Proximal Extrahepatic Bile Duct Research Articles

Oncological outcome of proximal and mid extrahepatic bile duct cancer according to the surgical extend (Is the segmental bile duct resection justified?)

Oncological outcome of proximal and mid extrahepatic bile duct cancer according to the surgical extend (Is the segmental bile duct resection justified?)

Prognostic and Predictive Molecular Markers in Cholangiocarcinoma.

Simple SummaryCholangiocarcinoma (CCA) is a heterogenous and aggressive malignancy of the intra- and extrahepatic biliary tract, marked by a steeply rising incidence on a global scale. While surgery remains the only curative treatment option, most patients present with advanced or unresectable disease, and are, therefore, treated with systemic therapy, albeit with limited benefit. Biomarkers obtained from either the patients’ serum or tumor tissue might facilitate therapy guidance by selecting patients who would benefit the most from surgical and adjuvant treatment strategies, as well as by identifying those with higher risk of disease recurrence. Furthermore, several genetic aberrations in CCA have been linked with improved response upon targeted therapies, thus highlighting their role as predictive biomarkers. In this review we provide an overview of currently known prognostic and predictive biomarkers and discuss their role in CCA.Cholangiocarcinoma (CCA) is the second most common primary liver cancer and subsumes a heterogeneous group of malignant tumors arising from the intra- or extrahepatic biliary tract epithelium. A rising mortality from CCA has been reported worldwide during the last decade, despite significant improvement of surgical and palliative treatment. Over 50% of CCAs originate from proximal extrahepatic bile ducts and constitute the most common CCA entity in the Western world. Clinicopathological characteristics such as lymph node status and poor differentiation remain the best-studied, but imperfect prognostic factors. The identification of prognostic molecular markers as an adjunct to traditional staging systems may not only facilitate the selection of patients who would benefit the most from surgical, adjuvant or palliative treatment strategies, but may also be helpful in defining the aggressiveness of the disease and identifying patients at high-risk for tumor recurrence. The purpose of this review is to provide an overview of currently known molecular prognostic and predictive markers and their role in CCA.

Standard radical bile duct surgery focused on vascular reconstruction

Since the mid bile duct cancers often involve the intrapancreatic bile duct, resection of the extrahepatic bile duct results in a tumor-positive distal resection margin. Extended extrahepatic bile duct resection is a surgical procedure to obtain a tumor-free distal resection margin during extrahepatic bile duct resection, in which R0 resection can be achieved without performing pancreatoduodenectomy. The extent of intrapancreatic bile duct excavation was designed to resemble making a several cm-long funnel. The surgical procedure for pancreatic excavation was derived from those used for choledochal cyst excision. Special attention should be paid to prevent pancreatic leak at the bile duct excavation portion at the pancreatic head. If the proximal extrahepatic bile duct is tumor-positive, major or parenchyma-preserving hepatectomy is necessary to achieve R0 resection. Resection of segment I and segment IV with bile duct resection offers very wide operative field and allows wider extent of hilar bile duct resection, thus presents the most common type of parenchyma-preserving hepatectomy. When the portal vein is focally involved by the tumor, hilar portal vein wedge resection and roofing patch venoplasty using a autograft or homograft vein patch is a useful option to facilitate complete tumor resection in patients undergoing bile duct resection. Regarding roofing patch venoplasty, it is important to make the portal vein wall defect as small as possible as well as to make the size of the vein patch either twice or three times larger than the defect size at the portal vein wall. The patch should be large enough to make the patch roof redundant. Even if the patch roof appears to be noticeably redundant at the time of operation, it is vulnerable to shrinkage due to compression of the jejunal loop and through degenerative changes of the patch per se. The availability of vein autografts or homografts facilitates combined vascular resection and reconstruction during aggressive surgery for hepatobiliary malignancies.

Proximal Extrahepatic Bile Ducts: Comprehensive Review

Proximal extrahepatic bile ducts are the biliary tree segment within formal boundaries from cystic ductcommon hepatic duct junction to sectoral hepatic ducts. Despite being a focus of attention of diagnostic and interventional radiologists, endoscopists, hepatobiliary surgeons and transplantologists they weren’t comprehensively described in available papers. The majority of the authors regard bile duct confluence as a group of merging primitively arranged tubes providing bile flow. The information on the proximal extrahepatic bile duct embryonal development, variant anatomy, innervation, arterial, venous and lymphatic supply is too general and not detailed. The present review brought together and systemized exiting to the date data on anatomy and function of this biliary tract portion. Unique, different from the majority of hollow organs organization of the proximal extrahepatic bile duct adapts them to the flow of the bile, i.e. viscous aggressive due to pH about 8.0 and detergents fluid, under higher wall pressure than in other parts of biliary tree.

Balloon Dilation and Triple Catheter Placement Technique for Treatment of Proximal Biliary Stenosis

Introduction: Post-surgical bile duct lesions occurred in approximately 0.5% of cholecystectomies and are associated with high mortality. These lesions include leaks, stenosis, removal of part of the duct and arterial injury. Percutaneous and endoscopic approaches can definitely treat biliary lesions. Objective: To present the experience of a clinical case where percutaneous interventional treatment of a bile duct stenosis with cholangioplasty and placement of tutors was performed in a single time. Methods: 79-year-old male with a history of high blood pressure, left cerebrovascular accident, open cholecystectomy 20 years ago and bile duct stenosis. tomography with contrast that showed proximal extrahepatic bile duct stenosis Bismuth II. An endoscopic cholangiopancreatography is performed that identifies the bile duct stenosis and an attempt is made to place a stent while passing a guide, but the catheter device cannot be placed through the diameter of the stenosis. Interventional radiology performs a percutaneous cholangiophraphy identifying the stenosis and performs balloon expansion of the same and inserts a biliary silicone drain along with two 8 fr and 10 fr tutors handcrafted from multipurpose drainage catheters (Cook medical) in parallel at the level of stenosis (maximum diameter 20 Fr) Outcome: patient presented a favorable evolution after the procedure, presented as a minor complication an acute renal injury that resolved with observation Conclusion: Percutaneous treatment with balloon dilation and the use of tutors at the level of stenosis was safe and successful in our patient.

A Proposed Algorithm for Endoscopic Ultrasound-Guided Rendezvous Technique in Failed Biliary Cannulation.

Background: The selection of an approach route in endoscopic ultrasound-guided rendezvous (EUS-RV) for failed biliary cannulation is complicated. We proposed an algorithm for EUS-RV. Methods: We retrospectively evaluated consecutive EUS-RV cases between April 2017 and July 2020. Puncturing the distal extrahepatic bile duct (EHBD) from the duodenal second part (D2) (DEHBD/D2 route) was attempted first. If necessary, puncturing the proximal EHBD from the duodenal bulb (D1) (PEHBD/D1 route), puncturing the left intrahepatic bile duct (IHBD) from the stomach (LIHBD/S route), or puncturing the right IHBD from the D1 (RIHBD/D1 route) were attempted in this order. Results: A total of 16 patients were included. The DEHBD/D2 route was used in 10 (62.5%) patients. The PEHBD/D1 route was attempted in five (31.3%) patients, and the biliary puncture failed in one patient in whom the RIHBD/D1 route was used because of tumor invasion to the left hepatic lobe. The LIHBD/S route was applied in one (6.3%) patient. Successful biliary cannulation was achieved in all patients eventually. The time from the puncture to the guidewire placement in the DEHBD/D2 route (3.5 min) was shorter than that in other methods (14.0 min) (p = 0.014). Adverse events occurred in one (6.3%) patient with moderate pancreatitis. Conclusions: The proposed algorithm might be useful for the selection of an appropriate approach route in EUS-RV.

Phosphorylated Akt Expression as a Favorable Prognostic Factor for Patients Undergoing Curative Resection and Adjuvant Chemoradiotherapy for Proximal Extrahepatic Bile Duct Cancer.

To evaluate the prognostic significance of phosphorylated Akt (p-Akt), phosphorylated mammalian target of rapamycin (p-mTOR), and total phosphatase and tensin homolog deleted on chromosome 10 (PTEN) expressions in patients undergoing adjuvant chemoradiotherapy (CRT) for proximal extrahepatic bile duct (EHBD) cancer. Sixty-three patients with proximal EHBD cancer who underwent curative resection followed by adjuvant CRT were enrolled into this study. Postoperative radiotherapy was delivered to tumor bed and regional lymph nodes up to a median of 40 Gy (range, 40 to 54 Gy). Fifty-nine patients also received fluoropyrimidine chemotherapy as a radiosensitizer. p-Akt, p-mTOR, and PTEN expression were assessed with immunohistochemical staining on the tissue microarray. p-Akt, p-mTOR, and PTEN were expressed in 23 (36.5%), 17 (27.0%), and 24 patients (38.1%), respectively. p-Akt expression was associated with distant metastasis and overall survival (OS), but not with locoregional recurrence. The 5-year distant metastasis-free and OS rates were 25.8% versus 58.2% (P=0.007), and 27.5% versus 50.2% (P=0.0167) in patients with negative and positive expression, respectively. On multivariate analysis, nodal involvement was the only significant prognosticator predicting inferior distant metastasis-free survival (P=0.0105), whereas p-Akt expression had a borderline significance (P=0.0541). As for OS, p-Akt expression was a marginally significant prognosticator (P=0.0635), whereas other risk factors lost the statistical significance. p-Akt expression tended to be associated with a favorable prognosis in patients undergoing curative resection followed by adjuvant CRT for proximal EHBD cancer.

Diagnostics of the tumour of the proximal extrahepatic bile ducts at the early stage of its development with the use of per-oral cholangioscopy

Cholangiocarcinoma is a disease having the unfavourable prognosis and difficult to diagnose. This pathology is usually detected at the late stages of its evolution when the possibilities for its specialized treatment are virtually exhausted. In most cases, obstructive jaundice is the earliest manifestation of the disease. The standard diagnostic methods including transabdominal ultrasound study, computed tomography, magnetic resonance imaging, and endoscopic retrograde cholangiopancreatography not infrequently fail to provide all necessary clinical information. It is concluded that cholangioscopy provides a promising tool for the diagnostics of cholangiocarcinoma at the early stages of the disease.

Phosphorylated Akt expression as a favorable prognostic factor for patients undergoing curative resection and adjuvant chemoradiotherapy for proximal extrahepatic bile duct cancer.

182 Background: To evaluate the prognostic significance of phosphorylated Akt (p-Akt), phosphorylated mammalian target of rapamycin (p-mTOR), and total phosphatase and tensin homolog deleted on chromosome 10 (PTEN) expression in patients undergoing adjuvant chemoradiotherapy for proximal extrahepatic bile duct (EHBD) cancer. Methods: Sixty-three patients with proximal EHBD cancer who underwent curative resection followed by adjuvant chemoradiotherapy were enrolled into this study. Postoperative radiotherapy was delivered to tumor bed and regional lymph nodes up to a median of 40 Gy (range; 40-54). Fifty-nine patients also received fluoropyrimidine chemotherapy as a radiosensitizer. p-Akt, p-mTOR, and PTEN expression were assessed with immunohistochemical staining on the tissue microarray. Results: p-Akt, p-mTOR, and PTEN were expressed in 23 (36.5%), 17 (27.0%) and 25 patients (39.7%), respectively. p-Akt expression was associated with distant metastasis and overall survival, but not with loco-regional recurrence. The 5-yr distant metastasis-free and overall survival rates were 25.8% vs. 58.2% (p = 0.007), and 27.5% vs. 50.2% (p = 0.0167) in patients with negative and positive expression, respectively. On multivariate analysis, nodal involvement was the only significant prognosticator predicting inferior distant metastasis-free survival (p = 0.0105), while p-Akt expression had a borderline significance (p = 0.0541). As for overall survival, p-Akt expression was a marginally significant prognosticator (p= 0.0635), whereas other risk factors lost the statistical significance. Conclusions: p-Akt expression was a favorable prognostic factor for patients undergoing curative resection followed by adjuvant chemoradiotherapy for proximal EHBD cancer.

Choledochal cysts in infancy and childhood

To study the clinical presentation, management and results of treatment of 41 consecutive cases of choledochal cyst (CC) managed from 1999 to 2006. The age of the patients ranged from 20 days to 11 years. Eleven cases were 1 year or less in age (infantile group) and 30 patients were more than 1 year old (classical pediatric group). Children less than 1 year old presented with jaundice (72%), hepatomegaly (54%) and clay-colored stools (63%); whereas those above one year in age presented with pain (83.3%) and jaundice (47.6%). Three cases had biliary perforation with localized or generalized biliary peritonitis. Ultrasonography (US) diagnosed/suggested CC in all 41 patients, however, contrast-enhanced computed tomographic (CECT) scan (n=12), radionuclide DISIDA scan (n=5) and magnetic resonance cholangiopancreatogram (MRCP) (n=3) also contributed to the diagnosis. 19 patients, including 4 from the 'infantile' group, had significant dilatation of intrahepatic biliary ducts. Nine patients from the 'infantile' group had cystic type I CC (type Ic), while 2 patients had fusiform dilatation of the common bile duct (type If disease). In contrast, 21 of the older patients had type If disease while 9 had type Ic disease. Operative management included primary complete excision of the cyst with a Roux-en-Y hepaticodochojejunostomy (HDJ) (n=32), Lilly's modification of submucosal resection with a HDJ (n=8) and cyst excision with a hepaticodochoduodenostomy (HDD) (n=1). All 3 patients with biliary perforation had primary excision of the CC with a HDJ. Unusual operative findings included accessory hepatic ducts (n=2), anteriorly placed common or right hepatic arteries (n=3) and partially or completely blocked proximal extrahepatic bile ducts (n=3). There were 2 postoperative deaths, one had cirrhotic liver disease with portal hypertension, the other had deep icterus with poor general condition. Both patients succumbed to overwhelming sepsis. One patient required reexploration and refashioning of the HDJ for biliary leak. Short-term follow-up was satisfactory in all 39 patients. Infants with CC constitute a distinct group with regard to clinical presentation and the pathological should be kept in mind while evaluating neonates and infants with cholestatic jaundice and older children with recurrent abdominal pain. Primary excision of the cyst with a HDJ provides satisfactory results in the management of the vast majority of cases of CC including those in infants, massive CC and in the presence of biliary perforation and peritonitis.

Immune pathogenesis of sclerosing cholangitis in biliary atresia

Biliary atresia (BA) is the most frequent single life-threatening hepatic disorder in early childhood in Japan, Europe and North America. It affects one in 9000 live-born infants in our country. BA is characterized by complete inability to excrete bile associated with obstruction, destruction or absence of the extrahepatic bile ducts. Pathologic study of tissues removed from the porta hepatis and of the proximal extrahepatic bile ducts suggests that BA in the vast majority of infants results from a sclerosing, inflammatory lesion initiated in ductular tissues. Kasai procedure (KP) is in the first line of treatment for BA infants in the developed countries all over the world. In KP, bile duct remnants or fibrous tissues in front of the hepatic artery are dissected and a Roux-en -Y anastomosis is fashioned between the area of the porta hepatic and the jejunum. KP has provided opportunities to survive years for some infants with BA with reasonable quality of life. However in BA, bile duct injury and sclerosing inflammation is ongoing even after apparently successful KP. A 10-year survival rates with native liver is still 53% in 1999 according to multi-centre analysis in Japan. BA is still the leading cause of paediatric liver transplantation. Poor prognosis of BA is, of course, due to unknown aetiology. Potential aetiologies for more common perinatal form of BA include viral infections, immune-mediated injuries and autoimmune disease involving biliary systems. Details of each theory including our updated findings will be reviewed and discussed.

Chemotherapy-induced sclerosing cholangitis

To review the computed tomography (CT), magnetic resonance imaging (MRI) and cholangiographic findings of chemotherapy-induced sclerosing cholangitis (CISC). Between January 1995 and December 2004, 11 patients in the endoscopic retrograde cholangiography database were identified with CISC. Twelve CT, four MRI, 69 endoscopic and nine antegrade cholangiographic studies in these patients were reviewed. Serial change in appearance and response to endoscopic treatment were recorded. CISC showed segmental irregular biliary dilatation with strictures of proximal extrahepatic bile ducts. The distal 5cm of common bile duct was not affected in any patient. CT and MRI findings included altered vascular perfusion of one or more liver segments, liver metastases or peritoneal carcinomatosis. Biliary strictures needed repeated stenting in 10 patients (mean: every 4.7 months). Cirrhosis (n=1) or confluent fibrosis (n=0) were uncommon findings. CISC shares similar cholangiographic appearances to primary sclerosing cholangitis (PSC). Unlike PSC, biliary disease primarily involved ducts at the hepatic porta rather than intrahepatic ducts. Multiphasic contrast-enhanced CT or MRI may show evidence of perfusion abnormalities, cavitary liver lesions, or metastatic disease.

Surgical treatment of hilar bile duct cancer: A critical review of 291 cases

To summarize the clinical experience in the treatment of hilar bile duct carcinoma in a single institute through 1986–2002. 291 cases admitted to the General Hospital of P. L. A. were reviewed. The cases were divided into two groups: Group I, cases were admitted from 1986.1 to 1999.1, totally 157 cases; and Group II included cases which were treated from 1999.2 to 2002.6, totally 134 cases. The methods of surgical treatment included radical resection, palliative resection, external or internal drainage, according to the pathology found during surgery. Radical resection (free of residual tumor cells at the resection edge of the resected specimens) was 37.6% in group I and 41.2% in group II, respectively. There was no death within 30 days after resectional operation. Follow-up data was obtained through correspondence and outpatient department visits with the follow-up rate being 88.8%. Carcinoma of the proximal extrahepatic bile duct was not a rare disease in China and the number of operations on bile duct cancer was increased in recent years. Owing to the location of the tumor, radical resection was difficult to reach even supplemented by liver lobe resection. Radical resection rate was from 37.6% to 41.2% in these two series of cases studied. There were 4 cases of tumor-free survivals in the group I (13.3%), and furthermore, there were also 2 cases with tumor recurrence and still under treatment. In group II, there was no 5 year survivals and the 3-year survival rate was 13.6%. Carcinoma of the hilar bile duct is a disease of multiformity. Rarely, it may behave a rather benign course, but, in the majority, the disease was likely to be recurrent even after a seemingly radical resection. However, resectional treatment, even palliative, may prolong life and improve the quality of life. The value of extended resection and lymph nodes dissection operation is still uncertain.

Villous adenoma of the common hepatic duct

A 78-year-old woman presented with painless jaundice 8 months after laparoscopic cholecystectomy for acute calculous cholecystitis. An intraoperative cholangiogram did not visualize the proximal extrahepatic bile duct. ERCP showed a 2-cm lobulated fixed filling defect within the common hepatic duct distal to the hepatic bifurcation (A). The papilla was in a large peripapillary diverticulum and attempts to obtain a tissue diagnosis were unsuccessful. A cytologic specimen, obtained with a brush by means of a percutaneous approach, was interpreted as containing atypical glandular cells. Biopsy specimens obtained at subsequent percutaneous cholangioscopy showed mucinous debris, degenerative cells, and acute inflammatory fibrous tissue. At exploratory laparotomy, a frozen section biopsy specimen was interpreted as consistent with villous adenoma. The bile duct was resected and a hepaticojejunostomy performed. Histopathologic evaluation of the resection specimen (B) showed a villous adenoma with marked cytologic atypia and rare foci of superficially invasive adenocarcinoma. Five lymph nodes were negative for metastasis. The patient recovered from the surgery and is doing well.

Biliary distensibility during per-operative cholangiography as compared to pre-operative ultrasound: A four year follow-up study

Introduction: It is well recognized that corrected bile duct diameters, as measured by endoscopic retrograde cholangiography (ERC), are often significantly greater than the corresponding ultrasound measurement. This can be attributed to variation in bile duct distensibility and is particularly noted in post cholecystectomy patients, possibly due to loss of the gall bladder reservoir effect. It has been suggested that increased bile duct distensibility may be related to the post-cholecystectomy syndrome. We have observed a similar discrepancy between ultrasound and per-operative cholangiography (POC). This trial investigates whether the discrepancy between ultrasound and POC measurements has clinical significance. Method: Seventy-five patients with normal pre-operative ultrasound and POC undergoing standard open cholecystectomy (with benzodiazepine pre-medication) in 1990 were identified. After allowance for magnification, maximum biliary diameters were obtained for the proximal extra-hepatic bile duct. Follow-up was obtained in 67 patients from clinical case notes and contact with general practitioners. Results: Considerable variation of bile duct distensibility was recorded (range 83% to 410%) with 12 cases having POC biliary diameters outside radiological guidelines (12 mm as recorded on the radiograph). This distension is shown to increase with age. After 4 years, 16 patients had recurrent abdominal pain of which nine had undiagnosed right upper quadrant pain. There were no clinical cases of retained stone post-operatively. There was no correlation between POC measured bile duct diameter or distensibility and post-operative or long term problems. This study suggests that the bile duct has a normal variation of distensibility which increases with age and that radiological guidelines, as regards the upper limit for normal POC biliary diameters, can be relaxed.

2050 External radiation therapy and transcatheter iridium in the treatment of proximal extrahepatic bile duct carcinoma

2050 External radiation therapy and transcatheter iridium in the treatment of proximal extrahepatic bile duct carcinoma

Peribiliary cysts associated with severe liver disease: imaging-pathologic correlation.

Prior pathology reports describe peribiliary cysts in patients who have severe liver disease. The purpose of this study was to determine whether these cysts could be identified on imaging studies, and to determine the range of imaging findings when identified. Imaging and pathologic findings were correlated in 12 patients in whom peribiliary cysts were found on gross inspection of the liver after autopsy (one) or liver transplantation. All patients had been examined with CT and sonography, three patients had undergone MR imaging, and one had had cholangiography. The liver was sectioned in the axial plane at 1-cm intervals, and the porta hepatis and the proximal extrahepatic bile ducts were examined macroscopically. Pathologic findings were recorded and compared with the patients' imaging findings and clinical course. CT showed the peribiliary cysts in the porta hepatis in 10 of 12 patients. These appeared as discrete cysts in four patients, a tubular structure paralleling the portal structures in four patients, and a string of cysts that simulated abnormal bile ducts in two patients. Sonography showed the cysts in four of 12 patients, as anechoic cystic structures in three and as a septated, tubular channel in one. MR showed the cysts in two of three patients, and T2-weighted images were better than T1-weighted images. The cysts appeared in a cluster in one patient, and as a tubular structure of high intensity on T2-weighted images that simulated a dilated bile duct in the other. Patients were asymptomatic in 11 of 12 cases. In one case, large cysts caused biliary obstruction, which was apparent on CT scans, sonograms, and cholangiograms. Peribiliary cysts associated with a variety of disorders can be detected with CT, sonography, and MR imaging. Recognition of the imaging appearance of these cysts may avoid the misdiagnosis of dilated bile ducts, cystic neoplasm, or abscess. Conversely, when seen on images, these cysts might suggest one of the underlying associated disorders.

Preoperative TNM Classification of Proximal Extrahepatic Bile Duct Carcinoma by Endosonography

ES was performed preoperatively in 39 patients with a proximal bile duct carcinoma. The results were correlated with the histologic findings of resected specimens or intraoperative excision according to the new (1987) TNM classification. ES was accurate in assessing the depth of tumor infiltration. The overall accuracy of ES was 83.8%. Overstaging of T2 carcinoma occurred in three of ten patients (30%) and understaging of T3 carcinoma occurred in 3 of 27 patients (11%). ES was helpful in diagnosing lymph node metastasis (accuracy, 92.9%) but not accurate in defining nonmetastatic lymph nodes (accuracy, 18.8%). Difficulties occurred in distinguishing inflammatory lymph nodes and micrometastatic lymph node involvement. ES was not accurate in diagnosing hepatic metastases and peritoneal dissemination because of the limited penetration depth of ultrasound. The incidence of lymph node metastasis of advanced stage carcinoma was approximately 40%. Technical improvements, such as reduction of the diameter of the echoprobe, easy handling of ES-guided cytologic puncture, and the routine use of a catheter echoprobe during ERCP will further enhance the accuracy of ES.

Proximal extrahepatic bile duct tumors. Analysis of a series of 52 consecutive patients treated over a period of 13 years.

Fifty-two consecutive patients with proximal extrahepatic bile duct tumors were treated by one of us (J.G.F.) between 1974 and 1987 at Memorial Sloan-Kettering Cancer Center, New York, NY. Thirty-eight patients (73%) underwent palliative procedures aimed at relieving the biliary obstruction (group A) and 14 patients (27%) were operated on with curative intent (group B). The choice of the surgical procedure employed to relieve the biliary obstruction did not significantly influence the length of survival of patients in group A in whom the median survival was 13.5 months and the in-hospital mortality was 15.7%. Fifty percent of the patients in group B underwent major liver resections to macroscopically encompass the tumor. In this group, although 35% of the patients experienced major complications, no in-hospital mortalities were encountered and the median actuarial survival was 38 months. The projected and crude 5-year survival rates were 28% and 21%, respectively. Age, gender, extent of resection, microscopic status of margins of resection, and grade of the lesion did not affect the length of survival in patients in group B. Locoregional failure, either isolated or as a component of peritoneal failure, was detected in the 6 patients in whom the disease has recurred. Eighty-three percent of the patients in whom the disease has recurred were dead within 12 months of the diagnosis of recurrence. Two long-term survivors (14%) developed second primary tumors in the follow-up period.

Clinicopathological aspects of high bile duct cancer. Experience with resection and bypass surgical treatments.

This report reviews the experience of the Hepatobiliary Unit, Royal Postgraduate Medical School, Hammersmith Hospital, London with 16 patients having proximal extrahepatic bile duct malignancy who underwent resection and a comparable group of 15 patients who had surgical bypass. The purposes of the review were to evaluate morbidity and mortality in both treatment groups, to assess whether either treatment influenced the natural history of the disease, and to examine the pathological features of the resected lesions, attempting to correlate the macroscopic and microscopic features with radiological and surgical observations and survival. The presenting symptoms, average age, clinical data, and length of hospital stay were similar in both groups. Hospital mortality, despite 12 major liver resections, was less in the resectional than in the bypass group--19% versus 26%. The average survival for resectional patients was 16.5 months with six of the 13 patients who left hospital still alive, one at 5 years. The bypass patients lived an average of 7 months with no patients surviving beyond 11 months. Both resectional and bypass treatments appeared to influence survival in this disease with greater length and quality of survival being associated with resection. While there were a number of distinctive pathological features associated with the resected tumors, none correlated with survival.