Staging laparoscopy for hilar cholangiocarcinoma in 100 patients

Purpose

Accurate preoperative radiological staging of hilar cholangiocarcinoma remains difficult, and a number of patients are found to have irresectable advanced tumours or occult metastases at exploration. Staging laparoscopy can improve the detection of irresectable disease, avoiding unnecessary laparotomy. This study examines the role of staging laparoscopy in hilar cholangiocarcinoma, with a focus on yield over different time periods and identification of preoperative factors increasing the risk of irresectable disease.

Methods

Retrospective case note review of all patients undergoing staging laparoscopy for radiologically resectable hilar cholangiocarcinoma, identified from the hepatobiliary multidisciplinary team database, was performed.

Results

One hundred consecutive patients underwent staging laparoscopy between 1998 and 2011. Of these, 34 patients were found to be irresectable due to metastatic disease, and 11, due to extensive local disease. Fifty patients proceeded to exploratory laparotomy following staging laparoscopy, and 36 % (18/50) of whom were found to have irresectable disease: 12 patients due to advanced local disease and 6 patients due to metastases. The overall yield of laparoscopy was 45 %, and the accuracy was 71 %. There was no significant difference in age, preoperative bilirubin, neutrophil/lymphocyte ratio, Ca19-9 levels or T stage between patients with resectable disease and with irresectable disease on laparoscopy. There was also no change in the yield of laparoscopy over time, despite advances in radiological imaging.

Conclusion

In this series, staging laparoscopy avoided unnecessary laparotomy in 45 % of patients with radiologically resectable hilar cholangiocarcinoma. No factor was able to predict positive yield, and therefore, all patients with potentially resectable hilar cholangiocarcinoma should undergo staging laparoscopy.     

Staging laparoscopy and laparoscopic ultrasonography in more than 400 patients with upper gastrointestinal carcinoma.

BACKGROUND: Resection offers the only chance of cure to patients with esophageal, gastroesophageal junction, and hepatopancreatobiliary tumors. Staging is essential to select patients who will benefit from operation because palliation can also be performed nonoperatively. Several studies, including limited numbers of patients, have shown that laparoscopic staging prevents unnecessary laparotomies, but it is doubtful whether general application of this staging method can be advised. The aim of this study was to assess the benefit of diagnostic laparoscopy for staging patients with esophageal, gastroesophageal junction, and hepatopancreatobiliary tumors. STUDY DESIGN: Between June 1992 and December 1996, 420 patients with a resectable tumor after conventional staging underwent diagnostic laparoscopy combined with laparoscopic ultrasonography. Histologic proof of metastases or ingrowth was used to cancel laparotomy. RESULTS: Laparoscopic staging avoided laparotomy in 20% of patients (sensitivity 0.70): 5% with an esophageal tumor, 20% with a gastroesophageal junction tumor, 15% with a periampullary tumor, 40% with a proximal bile duct tumor, 35% with a liver tumor, and 40% with a pancreatic body or tail tumor. Complications and port-site metastases were seen in 4% and 2% of patients, respectively. CONCLUSIONS: Laparoscopic staging is a safe procedure with low morbidity and without mortality in this series. It has shown no benefit in esophageal cancer, but seems beneficial for staging tumors located at the gastroesophageal junction, proximal bile duct tumors, liver tumors, and pancreatic body and tail tumors. The value of laparoscopic staging for patients with periampullary tumors is not as great as stated in previous studies and is still the subject of investigation.     

两镜联合微创治疗肝外胆管结石30例临床分析

目的:总结应用腹腔镜、十二指肠镜联合治疗肝外胆管结石的手术经验。方法:回顾分析2003年10月~2006年2月应用腹腔镜、十二指肠镜联合治疗肝外胆管结石30例的临床资料及随访结果。结果:术后均无严重并发症发生。创伤小,住院时间明显缩短。结论:利用两镜联合微创治疗肝外胆管结石,患者创伤小,住院时间短,充分体现了内镜、腹腔镜的优越性,扩大了微创治疗肝外胆管结石的范围。     

肝外胆道癌830例临床分析

作者总结并分析了４０年来收治的肝外胆道肿瘤８３０例,其中胆囊癌６０１例,胆管癌２２９例。结果表明：肝外胆道癌占同期肝外胆道疾病患者的６．７７％;胆囊癌占肝外胆道癌的７２．４％,平均年龄为５６．６岁,男女比例为１∶２．５,手术率为６５．１％,肿瘤切除率为２９．４％;胆管癌占肝外胆道肿瘤的２７．６％,平均年龄为５６．４岁,男女比例为１．５∶１,手术率为６６．４％,肿瘤切除率为２０．４％。作者在对不同时间段进行分析时发现：胆囊癌及胆管癌的发病率均有上升趋势;肿瘤切除率亦有升高。     

肝外胆道癌1 430例临床及ICD-10编码分析

目的探讨某院肝外胆道癌的发病、诊断及治疗情况。 方法用ICD-10编码总结并分析了1950年至2010年广州市某三甲医院收治的肝外胆道癌1 430例临床资料,其中胆囊癌417例,胆道癌1 013例。 结果肝外胆道癌占同期肝外胆道疾病患者的3.73%,10年发病率增加87.03%;胆囊癌占肝外胆道癌的29.2%,中位年龄为47.3岁,男女比例为1∶1.12;手术率为63.5%,肿瘤切除率为55.5%;胆管癌占肝外胆道肿瘤的70.8%,中位年龄为47.3岁,男女比例为1.56∶1,手术率为76.0%,肿瘤切除率为45.1%。肝外胆道癌病案首页信息编码错码率为37.8%(391/1 035)。 结论胆囊癌及胆管癌的发病率均有上升趋势;肿瘤切除率有所提高,ICD-10错码率有待优化。     

Pancreatic enzyme levels in bile of patients with extrahepatic biliary tract disease.

A total of ninety three patients with biliary tract disease were studied to determine the concentration of the pancreatic enzymes, amylase and lipase, in bile obtained from the gallbladder and/or common bile duct. Of seventy gallbladder bile samples, amylase levels were higher than actual or predicted serum levels in 87 per cent, while bile lipase were higher than serum lipase values in 66 per cent. Bile obtained from the common bile duct had enzyme concentrations which fluctuated from values similar to those in serum to remarkably high levels. This suggests that pancreatic enzymes enter the biliary system through a common terminal ampulla which is known to exist in 60 to 90 per cent of human subjects. The premise is advanced that pancreatic enzymes may initiate inflammatory changes in the gallbladder and could play a role in gallstone formation by altering the constituents which maintain cholesterol in a soluble state. Biliary reflux of pancreatic enzymes could play a role in the pathogenesis of some cases of cholecystitis can cholelithiasis.     

Staging laparoscopy and its indications in pancreatic cancer patients

BACKGROUND: Laparoscopy has become a popular and widespread surgical technique. An important goal in the treatment of patients with pancreatic cancer is to avoid any unnecessary procedure. Laparoscopy has been suggested as a routine tool for staging in order to prevent unnecessary laparotomies in these patients. METHODS: In this article we present our experience regarding the value of laparoscopic staging and review the literature on this topic. RESULTS AND CONCLUSION: A direct and conclusive comparison of the controversial literature is difficult because of different study designs. Inconsistent use of high-quality CT scans significantly affects the results. However, recent studies reveal that not more than 14% of the patients benefit from diagnostic laparoscopy when a state-of-the-art CT scan has been performed previously. Therefore, we conclude that routine diagnostic laparoscopy is not justified in all patients with pancreatic cancer. Rather, selective use is appropriate, especially in patients in whom ascites is an indirect sign of peritoneal metastases, or if liver metastases cannot be surely excluded preoperatively. This approach is cost-effective and limits diagnostic laparoscopy to a subgroup of patients in whom a laparotomy can be avoided.     

Adenocarcinoma of the extrahepatic biliary tree.

Increasing survival rates for carcinoma of the biliary tree could reflect the selection of patients for referral to a specialist centre as well as modern improvements in diagnosis and treatment. To determine the true incidence and outcome of biliary cancer, the records of 243 unselected Bristol patients were reviewed retrospectively over a 15-year period. Mean age was 64 years. Gallstones were associated in 38% of cases. Sixty-nine of 87 patients with gallbladder carcinoma were submitted to laparotomy. The operative (30-day) mortality rate was 56% and the one-year survival rate was 7%; one patient with an unexpected carcinoma is alive 7 years after cholecystectomy (1% five-year survival rate). Among 31 patients with carcinoma of the ampulla the operative mortality rate was 27%; one-year and five-year survival rates were 46% and 15%. Bile duct cancers (n = 125) arose proximal to the entry of the cystic duct (n = 63), distal to that point (n = 46) or diffusely (n = 16). For proximal cholangiocarcinoma the operative mortality rate was 38% and 1-year survival rate 17%; no patient lived for 2 years. For distal cholangiocarcinoma the operative mortality rate was 45% and one-year survival rate 26%; no patient lived for 3 years. Only palliative procedures were undertaken for diffuse cholangiocarcinoma; 2 patients survived 1 year (13%). Overall 5 patients with carcinoma of the extrahepatic biliary tree appear to have been cured (2%).     

Immunohistochemistry of the liver and biliary tree in extrahepatic biliary atresia.

BACKGROUND: Progressive destruction of intrahepatic bile ducts may determine outcome in extrahepatic biliary atresia (EHBA) despite successful portoenterostomy. The aim of this study was to characterize the inflammatory infiltrate of a large series of cases of biliary atresia and relate these findings to clinical outcome. METHODS: Immunohistochemical analysis was performed on frozen tissue sections of extrahepatic biliary tree and liver biopsies obtained (August 1996 to March 1998) from 28 infants with EHBA and 8 liver biopsy specimens from age-matched controls with other cholestatic liver disorders. A semiquantitative scoring system was designed to evaluate the staining with a panel of antibodies to the CD4, CD8, CD25, CD56, CD68, CD71 antigens and to HLA-DR, ICAM-1, VCAM-1, E-selectin and LFA-1. The infants then underwent followup prospectively and divided into 2 prognostic groups at 12 months postoperatively: those who had cleared their jaundice (graded as a good outcome [n = 19]), and those who required liver transplantation or who had failed to clear their jaundice (defined as > 50 micromol/L; graded as poor outcome [n = 9]). RESULTS: CD4(+) lymphocytes and CD56(+) (NK cells) predominated in the liver of infants with EHBA as compared with controls. The infiltrating cells exhibited marked proliferation (CD71 expression) and activation (particularly LFA-1 but also CD25 expression). A smaller subpopulation of the cells also expressed VCAM and E-selectin. HLA-DR was strongly expressed on Kupffer cells and to a lesser extent on proliferating bile ducts and sinusoidal endothelium. Expression of the majority of markers was lower in the remnant bile duct tissue than in the liver of EHBA (P <.05) with only HLA-DR and LFA-1 (on infiltrating cells) and ICAM (on endothelium) expressed strongly in the remnant bile duct tissue. Although quantitatively less pronounced, all of these immunohistochemical features also were noted in non-EHBA cholestatic liver tissue. A good outcome at 12 months was associated with lower CD68 (macrophage) expression in both the liver (P <.05) and biliary tree (P <.05) and with reduced expression of ICAM-1 (P =.05) on infiltrating cells in the biliary remnant. CONCLUSIONS: Immunohistochemical patterns of immune-mediated liver injury and inflammation were prevalent features at the time of portoenterostomy. They were neither exclusive to nor characteristic of EHBA. A reduction in the expression of the macrophage marker (CD68) within the liver and biliary remnants and reduction of ICAM-1 expression on infiltrating cells in the biliary remnants appear to be associated with a better postoperative prognosis.     

Gunshot injuries of the extrahepatic biliary ducts.

OBJECTIVE: To assess our management of gunshot injuries of the extrahepatic biliary ducts. DESIGN: Retrospective study. SETTING: Urban teaching hospital, South Africa. SUBJECTS: 17 patients who were found to have gunshot injuries of the extrahepatic bile ducts, January 1993-June 1998. INTERVENTIONS: Packing and damage control, staged repair, or definitive repair. MAIN OUTCOME MEASURES: Morbidity and mortality: Three of the 17 died intraoperatively or postoperatively from causes unrelated to the biliary injury. Of the 14 survivors, 3 were managed initially with packing and damage control, 7 by staged repair, and 4 by definitive biliary repair. Eleven patients had a Roux-en-Y biliary jejunostomy, of whom 1 developed a late biliary stricture related to a postoperative anastomotic leak. End-to-end anastomosis of the bile duct was done for 2 patients and they both developed late biliary strictures. Ligation of the injured duct and cholecystojejunostomy was done for I patient. CONCLUSION: Roux-en-Y biliary-jejunal anastomosis is appropriate in the treatment of gunshot injuries of the extrahepatic biliary ducts as there is always a degree of tissue loss and some debridement is required, making it difficult to do a tension-free anastomosis.     

腹腔镜联合胆道镜治疗老年患者肝外胆管结石的疗效分析

目的探讨腹腔镜联合胆道镜治疗老年患者肝外胆管结石的临床效果。方法回顾性分析2012年1月至2016年5月我科收治的老年肝外胆管结石患者82例,分为观察组(43)例和对照组(39例)。观察组采用腹腔镜联合胆道镜进行治疗,对照组采用传统的开腹手术治疗,观察两组治疗效果及安全性。结果观察组患者出血量、手术时间、排气时间、住院时间均明显小于对照组(P0.05)。观察组结石残留率、切口感染的发生率也明显低于对照组(P0.05),但是胆道出血、胆道感染、胆漏的发生率两组无明显统计学差异。结论临床上采用腹腔镜联合胆道镜治疗老年患者肝外胆管结石效果确切,并发症发生几率小,有较好的应用前景。     

Histopathologic changes in the intra- and extrahepatic biliary tree in patients with postcholecystectomy choledocholithiasis

To assess the incidence of biliary stasis in recurrent choledocholithiasis, 155 patients with postcholecystectomy choledocholithiasis, all of whom were recommended for choledochoduodenostomy, are presented in this paper. Data show that in patients of advanced age and with a long history of the disease there is a higher incidence of common bile duct dilatation, primary common bile duct stones, and increased bile contamination rate. Furthermore, these elements are associated with advanced pathologic changes in the liver and biliary tree histology. This hypothesis is supported by barium meal studies through the constructed choledochoduodenostomy where the extent and progress of those pathologic changes have been illustrated by visualization of the entire biliary tree at different postoperative intervals. In this series of patients, the progress of the liver and biliary damage was studied after the relief of the obstruction. It would appear reasonable to accept that in patients with the above-mentioned characteristics, the evidence of biliary stasis is clear. In these patients, the demand for a drainage procedure supplementary to choledochotomy seems to be warranted in order to eliminate the risk of recurrent choledocholithiasis as a result of existing biliary stasis.     

Repair of extrahepatic biliary duct

A new technique is reported for repair of extrahepatic biliary tract injury at the confluence of right and left hepatic and common bile duct. This is an experience of 03 cases of such an injury. We used T-tube, angulated in such a way as to make a Y-tube with short limbs for right hepatic duct and left hepatic duct.     

Iatrogenic injuries to the extrahepatic biliary tract.

Iatrogenic injuries to the extrahepatic biliary tract continue to occur and result in significant morbidity. Over the last 10 years, 26 patients have been referred to Westmead Hospital for management of iatrogenic biliary tract injuries. Of these injuries, 22 occurred during cholecystectomy, three during hepatectomy and one during a pancreaticoduodenectomy. The principles of avoidance and repair are discussed. It is concluded that these injuries, although uncommon, continue to occur and that the best treatment results are achieved in specialized hepatobiliary units.     

Management of biliary obstruction in patients with unresectable carcinoma of the pancreas.

Clinical and pathologic data from 73 patients with unresectable carcinoma of the pancreas treated from 1980 to 1987 were reviewed to evaluate the efficacy of biliary enteric bypass and percutaneous transhepatic biliary drainage (PTBD) in the treatment of malignant biliary obstruction. Fifty-two patients underwent biliary enteric bypass with no operative deaths and with a 15% operative morbidity. These patients had a median postoperative hospitalization of 12 days. Four patients (8%) eventually developed recurrent jaundice, and three of these were successfully treated with PTBD. The median survival for these 52 patients was 7 months. Twenty-one patients underwent PTBD with an 81% technical-success rate. These patients had a 33% early complication rate and a 33% in-hospital mortality. The median hospitalization was 13 days postdrainage. Of the 14 patients surviving the initial hospitalization, 86% developed late complications requiring 16 hospital admissions and ten emergency room visits for a total of 155 days of hospitalization. The median survival for those patients undergoing PTBD was 4 months from the time of diagnosis and 2 months from the time of catheter drainage. Surgical bypass offers excellent palliation for malignant biliary obstruction with extremely low morbidity and mortality in properly selected patients; PTBD is useful in the treatment of those patients with extensive disease, who are poor surgical candidates, or who have failed previous surgical drainage. There is a role for both of these palliative procedures in the management of patients with biliary obstruction from pancreatic cancer.