Phagocytosing Neutrophils and Granulopoiesis

Digestive Diseases and Sciences, 1995

Forty patients with cholangiocarcinoma (23 men, 17 women) underwent nonsurgical palliative biliary drainage over a period of 12 years. All were surgically unfit or had unresectable disease. All were jaundiced at presentation with a mean serum bilirubin of 11.5-1.9 mg/dl. Thirty patients (75%) had hilar obstruction. Twenty-eight were drained percutaneously, three endoscopically and nine by a combined endoscopic and percutaneous procedure. Technical success was 97.5%. Final mean bilirubin was 1.5 __+ 0.4 mg/dl. Minor complications occurred in 10 (25%) patients, and major complications in four (10%). Procedure-related mortality was 2,5% with a 30-day mortality of 7.5%. Mean survival was 8.2-2-0.5 months. Stent changes were required in eight patients. In patients with inoperable or unresectable cholangiocarcinoma, percutaneous or endoscopic biliary drainage offers effective palliation.

Hepatoma Research, 2021

Cholangiocarcinoma (CCA) is a rare but lethal tumor that arises from the intrahepatic, perihilar, or extrahepatic bile ducts. Complete surgical resection remains the only chance at long-term survival. Unfortunately, most cases of CCA are clinically silent until late in the disease process, and, combined with the lack of effective screening tests, many CCAs present as unresectable tumors. CCA workup typically includes a multiphasic chest, abdominal, and pelvic imaging, liver function tests, and tumor markers (CEA, CA 19-9). Tissue diagnosis is encouraged but not always necessary. In certain situations, esophagogastroduodenoscopy, colonoscopy, and mammography are recommended. If resectable, intrahepatic CCAs and perihilar CCAs require a hepatectomy ranging from a wedge resection to an extended hepatectomy with reconstruction depending on the location and tumor size. In certain specialized centers, portal vein and hepatic artery reconstruction can be performed with good outcomes and acceptable morbidity. For resectable extrahepatic CCAs, a pancreaticoduodenectomy is recommended. Traditionally, few effective adjuvant options have existed for patients after surgery. However, recent randomized controlled trials support the use of either adjuvant chemotherapy or chemoradiation therapy after surgical resection. In select patients, intra-arterial therapy options such as transarterial chemoembolization, hepatic artery infusion therapy, or yttrium-90 radioembolization, as well as liver transplant, are effective treatment modalities. Improved surgical techniques, regionalization of care to high-volume centers, and appropriate application of preoperative optimization techniques have safely expanded the candidates of potentially resectable patients and improved patient outcomes.

Updates in Surgery, 2020

The primary endpoint of this study is to evaluate the feasibility and safety of the laparoscopic approach in selected types of PeriHilar Cholangiocarcinoma (PHC). Secondary endpoint is to evaluate the potential advantages of laparoscopic approach over the open counterpart. From 2018, an MILS program for PHC was undertaken in selected patients: 16 patients constituted the study group (out of 261 operated between 2004 and 2019) and was compared with a group of patients operated by open technique (control group) in the previous period through a propensity score matching with a 1:2 ratio. Intraoperative and postoperative outcomes were evaluated and compared, focusing on blood loss, length of surgery, conversion to open approach, and complications. Laparoscopic resections resulted in statistically significant longer procedures (360 vs 275 min, p = 0.048). Conversion rate was 18.8%, being oncological concerns the most frequent reason for conversion (3/3 cases). A lower blood loss (380 vs 470, p = 0.048) and minor intraoperative blood transfusions (12.5% vs 21.9%, p = 0.032) were recorded in the study group. A number of retrieved nodes and rate of R0 resections were similar between the two groups. Patients in the MILS group had shorter length of stay (median 10) compared with open group (median 14), p = 0.048. The laparoscopic approach in PHC, so far maintained in an exploratory phase with the biliary-enteric anastomosis performed through the service incision, demonstrates adequate feasibility and safety standards when conducted in carefully selected patients and in centers with expertise.

Journal of Gastrointestinal Surgery, 2009

Introduction Controversy exists over the preferred technique of preoperative biliary drainage (PBD) in patients with hilar cholangiocarcinoma (HCCA) requiring major liver resection. The current study compared outcomes of endoscopic biliary drainage (EBD) and percutaneous transhepatic biliary drainage (PTBD) in patients with resectable HCCA. Methods One hundred fifteen consecutive patients were explored for HCCA between 2001 and July 2008 and assigned by initial PBD procedure to either EBD or PTBD. Results Of these patients, 101 (88%) underwent PBD; 90 patients underwent EBD as primary procedure, and 11 PTBD. The technical success rate of initial drainage was 81% in the EBD versus 100% in the PTBD group (P=0.20). Stent dislocation was similar in the EBD and PTBD groups (23% vs. 20%, P=0.70). Infectious complications were significantly more common in the endoscopic group (48% vs. 9%, P<0.05). Patients in the EBD group underwent more drainage procedures (2.8 vs. 1.4, P<0.01) and had a significantly longer drainage period until laparotomy (mean 15 weeks vs. 11 weeks in the PTBD group; P<0.05). In 30 patients, EBD was converted to PTBD due to failure of the endoscopic approach. Conclusions Preoperative percutaneous drainage could outperform endoscopic stent placement in patients with resectable HCCA, showing fewer infectious complications, using less procedures.

Seminars in Liver Disease, 2013

Cholangiocarcinomas (CCAs) are rare malignancies that originate from the epithelial cells of the bile ducts. These account for $10 to 15% of primary liver cancers, and 3% of gastrointestinal cancers. 1,2 It is the second most common primary liver cancer after hepatocellular carcinoma (HCC) and is classified according to its anatomical location within the biliary tree, intrahepatic or extrahepatic, the latter including perihilar (also commonly termed Klatskin tumor) and distal extrahepatic CCA. (►Fig. 1) Traditionally, $60% arises at the bifurcation of the hepatic ducts, while 20 to 30% arise in the distal common bile duct, with the remaining 10% of CCA being peripherally sited, arising within intrahepatic ducts of the liver parenchyma itself. 3-5 In recent years, epidemiological studies have shown that the incidence of intrahepatic CCA (iCCA) has increased significantly while extrahepatic CCA (eCCA) decreased or remained stable; based on a recent United States Surveillance, Epidemiology, and End Results study, intrahepatic CCA has become more common than eCCA. 5,6 In the United States, it has an overall incidence rate of 0.95 cases per 100,000 adults and accounts for $4,000 new cases a year, but the rate varies widely around the world from 0.2 per 100,000 in Australia to 96 per 100,000 in Thailand due to differences in local risk factors and genetics. 7-9 Recent epidemiological studies have shown that the overall incidence and mortality rates of CCA are on an upward trend in Western countries. 7,10,11 The purpose of this article is to review the recent developments in the management of CCA with emphasis on surgical management. Clinical Features and Risk Factors Perihilar CCA is pathologically similar to distal eCCA: They share similar predisposing factors and are mainly related to chronic inflammation of the biliary tract such as primary sclerosing cholangitis (PSC) in Western countries; liver fluke infestation and recurrent pyogenic cholangitis in Asia; various types of biliary malformations such as choledochal cysts, Caroli disease, congenital hepatic fibrosis, and exposure to carcinogenic agents such as Thorotrast, dioxins, nitrosamines, and vinyl chloride. 4,8,10-12 Most cases are sporadic and no risk factors can be identified. In iCCA, hepatitis C virus infection, nonalcoholic fatty liver disease, diabetes, smoking, and obesity have been identified as risk factors (►Table 1). 10,12-14

Gastrointestinal Endoscopy, 2002

Local and infiltrative extension make some biliary carcinomas accessible to nonoperative intraductal destruction. This study assessed the clinical feasibility and short-term results of local tumor destruction with an intraductal high-intensity US probe during ERCP. The probe is a flexible catheter with an 8 x 2.8 mm US transducer and a lumen for a guidewire. Ten patients (6 women, 4 men; mean age 74.8 years) were treated with this device. Lesions treated included carcinoma of the papilla (3), bile duct cholangiocarcinoma (2), Bismuth grade I and II hilar cholangiocarcinomas (4), and intrahepatic cystadenocarcinoma (1). Two patients underwent US therapy before surgery. Treatment was performed during standard ERCP: the probe was inserted through the malignant stricture and US therapy was applied over 360 degrees under fluoroscopic control. No serious adverse effects were observed; right upper abdominal pain developed in one patient for 12 hours. In one patient, histopathologic assessment of the resected tumor revealed extensive coagulation necrosis with inflammation up to 10 mm in depth surrounding the bile duct lumen. In the other operated patient, biopsy specimens from the treated portion of the bile duct were negative for malignancy. There was complete regression of cholangiocarcinoma of the bile duct in our patient, allowing for permanent stent removal (follow-up 30 months). A partial response was noted in 4 other patients and no response in 3 patients. This new method of intraductal tumor destruction by high-intensity US during ERCP is feasible and can induce objectively measurable tumor necrosis. Long-term follow-up will determine whether this method is curative in some cases and if it can reduce the need for biliary stent placement.

World journal of gastrointestinal endoscopy, 2015

In the last decades many advances have been achieved in endoscopy, in the diagnosis and therapy of cholangiocarcinoma, however blood test, magnetic resonance imaging, computed tomography scan may fail to detect neoplastic disease at early stage, thus the diagnosis of cholangiocarcinoma is achieved usually at unresectable stage. In the last decades the role of endoscopy has moved from a diagnostic role to an invaluable therapeutic tool for patients affected by malignant bile duct obstruction. One of the major issues for cholangiocarcinoma is bile ducts occlusion, leading to jaundice, cholangitis and hepatic failure. Currently, endoscopy has a key role in the work up of cholangiocarcinoma, both in patients amenable to surgical intervention as well as in those unfit for surgery or not amenable to immediate surgical curative resection owing to locally advanced or advanced disease, with palliative intention. Endoscopy allows successful biliary drainage and stenting in more than 90% of pa...

Liver International

Surgical resection is the only potentially curative treatment for patients with cholangiocarcinoma. For both perihilar cholangiocarcinoma (pCCA) and intrahepatic cholangiocarcinoma (iCCA), 5-year overall survival of about 30% has been reported in large series. This review addresses several challenges in surgical management of cholangiocarcinoma. The first challenge is diagnosis: a biopsy is typically avoided because of the risk of seeding metastases and the low yield of a brush of the bile duct. However, about 15% of patients with suspected pCCA are found to have a benign diagnosis after resection. The second challenge is staging; even with the best preoperative imaging, a substantial percentage of patients has occult metastatic disease detected at staging laparoscopy or early recurrence after resection. The third challenge is an adequate volume and function of the future liver remnant, which may require preoperative biliary drainage and portal vein embolization. The fourth challenge is a complete resection: a positive bile duct margin is not uncommon because the microscopic biliary extent of disease may be more extensive than perceived on imaging. The fifth challenge is the high post-operative mortality that has decreased in very high volume Asian centres, but remains about 10% in many Western referral centres. The sixth challenge is that even after a complete resection most patients develop recurrent disease. Recent randomized controlled trials found conflicting results regarding the benefit of adjuvant chemotherapy. The final challenge is to determine which patients with cholangiocarcinoma should undergo liver transplantation rather than resection.

World Journal of Gastrointestinal Oncology, 2021

Hilar cholangiocarcinoma (hCCA) is a primary liver tumor associated with a dim prognosis. The role of preoperative and palliative biliary drainage has long been debated. The most common techniques are endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic biliary drainage (PTBD); however, recently developed endoscopic ultrasound-assisted methods are gaining more atention. Selecting the best available method in any specific scenario is crucial, yet sometimes challenging. Thus, this review aimed to discuss the available techniques, indications, perks, pitfalls, and timing-related issues in the management of hCCA. In a preoperative setting, PTBD appears to have some advantages: low risk of postprocedural complications (namely cholangitis) and better priming for surgery. For palliative purposes, we propose ERCP/PTBD depending on the experience of the operators, but also on other factors: the level of bilirubin (if very high, rather PTBD), length of the steno...

Gastroenterology Research and Practice, 2014

Objective. We aimed to determine the effectiveness of endoscopic retrograde cholangiopancreatography (ERCP) in patients with inoperable perihilar cholangiocarcinoma and establish the incidence of cholangitis development following ERCP. Material and Method. This retrospective study enrolled patients diagnosed with inoperable perihilar cholangiocarcinoma who underwent endoscopic drainage (stenting) with ERCP. Patients were evaluated for development of cholangitis and the effectiveness of ERCP. The procedure was considered successful if bilirubin level fell more than 50% within 7 days after ERCP. Results. Post-ERCP cholangitis developed in 40.7% of patients. Cholangitis development was observed among 39.4% of patients with effective ERCP and in 60.6% of patients with ineffective ERCP. Development of cholangitis was significantly more common in the group with ineffective ERCP compared to the effective ERCP group ( = 0.001). The average number of ERCP procedures was 2.33 ± 0.89 among patients developing cholangitis and 1.79 ± 0.97 in patients without cholangitis. The number of ERCP procedures was found to be significantly higher among patients developing cholangitis compared to those without cholangitis ( = 0.012). Conclusion. ERCP may not provide adequate biliary drainage in some of the patients with perihilar cholangiocarcinoma and also it is a procedure associated an increased risk of cholangitis.