Risk factors for intrahepatic and extrahepatic cholangiocarcinoma: a case–control study in China

Background/Aims: The risk factors for cholangiocarcinoma are incompletely defined in China, especially for intrahepatic cholangiocarcinoma (ICC). We evaluated the risk factors for both ICC and extrahepatic cholangiocarcinoma (ECC). Methods: A case–control study in which cases were cholangiocarcinoma patients referred to Peking Union Medical College Hospital (PUMCH) between 1998 and 2008 and controls were healthy individuals. Controls were randomly selected from an existing database of healthy individuals at the Health Screening Center of PUMCH. Data on liver disease, family history, diabetes, smoking and drinking were collected by a retrospective review of the patients' records and health examination reports or by interview. Results: A total of 190 patients (61 ICC; 129 ECC) and 380 age‐ and sex‐matched controls were enrolled. HBsAg (P<0.001) and anti‐HBc without HBsAg (P=0.001) were significantly related to ICC. The adjusted odds ratios (OR) and 95% confidence intervals (CI) were 18.1 (95% CI: 7.5–44.0) and 3.6 (95% CI: 1.7–7.6) respectively. Diabetes mellitus (P=0.007), cholecystolithiasis (P=0.004) and previous cholecystectomy (P<0.001) were significantly associated with ECC. The prevalence of cirrhosis was higher in ICC than that in ECC (P<0.001). Furthermore, on excluding the ICC patients with cirrhosis, ICC patients showed significant independent associations with HBsAg (OR: 7.3; 95% CI: 3.1–17.2) and anti‐HBc without HBsAg (OR: 2.4; 95% CI: 1.1–5.2). Conclusion: Cirrhosis and chronic hepatitis B virus infection are risk factors for ICC, while cholecystolithiasis, diabetes and previous cholecystectomy are risk factors for ECC.     

Protective effect of methylprednisolone and of intermittent hepatic pedicle clamping during liver vascular inflow occlusion in the rat

BACKGROUND/AIMS: One of the main causes of postoperative morbidity and mortality following major hepatic resection is hepatic ischemia deliberately designed to reduce intraoperative hemorrhage. This study assessed the effects of intermittent or continuous hepatic ischemia and reperfusion with or without methylprednisolone pretreatment in the rat. METHODOLOGY: One hundred and eighty rats were divided into 3 groups undergoing hepatic ischemia of 60, 90, and 120 minutes total duration. Each group of rats were subdivided to receive either a continuous Pringle maneuver, or 30 min or 15 min of intermittent liver pedicle clamping. Ten minutes before ischemia induction, 10 rats from each group were pretreated with intravenous 3 mg/100 g bw methylprednisolone. RESULTS: With continuous hepatic pedicle clamping the rat survival rates inversely correlated with the duration of ischemia (survival: 70%, 40%, and 20% with ischemia of 60, 90, and 120 min). Survival rates at 15-min and 30-min intermittent ischemia groups were significantly higher than in the continuous clamping group (p<0.05). Methylprednisolone pretreatment did not significantly increase survival but resulted as a significant reduction in liver enzyme release (AST, ALT), at 90 min (p<0.05) and at 120 min (p<0.05) in the continuously clamped groups. When ischemia lasted 120 min, methylprednisolone pretreatment was associated with higher preservation of ATP liver content (p<0.05). CONCLUSIONS: This study confirms that intermittent hepatic pedicle clamping significantly improves survival in rats undergoing hepatic vascular inflow occlusion with a decrease in transaminase release and greater maintenance of intrahepatic ATP after prolonged total ischemia when animals were pretreated with methylprednisolone.     

Blocking intrahepatic inflow and backflow using Chang's needle during hepatic resection: Chang's maneuver

Background. Chang''s needle is a straight, 18-gauge stainless steel needle with a hook near its top to catch the thread and can be used for various hepatic resections. Since its introduction in 1996, accumulated experience has shown that using Chang''s needle is simple and safe. We recently explored a new application for the needle with an intrahepatic vascular block during hepatic resections. Methods. Using Chang''s needle makes whole-thickness interlocking sutures of the liver possible. One or two rows of multiple sutures secure the inflow and backflow while allowing a hepatic parenchymal division with less blood loss. Under ultrasound guidance, single temporary sutures can be made in the respective branches of the Glisson sheath to block inflow, and, on the right or left hepatic vein, to block backflow as well. Results. We did 89 hepatic resections without specifically aimed inflow or backflow blocks, including 12 right lobectomies, three trisegmentectomies, 21 bisegmentectomies, and 15 segmentectomies. Twenty-seven patients had mild to severe liver cirrhosis. Specifically aimed inflow blocks for partial hepatic resections were done on the Glisson sheath (G) of segment 8 (two patients), segment 6 (one patient), and segment 3 (one patient). One patient with a G8 block had a concomitant backflow block of the right hepatic vein. Overall, there was no procedure-related mortality or hepatic failure. Ischemia and reperfusion induced liver function deterioration was minimal in the group with this kind of temporary vascular blocks. Conclusion. In addition to hepatic resections, Chang''s maneuver can be used for intrahepatic individual inflow or backflow blocks, or both, to minimize ischemic and reperfusion injuries.     

Risk factors for intrahepatic and extrahepatic cholangiocarcinoma: a hospital-based case-control study

BACKGROUND: The risk factors for cholangiocarcinoma are poorly defined in the United States. We evaluated hepatitis C virus (HCV), hepatitis B virus (HBV), and liver cirrhosis as risk factors for intrahepatic cholangiocarcinoma (ICC) and extrahepatic cholangiocarcinoma (ECC). METHODS: A case-control study in which cases were cholangiocarcinoma patients referred to the M.D. Anderson Cancer Center between 1992 and 2002 and controls were healthy individuals. Information about liver diseases, family history, diabetes, smoking, and alcohol consumption were collected on both groups. Blood from all participants was tested for HBV and HCV markers. RESULTS: We identified 246 cases (83 ICC and 163 ECC) and matched them to 236 controls. Compared with controls, ICC patients had a higher prevalence of anti-HCV antibodies (6.0%vs 0.8%, P=0.01), anti-HBc (9.6%vs 0%, P<0.0001), and heavy alcohol consumption (21.7%vs 3.8%, P<0.0001). The adjusted odds ratio and 95% confidence interval (CI) were 7.9 (95% CI 1.3-84.5), 28.6 (95% CI 3.9-1,268.1), and 5.9 (95% CI 2.1-17.4), respectively. Only heavy alcohol consumption was higher in patients with ECC than in controls (17.8%vs 3.8%, P=0.003). The prevalence of diabetes and smoking were not significantly different between cases (ICC or ECC) and controls. The prevalence of cirrhosis was higher in patients with ICC than those with ECC (24.1%vs 4.9%, P<0.0001). CONCLUSIONS: Liver cirrhosis and chronic HCV infection are possible risk factors for ICC but not ECC. Heavy alcohol consumption is a risk factor for both ICC and ECC.     

Analysis of metastasis and survival between extrahepatic and intrahepatic cholangiocarcinoma: A large population-based study

To date, extrahepatic cholangiocarcinoma (ECCA) and intrahepatic cholangiocarcinoma (ICCA) have rarely been compared; therefore, we attempted to learn more about the rates of metastasis and survival in both ICCA and ECCA.Data of patients in the SEER database diagnosed with ICCA or ECCA were extracted to analyse the rate of metastasis and survival. Univariate and multivariate logistic regression analyses were performed to identify the risk factors for metastasis. Propensity score matching (PSM) was used to compare survival rates between ECCA and ICCA.Data from a total of 15,751 patients diagnosed with ICCA or ECCA were extracted to analyse the rate of metastasis. Metastasis was more common in ECCA than ICCA (42.62% vs. 31.46%, P < .05), while ICCA in the T1 stage had a lower rate of metastasis (25.35% vs. 30.61%, P < .05). Age, pathology grade, tumour size, lymph node metastasis and T stage were independent risk factors for metastasis in both ECCA and ICCA. There was an inverse correlation between age and metastasis in both ICCA and ECCA. Moreover, PSM demonstrated that patients with ECCA had a better prognosis than patients with ICCA. Patients with ICCA in the T1 stage had better survival than those with ECCA in the T1 stage.Our study was the first to compare the rates of metastasis and survival between ECCA and ICCA. We observed an inverse association between age and metastasis, that patients with ECCA had a better prognosis than patients with ICCA, and that patients with ECCA in the T1 stage had worse survival than patients with ICCA in the T1 stage.     

Vascular involvement in pancreatic neoplasm: a comparison between spiral CT and DSA

The principal criterion for resectability of pancreatic carcinoma is the assessment of vascular involvement. In a prospective evaluation the ability of Spiral CT Angiography (CTA) to detect vascular involvement in 50 patients with pancreatic carcinoma, was proved; DSA was performed later in all patients. In 20 patients, without vascular involvement, a complete concordance was obtained. Of 30 patients with vascular involvement, there was complete concordance between CTA and angiography in 22 patients and discordance in 8 patients. CTA was superior in 2 cases with periadventitial infiltration and in 5 patients with splenoportal confluence thrombosis. DSA was superior in 1 case with infiltration of the superior mesenteric vein. After surgical evaluation, sensitivity of CTA and DSA was 97% and 77%, respectively, and the negative predictive values were 95% and 74%. As compared to DSA, CTA is more rapid and less invasive and can be considered the modality of choice for preoperative work-up of pancreatic neoplasm.     

肝内血管病变与肝炎病变关系的研究

目的　研究肝血管病变与肝损伤的关系．方法　肝病变标本２０００ 例，用ＨＥ、免疫组化及电镜技术进行研究．结果　在急性肝炎肝血管炎症、破坏及阻塞随肝坏死加重而上升（ Ｐ＜ ０－０１） ；在慢性肝炎肝血管炎症、破坏、阻塞及增生随肝病变的轻重程度而示梯度变化（ Ｐ＜ ０－０１） ；在肝硬变肝血管增生及纤维化最明显，与结节大小及纤维带宽窄相关（ Ｐ＜ ０－０１） ，伴弹力纤维化． 免疫组化示纤维带、血管内皮细胞及成肌纤维细胞αＳＭＡ 强阳性； 电镜示血管内皮细胞出芽并形成管状结构．结论　肝血管病变在各型肝病变中担当一关键角色     

Role of intrahepatic tumor control in the prognosis of patients with hepatocellular carcinoma and extrahepatic metastases

Background and Aim: There has been little information about the long‐term outcome and prognostic factors in patients with hepatocellular carcinoma (HCC) and extrahepatic metastases. The purpose of this study was to investigate the clinical factors affecting survival after extrahepatic metastasis and to determine the survival benefit of controlling intrahepatic HCC. Methods: Between 2004 and 2009, a total of 240 consecutive patients with HCC and extrahepatic metastasis were recruited. Based on tumor extent, performance, and hepatic function, the patients underwent locoregional and/or systemic treatments. The treatment response of the intrahepatic tumor after extrahepatic metastasis and other prognostic parameters were analyzed retrospectively. Results: During the mean follow up of 276 days, 222 patients died; the median survival time was 146 days. Multivariate analysis revealed that Child–Pugh class A, smaller hepatic tumor size, absence of portal venous invasion, single metastatic organ involvement, and objective treatment response of the intrahepatic tumor were the favorable prognostic factors for survival. Of the 183 evaluable patients, 24 achieved complete or partial response for intrahepatic tumors after treatment. The overall survival for the 24 responders was significantly improved, with a median of 521 days, as compared to 170 days for the remaining 159 patients without objective tumor response. The leading cause of death was progressive intrahepatic tumor. Conclusions: Intrahepatic tumor status and hepatic reserve are among the significant predictors of survival in patients with HCC and extrahepatic metastases. This study indicates that even in patients with metastases from advanced HCC, therapeutic approaches to control intrahepatic tumors are important in improving patient survival.     

Risk factors for intrahepatic and extrahepatic cholangiocarcinoma: A systematic review and meta-analysis

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Mechanism of gamma-glutamyl transpeptidase release in serum during intrahepatic and extrahepatic cholestasis in the rat: a histochemical, biochemical and molecular approach

The mechanism of the elevation of serum gamma-glutamyl transpeptidase activity in cholestasis is not clear. We therefore analyzed rat gamma-glutamyl transpeptidase activities in liver, bile and serum during intrahepatic cholestasis induced by a single dose of alpha-naphthyl isothiocyanate (20 mg/100 gm body weight) and during extrahepatic cholestasis after bile duct ligation. At days 1 and 2 after alpha-naphthyl isothiocyanate ingestion, we saw a fivefold and a 60-fold increase in serum and bile gamma-glutamyl transpeptidase activities, respectively. These increases were associated with a decrease in hepatic gamma-glutamyl transpeptidase activity and of corresponding mRNA. Simultaneously, necrosis of the biliary epithelium appeared in portal tracts. From day 2 to day 14, gamma-glutamyl transpeptidase activity in bile and serum progressively returned to basal levels; in the liver, cholangiolar proliferation was mild and was associated with moderate elevation of the gamma-glutamyl transpeptidase activity and of its corresponding mRNA. In extrahepatic cholestasis, a 10-fold increase in serum gamma-glutamyl transpeptidase activity was detected between day 0 and day 14. This increase was associated with major cholangiolar proliferation and with a progressive rise in hepatic gamma-glutamyl transpeptidase activity and in specific mRNA; in bile, gamma-glutamyl transpeptidase activity was slightly elevated. In these two models of cholestasis, histochemically detected gamma-glutamyl transpeptidase activity was largely predominant in biliary cells. We found no significant induction of gamma-glutamyl transpeptidase activity in hepatocytes. These results suggest that in these two models of cholestasis, the increase in serum gamma-glutamyl transpeptidase activity is of biliary cell origin and does not originate from hepatocytes.(ABSTRACT TRUNCATED AT 250 WORDS)     

经皮经肝胆管引流术联合经皮经肝胆道镜治疗肝内外胆管结石的效果分析

目的探讨经皮经肝途径治疗肝内外胆管结石的可行性及疗效。方法选取2000年1月-2014年10月在河南省第三人民医院治疗的胆管结石患者19例,通过经皮经肝途径,配合应用胆道镜和碎石仪器,治疗胆管结石。结果 19例患者中12例1次成功取石,5例3次经肝脏窦道完全取石,2例肝内三级胆管结石残留,取石成功率89.47%(17/19)。结论经皮经肝途径治疗胆管结石,创伤轻微,痛苦小,可根据病情需要选择性应用。     

Temporal control of rhythmic performance: a comparison between young and old adults

Young (20-30-year-old) and older (60-76-year-old) adults were tested on two measures of rhythmic performance. The first involved tapping at the subject's own preferred rate, a measure of so-called internal tempo. Over five sessions of testing, tapping rates were consistently and significantly slower on average in the older subjects than the younger ones, but rates were not relatively more variable in older subjects (i.e., coefficients of variation, standard deviation/mean, did not differ between the older and young people). In addition, both old and younger subjects performed on a synchronized-tapping and continuation task of the type used by Wing and Kristofferson (1973, Perception and Psychophysics, 14, 3-12). Target interresponse times were 300, 400, 500, 600, and 700 ms, and in all cases interresponse intervals produced by both the old and young adults matched the target times very closely. Wing and Kristofferson's analytical procedure was used to decompose tapping variance into that attributable to timing processes and that resulting from motor implementation of the timing signal. Both sorts of variance increased with increasing target interresponse time (with timer variance increasing most markedly), but no difference was found in either type of variance in comparisons between the old and younger subjects. If the internal tempo measure directly reflects the speed of internal timing processes, the data suggest that such processes are slower, but not relatively more variable, in older than younger subjects (consistent with some previous evidence and speculation), but that the calibration of performance forced by the synchronization task will make such an age-related difference in "internal clock speed" unobservable on synchronized-tapping tasks.     

Endoscopic ligation vs. sclerotherapy in adults with extrahepatic portal venous obstruction: a prospective randomized study

BACKGROUND: Endoscopic sclerotherapy is a well-established treatment for bleeding esophageal varices, although it has a substantial complication rate. A prospective randomized trial was conducted to determine whether endoscopic variceal ligation is safer and more effective than sclerotherapy in adults with bleeding esophageal varices because of extrahepatic portal venous obstruction. METHODS: Thirty-six patients underwent sclerotherapy and 37 had band ligation. RESULTS: Ligation and sclerotherapy were equally effective for achieving variceal eradication (94.6% vs. 91.7%, respectively; p=0.67). However, ligation achieved eradication with fewer endoscopic sessions (3.7 [1.2] vs. 7.7 [3.3]; p <0.0001) and within a shorter time interval (50.1 [17.7] days vs. 99 [54.8] days; p <0.0001). In the ligation group, recurrent bleeding was less frequent (2.7% vs. 19.4%; p=0.028; however, Bonferroni correction for multiple testing removes this significance) and the rate of major complications was lower (2.7% vs. 22.2%; p=0.014). Total cost per patient was significantly higher in the sclerotherapy vs. the ligation group ($216.6 [71.8] vs. $182.6 [63.4]; p=0.035). During the follow-up period after variceal eradication, no significant differences were found between the sclerotherapy and the ligation groups with respect to recurrent bleeding (3% vs. 2.9%; p=1.0), esophageal variceal recurrence (9.1% vs. 11.4%; p=1.0), and formation of new gastric varices (9.1% vs. 14.3%; p=0.51). CONCLUSIONS: Variceal band ligation is superior to sclerotherapy, because it is less costly and achieves variceal eradication more quickly, with lower relative frequencies of recurrent variceal bleeding and complications.     

内镜静脉曲张结扎术与十四肽生长抑素治疗肝硬化食管静脉曲张破裂出血的疗效比较

目的 比较内镜静脉曲张结扎术与十四肽生长抑素在治疗肝硬化食管静脉曲张破裂出血中的效果.方法 将2003年1月至2006年4月广东省江门市中心医院消化科收治的80例肝硬化食管静脉曲张破裂出血患者分为内镜治疗组(40例)和十四肽生长抑素治疗组(40例).内镜治疗组在内镜下用多环连发皮圈结扎器行静脉曲张结扎术(EVL),然后静脉滴注垂体后叶素7 d;生长抑素治疗组先以十四肽生长抑素持续静脉滴注72 h,再以垂体后叶素静脉滴注持续4 d.结果 内镜治疗组中39例72 h内止血(97.5%).1个月内再出血4例(10%,其中1周内再出血3例),发生肝肾综合征1例,肝性脑病1例,死亡2例(5%).生长抑素治疗组72 h完全止血32例,1个月内再出血5例(12.5%),出现肝肾综合征5例(12.5%),P＞0.05;肝性脑病6例(15%),P＜0.05;死亡6例(15%),P＞0.05.结论 食管静脉曲张皮圈结扎治疗肝硬化食管静脉曲张破裂大出血优于生长抑素治疗,尽早EVL治疗能减少肝性脑病的发生.     

猪心肌梗死后室性心律失常模型建立方法的比较

目的比较不同的急性心肌梗死(简称心梗)造模方法导致室性心律失常发生的差异,探索最佳造模方法。方法 45只苏中幼猪随机分为假手术组(Sham组,n=5)、开胸结扎左前降支(LAD)组(结扎组,n=17)和经导管球囊封堵LAD组(封堵组,n=23)。结扎/封堵后90 min内心电图监测动物室性心律失常发生情况。饲养8周后,以2,3,5-氯化三苯基四氮唑(TTC)染色、HE染色鉴定梗死模型是否成功。结果与结扎组相比,封堵组术后即刻存活率低(60.87%vs 94.12%,P<0.05),室性早搏、室性心动过速的发生率没有明显差异(91.30%vs 70.59%,30.43%vs 29.41%;P均>0.05);但封堵组心室颤动发生率明显增高(69.57%vs 5.88%,P<0.001)。8周后经TTC、HE染色鉴定,两组造模成功率无显著差异(68.75%vs 92.86%,P=0.234),但是封堵组梗死面积较大。结论与结扎法相比,封堵法可以导致大面积心梗,室性心律失常发生率高。     

Endoscopic band ligation for control of nonvariceal upper GI hemorrhage: comparison with bipolar electrocoagulation

BACKGROUND: Despite advances in endoscopic treatment methods for upper GI hemorrhage, hemostasis is often difficult to achieve. This study evaluated the usefulness of endoscopic band ligation for upper GI hemorrhage exclusive of hemorrhage from chronic gastroduodenal ulcer and varices. METHODS: This prospective study included 27 patients who underwent endoscopic band ligation and 31 patients in whom bipolar electrocoagulation was performed for upper GI hemorrhage. In both groups, the causes of hemorrhage included Dieulafoy's ulcer, Mallory-Weiss tear, gastric ulcer after polypectomy, and gastric angiodysplasia. Patients with esophageal varices and those with chronic gastroduodenal ulcer were excluded. RESULTS: Hemostasis was achieved in all 27 patients in the endoscopic band ligation group and in 26 of 31 patients (83.9%) in the bipolar electrocoagulation group. The median procedure time required for achieving hemostasis was 17.0 minutes (interquartile range: 11.5-23.5) in the endoscopic band ligation group versus 27.0 minutes (interquartile range: 20.5-40.0) in the electrocoagulation group. No major complications occurred in either group. CONCLUSION: Endoscopic band ligation is efficient, simple, and safe. Therefore, this technique should be considered as a treatment option for nonvariceal, nonchronic gastroduodenal ulcer upper GI hemorrhage.