Patterns of recurrence after resection of gallbladder cancer without routine extrahepatic bile duct resection

Objective

Routine extrahepatic bile duct (EBD) resection in non-jaundiced patients with gallbladder cancer (GBC) is controversial. The aim of this study was to retrospectively analyse patterns of recurrence in patients who underwent resection of GBC without routine EBD resection.

Methods

This analysis referred to 58 patients who had undergone explorative laparotomy for GBC during 2000–2012 at a single, tertiary referral centre. Overall survival, time to recurrence, and patterns of recurrence were assessed in patients who underwent conventional negative-margin (R0) resection without routine EBD resection.

Results

Of 58 patients submitted to explorative laparotomy for GBC, 26 (45%) patients underwent R0 resection without EBD resection (tumour stage T1b in five patients, T2 in 17, T3 in three, and T4 in one). The 3-year survival rate among these patients was 78% at a median follow-up of 33 months (range: 13–127 months). Seven patients developed recurrent disease at a median of 9 months (range: 2–25 months) after resection. No patients developed isolated recurrent disease at the EBD.

Conclusions

Of 26 patients resected for GBC, none developed isolated recurrent disease at the EBD after conventional resection of GBC without EBD resection. This finding suggests that routine EBD resection is of no additional value.     

Comparison between pancreatoduodenectomy and hepatopancreatoduodenectomy for bile duct cancer

BACKGROUND/AIMS: Pancreatoduodenectomy has been accepted as a standard operative procedure for distal bile duct cancer with low operative mortality. However, hepatopancreatoduodenectomy has not been accepted as a standard treatment modality for diffuse bile duct cancer. METHODOLOGY: From December 12, 1992 to December 15, 2000, 37 patients with the diagnosis of extrahepatic bile duct adenocarcinoma (cholangiocarcinoma) underwent pancreatoduodenectomy or hepatopancreatoduodenectomy, at the department of surgery, Ibaraki Prefectural Central Hospital and the Cancer Center. The differences in indications and results of both operative procedures were investigated retrospectively. RESULTS: Thirty-day operative mortality was 0% after either pancreatoduodenectomy or hepatopancreatoduodenectomy. One- to 5-year cumulative survival rates for the 24 patients after pancreatoduodenectomy were 76.3%, 41.5%, 41.5%, 41.5%, 41.5%, respectively. One- to 4-year cumulative survival rates for the 13 patients after hepatopancreatoduodenectomy were 48.0%, 32.0%, 32.0%, 16.0%, respectively. There were no statistically significant differences between cumulative survival rates after pancreatoduodenectomy and hepatopancreatoduodenectomy either in all the patients or in patients with UICC stage IV. CONCLUSIONS: Hepatopancreatoduodenectomy should be tried for patients with diffuse bile duct cancer, because only hepatopancreatoduodenectomy has the possibility of a cure at this time.     

Surgical resection for hepatoportal bile duct cancer

AIM To discuss the effect of surgical procedures on the prognosis of patients of bile duct cancer and their indications.METHODS A retrospective analysis was made for 52 cases of hepatoportal bile duct cancer treated from January 1991 to December 1996. All the cases were classified according to the modified Bismuth-Corlettle system and received appropriate operation. Therapeutic effects were evaluated on the basis of their survival rates, jaundice elimination, comfort index, operative mortality and complications.RESULTS Seventeen cases received surgical resection (32.7%). The survival rate was 71.4%, 35.7% and 10.4% for one, two and three years respectively, and was 30%, 16.8% and 0% for those with drainage (P＜0.05). The mortality rate was 6.0% for the drainage group and 5.9% for the resection group (P＞0.05). Of the 17 resected patients, 8 (47.1%) had curative resection and 9 (52.9%) noncurative resection. Their mean survival time was 21.1 months and 7.5 months respectively (P＜0.05).CONCLUSION Proper surgical procedure should be used on the basis of the local and general conditions of the patients, and aggressive resection with or without liver resection is a valid procedure for the treatment of hepatoportal bile duct cancer and can significantly improve the prognosis of patients.     

Curative resection of hepatocellular carcinoma with intrabile duct tumor growth mimicking hilar bile duct carcinoma

A 62-year-old Japanese male was admitted with obstructive jaundice and underwent percutaneous transhepatic cholangiodrainage (PTCD). An initial diagnosis was made of hilar bile duct carcinoma, based on demonstrated irregular stenosis of the hilar hepatic bile ducts without obvious tumor within the liver and negative alpha-fetoprotein (AFP). Enhanced computed tomography (CT) showed an irregular low density area around the hepatic hilum and the umbilical portion of the portal vein, suggesting carcinomatous invasion with blood flow disturbances. In contrast, intraoperative ultrasonography (US) raised the suspicion of an ill-defined lesion in Couinaud's segment 2 (segment 2) and intrabile duct tumor formation. A radical extended left and caudate lobectomy of the liver was successfully performed, with additional resection of extrahepatic bile duct and enbloc resection of regional lymph nodes. Unexpectedly, histological analysis of the resected specimen showed the final diagnosis to be hepatocellular carcinoma (HCC) of segment 2 with intrabile duct tumor growth. This case demonstrates that HCC with intrabile duct tumor growth toward the heptic hilum can mimic hilar bile duct carcinoma, when the tumor itself is equivocal on preoperative imaging and AFP is negative. In such cases, intraoperative US and guided biopsy may be of value for definitive diagnosis and selection of the optimal procedure.     

Metachronous bile duct cancer nine years after resection of gallbladder cancer

We report a rare case of a 74-year-old man with metachronous gallbladder cancer and bile duct cancer who underwent curative resection twice, with the operations nine years apart. At the age of 65 years, the patient underwent a cholecystectomy and resection of the liver bed for gallbladder cancer. This was a welldifferentiated adenocarcinoma, with negative resection margins （T2NOM0, stage Ⅰ B）. Nine years later, during a follow-up examination, abdominal computed tomography and MRCP showed an enhanced 1.7 cm mass in the hilum that extended to the second branch of the right intrahepatic bile duct. We diagnosed this lesion as a perihilar bile duct cancer, Bismuth type Ⅲ a, and performed bile duct excision, right hepatic Iobectomy and Roux-en-Y hepaticojejunostomy. The histological diagnosis was a well-differentiated adenocarcinoma with one regional lymph node metastasis （TINIM0, stage Ⅱ B）. Twelve months after the second operation, the patient is well, with no signs of recurrence. This case is compared with 11 other cases of metachronous biliary tract cancer published in the world medical literature.     

Superior mesenteric vein resection without reconstruction in pylorus-preserving pancreatoduodenectomy for pancreatic head cancer

The prognosis of pancreatic cancer is poor, even in resectable patients. The reason for this poor prognosis is partly due to local invasion of the tumor into the tissues around the pancreas. Pancreatic head cancer usually invades the mesentericoportal veins, so the combined venous resection is usually performed during pancreatoduodenectomy for the purpose of obtaining a negative surgical margin. We performed pancreatoduodenectomy for lower pancreatic head cancer together with superior mesenteric vein resection without reconstruction in two patients, after confirming adequate portal venous flow and small intestinal congestion, This is the first report of pancreatoduodenectomy combined with superior mesenteric vein resection without reconstruction for the purpose of obtaining a wide surgical margin.     

Pancreatoduodenectomy for local intrapancreatic recurrence after bile duct resection of mid bile duct carcinoma

Cancers originating from the proximal and mid portions of the common bile duct exhibit a variable degree of longitudinal tumor spread, thus curative resection with attainment of sufficient resection margins is often difficult to achieve. Not surprisingly, local tumor recurrence after noncurative resection occurs frequently, but most recurrences are not considered viable indications for a second operative intervention. We describe our experience of attempting to achieve curative repeat resection after local recurrence of bile duct carcinoma. Two male patients, aged 49 and 58 years, had localized tumor recurrence in the intrapancreatic bile duct 25 and 43 months after segmental bile duct resection for proximal-to-mid duct carcinoma. Following close observation for 3-4 months to determine operability, these 2 patients underwent pylorus-preserving pancreatoduodenectomy, in which both pre-existing hepaticojejunostomy and Roux jejunal limb were effectively used. There was no further recurrence for 65 and 37 months after repeat resection, respectively. Repeat resection with pancreatoduodenectomy may be a feasible treatment modality for selected patients showing late intrapancreatic recurrence after prior segmental bile duct resection.     

Hilar bile duct resection for bile duct carcinoma at the hilus of the liver

Hilar bile duct resection, by which only the bile duct is resected, was carried out in 31 patients with bile duct carcinoma at the hepatic hilus. However, curative resection was possible in only 4 patients (12.9%). The postoperative 1-, 3-, and 5-year survival rates were 58.1%, 19.4%, and 7.7%, respectively. These results indicate that treatment of this hilar bile duct carcinoma by hilar bile duct resection is of limited value. We believe that this operative procedure should be used only for papillary or nodular carcinoma at the hepatic confluence at relatively early stages of Bismuth's type I or II.     

Anomalous pancreaticobiliary ductal junction without bile duct dilatation in gallbladder cancer

BACKGROUND/AIMS: Anomalous pancreaticobiliary junction is a rare anomaly but is a risk factor for primary carcinoma of the gallbladder. To define the relationship between anomalous pancreaticobiliary junction, especially if it is not associated with common bile duct dilatation, and gallbladder carcinoma, we retrospectively reviewed data of 126 patients with gallbladder carcinoma. METHODOLOGY: All these patients had undergone direct cholangiography either by endoscopic retrograde cholangiopancreaticography or percutaneous transhepatic cholangiography. RESULTS: Among 126 patients with gallbladder cancer, 23 patients (18.3%) exhibited anomalous pancreaticobiliary junction. Patients with anomalous pancreaticobiliary junction were younger (mean age: 54 +/- 9.1 years) than patients without anomalous pancreaticobiliary junction (mean age: 65 +/- 9.7 years). The incidence of gallstones in patients with anomalous pancreaticobiliary junction (17%) was significantly lower than in those without this anomaly (64%) (P < 0.01). Among the 23 patients with anomalous pancreaticobiliary junction, 12 patients (52%) had no bile duct dilatation and, 11 patients (48%) had bile duct dilatation in the form of fusiform or cylindrical dilatation. However, no cases with severe cystic dilatation were found. Patients of anomalous pancreaticobiliary junction without common bile duct dilatation had more advanced disease and poor prognosis than those with common bile duct dilatation. CONCLUSIONS: The present study revealed that gallbladder cancer in the patients of anomalous pancreaticobiliary junction without common bile duct dilatation was diagnosed at advanced stage and the prognosis was very poor. Therefore, if a minor abnormality is detected in the wall of acalculous gallbladder on ultrasonography, direct cholangiography should be done to exclude this anomaly.     

Resection of liver metastasis from extrahepatic bile duct carcinoma previously treated by pancreatoduodenectomy

No English report of a 5-year survivor with liver metastasis from periampullary carcinoma has been published to date. Here, we report a 52-year-old woman with liver metastasis previously treated with pylorus-preserving pancreatoduodenectomy for extrahepatic bile duct carcinoma, who underwent hepatectomy and has survived for more than 5 years without recurrence after the procedure. This outcome suggests that hepatic resection is effective for selected patients with liver metastasis from extrahepatic bile duct carcinoma previously treated by pancreatoduodenectomy. When a patient has a solitary metastasis of the liver with no other evidence of recurrence, surgical resection of the liver metastasis should be considered a valid option.     

Curative reoperation for recurrent cancer of the extrahepatic bile duct: report of two cases

Local recurrence, following a resection for cancer of the extrahepatic bile duct, is usually incurable with second curative surgery being almost impossible. To determine the feasibility and significance of second curative surgery, our experiences are presented in this study. The medical records and clinical outcomes of two patients that underwent a re-resection for recurrent cancer of the extrahepatic bile duct were retrospectively reviewed. A 50-year-old female patient that had a recurrent disease at the intrahepatic and intrapancreatic bile duct, 66 months after a segmental resection of the bile duct for common bile duct (CBD) cancer, underwent a hepatopancreatoduodenectomy. A 29-year-old female patient had a recurrent tumor mass in the distal CBD, 28 months after a right hemihepatectomy and Roux-en-Y hepaticojejenostomy for a type IIIa Klatskin tumor, and underwent a segmental resection of the bile duct. The gross type of the above two cases was a papillary tumor. There was no operative mortality or morbidity. All patients are still alive after 46 and 9 months, respectively, without recurrence after the reoperation. It is concluded that a surgical re-resection is possible in selected patients with recurrent bile duct cancer, mostly of the papillary type. A primary operation for bile duct cancer should be performed with a wide surgical margin, and secondary curative surgery should be considered whenever possible in cases of recurrence.     

Hepatic resection for post-cholecystectomy bile duct injuries: a literature review

Objectives:

This study seeks to identify factors for hepatectomy in the management of post-cholecystectomy bile duct injury (BDI) and outcome via a systematic review of the literature.

Methods:

Relevant literature was found by searching the PubMed database and the bibliographies of extracted articles. To avoid bias selection, factors for hepatectomy were analysed in series reporting both patients undergoing hepatectomy and patients undergoing biliary repair without hepatectomy (bimodal treatment). Relevant variables were the presence or absence of additional hepatic artery and/or portal vein injury, the level of BDI, and a previous biliary repair.

Results:

Among 460 potentially relevant publications, only 31 met the eligibility criteria. A total of 99 hepatectomies were reported among 1756 (5.6%) patients referred for post-cholecystectomy BDI. In eight series reporting bimodal treatment, including 232 patients, logistic regression multivariate analysis showed that hepatic arterial and Strasberg E4 and E5 injuries were independent factors associated with hepatectomy. Patients with combined arterial and Strasberg E4 or E5 injury were 43.3 times more likely to undergo hepatectomy (95% confidence interval 8.0–234.2) than patients without complex injury. Despite high postoperative morbidity, mortality rates were comparable with those of hepaticojejunostomy, except in urgent hepatectomies (within 2 weeks; four of nine patients died). Longterm outcome was satisfactory in 12 of 18 patients in the largest series.

Conclusions:

Hepatectomies were performed mainly in patients showing complex concurrent Strasberg E4 or E5 and hepatic arterial injury and provided satisfactory longterm outcomes despite high postoperative morbidity.     

Bilateral intrahepatic lithiasis without extrahepatic bile duct stones

Bilateral intrahepatic lithiasis is a rare condition, and for this reason a nationwide survey was conducted. Reports on 675 patients with bilateral intrahepatic lithiasis over a 10-year-period were collected. Among these, 258 patients with bilateral intrahepatic lithiasis having no extrahepatic bile duct stones were analyzed. The peak incidence was seen in the fourth to sixth decades. Males and females were equally effected. The stones removed were mainly calcium bilirubinate stones (75.6%). The main clinical symptoms were abdominal pain, fever and jaundice. Charcot's triad was seen in 29.7%, while 12.4% of the patients had no symptoms. Visualization of each segmental duct of the liver by direct cholangiography was excellent in this survey and ranged from 88 to 97.3% of the patients. The most frequent site of stones was the left hepatic duct (60.1%). The site of bile duct dilatation coincided with the location of stones. The most common sites of stenosis were the central part of the lateral segmental duct (32.5%) and the left hepatic duct (37.6%). Hepatic resection was employed in 49.2% of the patients, and drainage procedures were added in 95.6%. Follow-up studies of 236 patients treated by surgery revealed good results in 67.4%, fair in 13.6%, and poor in 7.6%. In these patients, however, endoscopic lithotomy was often employed intra- and/or post-operatively. Conducting hepatic resection, with adequate biliary drainage procedure and cholangiofiberscopic lithotomy may help to improve the therapeutic results of bilateral intrahepatic lithiasis.