Combination therapy of resection and intraoperative radiation for patients with carcinomas of extrahepatic bile duct and ampulla of Vater: prognostic advantage over resection alone?

BACKGROUND/AIMS: To investigate the therapeutic efficacy of intraoperative radiation for carcinomas of the bile duct and ampulla of Vater. METHODOLOGY: Postoperative morbidity, mortality and survival of patients undergoing surgical resection of ampullary cancer (n = 19) and bile duct cancer (n = 28) were retrospectively compared between two groups with and without intraoperative radiation. RESULTS: Background items (age, gender, preoperative laboratory data, operative time and bleeding volume, tumor stage) did not differ significantly between the two groups. The predominant postoperative complication was leakage of pancreatic juice, which occurred in similar rates in both groups. No significant differences were noted in the 3-year survival rates between the resection plus intraoperative radiation group and resection alone group (60.0% (n = 5) vs. 50.1% (n = 13) for ampullary cancer; 0% (n = 4) vs. 27.1% (n = 24) for bile duct cancer, respectively). The main causes of recurrence were distant metastasis for ampullary cancer and microscopic residue of carcinoma for bile duct cancer. CONCLUSIONS: The combination of intraoperative radiation and resection may add no significant benefit to patients with ampullary and bile duct cancer when compared with resection alone.     

B超联合磁共振胰胆管成像对梗阻性黄疸的诊断价值

目的探讨B超与磁共振胰胆管成像检查在梗阻性黄疸诊断中的价值。方法对66例梗阻性黄疸患者进行超声和MRCP检查,并给予手术治疗。结果 B超联合MRCP诊断梗阻性黄疸的正确率为92.4%,其中对13例胰头癌的诊断正确率为100%,13例壶腹部癌的诊断正确率为84.6%,19例胆管癌的诊断正确率为84.2%;对15例胆管结石的诊断正确率为100%,6例良性胆道狭窄为100%。结论 B超联合MRCP检查对诊断梗阻性黄疸有很高的临床应用价值。     

超声内镜对壶腹癌及肝外胆管癌术前分期诊断

超声内镜对手术前Ｖａｔｅｒ＇ｓ壶腹癌及肝外胆管癌的原发病变范围、浸润深度、是否有区域淋巴结转移及远隔转移作出诊断及分期，将有助于选择最佳治疗方案及判断预后。对２８例Ｖａｔｅｒ＇ｓ壶腹癌及１８例肝外胆管癌于手术前进行了超声内镜检查，并按照国际ＴＮＭ分期方案进行了手术前分期。其中２２例Ｖａｔｅｒ＇ｓ壶腹癌及１８例肝外胆管癌进行了根治性切除及详细的病理组织学检查，有可能将超声内镜与病理诊断结果进行对照以检验超声内镜诊断的准确性。超声内镜判断Ｖａｔｅｒ＇ｓ壶腹癌及肝外胆管癌病变范围及浸润深度的准确性分别为８１．８％及７２．２％；判断其区域淋巴结转移的准确性分别为５９％及６１．６％。Ｖａｔｅｒ＇ｓ壶腹癌伴门静脉受侵的３例中有２例于术前超声内镜检查中获得了正确诊断，但３例肝转移均未能发现。     

108例阻塞性黄疸的超声诊断分析

目的 探讨超声在阻塞性黄疸诊断中的价值.方法 对我院2004-2007年收治并手术的108例阻塞性黄疸患者的超声声像图进行回顾性分析和总结.结果 阻塞性黄疸超声诊断与手术病理结果符合102例(94.4%),其中胆管结石65例,诊断符合率100%;胆管狭窄2例,诊断符合率66.6%;胰腺炎1例,诊断符合率50.0%;胆囊炎(向后压迫)3例,诊断符合率100%;胰头癌14例,诊断符合率87.5%;壶腹癌11例,诊断符合率91.7%;胆管癌6例,诊断符合率85.7%.结论 超声诊断阻塞性黄疸与手术病理结果符合率高,可作为阻塞性黄疸检查的首选方法,结合临床可提高诊断率.     

Diagnostic and surgical therapeutic features of extrahepatic bile duct carcinoma without jaundice

AIM: To analyze the diagnostic and therapeutic features of extrahepatic bile duct carcinoma (EBDC) without jaundice. METHODS: Between 1985 and 1999, 101 patients underwent surgery for EBDC in Xiangya Hospital. These patients were divided into two groups: 84 jaundiced patients and 17 nonjaundiced patients according to preoperative serum total bilirubin levels. The dinical manifestations, laboratory findings, location, pathology and surgical resectability of the tumors were compared between the two groups. RESULTS: The laboratory parameters such as hemoglobin,serum albumin ALB, AKP, γ-GT, and sonography appearancewere similar between the two groups, and there was no significant difference in tumor location, pathological type and resectability. However, the number of non-jaundiced patients associated with chololithiasis was significantly greater than that of jaundiced patients (P=0.008). CONCLUSION: The presence of jaundice is not a reliable criterion for the prediction of the resectability and the extent of tumor progression in extrahepatic bile duct carcinoma. Decreased levels of blood hemoglobin and serum albumin, elevated levels of AKP and γ-GT, and/or abnormal sonography may be suggestive. Biopsy of a stenotic or thickened bile duct is strongly recommended for a correct diagnosis before the appearance of jaundice.     

Undifferentiated carcinoma of the duodenal ampulla

This report demonstrates a case of undifferentiated carcinoma of the duodenal ampulla. A 74-year male experienced jaundice lasting for 3 weeks. An upper gastrointestinal series demonstrated a polypoid, ovoid filling defect in the second portion of the duodenum, and duodenoscopy disclosed a protruding mass involving the orifice of the papilla of Vater. Cholangiography demonstrated obstruction due to compression in the terminal common bile duct. Pylorus-preserving pancreatoduodenectomy was performed on the diagnosis of ampullary carcinoma. The gross specimen showed a polypoid mass, measuring 3.5 cm in diameter, in the ampulla, located mainly in the duodenal submucosal layer and invading the terminal common bile duct. Histologically, the tumor was small cell type, undifferentiated carcinoma, arising from the duodenal epithelium adjacent to the ampulla.     

Computed tomographic and ultrasonic appearances of primary carcinoma of the common bile duct.

Two patients with obstructive jaundice due to surgically proved primary carcinoma of the common bile duct were examined by CT and ultrasound. The combination of the two modalities showed dilatation of the extrahepatic biliary system and the main pancreatic duct. The diagnosis of primary bile duct carcinoma is suggested by these findings in the presence of a normal pancreatic head, although similar findings may occur with a small pancreatic or ampullary carcinoma.     

An investigation of primary malignancies associated with ampullary carcinoma

BACKGROUND/AIMS: As ampullary carcinoma has a favorable prognosis, associated malignancies have potential prognostic significance in these patients. This study focused on the incidence and characteristics of preexisting, coexisting and subsequent malignancies in patients with ampullary carcinoma. METHODOLOGY: Sixty-four cases of ampullary carcinoma were retrospectively identified. Fifty-four patients underwent surgical resection, while in the other ten, histological diagnosis was reached after biopsy and/or autopsy. Other primary malignancies associated with ampullary carcinoma, occurring in the prediagnostic or postdiagnostic period, were investigated. The mean postdiagnostic follow-up period was 3.9 years (range, 0-23 years). RESULTS: Other malignancies occurred in 17 patients (27%), being found before (n=9), at (n=7), or after (n=5) diagnosis of ampullary carcinoma. The total number of associated lesions was 23, including one case of quadruple and four cases of triple carcinoma. The major associated malignancies were colonic carcinoma (n=9), gastric carcinoma (n=5), and uterine carcinoma (n=3). Twenty-one lesions were treated surgically or endoscopically. One patient died from synchronous extrahepatic bile duct carcinoma and one from leukemia, and one died from subsequent urinary bladder carcinoma. Development of other malignancies was related to age but not to gender, family history, adjuvant chemo/radiotherapy, or tumor pathology. CONCLUSIONS: Ampullary carcinoma is associated with a high incidence of other malignancies, particularly colonic and gastric carcinomas. The possibility of associated malignancies should therefore be considered in preoperative screening and postoperative follow-up of patients with ampullary carcinoma.     

Guidelines for the management of biliary tract and ampullary carcinomas: surgical treatment

The only curative treatment in biliary tract cancer is surgical treatment. Therefore, the suitability of curative resection should be investigated in the first place. In the presence of metastasis to the liver, lung, peritoneum, or distant lymph nodes, curative resection is not suitable. No definite consensus has been reached on local extension factors and curability. Measures of hepatic functional reserve in the jaundiced liver include future liver remnant volume and the indocyanine green (ICG) clearance test. Preoperative portal vein embolization may be considered in patients in whom right hepatectomy or more, or hepatectomy with a resection rate exceeding 50%–60% is planned. Postoperative complications and surgery-related mortality may be reduced with the use of portal vein embolization. Although hepatectomy and/or pancreaticoduodenectomy are preferable for the curative resection of bile duct cancer, extrahepatic bile duct resection alone is also considered in patients for whom it is judged that curative resection would be achieved after a strict diagnosis of its local extension. Also, combined caudate lobe resection is recommended for hilar cholangiocarcinoma. Because the prognosis of patients treated with combined portal vein resection is significantly better than that of unresected patients, combined portal vein resection may be carried out. Prognostic factors after resection for bile duct cancer include positive surgical margins, especially in the ductal stump; lymph node metastasis; perineural invasion; and combined vascular resection due to portal vein and/or hepatic artery invasion. For patients with suspected gallbladder cancer, laparoscopic cholecystectomy is not recommended, and open cholecystectomy should be performed as a rule. When gallbladder cancer invading the subserosal layer or deeper has been detected after simple cholecystectomy, additional resection should be considered. Prognostic factors after resection for gallbladder cancer include the depth of mural invasion; lymph node metastasis; extramural extension, especially into the hepatoduodenal ligament; perineural invasion; and the degree of curability. Pancreaticoduodenectomy is indicated for ampullary carcinoma, and limited operation is also indicated for carcinoma in adenoma. The prognostic factors after resection for ampullary carcinoma include lymph node metastasis, pancreatic invasion, and perineural invasion.     

Bile duct carcinoma in Egypt: possible etiological factors.

Contrary to an old belief, bile duct carcinoma is not a rare disorder in Egypt. Among 730 patients referred for an ERCP examination, twenty-nine consecutive patients were diagnosed as having bile duct carcinoma. The cause of this type of carcinoma remains unknown. In the present study, only seven of the 29 (24.1%) with bile duct carcinoma patients had associated gallstones. In order to investigate the possible association between typhoid carrier state and bile duct carcinoma, stool cultures were performed for Salmonella typhi and Salmonella paratyphi A and B. Nine out of 23 patients (39.1%) with bile duct carcinoma, 17 out of 50 (34%) with calcular obstructive jaundice, and 1 out of 50 (2%) healthy individuals proved to be salmonella carriers. Statistical analysis of the results confirmed the presence of a significant association between chronic fecal thyphoid carrier state and bile duct carcinoma, while that between calcular obstructive jaundice and bile duct carcinoma was not significant. In conclusion, there might be an association between chronic fecal typhoid carrier state and bile duct carcinoma.     

Hepatocellular carcinoma with bile duct thrombi: analysis of surgical treatment

BACKGROUND/AIMS: To summarize the experience of surgical intervention for hepatocellular carcinoma with bile duct thrombi, and to evaluate the influence on prognosis. METHODOLOGY: From 1994 to 2002, 15 patients with hepatocellular carcinoma and bile duct thrombi who underwent surgical intervention were retrospectively analyzed. The operative procedures included hepatectomy with removal of bile duct thrombi (n=7), hepatectomy combined with extrahepatic bile duct resection (n=4), thrombectomy through choledochotomy (n=3), and piggyback orthotopic liver transplantation (n=1). RESULTS: The 1- and 3-year survival rates were 73.3% and 40%, respectively. Two patients survived over 5 years. There were no significant differences in the survival rates between patients with and without obstructive jaundice (P>0.05). The survival rate of patients with portal vein invasion was significantly lower than for those without portal vein invasion (P<0.05). CONCLUSIONS: Surgical intervention was effective for patients with hepatocellular carcinoma and bile duct thrombi. Operation for recurrent intrahepatic tumor can prolong the survival period. Liver transplantation is a new operative procedure worthy of investigation.     

Subtotal duodenopancreatectomy for pancreatic duct, distal bile duct and periampullary carcinoma: short- and long-term results

Ninety patients with pancreatic duct, distal bile duct, and ampullary carcinoma underwent pancreatic resection. Following a standard policy of resection based on surgical findings, all the patients who had resection first underwent subtotal extended pancreatectomy (n = 68) and if they were considered not to fulfill the criteria for this operation, total pancreatectomy (n = 22). Thus, 68 of the 90 patients (72%) were managed with subtotal pancreatic resection irrespective whether they had ampullary, pancreatic duct, or distal common bile duct carcinoma. On the basis of our results, subtotal duodenopancreatectomy is regarded as the method of choice for many patients with pancreatic duct, distal bile duct, or ampullary carcinoma.     

The morbidity, mortality, and prognostic factors for ampullary carcinoma and distal cholangiocarcinoma

BACKGROUND/AIMS: Ampullary carcinoma and distal cholangiocarcinoma are potentially more amenable to pancreaticoduodenectomy for long-term survival than pancreatic carcinoma. The aims of this study are to evaluate experience with ampullary carcinoma and distal cholangiocarcinoma at a single institution. METHODOLOGY: Seventy-two consecutive patients with ampullary carcinoma and distal cholangiocarcinoma who underwent radical resection at Chiba University Hospital from 1985 to 2001. Clinicopathological factors for survival were evaluated by univariate and multivariate analyses in a retrospective study. RESULTS: Pancreaticoduodenectomy was performed in 37 of 38 patients for ampullary carcinoma and 29 of 34 patients for distal cholangiocarcinoma. The morbidity rates of patients with ampullary carcinoma and distal cholangiocarcinoma were 21.1% and 20.6%, and mortality rates were 0% and 2.9%, respectively. The cumulative 5-year survival rates in cases of ampullary carcinoma and distal cholangiocarcinoma were 63% and 45%, respectively. By univariate analysis, pancreatic invasion, lymph node metastasis, and duodenal invasion were significant prognostic factors for ampullary carcinoma. Perineural invasion and histological grade, but not lymph node metastasis, were significant factors for distal cholangiocarcinoma. Multivariate analysis indicated that lymph node metastasis was the only independent prognostic factor for ampullary carcinoma, and that perineural invasion was the only independent prognostic factor for distal cholangiocarcinoma. CONCLUSIONS: The overall mortality of 1.4% and the cumulative 5-year survival rates for ampullary carcinoma and distal cholangiocarcinoma are acceptable. Ampullary carcinoma with lymph node metastasis and distal cholangiocarcinoma with perineural invasion have higher risk of recurrence.     

Increased procoagulant activity of peripheral blood monocytes in human and experimental obstructive jaundice

We studied the procoagulant activity of peripheral blood monocytes in 41 patients with severe obstructive jaundice and in 27 nonjaundiced control patients using a one-stage clotting assay. Mononuclear cells from jaundiced patients, tested immediately after isolation, expressed low levels of procoagulant activity, which were, however, significantly higher than in cells from controls (p less than 0.01). In addition, after incubation in short-term cultures with and without endotoxin, these cells generated more procoagulant activity than did the control ones (p less than 0.001). No significant difference in procoagulant activity was found between patients with and without malignancy in either group. The relief of biliary obstruction resulted in the reduction of both serum bilirubin levels and monocyte procoagulant activity. Endotoxin-induced monocyte procoagulant activity was about threefold higher in the jaundiced patients who died than in the survivors (p less than 0.001). In rabbits made icteric by bile duct ligation and separation (15 days), the endotoxin-induced monocyte procoagulant activity was markedly increased as compared with sham-operated animals (p less than 0.005). In all instances, procoagulant activity was identified as tissue factor. The increased capacity of mononuclear phagocytes to produce procoagulant activity might help explain the activation of blood coagulation in severe obstructive jaundice.     

Relationship between intraduodenal peri-ampullary diverticulum and biliary disease in 178 patients undergoing ERCP

BACKGROUND:The presence of intraduodenal peri-ampullary diverticulum is often observed during upper digestive tract barium meal studies and endoscopic retrograde cholangiopancreatography(ERCP).A few papers in China and overseas reported that the diverticulum had something to do with the incidence of cholelithiasis. This study was undertaken to further test this notion and ascertain the relationship between intraduodenal peri- ampullary diverticulum and biliary disease,especially the formation of bile duct pigment stones. METHODS:A total of 178 patients who had undergone ERCP or endoscopic sphincterotomy(EST)were studied retrospectively.They were divided into 6 groups according to the category of biliary disease,and the incidence rates of intraduodenal peri-ampullary diverticulum were calculated. RESULTS:There were 44 patients with intraduodenal peri- ampullary diverticulum in 81 patients with primary bile duct pigment stones(54.32%),4 in 8 patients with bile duct stones and gallbladder stones(50%),7 in 33 patients with bile duct stones secondary to gallbladder stones(21.21%), 3 in 21 patients with inflammation and stricture of the end of the bile duct and papilla(14.29%),1 in 22 patients with carcinoma of the end of the bile duct and papilla(4.54%), and 5 in 13 patients with post-cholecystectomy syndrome or sphincter of Oddi dysfunction(38.46%). CONCLUSIONS:The incidence rate of intraduodenal peri- ampullary diverticulum in patients with primary bileduct pigment stones is higher than that in patients with bile duct stones secondary to gallbladder stones,patients with inflammation and stricture of the end of the bile duct and papilla,and patients with carcinoma of the end of the bile duct and papilla.These findings indicate that the anatomical abnormalities and malfunction of the sphincter of Oddi play an important role in the formation of bile duct pigment stones.     

Differential effects of jaundice and cirrhosis on beta-adrenoceptor signaling in three rat models of cirrhotic cardiomyopathy

BACKGROUND/AIMS: Attenuated cardiac function has been reported in cirrhosis as well as in jaundice, but the mechanisms remain unclear. This study aimed to explore the differential effects of jaundice and cirrhosis on the heart. METHODS: Three rat models of cirrhosis were studied: chronic bile duct ligation, bile duct ligation followed by choledochojejunostomy to relieve jaundice, and a less jaundiced model induced by thioacetamide administration. Controls underwent a sham operation. Cardiac function was assessed by measuring isolated ventricular papillary muscle contractility. Cardiac beta-adrenergic receptor signaling was studied by measuring cAMP production stimulated at the receptor, G-protein, and adenylyl cyclase levels in the signaling pathway, using isoproterenol, aluminum fluoride and forskolin, respectively. RESULTS: Serum bilirubin and bile salt levels were markedly elevated in the bile duct-ligated group, moderately increased in the thioacetamide rats, and normal in the choledochojejunostomy and sham-operated controls. Papillary muscle contractile force after maximal beta-adrenergic receptor stimulation was decreased to a similar extent in all three cirrhotic models. In the bile duct-ligated and thioacetamide-induced cirrhotic rats, production of cAMP by all three drugs was significantly attenuated. However, the cAMP production in the choledochojejunostomy group was blunted only with isoproterenol and fluoride, and remained intact with forskolin stimulation. CONCLUSIONS: These results demonstrate that cirrhosis per se impairs cardiac function by attenuating the portion of the beta-adrenergic receptor signaling pathway upstream of adenylyl cyclase. Furthermore, significant jaundice and/or cholemia can inhibit adenylyl cyclase, which may contribute to blunted cardiac contractility in jaundiced patients.     

Periampullary choledochoduodenal fistula in ampullary carcinoma

Most patients with ampullary carcinoma have obstructive jaundice without cholangitis. We experienced a patient with ampullary carcinoma who presented with obstructive jaundice and cholangitis, probably because of an accompanying periampullary choledochoduodenal fistula. A 77-year-old Japanese man had jaundice, high fever, and upper abdominal pain and was diagnosed, at another hospital, with obstructive cholangitis. On admission to our hospital, his symptoms and signs had subsided spontaneously. Abdominal ultrasonography showed cholecystolithiasis and dilatation of the common bile duct. Duodenoscopy showed an ulcerating tumor at the oral prominence of the ampulla of Vater and a periampullary choledochoduodenal fistula at the bottom of the ulcer. Biopsy from the fistula showed well differentiated adenocarcinoma. With a diagnosis of ampullary carcinoma with fistula formation, the patient underwent pylorus-preserving pancreatoduodenectomy. The diagnosis was confirmed by histology. This communication presents a unique case of ampullary carcinoma that caused obstructive jaundice, which subsided spontaneously but was associated with cholangitis caused by the divergent effects of the periampullary choledochoduodenal fistula formed by the carcinoma.     

Simultaneous Courvoisier's and double duct signs

Presence of Courvoisier's or double duct signs in a jaundiced patient is suggestive of malignant obstruction of the pancreaticobiliary ductal system.The oncologic impact of the simultaneous occurrence of these signs on the survival of patients with periampullary cancer is unknown.We report a case of obstructive jaundice secondary to an ampullary cancer demonstrating the Courvoisier's sign on clinical examination and a double duct sign on imaging.The patient underwent a pancreaticoduodenectomy which confirmed an ampullary adenocarcinoma.     

Should jaundice preclude resection in patients with gallbladder cancer? Results from a nation-wide cohort study

BackgroundIt is controversial whether patients with gallbladder cancer (GBC) presenting with jaundice benefit from resection. This study re-evaluates the impact of jaundice on resectability and survival.MethodsData was collected on surgically explored GBC patients in all Dutch academic hospitals from 2000 to 2018. Survival and prognostic factors were assessed.ResultsIn total 202 patients underwent exploration and 148 were resected; 124 non-jaundiced patients (104 resected) and 75 jaundiced patients (44 resected). Jaundiced patients had significantly (P < 0.05) more pT3/T4 tumors, extended (≥3 segments) liver- and organ resections, major post-operative complications and margin-positive resection. 90-day mortality was higher in jaundiced patients (14% vs. 0%, P < 0.001). Median overall survival (OS) was 7.7 months in jaundiced patients (2-year survival 17%) vs. 26.1 months in non-jaundiced patients (2-year survival 39%, P < 0.001). In multivariate analysis, jaundice (HR1.89) was a poor prognostic factor for OS in surgically explored but not in resected patients. Six jaundiced patients did not develop a recurrence; none had liver- or common bile duct (CBD) invasion on imaging.ConclusionJaundice is associated with poor survival. However, jaundice is not an independent adverse prognostic factor in resected patients. Surgery should be considered in patients with limited disease and no CBD invasion on imaging.     

Carcinoma of cystic duct leading to obstructive jaundice

Summary Twenty-one cases of primary carcinoma of the cystic duct have been reported in the literature. Most cases were characterized by a hydrops or cholecystitis, whereas only two patients presented with jaundice. To our knowledge, this is only the third case of obstructive jaundice caused by a primary cystic duct carcinoma. The patient was treated by cholecystectomy with resection of the cystic duct tumor and a portion of the common bile duct. Reconstruction was performed by a Roux-en-Y choledocojejunostomy.