Transampullary pancreatic duct stenting decreases pancreatic fistula rate following left pancreatectomy

BACKGROUND/AIMS: Significant improvements in mortality following pancreatic surgery have been noted by high-volume centers in recent years. Despite this, morbidity from pancreatic resection remains high, with postoperative pancreatic fistula remaining a common problem following distal pancreatectomy (DP). Rates of pancreatic fistula following distal pancreatectomy have ranged from 0 to 61% in a recent meta-analysis of surgical techniques and impact upon pancreatic fistula rates. We postulated that intraoperative placement of a transampullary pancreatic duct stent (TAPDS) at the time of distal pancreatectomy, would decrease ampullary complex-mediated elevation in pancreatic duct pressures, improve healing of the ligated pancreatic duct and result in a decrease in pancreatic fistula following distal pancreatectomy. METHODOLOGY: Sixteen consecutive patients underwent distal pancreatectomy plus TAPDS and were compared to 43 control patients who underwent distal pancreatectomy by the same surgeon, with identical management of the pancreatic remnant. Distal pancreatectomy was performed as the primary operation or as part of an en-bloc resection for a primary malignancy other than pancreatic adenocarcinoma. In patients who underwent transampullary pancreatic duct stenting (TAPDS), the pancreatic duct was identified after transection of the pancreatic parenchyma. A soft, pediatric feeding tube was inserted directly into the pancreatic duct and carefully fed into the duodenum (confirmed by palpation). The stent was placed distally, one centimeter from the cut-edge of the pancreatic duct, which was then ligated as described earlier. Closure of the pancreatic parenchyma was identical to those patients who did not undergo TAPDS placement. Common perioperative outcomes were assessed, including pancreatic fistula. RESULTS: No statistically significant differences where found between the rates of intraabdominal abscess, intraabdominal hemorrhage or need for reoperation. Pancreatic fistula rates and average length of stay were significantly decreased in patients undergoing distal pancreatectomy with TAPDS (p<0.05 and p<0.0001 respectively). CONCLUSIONS: Statistically significant reductions in pancreatic fistula and average length of stay were noted in patients who underwent stenting of the pancreatic duct with TAPDS.     

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.     

Preoperative platelet count predicts survival after resection of periampullary adenocarcinoma.

BACKGROUND/AIMS: Thrombocytosis or thrombocytopenia have been shown to act as negative predictors of outcome for various solid tumors. No such effect is known for periampullary cancer. The preoperative peripheral blood platelet count impacts on outcome after resection of pancreatic and other periampullary adenocarcinomas. METHODOLOGY: Clinicopathologic information, treatment aspects, and outcome parameters of patients undergoing pancreatectomy at City of Hope Cancer Center were retrospectively collected and tabulated. The impact of the preoperative platelet count on postoperative recovery, disease-free survival, and overall survival was analyzed. RESULTS: Between 1988 and 1998, 65 patients underwent partial or total pancreatectomy at City of Hope Cancer Center, 49 of whom had a diagnosis of pancreatic or periampullary adenocarcinoma. There were 26 females and 23 males, with a median age of 64 years (range: 24-86). Median preoperative platelet count was 308 (x10(9)/L; range: 104 to 547). Diagnoses were pancreatic (n = 28), duodenal (n = 12), and bile duct/ampullary cancer (n = 9). Procedures included pancreatoduodenectomy (n = 42), distal pancreatectomy (n = 4), and total pancreatectomy (n = 3). Six patients underwent a splenectomy. A lower preoperative platelet count was correlated to a shortened prothrombin time (P = 0.02), and a positive resection margin (P = 0.01), but not operative blood loss or transfusion requirements. Postoperative complications and hospital stay were not affected by the platelet count. Preoperative platelets of < 300 were associated with a decreased median overall survival (13 vs. 33 months, P = 0.02) and disease-free survival (11 vs. 29 months, P = 0.02), at a median follow-up of 14 months (18 for survivors). On multivariate analysis, the platelet count remained a significant predictor of survival in addition to grade, perineural invasion, the primary tumor size, and the surgeon. CONCLUSIONS: Based on these retrospective data, a lower preoperative platelet count correlates with inferior, a higher count with superior survival outcome after resection of periampullary cancer. The mechanism is unclear, but may relate to general factors (bone-marrow suppression or hypersplenism for low platelets, systemic antitumor mediators for high platelets) or platelet-specific effects (platelet influence on tumor angiogenesis or metastatic efficiency). The preoperative thrombocyte count should be considered a parameter with potential clinical significance in prospective clinical studies of periampullary neoplasms.     

Periampullary and Pancreatic Head Carcinoma: Facts and Factors Influencing Mortality, Survival, and Quality of Postoperative Life

From September 1983 to December 1985 40 patients from a total of 55 with periampullary and pancreatic head carcinoma underwent resectional surgery in our department. Following a policy of precise evaluation of each patient's operative findings, six patients underwent a Whipple duodenopancreatectomy, 29 patients underwent regional subtotal pancreatectomy, and five underwent regional total pancreatectomy. Five patients underwent vascular reconstruction of their regional vascular structures after transection of the invaded segments of their vessels and eight had positive lymph nodes. Lymph node involvement was confined to the regional area. Patients with distant lymph node involvement (paraaortic) were not considered eligible to resection. Three patients died and 10 required reoperation. Thirty-one had radical resection, one palliative and eight equivocal resection. From the survived patients (n = 37) 33 are alive and doing well at the time of this report (overall mean survival 18 months). The results of this study demonstrate that a radical approach based on a precise evaluation of operative findings of the individual patient might well offer a higher resectability rate and is probably the only chance for radical resection and for a longer survival in patients with periampullary and pancreatic head carcinoma.     

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.     

Pancreaticoduodenectomy for metastatic ampullary and pancreatic tumors

BACKGROUND/AIMS: To report the clinical presentation, diagnosis and results of aggressive surgical management in patients with metastatic ampullary and pancreatic tumors. METHODOLOGY: Twelve patients underwent pancreaticoduodenectomy for ampullary or pancreatic metastases from January 1, 1987, to June 30, 1998, in 2 institutions. The primary cancer was renal cell carcinoma (n = 5), melanoma (n = 2), venous leiomyosarcoma (n = 1), carcinoid tumor (n = 1), colon carcinoma (n = 1), breast carcinoma (n = 1) and small-cell lung carcinoma (n = 1). The mean interval between primary treatment and metachronous pancreatic metastasis was 88 months. In 3 cases, pancreatic metastases were synchronous with the primary tumor. The main symptoms were jaundice (n = 8) and upper gastrointestinal tract bleeding (n = 2). The principal investigations were computed tomography scan (n = 9), arteriography (n = 7), duodenoscopy (n = 6) and fine-needle aspiration (n = 4). A correct preoperative diagnosis was made for 8 patients. RESULTS: In all cases, the pancreatic tumor was resected with intention to cure or provide useful palliation, using pancreaticoduodenectomy for isolated tumors (n = 11) or total pancreatectomy for multiple lesions (n = 1). Three out of 12 patents had positive lymph nodes, and the resection margin was free of disease in all cases. There was no postoperative mortality. Survival after pancreaticoduodenectomy averaged 26 months. Overall survival of patients undergoing pancreaticoduodenectomy was 35% at 2 years and 17% at 5 years. One patient is still alive more than 10 years after pancreaticoduodenectomy. CONCLUSIONS: Pancreaticoduodenectomy can be performed safely, representing a suitable option for resection in patients with symptomatic or late isolated pancreatic metastases in the absence of widely metastatic disease. The best indications are solitary metastases from renal cell carcinoma, sarcoma and neuroendocrine tumors. However, there is no evidence of survival benefit after pancreaticoduodenectomy for synchronous tumors or metachronous tumors from melanoma or colon carcinoma.     

Intraductal polypoid growth variant of pancreatic acinar cell carcinoma metastasizing to the intrahepatic bile duct 6 years after surgery: A case report and literature review

We present the first reported case of intraductal polypoid growth (IPG) variant of pancreatic acinar cell carcinoma (ACC) metastasizing to the intrahepatic bile duct. A 58-year-old Japanese woman had previously presented with obstructive jaundice and a 7.0 cm mass in the pancreatic head. She underwent biliary drainage for 2 months followed by pancreatectomy. Histological examination revealed a carcinoma with acinar pattern, immunohistochemically positive for trypsin, and acinar cell carcinoma was diagnosed. IPGs were prominent in the main pancreatic duct and its tributaries, extending into the intrapancreatic bile duct with tumor casts in the lumen. Imaging examinations 6 years later revealed a growing lesion within the intrahepatic bile duct. Needle biopsy examination suggested metastasis of ACC, and she underwent chemoradiation therapy and partial hepatectomy. Histological examination demonstrated ACC confined to the intrahepatic bile duct. The localization of metastasis and slow growth may indicate indolent biologic behavior of the IPG variant.     

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.

     

Laparoscopic pancreaticoduodenectomy via a reverse-’’V’’ approach with four ports:Initial experience and perioperative outcomes

AIM:To evaluate the feasibility,safety,and efficacy of laparoscopic pancreaticoduodenectomy(LPD) using a reverse-“V” approach with four ports.METHODS:This is a retrospective study of selected patients who underwent LPD at our center between April 2011 and April 2012.The following data were collected and reviewed:patient characteristics,tumor histology,surgical outcome,resection margins,morbidity,and mortality.All patients were thoroughly evaluated preoperatively by complete hematologic investigations,triple-phase helical computed tomography,upper gastrointestinal endoscopy,and biopsy of ampullary lesions(when present).Magnetic resonance cholangiopancreatography was performed for doubtful cases of lower common bile duct lesions.RESULTS:There was no perioperative mortality.LPD was performed with tumor-free margins in all patients,including patients with pancreatic ductal adenocarcinoma(n = 6),ampullary carcinoma(n = 6),intra-ductal papillary mucinous neoplasm(n = 2),pancreatic cystadenocarcinoma(n = 2),pancreatic head adenocarcinoma(n = 3),and bile duct cancer(n = 2).The mean patient age was 65 years(range,42-75 years).The median blood loss was 240 m L,and the mean operative time was 368 min.CONCLUSION:LPD using a reverse-“V” approach can be performed safely and yields good results in elective patients.Our preliminary experience showed that LDP can be performed via a reverse-“V” approach.This approach can be used to treat localized malignant lesions irrespective of histopathology.     

The outcome of patients with an extrahepatic biliary stricture secondary to chronic pancreatitis

Twenty-three chronic pancreatitis patients with abnormal liver function or cholangitis were shown at endoscopic retrograde cholangiopancreatography (ERCP) to have common bile duct strictures. Nine were investigated following a single episode of jaundice, 9 after multiple attacks, and 5 presented with an elevated alkaline phosphatase. Jaundice resolved spontaneously in 7 of the 9 patients presenting with a single episode. Fifteen patients required surgery: this was for recurrent or unremitting jaundice in eight, cholangitis in three, unmanageable pain in two, and radiological appearances suspicious of malignancy in two. Five had biliary bypass alone, seven underwent pancreatic resection, one had a pancreatico-jejunostomy, and two, drainage of a pseudocyst. There was one postoperative death following total pancreatectomy. The incidence of continuing pain and insulin-dependent diabetes was similar in the patients treated by biliary bypass or by pancreatic resection; one patient with a bypass had further cholangitis and two with pancreatic resection developed unmanageable steatorrhoea. The radiological severity of pancreatitis in the patients treated conservatively was similar to that in those requiring surgery. The latter group tended to have a shorter stricture of the distal common bile duct. Chronic pancreatitis patients with abnormal liver function resulting from bile duct stricture should first be managed conservatively. When surgical decompression is indicated, drainage of the pseudocyst or a simple bypass is advisable, rather than more radical measures.     

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.     

Treatment of disrupted and disconnected pancreatic duct in necrotizing pancreatitis: A systematic review and meta-analysis

BackgroundNecrotizing pancreatitis may lead to loss of integrity of the pancreatic duct, resulting in leakage of pancreatic fluid. Pancreatic duct disruption or disconnection is associated with a prolonged disease course and particular complications. Since a standard treatment for this condition is currently lacking, we performed a systematic review of the literature to compare outcomes of various treatment strategies.MethodsA systematic review was performed according to the PRISMA guidelines in the PubMed, EMBASE and Cochrane databases. Included were articles considering the treatment of patients with disrupted or disconnected pancreatic duct resulting from acute necrotizing pancreatitis.ResultsOverall, 21 observational cohort studies were included comprising a total of 583 relevant patients. The most frequently used treatment strategies included endoscopic transpapillary drainage, endoscopic transluminal drainage, surgical drainage or resection, or combined procedures. Pooled analysis showed success rates of 81% (95%-CI: 60–92%) for transpapillary and 92% (95%-CI: 77–98%) for transluminal drainage, 80% (95%-CI: 67–89%) for distal pancreatectomy and 84% (95%-CI: 73–91%) for cyst-jejunostomy. Success rates did not differ between surgical procedures (cyst-jejunostomy and distal pancreatectomy (risk ratio = 1.06, p = .26)) but distal pancreatectomy was associated with a higher incidence of endocrine pancreatic insufficiency (risk ratio = 3.06, p = .01). The success rate of conservative treatment is unknown.DiscussionDifferent treatment strategies for pancreatic duct disruption and duct disconnection after necrotizing pancreatitis show high success rates but various sources of bias in the available studies are likely. High-quality prospective, studies, including unselected patients, are needed to establish the most effective treatment in specific subgroups of patients, including timing of treatment and long-term follow-up.     

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.     

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。     

Surgical technique and results of intrapancreatic bile duct resection for hilar malignancy (with video)

Background

Hilar malignancy can occasionally be associated with high grade dysplasia (HGD) adjacent to invasive malignancy. For patients with HGD extending into the intrapancreatic bile duct, the authors adopted intrapancreatic bile duct resection (IP-BDR). The aims of this study were to compare the incidence of clinically relevant postoperative pancreatic fistula (CR-POPF), distal R0 resection and local recurrence within the distal bile duct remnant for patients undergoing extrahepatic bile duct resection without pancreaticoduodenectomy (with or without IP-BDR).

Distal pancreatectomy without splenectomy and with preservation of splenic vessels

BACKGROUND/AIMS: Conventional distal pancreatic resection routinely involves splenectomy. The awareness that spleen removal may lead to postoperative septic and hematological complications motivated the development of spleen-preserving procedures. Successful distal pancreatectomy with splenic conservation has been reported for treatment of benign pancreatic diseases of the distal pancreas. This report presents the results of spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein. METHODOLOGY: Ten patients underwent distal pancreatectomy with splenic vessel preservation. In all cases, both splenic vessels were separated from the pancreas towards the spleen after transecting the body of the pancreas. RESULTS: The indications for the procedure were: neuroendocrine pancreatic tumors (n = 4), cystic neoplasm of the pancreas (n = 4) and cystic-papillary pancreatic tumors (n = 2). Four patients developed pancreatic fistulas with spontaneous healing and there was no mortality. CONCLUSIONS: Spleen-preserving distal pancreatectomy with splenic vessel conservation can be safely performed and should be indicated in the surgical management of benign pancreatic diseases of the distal pancreas.     

IgG4-related sclerosing cholangitis and autoimmune pancreatitis: histological assessment of biopsies from Vater's ampulla and the bile duct

Background and Aim: Autoimmune pancreatitis is commonly associated with immunoglobulin (Ig) G4‐related sclerosing cholangitis (IgG4‐SC). The discrimination between IgG4‐SC and pancreatobiliary malignancies or primary sclerosing cholangitis (PSC) is now an important issue. The present study was carried out to examine the usefulness of endoscopic biopsies from Vater's ampulla and the bile duct to diagnose IgG4‐SC. Methods: The present study included 29 IgG4‐SC patients (26 with both pancreatitis and cholangitis, and 3 with cholangitis only), 6 PSC patients, and 27 pancreatobiliary carcinoma patients. All patients underwent endoscopic biopsies from Vater's ampulla and the common bile duct. Biopsied specimens were histologically examined using immunostaining for IgG4. Results: For the ampullary and bile duct biopsies, the IgG4‐SC samples had a significantly greater number of IgG4‐positive plasma cells than the PSC or pancreatobiliary carcinoma specimens. In addition, bile duct biopsies from five patients (17%) with IgG4‐SC showed diffuse inflammatory cell infiltration with irregular fibrosis corresponding to the histological features of lymphoplasmacytic sclerosing pancreatocholangitis. Based on the threshold of 10 IgG4‐positive plasma cells per high power field, the diagnostic rates of the ampullar and bile duct biopsies were both 52% (15/29 cases). Twenty‐one patients (72%) had more than 10 IgG4‐positive plasma cells in at least one biopsy. The bile duct biopsy was significantly valuable for IgG4‐SC patients with swelling of the pancreatic head. Conclusion: The present study suggested that ampullar and bile duct biopsies are useful for diagnosing IgG4‐SC.     

Endoscopic therapy for stenosis of the biliary and pancreatic duct orifices

BACKGROUND: Manipulation of the duodenal papilla may lead to symptomatic stenosis of the orifices of bile duct, main pancreatic duct or accessory pancreatic duct. METHODS: Seventeen patients with stenosis of the orifice (bile duct 7, bile duct/main pancreatic duct 7, accessory pancreatic duct 3) underwent sphincterotomy and/or dilation and stent placement for a median of 140 days (range 30 to 1080 days). Patients were interviewed at a median of 720 days (range 120 to 990 days) after removal of the final stent. RESULTS: Median age was 50 years (range 17 to 68 years); 78% were women.The etiology of stenosis of the orifice was sphincterotomy in 8, sphincteroplasty in 7 and papillectomy in 2 patients. Indications for treatment were abdominal pain (100%), dilated bile duct and/or main pancreatic duct (14 patients) and pancreas divisum (3 patients). Sixty procedures (median 4 per patient) were performed with mild morbidity (hospital stay less than 3 days) in 17% of procedures and 35% of patients. Symptoms improved in 100%, 57% and 33% of patients with bile duct, bile duct/main pancreatic duct and accessory pancreatic duct, respectively. Surgery was ultimately needed in 3 (43%) patients with bile duct/main pancreatic duct and 2 (67%) with accessory pancreatic duct stenosis. CONCLUSIONS: Endoscopic therapy successfully relieves pain due to biliary stenosis of the orifice but less frequently relieves pain due to pancreatic stenosis of the orifice.     

Benefits and limitations of middle bile duct segmental resection for extrahepatic cholangiocarcinoma

Background:Pancreaticoduodenectomy(PD)is a standardized strategy for patients with middle and distal bile duct cancers.The aim of this study was to compare clinicopathological features of bile duct segmen-tal resection(BDR)with PD in patients with extrahepatic cholangiocarcinoma.Methods:Consecutive cases with extrahepatic cholangiocarcinoma who underwent BDR(n=21)or PD(n=84)with achievement of R0 or R1 resection in Kobe University Hospital between January 2000 and December 2016 were enrolled in the present study.Results:Patients who underwent PD were significantly younger than those receiving BDR.The frequency of preoperative jaundice,biliary drainage and cholangitis was not significantly different between the two groups.The duration of surgery was longer and there was more intraoperative bleeding in the PD than in the BDR group(553 vs.421 min,and 770 vs.402 mL;both P<0.01).More major complications(>Clavien-DindoⅢa)were observed in the PD group(46%vs.10%,P<0.01).Postoperative hospital stay was also longer in that group(30 vs.19 days,P=0.02).Pathological assessment revealed that tumors were less advanced in the BDR group but the rate of lymph node metastasis was similar in both groups(33%in BDR and 48%in PD,P=0.24).The rate of R0 resection was significantly higher in the PD group(80%vs.38%,P<0.01).Adjuvant chemotherapy was more frequently administered to patients in the BDR group(62%vs.38%,P=0.04).Although 5-year overall survival rates were similar in both groups(44%for BDR and 51%for PD,P=0.72),in patients with T1 and T2,the BDR group tended to have poorer prognosis(44%vs.68%at 5-year,P=0.09).Conclusions:BDR was comparable in prognosis to PD in middle bile duct cancer.Less invasiveness and lower morbidity of BDR justified this technique for selected patients in a poor general condition.     

Lymphatic spread differs according to tumor location in extrahepatic bile duct cancer

BACKGROUND/AIMS: Identification of nodal involvement according to primary tumor location in extrahepatic bile duct carcinoma may guide surgical therapy. METHODOLOGY: Pathologic data of 81 patients who underwent curative operation for bile duct carcinoma were studied to clarify the differences in lymphatic spread from distal bile duct carcinoma, middle bile duct carcinoma, and proximal bile duct carcinoma. RESULTS: Lymph node metastases were present in 25 of 41 patients (61%) with distal bile duct carcinoma, 9 of 19 (47%) with middle bile duct carcinoma, and 11 of 21 (52%) with proximal bile duct carcinoma. The number of positive nodes per node-positive patient was greater in patients with middle bile duct carcinoma than in those with distal- or proximal bile duct carcinoma (mean 5.33 vs. 3.56 or 2.64, p < 0.05). Lymph nodes in the hepatoduodenal ligament were most frequently involved regardless of the primary tumor location. The frequency of distal- and middle bile duct carcinoma patients with metastasis to the superior mesenteric or para-aortic nodes was significantly higher than that of proximal bile duct carcinoma patients (p < 0.05 and p < 0.05). CONCLUSIONS: Patterns of lymphatic spread were different according to primary tumor location in bile duct carcinoma. Metastatic nodes were spread widely, from the hepatoduodenal ligament or posterior pancreaticoduodenal region to the nodes around the superior mesenteric artery and abdominal aorta, in distal- and middle bile duct carcinoma.