Heterotopic gastric mucosa in the hilar bile duct mimicking hilar cholangiocarcinoma: report of a case

We herein report a case of heterotopic gastric mucosa in the hilar bile duct. An asymptomatic 58-year-old male was noted to have mild liver dysfunction in March 2009 during the follow-up for angina pectoris. Abdominal-enhanced CT revealed wall thickening from the upper common hepatic bile duct to the left hepatic bile duct. Endoscopic retrograde cholangiopancreatography (ERCP) showed stenosis at the junction of the left hepatic bile duct. Although the patient??s serum tumor markers were all within the normal ranges, the possibility of malignant disease of the biliary tree could not be ruled out. Left hepatectomy with the caudate lobe and resection of the extrahepatic bile duct were performed. Histopathologically, the resected specimen showed a polypoid lesion measuring 2 × 2 cm in size that projected into the lumen of the left hepatic bile duct. Microscopic examination revealed this polypoid lesion to be composed of mucous glands resembling gastric fundic glands, with parietal and chief cells. We also review eight other reports of heterotopic gastric mucosa in the biliary tree previously published in the English literature.     

手术切除治疗肝门部胆管癌

目的 总结肝门部胆管癌手术治疗的经验.方法 回顾性分析本院9年因肝门部胆管癌行手术切除的83例病人的临床资料和随访结果.结果 83例手术切除病人中行根治性切除（R0）31例,非根治切除52例（R1,R2）,术后出现并发症29例,死亡5例.根治性切除组中位生存期21.5个月,1、3、5年生存率分别为79.6%,43.3%和25.9%,明显优于非根治性切除组（P＜0.05），近5年本院根治性切除率达44.8%,中位生存期18.7个月,疗效明显提高（P＜0.05），结论 加强围手术期处理、术中行切缘冰冻病理检查、联合肝切除等可提高肝门部胆管癌根治性切除率、减少并发症和死亡率;根治性切除可更好延长病人生存期,使手术治疗肝门部胆管癌获得良好的疗效.     

A hepatic lipoma mimicking angiomyolipoma of the liver: Report of a case

Lipoma of the liver is extremely rare. Since the current knowledge of such tumors is based primarily on individual case reports and small case series, little is so far known about this disease. This report presents a case of lipoma of the liver mimicking angiomyolipoma. The patient was a 38-year-old man, who was hospitalized without any symptoms after a medical check. Radiological examinations (computed tomography, ultrasonography, magnetic resonance imaging) showed a well-defined mass, which was finally diagnosed to be located in the left part of the caudate lobe of the liver, containing two spotty enhanced nodules within the tumor. These were diagnosed to be either lipoma or angiomyolipoma of the liver. The resected specimen measured 9 cm in diameter. The cut surface of the specimen showed an encapsulated, homogeneous, yellowish tumor consisting of mature adipose tissue, which was diagnosed as lipoma of the liver. The two nodules within the tumor were encapsulated hemorrhage. Histopathological examinations revealed the lipoma to be composed of mature lipocytes without angiomatous or myomatous elements. There was no immunoreactivity to homatropine methylbromide 45. Therefore, the final diagnosis was lipoma of the liver, which is an extremely rare benign liver tumor.     

肝门部胆管癌根治性切除中围肝门区手术处理

目的探讨围肝门区手术处理手段在肝门部胆管癌外科治疗中的临床应用。方法回顾性分析我院2002年1月-2007年12月诊治的86例肝门部胆管癌病人的临床资料。其中,实施单纯内引流术38例,姑息性切除术11例,采取联合尾状叶切除、受侵门静脉肝动脉切除重建、肝内胆管断端整形、肝门区淋巴结清扫等技术完成根治性切除37例。结果肝门部胆管癌的根治性切除率由2002年的33．3％,提高到2007年的75．0％。无围手术期死亡发生。结论联合采用尾状叶切除、肝门部胆管断端整形、受侵门静脉切除重建及肝门区淋巴清扫等围肝门区处理手段可提高肝门部胆管癌根治性切除率,降低手术并发症的发生率。     

In-continuity hepatic resection for advanced hilar cholangiocarcinoma

BACKGROUND: The purpose of this study was to examine outcomes of patients undergoing concomitant hepatectomy and bile duct excision for advanced Klatskin tumors. METHODS: Thirty-one patients, 16 men and 15 women, with an average age of 64 years, underwent concomitant biliary and hepatic resections for Klatskin tumors. Outcomes, including complications and survival, are reported. RESULTS: Fifteen patients had postoperative courses free of complications. Sixteen patients experienced a total of 50 complications; 13 patients experienced 1 or more major complications (including hemorrhage [n = 1], pneumonia [n = 5], intra-abdominal abscess [n = 8], hepatic failure [n = 3], and myocardial infarction [n = 2]). Five patients died perioperatively, 1 from adult respiratory distress syndrome and 4 from multisystem organ failure precipitated by hepatic failure. One-, 3-, and 5-year survival after resection was 69%, 33%, and 26%, respectively. American Joint Committee on Cancer stage and margin status did not impact long-term survival after resection. CONCLUSIONS: Concomitant hepatic and biliary resections for Klatskin tumors carry relatively high risk but offer hope for long-term survival. This study supports in-continuity hepatectomy and extrahepatic biliary resection for advanced Klatskin tumors even when microscopically negative margins cannot be obtained.     

保留肝动脉血供对减少肝门胆管癌术后并发症的作用

目的 探讨肝动脉血供对减少肝门胆管癌术后并发症的作用。方法 分析我院近5年来收治的肝门胆管癌经手术治疗病人的资料,比较术中损伤肝动脉分支及侧支循环组与无损伤侧支循环组的术后并发症发生率。结果 术中损伤肝动脉分支及其侧支循环组术后并发症发生率明显高于无损伤组。结论 肝门胆管癌术中如能尽量保护肝动脉分支及其侧支循环,可减少术后并发症的发生。     

第一肝门的骨骼化清扫治疗肝门部胆管癌

目的评价肝门胆管癌的根治性切除运用骨骼化清扫技术以减少并发症和提高手术效果的意义。方法回顾性分析1999年以来收治的80例肝门部胆管癌患者的临床资料,其中应用常规胆管癌切除技术32例(A组),应用胆管的骨骼化清扫技术48例(B组),比较其并发症和生存率状况。结果A组并发症发生率和围术期死亡率分别为37.5%和18.8%,B组则为27.08%和8.3%,两者比较差异有统计学意义(P<0.05)。B组的术后1年生存率明显提高(P<0.05)。结论第一肝门的骨骼化处理是提高肝门部胆管癌手术预后的关键,综合措施提高吻合口的安全性是预防术后胆漏发生的首要选择。     

Major hepatic resection for hilar cholangiocarcinoma: analysis of 46 patients

HYPOTHESIS: Major hepatectomy, bile duct resection, and regional lymphadenectomy for hilar cholangiocarcinoma are associated with actual long-term (>5 years) survival. DESIGN: Retrospective outcome study. SETTING: Single tertiary referral institution. PATIENTS: Between 1979 and 1997, 46 consecutive patients had resection of hilar cholangiocarcinoma by major hepatectomy, bile duct resection, and regional lymphadenectomy. MAIN OUTCOME MEASURES: Overall survival and tumor recurrence were correlated to clinicopathological factors, operative morbidity, and mortality. RESULTS: Twenty-five patients underwent left hepatectomy, 17 underwent right hepatectomy, and 4 had extended right hepatectomy. Eighteen patients underwent resection of segment 1. Negative (R0) resection margins were achieved in 37 patients (80%). The operative mortality rate was 9%, and the surgical morbidity rate was 52%. Actual 1-year, 3-year, and 5-year survival rates were 80%, 39%, and 26%, respectively. Factors adversely associated with patient survival rates included: male sex, lymph node metastases, tumor grade 3 or 4, elevated direct serum bilirubin level at diagnosis, elevated preoperative activated partial thromboplastin time, and more than 4 U of red blood cells transfused perioperatively. Tumor size and R0 resection approached significance for survival. Factors associated with tumor recurrence included: male sex, tumor grade 3 or 4, a low hemoglobin level both at diagnosis and preoperatively, and a low preoperative prothrombin time and low alkaline phosphatase level at diagnosis and preoperatively. Median time to recurrence was 3.6 years. Tumor recurrence was predominantly local and regional. CONCLUSIONS: The actual 5-year survival rate of 26% justifies major partial hepatectomy, bile duct resection, and regional lymphadenectomy for hilar cholangiocarcinoma. The high frequency of local and regional recurrence warrants investigation of adjuvant therapy.     

Curative resection of hilar cholangiocarcinoma in a 25-year-old woman: report of a case

A 25-year-old woman was referred to our hospital with persistent upper abdominal pain. Preoperative imaging studies revealed a hilar bile duct stricture with portal venous encasement, and the patient underwent curative resection involving extended left hepatectomy and segmental portal vein resection. The pathological findings demonstrated a well-differentiated tubular adenocarcinoma of the bile duct with regional lymph node metastasis (stage IIIB according to the UICC TNM classification), as well as the overexpression of p53 proteins and the K-ras gene mutation in tumor cells. The patient has shown no evidence of recurrence in the 10 months since the operation. Although there are several reports of relatively young adults with cholangiocarcinoma, the majority of such patients demonstrate either an anomalous arrangement of the pancreaticobiliary duct system or primary sclerosing cholangitis. The absence of any morphological abnormalities in this patient’s biliary system implicates de novo carcinogenesis as the most likely cause of the cholangiocarcinoma.     

MRI及MRCP评估肝门部胆管癌可切除性应用价值研究

目的 研究肝门部胆管癌的影像学表现,探讨增强MRI及磁共振胆胰管成像（MRCP）对肝门部胆管癌可切除性评估价值。方法 回顾性分析2006年6月至2009年10月间广州军区广州总医院经病理证实的30例肝门部胆管癌MRI增强扫描、MRCP表现,将MRI术前可切除性评估与手术结果进行比较。结果 30例肝门部胆管癌均显示肝门部肿块,增强以延迟强化为主,肝内胆管不同程度扩张;MRI增强扫描结合MRCP可有效显示胆管受侵范围、门静脉血管受侵情况、肝实质及淋巴结有无转移。MRI综合评价肿瘤可切除的敏感性、特异性及准确性分别为81.8％、91.6％及86.9％。结论 增强MRI结合MRCP,能在术前较为客观地对肝门部胆管癌的可切除性进行评价。     

肝内胆管结石合并肝胆管癌32例诊治分析

目的 探讨肝内胆管结石合并肝胆管癌的临床特点和诊治经验。方法 对1993-2007年间华中科技大学同济医学院附属同济医院肝胆胰外科研究所收治的32例肝内胆管结石并发肝胆管癌病例的临床资料进行回顾性分析。结果 32例肝胆管癌占同期肝内胆管结石病人的1.9%,术前确诊率为59 .4%（19/32）。其中周围型胆管癌占43.8%（14/32）,肝门部胆管癌占50%（16/32）。肿瘤根治性切除率为31.3%（10/32）,姑息性手术46.9%（15/32）。有随访资料的28例中,根治组平均存活时间22个月,姑息手术组平均存活9个月。结论 肝内胆管结石造成的胆管系统内慢性炎症环境可能是诱发胆管癌的重要原因。对于有长期肝内胆管结石病史以及胆道手术史的病人,必须警惕并发肝胆管癌的可能。该病的早期诊断和根治性切除率低,预后差。     

肝门部胆管癌根治术肝切除范围的合理选择

外科手术切除是肝门部胆管癌最有效和首选的治疗方法,笔者根据该病的4种类型提出合理的手术切除范围选择,旨在进一步规范肝门部胆管癌的外科治疗。     

A case of gossypiboma mimicking intrahepatic cholangiocarcinoma

Introduction

A gossypiboma refers to a cotton-based foreign body left inadvertently in the human body following a surgical procedure. Although a rare event, they tend to be found in the abdomen but few are known to be intrahepatic.

Case history

We report the case of a 44 year-old man who presented with recurrent episodes of jaundice and cholangitis, on a background of a right hepatectomy for hydatid cyst excision 20 years previously. This case was discussed at our hepatobiliary multidisciplinary team meetings on several occasions and a presumed diagnosis of intrahepatic cholangiocarcinoma was made. Biopsies of the mass had purely shown inflammation and remained inconclusive. It was decided that the patient should undergo a complete extended right hepatectomy with resection and reconstruction of the left branch of the portal vein. On attempting to obtain intraoperative frozen section specimens prior to resection, open excision revealed two large swabs encased in a calcified cavity. Removal of the swabs resulted in resolution of the mass and obstructive symptoms.

Conclusions

Gossypiboma should be a rare differential diagnosis in all patients following a laparotomy presenting with obstructive symptoms, particularly in countries where strict surgical protocols may not be in place. This case also highlights the need to perform an intraoperative biopsy in any uncertain case of a liver lesion as we have shown that an extensive operation with its increased morbidity can occasionally be avoided.     

原位肝移植联合胰十二指肠切除术治疗肝门部胆管癌1例

2007年11月21日我院对1例Bismuth分型为Ⅳ型且合并肝门部及胰头后淋巴结转移的肝门部胆管癌患者施行了肝、胰头十二指肠联合切除同时原位肝移植手术,受者至今已存活1年.     

肝门胆管癌手术切缘残癌与预后

目的：探讨经手术切除肝门胆管癌（hepatic hilar cholangocarcinoma,HHCC) 手术切缘有无残癌对预后的影响,方法：比较切缘有残癌组（43例）和无残癌组（40例）患者的临床分型,手术方式,肿瘤分程度及生存情况,结果：切缘有残癌组患者1、2、3和5年生存率,分别为37．2％、6．3％、3．5％和2．4％,切缘无残癌组患者分别为82．2％、58．2％、41．65和27．75,结论：手术切缘残癌率与肿瘤分化程度关系密切,在BismuthIV型中发生率最主,BismuthIV型中的低分化型腺癌患者,手术切除疗效差,对无肝外转移者可以选择肝移植术。     

Central hepatic bisectionectomy with hepatic artery and biliary tracts reconstruction for the patient with nodular type intrahepatic hilar cholangiocarcinoma: A case report

Introduction and importanceA central hepatic bisectionectomy (CHBS) for a hilar cholangiocarcinoma (CCA) is technically challenging because bilateral biliary reconstruction is required after resection. On the other hand, hepatic artery resection and reconstruction in a major liver resection are also technical procedures. In this report, we describe our radical CHBS with hepatic artery and biliary tracts reconstruction for a patient with nodular type intrahepatic hilar CCA.Case presentationA 76-year-old man was referred for further investigation of an incidental hepatic tumor. The hepatic tumor was located from medial sector to anterior sector with encasement of the anterior branch of the right hepatic artery. Based on these findings, we performed a CHBS with right hepatic artery and biliary tracts reconstruction. The histopathological findings revealed that the tumor consisted of moderately differentiated tubular adenocarcinoma with tumor necrosis without a fibrous capsule. In this area, tumors cells had invaded branches of the hepatic vein; however, there was no destructive invasion to the hepatic artery. Consequently, he was diagnosed with a nodular type intrahepatic hilar CCA with pT2aN0M0.Clinical discussionA CHBS is usually performed with the intent of anatomically preserving a patient’s liver as much as possible. Concomitant resection and reconstruction of the hilar vessels and biliary tracts with CHBS is one of the most technically challenging procedures in liver resections.ConclusionA CHBS with hepatic artery and biliary reconstruction may be a promising alternative if expert surgeons perform it on strictly selected patients.     

肝门部胆管癌165例的诊断与外科治疗

目的 总结肝门部胆管癌的诊断及外科治疗.方法 回顾性分析1972-2001年收治的肝门部胆管癌165例的临床资料.结果 根据不同时期的发病例数、手术切除率不同,分为前15年第一阶段及后15年的第二阶段.首发症状为上腹不适或闷痛、胀痛、乏力、食欲减退及进行性黄疸.B超、CT、MRI和MRCP是无损伤诊断的首选方法;若显示肝内胆管扩张或诊断肝外梗阻性黄疸,则应行PTC（27例）、MRCP（15例）或ERCP（78例）.本组手术切除73例,切除率44.2%,其中根治性切除38例;非根治性切除35例.第一阶段切除15例,切除率27.3%;第二阶段切除58例,切除率52.7%.本组54例得到随访,其中根治性切除术5年生存率39.5%,非根治性切除术为14.3%;未切除的62例得到随访,均于1～1.5年死亡.结论 一旦诊断为肝门部胆管癌,就应积极剖腹探查,不要延误切除时机.手术切除是治疗肝门部胆管癌的最有效的治疗方法.     

Perioperative and long-term outcome of intrahepatic cholangiocarcinoma involving the hepatic hilus after curative-intent resection: comparison with peripheral intrahepatic cholangiocarcinoma and hilar cholangiocarcinoma

Background

Intrahepatic cholangiocarcinoma with hepatic hilus involvement has been either classified as intrahepatic cholangiocarcinoma or hilar cholangiocarcinoma. The present study aimed to investigate the clinicopathologic characteristics and short- and long-term outcomes after curative resection for hilar type intrahepatic cholangiocarcinoma in comparison with peripheral intrahepatic cholangiocarcinoma and hilar cholangiocarcinoma.