Advanced Hilar Cholangiocarcinoma Research Articles

Major hepatic resection for locally advanced hilar cholangiocarcinoma: Experience from a tertiary care centre

Major hepatic resection for locally advanced hilar cholangiocarcinoma: Experience from a tertiary care centre

A Case Report on the Palliative Role of Intraluminal Brachytherapy (IIBT) in Advanced Hilar Cholangiocarcinoma

Cholangiocarcinoma (CCA) is the primary malignant tumor of bile ducts which originates from the cholangiocytes. It accounts for 10-15% of all Hepato-biliary malignancies. Hilar Cholangiocarcinoma (Klatskin tumor) is a type of extrahepatic CCA. We present a case of 37-year-old female patient diagnosed with Hilar Cholangiocarcinoma who presented with complaints of loss of appetite since 2 months associated with generalized itching and yellowish discoloration of sclera & skin with palpable firm mass in right hypochondriac region. The patient underwent Percutaneous Transhepatic Biliary Drainage (PTBD) followed by internalization to relieve the biliary obstruction along with Intra Luminal Brachytherapy (ILBT) of 20Gy (4 fractions of 5Gy each). The patient was symptomatically better for 6 months with much alleviation of pain, jaundice and was able to continue with her daily activities. Therefore, it can be concluded by saying that ILBT is an effective modality of treatment in HCCA for alleviation of pain and maintaining patency post PTBD procedure.

A Case Report on the Palliative Role of Intraluminal Brachytherapy (IIBT) in Advanced Hilar Cholangiocarcinoma

A Case Report on the Palliative Role of Intraluminal Brachytherapy (IIBT) in Advanced Hilar Cholangiocarcinoma

Effect of hepatic artery resection and reconstruction on the prognosis of patients with advanced hilar cholangiocarcinoma

BACKGROUNDHilar cholangiocarcinoma (HC) is a good adaptation certificate of hepatic arterectomy, and hepatic arterectomy is conductive to the radical resection of cholangiocarcinoma, which simplifies the operation and helps with a combined resection of the peripheral portal tissue. With continuous development of surgical techniques, especially microsurgical technique, vascular invasion is no longer a contraindication to surgery in the past 10 years. However, hepatic artery reconstruction after hepatic arterectomy has been performed to treat liver tumor in many centers with better results, but it is rarely applied in advanced HC. AIMTo determine the prognosis of patients with advanced HC after hepatic artery resection and reconstruction.METHODSA total of 98 patients with HC who underwent radical operation in our hospital were selected for this retrospective analysis. According to whether the patients underwent hepatic artery resection and reconstruction or not, they were divided into reconstruction (n = 40) and control (n = 58) groups. The traumatic indices, surgical resection margin, liver function tests before and after the operation, and surgical complications were compared between the two groups.RESULTSOperation time, blood loss, hospital stay, and gastrointestinal function recovery time were higher in the reconstruction group than in the control group (P < 0.05); The R0 resection rates were 90.00% and 72.41% in the reconstruction and control groups, respectively (P < 0.05). Serum alanine aminotransferase was lower in the reconstruction group on day one and three postoperatively, whereas serum aspartate aminotransferase was lower on the third day (P < 0.05). Preoperatively, the Karnofsky performance status scores were similar between the groups (P > 0.05), but was higher in the reconstruction group (P < 0.05) two weeks postoperatively. There was no difference in the complication rate between the two groups (27.50% vs 32.67%, P > 0.05). Two-year survival rate (42.50% vs 39.66%) and two-year survival time (22.0 mo vs 23.0 mo) were similar between the groups (P > 0.05).CONCLUSIONRadical surgery combined with reconstruction after hepatic artery resection improves R0 resection rate and reduces postoperative liver injury in advanced HC. However, the operation is difficult and the effect on survival time is not clear.

Right hepatic trisectionectomy combined total caudate lobectomy with non-touch technique for advanced hilar cholangiocarcinoma: A surgical case report (with video).

BackgroundExtended resection such as right trisegmentectomy combined with total caudate lobectomy with non-touch technique for advanced hilar cholangiocarcinoma (CCA) is still challenging for all Hepato-pancreato-biliary surgeons.PresentationA 45-year-old female with advanced hilar CCA involved the right intrahepatic bile ducts in continuity with the left medial sectional bile duct without PV invasion had undergone right trisegmentectomy combined with total caudate lobectomy with non-touch technique. Dissection of the hepatic peduncle by Lorta-Jacob Procedure, ligation, and resection of the right hepatic artery (RHA) and the right portal vein (PV), before that determine whether portal bifurcation's tumor infiltration or not. Mobilization of the right liver lobe, ligate all the short hepatic veins from the caudal to cranial direction, as well as the right hepatic vein (RHV) and the middle hepatic vein (MHV). Complete caudate lobectomy with right–left approach. Determine hepatic parenchyma cut, left cholangiostomy to the division of the subsegments 2,3, stitch formation of the subsegments 2,3 bile duct. Determine negative upper section of the biliary tract. The operative time was 432 min, and the blood loss was 750 ml. Postoperative recovery was uneventful without any major complications but developed intra-abdominal abscess that required percutaneous drainage.DiscussionExtended resection procedures such as extend right/left trisectionectomy, hepato-pancreaticoduodenectomy (HPD) and/or combined vascular resection are only curative treatment for advanced hilar CCA. There hadn't been any reported cases describing step-by-step right trisegmentectomy combined with total caudate lobectomy with non-touch technique with clear illustrations and videos yet.ConclusionCareful preparation with preoperative biliary drainage as well as precise evaluation of the functional capacity of the future liver remnant, as well as meticulous experience of surgeons in hepatic anatomy and non-touch resection technique are key points for success in extended resection for advanced hilar CCA.

Novel Two Stage Operation for Advanced Hilar Cholangiocarcinoma with Dearterialization of the Liver

Introduction: Advanced hilar cholangiocarcinoma may involve both hepatic arteries or extend to the proper hepatic artery. These patients are often not resectable. Intrahepatic artery reconstruction and preoperative arterial embolization are often insufficient techniques.

The impact of portal vein resection on outcome of hilar cholangiocarcinoma.

Backgrounds/AimsPortal vein resection (PVR) with major hepatic resection can increase the rate of curative resection for hilar cholangiocarcinoma (HC). However, the oncologic role and safety of PVR is still debatable. This study aims to analyze PVR in terms of safety and therapeutic effectiveness.MethodsWe retrospectively analyzed 235 patients who had undergone major hepatic resection for HC with curative intent, including patients with PVR (PVR, n=35) consisting of PV invasion (PVR-A, n=9), No PV invasion (PVR-B, n=26); and patients without PVR (No PVR, n=200).ResultsThere was no significant difference in the 30-day mortality or postoperative morbidity between PVR and No PVR (2.9% vs. 1.0%; p=0.394 and 34.3% vs. 35.0%; p=0.875). The rate of advanced HC (T3: 40% vs. 12%; p<0.001 and nodal metastasis: 60% vs. 28%; p<0.001) was higher in PVR compared to No PVR. There was no significant difference in the 5-year overall survival rates and disease-free survival between PVR-A vs. PVR-B vs. No PVR. In multivariate analysis, estimated blood loss >600 ml (p=0.010), T3 diseases (p=0.001), nodal metastasis (p=0.001) and poor differentiation (p=0.002) were identified as independent risk factors for survival.ConclusionsPVR does not increase postoperative mortality or morbidity. It showed a similar oncologic outcome, despite a more advanced disease state in patients with HC. Given these findings, PVR should be actively performed if necessary, after careful patient selection.

Technical Pitfalls and Complications after Vascular Resection for Advanced Hilar Cholangiocarcinoma

Technical Pitfalls and Complications after Vascular Resection for Advanced Hilar Cholangiocarcinoma

Vascular resection and reconstruction in hilar cholangiocarcinoma.

The aggressive approach of vascular resection plus reconstruction in curative resection of hilar cholangiocarcinoma (HC) remains controversial. This retrospective study investigated its short- and long-term outcomes. Data of HC patients from 1989 to 2016 were reviewed. Operated patients were divided into two groups (with and without vascular resection) and compared in terms of perioperative results. Patients who had unresectable HC were also compared with patients who had been operated. Ninety patients underwent curative HC resection. They were divided into group A (without aggressive approach, n = 68) and group B (with aggressive approach, n = 22). The groups were comparable in all parameters including rates of overall and major complication and in-hospital, 30-day and 90-day mortality except that group B had more patients with more advanced disease (P = 0.008), more patients with tumour invasion of the vasculature (40.9% versus 7.4%, P = 0.001), and fewer patients with blood transfusion (27.3% versus 52.9%, P = 0.036). The groups had similar disease-free survival (group A: median, 17.9 months, 5 years, 27.4%; group B: median, 11.7 months, 5 years, 14.3%; P = 0.427) and overall survival (group A: median, 22.0 months, 5 years, 26.5%; group B: median, 26.5 months, 5 years, 14.7%; P = 0.90). Two hundred patients with unresectable HC were compared with patients who had received operation and found to have worse survival outcomes (P < 0.001). Vascular resection plus reconstruction in HC resection was feasible and safe and might improve the long-term survival of patients with advanced HC. This aggressive approach should be adopted if the expertise is available and the patient's condition allows.

Right trisectionectomy with portal reconstruction for klatskin tumor

Abstract Background: Many techniques of right hepatic trisectionectomy (extended right hepatectomy) are now standardized in patients with hepatocellular carcinoma or metastatic tumors, but in case of hilar cholangiocarcinoma are not yet. Materials: We present a 66 years old male, under preoperative diagnosis of hilar cholangiocarcinoma, a patient underwent right hepatic trisectionectomy with previous portal embolization and hepaticojejunostomy. During the procedure a part of portal vein was resected for infiltration and embolization at the first stage. Limph nodes were resected too. Results: In the second stage the extended right hepatectomy was successfully performed, and the patient was discharged from the hospital in good condition. Histologically was diagnosed as having cholangiocarcinoma. The resection margins, proximal and distal, were negative. The lymph nodes were neoplasia-negatives. Conclusions: Extended right hepatectomy with portal vein reconstruction can be used for a longer proximal resection and can offer a better chance of long-term survival in selected patients with locally advanced hilar cholangiocarcinoma.

Long-term survival of a patient with locally advanced hilar cholangiocarcinoma (Klatskin tumor): A case report and review on high level evidence

Cholangiocarcinoma, malignant tumor of epithelial cells of bile ducts has poor overall survival and prognosis. We report a case of non-resectable cholangiocarcinoma with a 57-month survival after incomplete R2 surgical margin resection of the tumor. A 52-year old man with generalized itching, jaundice, brownish urine, mild abdominal pain and weight loss of 8 kg in last two months presented. Imaging and surgical workups showed hilar cholangiocarcinoma (Klatskin tumor). Along with incomplete R2 margin resection we performed stent embedding and post-operative adjuvant chemotherapy. Based on current literature data there is no superiority of adjuvant chemotherapy after complete R0 resection compared to incomplete R2 resection. However, it seems that partial resection along with stent embedding and applied adjuvant chemotherapy in cases of locally advanced non-resectable cholangiocarcinoma may increase survival rate.

Assessment of treatment outcomes in patients with advanced hilar cholangiocarcinoma (stages III-IV): Clinical significance of interventional therapy.

The clinical significance of palliative interventional therapy in the management of patients with advanced hilar cholangiocarcinoma (HCCA; stages III–IV) has yet to be studied. The present work was aimed to compare the clinical outcomes of the patients treated with surgery or interventional therapy.A total of 90 patients with advanced HCCA, who admitted Fuyang First People's Hospital from May 2015 to February 2016, were enrolled. Forty-five of them were assigned to the experimental group receiving biliary drainage as the interventional therapy, and the remaining 45 patients were designated as the conventional group receiving radical/palliative surgery. Before and after the treatment total bilirubin from blood was measured. The length of treatment and medical cost were also examined. All patients were followed up for at least 1 year after the treatment.For both the experimental and conventional groups, the serum bilirubin levels after treatment were significantly lower than those before treatment (P < .05); however, no significant differences between groups were seen. There were no significant differences between experimental and conventional groups in the incidence of postoperative complications and survival outcomes. Of note, the length of treatment of the experimental group was substantially shorter than that of the conventional group (P < .05). The medical expense of the experimental group was only about one-third of that of the conventional group (P < .05).Although the interventional therapy does not improve patients’ survivals and reduce the incidence of complications, it significantly shortens the treatment length, reducing substantially the medical expense. This finding provides new insights into the treatment strategy for patients with advanced HCCA.

Safety and efficacy of irreversible electroporation in the treatment of obstructive jaundice in advanced hilar cholangiocarcinoma

BackgroundIrreversible electroporation (IRE) has successfully been used for palliation of pancreatic and liver cancers due to its ability to ablate tumors without destroying nearby vital structures. To date, it has not been evaluated in patients with advanced hilar cholangiocarcinoma (AHC). This study presents a single-institution experience with IRE for management of obstructive jaundice in AHC. MethodsA single-institution database was queried for patients undergoing IRE for AHC after PTBD placement for relief of obstructive jaundice from 2010 to 2017 and compared to a control group treated with standard of care only (No IRE). ResultsTwenty-six patients underwent IRE for AHC after PTBD replacement. Three patients experienced complications, with two experiencing severe (≥ grade 3) complications. After IRE, median time to PTBD removal was 122 days (range 0–305 days) and median catheter-free time before requiring PTBD replacement was 305 days (range 92–458 days). In comparison, the 137 control patients had an admission rate of 59% (N = 80 patients) for PTBD infection, occlusion, or catheter related problem. ConclusionIRE safely achieves biliary decompression via tumor electroporation and allows PTBD removal for an extended period of time. In appropriately selected patients with obstructive jaundice in the setting of AHC, IRE can be used to increase catheter-free days and optimize overall quality of life.

Nutritional prognostic scores in patients with hilar cholangiocarcinoma treated by percutaneous transhepatic biliary stenting combined with 125I seed intracavitary irradiation: A retrospective observational study.

We mainly aimed to preliminarily explore the prognostic values of nutrition-based prognostic scores in patients with advanced hilar cholangiocarcinoma (HCCA).We retrospectively analyzed 73 cases of HCCA, who underwent percutaneous transhepatic biliary stenting (PTBS) combined with 125I seed intracavitary irradiation from November 2012 to April 2017 in our department. The postoperative changes of total bilirubin (TBIL), direct bilirubin (DBIL), alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (ALP), and albumin (ALB) were observed. The preoperative clinical data were collected to calculate the nutrition-based scores, including controlling nutritional status (CONUT), C-reactive protein/albumin ratio (CAR), and prognostic nutritional index (PNI). Kaplan–Meier curve and Cox regression model were used for overall survival (OS) analyses.The serum levels of TBIL, DBIL, ALT, AST, and ALP significantly reduced, and ALB significantly increased at 1 month and 3 months postoperatively. The median survival time of the cohort was 12 months and the 1-year survival rate was 53.1%. Univariate analysis revealed that the statistically significant factors related to OS were CA19-9, TBIL, ALB, CONUT, and PNI. Multivariate analysis further identified CA19-9, CONUT, and PNI as independent prognostic factors.Nutrition-based prognostic scores, CONUT and PNI in particular, can be used as predictors of survival in unresectable HCCA.

Assessment of clinical outcomes of advanced hilar cholangiocarcinoma

BackgroundLow resectability and poor survival outcome are common for hilar cholangiocarcinoma (HCCA), especially in advanced stages. The present study was to assess the clinical outcome of advanced HCCA, focusing on therapeutic modalities, survival analysis and prognostic assessment. MethodsClinical data of 176 advanced HCCA patients who had been treated in our hospital between January 2013 and December 2015 were analyzed retrospectively. Prognostic effects of clinicopathological factors were explored by univariate and multivariate analysis. Survival predictors were evaluated by the receiver operating characteristic (ROC) curve. ResultsThe 3-year overall survival rate was 13% for patients with advanced HCCA. Preoperative total bilirubin (P = 0.009), hepatic artery invasion (P = 0.014) and treatment modalities (P = 0.020) were independent prognostic factors on overall survival. A model combining these independent prognostic factors (area under ROC curve: 0.748; 95% CI: 0.678–0.811; sensitivity: 82.3%, specificity: 53.5%) was highly predictive of tumor death. After R0 resection, the 3-year overall survival was up to 38%. Preoperative total bilirubin was still an independent negative factor, but not for hepatic artery invasion. ConclusionsSurgery is still the best treatment for advanced HCCA. Preoperative biliary drainage should be performed in highly-jaundiced patients to improve survival. Prediction of survival is improved significantly by a model that incorporates preoperative total bilirubin, hepatic artery invasion and treatment modalities.

Safety and efficacy of irreversible electroporation in the treatment of obstructive jaundice in locally advanced hilar cholangiocarcinoma

Safety and efficacy of irreversible electroporation in the treatment of obstructive jaundice in locally advanced hilar cholangiocarcinoma

Peripheral hepatojejunostomy: a last resort palliative solution in Greece during the economic crisis

The geographical distribution of Greece and the growing proportion of uninsured patients make imperative the need for effective and efficient palliative solutions regarding obstructive jaundice due to hepatic malignancy, while...

Clinical Implications of Biliary Confluence Pattern for Bismuth-Corlette Type IV Hilar Cholangiocarcinoma Applied to Hemihepatectomy

BackgroundSince biliary variations are commonly seen, our aims are to clarify these insidious variations and discuss their surgicopathologic implications for Bismuth-Corlette (BC) type IV hilar cholangiocarcinoma (HC) applied to hemihepatectomy. MethodsThree-dimensional images of patients with distal bile duct obstruction (n = 97) and advanced HC (n = 79) were reconstructed and analyzed retrospectively. Normal biliary confluence pattern was defined as the peripheral segment IV duct (B4) joining the common trunk of segment II (B2) and segment III (B3) ducts to form the left hepatic duct (LHD) that then joined the right hepatic duct (RHD). The lengths from left and right secondary biliary ramifications to the right side of the umbilical portion of the left portal vein (Rl-L) and the cranio-ventral side of the right portal vein (Rr-R) were measured, respectively, and compared with the resectable bile duct length in HCs. Surgicopathologic findings were compared between different BC types. ResultsThe resectable bile duct length in right hemihepatectomy for eradication of type IV tumors was significantly longer than the Rl-L length in normal biliary configuration (17.4±1.8 and 10.3±3.4 mm, respectively, p < 0.001), and type III variation (B2 joining the common trunk of B3 and B4) was the predominant configuration (53.8%). The resectable length in left hemihepatectomy for eradication of type IV tumors was comparable with the Rr-R length in RHD absent cases (15.2±2.5 and 16.4±2.6 mm, respectively, p = 0.177) but significantly longer than that in normal configuration (p < 0.001). The estimated length was 8.5 ± 2.0mm in unresectable cases. There was no significant difference between type III and IV tumors, except for the rate of nodal metastasis (29.7 and 76.0%, respectively, p < 0.001). ConclusionHemihepatectomy might be selected for curative-intent resection of BC type IV tumors considering the advantageous biliary variations, whereas anatomical trisegmentectomy is recommended for the resectable bile duct length less than 10 mm. Biliary variations might result in excessive classification of BC type IV but require validation on further study.

Endoscopic Nested Y-Shaped Self-Expanding Metal Stent Placement for Advanced Hilar Cholangiocarcinoma: A Study of a Novel Stent With a Unique Mesh Structure

Endoscopic Nested Y-Shaped Self-Expanding Metal Stent Placement for Advanced Hilar Cholangiocarcinoma: A Study of a Novel Stent With a Unique Mesh Structure

Multimodal treatment strategies for advanced hilar cholangiocarcinoma.

Cholangiocarcinoma (CCA) is the second most common primary malignancy of the liver arising from malignant transformation and growth of biliary ductal epithelium. Approximately 50-70 % of CCAs arise at the hilar plate of the biliary tree, which are termed hilar cholangiocarcinoma (HC). Various staging systems are currently employed to classify HCs and determine resectability. Depending on the pre-operative staging, the mainstays of treatment include surgery, chemotherapy, radiation therapy, and photodynamic therapy. Surgical resection offers the only chance for cure of HC and achieving an R0 resection has demonstrated improved overall survival. However, obtaining longitudinal and radial surgical margins that are free of tumor can be difficult and frequently requires extensive resections, particularly for advanced HCs. Pre-operative interventions may be necessary to prepare patients for major hepatic resections, including endoscopic retrograde cholangiopancreatography, percutaneous transhepatic cholangiography, and portal vein embolization. Multimodal therapy that combines chemotherapy with external beam radiation, stereotactic body radiation therapy, bile duct brachytherapy, and/or photodynamic therapy are all possible strategies for advanced HC prior to resection. Orthotopic liver transplantation is another therapeutic option that can achieve complete extirpation of locally advanced HC in judiciously selected patients following standardized neoadjuvant protocols.