The role of extra-hepatic bile duct resection in the surgical management of gallbladder carcinoma. A first meta-analysis

ObjectiveTo systematically evaluate the clinicopathological and prognostic value of extra-hepatic bile duct resection (EHBDR) in the surgical management of patients with gallbladder carcinoma (GBC), especially in non-jaundiced patients.MethodsPubMed, EMBASE and the Cochrane Library were searched up to March 1^st 2021 for comparative studies between bile duct resected and non-resected groups. RevMan5.3 and Stata 13.0 software were used for the statistical analyses.ResultsEHBDR did not correlate with a better overall survival (OS) (P = 0.17) or disease-free survival (P = 0.27). No survival benefit was also observed in patients with T2N1 (P = 0.4), T3N0 (P = 0.14) disease and node-positive patients (P = 0.75), rather, EHBDR was even harmful for patients with T2N0 (P = 0.01) and node-negative disease (P = 0.02). Significantly higher incidences of recurrent disease (P = 0.0007), postoperative complications (P < 0.00001) and positive margins (P = 0.02) were detected in the bile duct-resected group. The duration of postoperative hospital stay between the two groups was comparable (P = 0.58). Selection bias was also detected in our analysis that a significantly higher proportion of advanced lesions with T3-4 or III-IV disease was observed in the bile duct-resected group (P < 0.00001). EHBDR only contributed to a greater lymph yield (P = 0.01).ConclusionEHBDR has no survival advantage for patients with GBC, especially for those with non-jaundiced disease. Considering the unfairness of comparing OS between jaundiced patients receiving EHBDR with non-jaundiced patients without EHBDR, we could only conclude that routine EHBDR in non-jaundiced patients is not recommended and future well-designed studies with more specific subgroup analyses are required for further validation.     

Intermittent Internal Fixation With a Locking Plate to Preserve Epiphyseal Growth Function During Limb-Salvage Surgery in a Child With Osteosarcoma of the Distal Femur: A Case Report

Limb shortening is a problem associated with surgery for osteosarcoma of the lower extremity in adolescents, as the tumors frequently occur near the epiphysis. Herein we report the use of a less invasive stabilization system (LISS) and an intermittent fixation method to preserve the growth function of epiphysis in an 11-year-old patient with an osteosarcoma of the distal femur.The 11-year-old male presented with left knee enlargement and pain for 2 weeks, and magnetic resonance imaging (MRI) and biopsy were consistent with osteosarcoma of the left distal femur. After preoperative chemotherapy, en bloc tumor resection was performed with margins based on MRI findings preserving the epiphyseal growth plate, the tumor cavity was filled with inactivated bone and bone cement, and a LISS was used to stabilize the femur. Aggressive postoperative chemotherapy was given. Approximately 105 weeks after surgery radiography showed that the distal end of the plate had moved superior to the epiphysis along with bone growth. Locking screws were placed in the distal part of the LISS plate to stabilize the re-implanted bone, and external fixation was not needed.The patient was able to walk with the crutches 1 week postoperatively, and bear weight on the extremity 6 weeks postoperatively. At 6 years after surgery, the patient''s height had increased 52 cm, shortening of the affected limb was only 1 cm, and the circumference of the affected limb was 2 cm smaller than that of the contralateral limb. There was no significant discomfort in the affected limb, and there was no gait abnormality. The patient could jump and run, and could participate in sports including basketball and badminton to the same degree as his peers.In summary, the novel method of bone reconstruction and fixation provided good results in a child with an osteosarcoma of the distal femur. This fixation method preserves the osteogenic function of the epiphysis and restored bone integrity simultaneously, and provides good functional recovery.     

Current standards and future perspectives in adjuvant treatment for biliary tract cancers

Biliary tract cancer, including cholangiocarcinoma (CCA) and gallbladder cancer (GBC) are rare tumours with a rising incidence. Prognosis is poor, since most patients are diagnosed with advanced disease. Only ~20% of patients are diagnosed with early-stage disease, suitable for curative surgery. Despite surgery performed with potentially-curative intent, relapse rates are high, with around 60–70% of patients expected to have disease recurrence. Most relapses occur in the form of distant metastases, with a predominance of liver spread. In view of high tumour recurrence, adjuvant strategies have been explored for many years, in the form of radiotherapy, chemo-radiotherapy and chemotherapy. Historically, few randomised trials were available, which included a variety of additional tumours (e.g. pancreatic and ampullary tumours); most evidence relied on phase II and retrospective studies, with no high-quality evidence available to define the real benefit derived from adjuvant strategies.Since 2017, three randomised phase III clinical trials have been reported; all recruited patients with resected biliary tract cancer (CCA and GBC) who were randomised to observation alone, or chemotherapy in the form of gemcitabine (BCAT study; included patients diagnosed with extrahepatic CCA only), gemcitabine and oxaliplatin (PRODIGE-12/ACCORD-18; included patients diagnosed with CCA and GBC) or capecitabine (BILCAP; included patients diagnosed with CCA and GBC). While gemcitabine-based chemotherapy failed to show an impact on patient outcome (relapse-free survival (RFS) or overall survival (OS)), the BILCAP study showed a benefit from adjuvant capecitabine in terms of OS (pre-planned sensitivity analysis in the intention-to-treat population and in the per-protocol analysis), with confirmed benefit in terms of RFS. Based on the BILCAP trial, international guidelines recommend adjuvant capecitabine for a period of six months following potentially curative resection of CCA as the current standard of care for resected CCA and GBC. However, BILCAP failed to show OS benefit in the intention-to-treat (non-sensitivity analysis) population (primary end-point), and this finding, as well as some inconsistencies between studies has been criticised and has led to confusion in the biliary tract cancer medical community.This review summarises the adjuvant field in biliary tract cancer, with evidence before and after 2017, and comparison between the latest randomised phase III studies. Potential explanations are presented for differential findings, and future steps are explored.     

腹腔镜胆囊切除术中意外胆囊癌12例诊治分析

目的:探讨腹腔镜胆囊切除术(LC)中意外胆囊癌(unexpected gallb ladder carc inom a,UGC)的处理措施。方法:回顾分析本院955例LC术中遇到的12例(1.26%)UGC的临床资料。结果:随诊3~36个月,平均18个月。迄今全部存活。5例PT1、5例PT2、1例PT3(中转开腹)随访至今未发现癌复发及转移。1例PT2因拒绝根治术,现出现肝多发转移。1例PT4因腹腔种植转移,无法根治,故仅部分切除胆囊(胆囊粘连重),以解决急性胆囊炎问题,现有腹水、恶液质表现。所有病例均未见脐部戳孔处肿瘤种植转移。结论:LC术中应常规切开胆囊标本,必要时送术中冰冻。PT1单纯切除胆囊已足够;PT2要额外楔形切除肝组织及区域淋巴结;PT3中转开腹,行根治手术或姑息手术。     

MR T2加权成像显示胆囊壁增厚点状高信号的意义

目的研究病理组织学证实的胆囊腺肌瘤病、慢性胆囊炎和管壁增厚型胆囊腺癌在MRL加权成像（T2WI）显示病变胆囊壁点状高信号的特征。方法38例患者（胆囊腺肌瘤病16例，慢性胆囊炎13例，管壁增厚型胆囊腺癌9例），每例均进行了MR常规T1WI、常规T2WI和3mm薄层T2WI及MR胰胆管成像（MRCP）。所有患者均接受了胆囊切除手术。2名高年资放射科医生共同分析不同序列MRI，观察胆囊壁增厚及T2WI显示病变胆囊壁点状高信号的不同表现，将观察结果与病理组织学检查所见对照。结果所有患者的胆囊壁均明显增厚，厚度范围5～15mm，平均9mm。T2WI显示病变胆囊壁存在各种各样的点状高信号，在胆囊腺肌瘤病，点状高信号分布于整个增厚的胆囊壁，且数量较多（5～15个／cm^2），较大（直径2～7mm），边界清楚，呈现中等至明显高信号；在慢性胆囊炎，点状高信号主要位于增厚胆囊壁的黏膜侧，数量较少（3～5个／cm^2），较小（直径2～4mm），边界清楚，呈中等至明显高信号；在管壁增厚型胆囊腺癌，点状高信号边界欠清，呈现稍高信号，其数量和大小差异较大，分布范围取决于癌组织浸润胆囊壁的深度。结论胆囊腺肌瘤病、慢性胆囊炎和管壁增厚型胆囊腺癌在T2WI呈现的点状高信号有一定差别，正确识别这些点状高信号的特征有助于鉴别诊断良恶性胆囊壁增厚。     

经单根冠状动脉与冠状静脉窦同时灌注心肌保护的实验研究

目的探讨经单根冠状动脉和冠状静脉窦（CS）顺行性／逆行性同时心肌灌注（SARC）的效果。方法将离体猪心分别经左前降支（LAD）、左回旋支（LCX）或右冠状动脉（RCA）中的1支和CS行SARC，再依次向动、静脉灌注通路内注入磁共振造影剂[钆喷替酸葡甲胺（Gd-DTPA）]。应用磁共振成像（MRI）检测心肌内造影剂的分布以及对非灌注冠状动脉回流液进行分析，评估心肌灌注效果。结果SARC期间经单根冠状动脉注入Gd-DTPA不但使其支配区域磁共振信号增强，而且其余2根非灌注冠状动脉的支配区域信号也增强（包括右心室游离壁）；而SARC期间经CS注入Gd-DTPA只引起非灌注冠状动脉支配区变亮，灌注冠状动脉的支配区和右心室游离壁的信号强度无改变。SARC期间非灌注冠状动脉收集的回流液速度分别为：LAD 10．5～17．7ml／min，LCX 9．7～15．2ml／min，RCA 4．7～7．8ml／min。结论经单根冠状动脉和CS同时灌注可以提供全面均匀的心肌灌注，足以防止非灌注冠状动脉支配区发生心肌缺血损伤。     

Strain difference in tolerance to low-temperature treatment of fertilized mouse oocytes

Background and Aims:  The aim of this study was to determine which mouse strains exhibit tolerance to cooling when fertilized oocytes have been stored at 4°C.
Methods:  In-vitro -fertilization-derived oocytes of eight mouse strains were incubated at 4°C in 20 mmol/L Hepes-potassium modified simplex optimized medium (KSOM) medium for 0, 24, 48, 60 or 72 h, and then returned to normal culture conditions at 37°C in KSOM medium. The rates of development of cultured oocytes into blastocysts and cell numbers of blastocysts were examined. In some cases, a Comet assay was carried out to evaluate DNA damage. In addition, the effects of β-mercaptoethanol on the development of the 4°C-treated oocytes were assessed.
Results:  Of the eight strains tested, BDF1, B6C3F1 and FVB/N strains exhibited relatively higher degrees of tolerance to 4°C treatment and approximately 90%, 83% and 78% of oocytes treated at 4°C for 48 h developed to morphologically normal blastocysts, respectively. Comet assay revealed no clear DNA damage in oocytes treated at 4°C. Treatment with β-mercaptoethanol failed to improve the in vitro survival rate of low-temperature-treated oocytes.
Conclusion:  Strain differences were observed in tolerance to cooling treatment when fertilized oocytes were temporarily treated with 4°C, although the reasons for this remain unclear. (Reprod Med Biol 2006; 5 : 43–50)