The Impact of Prehabilitation on Patient Outcomes in Hepatobiliary, Colorectal, and Upper Gastrointestinal Cancer Surgery: A PRISMA-Accordant Meta-analysis

OBJECTIVE

To determine the impact of prehabilitation on hospital length of stay, functional capacity, complications, and mortality after surgery in patients with hepatobiliary, colorectal, and upper gastrointestinal cancer.

BACKGROUND

"Prehabilitation" encompasses exercise, nutrition, and psychosocial interventions to optimize health before surgery. The benefits of prehabilitation are ill-defined.

METHODS

Medline, Embase and Cochrane Databases were searched systematically for the terms "prehabilitation AND exercise," "perioperative care AND cancer surgery," and "colorectal AND hepatobiliary AND hepatopancreatobiliary AND esophagogastric AND recovery AND outcomes." Primary outcomes analyzed were hospital length of stay, functional capacity, significant postoperative complications (Clavien Dindo ≥ III), and mortality. A meta-analysis was conducted on the effect of all-modality prehabilitation for patients with colorectal, hepatopancreatobiliary and upper gastrointestinal cancer surgery using the raw mean difference, risk difference, and a random-effects model.

RESULTS

Three hundred and seventy seven original titles were identified. Fifteen studies (randomized controlled trials; n = 9 and uncontrolled trials; n = 6) were included in the meta-analysis. Prehabilitation reduced hospital length of stay by 1.78 days versus standard care (95% CI: -3.36, -0.20, P < 0.05). There was no significant difference in functional capacity with prehabilitation determined using the 6-minute walk test (P = 0.816) and no significant reduction in postoperative complications (P = 0.378) or mortality rates (P = 0.114).

CONCLUSIONS

Prehabilitation was associated with reduced hospital length of stay but had no effect on functional capacity, postoperative complications, or mortality rates. Thus, prehabilitation should be recommended to accelerate recovery from cancer surgery, demonstrated by reduced hospital length of stay.

Clinical application of "Double R" anastomosis technique in laparoscopic pancreaticoduodenectomy procedure

Laparoscopic pancreaticoduodenectomy (LPD) is widely used as a treatment for periampullary tumors and pancreatic head tumors. However, postoperative pancreatic fistula (POPF), which significantly affects mortality and length of hospital stay of patients, remains one of the most common and serious complications following LPD. Though numerous technical modifications for pancreaticojejunostomy (PJ) have been proposed, POPF is still the "Achilles heel" of LPD.To reduce POPF rate and other postoperative complications following LPD by exploring the best approach to manage with the pancreatic remnant, a novel duct-to-mucosa anastomosis technique named Double Layer Running Suture (Double R) for the PJ was established. During 2018 and 2020, a totally 35 patients who underwent LPD with Double R were included, data on the total operative time, PJ duration, estimated blood loss, recovery of bowel function, postoperative complications, and length of hospital stay were collected and analyzed.The average duration of surgery was (380 ± 69) minutes. The mean time for performing PJ was (34 ± 5) minutes. The average estimated blood loss was (180 ± 155) mL. The overall POPF rate was 8.6% (3/35), including 8.6% (3/35) for the biochemical leak, 0% (0/35) for Grade B, and 0% (0/35) for Grade C. No patient suffered from biliary fistula, post-pancreatectomy hemorrhage, and intra-abdominal infection, the 30-day mortality was 0%.Double R anastomosis is potentially a safe, reliable, and rapid anastomosis with a low rate of POPF and post-pancreatectomy hemorrhage. It provides surgeons more options when performing LPD. However, its safety and effectiveness should be verified further by a larger prospective multicenter study.

SEOM clinical guidelines for pancreatic and biliary tract cancer (2020)

Pancreatic cancer (PC) and biliary tract cancer (BTC) are both aggressive and highly fatal malignancies. Nowadays we have a profound knowledge about the molecular landscape of these neoplasms and this has allowed new therapeutic options. Surgery is the only potentially curative therapy in both cancers, but disease recurrence is frequent. In PC, adjuvant treatment with mFOLFIRINOX has improved overall survival (OS) and in BTC adjuvant treatment with capecitabine seems to improve OS and relapse-free survival. Concomitant radio-chemotherapy could also be considered following R1 surgery in both neoplasms. Neoadjuvant treatment represents the best option for achieving an R0 resection in borderline PC. Upfront systemic chemotherapy is the treatment of choice in unresectable locally advanced PC and BTC; then locoregional therapy could be considered after an initial period of at least 3-4 months of systemic chemotherapy. In metastatic PC, FOLFIRINOX or Gemcitabine plus nab-paclitaxel have improved OS compared with gemcitabine alone. In metastatic BTC, cisplatin plus gemcitabine constitute the standard treatment. Progress in the knowledge of molecular biology has enabled the identification of new targets for therapy with encouraging results that could in the future improve the survival and quality of life of patients with PC and BTC.

Stent insertion with high-intensity focused ultrasound ablation for malignant biliary obstruction: A protocol of systematic review and meta-analysis

BACKGROUND

This meta-analysis was conducted in order to understand the clinical efficacy of stent insertion with high-intensity focused ultrasound (HIFU) ablation for the treatment of malignant biliary obstruction (MBO).

METHODS

The Pubmed, Embase, and Cochrane Library databases were searched for all relevant studies published through July 2020. The meta-analysis was conducted using RevMan v5.3, with analyzed study endpoints including the rate of stent dysfunction, time to stent dysfunction, stent patency, complication rate, and overall survival (OS).

RESULTS

In total, 35 potentially relevant studies were initially identified, of which 6 were ultimately included in the present meta-analysis. These 6 studies included 429 MBO patients that were treated either only via stenting (n = 221) or via stenting in combination with HIFU ablation (n = 208). Pooled stent dysfunction rates in the stent and stent with HIFU groups were 25.9% and 18.0%, respectively (OR: 1.59; 95% CI: 0.88, 2.84, P = .12). The average time to stent dysfunction was significantly longer in the stent with HIFU group relative to the stent group (MD: -3.15; 95% CI: -3.53, -2.77, P < .0001). Pooled complication rates in the stent and stent with HIFU groups were 17.1% and 19.6%, respectively (OR: 0.88; 95% CI: 0.49, 1.58, P = .67). Stent patency and OS were both significantly longer in the stent with HIFU group relative to the stent group (P < .0001 and.0001, respectively). Funnel plot analyses did not reveal any significant evidence of publication bias linked to the selected study endpoints.

CONCLUSIONS

This meta-analysis found that a combined stenting and HIFU ablation approach can achieve better stent patency and OS in MBO patients relative to stent insertion alone.

Hospital Surgical Volume and 3-Year Mortality in Severe Prognosis Cancers: A Population-Based Study Using Cancer Registry Data

BACKGROUND

The impact of hospital surgical volume on long-term mortality has not been well assessed in Japan, especially for esophageal, biliary tract, and pancreatic cancer, although these three cancers need a high level of medical-technical skill. The purpose of this study was to examine associations between hospital surgical volume and 3-year mortality for these severe-prognosis cancer patients.

METHODS

Patients who received curative surgery for esophageal, biliary tract, and pancreatic cancers were analyzed using the Osaka Cancer Registry data from 2006-2013. Hospital surgical volume was categorized into tertiles (high/middle/low) according to the average annual number of curative surgeries per hospital for each cancer. Three-year survivals were calculated using the Kaplan-Meier method. Hazard ratios (HRs) of 3-year mortality were calculated using Cox proportional hazard models, adjusting for patient characteristics.

RESULTS

Three-year survival was higher with increased hospital surgical volume for all three cancers, but the relative importance of volume varied across sites. After adjustment for all confounding factors, HRs in middle- and low-volume hospitals were 1.34 (95% confidence interval [CI], 1.14-1.58) and 1.57 (95% CI, 1.33-1.86) for esophageal cancer; 1.39 (95% CI, 1.15-1.67) and 1.57 (95% CI, 1.30-1.89) for biliary tract cancer; 1.38 (95% CI, 1.16-1.63) and 1.90 (95% CI, 1.60-2.25) for pancreatic cancer, respectively. In particular for localized pancreatic cancer, the impact of hospital surgical volume on 3-year mortality was strong (HR 2.66; 95% CI, 1.61-4.38).

CONCLUSION

We suggest that patients who require curative surgery for esophageal, biliary tract, and pancreatic cancer may benefit from referral to high-volume hospitals.

HER2 Overexpression as a Poor Prognostic Determinant in Resected Biliary Tract Cancer

BACKGROUND

HER2 overexpression has been investigated as a potential biomarker and therapeutic target in biliary tract cancer (BTC), but a prognostic role of such alteration has not been demonstrated yet.

MATERIALS AND METHODS

We retrospectively evaluated HER2 protein expression by immunohistochemistry (IHC) in 100 patients with radically resected BTC. HER2 gene amplification was assessed by fluorescence in situ hybridization (FISH) in 2+ and 3+ cases at IHC. High HER2 protein expression was defined as either IHC 3+ or 2+ associated with FISH positivity. The primary objective of the study was to evaluate the prognostic role of HER2 overexpression in terms of disease-free survival (DFS) and overall survival (OS). Secondary endpoints were the prevalence of HER2 overexpression and the possible correlation with other clinicopathological features.

RESULTS

HER2 overexpression was identified in 11 patients and was not related to other clinicopathological factors. DFS was significantly shorter in HER2-positive compared with HER2-negative patients (10.6 vs. 20.9 months, log-rank p = .017). HER2 confirmed its prognostic value for DFS at multivariate analysis (hazard ratio 2.512; 95% confidence interval, 1.232-5.125; p = .011) together with nodal stage (p < .001), resection margin (p = .027), and tumor site (p = .030). There was no difference in OS between HER2-positive and -negative patients (p = .068).

CONCLUSION

HER2 overexpression represents an independent prognostic factor for disease recurrence in patients with BTC treated with potentially curative surgery.

IMPLICATIONS FOR PRACTICE

HER2 overexpression may play an independent role in promoting an aggressive behavior in resectable biliary tract cancer. This evidence could be helpful in improving prognostic stratification after resection and, primarily, should endorse the rationale to investigate HER2 as a therapeutic target in biliary tract cancer.

Needle Catheter Jejunostomy in Patients Undergoing Surgery for Upper Gastrointestinal and Pancreato-Biliary Cancer-Impact on Nutritional and Clinical Outcome in the Early and Late Postoperative Period

The metabolic risk for patients undergoing abdominal cancer resection increases in the perioperative period and malnutrition may be observed. In order to prevent further weight loss, the guidelines recommend for high-risk patients the placement of a needle catheter jejunostomy (NCJ) for supplementing enteral feeding in the early and late postoperative period. Our aim was to evaluate the safety of NCJ placement and its potential benefits regarding the nutritional status in the postoperative course. We retrospectively analyzed patients undergoing surgery for upper gastrointestinal cancer, such as esophageal, gastric, and pancreato-biliary cancer, and NCJ placement during the operation. The nutritional parameters body mass index (BMI), perioperative weight loss, phase angle measured by bioelectrical impedance analysis (BIA) and the clinical outcome were assessed perioperatively and during follow-up visits 1 to 3 months and 4 to 6 months after surgery. In 102 patients a NCJ was placed between January 2006 and December 2016. Follow-up visits 1 to 3 months and 4 to 6 months after surgery were performed in 90 patients and 88 patients, respectively. No severe complications were seen after the NCJ placement. The supplementing enteral nutrition via NCJ did not improve the nutritional status of the patients postoperatively. There was a significant postoperative decline of weight and phase angle, especially in the first to third month after surgery, which could be stabilized until 4-6 months after surgery. Placement of NCJ is safe. In patients with upper gastrointestinal and pancreato-biliary cancer, supplementing enteral nutrition during the postoperative course and continued after discharge may attenuate unavoidable weight loss and a reduction of body cell mass within the first six months.

Delivery of hepato-pancreato-biliary surgery during the COVID-19 pandemic: an European-African Hepato-Pancreato-Biliary Association (E-AHPBA) cross-sectional survey

BACKGROUND

The extent of the COVID-19 pandemic and the resulting response has varied globally. The European and African Hepato-Pancreato-Biliary Association (E-AHPBA), the premier representative body for practicing HPB surgeons in Europe and Africa, conducted this survey to assess the impact of COVID-19 on HPB surgery.

METHODS

An online survey was disseminated to all E-AHPBA members to assess the effects of the pandemic on unit capacity, management of HPB cancers, use of COVID-19 screening and other aspects of service delivery.

RESULTS

Overall, 145 (25%) members responded. Most units, particularly in COVID-high countries (>100,000 cases) reported insufficient critical care capacity and reduced HPB operating sessions compared to COVID-low countries. Delayed access to cancer surgery necessitated alternatives including increased neoadjuvant chemotherapy for pancreatic cancer and colorectal liver metastases, and locoregional treatments for hepatocellular carcinoma. Other aspects of service delivery including COVID-19 screening and personal protective equipment varied between units and countries.

CONCLUSION

This study demonstrates that the COVID-19 pandemic has had a profound adverse impact on the delivery of HPB cancer care across the continents of Europe and Africa. The findings illustrate the need for safe resumption of cancer surgery in a "new" normal world with screening of patients and staff for COVID-19.

Neuroendocrine Tumors of the Pancreatobiliary and Gastrointestinal Tracts

Incidence of neuroendocrine tumors (NETs) is increasing, including those of the gastroenteropancreatic tract. A proper understanding of the management of this disease has become necessary for the general surgeon. This article addresses current guidelines for diagnosis and localization of NETs, including somatostatin receptor PET. Updated treatment and outcomes of NETs by primary tumor site are discussed as well as those metastatic to the liver.

A systematic review and network meta-analysis of adjuvant therapy for curatively resected biliary tract cancers

Background

Recent randomized controlled trials (rcts) have contributed high-quality data about adjuvant therapy in curatively resected biliary tract cancer (btc); however, a standard approach to treating those patients still has not been developed.

Methods

We conducted a systematic review of published studies and abstracts up to and including June 2018, choosing rcts involving patients with btc receiving adjuvant chemotherapy after complete surgical resection. Network meta-analysis methods were used for indirect comparisons of overall survival (os) and relapse-free survival (rfs) for various adjuvant therapies.

Results

Five rcts were included in qualitative synthesis, and three rcts (bilcap, prodige 12-accord 18, and bcat) had data sufficient for inclusion in the meta-analysis. Results from the indirect comparison demonstrated no significant improvement in os for capecitabine compared with gemcitabine or with gemcitabine-oxaliplatin (gemox), the hazard ratios (hrs) being 0.82 [95% confidence interval (ci): 0.53 to 1.27] and 0.86 (95% ci: 0.56 to 1.34) respectively. Similarly, no significant improvement in rfs was observed for capecitabine compared with gemcitabine or gemox.

Conclusions

Although in the present analysis, we found no statistically significant improvements in os or rfs for capecitabine compared with gemox or gemcitabine, capecitabine can-until further prospective trials are completed-be considered the standard of care in the adjuvant setting based on a single randomized phase iii study.

[Analysis of Surgical Resection for Elderly Patients with Biliary Tract Cancer]

Although surgical resection is the first-line treatment for biliary tract cancer(BTC), elderly patients often have underlying diseases and decreased cardiopulmonary function that place them at a high risk of undergoing surgery. We examined the safety and efficacy of surgical resection in elderly BTC patients. Among the BTC cases that underwent surgical resection at Kobe University Hospital from 2009 to 2015, the safety and prognosis ofthose aged 75 years or older(Group 1)were compared to those younger than 75 years(Group 2)at the time ofsurgery. Fifty-two patients with perihilar cholangiocarcinoma( Bp), 29 patients with intrahepatic cholangiocarcinoma(ICC), and 40 patients with ampulla ofVater cancer(AV) were included. There was no significant difference between the 2 groups with respect to complications of Grade Ⅲor above, while surgery-related death was more common in Bp and ICC ofGroup 1. The median survival ofGroup 1 following hepatectomy for Bp and ICC(22 months)was significantly shorter than that of Group 2(40 months)(p=0.023). There was no significant difference in overall survival of Group 1 and Group 2 patients with AV(p=0.094). Surgical resection for BP and ICC for elderly patients has a higher risk of hepatectomy; therefore, precise assessment of oncologic and patient risk factors should be performed. As we can expect to achieve similar prognoses between non-elderly and elderly patients with AV, aggressive treatments should be considered for elderly patients with AV.

Apparent diffusion coefficient-based histogram analysis differentiates histological subtypes of periampullary adenocarcinoma

BACKGROUND

For periampullary adenocarcinoma, the histological subtype is a better prognostic predictor than the site of tumor origin. Intestinal-type periampullary adenocarcinoma (IPAC) is reported to have a better prognosis than the pan-creatobiliary-type periampullary adenocarcinoma (PPAC). However, the classification of histological subtypes is difficult to determine before surgery. Apparent diffusion coefficient (ADC) histogram analysis is a noninvasive, non-enhanced method with high reproducibility that could help differentiate the two subtypes.

AIM

To investigate whether volumetric ADC histogram analysis is helpful for distinguishing IPAC from PPAC.

METHODS

Between January 2015 and October 2018, 476 consecutive patients who were suspected of having a periampullary tumor and underwent magnetic resonance imaging (MRI) were reviewed in this retrospective study. Only patients who underwent MRI at 3.0 T with different diffusion-weighted images (b-values = 800 and 1000 s/mm²) and who were confirmed with a periampullary adenocarcinoma were further analyzed. Then, the mean, 5th, 10th, 25th, 50th, 75th, 90th, and 95th percentiles of ADC values and ADC_min, ADC_max, kurtosis, skewness, and entropy were obtained from the volumetric histogram analysis. Comparisons were made by an independent Student's t-test or Mann-Whitney U test. Multiple-class receiver operating characteristic curve analysis was performed to determine and compare the diagnostic value of each significant parameter.

RESULTS

In total, 40 patients with histopathologically confirmed IPAC (n = 17) or PPAC (n = 23) were enrolled. The mean, 5th, 25th, 50th, 75th, 90th, and 95th percentiles and ADC_max derived from ADC₁₀₀₀ were significantly lower in the PPAC group than in the IPAC group (P < 0.05). However, values derived from ADC₈₀₀ showed no significant difference between the two groups. The 75th percentile of ADC₁₀₀₀ values achieved the highest area under the curve (AUC) for differentiating IPAC from PPAC (AUC = 0.781; sensitivity, 91%; specificity, 59%; cut-off value, 1.50 × 10^-3 mm²/s).

CONCLUSION

Volumetric ADC histogram analysis at a b-value of 1000 s/mm² might be helpful for differentiating the histological subtypes of periampullary adenocarcinoma before surgery.

Effectiveness of omega-3 fatty acid administration on completion rate of adjuvant chemotherapy for biliary tract cancer: study protocol for a single-centre, open-label, single-arm, historically controlled study

INTRODUCTION

Multimodal treatment prolongs the survival of patients with biliary tract cancer (BTC). However, the chemotherapy choices for this disease are few, and completing each chemotherapy session is important. Adjuvant chemotherapy has been attempted for BTC, but has only had a 75% completion rate. Body weight loss and cholangitis are reasons for the interruption of chemotherapy. Previous reports suggested that nutritional intervention with omega-3 fatty acids maintained body weight and improved the completion rate for chemotherapy. Moreover, omega-3 fatty acids have an anti-inflammatory effect. Therefore, we theorised that omega-3 fatty acids would improve the completion rate of adjuvant chemotherapy in patients with BTC. The aim of this study is thus to evaluate the effectiveness of omega-3 fatty acids for patients planning adjuvant chemotherapy for BTC.

METHOD AND ANALYSIS

This study is a single-centre, open-label, single-arm, historically controlled study with a planned enrolment of 55 participants. Protocol treatment consists of four courses of S-1 adjuvant chemotherapy and an oral omega-3 fatty acid pharmaceutic adjuvant (LOTRIGA 2 g (Takeda Pharmaceutical Co.)), which includes 2 g of omega-3 fatty acids from day 1 until day 168 of the treatment period. The primary endpoint is the completion rate of four total courses of S-1. Secondary endpoints are postoperative cholangitis, time to recurrence or distant metastasis, changes in nutritional index, changes in the lymphocyte blast transformation test induced by phytohaemagglutinin, and concanavalin A and diamine oxidase serum activity during adjuvant chemotherapy. All adverse events will be evaluated.

ETHICS AND DISSEMINATION

This protocol was approved by the Institutional Review Board of Kobe University Hospital. The findings from this study will be presented at national and international conferences and published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

UMIN000031247.

Case Report: Intraductal Papillary Mucinous Neoplasms of the Biliary Tract

The present case report describes intraductal papillary mucinous neoplasms of the biliary tract (IPMN-BT), a rare neoplasm of the biliary tract that is described as the biliary counterpart of intraductal papillary mucinous neoplasms of the pancreas (IPMN-P). The importance of appropriate diagnosis and awareness of the clinical manifestations is highlighted. IPMN-BT has a more favorable prognosis and is easier to resect than other forms of intrahepatic cholangiocarcinomas; therefore, early and accurate diagnosis is required for planning of the best treatment strategies for this neoplasm.

[A Case of Laparoscopic Whole Layer Cholecystectomy for Elevated Lesion Suspected Biliary Cancer]

A case of attempted laparoscopic cholecystectomy for elevated lesion which was clearly early biliary cancer. Laparoscopic cholecystectomy has become popular as a minimally invasive surgical method, and is the primary choice for benign diseases. However for cases of suspected biliary cancer, open cholecystectomy, rather than laparoscopic, is recommended according to medical guidelines. The reason for this is that in cases of damage to the gallbladder, bile spillage to the abdominal cavity may occur, leading to port site recurrence and peritoneal recurrence. In addition, for invasion depth exceeding ss, or in cases of RAS cancer, the cancer may become exposed on the resected surface and remain. Hypothetically though, if the gallbladder is resected by total layer resection, RAS cancer can be removed. At this time, we performed a laparoscopic whole layer cholecystectomy for elevated lesion. We would like to report this case along with some bibliographic considerations.

Pancreas-preserving management of grade-C pancreatic fistula and a novel bridging technique for repeat pancreaticojejunostomy: An observational study

PURPOSE

Optimal surgical strategy for grade-C postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD) is not justified. External wirsungostomy is feasible. However, the subsequent repeat pancreaticojejunostomy (PJ) is challenging. This study aims to introduce our experience of external wirsungostomy for grade-C POPF and a novel technique to do the repeat PJ (re-PJ).

MATERIALS AND METHODS

From January 1, 2012 to December 31, 2016, all consecutive patients who underwent pancreaticoduodenectomy (PD) with PJ were identified. The clinical data were retrospectively collected and analyzed.

RESULTS

Out of 325 patients, 11 patients (3.38%) underwent salvage re-laparotomy for grade-C POPF. External wirsungostomy was performed in 10 patients (3.08%). Four patients died of severe complications within 90 days postoperatively or tumor progression before the scheduled re-PJ was performed. Three patients got their external pancreatic drainage tube pulled out accidentally without causing severe consequences. Three patients underwent planned re-PJ after external wirsungostomy, including one with duct-to-mucosa PJ and two with the novel bridging technique. The operative times of the two patients undergoing the novel bridging technique were 120 min, 135 min, respectively, and the length of post-operative hospital stay (LPHS) were 7 d, 5 d, respectively. The operative time and the LPHS of whom underwent duct-to-mucosa PJ were 315 min, 24 d, respectively. There was no major post-operative complication.

CONCLUSION

External wirsungostomy may be a safe way to preserve the pancreas remnant in grade-C POPF patients. The novel bridging technique may be a simpler alternative to traditional PJ.

[Clinical, epidemiological and therapeutic features of biliary tract cancers: about 20 cases]

Biliary tract cancers mainly occur in two sites: gallbladder cancer which are adenocarcinomas and intra- and extrahepatic cholangiocarcinomas. We conducted a retrospective study of 20 cases with biliary tract cancer in the Department of Surgery at the General Hospital in Grand-Yoff between January 2006 and October 2014. 40% of patients had gallbladder cancer, 60% of patients had common bile duct cancer. Sex ratio was 1. The average age of patients was 58.1 years. The average time to diagnosis was 3.77 months. Symptomatology was dominated by icteric syndrome and right hypochondrium pain. All patients had biological manifestation of cholestatic syndrome. Abdominal ultrasound was performed in 65% of patients, while abdominal CT scan in 85% of cases and MRI in 35% of cases. Advanced cancers were predominant in our case series (n=19). The majority of patients underwent palliative surgery. The most practiced treatment was biliary diversion (50% of patients). There was a predominance of cholangiocarcinomas. The overall operative morbidity rate was 43.75%. The overall mortality rate in our patients with biliary tract cancers of any site was 31.25%. Median survival was 4 months and a half. Biliary tract cancers have multifaceted features and can be differentiated essentially among intrahepatic cholangiocarcinoma, extrahepatic cholangiocarcinoma, gallbladder adenocarcinoma whose evolution is globally different but the prognosis is spontaneously poor.

Characterisation of the immune-related transcriptome in resected biliary tract cancers

Although biliary tract cancers (BTCs) are known to have an inflammatory component, a detailed characterisation of immune-related transcripts has never been performed. In these studies, nCounter PanCancer Immune Profiling Panel was used to assess the expression of 770 immune-related transcripts in the tumour tissues (TTs) and matched adjacent tissues (ATs) of resected BTCs. Cox regression analysis and Kaplan-Meier methods were used to correlate findings with relapse-free survival (RFS). The first analysis in the TT and AT of an exploratory set (n = 22) showed deregulation of 39 transcripts associated with T-cell activation. Risk of recurrence was associated with a greater number of genes deregulated in AT in comparison to TT. Analysis in the whole set (n = 53) showed a correlation between AT cytotoxic T-lymphocyte antigen-4 (CTLA4) expression and RFS, which maintained statistical significance at multivariate analysis. CTLA4 expression correlated with forkhead box P3 (FOXP3) expression, suggesting enrichment in T regulatory cells. CTLA4 is known to act by binding to the cluster of differentiation 80 (CD80). No association was seen between AT CD80 expression and RFS. However, CD80 expression differentiated prognosis in patients who received adjuvant chemotherapy. We showed that the immunomodulatory transcriptome is deregulated in resected BTCs. Our study includes a small number of patients and does not enable to draw definitive conclusions; however, it provides useful insights into potential transcripts that may deserve further investigation in larger cohorts of patients.

TRANSCRIPT PROFILING

Nanostring data have been submitted to GEO repository: GSE90698 and GSE90699.

The role of the irreversible electroporation in the hepato-pancreatico-biliary surgery

Irreversible electroporation is a novel technique growing in popularity over the last years among the ablative modalities. Its unique action mechanism produces irreversible nanopores in the membrane of the cell leading to apoptosis; therefore irreversible electroporation can be used to ablate substantial volumes of tissue without the undesirable thermal effects as the "heat sink effect". Moreover the extracellular matrix is left unperturbed, thus sparing the structural architecture of surrounding structures such as bile ducts and blood vessels. In the last years its use has been widespread in both liver and pancreatic ablation. Irreversible electroporation has shown its safety with however some caution, feasibility and favorable outcomes in clinical settings such as unresectable locally advanced disease in which the surgical and therapeutic options are very limited.

Over 700 Whipples for Pancreaticobiliary Malignancies: Postoperative Morbidity Is an Additional Negative Prognostic Factor for Distal Bile Duct Cancer

BACKGROUND

Distal cholangiocarcinomas and pancreatic cancers both arise from pancreaticobiliary epithelium. Despite their common origin, there is a possible discrepancy in outcome. We analysed the surgical, pathological and survival outcome of resected distal cholangiocarcinoma compared with pancreatic cancer.

METHODS

All cases of resected distal cholangiocarcinoma and pancreatic cancer from 1998 to 2014 were extracted from our database. Outcomes were compared.

RESULTS

There were 54 (7.6%) cases of cholangiocarcinoma and 656 (92.4%) pancreatic cancer. Cholangiocarcinoma showed lower T and N stage, lymphatic and perineural invasion (p < 0.05), worse surgical outcome (p < 0.05) and less access to adjuvant therapy if compared with pancreatic cancer (72.7 vs. 83.1%, p = 0.05). Both showed a similar disease-specific survival (35 vs. 29 months, p = 0.3). Independent predictors of prognosis for pancreatic cancer were resection margin, grading, perineural invasion, T and N status, whereas for cholangiocarcinoma were grading and occurrence of POPF.

CONCLUSION

Considering a large cohort of resected periampullary cancers, cholangiocarcinoma is extremely rare. An earlier diagnosis is associated with better pathological predictors of outcome but increased postoperative morbidity compared to pancreatic cancer, particularly POPF. Consequent decrease in the access to adjuvant therapy for complicated cholangiocarcinoma might explain why survival is as poor as for pancreatic cancer.

DNA Methylation of PITX2 and PANCR Is Prognostic for Overall Survival in Patients with Resected Adenocarcinomas of the Biliary Tract

Biliary tract cancers (BTC) are rare but highly aggressive malignant epithelial tumors. In order to improve the outcome in this lethal disease, novel biomarkers for diagnosis, prognosis, and therapy response prediction are urgently needed. DNA promoter methylation of PITX2 variants (PITX2ab, PITX2c) and intragenic methylation of the PITX2 adjacent non-coding RNA (PANCR) were investigated by methylations-specific qPCR assays in formalin-fixed paraffin-embedded tissue from 80 patients after resection for BTC. Results were correlated with clinicopathologic data and outcome. PITX2 variants and PANCR showed significant hypermethylation in tumor vs. normal adjacent tissue (p < 0.001 and p = 0.015), respectively. In survival analysis, dichotomized DNA methylation of variant PITX2c and PANCR were significantly associated with overall survival (OS). Patients with high tumor methylation levels of PITX2c had a shorter OS compared to patients with low methylation (12 vs. 40 months OS; HR 2.48 [1.38-4.48], p = 0.002). In contrast, PANCR hypermethylation was associated with prolonged survival (25 vs. 19 months OS; HR 0.54 [0.30-0.94], p = 0.015) and qualified as an independent prognostic factor on multivariate analysis. The biomarkers investigated in this study may help to identify BTC subpopulations at risk for worse survival. Further studies are needed to evaluate if PITX2 might be a clinically useful biomarker for an optimized and individualized treatment.

Preoperative 6-minute walk distance accurately predicts postoperative complications after operations for hepato-pancreato-biliary cancer

BACKGROUND

Operation for hepato-pancreato-biliary cancer is among the most invasive open abdominal operations, with a high postoperative morbidity and mortality rate. The purpose of the present study is to investigate whether a preoperative 6-minute walk distance can predict major postoperative complications after operation for hepato-pancreato-biliary diseases.

METHODS

A total of 81 participants who underwent pancreaticoduodenectomy, major hepatectomy with extrahepatic bile duct resection, or hepatopancreatoduodenectomy were included. The 6-minute walk distance was performed within 1 week before operation. Patients were categorized into 2 groups based on surgical complications: Clavien-Dindo grade <3 and Clavien-Dindo grade ≥3. Clinical differences between the 2 groups were analyzed. Multivariate logistic regression analysis was performed to identify risk factors for postoperative complications that were categorized as Clavien-Dindo grade ≥3.

RESULTS

The multiple logistic regression model revealed a significant correlation between major postoperative complications and preoperative low 6-minute walk distance, low body mass index, and major blood loss. In patients with 6-minute walk distance <400 m (1,312 feet), the Clavien-Dindo grade was considerably greater than patients with ≥400 m.

CONCLUSION

The 6-minute walk distance is useful in identifying patients with a greater chance of developing major postoperative complications after surgery for hepato-pancreato-biliary cancer.

Schwannoma of the biliary tract resembling cholangiocarcinoma: A case report and review

Schwannomas are benign tumours derived from Schwann cells and are extremely rare in the biliary tract. We present the case of a 62-year-old patient with a common bile duct schwannoma that resembled a cholangiocarcinoma. We also review all 17 previously published cases of schwannoma of the biliary tract and discuss the challenges of preoperative diagnosis.

Efficacy of preoperative biliary drainage in malignant obstructive jaundice: a meta-analysis and systematic review

BACKGROUND

In patients requiring surgical resection for malignant biliary jaundice, it is unclear if preoperative biliary drainage (PBD) would improve mortality and morbidity by restoration of biliary flow prior to operation. This is a meta-analysis to pool the evidence and assess the utility of PBD in patients with malignant obstructive jaundice. The primary outcome is comparing mortality outcomes in patients with malignant obstructive jaundice undergoing direct surgery (DS) versus PBD. The secondary outcomes include major adverse events and length of hospital stay in both the groups.

METHODS

Studies using PBD in patients with malignant obstructive jaundice were included in this study. For the data collection and extraction, articles were searched in MEDLINE, PubMed, Embase, Cochrane Central Register of Controlled Trials & Database of Systematic Reviews, etc. Pooled proportions were calculated using both Mantel-Haenszel method (fixed effects model) and DerSimonian-Laird method (random effects model).

RESULTS

Initial search identified 2230 reference articles, of which 204 were selected and reviewed. Twenty-six studies (N = 3532) for PBD in malignant obstructive jaundice which met the inclusion criteria were included in this analysis. The odds ratio for mortality in PBD group versus DS group was 0.96 (95 % CI = 0.71 to 1.29). Pooled number of major adverse effects was lower in the PBD group at 10.40 (95 % CI = 9.96 to 10.83) compared to 15.56 (95 % CI = 15.06 to 16.05) in the DS group. Subgroup analysis comparing internal PBD to DS group showed lower odds for major adverse events (odds ratio, 0.48 with 95 % CI = 0.32 to 0.74).

CONCLUSIONS

In patients with malignant biliary jaundice requiring surgery, PBD group had significantly less major adverse effects than DS group. Length of hospital stay and mortality rate were comparable in both the groups.

Assessment of Surgical Outcome After Pancreatic Resection in Extremely Elderly Patients

BACKGROUND/AIM

Pancreatic resection is the only curative treatment for pancreatic and certain biliary malignancies. However, the mortality and morbidity associated with pancreatic resection remain high.

PATIENTS AND METHODS

The study included 114 patients with age 70 years or older who underwent pancreatic resection for pancreatic or biliary cancer between 2005 and 2014 at the Jikei University Hospital. We analyzed surgical outcomes, complications, mortality and long-term survival between patients aged 70-79 years (n=97) and those aged 80 years or over (n=17).

RESULTS

In patients aged 70 to 79 years, two died in-hospital and 8 required reoperation or interventional radiology (IVR). In patients aged 80 years or over, on the other hand, there was no in-hospital mortality. The incidence of complications and long-term survival were comparable.

CONCLUSION

Pancreatic resection for pancreatic and biliary malignancies in patients aged 80 years or over with good general condition and proper selection seems safe and acceptable.

Contrast-enhanced harmonic endoscopic ultrasonography for assessment of lymph node metastases in pancreatobiliary carcinoma

AIM: To assess the usefulness of contrast-enhanced harmonic endoscopic ultrasonography (CH-EUS) for lymph node metastasis in pancreatobiliary carcinoma.

METHODS: All patients suspected of pancreatobiliary carcinoma with visible lymph nodes after standard EUS between June, 2009 and January, 2012 were enrolled. In the primary analysis, patients with successful EUS-fine needle aspiration (FNA) were included. The lymph nodes were assessed by several standard EUS variables (short and long axis lengths, shape, edge characteristic and echogenicity), color Doppler EUS variable [central intranodal blood vessel (CIV) presence] and CH-EUS variable (heterogeneous/homogeneous enhancement patterns). The diagnostic accuracy relative to EUS-FNA was calculated. In the second analysis, N-stage diagnostic accuracy of CH-EUS was compared with EUS-FNA in patients who underwent surgical resection.

RESULTS: One hundred and nine patients (143 lymph nodes) fulfilled the criteria. The short axis cut-off ≥ 13 mm predicted malignancy with a sensitivity and specificity of 72% and 85%, respectively. These values were 72% and 63% for the long axis cut-off ≥ 20 mm, 62% and 75% for the round shape variable, 81% and 30% for the sharp edge variable, 66% and 61% for the hypoechogenicity variable, 70% and 72% for the CIV-absent variable, and 83% and 91% for the heterogeneous CH-EUS-enhancement variable, respectively. CH-EUS was more accurate than standard and color Doppler EUS, except the short axis cut-off. Notably, three patients excluded because of EUS-FNA failure were correctly N-staged by CH-EUS.

CONCLUSION: CH-EUS complements standard and color Doppler EUS and EUS-FNA for assessment of lymph node metastases.

A phase II study of capecitabine and oxaliplatin combination chemotherapy in patients with inoperable adenocarcinoma of the gall bladder or biliary tract

BACKGROUND

Advanced biliary tract carcinomas are associated with a poor prognosis, and palliative chemotherapy has only modest benefit. This multi-centre phase II study was conducted to determine the efficacy of capecitabine in combination with oxaliplatin in patients with inoperable gall bladder or biliary tract cancer.

METHODS

This was a Phase II, non-randomised, two-stage Simon design, multi-centre study. Ethics approval was sought and obtained by the North West MREC, and then locally by the West Glasgow Hospitals Research Ethics Committee. Eligible patients with inoperable locally advanced or metastatic adenocarcinoma of the gall bladder or biliary tract and with adequate performance status, haematologic, renal, and hepatic function were treated with capecitabine (1000 mg/m(2) po, twice daily, days 1-14) and oxaliplatin (130 mg/m(2) i.v., day 1) every 3 weeks for up to six cycles. The primary objective of the study was to determine the objective tumour response rates (complete and partial). The secondary objectives included assessment of toxicity, progression-free survival, and overall survival.

RESULTS

Forty-three patients were recruited between July 2003 and December 2005. The regimen was well tolerated with no grade 3/4 neutropenia or thrombocytopenia. Grade 3/4 sensory neuropathy was observed in six patients. Two-thirds of patients received their chemotherapy without any dose delays. Overall response rate was 23.8% (95% CI 12.05-39.5%). Stable disease was observed in a further 13 patients (31%) and progressive disease observed in 12 (28.6%) of patients. The median progression-free survival was 4.6 months (95% CI 2.8-6.4 months; Fig. 1) and the median overall survival 7.9 months (95% CI 5.3-10.4 months; Fig. 2). Fig. 1 Progression-free survival Fig. 2 Overall survival

CONCLUSION

Capecitabine combined with oxaliplatin has a lower disease control and shorter overall survival than the combination of cisplatin with gemcitabine which has subsequently become the standard of care in this disease. However, capecitabine in combination with oxaliplatin does have modest activity in this disease, and can be considered as an alternative treatment option for patients in whom cisplatin and/or gemcitabine are contra-indicated.

Covered versus Uncovered Self-Expandable Metal Stents for Managing Malignant Distal Biliary Obstruction: A Meta-Analysis

AIM

To compare the efficacy of using covered self-expandable metal stents (CSEMSs) and uncovered self-expandable metal stents (UCSEMSs) to treat objective jaundice caused by an unresectable malignant tumor.

METHODS

We performed a comprehensive electronic search from 1980 to May 2015. All randomized controlled trials comparing the use of CSEMSs and UCSEMSs to treat malignant distal biliary obstruction were included.

RESULTS

The analysis included 1417 patients enrolled in 14 trials. We did not detect significant differences between the UCSEMS group and the CSEMS group in terms of cumulative stent patency (hazard ratio (HR) 0.93, 95% confidence interval (CI) 0.19-4.53; p = 0.93, I2 = 0%), patient survival (HR 0.77, 95% CI 0.05-10.87; p = 0.85, I2 = 0%), overall stent dysfunction (relative ratio (RR) 0.85, M-H, random, 95% CI 0.57-1.25; p = 0.83, I2 = 63%), the overall complication rate (RR 1.26, M-H, fixed, 95% CI 0.94-1.68; p = 0.12, I2 = 0%) or the change in serum bilirubin (weighted mean difference (WMD) -0.13, IV fixed, 95% CI 0.56-0.3; p = 0.55, I2 = 0%). However, we did detect a significant difference in the main causes of stent dysfunction between the two groups. In particular, the CSEMS group exhibited a lower rate of tumor ingrowth (RR 0.25, M-H, random, 95% CI 0.12-0.52; p = 0.002, I2 = 40%) but a higher rate of tumor overgrowth (RR 1.76, M-H, fixed, 95% CI 1.03-3.02; p = 0.04, I2 = 0%). Patients with CSEMSs also exhibited a higher migration rate (RR 9.33, M-H, fixed, 95% CI 2.54-34.24; p = 0.008, I2 = 0%) and a higher rate of sludge formation (RR 2.47, M-H, fixed, 95% CI 1.36-4.50; p = 0.003, I2 = 0%).

CONCLUSIONS

Our meta-analysis indicates that there is no significant difference in primary stent patency and stent dysfunction between CSEMSs and UCSEMSs during the period from primary stent insertion to primary stent dysfunction or patient death. However, when taking further management for occluded stents into consideration, CSEMSs is a better choice for patients with malignant biliary obstruction due to their removability.

Clinicopathological Features of Surgically-resected Biliary Tract Cancer Following Chemo-radiation Therapy

AIM

We retrospectively investigated surgery following chemo-radiation in patients with biliary tract cancer (BTC) treated at our Institution.

PATIENTS AND METHODS

Among 339 patients, 44 patients underwent chemo-radiation prior to surgery. Chemo-radiation entailed 2-3 months of standardized chemotherapy and 50-60 Gy radiation at the main tumor and regional and para-aortic lymph nodes.

RESULTS

Thirty-one BTC cases were classified as initially resectable (IR) and 13 as initially un-resectable (UR). Eighty percent of the BTCs were diagnosed as extrahepatic bile duct cancers. Gemcitabine (1,000 mg/m(2)) and radiation was used to treat 59% of patients. Thirty percent of patients underwent hemi-hepatectomy, and 50% underwent pancreatoduodenectomy. The R0 resection rate was 90% among IR and 54% among UR, and 3-year survival rates were 82% for IR and 17% for UR, respectively.

CONCLUSION

This retrospective analysis suggests that surgery after chemoradiation may contribute to R0 resection rate and survival for initially resectable BTC.

Pharmacokinetic Study of Adjuvant Gemcitabine Therapy for Biliary Tract Cancer following Major Hepatectomy (KHBO1101)

Background

Biliary tract cancer (BTC) patients who have undergone surgical resection with major hepatectomy cannot tolerate the standard gemcitabine regimen (1,000 mg/m² on days 1, 8, and 15 every 4 weeks) due to severe toxicities such as myelosuppression. Our dose-finding study of adjuvant gemcitabine therapy for biliary tract cancer following major hepatectomy determined that the recommended dose is 1,000 mg/m² on days 1 and 15 every 4 weeks. Here, we evaluate the pharmacokinetics and pharmacodynamics of gemcitabine in these subjects.

Methods

We evaluated BTC patients scheduled to undergo surgical resection with major hepatectomy followed by gemcitabine therapy. A pharmacokinetic evaluation of gemcitabine and its main metabolite, 2′,2′-difluorodeoxyuridine (dFdU), was conducted at the initial administration of gemcitabine, which was given by intravenous infusion over 30 min at a dose of 800–1,000 mg/m². Physical examination and adverse events were monitored for 12 weeks.

Results

Thirteen patients were enrolled from August 2011 to January 2013, with 12 ultimately completing the pharmacokinetic study. Eight patients had hilar cholangiocarcinoma, three had intrahepatic cholangiocarcinoma, and one had superficial spreading type cholangiocarcinoma. The median interval from surgery to first administration of gemcitabine was 65.5 days (range, 43–83 days). We observed the following toxicities: neutropenia (n = 11, 91.7%), leukopenia (n = 10, 83.3%), thrombocytopenia (n = 6, 50.0%), and infection (n = 5, 41.7%). Grade 3 or 4 neutropenia was observed in 25% (n = 3) of patients. There were differences in clearance of gemcitabine and dFdU between our subjects and the subjects who had not undergone hepatectomy.

Conclusion

Major hepatectomy did not affect the pharmacokinetics of gemcitabine or dFdU.

Trial Registration

UMIN-CTR in (JPRN) UMIN000005109

[Peritoneovenous Shunting as a Palliative Therapy for Refractory Ascites after Biliary Cancer Surgery]

The quality of life of patients with recurrence of biliary cancer is remarkably diminished by the occurrence of refractory ascites caused by peritoneal dissemination or portal vein obstruction. In this study, we examined the effectiveness of peritoneovenous shunting (PVS) in patients with refractory ascites after recurrence of biliary cancer. PVS was performed 7 times in 5 patients, with 6 shunts (85.7%) placed from the left-side abdomen to the left subclavian vein. During the median observation period of 136 days, the ascites and symptoms of abdominal distension disappeared in 4 patients. Severe complications consisting of shunt obstruction in 2 patients and post-shunt coagulopathy in 1 patient were also observed. PVS is a useful palliative therapy for refractory ascites in patients with recurrence of biliary cancer. In patients after cancer resection, an appropriate choice of a safe placement route is critical for avoiding abdominal organ injury. The feasibility of PVS in patients with refractory ascites should be considered carefully and in context of their prognosis and performance status because severe complications may occur after this procedure.

Postoperative External Irradiation of Patients with Primary Biliary Tract Cancer: A Multicenter Retrospective Study

BACKGROUND/AIM

The aim of the present study was to assess clinical outcomes of postoperative radiotherapy for biliary tract cancer patients.

PATIENTS AND METHODS

Clinical results of 187 patients treated with external irradiation in 31 Japanese Institutions between 2000 and 2011 were retrospectively analyzed. The median radiation dose was 50.4 Gy in fractions of 1.8-2 Gy.

RESULTS

Two-year actuarial overall survival and locoregional control (LCs) rates were 56% and 68%, respectively. In multivariate analysis, macroscopic residual tumor (R2) and irradiated doses <54 Gy were significant indicators of poor LC prognosis. For patients with complete resection (R0) or microscopic residual tumor (R1), 2-year LCs were 71% for <54 Gy and 83% for ≥54 Gy; doses ≥54 Gy were associated with high long-term LCs. There was no significant difference in acute adverse event rates between <54 Gy and ≥54 Gy.

CONCLUSION

Postoperative irradiation doses of approximately 54 Gy are safe and effective for R0 or R1 resection patients.

[Four Cases of Hepatectomy for Liver Metastases of Intractable Hepatobiliary Pancreatic Cancers]

The treatment of recurrences that occur after radical resection of intractable hepatobiliary pancreatic cancers such as intrahepatic cholangiocarcinoma, pancreatic carcinoma, and biliary tract carcinoma is more difficult than the treatment of primary lesions. In our institute, chest and abdominal CT examinations after radical resection of intractable hepatobiliary pancreatic cancers are performed about 3 times a year in order to evaluate for the possible emergence of small nodules in the liver. Instead of performing hepatectomy immediately after detecting small nodules, we conduct observations essentially for 3 to 6 months. Meanwhile, if the number of metastatic lesions tends to increase and absence of spread to other organs is confirmed, we decide to perform hepatectomy. In particular, when the detected nodule is solitary and larger than 1 cm, immediate hepatectomy is considered. We present the following 4 cases of hepatectomy for liver metastases after radical resection of intractable hepatobiliary pancreatic cancers: intrahepatic cholangiocarcinoma (n=1), gallbladder carcinoma (n=1), and pancreatic carcinoma (n=2). Liver metastases were detected at 3 to 17 months after radical resection of the primary lesion. Hepatectomy for the liver metastases was performed 14 to 18 months after the primary resection. Survival after hepatectomy was 22 to 45 months. The median survival was more than 25 months. By carefully selecting the indication for surgery, good results were obtained after hepatectomy even in cases of intractable cancers.

Stenting in Malignant Biliary Obstruction

Decompression of the biliary system in patients with malignant biliary obstruction has been widely accepted and implemented as part of the care. Despite a wealth of literature, there remains a significant amount of uncertainty as to which approach would be most appropriate in different clinical settings. This review covers stenting of the biliary system in cases of resectable or palliative malignant biliary obstruction, potential candidates for biliary drainage, technical aspects of the procedure, as well as management of biliary stent dysfunction. Furthermore, periprocedural considerations including proper mapping of the location of obstruction and the use of antibiotics are addressed.

Curative Resection After Gemcitabine, Cisplatin and S-1 Chemotherapy for Initially Unresectable Biliary Duct Cancer: A Case Report

A 68-year-old woman was diagnosed with unresectable upper bile duct cancer with suspected invasion of the right hepatic artery and para-aortic lymph node metastasis (T4N3M0, stage IVb). She underwent plastic stent placement for obstructive jaundice and enrolled in our phase I study for unresectable biliary tract cancer consisting of cisplatin (25 mg/m(2) i.v. for 120 min) followed by gemcitabine (1,000 mg/m(2) i.v. for 30 min) on days 1 and 8, and oral S-1 on alternate days. After 8 courses of neoadjuvant chemotherapy without adverse effects, computed tomography showed near-complete disappearance of the tumor of the upper bile duct and of swollen lymph nodes. She then underwent sub-total stomach-preserving pancreatico duodenectomy and lymph node dissection. The pathological stage was pT1N0M0, stage I. The patient made a satisfactory recovery, was discharged 29 days after operation, and remains free of disease at 3 months after the operation under adjuvant chemotherapy using S-1.

Portal Vein Embolization Followed by Liver Resection versus Liver Resection Alone: a Comparison of Liver Regeneration Dynamics

BACKGROUND/AIMS

Portal vein embolization (PVE) is an accepted procedure, which, by redirecting portal vein flow toward specific hepatic segments, is able to pre-operatively increase the volume of the future liver remnant (FLR). The consequent reduction of liver dysfunction risk enables to extend the number of pa tients eligible for major hepatic resection. This study aims at comparing liver regeneration dynamics and long-term volumetric recovery after major hepatic re section preceded by PVE versus major hepatic resec tion not preceded by PVE.

METHODOLOGY

Data from 24 consecutive patients who underwent PVE prior to major hepatic resection were collected and compared to 24 consecutive patients who underwent major hepatic resection, but on whom PVE was not performed.

RESULTS

A significant growth of the FLR was observed after PVE. The liver remnant underwent a further regeneration burst after resection, with long-term volumetric recovery rates around 85% of the estimated total liver volume, similar to those observed for the control group and to those previously documented in the relevant literature.

CONCLUSION

PVE gives a first impulse to liver regeneration before liver resection without compromising further regeneration after resection, resulting in long-term volumetric recovery rates similar to those known for regeneration after liver resection without prior PVE.

Intraoperative radiation therapy for pancreatic, biliary and gastric carcinoma: the US experience

The experience with pancreatic, biliary and gastric cancer in the US has demonstrated that IORT is technically a feasible and therapeutically relatively safe modality. However, much research remains to be done. The toxicity in humans of single large dose radiation to normal tissue has not been firmly established. Clinical studies must be able to demonstrate the efficacy of IORT as well as a therapeutic advantage for this approach. IORT is potentially a very effective adjuvant therapy in treating tumors which are technically difficult to treat surgically or which have a high rate of recurrence following radical surgery. The combination of surgery and IORT may improve local control of the tumor by removing gross disease and identifying areas of potential risk for recurrence. Regional and distant failure, however, remains a problem. Because of this, future investigations are underway to combine chemotherapy with IORT, surgery and EBRT. The effectiveness of IORT needs to be established with prospective randomized trials. The appeal of this procedure is demonstrated by its rapidly growing popularity, and this very appeal requires that the value of the procedure be determined.

Biliary tract intraductal papillary mucinous neoplasm: Report of 19 cases

AIM: To gain a better understanding of biliary tract intraductal papillary mucinous neoplasm (BT-IPMN).

METHODS: From January 2000 to December 2013, 19 cases of BT-IPMN were retrospectively identified from a total of 343 biliary tract tumors resected in our single institution. Demographic characteristics, clinical data, pathology, surgical strategies, and long-term follow-up were analyzed.

RESULTS: The mean age of the 19 BT-IPMN cases was 53.8 years (range: 25-74 years). The most common symptom was abdominal pain (15/19; 78.9%), followed by jaundice (7/19; 36.8%). Cholangitis was associated with most (16/19; 84.2%) of the BT-IPMN cases. Macroscopically visible mucin was detected in all 19 patients, based on original surgical reports. The most common abnormal preoperative imaging findings for BT-IPMN were bile duct dilation (19/19; 100%) and intraluminal masses (10/19; 52.6%). Thirteen (68.4%) cases involved the intrahepatic bile duct and hilum. We performed left hepatectomy in 11/19 (57.9%), right hepatectomy in 2/19 (10.5%), bile duct resection in 4/19 (21.1%), and pancreatoduodenectomy in 1/19 (5.3%) patients. One (5.3%) patient was biopsied and received a choledochojejunostomy because of multiple tumors involving the right extrahepatic and left intrahepatic bile ducts. Histology showed malignancy in 10/19 (52.6%) patients. The overall median survival was 68 mo. The benign cases showed a non-significant trend towards improved survival compared to malignant cases (68 mo vs 48 mo, P = 0.347). The patient without tumor resection died of liver failure 22 mo after palliative surgery.

CONCLUSION: BT-IPMN is a rare biliary entity. Complete resection of the tumor is associated with good survival, even in patients with malignant disease.

Planning to avoid trouble in the operating room: experts' formulation of the preoperative plan

OBJECTIVE

The purpose of this study was to capture the preoperative plans of expert hepato-pancreato-biliary (HPB) surgeons with the goal of finding consistent aspects of the preoperative planning process.

DESIGN

HPB surgeons were asked to think aloud when reviewing 4 preoperative computed tomography scans of patients with distal pancreatic tumors. The imaging features they identified and the planned actions they proposed were tabulated. Surgeons viewed the tabulated list of imaging features for each case and rated the relevance of each feature for their subsequent preoperative plan. Average rater intraclass correlation coefficients were calculated for each type of data collected (imaging features detected, planned actions reported, and relevance of each feature) to establish whether the surgeons were consistent with one another in their responses. Average rater intraclass correlation coefficient values greater than 0.7 were considered indicative of consistency.

SETTING

Division of General Surgery, University of Toronto.

PARTICIPANTS

HPB surgeons affiliated with the University of Toronto.

RESULTS

A total of 11 HPB surgeons thought aloud when reviewing 4 computed tomography scans. Surgeons were consistent in the imaging features they detected but inconsistent in the planned actions they reported. Of the HPB surgeons, 8 completed the assessment of feature relevance. For 3 of the 4 cases, the surgeons were consistent in rating the relevance of specific imaging features on their preoperative plans.

CONCLUSION

These results suggest that HPB surgeons are consistent in some aspects of the preoperative planning process but not others. The findings further our understanding of the preoperative planning process and will guide future research on the best ways to incorporate the teaching and evaluation of preoperative planning into surgical training.

Treatment outcomes of chemotherapy between unresectable and recurrent biliary tract cancer

AIM: To evaluate the differences in the treatment outcomes between the unresectable and recurrent biliary tract cancer patients who received chemotherapy.

METHODS: Patients who were treated with gemcitabine and S-1 combination therapy in the previous prospective studies were divided into groups of unresectable and recurrent cases. The tumor response, time-to-progression, overall survival, toxicity, and dose intensity were compared between these two groups.

RESULTS: Response rate of the recurrent group was higher than that of the unresectable group (40.0% vs 25.5%; P = 0.34). Median time-to-progression of the recurrent and unresectable groups were 8.7 mo (95%CI), 1.2 mo, not reached) and 5.7 mo (95%CI: 4.0-7.0 mo), respectively (P = 0.14). Median overall survival of the recurrent and the unresectable groups were 16.1 mo (95%CI: 2.0 mo-not reached) and 9.6 mo (95%CI: 7.1-11.7 mo), respectively (P = 0.10). Dose intensities were significantly lower in the recurrent groups (gemcitabine: recurrent group 83.5% vs unresectable group 96.8%; P < 0.01, S-1: Recurrent group 75.9% vs unresectable group 91.8%; P < 0.01). Neutropenia occurred more frequently in recurrent group (recurrent group 90% vs unresectable group 55%; P = 0.04).

CONCLUSION: Not only the efficacy but also the toxicity and dose intensity were significantly different between unresectable and recurrent biliary tract cancer.

[Results of preoperative embolization of portal vein in patients with biliary hepatic tumors]

The results of preoperative embolization of portal vein (EPV) in 90 patients, operated on for biliary hepatic tumors, were analyzed. In 47 patients Klatskin tumor was revealed, in 29--peripheral cholangiocarcinoma, in 14--tumor of a gallbladder. In all the patients a radical major hepatic resection was planned, a checking hepatic volume (CHHV) did not exceed 40% of a noninvolved parenchyma. The EPV volume have corresponded generally to the planned resection volume. After performance of EPV a pressure in a portal vein have risen by 75%, and later it have had lowered step by step during 24 h. The CHHV index have raised from (354 +/- 72) up to (462 +/- 118) cm3, or from (33 +/- 7) up to (45 +/- 11)%, permitting to perform radical hepatic resection in 79 (87.8%) patients. Thus, application of EPV in patients, suffering biliary hepatic tumors, have permitted to increase the CHHV index after radical resection, and to raise resectability of such tumors.

[Current status of adjuvant therapy for biliary tract cancer]

While surgical resection remains the only potentially curative treatment for biliary tract cancer (BTC), most cases are discovered at an advanced stage and radical resection is possible in only a limited number. Furthermore, most patients develop recurrence even after curative resection. Therefore, effective adjuvant therapies including chemotherapy, radiotherapy, immunotherapy, and photodynamic therapy are necessary to improve the survival and quality of life (QOL) of patients with BTC. A few randomized controlled trials have demonstrated the survival benefit of chemotherapy in patients with unresectable BTC. The combination of gemctitabine and cisplatin is considered the standard treatment for patients with locally advanced or metastatic BTC, according to the results of a randomized phase III study (ABC-02) in the UK. There are no adequate data supporting any second-line therapy, radiotherapy, or adjuvant chemotherapy after surgical resection. Downsizing chemotherapy and subsequent surgical resection for initially unresectable locally advanced BTC may have potential for disease eradication as a new multidisciplinary approach. Well-designed prospective trials in this field should be organized through multicenter and international collaborations to improve the survival and QOL of patients with BTC.

[The choice of pancreaticojejunal anastomosis based on the performance experience of 200 operations of pancreaticoduodenal resection]

Analysis of the surgical treatment results in 200 patients, operated for obstructive diseases of the biliopancreatoduodenal zone, in whom pancreaticoduodenal resection (PDR) was performed in 1991 - 2013 yrs period, were presented. The choice of the pancreaticojejunoanastomosis (PJA) variant in PDR have depended on dimension of diameter of the pancreatic gland stump and the jejunum diameter, as well as from state of pancreatic parenchyma and duct. Application of differentiated approach to choice of the PJA variant have permitted to reduce the complications rate, including the sutures insufficiency.

Phase I study of adjuvant chemotherapy with gemcitabine plus cisplatin in patients with biliary tract cancer undergoing curative resection without major hepatectomy (KHBO1004)

PURPOSE

We conducted a phase I study to determine the maximum tolerated dose and recommended dose (RD) of this gemcitabine plus cisplatin (GC) combination in the adjuvant setting for biliary tract cancer (BTC). GC has become a standard chemotherapy regimen for patients with locally advanced or metastatic BTC; however, the benefit of adjuvant therapy for BTC is unclear.

METHODS

Patients with BTC were eligible if they met the following criteria: Stage IB or higher; and undergoing resection without major hepatectomy. The starting dose matched the standard dose of gemcitabine (1,000 mg/m(2)) and cisplatin (25 mg/m(2)) on days 1 and 8, every 3 weeks for up to 24 weeks. The dose limiting toxicities (DLTs) were determined during the first 6 weeks, and a 3+3 dose finding design with cohorts of 3-6 patients was used. Further cohort expansion took place.

RESULTS

One DLT, namely grade 4 neutropenia, was observed among six patients at the starting dosages. Then, we expanded the cohort with a total of eighteen patients to evaluate RD and no further DLTs were observed. During the entire study, the most common grade 3/4 adverse events were neutropenia (94 %) and leucopenia (56 %). Non-hematological toxicities were manageable.

CONCLUSIONS

We defined the standard dose of GC as the RD for adjuvant chemotherapy for BTC treated by curative resection without major hepatectomy. Further study is warranted to clarify the safety and efficacy of this regimen for all patients.