What is the impact of coexistence of hepatolithiasis on cholangiocarcinoma?

Classification of left-side hepatolithiasis for laparoscopic middle hepatic vein-guided anatomical hemihepatectomy combined with transhepatic duct lithotomy

BACKGROUND

Laparoscopic middle hepatic vein-guided anatomical hemihepatectomy combined with transhepatic duct lithotomy (MATL) is an approach that can substantially improve stone clearance rates while reducing the rate of postoperative biliary fistula formation, residual stone rates, and rates of recurrence. In this study, we classified left-side hepatolithiasis cases into four subtypes based upon the diseased stone-containing bile duct, the middle hepatic vein, and the right hepatic duct. We then investigated the risk associated with different subtypes and evaluated the safety and efficacy of the MATL procedure.

METHODS

In total, 372 patients who underwent left hemihepatectomy for left intrahepatic bile duct stones were enrolled. Based on the distribution of the stones, the cases could be divided into four types. The risk of surgical treatment was compared for the four types and the safety, short-term efficacy, and long-term efficacy of the MATL procedure in the four types of left intrahepatic bile duct stones were studied.

RESULTS

Type II was found to be the most likely to cause intraoperative bleeding while type III was likely to cause biliary tract damage and type IV was associated with the highest stone recurrence rate. The MATL procedure did not increase the risk of surgery and was found to reduce the rate of bile leakage, residual stones, and stone recurrence.

CONCLUSION

Left-side hepatolithiasis-associated risk classification is feasible and may represent a viable means of improving the safety and feasibility of the MATL procedure.

Endoscopic Evaluation and Management of Cholangiocarcinoma

Cholangiocarcinoma is a rare malignancy of the biliary tract with a relatively poor prognosis. As a gastroenterologist, our main role is to differentiate between benign and malignant biliary disease, help achieve a diagnosis, and palliate jaundice related to biliary obstruction. This article focuses on summarizing the various tools currently available for endoscopic evaluation and management of cholangiocarcinoma.

The association between circulating MicroRNA-150 level and cholangiocarcinoma

Cholangiocarcinoma (CCA) is a rare tumor which requires a multimodality approach for its diagnosis. Carbohydrate antigen 19‐9 (CA19‐9) is currently the most commonly used tumor marker for CCA; nevertheless, it has certain limitations which need to be considered when using it as a tumor marker. MiRNA‐150 altered expression has been linked to the development and tumorigenesis of several cancers including CCA. This work aimed to study the serum level of CA19‐9 and miRNA‐150 expression in CCA patients and, also, to correlate their levels with tumor staging and different studied clinical and laboratory parameters. This work included 35 patients with CCA who were admitted to Hepatobiliary Unit, Alexandria Main University Hospital (Group I). Also, 35 age‐ and sex‐matched healthy subjects were included as a control group (Group II). All included subjects were submitted to measurement of serum CA19‐9 and MiRNA‐150 expression levels. Serum CA19‐9 levels showed an evident high median among CCA patients, while serum miRNA‐150 expression levels were evidently low among those patients. Moreover, combining miRNA‐150 with CA19‐9 made the accuracy of diagnosis of CCA much more reliable. Thus, miRNA‐150 can be considered as a non‐invasive, sensitive serum biomarker for the diagnosis of CCA especially when combined with CA 19‐9.

The prognostic value of sarcopenia combined with hepatolithiasis in intrahepatic cholangiocarcinoma patients after surgery: A prospective cohort study

INTRODUCTION

Intrahepatic Cholangiocarcinoma (ICC) is the second most common primary liver cancer with dismal survival rates. This study aimed to explore the prognostic value of sarcopenia combine with hepatolithiasis in surgically treated ICC patients and develop a prognostic nomogram to help make clinical decisions.

MATERIALS AND METHODS

A prospective cohort study was conducted including patients who underwent hepatectomy for ICC between August 2012 and October 2019. The association between the sarcopenia combined with hepatolithiasis and survival, including overall survival (OS) and recurrence-free survival (RFS) was investigated using the Kaplan-Meier (K-M) method. Univariable and multivariable Cox regression analysis was performed to determine the independent prognostic factors and a nomogram establishment was undertaken based on the multivariable analysis.

RESULTS

A total of 121 ICC patients were included in the study. K-M analysis revealed that ICC patients with sarcopenia and hepatolithiasis have worse OS and RFS than those without sarcopenias and/or hepatolithiasis (p < 0.01). Multivariable analysis showed that age, serum CEA, hepatolithiasis, sarcopenia and diabetes were independent prognostic factors for OS(p < 0.05). Finally, a nomogram with good performance in survival prediction was established (C-index was 0.721; the area under the curve of OS was 0.837). The stratified analysis based on the nomogram disclosed that the median OS was 11.9 months in high-risk patients and 51.2 months in low-risk patients (p < 0.001).

CONCLUSIONS

ICC patients with sarcopenia and hepatolithiasis have worse OS and RFS. The nomogram we developed is a practical tool that can provide a more individualized risk assessment for surgically treated ICC patients.

Endoscopic mucosal resection of a bile duct polyp: A case report

BACKGROUND

Bile duct polyps are difficult to diagnose and are usually excised by open abdominal surgery or snare polypectomy using choledochoscopy via the T-tube sinus tract. However, these two resection methods require the surgeon to open the abdomen and cut the bile duct to place the “T” tube. Moreover, simple snare polypectomy, without submucosal injection, can only remove pedunculated polyps and not flat polyps. Therefore, a new method is required for the excision of bile duct polyps, including flat polyps.

CASE SUMMARY

A 63-year-old woman was hospitalized following epigastric pain lasting a month. She had a 30-year history of cholelithiasis and had undergone cholecystectomy because of cholecystolithiasis, and had undergone cholangiolithotomy twice due to choledocholithiasis. Computed tomography (CT) and magnetic resonance imaging showed a communication between the bile duct and duodenal bulb. Inside the communication, CT showed a high-density shadow which was a hypointense lesion in T2 weighted image. The lesion showed no enhancement in T1 weighted image contrast enhanced. Gastroscopy revealed an incarcerated bile duct stone in the anterior wall of the duodenal bulb, which was removed with a basket under gastroscopy. Thereafter, a choledochoduodenal fistula was revealed. Finally, a flat polyp was detected in the lower part of the common bile duct and was removed by endoscopic mucosal resection (EMR) through the fistula. To our knowledge, this is the first reported case of the removal of a bile duct polyp using EMR.

CONCLUSION

EMR is a safe, effective, and low-cost method for the resection of all bile duct polyps.

Incidence and Prognosis of Subsequent Cholangiocarcinoma in Patients with Hepatic Resection for Bile Duct Stones

BACKGROUND AND AIM

Cholangiocarcinoma (CCA) often develops after the hepatic resection for hepatolithiasis as well as indwelling it. We studied the incidence and prognosis of subsequent CCA in patients with hepatolithiasis in South Korea.

METHODS

We identified individuals with diagnosed CCA at the time of or after surgery, during 2002-2016, from the Korean National Health Insurance. The incidences and survival rates of subsequent CCA were analyzed and compared with concomitant CCA. The standardized incidence ratios (SIRs) of CCA in this cohort were evaluated in the standard Korean population. All data were stratified by the presence of intrahepatic or extrahepatic CCA, age and sex.

RESULTS

Of the 7852 patients with hepatectomy for BDS, 433 (5.84%) had concomitant CCA. Over the 12-year follow-up, 107 of 7419 (1.98%) patients were diagnosed with subsequent CCA. Patients with hepatic resection for BDS revealed higher SIRs for subsequent CCA (12.89, 95% CI 10.96-15.15) in cases of both intrahepatic CCA (13.40, 10.55-17.02) and extrahepatic CCA (12.42, 9.98-15.46). The median survival time for subsequent CCA was 0.87 years, while that for concomitant CCA was 2.79 years. Having subsequent CCA (HR 2.71, 95% CI 2.17-3.40) and being male (HR 1.28, 1.05-1.57) were related to a shorter survival time. The CCA site and age at CCA diagnosis were not related to prognoses.

CONCLUSIONS

Subsequent CCA developed in 2% of the patients with hepatic resection for benign BDS until 10 years and was associated with poorer prognoses than concomitant CCA. Future studies focused on the long-term surveillance for CCA in such patients are needed.

Recurrent pyogenic cholangitis - an independent poor prognostic indicator for resectable intrahepatic cholangiocarcinoma: A propensity score matched analysis

BACKGROUND

Recurrent pyogenic cholangitis (RPC) is a known risk factor for intrahepatic cholangiocarcinoma (ICC), whether it represents a poor prognostic factor remains controversial. The aim of this study was to investigate the post-hepatectomy oncological outcomes of patients with ICC and coexisting RPC.

METHOD

A retrospective analysis with propensity score matching (PSM) was performed for comparison between ICC patient with and without RPC.

RESULTS

There were 143 patients with ICC with a median follow-up of 21 months. RPC was diagnosed in 18% of patients. The time from RPC diagnosis to ICC diagnosis was 137(47-481) months. The 3-year disease-free (DFS) and overall survival for the whole population was 34% and 43% respectively. Preoperative child score, elevated carcinoembryonic antigen, presence of microvascular invasion, multiple tumours, presence of postoperative complications and RPC were independent factors for DFS and OS. After PSM, 60 ICC patients who did not have RPC were compared with 20 ICC patients with RPC. Patients with RPC had significantly worse median DFS (10 vs 23 months, P = 0.020) and OS (15 vs 45 months, P = 0.004) when compared to the patients without RPC.

CONCLUSION

RPC represents a poor prognostic factor affecting outcomes after hepatectomy for patients with ICC.

Implications of Intrahepatic Cholangiocarcinoma Etiology on Recurrence and Prognosis after Curative-Intent Resection: a Multi-Institutional Study

BACKGROUND

We sought to investigate the prognosis of patients following curative-intent surgery for intrahepatic cholangiocarcinoma (ICC) stratified by hepatitis B (HBV-ICC), hepatolithiasis (Stone-ICC), and no identifiable cause (conventional ICC) etiologic subtype.

METHODS

986 patients with HBV-ICC (n = 201), stone-ICC (n = 103), and conventional ICC (n = 682) who underwent curative-intent resection were identified from a multi-institutional database. Propensity score matching (PSM) was used to mitigate residual bias.

RESULTS

HBV-ICC patients more often had cirrhosis, earlier stage tumors, a mass-forming lesion, well-to-moderate tumor differentiation, and an R0 resection versus stone-ICC or conventional ICC patients. Five-year recurrence-free survival among HBV-ICC and conventional ICC patients was 23.9 and 17.8%, respectively, versus a recurrence-free of only 8.3% among patients with stone-ICC. Similarly, 5-year overall survival among patients with stone-ICC was only 18.3% compared with 48.9 and 38.0% for patients with HBV-ICC and conventional ICC, respectively. On PSM, patients with stone-ICC group had equivalent long-term outcomes as HBV-ICC patients. In contrast, on PSM, stone-ICC patients had a median overall survival of only 18.0 months versus 44.0 months for patients with conventional ICC. Median overall survival after intrahepatic-only recurrence among patients who had stone-ICC (6.0 months) was worse than OS among HBV-ICC (13.0 months) or conventional ICC (12.0 months) (p = 0.006 and p = 0.082, respectively).

CONCLUSIONS

While HBV-ICC had a better prognosis on unadjusted analyses, these differences were mitigated on PSM suggesting no stage-for-stage differences in outcomes compared with stone-ICC or conventional ICC. In contrast, patients with stone-ICC had worse long-term outcomes. These data highlight the relative importance of ICC etiology relative to established clinicopathological factors in the prognosis of patients with ICC.

Risk Factors for Cholangiocarcinoma After Initial Hepatectomy for Intrahepatic Stones

BACKGROUND

Aggressive hepatectomy is effective in treating intrahepatic stones and may minimize the deleterious consequences of subsequent cholangiocarcinoma (S-CCA). The risk factors of S-CCA after different methods of hepatectomy may vary with the resection scope of stone-affected segments.

METHODS

We reviewed the records of 981 patients of primary intrahepatic stones with elective hepatectomy from January 2000 to December 2010. The clinical characteristics of patients in the S-CCA group (n = 55) and the control group (n = 926) were compared. The uniformity between extent of liver resection (ELR) with stone-affected segments (SAS) was segmented into 2 varieties: ELR = SAS with ELR < SAS according to the different hepatic resection scopes. Cox regression model with forward selection was used to identify the risk factors of S-CCA.

RESULTS

In the univariate analysis, significant differences were observed between the S-CCA and control groups concerning stone location (unilateral 43.6 and 65.2 %, bilateral 56.4 and 34.8 %), residual stones (32.7 and 11.6 %), hepaticojejunostomy (43.6 and 30.9 %), and uniformity between ELR with SAS (ELR = SAS 20.0 and 42.6 %, ELR < SAS 80.0 and 57.4 %). Residual stones [hazard ratio (HR) 2.101, P = 0.016], hepaticojejunostomy (HR 1.837, P = 0.026) and uniformity between ELR and SAS (HR 2.442, P = 0.013) were independent prognostic factors for S-CCA by a Cox regression analysis with forward selection. In the subsection of ELR = SAS group, the 5- and 10-year postoperative tumor occurrence rates of unilateral and bilateral stones group were 0.9 versus 1.9 % and 3.0 versus 4.1 %, respectively (P = 0.663, log-rank). In the other subsection of ELR < SAS group, the 5- and 10-year postoperative tumor occurrence rates of unilateral and bilateral stones group were 3.4 versus 3.9 % and 6.8 versus 13.2 %, respectively (P = 0.047, log-rank), and the 5- and 10-year postoperative tumor occurrence rates of residual stones and non-residual stones group were 5.8 versus 3.0 % and 16.0 versus 7.9 %, respectively (P = 0.015, log-rank).

CONCLUSIONS

Patients who underwent aggressive hepatectomy and had ELR = SAS had better outcomes than those with ELR < SAS. In the patients with ELR = SAS, the S-CCA rates of unilateral and bilateral stones were low and comparable. However, patients with ELR < SAS and bilateral intrahepatic or residual stones should be monitored more carefully for high-risk factors of S-CCA.

Helicobacter Species are Possible Risk Factors of Cholangiocarcinoma

Several infectious agents are considered to be causes of cancer in human, mainly hepatitis B and C viruses, high-risk human pailloma viruses, Helicobacter pylori, Clonorchis sinensis, and Opisthorchis viverrini. Here we described the evident research and the association between Helicobacter spp. and biliary tract cancer particularly cholangiocarcinoma (CCA). Global epidemiological studies have suggested that Helicobacter spp. are possible risk factors for biliary tract diseases. Molecular studies support a linkage of Helicobacter spp. with CCA development. H. pylori, H. bilis, and H. hepaticus, are found in CCA, but the most common species are H. pylori and H. bilis. The type of CCA are associated with Helicobacter spp. include extrahepatic CCA, and common bile duct cancer. Up to the present, however, the results from different regions, materials and methods, sub-sites of cancer, and controls have not been consistent, thus introducing heterogeneity. Therefore, a comparison between co-Helicobacter spp.-CCA in the countries with low and high incident of CCA is required to settle the question. Furthermore, clarifying variation in the role of Helicobacter species in this CCA, including pathogenesis of CCA through enhanced biliary cell inflammation and proliferation, is necessary.

Hepatolithiasis and intrahepatic cholangiocarcinoma: A review

Although the incidence of hepatolithiasis is decreasing as the pattern of gallstone disease changes in Asia, the prevalence of hepatolithiasis is persistently high, especially in Far Eastern countries. Hepatolithiasis is an established risk factor for cholangiocarcinoma (CCA), and chronic proliferative inflammation may be involved in biliary carcinogenesis and in inducing the upregulation of cell-proliferating factors. With the use of advanced imaging modalities, there has been much improvement in the management of hepatolithiasis and the diagnosis of hepatolithiasis-associated CCA (HL-CCA). However, there are many problems in managing the strictures in hepatolithiasis and differentiating them from infiltrating types of CCA. Surgical resection is recommended in cases of single lobe hepatolithiasis with atrophy, uncontrolled stricture, symptom duration of more than 10 years, and long history of biliary-enteric anastomosis. Even after resection, patients should be followed with caution for development of HL-CCA, because HL-CCA is an independent prognostic factor for survival. It is not yet clear whether hepatic resection can reduce the occurrence of subsequent HL-CCA. Furthermore, there are no consistent findings regarding prediction of subsequent HL-CCA in patients with hepatolithiasis. In the management of hepatolithiasis, important factors are the reduction of recurrence of cholangitis and suspicion of unrecognized HL-CCA.

Integrated genomic characterization reveals novel, therapeutically relevant drug targets in FGFR and EGFR pathways in sporadic intrahepatic cholangiocarcinoma

Advanced cholangiocarcinoma continues to harbor a difficult prognosis and therapeutic options have been limited. During the course of a clinical trial of whole genomic sequencing seeking druggable targets, we examined six patients with advanced cholangiocarcinoma. Integrated genome-wide and whole transcriptome sequence analyses were performed on tumors from six patients with advanced, sporadic intrahepatic cholangiocarcinoma (SIC) to identify potential therapeutically actionable events. Among the somatic events captured in our analysis, we uncovered two novel therapeutically relevant genomic contexts that when acted upon, resulted in preliminary evidence of anti-tumor activity. Genome-wide structural analysis of sequence data revealed recurrent translocation events involving the FGFR2 locus in three of six assessed patients. These observations and supporting evidence triggered the use of FGFR inhibitors in these patients. In one example, preliminary anti-tumor activity of pazopanib (in vitro FGFR2 IC₅₀≈350 nM) was noted in a patient with an FGFR2-TACC3 fusion. After progression on pazopanib, the same patient also had stable disease on ponatinib, a pan-FGFR inhibitor (in vitro, FGFR2 IC₅₀≈8 nM). In an independent non-FGFR2 translocation patient, exome and transcriptome analysis revealed an allele specific somatic nonsense mutation (E384X) in ERRFI1, a direct negative regulator of EGFR activation. Rapid and robust disease regression was noted in this ERRFI1 inactivated tumor when treated with erlotinib, an EGFR kinase inhibitor. FGFR2 fusions and ERRFI mutations may represent novel targets in sporadic intrahepatic cholangiocarcinoma and trials should be characterized in larger cohorts of patients with these aberrations.

Cholangiocarcinoma is a cancer that affects the bile ducts. Unfortunately, many patients diagnosed with cholangiocarcinoma have disease that cannot be treated with surgery or has spread to other parts of the body, thus severely limiting treatment options. New advances in drug treatment have enabled treatment of these cancers with “targeted therapy” that exploits an error in the normal functioning of a tumor cell, compared to other cells in the body, thus allowing only tumor cells to be killed by the drug. We sought to identify changes in the genetic material of cholangiocarcinoma patient tumors in order to identify potential errors in cellular functioning by utilizing cutting edge genetic sequencing technology. We identified three patient tumors possessing an FGFR2 gene that was aberrantly fused to another gene. Two of these patients were able to receive targeted therapy for FGFR2 with resulting tumor shrinkage. A fourth tumor contained an error in a gene that controls a very important cellular mechanism in cancer, termed epidermal growth factor pathway (EGFR). This patient received therapy targeting this mechanism and also demonstrated response to treatment. Thus, we have been able to utilize cutting edge technology with targeted drug treatment to personalize medical treatment for cancer in cholangiocarcinoma patients.

Hepatolithiasis-associated cholangiocarcinoma: results from a multi-institutional national database on a case series of 23 patients

AIMS

Few papers focused on association between hepatolithiasis (HL) and cholangiocarcinoma (CCC) in Western countries. The aims of this paper are to describe the clinical presentation, treatment, and postoperative outcomes of CCC with HL in a cohort of Western patients and to compare the surgical outcomes of these patients with patients with CCC without HL.

MATERIALS AND METHODS

Among 161 patients with HL from five Italian tertiary hepato-biliary centers, 23 (14.3%) patients with concomitant CCC were analyzed. The results of surgery in these patients were compared with patients with CCC without HL.

RESULTS

The 60.9% of patients with HL received the diagnosis of CCC intra- or postoperatively, with a resectability rate of 91.3%. The postoperative morbidity was 61.6%. The 1- and 3-year survival rates were 78.6% and 21.0%, respectively. The recurrence rate was 44.4% and the 3-year disease-free survival rates were 18.8%. The comparison with patients with CCC without HL showed a higher resectability rate (p = 0.02) and a higher frequency of earlier stage (p = 0.04) in CCC with HL. Biliary leakage was more frequent in CCC with HL group (p = 0.01) compared to CCC without HL group. We found no differences in overall and disease-free survival between the two groups.

CONCLUSIONS

Patients with HL and CCC showed a high resectability rate but a higher morbidity. Nevertheless, overall and disease-free survival of patients with CCC and HL showed no differences compared to those of patients with CCC without HL. Also in Western countries, HL needs a careful management for the possible presence of CCC.

Comparison of concomitant and subsequent cholangiocarcinomas associated with hepatolithiasis: Clinical implications

AIM: To compare the outcomes of concomitant cholangiocarcinoma (C-CCA) and subsequent cholangiocarcinoma (S-CCA) associated with hepatolithiasis.

METHODS: From December 1987 to December 2007, 276 patients underwent hepatic resection for hepatolithiasis in Changhua Christian Hospital. Sixty-five patients were excluded due to incomplete medical records and the remaining 211 patients constituted our study population base. Ten patients were diagnosed with C-CCA based on the preoperative biopsy or postoperative pathology. During the follow-up period, 12 patients developed S-CCA. The diagnosis of S-CCA was made by image-guided biopsy or by pathology if surgical intervention was carried out. Patient charts were reviewed to collect clinical information. Parameters such as CCA incidence, interval from operation to CCA diagnosis, interval from CCA diagnosis to disease-related death, follow-up time, and mortality rate were calculated for both the C-CCA and S-CCA groups. The outcomes of the C-CCA and S-CCA groups were mathematically compared and analysed.

RESULTS: Our study demonstrates the clinical implications and the survival outcomes of C-CCA and S-CCA. Among the patients with unilateral hepatolithiasis, the incidence rates of C-CCA and S-CCA were fairly similar (4.8% vs 4.5%, respectively, P = 0.906). However, for the patients with bilateral hepatolithiasis, the incidence rate of S-CCA (12.2%) was higher than that of C-CCA (4.7%), although the sample size was limited and the difference between two groups was not statistically significant (P = 0.211). The average follow-up time was 56 mo for the C-CCA group and 71 mo for the S-CCA group. Regard to the average time intervals from operation to CCA diagnosis, S-CCA was diagnosed after 67 mo from the initial hepatectomy. The average time intervals from the diagnoses of CCA to disease-related death was 41 mo for the C-CCA group and 4 mo for the S-CCA group, this difference approached statistical significance (P = 0.075). Regarding the rates of overall and disease-related mortality, the C-CCA group had significantly lower overall mortality (70% vs 100%, P = 0.041) and disease-related mortality (60% vs 100%, P = 0.015) than the S-CCA group. For the survival outcomes of two groups, the Kaplan-Meier curves corresponding to each group also demonstrated better survival outcomes for the C-CCA group (log rank P = 0.005). In the C-CCA group, three patients were still alive at the time of data analysis, all of them had free surgical margins and did not have pathologically proven lymph node metastasis at the time of the initial hepatectomy. In the S-CCA group, only one patient had chance to undergo a second hepatectomy, and all 12 S-CCA patients had died at the time of data analysis.

CONCLUSION: C-CCA has better outcomes than S-CCA. The first hepatectomy is crucial because most patients with recurrent CCA or S-CCA are not eligible for repeated surgical intervention.

Hepatolithiasis combined with intrahepatic cholangiocarcinoma

Hepatolithiasis is a relatively common disease in East Asian countries. It is one of the leading causes of intrahepatic cholangiocarcinoma. The long-term stimulation of bile duct stones and hepatolithiasis-induced bile duct stricture or obstruction cause chronic irritation of cholestasis. In the presence of bacterial infection and other etiological factors, chronic proliferative inflammation of bile ducts will be caused. Eventually, biliary epithelial dysplasia, metaplasia, and even malignant transformation develop. In this paper, we describe the etiology, clinical manifestations, pathological characteristics, imaging diagnosis, and treatment of hepatolithiasis with intrahepatic cholangiocarcinoma. Diagnosis and treatment of hepatolithiasis with intrahepatic cholangiocarcinoma represent a great challenge to surgeons.

Diagnosis of distal cholangiocarcinoma after the removal of choledocholithiasis

Background and Aim. Distal cholangiocarcinoma associated with choledocholithiasis has not been reported, and the causal relationship remains to be established. We evaluated diagnosis of distal cholangiocarcinoma diagnosed after the removal of choledocholithiasis. Patients and Methods. We assigned 9 cases of cholangiocarcinoma with choledocholithiasis to Group A. As a control group, 37 patients with cholangiocarcinoma without choledocholithiasis were assigned to Group B. Results. Abdominal pain at admission is the only significant difference between Group A and Group B (P = 0.001). All patients in Group A had gall bladder stones, compared with 7 patients (19%) in Group B (P < 0.01). Of the 9 patients in Group A, endoscopic retrade cholangiopancreatography (ERCP) detected normality in 2 patients (22%) and abnormalities in 7 patients (78%). Of the 32 patients in Group B, ERCP detected normality in 4 patients (13%) and abnormalities in 28 patients (88%) (P = 0.597). Intraductal ultrasonography (IDUS) detected a tumor in 8 patients in Group A, while in Group B, IDUS detected normality in 1 patient (3%) and tumors in 29 patients (97%) (P = 1.000). Conclusions. IDUS after stone removal may potentially help in the detection of unexpected tumors. Therefore, we believe that IDUS after stone removal will lead to improve outcome and prognosis.

Long-term clinical outcome of the surgically resected intraductal papillary neoplasm of the bile duct

BACKGROUND & AIMS

Intraductal papillary neoplasm of the bile duct (IPNB) is a biliary neoplasm with predominant intraductal papillary growth and various degrees of malignant transformation. Although IPNB has been recently added to the WHO classification, the classification system needs refinements.

METHODS

We retrospectively reviewed 93 non-invasive and invasive IPNB cases, surgically resected from 1996 to 2006. To further characterize their biologic behavior, we modified the WHO classification into a 4-tier category system in which non-invasive IPNB cases with complex fused or cribriform papillae were separately designated. Epithelial types such as intestinal, gastric, pancreatobiliary, and oncocytic type were determined by morphology and mucin core protein immunohistochemistry. Resection margins were classified based on their microscopic appearances. The prognostic values of mucinous histology and MUC1 protein expression were also determined.

RESULTS

IPNB with complex fused or cribriform papillae showed a worse prognosis than IPNB with simple papillae and one such case showed a metachronous metastasis. In addition, a positive surgical margin including dysplasia was associated with worse outcomes. Among the invasive IPNB cases, MUC1-positive tumors were more aggressive than MUC1-negative tumors.

CONCLUSIONS

We propose that non-invasive IPNB with complex fused or cribriform papillae might be better classified as mucosa-confined cholangiocarcinoma rather than IPNB with high grade dysplasia. In addition, aggressive further resection is recommended when a positive surgical margin including dysplasia is reported during intraoperative histopathological evaluation.

Risk factors for gallbladder cancer and cholangiocarcinoma: similarities, differences and updates

INTRODUCTION

Far-ranging variation in the incidence of gallbladder cancer (GBC) and cholangiocarcinoma (CCA) in different geographic regions on the globe may reflect the risk factor distribution for these tumors

METHODS

The authors give a comprehensive review on the known risk factors for GBC and CCA, and analyze both similarities and differences between the risk factors for the two main types of biliary cancer

DISCUSSION AND CONCLUSION

Leading risk factors for GBC include gallstones, female gender, and advancing age. Primary sclerosing cholangitis, nitrosamine exposure, choledochal cysts, Clonorchis sinensis and Opisthorchis viverrini represent important risk factors for CCA, although a specific risk factor cannot be identified for many patients. While both cancers affect mostly individuals in their sixth decade or older, CCA has a male predominance and GBC--a predilection for females. Although the current level of understanding of the molecular pathogenesis of GBC and CCA at the interface with specific risk factors is significantly lower than for other gastrointestinal malignancies, it continues to evolve and may soon open new avenues for the therapy of biliary cancers.

Intrahepatic cholangiocarcinoma: prognostic factors after liver resection

Liver resection may represent the only hope of cure for patients with intrahepatic cholangiocarcinoma (IHC) but long-term results are still far from satisfactory and the impact of prognostic factors is still controversial. Fifty-five patients underwent hepatectomy for IHC between 1997 and 2008 in our unit. Features of the patients and the tumors, operations, postoperative and long-term results were retrospectively assessed. Twenty-one patients had HBV/HCV infection, four had congenital biliary dilatation. Thirty-two patients had increased CA 19-9; 12 had multiple (≥ 4) tumors. Operations included 43 major resections, with 9 resections of biliary confluence, 40 regional lymphadenectomies. Operative mortality and morbidity were 0 and 27.3%, respectively. There were 44 R0-resections (80.0%). Lymphadenectomy yielded lymph node metastases in 14 cases (14/40; 35.0%). Five-year overall and disease-free survival rates were 30.2 and 27.5%, respectively. At multivariate analysis the strongest poor prognostic factor for overall survival was tumor stage. This factor, with multiplicity of lesions (≥ 4) and tumor grading > 2, was significant predictor of recurrence. CA19-9 > 100 IU/mL and tumor grading > 2 were found to be significantly related with early multinodular hepatic recurrence. Patients with lymph node metastases had significantly lower overall and disease-free survival but patients who underwent lymph node dissection with negative lymph nodes at final pathology showed significantly higher 5-year disease-free survival than patients who did not underwent lymphadenectomy. In conclusion, these results support the role of hepatectomy with regional lymphadenectomy as the best available treatment for IHC. Prognosis after liver resection correlates with clinical stage and multiplicity of lesions.

Epidemiology of primary and secondary liver cancers

Primary liver cancer is the sixth most common cancer worldwide with a wide geographic distribution. The incidence of primary liver cancer is increasing and there is still a higher prevalence in developing countries. Early recognition remains an obstacle and lack of it results in poor outcomes for hepatocellular carcinoma (HCC), the most prevalent primary liver cancer, and cholangiocarcinoma. The most common risk factors associated with HCC are hepatitis B and chronic hepatitis C infections, alcohol use, smoking, and aflatoxin exposure. Emerging risk factors such as obesity might play an important role in the future because of the increasing prevalence of this condition.

Bilateral liver resection for bilateral intrahepatic stones

AIM: To evaluate the short- and long-term outcomes of bilateral liver resection for bilateral intrahepatic stones.

METHODS: We reviewed retrospectively 101 consecutive patients with bilateral intrahepatic stones who underwent bilateral liver resection in the past 10 years. The short- and long-term outcomes of the patients were analyzed. The Cox proportional hazards model was used to identify the risk factors related to stone recurrence.

RESULTS: There was no surgical mortality in this group of patients. The surgical morbidity was 28.7%. Stone clearance rate after hepatectomy was 84.2% and final clearance rate was 95.0% following postoperative choledochoscopic lithotripsy. The stone recurrence rate was 7.9% and the occurrence of postoperative cholangitis was 6.5% in a median follow-up period of 54 mo. The Cox proportional hazards model indicated that liver resection range, less than the range of stone distribution (P = 0.015, OR = 2.152) was an independent risk factor linked to stone recurrence.

CONCLUSION: Bilateral liver resection is safe and its short- and long-term outcomes are satisfactory for bilateral intrahepatic stones.

Selection of appropriate liver resection in left hepatolithiasis based on anatomic and clinical study

BACKGROUND

Because of the possibility of injury to the left medial section of the bile duct (B4) and the presumed higher recurrence rate of hepatolithiasis, some surgeons have recently preferred left hepatectomy for left hepatolithiasis. We investigated the appropriate treatment for left hepatolithiasis by evaluating the anatomy and variations of the left hepatic duct system in a normal population and analyzed the clinical outcome of liver resection.

METHODS

We reviewed the magnetic resonance imaging results of 115 normal subjects who underwent a workup for living related liver donation. An imaginary surgical resection line was established based on the lateral margin of the umbilical portion of the liver in T2-weighted axial images. The junction of B4 with the left hepatic duct was evaluated to determine the possibility of injury during liver resection. We also analyzed the clinical outcomes of 181 patients who underwent left lateral sectionectomy or left hepatectomy.

RESULTS

The anatomic evaluation showed that B4 joined lateral to the umbilical portion of the liver in 7.0% (8/115) of cases. In patients with left hepatolithiasis, left hepatectomy was performed in 79 patients and left lateral sectionectomy in 102. The operating time for the left lateral sectionectomy was significantly shorter than that for left hepatectomy (p=0.001). There were no significant differences in complications or recurrence of stones.

CONCLUSION

Preoperative cholangiography should be performed to evaluate the anatomy of the left hepatic duct to avoid injuring B4. For most cases of left hepatolithiasis without a left hilar stricture, left lateral sectionectomy is the safest, most effective treatment.

Intraoperative biliary exploration through the left hepatic duct orifice during left hepatectomy in patients with left-sided hepatolithiasis

BACKGROUND AND AIMS

Left-sided hepatolithiasis often requires left hepatectomy and exploration of the common bile duct and right hepatic duct. The aim of this study was to assess the feasibility of alternative method of bile duct exploration other than choledochotomy.

MATERIALS AND METHODS

A prospective study involving 50 cases of left hepatectomy for left or bilateral intrahepatic stone was performed. Left hepatic duct (LHD) orifice was used as primary access route for biliary exploration. Choledochotomy was performed only for large common bile duct stones, variant bile duct anatomy, or intentional T-tube insertion for later removal of residual stones.

RESULTS

In 44 patients with left-sided hepatolithiasis, biliary exploration through LHD orifice was performed in 40 (90.9%); T-tube choledochotomy was required in three (9.1%). There was neither residual stone nor major surgical complication except infection, and recurrence occurred in one patient during mean follow-up of 32 months. On the other hand, T-tube choledochotomy was performed in three of six patients with bilateral hepatolithiasis (50%). Three patients had residual stones, and two of them were treated by cholangioscopy through the T-tube tract. Recurrence occurred in two patients.

CONCLUSION

We think that intraoperative biliary exploration through LHD orifice in left-sided hepatolithiasis patients is an effective approach simplifying the operation procedure by avoiding choledochotomy and subsequent T-tube insertion.

Outcomes of Hepatectomy for Hepatolithiasis

AIM

Surgical and nonsurgical procedures for management of hepatolithiasis have been reported. The aim of this study was to evaluate immediate and long-term results of hepatectomy as treatment for hepatolithiasis.

MATERIALS AND METHODS

Immediate and long-term outcomes of 123 consecutive patients who underwent hepatectomy for hepatolithiasis at our institution from 2000 to 2005 were analyzed retrospectively. Acute cholangitis was the major presenting symptom (in 106 out of 123, 86.2% of cases).

RESULTS

The immediate stone clearance rate was 92.7% (114 out of 123) and final stone clearance rate was 96% (118 out of 123) after subsequent T-tube route or endoscopic retrograde cholangiopancreatography (ERCP). Residual stones were identified in 5 patients (4%). The surgical morbidity and mortality rates were 33.3% (41 out of 123) and 1.6% (2 out of 123) respectively. Of the 123 patients, 3 (2.4%) had associated cholangiocarcinoma at the time of hepatectomy. With a median follow-up of 40.3 months (range 5-58), a recurrent stone developed in 7 patients (5.7%) and cholangiocarcinoma in 2 (1.6%). Ten patients died during the follow-up period, with 4 of them (out of 123, 3.2%) due to recurrent stone with sepsis.

CONCLUSION

Hepatectomy is a safe and effective treatment for hepatolithiasis, with a high stone clearance rate and fair rate of surgical complications. Recurrent stone-induced sepsis and cholangiocarcinoma are the major factors compromising long-term survival in these patients.

CT Findings of Cholangiocarcinoma Associated with Recurrent Pyogenic Cholangitis

OBJECTIVE

The purpose of our study was to determine the characteristic CT findings of cholangiocarcinoma associated with recurrent pyogenic cholangitis.

CONCLUSION

CT findings of cholangiocarcinoma associated with recurrent pyogenic cholangitis are important in order to improve early diagnosis and proper treatment. Cholangiocarcinoma associated with recurrent pyogenic cholangitis is predominantly located in the atrophic hepatic lobes and in the hepatic lobes of biliary calculi and is associated with the narrowing or obliteration of the portal vein.

CT Differentiation of cholangiocarcinoma from periductal fibrosis in patients with hepatolithiasis

OBJECTIVE

The objective of our study was to determine useful CT findings for differentiating cholangiocarcinoma from periductal fibrosis in patients with hepatolithiasis.

MATERIALS AND METHODS

CT images of 30 patients with hepatolithiasis and pathologically proven cholangiocarcinoma (n = 14) or periductal fibrosis (n = 16) were retrospectively reviewed. Helical CT scans were obtained before, 30 seconds after, and 65 seconds after the start of contrast material injection. Analysis of CT findings included evaluation for the presence of periductal soft-tissue density, bile duct wall thickening at the stricture site, ascites, portal vein obliteration, lymph node enlargement, and a duct stone; assessment of the degree of ductal dilatation; and evaluation of the enhancement pattern of periductal lesions, thickened ductal wall, and hepatic parenchyma. The CT attenuation coefficients of the thickened ductal wall and adjacent normal-looking bile duct were measured on images obtained during each phase. Among these findings, statistically significant variables were determined using the Fisher's exact test and Student's t test. Sensitivity and specificity values of the CT criteria were also calculated.

RESULTS

The presence of periductal soft-tissue density (p = 0.002), higher enhancement of the duct than adjacent bile duct on portal venous phase images (p = 0.008), ductal wall thickening (p = 0.026), portal vein obliteration (p = 0.031), and lymph node enlargement (p = 0.031) were found to be the significant findings for differentiating cholangiocarcinoma from fibrosis in patients with hepatolithiasis. When any two or more of these five criteria were used in combination, we could identify 100% of the patients with cholangiocarcinoma but only 12.5% of the patients with fibrosis.

CONCLUSION

Cholangiocarcinoma in patients with hepatolithiasis can be diagnosed using specific CT criteria.

Significance of fluorodeoxyglucose PET imaging in the diagnosis of malignancies in patients with biliary stricture

AIM

This study was performed to evaluate the significance of positron emission tomography using fluorodeoxyglucose (FDG-PET) in diagnosing malignancy in patients with biliary stricture by comparing the sensitivity and specificity of FDG-PET with those of CT scans and cytological examination of the bile.

METHODS

Thirty patients who underwent FDG-PET for differential diagnosis of the disease causing biliary stricture were included in this study. The sites of the strictures were as follows: in the intrahepatic bile duct in five patients, in the peripheral extrahepatic bile duct in 17 patients, and in the distal extrahepatic bile duct in eight patients. The sensitivity and specificity (%) of FDG-PET in diagnosing malignancies were evaluated and compared with those of CT scans and cytological examination using obtained bile. Final diagnoses were based on surgical or biopsy findings. Data was collected and analysed in a retrospective fashion.

RESULTS

Malignant diseases were diagnosed in 21 patients, as follows: cholangiocarcinoma including Klatskin tumour in 10 patients, gallbladder cancer in eight, duodenal and ampulla cancer in two, and pancreatic cancer in one. In diagnosing malignancy in patients with biliary stricture, overall sensitivity and specificity were 85.7 (18/21) and 55.6 (5/9), respectively, for CT, 64.7 (11/17) and 100 (7/7), respectively, for cytological examination of the bile, and 90.5 (19/21) and 77.8 (7/9), respectively, for FDG-PET.

CONCLUSIONS

In diagnosing malignant diseases in patients with biliary stricture, FDG-PET was superior to CT examination in both sensitivity and specificity, and superior to cytological examination of the bile in sensitivity. However, in patients with inflammatory disease, such as primary sclerosing cholangitis and cholecystitis, false positive rates were found. Therefore, a multidisciplinary diagnostic approach using FDG-PET in conjunction with conventional modalities seems essential to a precise differential diagnosis.

[Intra-hepatic cholangiocarcinoma]

Intra-hepatic cholangiocarcinoma (IHCC) is a rare tumor which arises from the epithelial cells of the intra-hepatic bile ducts; it may develop in a healthy liver and bile ducts or in bile ducts with malignant predisposition (Caroli's syndrome, primary sclerosing cholangitis). It has the worst prognosis of any tumor arising in the liver. Unlike hepatocellular carcinoma, no predisposing factors or high-risk populations have been demonstrated for cholangiocarcinoma other than intraphepatic choledocholithiasis such as is seen in east Asian populations. The most common clinical sign is a palpable tumor mass emphasizing that the tumor is usually detected at an advanced stage. CT scanning yields much clinical information but ultrasound-guided needle biopsy is necessary for diagnosis. Aggressive surgical resection is the only treatment modality which has afforded even slight prolongation of survival; hepatic resection must be large with uninvolved resection margins. When an IHCC is deemed resectable (localized tumor without hepatic metastases or intrahepatic or extrahepatic lymph node spread), pre-operative tumor embolization may be useful; when jaundice is present, percutaneous drainage of the dilated biliary system of the liver to be spared may also be necessary. Neither adjuvant nor neo-adjuvant chemotherapy or radiotherapy have shown proof of efficacity. Cholangiocarcinoma complicates sclerosing cholangitis in 10-15% of cases and is very difficult to diagnose. IHCC may also develop in Caroli's syndrome, where it is commonly found incidentally on pathologic examination of a resection specimen after surgery for a complication of the disease.

Immediate and long-term outcomes of hepatectomy for hepatolithiasis

OBJECTIVE

The aim of this study was to evaluate the perioperative and long-term results of hepatectomy for hepatolithiasis.

PATIENTS AND METHODS

Immediate and long-term outcomes of 103 consecutive patients with hepatolithiasis who underwent hepatectomy from 1989 to 2001 were analyzed. Immediate outcomes included stone clearance rate, operative morbidity, and mortality. Long-term results included stone recurrence rate and survival.

RESULTS

The immediate stone clearance rate was 90%, and the final stone clearance rate was 98% after subsequent choledochoscopic lithotripsy by cutaneous stoma or T-tube route. The operative morbidity and hospital mortality rates were 28% and 2%, respectively. Multivariate analysis showed that right hepatectomy (P=.006) and preoperative hyperbilirubinemia (P=.038) were predictive of postoperative complications. Ten patients (10%) had associated cholangiocarcinoma (four known preoperatively) at the time of hepatectomy. With a median follow-up of 56 months (range 6-158), recurrent stones developed in eight patients and cholangiocarcinoma developed in three patients (range: 7-30 months postoperatively). Sixteen patients had died during the follow-up period, none of recurrent cholangitis. Cholangiocarcinoma was the only significant prognostic factor of long-term survival by Cox regression analysis.

CONCLUSIONS

Hepatectomy is a safe and effective treatment for hepatolithiasis, with a high immediate stone clearance rate and a low long-term stone recurrence rate. The presence of associated cholangiocarcinoma is the main factor compromising long-term survival in patients with hepatolithiasis.