[Resection of Klatskin tumors]

Prediction of the Postoperative Outcome in Liver Resection Using Perioperative Serum Lactate Levels

Background: The aim of our study was to analyze perioperative lactate levels and their predictive value for postoperative mortality and morbidity after liver resection. Methods: The clinicopathological characteristics and outcomes of 152 patients who underwent liver resection for benign and malign diagnoses were analyzed retrospectively. Lactate concentrations at three different time points, (1) before liver resection (LAC-PRE), (2) after liver resection on day 0 (LAC-POST), and (3) on day one after the operation (LAC-POD1) were assessed regarding the prognostic value in predicting postoperative complications and mortality according to the Clavien–Dindo (CD) classification. Results: The rates of postoperative complications (CD ≥ IIIb) and mortality rates were 19.7% (N = 30) and 4.6% (N = 7), respectively. The LAC-PRE levels showed no correlation with the postoperative outcome. The ROC curve analysis showed that LCT-POST and LCT-POD1 values were moderately strong in predicting postoperative morbidity (0.681 and 0.768, respectively) and had strong predictive accuracies regarding postoperative mortality (0.800 and 0.838, respectively). The multivariate analysis revealed LAC-POST as a significant predictor of postoperative complications (CD ≥ IIIb: OR 9.28; 95% CI: 2.88–29.9; p < 0.001) and mortality (OR 11.69; 95% CI: 1.76–77.7; p = 0.011). Conclusion: Early postoperative lactate levels are a useful and easily practicable predictor of postoperative morbidity and mortality in patients after liver resection.

Klatskin Tumor: A Population-Based Study of Incidence and Survival

BACKGROUND Klatskin tumor (KCC) is a rare type of tumor, with an annual incidence rate of no more than 1: 100 000. Because of its rarity, KCC is difficult to investigate. The present study provides new insights into KCC by a using public database. MATERIAL AND METHODS We used the Surveillance, Epidemiology, and End Results (SEER) database to conduct the analysis. Klatskin tumor patients were identified and compared with patients that had other kinds of cholangiocarcinomas (OCC). We identified differences between the 2 groups of patients and assessed tumor characteristics. We used Cox regression analysis to identify the prognostic indicators for KCC. The propensity score 1-to-1 matching method was used to compare the survival difference between KCC and OCC. RESULTS We extracted data on 26 137 patients diagnosed with cholangiocarcinomas between 1973 and 2014 from the SEER database: 1341 cases were diagnosed with KCC and 24 796 cases were diagnosed with OCC. The number of diagnoses has gradually increased in both groups. There were significant differences in pathology grades, T stage, N stage, M stage, and SEER historic stage between the KCC and OCC groups. Survival analysis showed that the OCC group had better survival compared to the KCC group, both in matched and unmatched cohorts. The Cox regression results showed that older age, higher M stages, and higher pathology grades were associated with worse prognosis for KCC patients. CONCLUSIONS KCC patients have worse survival compared to OCC patients. Older age, higher M stages, and higher pathology grades were associated with worse survival in KCC patients.

The diagnosis and treatment of cholangiocarcinoma

BACKGROUND

Cholangiocarcinoma (CCA) is the second most common primary hepatic tumor in Germany, with about 3500 new cases per year. In recent years, its prognosis has improved because of wider resections and the establishment of local treatment and chemotherapy in the palliative situation.

METHODS

This review is based on pertinent articles that were retrieved by a selective literature search in the PubMed database with the keywords "cholangiocarcinoma AND diagnostic OR therapy." Articles in English or German published up to January 2014 were considered.

RESULTS

The sole curative treatment for CCA is surgery, but 40-85% of all patients have recurrent disease even after radical excision. Because of this high recurrence rate, adjuvant treatments are now under intense discussion. For unresectable CCA without distant metastases, small case series have shown that liver transplantation can yield promising survival rates of over 50% at 5 years. For many patients with CCA, however, only palliative treatments can be offered, including endoscopic clearing of the biliary pathways. Because of the low prevalence of the disease, there have been only a few phase 3 studies of palliative chemotherapy for CCA. On the basis of one positive phase 3 study, chemotherapy with gemcitabine and cisplatin is considered the standard and now plays an established role in palliative care.

CONCLUSION

CCA presents a special challenge in gastroenterology, oncology, and visceral surgery because of the difficulty in establishing the diagnosis, local complications in the biliary pathways, and a high recurrence rate after resection. Future studies should address not only the role of adjuvant chemotherapy, but also the efficacy of combined local and systemic treatment.

Individualized preoperative planning using three-dimensional modeling for Bismuth and Corlette type III hilar cholangiocarcinoma

Background

A detailed evaluation of blood supply anatomy, especially the biliary anatomy at the hepatic hilus, is essential to ensure a complete and curative resection for Bismuth and Corlette type III hilar cholangiocarcinoma. The study aimed to investigate the impact of individualized preoperative planning using 3D modeling on surgical treatment for type III hilar cholangiocarcinoma.

Methods

This was a retrospective study of patients with type III hilar cholangiocarcinoma (n = 47) who underwent surgery at the Hepatobiliary Surgery Department of Zhujiang Hospital between March 2007 and January 2015. All patients had undergone preoperative computed tomography (CT) examination, and 3D images were reconstructed. Preoperative surgery simulation was performed, and the simulation was applied in the subsequent surgery. Clinical, surgical, and pathological characteristics were compared between patients undergoing preoperative planning (n = 25) and those who did not (n = 22). Complications were examined.

Results

Surgical time and blood loss were significantly smaller in patients with 3D reconstruction compared to those without. The number of bile duct orifices was correctly estimated in 14/25 (56.0 %) patients with preoperative planning. The width of the hepatic surgical margin could be measured for 18 hepatic ducts, and 17 (68.0 %) of them were pathologically diagnosed as margin-negative.

Conclusions

This technique has the advantages of precise visualization of the anatomic structures and 3D assessment of biliary branches and vessels, allowing improved operative planning for the treatment of hilar cholangiocarcinoma.

Neoadjuvant Down-Sizing of Hilar Cholangiocarcinoma with Photodynamic Therapy--Long-Term Outcome of a Phase II Pilot Study

Hilar cholangiocarcinoma (CC) is non-resectable in the majority of patients often due to intrahepatic extension along bile duct branches/segments, and even after complete resection (R0) recurrence can be as high as 70%. Photodynamic therapy (PDT) is an established palliative local tumor ablative treatment for non-resectable hilar CC. We report the long-term outcome of curative resection (R0) performed after neoadjuvant PDT for downsizing of tumor margins in seven patients (median age 59 years) with initially non-resectable hilar CC. Photofrin(®) was injected intravenously 24-48 h before laser light irradiation of the tumor stenoses and the adjacent bile duct segments. Major resective surgery was done with curative intention six weeks after PDT. All seven patients had been curatively (R0) resected and there were no undue early or late complications for the neoadjuvant PDT and surgery. Six of seven patients died from tumor recurrence at a median of 3.2 years after resection, the five-year survival rate was 43%. These results are comparable with published data for patients resected R0 without pre-treatment, indicating that neoadjuvant PDT is feasible and could improve overall survival of patients considered non-curatively resectable because of initial tumor extension in bile duct branches/segments--however, this concept needs to be validated in a larger trial.

[Perihilar cholangiocarcinoma (Klatskin tumor)]

Perihilar cholangiocarcinoma or Klatskin tumors are a rare entity arising from the extrahepatic bile duct bifurcation. Considering the close anatomical relationship of the bile duct bifurcation with the portal vein bifurcation and hepatic arteries, surgical treatment is demanding. With an incidence of only 2-4 cases/100,000 population/year patients should be referred to a specialized center. The tumors are usually poorly differentiated adenocarcinomas growing diffusely along the duct and also the perineural sheath. Only radical surgery offers a curative option and currently surgical strategy usually consists of en bloc resection of the bile duct, extended liver resection and portal vein resection. Proximal and lateral safety margin R0 resections are technically very demanding procedures because of the local anatomy.