An aggressive surgical approach leads to improved survival in patients with gallbladder cancer: a 12-year study at a North American Center.
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OBJECTIVE: To determine if an aggressive surgical approach, with an increase in R0 resections, has resulted in improved survival for patients with gallbladder cancer. SUMMARY BACKGROUND DATA: Many physicians express a relatively nihilistic approach to the treatment of gallbladder cancer; consensus among surgeons regarding the indications for a radical surgical approach has not been reached. METHODS: A retrospective review of all patients with gallbladder cancer admitted during the past 12 years was conducted. Ninety-nine patients were identified. Cases treated during the 12-year period 1990 to 2002 were divided into 2 time-period (TP) cohorts, those treated in the first 6 years (TP1, N = 35) and those treated in the last 6 years (TP2, N = 64). RESULTS: Disease stratification by stage and other demographic features were similar in the 2 time periods. An operation with curative intent was performed on 38 patients. Nine (26%) R0 resections were performed in TP1 and 24 (38%) in TP2. The number of liver resections, as well as the frequency of extrahepatic biliary resections, was greater in TP2 (P < 0.04). In both time periods, an R0 resection was associated with improved survival (P < 0.02 TP1, P < 0.0001 TP2). Overall survival of all patients in TP2 was significantly greater than in TP1 (P < 0.03), with a median survival of 9 months in TP1 and 17 months in TP2. The median 5-year survival in TP1 was 7%, and 35% in TP2. The surgical mortality rate for the entire cohort was 2%, with a 49% morbidity rate. CONCLUSIONS: A margin-negative, R0 resection leads to improved survival in patients with gallbladder cancer. (+info)
Long-term curative effects of combined hepatocholangioplasty with choledochostomy through an isolated jejunum passage on hepatolithiasis complicated by stricture.
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BACKGROUND: Hepatocholangioplasty combined with choledochostomy was designed through an isolated jejunum passage in 1988. This study was undertaken to evaluate its long-term curative effects in 163 patients. METHODS: The 163 patients with hepatolithiasis complicated by stricture were treated with this procedure from 1988 to 2003. RESULTS: Among these patients, 19 patients with postoperative hepatolithiasis complicated by acute cholangitis were treated successfully with percutaneous paracentesis drainage through the isolated jejunum passage and without operation, 36 patients had postoperative residual or recurrent stones (35 patients had stones removed through the stoma and one underwent relaparotomy because of stenosis of the common bile duct along with stone in canceration). The clearance rate of stones after the isolated jejunum passage was 97%; 35 patients (21%) complicated with stricture due to hepatolith were treated with combined hepatocholangioplasty and choledochostomy. Follow-up for 1 to 15 years showed no recurrent stricture of the biliary tract. The operation also successfully prevented reflux cholangitis and other serious complications after Roux-en-Y cholangio-jejunostomy. CONCLUSION: Hepatocholangioplasty combined with choledochostomy through an isolated jejunum passage may significantly improve the long-term curative effects of hepatolithiasis with stricture. (+info)
Regression of liver fibrosis after biliary drainage in patients with choledocholith: a preliminary report.
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BACKGROUND: Choledocholith is prevalent in some Asian countries and may lead to liver fibrosis and portal vein hypertension. Biliary drainage is an effective treatment for choledocholith. The aim of this study was to assess the impact of biliary drainage on liver fibrosis due to choledocholith. METHODS: Eight patients with liver fibrosis caused by choledocholith were followed up by biochemical tests (aspartate aminotransferase, alanine aminotransferase) and liver biopsy before and after biliary drainage, respectively. The severity of the fibrosis was scored on a scale from 0 to 3 (0: denoting none; 1: portal and periportal fibrosis; 2: the presence of numerous fiber septa; and 3: cirrhosis). The results were analyzed statistically. RESULTS: The severity scores of liver fibrosis in the 8 patients were 2,1; 2,1; 1,0; 1,1; 2,1; 1,1; 2,1; 1,0 before and after biliary drainage, respectively. The results showed that the average severity of liver fibrosis decreased significantly after biliary drainage (n=8, t=4.573, P=0.003). CONCLUSION: Liver fibrosis due to choledocholith may regress after biliary drainage. (+info)
Outcomes in 139 cases of biliary tract reconstructions from a transplant surgery center.
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OBJECTIVES: The purpose of this study is to report our single institution transplant surgery referral center's experience with 139 consecutive biliary tract reconstructions performed in a mixed cohort of liver transplant recipients and patients with biliary tract malignancies, iatrogenic injuries, or other benign biliary pathology. MATERIALS AND METHODS: Between July 1999 and February 2003, 139 biliary tract reconstructions were performed in 119 patients, using five various types of biliary reconstructions. The records and operative notes of all patients were reviewed with particular attention to surgical technique, operative mortality, post-operative complications and post-operative liver function tests with respect to biliary function. RESULTS: The mean duration of follow-up was 19.4 months (range 1.0 - 44.7 months). We were pleased to find excellent results from bilio-enteric reconstruction as no patient in our series developed cholangitis, jaundice or liver failure. CONCLUSION: Our goal is to inform the hepatobiliary and general surgeons of the principles of restoring biliary drainage that have arisen from our experience in a variety of reconstruction. (+info)
Pathogenesis and treatment to postoperative bile leakage: report of 38 cases.
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BACKGROUND: Bile leakage remains a serious complication after biliary surgery. The aim of this study was to assess the etiology, diagnosis and treatment of postoperative biliary leakage. METHODS: Thirty-eight patients with biliary leakage we treated in recent 8 years were analyzed retrospectively. Among them, 8 patients had bilioenterostomy leakage, 7 accessory bile duct leakage, 7 cholecyst bed leakage, 6 leakage after removal of T-tube, 5 leakage after laparoscopic cholecystectomy, 3 leakage around T-tube, and 2 leakage caused by choledochal damage. Drainage was performed in 17 patients, reoperation in 13, drainage plus percutaneous transhepatic cholangio drainage (PTCD), endoscopic retrograde cholangiography (ERCP), endoscopic nasobiliary drainage (ENBD) and endostenting in 5, and drainage plus growth hormone in 3. RESULTS: In this series, 37 patients were cured, and 1 died of multiple organ dysfunction syndrome (MODS). These patients were hospitalized for 2 weeks to 8 weeks. The drainage group was hospitalized shorter than the undrainage group. CONCLUSIONS: A piece of white gauze can be used to touch surgical area in detecting biliary leakage intraoperatively. Mucous to mucous suture of the bile duct and appropriate time for removal of T-tube are recommended to prevent biliary leakage. Reoperation is essential to acute peritonitis. Drainage can be used if leakage don't diffuse or it occurs after pulling out T-tube. Drainage plus ERCP, ENBD, PTCD and drainage are effective. (+info)
Middle and long-term clinical outcomes of patients with regional hepatolithiasis after subcutaneous tunnel and hepatocholangioplasty with utilization of the gallbladder.
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BACKGROUND: Roux-en-Y choledochojejunostomy is routinely performed in patients with regional hepatolithiasis. However, some of these patients, who have a normal gallbladder and normal Oddi's sphincter, are unnecessarily undergoing bilio-intestinal drainage. Alternatively, reconstruction can be achieved by subcutaneous tunnel and hepatocholangioplasty with the utilization of the gallbladder (STHG). This method is effective to potential endoscopic tunnel and intervention during follow-up, and prevention of reflux cholangitis as well as the disorders of the GI tract. METHODS: The middle and long-term complications of 46 patients who underwent STHG were analyzed. With B-ultrasonography and biochemical assay, the contraction and concentration function of the gallbladder were also studied. RESULTS: Follow-up showed that all patients survived with a relatively normal life. One patient experienced right epigastric pain, chills and fever because of a stone which impacted in the left hepatic bile duct. Another patient had cholangitis because of biliary ascariasis. The two patients were treated by endoscopic therapy within the subcutaneous gallbladder under local anesthesia. CONCLUSIONS: This operation not only keeps the normal physical functional of the gallbladder, Oddi's sphincter and gastrointestinal tract, but also prevents reflux cholangitis and the disorder of the digestive tract. Hence STHG is a novel operation dealing with regional hepatolithiasis. (+info)
Catheter tract implantation metastases associated with percutaneous biliary drainage for extrahepatic cholangiocarcinoma.
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AIM: To estimate the incidence of catheter tract implantation metastasis among patients undergoing percutaneous transhepatic biliary drainage (PTBD) for extrahepatic cholangiocarcinoma, and to provide data regarding the management of this unusual complication of PTBD by reviewing cases reported in the literature. METHODS: A retrospective analysis of 67 consecutive patients who underwent PTBD before the resection of extrahepatic cholangiocarcinoma was conducted. The median follow-up period after PTBD was 106 mo. The English language literature (PubMed, National Library of Medicine, Bethesda, MD, USA), from January 1966 through December 2004, was reviewed. RESULTS: Catheter tract implantation metastasis developed in three patients. The cumulative incidence of implantation metastasis reached a plateau (6%) at 20 mo after PTBD. All of the three patients with implantation metastasis died of tumor progression at 3, 9, and 20 mo after the detection of this complication. Among the 10 reported patients with catheter tract implantation metastasis from extrahepatic cholangiocarcinoma (including our three patients), two survived for more than 5 years after the excision of isolated catheter tract metastases. CONCLUSION: Catheter tract implantation metastasis is not a rare complication following PTBD for extrahepatic cholangiocarcinoma. Although the prognosis for patients with this complication is generally poor, the excision of the catheter tract may enable survival in selected patients with isolated metastases along the catheter tract. (+info)
Endoscopic management of post-laparoscopic cholecystectomy biliary strictures. Long-term outcome in a multicenter study.
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OBJECTIVES: The aim of this retrospective study was to assess the long term results of long-lasting endoscopic stenting for benign biliary strictures related to laparoscopic cholecystectomy. Additional biological and morphological data were collected from these patients during follow-up. METHODS: Patients undergoing ERCP for post-laparoscopic cholecystectomy biliary stricture in one of the three participating centers between 1990 and December 2001 were identified. Only patients with successful endoscopic stenting were subsequently included and analyzed. Follow-up data were obtained from referring centers, general practitioners and patients or relatives. Hepatic blood tests and abdominal ultrasound were proposed to all the patients who had not undergone further treatments after stent removal. RESULTS: Eight-eight patients had undergone ERCP for benign biliary stricture related to laparoscopic cholecystectomy. Stenting failed in 19 patients. Balloon dilatation alone was used in four patients. Strictures were successfully stented in 65 patients. The mean number of stents inserted at the same time was 1.6. The mean duration of stenting was 14 months (range 1-120 months). Eighteen patients (28%) developed biliary or pancreatic symptoms during stenting. ERCP was considered satisfactory at the end of stenting (i.e. no remaining stricture or minor remaining change on ERCP) in 45 patients (69%). Twenty-two patients were lost to follow-up. Twenty-nine out of forty-three patients (67%) remained symptom-free with normal updated blood tests and abdominal ultrasound during a mean follow-up of 28 months (range 12-117 months) after stent removal. None of the patients with a normal ERCP at the end of stenting developed stricture recurrence during follow-up. Eleven patients were operated (8 with persistence of stricture, 2 for stricture recurrence up to 63 months after stent removal, 1 for pancreatitis). CONCLUSION: Based on clinical, morphological and biological criteria, a long-term success was obtained in 70% of patients with post-laparoscopic cholecystectomy benign biliary strictures, after several months of endoscopic stenting. (+info)