The role of extra-hepatic bile duct resection in the surgical management of gallbladder carcinoma. A first meta-analysis

ObjectiveTo systematically evaluate the clinicopathological and prognostic value of extra-hepatic bile duct resection (EHBDR) in the surgical management of patients with gallbladder carcinoma (GBC), especially in non-jaundiced patients.MethodsPubMed, EMBASE and the Cochrane Library were searched up to March 1^st 2021 for comparative studies between bile duct resected and non-resected groups. RevMan5.3 and Stata 13.0 software were used for the statistical analyses.ResultsEHBDR did not correlate with a better overall survival (OS) (P = 0.17) or disease-free survival (P = 0.27). No survival benefit was also observed in patients with T2N1 (P = 0.4), T3N0 (P = 0.14) disease and node-positive patients (P = 0.75), rather, EHBDR was even harmful for patients with T2N0 (P = 0.01) and node-negative disease (P = 0.02). Significantly higher incidences of recurrent disease (P = 0.0007), postoperative complications (P < 0.00001) and positive margins (P = 0.02) were detected in the bile duct-resected group. The duration of postoperative hospital stay between the two groups was comparable (P = 0.58). Selection bias was also detected in our analysis that a significantly higher proportion of advanced lesions with T3-4 or III-IV disease was observed in the bile duct-resected group (P < 0.00001). EHBDR only contributed to a greater lymph yield (P = 0.01).ConclusionEHBDR has no survival advantage for patients with GBC, especially for those with non-jaundiced disease. Considering the unfairness of comparing OS between jaundiced patients receiving EHBDR with non-jaundiced patients without EHBDR, we could only conclude that routine EHBDR in non-jaundiced patients is not recommended and future well-designed studies with more specific subgroup analyses are required for further validation.     

Current standards and future perspectives in adjuvant treatment for biliary tract cancers

Biliary tract cancer, including cholangiocarcinoma (CCA) and gallbladder cancer (GBC) are rare tumours with a rising incidence. Prognosis is poor, since most patients are diagnosed with advanced disease. Only ~20% of patients are diagnosed with early-stage disease, suitable for curative surgery. Despite surgery performed with potentially-curative intent, relapse rates are high, with around 60–70% of patients expected to have disease recurrence. Most relapses occur in the form of distant metastases, with a predominance of liver spread. In view of high tumour recurrence, adjuvant strategies have been explored for many years, in the form of radiotherapy, chemo-radiotherapy and chemotherapy. Historically, few randomised trials were available, which included a variety of additional tumours (e.g. pancreatic and ampullary tumours); most evidence relied on phase II and retrospective studies, with no high-quality evidence available to define the real benefit derived from adjuvant strategies.Since 2017, three randomised phase III clinical trials have been reported; all recruited patients with resected biliary tract cancer (CCA and GBC) who were randomised to observation alone, or chemotherapy in the form of gemcitabine (BCAT study; included patients diagnosed with extrahepatic CCA only), gemcitabine and oxaliplatin (PRODIGE-12/ACCORD-18; included patients diagnosed with CCA and GBC) or capecitabine (BILCAP; included patients diagnosed with CCA and GBC). While gemcitabine-based chemotherapy failed to show an impact on patient outcome (relapse-free survival (RFS) or overall survival (OS)), the BILCAP study showed a benefit from adjuvant capecitabine in terms of OS (pre-planned sensitivity analysis in the intention-to-treat population and in the per-protocol analysis), with confirmed benefit in terms of RFS. Based on the BILCAP trial, international guidelines recommend adjuvant capecitabine for a period of six months following potentially curative resection of CCA as the current standard of care for resected CCA and GBC. However, BILCAP failed to show OS benefit in the intention-to-treat (non-sensitivity analysis) population (primary end-point), and this finding, as well as some inconsistencies between studies has been criticised and has led to confusion in the biliary tract cancer medical community.This review summarises the adjuvant field in biliary tract cancer, with evidence before and after 2017, and comparison between the latest randomised phase III studies. Potential explanations are presented for differential findings, and future steps are explored.     

腹腔镜胆囊切除术中意外胆囊癌12例诊治分析

目的:探讨腹腔镜胆囊切除术(LC)中意外胆囊癌(unexpected gallb ladder carc inom a,UGC)的处理措施。方法:回顾分析本院955例LC术中遇到的12例(1.26%)UGC的临床资料。结果:随诊3~36个月,平均18个月。迄今全部存活。5例PT1、5例PT2、1例PT3(中转开腹)随访至今未发现癌复发及转移。1例PT2因拒绝根治术,现出现肝多发转移。1例PT4因腹腔种植转移,无法根治,故仅部分切除胆囊(胆囊粘连重),以解决急性胆囊炎问题,现有腹水、恶液质表现。所有病例均未见脐部戳孔处肿瘤种植转移。结论:LC术中应常规切开胆囊标本,必要时送术中冰冻。PT1单纯切除胆囊已足够;PT2要额外楔形切除肝组织及区域淋巴结;PT3中转开腹,行根治手术或姑息手术。     

MR T2加权成像显示胆囊壁增厚点状高信号的意义

目的研究病理组织学证实的胆囊腺肌瘤病、慢性胆囊炎和管壁增厚型胆囊腺癌在MRL加权成像（T2WI）显示病变胆囊壁点状高信号的特征。方法38例患者（胆囊腺肌瘤病16例，慢性胆囊炎13例，管壁增厚型胆囊腺癌9例），每例均进行了MR常规T1WI、常规T2WI和3mm薄层T2WI及MR胰胆管成像（MRCP）。所有患者均接受了胆囊切除手术。2名高年资放射科医生共同分析不同序列MRI，观察胆囊壁增厚及T2WI显示病变胆囊壁点状高信号的不同表现，将观察结果与病理组织学检查所见对照。结果所有患者的胆囊壁均明显增厚，厚度范围5～15mm，平均9mm。T2WI显示病变胆囊壁存在各种各样的点状高信号，在胆囊腺肌瘤病，点状高信号分布于整个增厚的胆囊壁，且数量较多（5～15个／cm^2），较大（直径2～7mm），边界清楚，呈现中等至明显高信号；在慢性胆囊炎，点状高信号主要位于增厚胆囊壁的黏膜侧，数量较少（3～5个／cm^2），较小（直径2～4mm），边界清楚，呈中等至明显高信号；在管壁增厚型胆囊腺癌，点状高信号边界欠清，呈现稍高信号，其数量和大小差异较大，分布范围取决于癌组织浸润胆囊壁的深度。结论胆囊腺肌瘤病、慢性胆囊炎和管壁增厚型胆囊腺癌在T2WI呈现的点状高信号有一定差别，正确识别这些点状高信号的特征有助于鉴别诊断良恶性胆囊壁增厚。     

Outpatient laparoscopic cholecystectomy: a reality.

BACKGROUND: The author reports on his personal experience with outpatient laparoscopic cholecystectomy (LC), focusing on the main guidelines for preoperative and postoperative care and operating technique. METHODS: From January 1, 2000 to December 31, 2000, 71 laparoscopic cholecystectomies were performed on outpatients. The patients remained in the outpatient surgery center for 36 hours. In 4 cases, the operation was converted into laparotomy. Twenty patients remained in the hospital and were discharged 5 to 7 days later. Twelve were rehospitalized due to pathologies that could not be treated at home. RESULTS: In all 71 cases, a complete remission of the symptoms occurred, and none of the patients died either during the operation or during the postoperative period. Eighty percent of patients were treated in outpatient surgery centers. CONCLUSIONS: With clear guidelines, LC is a major surgical operation that can be performed in outpatient surgery centers without death or other major complications and with very good remission of symptoms.     

Sonographic evaluation of gallbladder kinetics: in vitro and in vivo comparison of different methods to assess gallbladder emptying.

In an in vitro study, 10 gallbladders of adult pigs and 6 gallbladders of lambs, all removed immediately after slaughtering, were stimulated in a water bath by electric means to induce active contraction. Gallbladder emptying was followed by ultrasonography employing five measurement procedures: (1) gallbladder width, (2) longitudinal planimetry, (3) transverse planimetry, (4) ellipsoid method, and (5) sum of cylinders method. In an in vivo investigation, gallbladder emptying of 30 volunteers (12 healthy subjects, 18 diabetics) was evaluated in the same way after ingestion of a fatty meal. Gallbladder width was found to be unsuitable to estimate the decrease in gallbladder volume due to a nonlinear relation of the parameters. Longitudinal planimetry tended to be less valid than transverse planimetry in assessing gallbladder volume reduction. The most valid estimation of gallbladder volume decreases was obtained by the two three-dimensional procedures. However, in neither in vitro nor in vivo could a significant difference between the sum of cylinders method and the ellipsoid method in determining relative volume reduction be established. We conclude that a three-dimensional measurement procedure should be used for valid assessments of gallbladder motility. However, according to our data there is no advantage in using the time-consuming sum of cylinders method compared to the simple ellipsoid method.     

Lymph Node Dissection Impact on Staging and Survival of Extrahepatic Cholangiocarcinomas,Based on U.S. Population Data

Cholangiocarcinomas (CC) frequently demonstrate lymphatic spread. We investigated lymph node (LN) counts after resection of extrahepatic CC and survival based on the SEER 1973–2004 database. Out of 20,068 CC patients, 1,518 individuals were selected based on M0 stage and at least one LN examined. Primary cancer sites included gallbladder (29%), extrahepatic bile ducts (26%), and intrapancreatic/ampullary bile ducts (45%); 42% of patients were LN-positive. The median number of LNs examined was four (range 1–39). Median survival was 37 months for LN-negative and 16 months for LN-positive cancers. Multivariate prognostic variables were the number of positive LNs, primary site, age (all at p < 0.0001), gender (p = 0.002), size (p = 0.005), T category (p = 0.009), and total LN count (or number of negative LNs obtained, p = 0.01). The impact of total LN counts was seen in LN-negative (median survival, 1 vs 10 or more LNs examined: 27 vs 51 months, p = 0.002) and LN-positive disease (10 vs 22 months, p < 0.0001). Survival prediction of extrahepatic CCs is strongly influenced by total LN counts and numbers of negative LNs obtained. Although the resulting incremental benefit is small, dissection and examination of 10 or more LNs should be considered for curative intent resections.     

雌激素及其受体与胆囊癌关系的研究现状及进展

目的:探讨并讨论雌激素及其抗体与胆囊癌的关系.方法:阅读关于雌激素和胆囊癌方面的文献并进行总结.结果:雌激素在胆囊癌转变过程中起极为重要的作用.结论:研究胆囊癌患者血清中的雌激素水平对胆囊癌的发生、发展、预后及指导相应临床内分泌治疗具有重要的理论意义.     

99Tcm-EHIDA肝胆动态显像判断肝硬化患者胆囊运动功能

目的研究^99Tc^m-二乙基乙酰苯胺亚氨二醋酸（EHIDA）肝胆动态显像在判断肝硬化患者胆囊运动功能中的作用.方法研究对象分为正常对照组和肝硬化组,其中肝硬化组分为胆石组和非胆石组.受试者均行^99Tc^m-EHIDA肝胆动态显像.获得图像后应用胆囊感兴趣区（ROI）技术,由计算机自动绘制胆囊时间-放射性曲线,并计算潜伏期（LP）、排胆期（EP）、排胆分数（GBEF）和排胆率（ER）.结果肝硬化组患者GBEF和ER明显低于正常对照组（t值均为2.767,P均＜0.01）,但其LP高于正常对照组（Z=-1.989,P＜0.05）.肝硬化胆石组胆囊运动异常率（x^2=4.538,P=0.033）、胆囊壁厚度（t=-2.386,P=0.02）和血清总胆汁酸（t=-2.442,P=0.018）明显高于非胆石组.结论肝硬化患者胆囊运动功能减弱.^99Tc^m-EHIDA肝胆动态显像可作为检查胆囊运动功能的一种无创、准确的方法.