Surgical technique for complete resection of the extrahepatic portion of the common bile duct and the ampulla of Vater for tumors of the ampulla of Vater

Background

Ampullary tumors have to be completely resected, but substantial morbidity and mortality rates are associated with pancreaticoduodenectomy (PD). Local resection can be the procedure of choice in selected ampullary lesions for high-risk patients.

Methods

Preoperative examination indicated that the ampullary tumor extended into the common bile duct without evidence of pancreatic duct involvement and no definite invasion into either the duodenum or the pancreas. We performed a complete resection of the extrahepatic bile duct and the ampulla of Vater, including the tumor, without performing PD by dissecting the intrapancreatic bile duct from the pancreas both downward towards the ampulla of Vater and upward using a transduodenal approach.

Results

The operation was successfully completed, and the postoperative course was uneventful, with the exception of a minor pancreatic fistula from retropancreatic dissection. The final pathological examination demonstrated well-differentiated tubular adenocarcinoma limited to the mucosa with negative surgical margins.

Conclusion

Complete resection of the extrahepatic bile duct and the ampulla of Vater through a transduodenal approach can be a feasible and safe surgical procedure for selected ampullary tumors in high-risk patients.     

A case report: endoscopic enucleation of gastrointestinal stromal tumor of the ampulla of Vater

Objective

To report a case of endoscopic enucleation of a gastrointestinal stromal tumor of the ampulla of Vater.

Design

The tumor resection was performed by needle knife endoscopic submucosal dissection.

Results

The tumor was resected completely without serious complications and the patient recovered rapidly.

Conclusion

Endoscopic enucleation may be an alternative treatment for gastrointestinal stromal tumors of the ampulla of Vater for patients who fulfill certain requirements.     

Proposal for a morphological classification of intraductal papillary neoplasm of the bile duct (IPN-B)

Purpose

We propose a morphological classification of intraductal papillary neoplasm of the bile duct (IPN-B).

Methods

A retrospective analysis of 16 patients with IPN-B who had undergone surgical resection was conducted. These 16 cases were classified into three types based on the primary lesion’s anatomical location: branch duct type (6 cases), main duct type (5 cases) and mixed type (5 cases). In this paper we have analyzed the characteristics of IPN-B according to our new classification.

Results

All branch duct type IPN-B was located in the left lobe and 5 of them were resected by left hepatectomy without extrahepatic bile duct resection (EBDR). On the other hand, all patients with main duct and mixed type IPN-B underwent EBDR in addition to hepatectomy or pancreatoduodenectomy. Microscopically, 2 of 6 patients with branch duct type IPN-B had no malignant component and, in the remaining 4 patients, cancer invasion was restricted to within the ductal wall. There were no cases of branch duct type IPN-B with lymph node metastasis and superficial intraductal tumor spread. In contrast, all patients with main duct and mixed duct type IPN-B had the malignant component. In all cases, lymph node metastasis was not observed, but superficial intraductal tumor spread was frequently found in extrahepatic bile duct lesions: 3 of main duct type and 3 of mixed type. Four patients with superficial intraductal spread had non-curative resection due to a cancer-positive ductal margin. Most patients with IPN-B obtained a good prognosis, but two patients with a cancer-positive ductal margin developed local recurrence.

Conclusions

Our classification vividly reflects clinical and pathological characteristics of IPN-B and is useful to determine appropriate surgical strategy.     

Serosal invasion in TNM staging of mass-forming intrahepatic cholangiocarcinoma

Background/Purpose

The Liver Cancer Study Group of Japan established a tumor-nodule-metastasis (TNM) staging system for mass-forming intrahepatic cholangiocarcinoma, with T determined by tumor number and size and vascular or serosal invasion. Serosal invasion is not considered in the designation established by the International Union Against Cancer.

Methods

Sixty-three patients who underwent hepatic resection for mass-forming intrahepatic cholangiocarcinoma were investigated retrospectively, with the investigation including univariate and multivariate analyses of potential prognostic factors.

Results

By log-rank test, tumor size more than 3.0?cm, vascular invasion, lymph node metastasis, intrahepatic metastasis, and involved resection margin, but not serosal invasion, were associated significantly with poor prognosis. Even in patients with serosal invasion, the postoperative outcome was much better in those without than in those with vascular invasion. Multivariate analysis identified vascular invasion, lymph node metastasis, and an involved resection margin as independent prognostic factors. When serosal invasion was excluded from tumor staging, the 5-year survival rates became more clearly stratified: 100% in those with stage I disease, 62% in those with stage II, 25% in those with stage III, and 7% for patients with stage IV.

Conclusions

Serosal invasion showed no survival impact after hepatic resection for mass-forming intrahepatic cholangiocarcinoma. When serosal invasion was omitted from the TNM staging proposed by the Liver Cancer Study Group of Japan, stratification of postoperative survival between stages was more effective.     

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.     

Pancreatic invasion is a prognostic indicator after radical resection for carcinoma of the ampulla of Vater

Sixty-three patients who had undergone pancreatoduodenectomy for carcinoma of the ampulla of Vater were analyzed with respect to tumor extent and prognosis. The postoperative mortality rate was 3% and overall survival rates 3 and 5 years after surgery were 55% and 46%, respectively. pTNM stage did not reflect prognosis after resection in patients at stages 2 and 3, while pancreatic invasion and regional lymph node metastasis clearly reflected prognosis after resection. Of the 26 patients who had no pancreatic invasion, regional lymph node metastasis was seen in only 19%, whereas of the 37 patients with pancreatic invasion, 62% exhibited lymph node metastasis. These factors were significantly correlated (P<0.001). Pancreatic invasion appeared to be an indirect indicator of regional lymph node metastasis. We conclude that, to improve prognosis for patients with pancreatic invasion, extended resection including extended lymphadenectomy, is a preferable additional procedure.     

Gallbladder bed resection or hepatectomy of segments 4a and 5 for pT2 gallbladder carcinoma: analysis of Japanese registration cases by the study group for biliary surgery of the Japanese Society of Hepato-Biliary-Pancreatic Surgery

Purpose

Hepatectomy of segments 4a and 5 (S4a+5) is the recommended treatment for pT2 gallbladder cancer. However, gallbladder bed resection is also occasionally used. Using nationwide data from the Japanese Biliary Tract Cancer Registry and a questionnaire survey, we retrospectively compared these 2 methods of treatment.

Method

The study involved 85 patients with pT2, pN0 gallbladder cancer (55 treated with gallbladder bed resection, and 30, with S4a+5 hepatectomy). The prognosis and mode of tumor recurrence following treatment were analyzed retrospectively, with overall survival as the endpoint.

Results

The 5-year survival rate did not differ significantly between the 2 groups. Univariate analysis showed that bile duct resection and perineural tumor invasion were significant prognostic factors, but the extent of hepatectomy, location of the major intramural tumor, regional lymph node excision, and histological type were not. Multivariate analysis identified perineural tumor invasion as a significant prognostic factor. Recurrence occurred most frequently in both lobes than S4a+5 of the liver following gallbladder bed resection.

Conclusion

In the present study of cases of Japanese Biliary Tract Cancer Registry, it was not possible to conclude that S4a+5 hepatectomy was superior to gallbladder bed resection.     

Should lymph nodes along the thoracic duct be dissected routinely in radical esophagectomy?

Background

Although dissection of mediastinal lymph nodes along the thoracic duct is included in standard radical esophagectomy, it is not routinely performed because of the undesirable hemodynamic effects. This study aims to investigate whether dissection of the nodes along the thoracic duct has prognostic benefits.

Methods

A total of 778 consecutive patients who underwent radical esophagectomy with three-field lymph node dissection for squamous cell carcinoma of the thoracic esophagus from 1984 to 2011 were included. The incidence of metastasis in thoracic duct nodes and that in nodes within #112 station excluding thoracic duct nodes were studied in relation to the depth of the main tumor. The survival curves of lymph node-positive patients were compared.

Results

The metastatic incidence was 2.2 % in T1b/T2, whereas it was 10.0 % in T3/T4. The survival curves in patients with metastasis in the thoracic duct nodes and in the #112 station were not statistically different.

Conclusion

The dissection of the nodes along the thoracic duct along with thoracic duct resection should be performed routinely; however, reliable indicator of the necessity of its dissection is awaited in T1b/T2 tumors because of the low metastatic rate and the potential risk associated with resection of the thoracic duct.     

Surgical outcome of solid pseudopapillary tumor of the pancreas

Background/Purpose

The best surgical treatment for solid pseudopapillary tumor of the pancreas is a matter of debate.

Methods

Fourteen patients with solid pseudopapillary tumor of the pancreas who underwent surgical resection, including enucleation, between June 1996 and January 2007 were retrospectively analyzed to evaluate the effect of the treatment.

Results

The mean age of the patients was 39 years (range, 15 to 59 years). The mean size of the tumor was 4.4 cm (range, 2.0 to 12 cm). Ten tumors (71%) had a well-defined capsule, and 6 tumors (43%) extended beyond the pancreas. Eight of the 14 tumors (57%) had a cystic component, and calcification was observed in 6 tumors (43%). The frequency of microscopic venous invasion, lymphatic invasion, and nerve invasion was 29% (4 of 14), 0%, and 21% (3 of 14), respectively. No lymph node involvement or liver metastasis was observed. Six patients underwent positron emission tomography with 2-deoxy-2-[¹⁸F] fluoro-D-glucose (FDG), and stronger FDG accumulation compared with the surrounding pancreatic parenchyma was observed in 5 of the 6 patients. The median standardized uptake value (SUV) was 6.3 (range, 0.9 to 42.8). Distal pancreatectomy (n = 5), subtotal stomach-preserving pancreatoduodenectomy (n = 3), local resection (n = 3), enucleation (n = 2), and duodenum-preserving pancreatic head resection (n = 1) were performed. Overall morbidity and mortality rates were 43% and 0%, respectively. All patients were still alive without recurrent disease after a median follow-up of 46 months.

Conclusions

Patients with solid pseudopapillary tumor of the pancreas had a favorable outcome after surgical treatment, including enucleation.     

Analysis of lymph node metastasis in pancreatic neuroendocrine tumors (PNETs) based on the tumor size and hormonal production

Background

Because of the rarity and variety of pancreatic neuroendocrine tumors (PNETs), there have been few reports regarding the indication for lymph node dissection in patients with these tumors. This study aimed to evaluate the risk of lymph node metastasis of PNETs based on the tumor size and hormonal production.

Methods

Data for a total of 66 patients who had PNETs resected at our department between 1987 and 2010 were retrospectively studied. The clinicopathological features, including the disease-specific survival rate, were assessed based on the status of lymph node metastasis at the time of initial surgical resection. Then the cut-off point of tumor size to predict lymph node metastasis was estimated.

Results

There were 12 patients (18%) with lymph node metastasis. The frequency of lymph node metastasis tended to be higher in gastrinomas than that in other tumors (43 vs. 15%; P?=?0.08). The size of PNETs with lymph node metastasis was significantly larger than that of the PNETs without metastasis (P?=?0.04). The postoperative survival rate in the PNET patients with lymph node metastasis was significantly lower than that in the patients without metastasis (P?Conclusions Non-gastrinomas with a tumor size of ≥15?mm and all gastrinomas would be an indication for pancreatectomy with lymph node dissection.     

Clinicopathological evaluation of duodenal well-differentiated endocrine tumors

AIM:To assess the clinicopathological characteristics of duodenal well-differentiated endocrine tumors.METHODS:We examined clinicopathological characteristics in 11 consecutive patients with duodenal well-differentiated endocrine tumors treated by endoscopic therapy or surgery in our hospital from 1992 through 2007.Patients with well-differentiated endocrine tu-mors of the papilla of Vater or with gastrinoma were excluded.RESULTS:Three patients received endoscopic treatment,and 8 underwent surgery.In patients who received endoscopic treatment,the tumor diameter was less than 1.0 cm,with no histopathological evidence of lymphovascular invasion or invasion of the muscularis.There were no complications such as late bleedingor perforation after treatment.Among 8 patients with tumors less than 1.0 cm in diameter,3 underwent partial resection,and 2 underwent radical surgery.Three patients had lymphovascular invasion,1 had invasion of the muscularis,and 1 had proximal lymph node metastasis.Among 3 patients with tumors 1.0 cm or more in diameter,1 underwent partial resection,and 2 under-went radical surgery.One patient had lymphovascular invasion,with no lymph node metastasis.After treatment,all patients are alive and have remained free of metastasis and recurrence.CONCLUSION:Duodenal well-differentiated endocrine tumors less than 1.0 cm in diameter have a risk of lym-phovascular invasion,invasion of the muscularis,and lymph node metastasis,irrespective of procedural prob-lems.     

Clinical impact of endoscopic papillectomy for benign�Cmalignant borderline lesions of the major duodenal papilla

Background and purpose

The present study retrospectively analyzed the clinical impact of endoscopic papillectomy on the selection of a treatment strategy for patients with benign?Cmalignant borderline lesions of the major duodenal papilla.

Patients and methods

Between November 1995 and July 2009, 28 patients were selected for endoscopic papillectomy. The clinical impact of endoscopic papillectomy was assessed. Snare resection was performed in a radical fashion.

Results

An endoscopic papillectomy was technically feasible in all patients. En bloc excision was achieved in 22 cases (79%). The final histopathological diagnoses of the endoscopic specimen were 17 adenoma (61%), 7 carcinoma in adenoma (25%), and 4 adenocarcinoma (14%). Two out of the four adenocarcinoma cases were referred for surgery. The other two patients with negative margins have not experienced recurrences during the follow-up period. A residual tumor was detected in 1 out of 17 cases (6%) of adenoma and 2 out of 7 cases (29%) of carcinoma in adenoma.

Conclusions

Endoscopic papillectomy is therefore considered to be an effective treatment for patients with a benign?Cmalignant borderline lesion of the major duodenal papilla. This method also has an important clinical impact because it provides an accurate diagnosis, aids in the selection of an appropriate treatment strategy, and reduces unnecessary surgery.     

Lymph node navigation for pancreatic and biliary malignancy by NOTES

Background

Lymph node navigation and accurate staging of liver or peritoneal metastasis leads to better selection of the optimal treatment for patients with pancreatic and biliary malignancy. Less invasive techniques of detecting lymph node metastasis and distant metastasis would be valuable. Natural orifice translumenal endoscopic surgery (NOTES) is a new, evolving concept of minimally invasive surgery that may be useful for the staging of intraabdominal cancers.

Methods

Review of the literature regarding peritoneoscopy and lymph node mapping and biopsy by NOTES.

Results

NOTES peritoneoscopy for accurate diagnosis and staging of intraabdominal cancers is already in clinical use, and two case reports have shown the safety and feasibility of this technique. Previous experimental studies have also shown that lymph node mapping by NOTES is technically feasible with the currently available devices.

Conclusions

With the continued development of the techniques and technology of NOTES, peritoneoscopy and lymph node mapping by NOTES may become an alternative method for preoperative staging for patients with pancreatic and biliary malignancy.     

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.     

Cancer cells spread through lymph vessels in the submucosal layer of the common bile duct in gallbladder carcinoma

Introduction

In the present study, we performed immunohistochemical staining with a lymphatic epithelium-specific marker, D2-40, to analyze the status of lymphatic spreading in the hepatoduodenal ligament in T2 gallbladder carcinoma (GC).

Methods

One hundred and eighty-six paraffin-embedded specimens from 15 T2 GC patients were reviewed.

Results

Lymph vessels lined with D2-40 were visualized in the submucosal layer of the common bile duct in all cases. In 3 of 15 patients, clusters of cancer cells were identified in the submucosal lymph vessels of the extrahepatic bile duct, and this lymphatic invasion of cancer cells failed to be detected with only conventional hematoxylin–eosin staining. The frequency of the invasion to the submucosal lymph vessels in T2 GC correlated with presence of microscopic invasion to hepatoduodenal ligament and perineural invasion.

Conclusion

There were lymph vessels in the submucosal layer of the common bile duct, and cancer cells can spread through these channels in addition to the large lymph vessels in subserosal layer around the extrahepatic bile duct in GC. The present results would support the concept of en bloc resection of the extrahepatic bile duct in curative resection for T2 GC.     

Endoscopic necrosectomy of organized pancreatic necrosis: a currently practiced NOTES procedure

Background

Endoscopic necrosectomy is now an established minimally invasive method for treatment of organized pancreatic necrosis.

Methods

Review of methods and results of endoscopic treatment of pancreatic necrosis.

Results

Reports by multiple groups have demonstrated favorable results of endoscopic necrosectomy. The mortality of critically ill patients undergoing endoscopic treatment in several series is approximately 10%. Some patients will eventually also require surgery for situations such as complete pancreatic duct disruption, but even in these cases endoscopic necrosectomy is useful because pancreatic surgery can often be delayed until the patient is stable.

Conclusions

Endoscopic necrosectomy will likely assume an increasing role in the treatment of pancreatic necrosis. This should result in reduced morbidity and mortality in these critically ill patients.     

Additional colectomy after colonoscopic polypectomy for T1 colon cancer: a fine balance between oncologic benefit and operative risk

Purpose

The treatment of early-stage colorectal cancers removed endoscopically depends on histopathologic findings. This study aimed to assess the benefit–risk balance for patients who underwent additional surgery after endoscopic resection of a T1 carcinoma with unfavorable histology.

Methods

From 2000 to 2010, 64 consecutive patients were included in this retrospective study. Specimens resected after endoscopic polypectomy showed at least one of the following unfavorable factors: no free margin, lymphovascular invasion, poorly differentiated grade, SM2–3 involvement (submucosal invasion greater than 300?μm from the muscularis mucosae), tumor budding, sessile morphology, and piecemeal resection. The main objective was to assess the benefit–risk balance of an oncological resection performed after the polypectomy. Oncological benefit was measured by the lymph node metastasis rate and the persistence of a residual adenocarcinoma on the specimen. The risk was measured by the occurrence of severe complications of grade III–IV or death. The associations between these end points and clinicopathologic variables were evaluated by univariate analysis and logistic regression.

Results

Five patients (7.8?%) had lymph node metastases and two (3.1?%) had residual carcinomas. Eight patients (12.5?%) had grade III–IV morbidity. There were no deaths. Oncological benefit was associated by logistic regression analysis with patients who presented multiple criteria (≥2) that led to surgery (p?=?0.031). The benefit–risk balance was favorable only for those patients.

Conclusions

Additional surgery is required for patients who present multiple adverse histological criteria. If only one criterion is selected, the indication should be discussed, especially for patients with multiple comorbidities.     

Long-term survivors after resection of carcinoma of the head of the pancreas: significance of histologically curative resection

Background/Purpose

The prognosis of patients with pancreatic cancer is said to have not been improved markedly by any procedures in the past 20 years. Since 1973, we have gradually extended the area of dissection when performing curative resection for pancreatic cancer to improve the resection rate and prognosis. Nineteen patients have survived for 3 years or more, and the 5-year survival rates of patients with cancer of the head of the pancreas were 23.9% for macroscopically curative resection and 34.3% for histologically curative resection.

Methods

We histologically observed surgical specimens, cut into 3- to 5-mm sections and compared the histologic characteristics of the 19 patients who survived for 3 years or more with those of 41 patients who died of cancer within 3 years (excluding 6 operative and hospital deaths), in order to find the conditions required for long-term survival.

Results

The following conditions were associated with long-term survival: (1) tumor diameter 3?cm or less; (2) either absence of lymph node metastasis or metastasis limited to the n₁ group; (3) degree of invasion of the anterior pancreatic capsule of zero (s0); and (4) either no retropancreatic invasion (rp0) or exposed retropancreatic invasion (rpe) with no cancer invasion of dissected peripancreatic tissue ew(?).

Conclusions

At present, because the rpe rate is more than 70%, resection of the pancreas, including the superior mesenteric vein and the retropancreatic fusion fascia, is essential for a curative resection, because the retropancreatic tissue between the back of the pancreas and this fascia is anatomically considered to be in the position of the subserosal tissue in the gallbladder or stomach. Combined resection of the superior mesenteric artery may further improve the results of resection for pancreatic cancer, from the anatomical viewpoint.

     

Clinical Impact of HAb18G/CD147 Expression in Esophageal Squamous Cell Carcinoma

Background

HAb18G/CD147 expression has been associated with many tumor invasion molecules, which play important roles in recurrence and poor differentiation of esophageal squamous cell carcinoma (ESCC). However, the clinical implications of HAb18G/CD147 in ESCC are still unclear.

Aims

In this study, we clarified the clinical significance of HAb18G/CD147 and characterized the association between HAb18G/CD147 and tumor invasion in ESCC cases.

Methods

Tumor tissues were obtained from 86 ESCC patients who underwent surgical resection between 2002 and 2005. All patients that had received previous therapy were excluded. ESCC tissues were analyzed by IHC using anti HAb18G/CD147 antibody. The expression of HAb18G/CD147 mRNA in esophageal cancer cell lines was analyzed by RT?CPCR.

Results

HAb18G/CD147 was uniformly expressed in EC109 and EC871214 cell lines, but negatively expressed in EPC2, esophageal normal squamous cell line. HAb18G/CD147 mainly localized to the membrane of tumor cells in 84.9% of ESCC patients (64 out of 86 cases). Furthermore, we also found that higher HAb18G/CD147 expression levels significantly correlated with lymph node metastasis, depth of tumor invasion and differentiation (P < 0.05). But the expression levels of HAb18G/CD147 in lymph node metastatic tissues were almost equal to that in the primary tumor tissues. Furthermore, lymph node metastasis and expression of HAB18G/CD147 were independent prognostic indicators in ESCC.

Conclusions

The expression of HAb18G/CD147 might be involved in the progression and survival of ESCC. Therefore, HAb18G/CD147 could be a clinical marker for the poor prognosis in ESCC patients and may also be a potentially therapeutic target to improve the progression of ESCC.     

Carcinoma of the distal and middle bile duct: surgical results,prognostic factors,and long-term follow-up

Background/Purpose

Carcinoma of the distal bile duct is associated with poor prognosis. Surgical resection remains the only potentially curative treatment. We conducted a retrospective study to identify prognostic factors determining longterm survival.

Methods

From 1990 to 2006, 95 patients with distal and/or middle bile duct carcinoma had resections. Fifty-four patients underwent pylorus-preserving pancreaticoduodenectomy (57%) and 41 patients underwent standard Kausch-Whipple pancreaticoduodenectomy (43%). Nine patients underwent pancreaticoduodenectomy including portal vein resection (9%).

Results

Overall 1-, 3-, and 5-year survival rates were 60%, 36%, and 29%, respectively. Five-year survival after R0 resection was 34%, and after R1 resection it was 0%. Four patients died during their hospital stay (4%). Multivariate analysis showed negative resection margins (P = 0.040), lymphatic vessel invasion (P = 0.036), and portal vein infiltration (P = 0.027) as strong predictors for survival, whereas the location of the tumor (distal bile duct vs middle bile duct) and lymph node status were not identified as independent prognostic factors.

Conclusions

Five-year survival depends strongly on negative resection margins, independent of nodal status. Portal vein resections in patients with portal vein involvement fail to ameliorate long-term survival. Primary tumor site — middle bile duct or distal bile duct — did not determine prognosis.