT3 vs. pT4, pN1 vs. pN2 and stage III vs. stage IVa. For middle or distal bile duct cancer, the 5-year survival rate was lower with increase in pT, pN and f stage, except pT2 vs. pT3, pN2 vs. pN3, stage II vs. stage III and stage III vs. stage IVa. For gallbladder cancer, the 5-year survival rate was lower with increase in pT, pN and f stage. For cancer of the papilla of Vater, the 5-year survival rate was lower with increase in pT, pN and f stage, except pT1 vs. pT2, pN1 vs. pN2, and stage III vs. stage IVa.

Conclusions

In the present study, the outcomes of surgical treatment were better than that of the previous report from Japan and foreign countries. The pT, pN and stage of gallbladder cancer are well defined. However, there were no significant differences in some groups of those of bile duct cancer and cancer of the papilla of Vater.     

A Multicenter Prospective Study of the Short-Term Outcome of a Newly Developed Partially Covered Self-Expandable Metallic Biliary Stent (WallFlex?)

Background

Self-expandable metallic stent (SEMS) placement is a widely used, effective therapy for unresectable malignant stricture of the lower bile duct.

Aims

We evaluated the short-term outcome of the newly developed WallFlex^® Biliary RX Partially Covered Stent in patients with malignant lower and middle biliary stricture in five tertiary referral centers.

Methods

The subjects of this study were 52 patients in whom WallFlex^® Biliary RX Stents were inserted into the bile duct for malignant stenosis of the middle and lower bile duct at five medical facilities between April 2009 and November 2009.

Results

The stent placement success rate was 100%. Effective biliary decompression was achieved in all patients. The incidence of early complications was 7.7% (4/52). Stent occlusion occurred in two patients (3.8%) (one dislocation, one migration); cholecystitis occurred in two patients (3.8%). Neither acute pancreatitis nor stent kinking in the bile duct occurred.

Conclusions

The present results revealed that the new WallFlex^® Biliary RX Partially Covered SEMSs were useful for the short-term relief of biliary obstruction due to unresectable distal biliary malignancies.     

Different Expression of S100A8 in Malignant and Benign Gallbladder Diseases

Background

Proteomic analysis is a powerful tool for complete establishment of protein expression. Comparative proteomic analysis of human bile from malignant and benign gallbladder diseases may be helpful in research into gallbladder cancer.

Aims

Our objective was to establish biliary protein content for gallbladder cancer, gallbladder adenoma, and chronic calculous cholecystitis for comparative proteomic analysis.

Methods

Bile samples were collected from patients with gallbladder cancer, gallbladder adenoma, and chronic calculous cholecystitis. Peptides of biliary proteins were separated by two-dimensional liquid chromatography then identified by tandem mass spectrometry.

Results

Up to 544, 221, and 495 unique proteins were identified in bile samples from gallbladder cancer, gallbladder adenoma, and chronic calculous cholecystitis. Forty-three, 16, and 28 proteins with more than one unique peptide, respectively, were identified in the three groups. Among these, 30 proteins including S100A8 were overexpressed in gallbladder cancer, compared with benign gallbladder diseases. We also confirmed, by immunohistochemical analysis, that S100A8 is more abundant in tumor-infiltrating immune cells in cancerous tissue.

Conclusions

Compared with benign gallbladder diseases, consistently elevated S100A8 levels in malignant gallbladder bile and tissue indicate that gallbladder cancer is an inflammation-associated cancer. S100A8 may be a biomarker for gallbladder cancer.     

Retrospective analysis of outcome in 63 gallbladder carcinoma patients after radical resection

Background/Purpose

The aim of this study was to evaluate factors influencing outcome in gallbladder carcinoma after radical resection, in order to identify those patients benefiting from radical surgery.

Methods

Sixty-three patients (13 pT1, 28 pT2, 14 pT3, and 8 pT4) who underwent surgical resection for gallbladder carcinoma were retrospectively reviewed. Correlations were sought between survival and factors such as the depth of invasion (pT) including the status of infiltration of the hepatoduodenal ligament (pBinf) and liver bed (pHinf), the extent of lymph node metastasis, and other pathologic factors.

Results

Multivariate analysis showed that pBinf, pHinf, and lymph node metastasis were significant prognostic factors. We also analyzed survival rates for each operative procedure. There was no difference in survival between patients with or without bile duct resection for lymph node metastasis. The 5-year survival rates of pHinf-negative patients with stage 1B or more advanced disease after gallbladder bed resection or bisegmentectomy 4a,5 versus those without liver resection were 66% and 0%, respectively. Twelve patients survived for more than 5 years after surgery, including one patient undergoing HPD (liver resection with pancreatoduodenectomy) with positive lymph node metastasis; none was pBinf-positive.

Conclusions

Several factyors were identified as having prognostic significance for survival in patients with gallbladder carcinomas, and we suggest that radical surgery may be indicated for selected patients with advanced disease.     

Is major hepatectomy with pancreatoduodenectomy justified for advanced biliary malignancy?

Background/Purpose

Major hepatectomy with concomitant pancreatoduodenectomy (M-HPD) is usually indicated for the resection of diffuse bile duct cancer or advanced gallbladder cancer. This is the only procedure that can potentially cure such advanced cancers, so both a low mortality rate and long-term survival could potentially justify performing this procedure.

Methods

Between 1990 and 2005, the morbidity, mortality, and long-term survival of 26 patients with advanced biliary tract carcinoma 14 with diffuse bile duct cancer, 9 with advanced gallbladder cancer, and 3 with hilar bile duct cancer, who underwent hepatopancreatoduodectomy (HPD) were reviewed and analyzed.

Results

The overall morbidity and mortality rates were 30.8% and 0%, respectively. Postoperative infectious complications occurred in 6 patients (23.0%). The 5-year survival rate of the 14 patients with diffuse bile duct cancer who underwent HPD was 51.9%, while the 5-year survival rate in the 12 of these patients who underwent M-HPD was 61.4%. Patients with diffuse bile duct cancer without residual tumor and those without lymph node metastasis had 5-year survival rates of 68.6% and 80%, respectively. Thirty-three percent (2 of 6) of the patients who underwent M-HPD for advanced gallbladder cancer survived for more than 5 years.

Conclusions

Preoperative biliary drainage, portal embolization, complete external drainage of pancreatic juice, reduction of intraoperative bleeding, and prevention of bacterial colonization of bile may enable the incidence of mortality and hepatic failure to approach zero in patients who undergo HPD. Surgeons should strive for complete clearance of the tumor with a negative surgical margin to achieve long-term survival when performing M-HPD.

     

Variations anatomiques des voies biliaires et conséquences chirurgicales: à propos de 19 cas

Introduction

Both intra- and extrahepatic biliary anatomy is complex with the existence of many common and uncommon anatomic variations. The knowledge of these variations is necessary before biliary and hepatic surgery. Cholangiography peroperative is useful to evaluate the exact disposition of biliary tract. The aim of this study is to elucidate the anatomic variants of the biliary tract and there surgical consequences.

Materials and methods

We retrospectively analysed 70 cholangiography peroperative. We observed 19 anatomic variants of the biliary tree in 16 patients (27.1%). Three patients had two variations.

Results

Anatomic variants involved principally the right duct: 11 cases (57.8%). Five variants involved the cystic duct (26.3%) and three anomalies interested the confluence of choledoque into duodenum. Any variants in the left biliary duct were observed. These anomalies were associated with three complications: two biliary fistulas and one biliary peritonitis.

Conclusion

Our study confirmed the crucial role of the cholangiography peroperative in the detection of anatomic variants in the biliary tree that may increase the hepatic and biliary surgical complications.     

Biliary carcinoma risk in patients with pancreaticobiliary maljunction and the degree of extrahepatic bile duct dilatation

BACKGROUND/AIMS: Pancreaticobiliary maljunction (PBM) carries a high risk of biliary carcinoma. This study aimed to examine the biliary complications of patients with PBM in relation to the degree of extra-hepatic bile duct dilatation. METHODOLOGY: Ninety-eight cases of PBM could be divided into 5 groups according to the maximum diameter of the extrahepatic bile duct: < or = 10mm, 11-15mm, 16-20mm, 21-30mm, > or = 31mm. The clinicopathological findings of biliary carcinomas associated with PBM were compared with 232 cases of gallbladder carcinoma and 159 cases of bile duct carcinoma that were not associated with PBM. RESULTS: Gallbladder carcinoma occurred in 36 of 65 patients (55%) with PBM whose maximum diameter of the extrahepatic bile duct was < or = 30mm, but no gallbladder carcinoma occurred in patients with PBM whose diameter was > or = 31mm. Bile duct carcinoma occurred in 6 of 52 patients (12%) with PBM whose diameter was > or = 21mm, but no bile duct carcinoma occurred in patients with PBM whose diameter was < or = 20mm. The age at diagnosis of the patients with gallbladder or bile duct carcinoma associated with PBM was significantly younger than those without PBM (p<0.01). CONCLUSIONS: PBM with an extrahepatic bile duct diameter < or = 30mm is associated with a high risk of gallbladder carcinoma. PBM with an extrahepatic bile duct diameter > or = 21mm is associated with a high risk of bile duct carcinoma. Prophylactic cholecystectomy is recommended for patients with PBM without biliary dilatation.     

Intraoperative exploration of biliary anatomy using fluorescence imaging of indocyanine green in experimental and clinical cholecystectomies

Background/purpose

We evaluated the usefulness of intraoperative exploration of the biliary anatomy using fluorescence imaging with indocyanine green (ICG) in experimental and clinical cholecystectomies.

Methods

The experimental study was done using two 40-kg pigs and the clinical study was done in 12 patients for whom cholecystectomy was planned from January 2009 to June 2009. Initially we used a laparoscopic approach for the evaluation of fluorescence imaging of the biliary system in the two pigs. Then the clinical study was started on the basis of these experimental results. ICG (1.0 ml/body of 2.5 mg/ml ICG) was infused 1–2 h before surgery. With the subjects under general anesthesia we observed in real time the condition of the biliary tract under the guidance of fluorescence imaging employing an infrared camera or a prototype laparoscope. ICG was added intravenously to observe the location or flow condition of the cystic artery.

Results

We obtained a clear view of the biliary tract and the location of the cystic duct in the two pigs. Local compression with a transparent hemispherical plastic device was effective for offering a clearer view. The biliary tract, except for the gallbladder, was clearly recognized in all clinical subjects. Local compression with a transparent hemispherical plastic device for open cholecystectomy and a flat plastic device for laparoscopy provided clearer visualization of the confluence between the cystic duct and common bile duct or common hepatic duct. The location of the cystic artery was revealed after division of the connective tissues, and the flow condition of the cystic artery was confirmed 7–10 s after intravenous re-infusion of ICG. There were no adverse events related to the intraoperative procedure or the ICG itself.

Conclusions

This method is safe and easy for the identification of the biliary anatomy, without requiring cannulation into the cystic duct, X-ray equipment, or the use of radioactive materials. Although fluorescence imaging is still at an early stage of application in comparison with ordinary intraoperative cholangiography, we expect that this method will become routine, offering a lower degree of invasiveness that will help avoid bile duct injury.     

Usefulness of intraoperative fluorescence imaging to evaluate local anatomy in hepatobiliary surgery

Background/Purpose

One of the major complications encountered in hepatobiliary surgery is the incidence of bile duct and blood vessel injuries. It is sometimes difficult during surgery to evaluate the local anatomy corresponding to hepatic arteries and bile ducts. We investigated the potential utility of an infrared camera system as a tool for evaluating local anatomy during hepatobiliary surgery.

Methods

An infrared camera system was used to detect indocyanine green fluorescence in vitro. We also employed this system for the intraoperative fluorescence imaging of the arteries and biliary system in a pig. Further, we evaluated blood flow in the hepatic artery, portal vein, and liver parenchyma during a human liver transplant and we investigated local anatomy in patients undergoing cholecystectomy.

Results

Fluorescence confirmed that indocyanine green was distributed in serum and bile. In the pig study, we confirmed the fluorescence of the biliary system for more than 1 h. In the liver transplant recipient, blood flow in the hepatic artery and portal vein was confirmed around the anastomosis. In most of the patients undergoing cholecystectomy, fluorescence was observed in the gallbladder, cystic and common bile ducts, and hepatic and cystic arteries.

Conclusions

Intraoperative fluorescence imaging in hepatobiliary surgery facilitates better understanding of the anatomy of arteries, the portal vein, and bile ducts.     

Can Endoscopic Ultrasound-Guided Fine Needle Aspiration Offer Clinical Benefit for Thick-Walled Gallbladders?

Background

No previous studies have compared cytology obtained under endoscopic transpapillary gallbladder drainage (ETGD) and EUS-guided fine needle aspiration (EUS-FNA) for thick-walled gallbladders.

Aim

The present study investigated the diagnostic yield of bile cytology under ETGD and EUS-FNA for gallbladder tumors.

Methods

A total of 69 patients were diagnosed as having gallbladder wall thickening. Among these patients, 28 patients were diagnosed by clinical follow-up, solely by imaging such as computed tomography or by histological examination of surgical specimens. The remaining 41 patients underwent ETGD and/or EUS-FNA. In these 41 patients, the clinical data collected included gender, age, diameter of gallbladder wall, site of gallbladder wall thickening, final diagnosis, adverse events, and diagnostic yield of ETGD and EUS-FNA.

Results

Cyto-histological diagnosis with EUS-FNA was higher than that with ETGD, with a sensitivity of 100 versus 71 %, specificity of 100 versus 94 %, and accuracy of 100 versus 88 %, respectively, in the two groups. In addition, the sampling adequacy of EUS-FNA was 100 %. Adverse events were seen in five patients in the ETGD group (mild pancreatitis), although no adverse events were seen in the EUS-FNA group (P = 0.08).

Conclusion

Our results suggest that EUS-FNA can be safely performed for the diagnosis of gallbladder lesions. Further, this procedure may be the diagnostic method of choice over cytology of bile juice obtained via ETGD to obtain histological evidence of gallbladder cancer.     

Evaluation of compliance with the Tokyo Guidelines for the management of acute cholangitis based on the Japanese administrative database associated with the Diagnosis Procedure Combination system

Background/purpose

We aimed to evaluate compliance with the clinical practice guidelines for acute cholangitis (Tokyo Guidelines) using the Japanese administrative database associated with the Diagnosis Procedure Combination (DPC) system.

Methods

We collected database data from 60,842 acute cholangitis patients, examining 10 recommendations in the Tokyo Guidelines. We counted how many recommendations had been complied with for every patient. The patient compliance score was defined as the rate of compliance with these recommendations (score 0?=?0% to score 10?=?100%). An aggregated patient compliance score was measured according to the severity of acute cholangitis. Severity was categorized as grade I (mild cholangitis; n?=?49,630), grade II (moderate cholangitis; n?=?10,444), and grade III (severe cholangitis; n?=?768).

Results

The mean patient compliance score was significantly higher for patients with grade III than for those with grades II and I (7.6?±?2.1 vs. 6.5?±?3.0 vs. 2.9?±?0.9, p?<?0.001, respectively). Multiple linear regression analysis revealed that the severity of acute cholangitis was the parameter most significantly associated with the patient compliance score. The standardized coefficient of grade III was higher than that of grade II (0.657 vs. 0.248, p?<?0.001).

Conclusions

Compliance with the Tokyo Guidelines became higher in accordance with the severity of acute cholangitis.     

Key Factors Influencing Prognosis in Relation to Gallbladder Cancer

Introduction

The 5-year survival of patients with gallbladder cancer remains low. However, patients can be stratified into prognostic categories based on established factors such as T, N, and R status. New concepts regarding prognostic significance of lymph node disease, the importance of residual gallbladder fossa disease, and the gravity of presentation with jaundice are reviewed. In addition, a number of new prognostic factors proposed in recent years are considered.

Methods

PubMed was searched for “gallbladder cancer” with builder “date-completion” 2008 to present. A total of 1,490 articles were screened from which 168 were retrieved. From this, 40 articles specifically related to prognosis form the basis for this review.

Discussion

Key factors of prognostic significance remain T and N stage and R0 resection. Residual disease either in the gallbladder fossa, lymph nodes, or cystic duct margin dictates hepatectomy, lymphadenectomy and bile duct resection, respectively. Adequate lymphadenectomy requires removal of six nodes, and hepatectomy must be sufficient to achieve R0. Subtleties regarding lymph node ratio, significance of pathological features such as dedifferentiation, and budding may hold value for stratifying patients with early stage disease, but require further investigation.     

Small bile duct involvement in IgG4-related sclerosing cholangitis: liver biopsy and cholangiography correlation

Background

IgG4-related sclerosing cholangitis (IgG4-SC) needs to be differentiated from primary sclerosing cholangitis (PSC). In this study, we performed a retrospective study to reveal cases in which liver needle biopsy was useful for differential diagnosis.

Methods

Nineteen patients with IgG4-SC and 22 patients with PSC were studied. All patients underwent endoscopic retrograde cholangiography and liver needle biopsy. We defined small bile duct involvement of IgG4-SC histologically as damage to the small bile duct associated with infiltration of ??10 IgG4+ plasma cells per high power field (HPF). Clinicopathological characteristics were compared between IgG4-SC patients with and without small bile duct involvement.

Results

Small bile duct involvement was observed in 5 (26%) of the patients with IgG4-SC. Patients with small bile duct involvement showed a higher incidence of intrahepatic biliary strictures on cholangiography (80 vs. 21%, p?=?0.038). Conversely, 4 of 7 (57%) patients with intrahepatic biliary strictures on cholangiography had histologically evident small duct involvement. The number of IgG4+ plasma cells was significantly correlated with the site of the most proximal stricture on cholangiograms (p?=?0.021). The number of IgG4+ plasma cells per HPF was significantly higher in IgG4-SC patients with intrahepatic biliary strictures than in those with PSC (13.4 vs. 0.4?cells/HPF, p?<?0.001).

Conclusions

Involvement of small bile ducts is more frequent in patients with intrahepatic biliary strictures on cholangiography, and liver needle biopsy is especially useful for these patients.     

Technical refinements of bile duct division in living donor liver surgery

Background/purpose

In spite of the great risk involved, the donor bile duct division procedure has not been thoroughly addressed in the literature. The purpose of this study is to show the appropriate approach to bile duct division in living donor hepatectomy.

Methods

Of 87 living donor liver surgeries, we performed bile duct division by marking the cutting point using a small vascular clip under ordinary cholangiography in the first 37 patients, while the current procedure was used in 50 patients by encircling the cutting point using a radiopaque marker filament under real-time C-arm cholangiography.

Results

Regarding the procurement of the 51 right lobe grafts, the incidence of multiple bile ducts in the graft was significantly reduced by our novel procedure [20/28 (71%) vs. 7/23 (30%), P?<?0.01, Fisher??s test]. Overall, there were no biliary strictures after surgery in any of the donors, with a median follow-up period of 43?months (range 8?C136).

Conclusions

Our procedure of bile duct division in living liver donor surgery enabled us to avoid the biliary stricture while cutting the bile duct of the donor with great accuracy.