Effect of postoperative early enteral nutrition on clinical outcomes and immune function of cholangiocarcinoma patients with malignant obstructive jaundice

BACKGROUNDMost cholangiocarcinoma patients with malignant obstructive jaundice (MOJ) have varying degrees of malnutrition and immunodeficiency preoperatively. Therefore, perioperative nutritional support has important clinical significance in the treatment of cholangiocarcinoma.AIMTo investigate the effects of postoperative early enteral nutrition (EEN) on immunity function and clinical outcomes of cholangiocarcinoma patients with MOJ.METHODSThis prospective clinical study included 60 cholangiocarcinoma patients with MOJ who underwent surgery. The patients were randomly divided into an experimental group and a control group according to the nutrition support modes. The control group received postoperative total parenteral nutrition (TPN), whereas the experimental group received postoperative EEN and parenteral nutrition (PN; EEN + PN). The clinical outcomes, postoperative immune function, incidences of surgical site infection and bile leakage, intestinal function recovery time, average hospitalization days, and hospitalization expenses of the two groups were assessed on postoperative days (PODs) 1, 3, and 7.RESULTSThe CD3+T, CD4+T, CD8+T, and CD4+T/CD8+T cell count and the immunoglobulin (Ig) G, IgM, and IgA levels in the EEN + PN group were significantly higher than those in the TPN group on PODs 3 and 7 (P < 0.05), whereas no significant differences in the CD3+T, CD4+T, CD8+T, and CD4+T/CD8+T cell counts and IgG, IgM, and IgA levels before operation and on POD 1 were found between the two groups (P > 0.05). The intestinal function recovery time and postoperative hospital stay were shorter (P < 0.001 for both) in the EEN + PN group than in the TPN group. The hospitalization expenses of the EEN + PN group were lower than those of the TPN group (P < 0.001). However, the incidence of abdominal distension was higher than in the EEN + PN group than in the TPN group (P < 0.05). The incidence rates of biliary leakage and surgical site infection were not significantly different between the two groups (P > 0.05).CONCLUSIONA postoperative EEN program could reduce the incidence of postoperative complications and improve the clinical outcomes and immune functions of cholangiocarcinoma patients with MOJ and is thus beneficial to patient recovery.     

Low rate of active treatment of patients with hilar cholangiocarcinoma

Introduction

The results of surgical resection and palliative chemotherapy use in hilar cholangiocarcinoma (HC) have been well publicised but the proportion of patients able to undergo these treatments and the comparative outcomes in a population of patients with HC are less well known.

Methods

Patients with HC were identified by review of all patients undergoing percutaneous cholangiography over a nine-year period (2002–2010) in a tertiary facility. The treatment undertaken and outcomes were recorded.

Results

Overall, 68 patients were identified (37 female) with a median age of 70 years. Forty-five (66%) were treated solely by insertion of a metal stent (median survival 4.73 months) and nine (13%) also received palliative chemotherapy (median survival 13.7 months). Persisting jaundice after stent insertion was noted in 18 of 35 patients (51%) tested within one month of death. Fourteen patients (21%) underwent surgical resection (median survival 20.2 months).

Conclusions

Patients undergoing surgical resection had significantly longer survival than those receiving only a palliative stent but not compared with those also receiving palliative chemotherapy, with short-term follow-up. Only a third of patients, however, receive active treatment (surgery or chemotherapy) and improvements in long-term biliary palliation are needed.     

胆管细胞型肝癌临床诊治进展

胆管细胞型肝癌是原发性肝癌的少见类型,笔者结合有关胆管细胞型肝癌最近几年的文献资料进行概述,从胆管细胞癌的概念分型、发病因素、病理生理、临床症状、影像学检查、鉴别诊断、治疗与预后分析,进一步提高胆管细胞型肝癌的早期诊断率及改善其预后。     

Diagnostic and therapeutic direct peroral cholangioscopy using an intraductal anchoring balloon

AIM: To report our experience using a recently introduced anchoring balloon for diagnostic and therapeutic direct peroral cholangioscopy (DPOC).METHODS: Consecutive patients referred for diagnostic or therapeutic peroral cholangioscopy were evaluated in a prospective cohort study. The patients underwent DPOC using an intraductal anchoring balloon, which was recently introduced to allow consistent access to the biliary tree with an ultraslim upper endoscope. The device was later voluntarily withdrawn from the market by the manufacturer.RESULTS: Fourteen patients underwent DPOC using the anchoring balloon. Biliary access with an ultraslim upper endoscope was accomplished in all 14 patients. In 12 (86%) patients, ductal access required sphincteroplasty with a 10-mm dilating balloon. Intraductal placement of the ultraslim upper endoscope allowed satisfactory visualization of the biliary mucosa to the level of the confluence of the right and left hepatic ducts in 13 of 14 patients (93%). Therapeutic interventions by DPOC were successfully completed in all five attempted cases (intraductal biopsy in one and DPOC guided laser lithotripsy in four). Adverse events occurred in a patient on immunosuppressive therapy who developed an intrahepatic biloma at the site of the anchoring balloon. This required hospitalization and antibiotics. Repeat endoscopic retrograde cholangiopancreatography 8 wk after the index procedure showed resolution of the biloma.CONCLUSION: Use of this anchoring balloon allowed consistent access to the biliary tree for performance of diagnostic and therapeutic DPOC distal to the biliary bifurcation.     

保留下腔静脉的离体低温右肝扩大切除治疗不可切除IV型肝门部胆管癌

目的:探讨保留下腔静脉的离体低温肝切除治疗不可切除Ⅳ型肝门部胆管癌的效果.方法:回顾性分析2例Ⅳ型肝门部胆管癌患者临床资料,其中1例行保留下腔静脉的原位低温灌注扩大右肝切除术,另1例采用保留下腔静脉的全离体扩大右肝切除治疗.结果:原位低温灌注扩大右肝切除术历时14h,术中输血3 000 mL,然而,患者术后第1天死于多器官功能衰竭.全离体扩大右肝切除术历时15h,术中输血2 000 mL,热缺血时间20 min,冷缺血时间195 min,术后30d出院,无肝衰和其他重大并发症发生,随访11个月,患者仍然存活且无血管、胆管并发症及肿瘤复发和转移.结论:在有复杂肝切除经验和活体肝移植经验的前体下,保留下腔静脉的离体低温肝切除是安全的,且可能是治疗精选的不可切除Ⅳ型肝门部胆管癌的有效选择.     

肝门部胆管癌的精准外科手术治疗

医学及相关领域学科的持续发展推动着传统外科向以精确决策和精准操作为特征的精准外科转化.最大化清除病灶、最小创伤侵袭和最大程度脏器保护是精准外科的追求目标.由于特殊的解剖学位置和生物学特性,肝门部胆管癌的治疗极具挑战性.为了达到精准外科的要求,术前需对肝门部解剖结构、肿瘤的生物学特征以及肝脏功能储备情况等予以充分了解,同时对于术前预处理、肝切除技术和血管、胆管重建技术应予充分掌握.     

Impact of medical and surgical intervention on survival in patients with cholangiocarcinoma

AIM:To examine surgical and medical outcomes for patients with cholangiocarcinoma using a populationbased cancer registry.METHODS:Using the California Cancer Registry’s Cancer Surveillance Program,patients with intrahepatic cholangiocarcinoma treated in Los Angeles County from 1988 to 2006 were identified and evaluated for clinical and pathologic factors and therapies received(surgery,radiation,and chemotherapy).The surgical cohort was further categorized into three treatment groups:patients who received adjuvant chemotherapy,adjuvant chemoradiation,or underwent surgery alone(no chemotherapy or radiation administered).Survival was assessed by Kaplan-Meier method;and Cox proportional hazard modeling was used in multivariate analysis.RESULTS:Of 825 patients,60.2% received no treatment.Of the remaining 328 patients,18.5% chemotherapy only,7.4% chemoradiation,and 13.8% underwent surgery.More male patients underwent surgical resection(P = 0.004).Surgical patients were younger than the patients receiving chemotherapy or chemoradiation(P < 0.001).Of the surgical cohort(n = 114),60.5% underwent surgery alone while 39.5% underwent surgery plus adjuvant therapy(chemotherapy n = 20;chemoradiation,n = 21)(P < 0.001).Median survival for all patients in the study was 6.6 mo.Median survival was highest for patients who underwent surgery(23 mo),whereas both chemotherapy(9 mo) and chemoradiation(8 mo) alone were each less effective(P < 0.001).By multivariate analysis,extent of disease,receipt of surgery,and administration of chemotherapy(with/without surgery) were independent predictors of overall survival.CONCLUSION:This study demonstrates that surgery is a critical treatment modality.Multimodality treatment has yet to be standardized,but play a role in optimal therapy for cholangiocarcinoma.