Duct Margin Research Articles

Prognostic Impact of Margin Status in Distal Cholangiocarcinoma.

A positive ductal margin is strongly associated with poor survival in patients with distal cholangiocarcinoma. However, the significance of the radial margin status and its effect on survival are not fully clarified. All patients with distal cholangiocarcinoma who underwent pancreatoduodenectomy between January 2000 and December 2018 at Tokai University Hospital were retrospectively analyzed. Positive margins were divided into positive ductal margin and positive radial margin. One hundred and eight consecutive patients with distal cholangiocarcinoma underwent pancreatoduodenectomy. Margin-negative R0 resection was performed in 85 patients (79%). Twenty-three patients (21%) had a positive resection margin (R1 resection). The 5-year survival rate and median overall survival for patients with R0 resection and those with R1 resection was 64%, 98months and 25%, 26months, respectively. There was a significant difference in survival between patients with R0 resection and those with R1 resection (p < 0.001). Patients with positive radial margin (n = 10) had a significantly worse outcome than those with positive ductal margin (n = 13) (p = 0.016). Univariate analysis showed that R1 resection, lymph node metastasis, tumor depth, portal vein invasion, pancreatic invasion, lymphatic invasion, and venous invasion were significant prognostic factors. Multivariate analysis confirmed that R1 resection and nodal involvement were significant independent prognostic indicators after surgical resection for distal cholangiocarcinoma. Positive surgical margin and nodal involvement were the strongest predictors of poor survival in patients with distal cholangiocarcinoma. Patients with a positive radial margin had a significantly worse outcome than those with a positive ductal margin.

Secondary Budd-Chiari syndrome occurred after adjuvant radiotherapy for perihilar cholangiocarcinoma: a case report

BackgroundBudd–Chiari syndrome (BCS) is a rare vascular disorder of the liver, and acute and secondary BCS is even rarer.Case presentationA 62-year-old man with perihilar cholangiocarcinoma of Bismuth type IIIa underwent right hemi-hepatectomy with caudate lobectomy and pancreatoduodenectomy. Adjuvant chemoradiotherapy was performed due to a positive hepatic ductal margin. Subsequently, the disease passed without recurrence. The patient visited for acute onset abdominal pain at the 32nd postoperative month. Multidetector-row computed tomography (MDCT) showed stenosis of the left hepatic vein (LHV) root, which was the irradiated field, and thrombotic occlusion of the LHV. The patient was diagnosed with acute BCS caused by adjuvant radiotherapy. Although anticoagulation therapy was performed, the patient complained of sudden upper abdominal pain again. MDCT showed an enlarged LHV thrombus and hepatomegaly. The patient was diagnosed with exacerbated acute BCS, and stenting for the stenotic LHV root was performed with a bare stent. Although stenting for the LHV root was very effective, restenosis occurred twice due to thrombus in the existing stent, so re-stenting was performed twice. The subsequent clinical course was acceptable without recurrence or restenosis of the LHV root as of 6 months after the last stenting using a stent graft.ConclusionAlthough no case of BCS caused by radiotherapy has yet been reported, the present case showed that late side effect of radiotherapy can cause hepatic vein stenosis and secondary BCS.

A Novel Technique to Temporize a Destructive Common Bile Duct Injury in an Unstable Poly-Trauma Patient

We report a case of a 26-year-old patient presenting as a polytrauma with multiple devastating injuries, including a 1 cm destructive injury to the common bile duct (CBD) along with a laceration to the inferior vena cava (IVC). Studies on temporization strategies for common bile duct injuries in the context of damage control surgery are scarce, and guidelines for management of such injuries are limited due to low quality evidence. Surgical treatment for injuries to the extrahepatic bile ducts are individualized based on location, severity, and stability. In stable patients with less than 50% circumference injuries and healthy common bile duct margins, definitive repair can be attempted primarily. Destructive injuries that encompass greater than 50% circumference in stable patients are more challenging and there is controversy surrounding early versus delayed biliary reconstruction. In this case, an adequately sized T-tube was not available, and closed suction drainage was dismissed due to potential complications with early reconstruction. Due to the patient's critical condition and extraordinary circumstances, a LeMaitre carotid shunt was used to temporize the common bile duct injury for 6 days, a technique not previously described. The patient was then reconstructed with a hepaticojejunostomy in Roux-en-y fashion with a favorable outcome. We believe that this method of temporization may be an especially useful tool in the armamentarium of the surgeon practicing in an austere environment.

"Infiltrative" Versus "Mass-Forming" Pancreatic Cancer: A New Radiological Classification System for Pancreatic Head Ductal Carcinoma and Its Pathological Correlation.

Resectability in localized pancreatic ductal adenocarcinoma (PDAC) is deemed through radiological criteria. Despite initial evaluation classifying tumors as "resectable," they often have ill-defined borders that can result in more extensive cancer than predicted on final pathology analysis. We attempt to categorize these tumors radiologically and define them as "infiltrative" and contrast them to more well-defined or "mass-forming" tumors and assess their correlation with surgical oncological outcomes. We hypothesize that mass-forming lesions will result in fewer positive resection margins. Patients diagnosed with PDAC of the head of the pancreas and who underwent subsequent curative intent resection between 2016 and 2018 were included. A retrospective chart review of patients was conducted and computed tomography images at the time of diagnosis were reviewed by two radiologists and scored as "mass forming" or "infiltrative" using a newly developed classification system. These classifications were then correlated with margin status. Sixty-eight consecutive pancreatoduodenectomies performed for PDAC from 2016 to 2018 were identified. After screening, 54 patients were eligible for inclusion. Radiologically defined mass-forming lesions had a trend toward a lower rate of positive resection margins (35.7% vs. 50.0%; p = 0.18), specifically the bile duct margin and pancreas margin as well as an overall larger size (4.03 cm vs. 3.25 cm, p = 0.02) compared with infiltrative lesions. We propose a new radiological definition of PDAC into "mass forming" and "infiltrative," a nomenclature that resonates with other tumor sites. Infiltrative lesions trended toward a higher rate of positive resection margins. This classification may help tailor therapy for infiltrative tumors toward a neoadjuvant approach even if they appear resectable.

S1724 Eosinophilic Cholangitis: A Great Mimic

Introduction: Eosinophilic Cholangitis (EC) is a rare infiltrative disorder of the biliary tree and a diagnostic dilemma. The initial presentation mimics malignancy and is distinguished by histopathology. Steroid response supports the diagnosis. This case elucidates the diagnostic and therapeutic approach to EC in a patient with acute jaundice. Case Description/Methods: A 44-year-old female with a history of SLE and marginal cell lymphoma in remission presented with fevers, leukocytosis, abdominal pain, and hyperbilirubinemia. She underwent an ERCP that showed a common bile duct (CBD) stricture with stent placement that was removed 6 weeks later (Figure). She then underwent a cholecystectomy for chronic cholecystitis with an intraoperative liver biopsy for persistently elevated LFTs (AST 512 U/L, ALT 500 U/L). Surgical specimens showed dense eosinophils at the cystic duct margin with mild non-specific lobular inflammation involving 15% of liver parenchyma. Six months later, she presented to our hospital with worsening abdominal pain and jaundice. Pertinent labs included a total bilirubin of 16.9 mg/dL, AST 321 U/L, ALT 335 U/L, and alkaline phosphatase 2700 U/L. MRCP showed CBD narrowing at the hilum with intrahepatic ductal dilation She underwent an ERCP which identified a Bismuth IV hilar stricture and a ductal polypoid mass on cholangioscopy. Two biliary stents were placed across the stricture into the right and left intrahepatic ducts. A direct biopsy, while negative for malignancy, revealed marked eosinophilia. Labs included peripheral eosinophilia of 0.78 x109/L. IgG4 and Anti-mitochondrial antibody were normal. A month later, repeat ERCP with stents exchange and ductal mass re-biopsy was performed given high concern for malignancy, however again demonstrated sheets of eosinophils. After multidisciplinary discussion, she was presumptively diagnosed with EC and started on 40mg of prednisone. Seven weeks later, repeat ERCP showed complete resolution of the stricture. LFTs and bilirubin normalized. Her symptoms resolved and she was transitioned to azathioprine for maintenance. Discussion: EC is a rare, benign process affecting the biliary system and poses a significant diagnostic challenge. Our case supports proposed diagnostic criteria for EC, including biliary stricture, eosinophilic infiltration on histopathology, and steroid responsiveness. Our case is unique in our demonstration of the direct cholangioscopy view of this benign entity and the utility of cholangioscopy in achieving the diagnosis.Figure 1.: a) Ductal polypoid mass near common hepatic duct identified via endoscopic retrograde cholangiopancreatography with cholangioscopy. b) Intrahepatic biliary ductal dilatation seen on magnetic resonance cholangiopancreatography. c) Occlusion cholangiogram during endoscopic retrograde cholangiopancreatography showing a Bismuth Type IV common bile duct stricture. d) Occlusion cholangiogram during endoscopic retrograde cholangiopancreatography showing resolution of the common bile duct stricture after steroid treatment. e) Biliary stricture biopsies showing fragments of bile duct mucosa with acute and chronic inflammation with marked eosinophilia. f) Ductal mass/biliary stricture biopsy demonstrating inflammation and eosinophilia on Hematoxylin-eosin stain.

Accelerated T2-weighted MRI of the liver at 3T using a single-shot technique with deep learning-based image reconstruction: impact on the image quality and lesion detection.

Fat-suppressed T2-weighted imaging (T2-FS) requires a long scan time and can be wrought with motion artifacts, urging the development of a shorter and more motion robust sequence. We compare the image quality of a single-shot T2-weighted MRI prototype with deep-learning-based image reconstruction (DL HASTE-FS) with a standard T2-FS sequence for 3T liver MRI. 41 consecutive patients with 3T abdominal MRI examinations including standard T2-FS and DL HASTE-FS, between 5/6/2020 and 11/23/2020, comprised the study cohort. Three radiologists independently reviewed images using a 5-point Likert scale for artifact and image quality measures, while also assessing for liver lesions. DL HASTE-FS acquisition time was 54.93 ± 16.69, significantly (p < .001) shorter than standard T2-FS (114.00 ± 32.98s). DL HASTE-FS received significantly higher scores for sharpness of liver margin (4.3 vs 3.3; p < .001), hepatic vessel margin (4.2 vs 3.3; p < .001), pancreatic duct margin (4.0 vs 1.9; p < .001); in-plane (4.0 vs 3.2; p < .001) and through-plane (3.9 vs 3.4; p < .001) motion artifacts; other ghosting artifacts (4.3 vs 2.9; p < .001); and overall image quality (4.0 vs 2.9; p < .001), in addition to receiving a higher score for homogeneity of fat suppression (3.7 vs 3.4; p = .04) and liver-fat contrast (p = .03). For liver lesions, DL HASTE-FS received significantly higher scores for sharpness of lesion margin (4.4 vs 3.7; p = .03). Novel single-shot T2-weighted MRI with deep-learning-based image reconstruction demonstrated superior image quality compared with the standard T2-FS sequence for 3T liver MRI, while being acquired in less than half the time.

A retrospective analysis of the diagnostic accuracy and technical quality of frozen sections in detecting hepatobiliary lesions

IntroductionPathological consultation on intraoperative frozen sections plays a crucial role in the management of patients undergoing surgical therapy, and is also a key indicator for quality assurance in anatomical pathology. This study aimed to evaluate the diagnostic accuracy and technical quality of frozen sections in detecting hepatobiliary lesions with malignant potential. Patients and methodsA retrospective database review was performed for 1208 cases intraoperative pathology consultation who underwent hepatobiliary lesions resection at our institution from 2016 to 2020. The intraoperative consultation cases during a 5-year period were reviewed and analyzed, including the measurement of the diagnostic accuracy and turnaround time of frozen sections, the reasons for discrepancies, and the rates of discordance and deferral. ResultsIn this study, we confirmed that the overall accuracy, sensitivity and specificity were 95.3 %, 96.3 % and 96.6 %, respectively, in distinguishing benign from malignant lesions. The rates of deferred and discordant diagnoses were 2.57 % and 2.2 %, respectively. The overall frozen section turnaround time was 22.1 min. The most common cause of deferred and discordant was poor section quality, the lesion of bile duct margin on the frozen section, misinterpretation of difficult and complicated cases, etc. ConclusionsThis study confirms that the intraoperative frozen sections can serve as a rapid, accurate and robust method for the pathological diagnosis of suspected hepatobiliary lesions. However, it should be noted that some poor technical problems, pathological assessment of tumor margin and difficult cases are the most frequently causes of deferred and discordant interpretations.

Converted-hepatopancreatoduodenectomy for an intraoperative positive ductal margin after pancreatoduodenectomy in distal cholangiocarcinoma.

Pancreatoduodenectomy (PD) is the standard treatment for distal cholangiocarcinoma, and a negative ductal margin (DM0) is indispensable for the long-term survival. When intraoperative frozen sections of ductal margin after PD are positive, converted-hepatopancreatoduodenectomy (C-HPD) is the final option available to gain an additional ductal margin. However, the efficacy of C-HPD remains unclear. Patients who underwent PD or C-HPD for distal cholangiocarcinoma between 2002 and 2019 were analyzed. The type of hepatectomy in C-HPD was restricted to left hepatectomy to prevent posthepatectomy liver failure. Of 203 patients who underwent PD for distal cholangiocarcinoma, 49 patients exhibited intraoperative positive ductal margin (DM1) after PD. Eleven patients underwent C-HPD for intraoperative DM1 after PD, in which intraoperative DM1 with invasive carcinoma (DM1inv) was observed in 3 patients, and intraoperative DM1 with carcinoma in situ (DM1cis) was observed in 8 patients. The median additional ductal margin yielded by C-HPD was 9mm (interquartile range 7-13mm). C-HPD eradicated intraoperative DM1inv in 3 patients, with 2 patients showing DM0 and 1 patient showing DM1cis. Regarding 8 patients who underwent C-HPD for intraoperative DM1cis, 4 patients had DM0, but the others had DM1cis. C-HPD was associated with a high complication rate, but no mortality was observed. The median survival time of patients who underwent C-HPD was 48.8months. C-HPD was able to safely eradicate intraoperative DM1inv after PD. However, the length of the resected bile duct according to C-HPD may not be sufficient to remove intraoperative DM1cis after PD.

Does Intraoperative Frozen Section and Revision of Margins Lead to Improved Survival in Patients Undergoing Resection of Perihilar Cholangiocarcinoma? A Systematic Review and Meta-analysis.

Perihilar cholangiocarcinoma (PHC) is a rare malignancy that arises at the biliary confluence. Achieving a margin-negative resection (R0) is challenging given the anatomic location of tumors and remains the most important prognostic indicator of long-term survival. The objective of this study is to review the impact of intraoperative revision of positive biliary margins in PHC on oncologic outcomes. Electronic databases were searched from inception to October 2021. Studies comparing three types of patients undergoing resection of PHC with intraoperative frozen section of the proximal and/or distal bile ducts were identified: those who were margin-negative (R0), those with an initially positive margin who had revised negative margins (R1R0), and those with a persistently positive margin with or without revision of a positive margin (R1). The primary outcome was overall survival (OS). Secondary outcomes included risk of postoperative complication. A total of 449 studies were screened. Ten retrospective observational studies reporting on 1955 patients were included. Patients undergoing successful revision of a positive proximal and/or distal bile duct margin (R1R0) had similar OS to those with a primary margin-negative resection (R0) [hazard ratio (HR) 0.93, 95% confidence interval (CI) 0.72-1.19, p = 0.56, I2 = 84%], and significantly better OS than patients with a positive final bile duct margin (R1) (HR 0.52, 95% CI 0.34-0.79, p = 0.002, I2 = 0%). There was no increase in the risk of postoperative complications associated with additional resection, although postoperative morbidity was inconsistently reported. This review supports routine intraoperative biliary margin evaluation during resection of PHC with revision if technically feasible.

Value of routine intraoperative frozen sections of proximal bile duct margins in perihilar cholangiocarcinoma, a retrospective multicenter and matched case-control study

BackgroundCurrently, the potential benefits of additional resection after positive proximal intraoperative frozen sections (IFS) in perihilar cholangiocarcinoma (pCCA) on residual disease and oncological outcome remain uncertain. Therefore, the aim of this study is to investigate the number of R0 resections after additional resection of a positive proximal IFS and the influence of additional resections on overall survival (OS) in patients with pCCA. Materials and methodsA retrospective, multicenter, matched case-control study was performed, including patients undergoing resection for pCCA between 2000 and 2019 at three tertiary centers. Primary outcome was the number of achieved ‘additional’ R0 resections. Secondary outcomes were OS, recurrence, severe morbidity and mortality. ResultsForty-four out of 328 patients undergoing resection for pCCA had a positive proximal IFS. An additional resection was performed in 35 out of 44 (79.5%) patients, which was negative in 24 (68.6%) patients. Nevertheless, seven out of these 24 patients were eventually classified as R1 resection due to other positive resection margins. Therefore, 17 (48.6%) patients could be classified as “true” R0 resection after additional resection. Ninety-day mortality after R1 resections was high (25%) and strongly influenced OS. After correction for 90-day mortality, median OS after negative additional resection was 33 months (95%CI:29.5–36.5) compared to 30 months (95%CI:24.4–35.6) after initial R1 (P = 0.875) and 46 months (95%CI:32.7–59.3) after initial R0 (P = 0.348). ConclusionThere were only 17 patients (out of a total of 328 patients) that potentially benefitted from routine IFS. Additional resection for a positive IFS leading to R0 resection was not associated with improved long-term survival.

Spread of lymph node metastasis and adjuvant therapy for distal cholangiocarcinoma.

Lymphatic metastasis is a major route of metastasis in distal cholangiocarcinoma (DCC). The present study aimed to elucidate the pattern of lymph node (LN) metastasis and the effectiveness of LN dissection and postoperative adjuvant chemotherapy in patients with DCC. Patients who underwent surgical resection with curative intent for DCC were enrolled. The nomenclature of the LN stations was defined according to the Japanese Society of Hepato-Biliary-Pancreatic Surgery guidelines. Effectiveness of LN dissection of each station was calculated using frequency of LN metastasis to the station and 5-year survival rate of patients with LN metastasis to that station. Of the 105 patients included in the study, 46 (43.8%) had LN metastasis, and 43 (41.0%) underwent postoperative adjuvant therapy. LN metastasis, serum carbohydrate antigen (CA) 19-9 level > 37 U/mL, and positive bile duct margin were independent risk factors for shorter overall survival (OS). The most common metastatic LN station at surgery was No. 13 (32.7%), followed by No. 12 (19.2%), No. 17 (9.6%), and No. 8 (6.6%). There was no effectiveness of LN dissection of the station No. 8, 14, and 16. Adjuvant chemotherapy was significantly associated with longer OS in patients with LN metastasis but not in those with positive ductal margins or serum CA 19-9 level > 37 U/mL. Postoperative adjuvant chemotherapy was associated with a better prognosis in patients with DCC and LN metastasis. However, a more effective therapeutic strategy is required to improve the prognosis of patients with other negative prognostic factors.

Cancerization of ducts in hilar cholangiocarcinoma.

Invasive cancers that arise from ductal structures can infiltrate and colonize pre-existing ducts in a process referred to as cancerization of ducts (COD). COD in cholangiocarcinoma is an under-studied process whose clinical significance remains poorly understood. Even though both cancerized ducts and biliary intraepithelial neoplasias (BilINs) show dysplastic changes, hallmarks of COD are (i) an abrupt transition from the normal/reactive epithelium to severe dysplasia and (ii) close proximity to invasive carcinoma with similar cytologic features. We investigated 113 cases of surgically resected hilar cholangiocarcinoma and identified COD in 37 cases (33%). Using immunohistochemistry, we found that COD and adjacent invasive carcinoma had a concordant pattern of p53 and SMAD4 staining in 95% (21/22) and 100% (21/21) of cases, respectively. In contrast, BilINs and cancerized ducts showed significantly lower levels of concordance in p53 and SMAD4 staining at 44% (8/18) and 47% (8/17) of cases, respectively (P = 0.0007 and 0.0001, respectively). By univariate analysis, positive lymph node metastasis (P = 0.027), positive final bile duct margin (P = 0.021), and the presence of COD (P = 0.020) were associated with decreased overall survival. We further performed multivariate analysis to demonstrate that positive lymph node metastasis (P = 0.031), positive final bile duct margin (P = 0.035), and COD (P = 0.0051) were correlated with decreased overall survival. Together, our study highlights that COD is a clinically significant process in hilar cholangiocarcinoma that can be identified using morphological criteria in conjunction with p53 and SMAD4 immunolabeling.

Impact of Positive Radial Margin on Recurrence and Survival in Perihilar Cholangiocarcinoma.

Simple SummaryThe only potentially curative treatment of perihilar cholangiocarcinoma (PHC) is complete (R0) resection. This is difficult to achieve and great effort should be made to optimise surgical margins assessment and to thoroughly define their prognostic value. When considering resections for PHC, not only bile duct margins (ductal margins, DM), but also the liver transection plane and the dissection plane in the hepatoduodenal ligament (radial margins, RM) should be examined. Studies concerning PHC resections with comprehensive analyses of the recurrence and survival related to margins status most frequently consider only ductal margins. The importance of also assessing radial margins’ prognostic value was recently introduced and deserves to be further studied. To our knowledge, there is currently no evidence of prognostic value of isolated positive RM. Therefore, the aim of this study was to evaluate the incidence and to investigate the effects on the recurrence and survival of positive isolated RM in resected PHC.In resected perihilar cholangiocarcinoma (PHC), positive ductal margin (DM) is associated with poor survival. There is currently little knowledge about the impact of positive radial margin (RM) when DM is negative. The aim of this study was to evaluate the incidence and the role of positive RM. Patients who underwent surgery between 2005 and 2017 where retrospectively reviewed and stratified according to margin positivity: an isolated RM-positive group and DM ± RM group. Of the 75 patients identified; 34 (45.3%) had R1 resection and 17 had positive RM alone. Survival was poorer in patients with R1 resection compared to R0 (p = 0.019). After stratification according to margin positivity; R0 patients showed better survival than DM ± RM-positive patients (p = 0.004; MST 43.9 vs. 23.6 months), but comparable to RM-positive patients (p = 0.361; MST 43.9 vs. 39.5 months). Recurrence was higher in DM ± RM group compared to R0 (p = 0.0017; median disease-free survival (DFS) 15 vs. 30 months); but comparable between RM and R0 group (p = 0.39; DFS 20 vs. 30 months). In univariate and multivariate analysis, DM positivity resulted as a negative prognostic factor both for survival and recurrence. In conclusion, positive RM resections appear to have different recurrence patterns and survival rates than positive DM resections.

Triple gallbladder with heterotopic gastric mucosa: a case report

BackgroundTriple gallbladder is a rare congenital anomaly of the biliary tract that can be associated with heterotopic tissue. Gallbladder triplication results from the failure of rudimentary bile ducts to regress during embryological development, and can be difficult to distinguish from Todani type II choledochal cysts and biliary duplication cysts.Case presentationA 2-year-old patient presented to our institution with intermittent abdominal pain for 1 year. She had elevated transaminases with imaging concerning for a choledochal cyst. After assessment with magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography, she was diagnosed with a gallbladder multiplication and a common bile duct stricture. She underwent laparoscopic cholecystectomy, which confirmed the diagnosis of triple gallbladder. One of the three gallbladders demonstrated heterotopic gastric mucosa on final pathology, including at the cystic duct margin. Follow up testing with a technetium 99 m scan demonstrated a subtle focus of increased activity in the right upper abdomen at the expected location of the common bile duct, concerning for the presence of residual gastric mucosa. The patient remains well without abdominal pain.ConclusionsWe describe the first case of heterotopic gastric mucosa in a triple gallbladder in a young patient presenting with chronic abdominal pain. We also demonstrate the safety and feasibility of laparoscopic cholecystectomy in young children with triple gallbladder. Finally, we propose an interdisciplinary approach to the management of common bile duct strictures in the setting of ectopic acid secretion, involving a combination of medical management, endoscopic intervention, and possible salvage laparoscopic Roux-en-Y hepaticojejunostomy.

The Impact of Positive Resection Margin in Perihilar Cholangiocarcinoma, Ductal Margin vs Radial Margin

Introduction: Resection margin status is the most important prognostic factor in resected perihilar cholangiocarcinoma (pCCA). Although the impact of ductal margin (DM) was reported in many studies, the influence of radial margin (RM) is unclear. This study aims to investigate the incidence and the effect of positive RM on survival. Methods: Patients with pCCA who underwent curative resection between October 2013 to December 2018 were retrospectively reviewed. Resection margin status were divided into negative resection margin (R0) and positive resection margin (R1); positive RM alone (RM+) and positive DM with or without positive RM (DM+). Results: Of the 170 pCCA patients, 63 (37%) had R1 margin. Among 63 R1 patients; 18 (28.6%) had positive DM alone, 20 (31.7%) had positive RM alone and 25 (39.7%) had both positive DM and RM. The R1 patients had a significantly greater number of LN metastasis and advanced tumor staging than R0 patients, however there was no difference between the RM+ and DM+ patients. The median survival time of patients with RM+ was significantly poorer than R0 patients (13.8 vs 24.7 months; p<0.001, respectively) and similar to the DM+ patients (9.1 months, p=0.561). In multivariable analysis, positive resection margin and lymph node metastasis were independently prognostic factors. Conclusion: Positive resection margin remains the most important prognostic factors and positive RM is common in these patients. Positive RM also had a comparable effect on survival as positive DM. As a result, in pCCA, surgical resection should target both RM and DM. Tabled 1EP03A-039CharacteristicsUnivariableMultivariableNMST (months)p-valueHR95%CIp-valueBismuth type0.0441.3770.838-2.2620.207 1-314416.8 42310.6Portal vein invasion0.0291.0920.212-5.6130.916 Absence8418.4 Present6714.8Hepatic artery invasion0.0410.8560.465-1.5780.619 Absence10018.4 Present5114.2pT stage (AJCC 8th)0.0190.9970.211-4.7090.997 pT 1-29818.4 pT 3-46914.2pN stage (AJCC 8th)<0.0012.2931.437-3.6620.001 pN09025.7 pN1/2778.0Staging (AJCC 8th)<0.0011.3630.729-2.5490.332 Stage 1-24930.7 Stage 3-411810.6Surgical margin status<0.001 R010524.711.613-4.180<0.001 DM+429.12.5971.231-3.8510.008 RM+2013.82.177Surgical margin status<0.001 R010524.70.3850.239-0.620<0.001 DM+429.110.463-1.5190.561 RM+2013.80.838 Open table in a new tab

Proposing an Imaging-based Morphological Assessment of Pancreatic Ductal Adenocarcinoma as a Predictor of R1 Resection

Introduction: Pancreatic ductal adenocarcinoma (PDAC) can be clinically under-staged on preoperative cross-sectional imaging which may affect intraoperative resectability. The purpose of this study is to define imaging-based morphologic criteria for PDAC in tumors deemed resectable at presentation and assess their correlation with R1 resection. Methods: A retrospective chart review of 54 consecutive pancreatoduodenectomies performed for PDAC between 2016- 2018 was performed. Sectional computed Tomography (CT) images were reviewed by two senior radiologists who labeled tumors as “mass-forming” or “infiltrative” morphology. These classifications were then correlated with resection margin status. Significance was defined as a p value <0.1. Results: Of the 54 patients included in the study, 28 and 26 were classified as mass forming and infiltrative based on radiological review, respectively. There was no significant difference in pathological T and N staging (p=0.63 and p=0.62, respectively). Infiltrative tumors demonstrated smaller sizes on preoperative images (average: 3.3 versus 4 cm, p=0.02). Although no difference was appreciated between both morphologies regarding portal vein and superior mesenteric artery margins (p=0.64 and p=0.81, respectively), infiltrative tumors were found to be associated with more positive bile duct and pancreatic margins (p=0.06 and p=0.07, respectively). Conclusion: We propose a new imaging-based definition of PDAC into “mass-forming” and “infiltrative” morphologies. Understanding the higher rate of R1 resection in infiltrative tumors would improve selection process of patients with PDAC to neoadjuvant therapy prior to definitive resection.Tabled 1Radiological featureMass-formingInfiltrativeBorderPresence of a well-defined interfaceAbsence of a well-defined interfaceMassVisible and clearly identifiableInferred in the absence of a clear mass and presence of pancreatic and/or common bile ductal dilationp Open table in a new tab

Additional Intrapancreatic Bile Duct Resection and Additional Pancreaticoduodenecotmy for Positive Distal Ductal Margin of Hilar Cholangiocarcinoma

Introduction: The feasibility and effectiveness of intrapancreatic bile duct resection (IPBR) and additional pancreaticoduodenectomy (aPD) for initial cancer positive distal duct margin (DM) in perihilar cholangiocarcinoma cases remain to be elucidated. The aim of this study was to clarify the feasibility and efficacy of both operative procedures. Method: All patients who underwent major hepatectomy and extrahepatic bile duct resection for perihilar cholangiocarcinoma between 2000 and 2020 were analyzed. IPBR for cancer positive DMs were indicated for cases with cancer-negative proximal margin and no extra-bile duct invasion. Results: A total 364 patients were enrolled. Additional resection was performed in 69 of 89 cancer positive DMs, resulting in 53 negative DMs (77%). Procedures of additional resection were 59 IPBR and 10 aPD. A multivariate analysis demonstrated that high preoperative serum carbohydrate antigen 19-9 level, combined hepatic artery resection, nodal involvement, distant metastasis, severe perineural invasion and R 1 resection were independent worse prognostic factors. DM was not prognostic factors independently. Only three cases developed initial recurrence at intrapancreatic bile duct in all positive DM cases (one in invasive cancer positive DM case, 1 year after resection and two with cancer-in-situ (CIS) positive DM cases, 4 and 6 year after resection). Overall survival of patients with cancer positive initial DM and cancer negative or CIS final DM treated by IPBR (n=56) were statistically compared with that of the patients treated by aPD (P=0.24). Conclusions: IPBR was feasible and effective procedure for the selected patients of cancer positive DMs of wide spread perihilar cholangiocarcinoma.

An International Survey of the Operative Management of Gallbladder Cancer (OMEGA-S) – Global Consistency or Widespread Heterogeny?

Introduction: The rarity of gallbladder cancer (GBC) means that definitive evidence for optimal management is lacking. The extent of variability in diagnostic workup and management of GBC across HPB units globally has not been hitherto assessed. Method: A survey on the management of GBC was designed by the EAHPBA Scientific and Research committee and OMEGA study collaborators and disseminated to EAHPBA, A-PHPBA and AHPBA members. Results: Over 110 surgeons responded from more than 35 countries. Pre-operative staging was mainly via CT, while PET was predominantly performed for suspected metastases. Factors considered contraindications to resection varied between centres. Solitary right-sided liver metastasis or main portal vein involvement were only considered contraindications to resection by around 50% of centres. Half the centres would abort planned surgery if coeliac, SMA or para-aortic nodal involvement was suspected preoperatively for any stage of disease. However, for T3/4 tumours, regardless of pre-operative imaging appearances, a quarter of centres always resected this group of lymph nodes and 50% of centres always sampled para-aortic nodes for frozen section. SIVb/V resections were more commonly performed for T2b compared to T2a tumours, and extent of liver resection increased with stage of disease. Hepaticojejunostomy was always performed for T3/4 disease in 20% of units regardless of cystic duct margin histology. Conclusions: This is the first survey of GBC management across HPB units internationally, highlighting areas of consistency but also surprising areas of heterogeneity. More robust evidence and clinical trials are required to help guide the management and improve outcomes from GBC.

Delay in Resection of Choledochal Cysts Highlights the Significance of Malignancy Potential: A Case Report

Risks of choledochal cysts include obstructive jaundice, cholangitis, and malignancy. Therefore, cysts are typically resected especially if symptomatic. A 69 year old female who presented with cholangitis due to a common bile duct stone. Past medical history significant for type III choledochal cyst and recurrent cholangitis. Previous surgical interventions included biliary bypass at age 10 and revision in early 20s; choledochal cyst was not resected at either surgery. Imaging suggested hepaticojejunostomy stricture leading to recurrent cholangitis. Initially patient was very hesitant to undergo any further surgical intervention and opted for close surveillance. Shortly after patient develop rigors and while still reluctant to undergo large procedure did consent to choledochal cyst resection and hepaticojejunostomy revision. During the operation, choledochal cyst identified, mobilized and approximately 80% of it was excised. Hepaticojejunostomy appeared to incorporate remnant gallbladder based on intraoperative evaluation. Cholangiogram was attempted through duct of Luschka but was not completed due to difficult angle and subsequently ligated. New hepaticojejunostomy was created using original roux limb and good biliary drainage of right and left hepatic lobes demonstrated on completion cholangiogram. Final pathology significant for poorly differentiated adenocarcinoma, biliary type in choledochal cyst and remnant gallbladder; additionally bile duct margin showed invasive adenocarcinoma. Patient then underwent a completion pancreaticoduodenectomy with partial hepatectomy for complete oncologic resection. In adults presenting with a symptomatic choledochal cyst, excision should be recommended treatment. Risk of malignancy is present in biliary tree despite resection. Thus, the entire biliary tree should be inspected for multiple areas of neoplasm.

Efficacy of Extended Modification in Left Hemihepatectomy for Advanced Perihilar Cholangiocarcinoma: Comparison Between H12345'8'-B-MHV and H1234-B.

The aim of this study was to verify the prognostic impact of the tumor exposure at the liver transection margin (LTM) in left-sided perihilar cholangiocarcinoma and the impact of middle hepatic vein (MHV) resection on this exposure. In perihilar cholangiocarcinoma, tumors are unexpectedly exposed at the LTM during left hemihepatectomy (LH). Patients who underwent LH for perihilar cholangiocarcinoma during 2002 to 2018 were retrospectively evaluated. LH was classified into conventional and extended types, which preserved and resected the MHVs, respectively. Positive LTM was defined as the involvement of invasive carcinoma at the liver transection plane and/or the adjacent Glissonean pedicle exposed. The clinicopathologic features and survival outcomes were compared between procedures. Among 236 patients, conventional and extended LHs were performed in 198 and 38 patients, respectively. The LTM was positive in 31 (13%) patients, with an incidence of 14% versus 8% ( P = 0.432) and 24% versus 0% in advanced tumors ( P = 0.011). Tumor size ≥ 18 mm ( P = 0.041), portal vein invasion ( P = 0.009), and conventional LH ( P = 0.028) independently predicted positive LTM. In patients with negative LTM, the survival was comparable between the two groups: 60.4% versus 59.2% at 3 years ( P = 0.206), which surpassed 17.7% for those with positive LTM in the conventional group ( P < 0.001). Multivariable analysis demonstrated that LTM status was an independent prognostic factor ( P = 0.009) along with ductal margin status ( P = 0.030). The LTM status is an important prognostic factor in perihilar cholangiocarcinoma. Extended LH reduced the risk of tumor exposure at the LTM with a subsequent improvement in the survival, particularly in advanced tumors.