National guidelines for the diagnosis and treatment of hilar cholangiocarcinoma

A consensus meeting of national experts from all major national hepatobiliary centres in the country was held on May 26,2023,at the Pakistan Kidney and Liver Institute&Research Centre(PKLI&RC)after initial consultations with the experts.The Pakistan Society for the Study of Liver Diseases(PSSLD)and PKLI&RC jointly organised this meeting.This effort was based on a comprehensive literature review to establish national practice guidelines for hilar cholangiocarcinoma(hCCA).The consensus was that hCCA is a complex disease and requires a multidisciplinary team approach to best manage these patients.This coordinated effort can minimise delays and give patients a chance for curative treatment and effective palliation.The diagnostic and staging workup includes high-quality computed tomography,magnetic resonance imaging,and magnetic resonance cholangiopancreato-graphy.Brush cytology or biopsy utilizing endoscopic retrograde cholangiopancreatography is a mainstay for diagnosis.However,histopathologic confirmation is not always required before resection.Endoscopic ultrasound with fine needle aspiration of regional lymph nodes and positron emission tomography scan are valuable adjuncts for staging.The only curative treatment is the surgical resection of the biliary tree based on the Bismuth-Corlette classification.Selected patients with unresectable hCCA can be considered for liver transplantation.Adjuvant chemotherapy should be offered to patients with a high risk of recurrence.The use of preoperative biliary drainage and the need for portal vein embolisation should be based on local multidisciplinary discussions.Patients with acute cholangitis can be drained with endoscopic or percutaneous biliary drainage.Palliative chemotherapy with cisplatin and gemcitabine has shown improved survival in patients with irresectable and recurrent hCCA.

Accurate resection of hilar cholangiocarcinoma using eOrganmap 3D reconstruction and full quantization technique

BACKGROUND For treatment of hilar cholangiocarcinoma(HCCA),the rate of radical resection is low and prognosis is poor,and preoperative evaluation is not sufficiently accurate.3D visualization has the advantage of giving a stereoscopic view,which makes accurate resection of HCCA possible.AIM To establish precise resection of HCCA based on eOrganmap 3D reconstruction and full quantification technology.METHODS We retrospectively analyzed the clinical data of 73 patients who underwent HCCA surgery.All patients were assigned to two groups.The traditional group received traditional 2D imaging planning before surgery(n=35).The eOrganmap group underwent 3D reconstruction and full quantitative technical planning before surgery(n=38).The preoperative evaluation,anatomical classification of hilar hepatic vessels,indicators associated with surgery,postoperative complications,liver function,and stress response indexes were compared between the groups.RESULTS Compared with the traditional group,the amount of intraoperative blood loss in the eOrganmap group was lower,the operating time and postoperative intestinal ventilation time were shorter,and R0 resection rate and lymph node dissection number were higher(P<0.05).The total complication rate in the eOrganmap group was 21.05%compared with 25.71%in the traditional group(P>0.05).The levels of total bilirubin,Albumin(ALB),aspartate transaminase,and alanine transaminase in the eOrganmap group were significantly different from those in the traditional group(intergroup effect:F=450.400,79.120,95.730,and 13.240,respectively;all P<0.001).Total bilirubin,aspartate transaminase,and alanine transaminase in both groups showed a decreasing trend with time(time effect:F=30.270,17.340,and 13.380,respectively;all P<0.001).There was an interaction between patient group and time(interaction effect:F=3.072,2.965,and 2.703,respectively;P=0.0282,0.032,and 0.046,respectively);ALB levels in both groups tended to increase with time(time effect:F=22.490,P<0.001),and there was an interaction effect between groups and time(interaction effect:F=4.607,P=0.004).In the eOrganmap group,there was a high correlation between the actual volume of intraoperative liver specimen resection and the volume of preoperative virtual liver resection(t=0.916,P<0.001).CONCLUSION The establishment of accurate laparoscopic resection of hilar cholangiocarcinoma based on preoperative eOrganmap 3D reconstruction and full quantization technology can make laparoscopic resection of hilar cholangiocarcinoma more accurate and safe.

Precise mapping of hilar cholangiocarcinoma with a skip lesion by SpyGlass cholangioscopy:A case report

BACKGROUND Cholangiocarcinoma(CC)is a very aggressive cancer with a poor prognosis.As surgery is the only curative therapy,preoperative evaluation of the tumor extent is essential for surgical planning.Although high-quality image modalities such as computed tomography and magnetic resonance imaging have been used extensively in preoperative evaluation,the accuracy is low.To obtain precise localization of tumor spread arising from the hilar region preoperatively,the development of an acceptable imaging modality is still an unmet need.CASE SUMMARY A 52-year-old female presented to our emergency department with jaundice,abdominal pain,and fever.Initially,she was treated for cholangitis.Endoscopic retrograde cholangiopancreatography with the cholangiogram showed long segment filling defect in the common hepatic duct with dilatation of bilateral intrahepatic ducts.Transpapillary biopsy was performed,and the pathology suggested intraductal papillary neoplasm with high-grade dysplasia.After treatment of cholangitis,contrasted-enhanced computed tomography revealed a hilar lesion with undetermined Bismuth-Corlette classification.SpyGlass cholan gioscopy showed that the lesion involved the confluence of the common hepatic duct with one skip lesion in the posterior branch of the right intrahepatic duct,which was not detected by previous image modalities.The surgical plan was modified from extended left hepatectomy to extended right hepatectomy.The final diagnosis was hilar CC,pT2aN0M0.The patient has remained disease-free for more than 3 years.CONCLUSION SpyGlass cholangioscopy may have a role in precision localization of hilar CC to provide surgeons with more information before the operation.

Proposal of a modified classification for hilar cholangiocarcinoma

Hilar cholangiocarcinoma is a malignant tumor that originates from the left and right hepatic ducts and their confluence.It is highly malignant and associated with a poor prognosis.Surgical resection is the only available curative treatment option.A scientific classification system can aid in the preoperative assessment of resectability and guide the development of appropriate surgical strategies.Several classification systems are available,with the Bismuth-Corlette(BC)classification being the earliest and most widely used.Similar to many other classifications,the BC classification relies on the secondary branching of the bile ducts as an important anatomical landmark,making it unsuitable for cases with variations in the bile duct anatomy.With advances in understanding the hepatic plate and anatomical structures at the hilum,the secondary bile ducts are no longer considered important anatomical landmarks.Therefore,modifications to the BC classification are needed to align with modern anatomical improvements and advancements in surgical techniques.Herein,we propose a modification to the BC classification.In this new system,the boundary of the hilar plate is considered as limit of the proximal ductal margin and used as an anatomical landmark,rather than the concept of“secondary bile ducts”in the BC classification.

Preoperative assessment of hilar cholangiocarcinoma:combination of cholangiography and CT angiography

BACKGROUND: Hilar cholangiocarcinoma is one of the most difficult carcinomas to manage because of the location of the main tumor at the hepatic hilus and the complex anatomy of the biliary, arterial, and portal systems. To plan an operation, it is important to acquire accurate information about the relationship between hilar cholangiocarcinoma and adjacent vessels. This study aimed to evaluate the clinical value of cholangiography combined with spiral CT three-dimensional (3D) angiography for a preoperative assessment of hilar cholangiocarcinoma. METHODS: From March 2007 to August 2009, cholangiography was performed in 13 patients with hilar cholangiocarcinoma. Meanwhile, contrast-enhanced abdominal scanning was performed using 16-slice spiral CT, and the 3D images of the hepatic artery and portal vein were acquired. The level and range of invasion of the hepatic artery, the portal vein, and the bile duct, the preoperative Bismuth classification, and T-staging were recorded and compared with those after surgical exploration. RESULTS: The hepatic artery and portal vein were reconstructed successfully in all these patients. Percutaneous transhepatic cholangiography was performed in 9 patients, endoscopic retrograde cholangiopancreatography in 1, and magnetic resonance cholangiopancreatography in 3. The CT angiography records of invasion of the hepatic artery were consistent with the results of explorations in these patients. The data from 5 of the 13 patients were consistent with those on invasion of the portal vein. The results of the Bismuth classification and the T-staging system were consistent with those of surgical exploration in 12 of the 13 patients. Seven of 8 patients who were estimated to be suitable for operation based on images were curatively treated and 5 who were judged to be unsuitable for curative operation by cholangiography and CT angiography were confirmed intraoperatively and underwent palliative procedures. CONCLUSIONS: Cholangiography combined with multi-slice spiral 3D CT angiography can satisfactorily delineate the local invasion of hilar cholangiocarcinoma and accurately evaluate the resectability. This approach, therefore, contributes to the planning of safe operation. (Hepatobiliary Pancreat Dis Int 2010; 9: 186-191)

Combined vascular resection and analysis of prognostic factors for hilar cholangiocarcinoma

BACKGROUND： Hilar cholangiocarcinoma （HCCA） is a devastating malignancy arising from the bifurcation of the hepatic duct, whether combined vascular resection benefits HCCA patients is controversial. This study was undertaken to assess the effect of combined vascular resection in HCCA patients and to analyze the prognostic factors.

Effect of hepatitis C virus core protein on modulation of cellular proliferation and apoptosis in hilar cholangiocarcinoma

BACKGROUND: Hepatitis C virus (HCV) is believed to be an important human pathogen causing carcinoma. But the effect of HCV infection on the alteration of cellular pro- liferation and apoptosis and the relationship between the effect and the development of hilar cholangiocarcinoma are largely unknown. The aim of this study was to assess the effect of HCV core protein on proliferation and apoptosis of hilar cholangiocarcinoma. METHODS: HCV core protein (HCV C protein) was de- tected by peroxidase-antiperoxidase assay in surgical speci- mens from 48 patients with hilar cholangiocarcinoma. The apoptosis index ( AI) and PCNA index ( PI) in hilar cholangiocarcinoma were detected by in situ end labeling assay and streptavidin-biotin assay respectively. RESULTS: The expression of HCV C protein was observed in 32 (67.7%) of the 48 specimens of hilar cholangiocarci- noma. The mean ± standard deviation for AI and PI was 3.52%±0.64% and 46.24%±11.46% respectively. The AI of hilar cholangiocarcinoma specimens with HCV C protein expression was significantly lower than that of HCV C pro- tein negative specimens (P<0.01), whereas the PI of HCV C protein positive specimens was significantly higher than that of HCV C protein negative specimens (P<0.01). CONCLUSION: HCV C protein may promote the cellular proliferation of hilar cholangiocarcinoma and inhibit its cel- lular apoptosis.

Postoperative morbidity adversely impacts oncological prognosis after curative resection for hilar cholangiocarcinoma

BACKGROUND Postoperative morbidity after curative resection for hilar cholangiocarcinoma(HCCA)is common;however,whether it has an impact on oncological prognosis is unknown.AIM To evaluate the influence of postoperative morbidity on tumor recurrence and mortality after curative resection for HCCA.METHODS Patients with recently diagnosed HCCA who had undergone curative resection between January 2010 and December 2017 at The First Affiliated Hospital of Army Medical University in China were enrolled.The independent risk factors for morbidity in the 30 d after surgery were investigated,and links between postoperative morbidity and patient characteristics and outcomes were assessed.Postoperative morbidities were divided into five grades based on the Clavien-Dindo classification,and major morbidities were defined as Clavien-Dindo≥3.Univariate and multivariate Cox regression analyses were used to evaluate the risk factors for recurrence-free survival(RFS)and overall survival(OS).RESULTS Postoperative morbidity occurred in 146 out of 239 patients(61.1%).Multivariate logistic regression revealed that cirrhosis, intraoperative blood loss > 500 mL, diabetes mellitus,and obesity were independent risk factors. Postoperative morbidity was associated with decreasedOS and RFS (OS: 18.0 mo vs 31.0 mo, respectively, P = 0.003;RFS: 16.0 mo vs 26.0 mo, respectively,P = 0.002). Multivariate Cox regression analysis indicated that postoperative morbidity wasindependently associated with decreased OS [hazard ratios (HR): 1.557, 95% confidence interval(CI): 1.119-2.167, P = 0.009] and RFS (HR: 1.535, 95%CI: 1.117-2.108, P = 0.008). Moreover, majormorbidity was independently associated with decreased OS (HR: 2.175;95%CI: 1.470-3.216, P <0.001) and RFS (HR: 2.054;95%CI: 1.400-3.014, P < 0.001) after curative resection for HCCA.CONCLUSIONPostoperative morbidity (especially major morbidity) may be an independent risk factor forunfavorable prognosis in HCCA patients following curative resection.

Current therapy of hilar cholangiocarcinoma

BACKGROUND: Hilar cholangiocarcinoma (HC) is an adeno-carcinoma of the extrahepatic biliary tree arising from the main left or right hepatic ducts or their confluence. This tumor is still considered to be difficult to treat or to cure. DATA SOURCES: We reviewed the medical literature on HC. Relevant and updated information on this tumor was analyzed in a concise and easy-to-read manner. The article is not intended to be a systematic review, but an extensive search was conducted on PubMed and MEDLINE using the keywords 'hilar cholangiocarcinoma' and 'Klatskin tumor' until July 2011. RESULTS: The selection and the timing of management options for patients with HC are determined by the degree of certainty of the diagnosis, the general condition of the patients, the underlying liver function and the stage of the disease. Current treatment of HC can be divided into curative and palliative treatment. For the curative treatment, local excision should only be used on small tumors which are confined to the bile duct wall and Bismuth I papillary carcinoma. Partial hepatectomy should be combined with caudate lobe resection and porta-hepatis lymph node dissection. The results of these major resections can be improved with portal vein embolization, and staging laparoscopy and laparoscopic ultrasound. The role of preoperative biliary drainage is controversial. Autotransplantation for HC gave disappointing results while the Mayo Protocol of chemoradiation for selecting patients with unresectable HC for orthotopic liver transplantation has been widely accepted. Palliative treatment included bypass surgery, endoscopic or percutaneous stenting, photodynamic therapy, intraluminal brachytherapy, and external radiation and systemic therapy. CONCLUSIONS: Adequate surgery with R0 resection should be the main goal of treatment. For patients with unresectable HC, treatment aims to improve the quality and quantity of their survival.

The ratio of MMP-2 to TIMP-2 in hilar cholangiocarcinoma:a semi-quantitative study

BACKGROUND: Hilar cholangiocarcinoma is associated with low resectability and poor survival. The aim of this study was to evaluate the roles of matrix metalloproteinases- 2 (MMP-2 ) and its tissue inhibitor of metalloproteinase-2 (TIMP-2) in tumor invasion or as a prognostic factor in patients with human hilar cholangiocarcinoma. METHODS: The expressions of MMP-2 and TIMP-2 were investigated in patients. Paraffinized tissue sections ob- tained from 50 patients with human hilar cholangiocarcino- ma were analysed. The expressions of MMP-2 and TIMP-2 were examined immunohistochemically. Image analysis with image-pro plus analysis software was used to semi- quantitatively determine the ratio of MMP-2 to TIMP-2. RESULTS: The expression levels of MMP-2 and TIMP-2 were strongly associated with tumor hepatic invasion in pa- tients with hilar cholangiocarcinoma. Significant diffe- rences in the ratio of MMP-2 to TIMP-2 between some pathologic factors were observed in patients with hilar cholangiocarcinoma. CONCLUSIONS: MMP-2 plays an essential role in tumor invasion and metastasis,while TIMP-2 is shown to strongly inhibit cancer invasion and metastasis. The ratio of MMP-2 to TIMP-2 may be a prognostic indicator for patients with hilar cholangiocarcinoma.

Extended lymphadenectomy in hilar cholangiocarcinoma: What it will bring?

Lymph node dissection is always a hot issue in radical resection of hilar cholangiocarcinoma(HCCA).There are still controversies regarding whether some lymph nodes should be dissected,of which the para-aortic lymph nodes are the most controversial.This review synthesized findings in the literature using the PubMed database of articles in the English language published between 1990 and 2019 on the effectiveness of extended lymphadenectomy including paraaortic lymph nodes dissection in radical resection of HCCA.Hepatobiliary surgeons have basically achieved a consensus that enough lymph nodes should be obtained to accurately stage HCCA.Only a very small number of studies have focused on the effectiveness of extended lymphadenectomy including para-aortic nodes dissection on HCCA.They reported that extended lymphadenectomy can bring some survival benefits for patients with potential para-aortic lymph node metastasis and more lymph nodes can be obtained to make the patient's tumor staging more accurate without increasing the related complications.Extended lymphadenectomy should not be adopted for HCCA patients with intraoperatively confirmed distant lymph node metastases.For these patients,radical resection combined with postoperative adjuvant chemotherapy seems to be a better choice.A prospective,multicenter,randomized,controlled clinical study of regional lymphotomy and extended lymphadenectomy in HCCA should be conducted to guide clinical practice.A standardized extended lymphadenectomy may help to more accurately stage HCCA.Future studies are required to further assess whether extended lymphadenectomy can improve long-term survival in negative celiac,superior mesenteric,and para-aortic lymph node diseases.

The role of liver transplantation for hilar cholangiocarcinoma

BACKGROUND: Hilar cholangiocarcinoma is a devastating disease. Surgery is the only potentially curative modality. However, the results of surgical resection for hilar cholangiocarcinomas are disappointing. The introduction of liver transplantation for this condition has brought new hope for the management of this disease. The aim of this review is to discuss the role of liver transplantation in this disease. DATA SOURCES: A MEDLINE search was conducted for the articles on liver transplantation for hilar cholangiocarcinoma. Their results have been compiled and compared with the existing literature on resection for this disease. RESULTS: The earlier series on liver transplantation for hilar cholangiocarcinoma were not encouraging because of poor patient selection. The Mayo Clinic protocol of neoadjuvant chemoradiation followed by liver transplantation has shown remarkable success (survival at 1-, 3-, and 5-year post-transplantation being 92%, 82%, and 82%, respectively). With better patient selection and integration of neoadjuvant chemoradiation, the long-term survival is superior to that of the patients who undergo resection, as shown by the published literature on resection. The limitations of organ availability can be overcome by the living donor liver transplantation programme. This review article discusses the rationale, pros and cons of liver transplantation vis-à-vis resection for hilar cholangiocarcinoma.CONCLUSIONS: Liver transplantation, especially living donor liver transplantation, is a new and exciting alternative to resection for hilar cholangiocarcinoma. Integration of neoadjuvant chemoradiation has the potential to further improve the curative potential of liver transplantation. The strategy of combining neoadjuvant chemoradiation and liver transplantation brings new hope for the treatment of this difficult disease.

Postoperative Complications and Survival Analysis of Surgical Resection for Hilar Cholangiocarcinoma:A Retrospective Study of Fifty-Nine Consecutive Patients

Objective Hilar cholangiocarcinoma(HC)is invariably fatal without surgical resection.The primary aim of the current study was to determine the safety of variable surgical resections for patient with HC and their survival after surgical resection.In addition,prognostic factor for the overall survival was also evaluated.Methods The study included 59 consecutive patients who were newly diagnosed with HC and underwent surgical resections with curative intend between February 2009 and February 2017.Patients were followed up at 3-6 months intervals after hospital discharge.Postoperative complications and overall survival were determined.Associations of clinicopathologic and surgeon-related factors with overall survival were evaluated through univariate analysis and Cox regression analysis.Results Of patients with Bismuth and Corlette(B&C)type HI(n=19)and IV(n=25)HC lesions,33(55.9%)were treated with hilar resection combined with major liver resection(MLR),while the other 11 patients with type HI and IV,and those with type I(n=8)and II(n=7)HC lesions were treated with hilar resection.The overall surgical mortality was 5.1%and surgical morbidity was 35.6%.There was no statistical difference in the mortality between MLR group and hilar resection group(6.1%vs.3.8%;X2=0.703,P=0.145).The median follow-up period was 18 months(range,1-94 months).The 1-,3-,5-year survival rate was 59.3%,36.5%,and 17.7%,respectively.The overall survival after resections was 18 months.In HC patients with B&C type III and IV lesions,the median survival was 23 months for hilar resection with MLR and 8 months for hilar resection alone;the 1-,3-,5-year cumulative survival rate was 63.9%,23.3%,and 15.5%,respectively for hilar resection with MLR,and 11.1%,0,and 0,respectively for hilar resection alone,with significant diflerene observed(HR,9.902;95%CI,2.636-19.571,P=0.001).Four factors were independently associated with overall survival:preoperative serum Cal9-9(HR,7.039;95%CI,2.803-17.678,P<0.001),histopathologic grade(HR,4.964;95%CI,1.046-23.552,?=0.044),surgical margins(P=0.031),andAJCC staging(P=0.015).Conclusions R0 resection is efficacious in surgical treatment of HC.MLR in combination with caudate lobe resection may increase the chance of R0 resection and improve survival of HC patients with B&C type IK and IV lesions.Preoperatively prepared for biliary drainage may ensure the safety of MLR in most HC patients.Novel adjuvant therapies are needed to improve the survival of HC patients with poor prognostic factors.

Diagnosis and surgical treatment of hepatic hilar cholangiocarcinoma

BACKGROUND: Hepatic hilar cholangiocarcinoma can be diagnosed early with the progress in diagnostic imaging, and thus the rate of resection of the tumor has increased markedly. To assess the effectiveness of resection, we reviewed 185 cases of hepatic hilar cholangiocarcinoma diagnosed and treated at our hospital. METHODS: The clinical data of 185 patients with hepatic hilar cholangiocarcinoma who had been treated surgically from 1972 to 2006 were retrospectively analyzed. RESULTS: The records of the 185 patients were divided into first stage (1972-1986) or second stage (1987-2006) according to the incidence of the tumor and its resection rate. Primary symptoms included upper abdominal discomfort or pain, anorexia, tiredness, weight loss and progressive jaundice. Ultrasonography, computed tomography (CT), magnetic resonance imaging (MRI), and magnetic resonance cholangiopancreatography (MRCP) were first line methods for atraumatic diagnosis. If the patients displayed intrahepatic bile duct dilatation or were diagnosed as suffering from extrahepatic obstructive jaundice, percutaneous transhepatic cholangiography (PTC), MRCP or endoscopic retrograde cholangiopancreatography (ERCP) should be used. In this series, 87 patients underwent resection of the tumor (47.0%). Of the 87 patients, 43 received radical resection and 44 palliative resection. Fifteen patients underwent resection in the first stage and 72 in the second stage. A total of 74 patients were followed up after the resection. The median survival time of the radical resection group was 37 months and that of the palliative resection group was 17 months (P<0.001). The other 62 patients receiving no resection died within 1.5 years. CONCLUSIONS: Once patients are diagnosed with hepatic hilar cholangiocarcinoma, they should undergo exploratory laparotomy. Resection is the most effective method for the treatment of hepatic hilar cholangiocarcinoma.

Assessment of clinical outcomes of advanced hilar cholangiocarcinoma

Background: Low 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.Methods: Clinical 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.Results: The 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.Conclusions: Surgery 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.

Hepatic mucormycosis mimicking hilar cholangiocarcinoma:A case report and literature review

Mucormycosis is a rare but invasive opportunistic fungal infection associated with a high mortality rate,and normally occurs in immunocompromised patients. In this report,we describe an immunocompetent patient suffering from hepatic mucormycosis secondary to adrenal mucormycosis,which masquerades as hilar cholangiocarcinoma. After surgical procedure and treatment with amphotericin B and itraconazole,the patient recovered well and had a 2-year infection-free survival. To our knowledge,this special clinical manifestation of hepatic infection as well as adrenal mucormycosis has not been reported to date. Mean-while,this is the first case of an immunocompetent patient with both adrenal and hepatic mucormycosis who has been treated successfully.

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

BACKGROUND Hilar 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.AIM To determine the prognosis of patients with advanced HC after hepatic artery resection and reconstruction.METHODS A 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.RESULTS Operation 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).CONCLUSION Radical 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.

Endoscopic or percutaneous biliary drainage in hilar cholangiocarcinoma:When and how?

Hilar cholangiocarcinoma (hCCA) is a primary liver tumor associated with a dimprognosis. The role of preoperative and palliative biliary drainage has long beendebated. The most common techniques are endoscopic retrograde cholangiopancreatography(ERCP) and percutaneous transhepatic biliary drainage (PTBD);however, recently developed endoscopic ultrasound-assisted methods are gainingmore atention. Selecting the best available method in any specific scenario iscrucial, yet sometimes challenging. Thus, this review aimed to discuss theavailable techniques, indications, perks, pitfalls, and timing-related issues in themanagement of hCCA. In a preoperative setting, PTBD appears to have someadvantages: low risk of postprocedural complications (namely cholangitis) andbetter priming for surgery. For palliative purposes, we propose ERCP/PTBDdepending on the experience of the operators, but also on other factors: the levelof bilirubin (if very high, rather PTBD), length of the stenosis and the presence ofcholangitis (PTBD), ERCP failure, or altered biliary anatomy.

Expression of RECK Gene and MMP-9 in Hilar Cholangiocarcinoma and Its Clinical Significance

Summary： In order to study the expression of transformation suppressor gene RECK and MMP-9 in hilar cholangiocarcinomas and its clinical significance, and explore the roles of RECK gene in metastasis and invasion of hilar cholangiocarcinoma, the expression levels of RECK, and MMP-9 mRNA were detected by using reverse transcription-polymerase reaction in 42 paraffin-embedded samples of hilar cholangiocarcinomas and 10 samples of benign bile duct diseases. The results showed that in hilar cholangiocarcinoma tissues, the expression of RECK gene was 0. 235±0. 062, significantly lower than in normal bile duct tissues （0. 533±0. 024, P〈0.05）. In hilar cholangiocarcinoma tissues, the expression of MMP-9 （0. 528±0. 039） was significantly higher than in the normal tissues （0. 311±0. 032, P〈0.05）. The expression of RECK gene was closely related to the intrahepatic and surrounding organs invasion （P〈0.05）. It was concluded that RECK gene could inhibit the expression of MMP-9 in hilar cholangiocarcinomas and closely correlated with the biological behaviors. The abnormal expression of RECK gene might be one of the molecular mechanisms of hilar cholangiocarcinoma metastasis.

Application of multiple Roux-en-Y hepaticojejunostomy reconstruction by formation of bile hilar duct lake in the operation of hilar cholangiocarcinoma

BACKGROUND Hilar cholangiocarcinoma is the most common malignant tumor of the extrahepatic bile duct.Until now,radical resection has been the most effective method for the long-term survival of patients with the disease.However,many problems have emerged in the field of hepatobiliary surgery for a long time,including complex surgical procedures,low resection rate,and postoperative complications.We have adopted the“multiple Roux-en-Y hepaticojejunostomy reconstruction by formation of a bile duct lake”technique in the treatment of hilar cholangiocarcinoma since 2008,and obtained satisfactory short-and longterm results.AIM To examine the feasibility of the application of multiple Roux-en-Y hepaticojejunostomy reconstruction by formation of a bile duct lake in the operation of hilar cholangiocarcinoma METHODS A retrospective analysis was performed for the clinical data,surgical methods,and results of 76 patients with hilar cholangiocarcinoma who were treated with hilar bile duct lake-forming multiple Roux-en-Y hepaticojejunostomy reconstruction at Gansu Provincial Hospital.RESULTS In all 76 cases,the operation was successful and no operative death occurred.The mean(range)operation time was 215.4±53.5 min(124–678 min),and the amount of bleeding during the operation was 428.2±63.8 mL(240–2200 mL).The overall 1-year survival rate was 78.9%,and the 3-year survival rate was 32.8%.CONCLUSION The multiple Roux-en-Y hepaticojejunostomy reconstruction technique with formation of a bile duct lake is safe and effective for the surgical treatment of hilar cholangiocarcinoma.