Fu-Yu Li

Significance of Controlling Chronic Proliferative Cholangitis in the Treatment of Hepatolithiasis

BackgroundRecently, high stone recurrence and biliary restenosis rates in hepatolithiasis patients have been confirmed to be closely related to chronic proliferative cholangitis (CPC). However, the effective management of CPC has not yet been established.Methods and resultsA vicious cycle exists between the presence of intrahepatic calculi and CPC: both the stone itself and secondary biliary infection can stimulate persistent hyperplasia in the biliary duct wall, leading to the occurrence of CPC and biliary stricture. The recurrent attacks of CPC will, in turn, facilitate new stone formation via mucoglycoprotein production, or induced biliary stricture and cholestasis. Thus, even when the stone is completely removed and the biliary tract stenosis is corrected, residual CPC will persist and progress, with an underlying risk for postoperative stone recurrence and biliary tract restenosis. Therefore, the perfect hepatolithiasis treatment would target stone removal and correction of the biliary tract stricture, as well as control of postoperative residual CPC. In fact, CPC, the management of which has been traditionally ignored, is the key to breaking this vicious cycle.ConclusionsOverall, the subsequent treatment of residual CPC after operation or choledochoscopic lithotomy would be helpful to decrease postoperative stone recurrence and the rate of biliary restenosis. Adding such treatment would reduce the incidence of surgical reintervention and choledochoscopic lithotomy, and it would also improve the postoperative hepatolithiasis outlook.

Prognostic factors and long-term outcomes of hilar cholangiocarcinoma: A single-institution experience in China

AIM To evaluate the prognostic factors of hilar cholangiocarcinoma in a large series of patients in a single institution. METHODS Eight hundred and fourteen patients with a diagnosis of hilar cholangiocarcinoma that were evaluated and treated between 1990 and 2014, of which 381 patients underwent curative surgery, were included in this study. Potential factors associated with overall survival (OS) and disease-free survival (DFS) were evaluated by univariate and multivariate analyses. RESULTS Curative surgery provided the best long-term survival with a median OS of 26.3 mo. The median DFS was 18.1 mo. Multivariate analysis showed that patients with tumor size > 3 cm [hazard ratio (HR) = 1.482, 95%CI: 1.127-1.949; P = 0.005], positive nodal disease (HR = 1.701, 95%CI: 1.346-2.149; P < 0.001), poor differentiation (HR = 2.535, 95%CI: 1.839-3.493; P < 0.001), vascular invasion (HR = 1.542, 95%CI: 1.082-2.197; P = 0.017), and positive margins (HR = 1.798, 95%CI: 1.314-2.461; P < 0.001) had poor OS outcome. The independent factors for DFS were positive nodal disease (HR = 3.383, 95%CI: 2.633-4.348; P < 0.001), poor differentiation (HR = 2.774, 95%CI: 2.012-3.823; P < 0.001), vascular invasion (HR = 2.136, 95%CI: 1.658-3.236; P < 0.001), and positive margins (HR = 1.835, 95%CI: 1.256-2.679; P < 0.001). Multiple logistic regression analysis showed that caudate lobectomy [odds ratio (OR) = 9.771, 95%CI: 4.672-20.433; P < 0.001], tumor diameter (OR = 3.772, 95%CI: 1.914-7.434; P < 0.001), surgical procedures (OR = 10.236, 95%CI: 4.738-22.116; P < 0.001), American Joint Committee On Cancer T stage (OR = 2.010, 95%CI: 1.043-3.870; P = 0.037), and vascular invasion (OR = 2.278, 95%CI: 0.997-5.207; P = 0.051) were independently associated with tumor-free margin, and surgical procedures could indirectly affect survival outcome by influencing the tumor resection margin. CONCLUSION Tumor margin, tumor differentiation, vascular invasion, and lymph node status were independent factors for OS and DFS. Surgical procedures can indirectly affect survival outcome by influencing the tumor resection margin.

Lymphocyte to monocyte ratio and prognostic nutritional index predict survival outcomes of hepatitis B virus-associated hepatocellular carcinoma patients after curative hepatectomy.

Lymphocytes are an integral part of lymphocyte to monocyte ratio (LMR) and prognostic nutritional index (PNI). Both LMR and PNI which reflect bodys inflammatory and nutritional status can be obtained from routine blood and biochemical test conveniently. Little evidence concerning the prognostic value of LMR and PNI in hepatocellular carcinoma (HCC) patients has been published. This study aimed to investigate the prognostic value of LMR and PNI in hepatitis B virals (HBV)—associated HCC patients who underwent curative hepatectomy.

The current management of cholangiocarcinoma: A comparison of current guidelines

Cholangiocarcinoma (CC) accounts for about 3% of all gastrointestinal tumors and is the second most common primary liver tumor. Quality guidelines on CC are needed to guide hepatobiliary surgeons. Here, current guidelines on CC were reviewed to provide useful information and suggestions to help institutes and organizations all around the world to draft better guidelines on CC. Literature databases were electronically searched to identify guidelines or consensus statements regarding CC published from 2002-2016. Nine guidelines were included in this review. Comparison of the current guidelines revealed several inconsistencies. Signs of conflicting views indicated a lack of high level evidence. More studies need to be conducted in areas of contention to help update the guidelines. Organizations and medical societies need to be encouraged to use standard evaluation measures, to restrict tumors to CC or iCC, pCC, or dCC specifically, to give recommendations in accordance with the equipment that is available for diagnosis and treatment in different counties, and to use an appropriate and consistent structure when establishing and drafting guidelines for CC.

Prognostic value of alkaline phosphatase, gamma-glutamyl transpeptidase and lactate dehydrogenase in hepatocellular carcinoma patients treated with liver resection

BACKGROUND Alkaline phosphatase (ALP), gamma-glutamyl transpeptidase (GGT) and lactate dehydrogenase (LDH) are routinely tested before surgery and are easily obtained. They are also the most widely used tumor markers, which have a certain reference value in the diagnosis of hepatocellular carcinoma (HCC). The prognostic values of ALP, GGT and LDH have not been explored deeply and few studies have investigated the prognosis value of them in surgically treated HCC patients. Our study was performed to verify the prognostic significance of preoperative ALP, GGT and LDH in hepatitis B virus (HBV)-related HCC patients receiving curative hepatectomy. MATERIALS AND METHODS 469 pathologically confirmed HCC patients who received curative hepatectomy were retrospectively analyzed. Significant clinicopathological factors were collected and analyzed. Independent prognostic factors were identified by the multivariate analysis. Overall survival (OS) and recurrence-free survival (RFS) curves were analyzed and compared between different groups. RESULTS Patients with low level of ALP, GGT and LDH have favorable OS and RFS, even in cirrhosis subgroup. ALP, GGT and LDH were also closely related to some important clinicopathological parameters. GGT and LDH were significant independent prognostic factors of both OS and RFS, while ALP was just a significant independent prognostic factor of OS, rather than RFS. CONCLUSIONS Preoperative ALP, GGT and LDH could predict prognosis in HBV-related HCC patients who received curative liver resection.

Effectiveness of chemical biliary duct embolization for chemical hepatectomy.

Background and Aims:  The high recurrence of hepatolithiasis and high operative trauma of hepatectomy necessitate new therapeutic approaches. Thus, this study was designed to (i) investigate the effectiveness of chemical biliary duct embolization (CBDE) for chemical hepatectomy; and (ii) to determine the mechanism of CBDE.

Clinical prospect of applying the chemical bile duct embolization to achieve a chemical hepatectomy in the treatment of highly selected hepatolithiasis.

The high recurrence rate of hepatolithiasis, together with the high operative risk of hepatectomy for specifically located stones shows that an effective treatment for intrahepatic stones has not been settled upon. It is commonly accepted that a diseased biliary duct mucosa is a prerequisite for the development of intrahepatic stones, and that segmental biliary obstruction is able to induce hepatic atrophy, fibrosis, and “self-cut” the obstructed hepatic segment. Therefore, we previously put forward the hypothesis that performing deliberate chemical bile duct embolization (CBDE) to induce a segmental chemical hepatectomy might be the way of treating hepatolithiasis. In this study, we review the relative experimental basis for CBDE, preliminary report on its clinical use in 2 patients, and speculate on its future application. To completely embolize a diseased biliary duct, absolute ethanol or phenol is firstly used to ablate the biliary mucosa and eradicate biliary bacteria. Subsequently, cyanoacrylate or tissue adhesive glue is used to permanently fill the duct lumen, occupying the space where the stones would have formed. Our prior laboratory investigations and preliminary clinical treatments have confirmed that this combination of embolization agents could not only achieve the desired aim of preventing stone recurrence but could also lead to complete atrophy of the targeted hepatic segment, thereby achieving a chemical hepatectomy. In the future, CBDE is likely to help in resolving the problem of calculous recurrence and thereby reduce the incidence of surgical reintervention and endoscopic stone extractions, which are so frequently needed in patients with hepatolithiasis. Also chemical hepatectomy might provide a new less-invasive hepatectomy method, especially for the more difficult resections of the caudate or right posterior lobes.

Primary neurofibroma of the common bile duct as an unusual cause of obstructive jaundice: a case report.

Benign tumor of the extrahepatic bile duct is rare, accounting for 6% of biliary tumors(1–4). In addition, the majority of biliary benign tumors are papilloma and adenoma (2, 5). Thus, primary neurofibroma of the common bile duct is even more rarely seen and is usually very difficult to diagnose before surgery, easily being misdiagnosed as cholangiocarcinoma (6, 7). Our recent experience with one case of primary neurofibroma of the common bile duct prompted us to report this rarely encounted tumor.

Compression Stockings for Prevention of Postthrombotic Syndrome A Systematic Review and Meta-Analysis

Objective: The present meta-analysis aimed to evaluate the efficacy and safety of compression stockings for postthrombotic syndrome (PTS) prevention in patients with deep venous thrombosis (DVT). Methods: Randomized controlled trials (RCTs) regarding the use of compression stockings for prevention of PTS were identified from the Medline, PubMed, and Embase databases as well as the Cochrane library. The resulting manuscripts were analyzed according to the criteria in the Cochrane Handbook for Systematic Reviews of Interventions. Results: Six RCTs involving 1465 patients with DVT were included. The meta-analysis indicated no statistical differences between the compression stocking and the control groups in PTS incidence, using either the Villalta scale (odds ratio [OR], 0.63; 95% confidence interval [CI], 0.23-1.74) or the Ginsberg scale (OR, 1.13; 95% CI, 0.72-1.77). Based on the Villalta scale categorization, there were no differences in the incidence of mild–moderate PTS (OR, 0.71; 95% CI, 0.36-1.41) or incidence of severe PTS (OR, 0.68; 95% CI, 0.15-3.11). The difference in the recurrence of venous thromboembolism (OR, 0.89; 95% CI, 0.61-1.30) was also not significant. In the 3 RCTs that reported side effects of compression stockings, they were primarily related to discomfort, including itching, erythema, and rash. Conclusion: The present meta-analysis has indicated that compression stockings may not prevent PTS, as determined by either the Villalta or the Ginsberg scale, in patients with DVT. However, owing to the limited number of trials, the evidence is not strong enough to draw a reliable conclusion. Further larger, randomized, double-blind, placebo-controlled, multicenter trials are needed.

Treatment of hepatolithiasis by chemical bile duct embolization: report on 2 cases.

The high recurrence of hepatolithiasis has not been settled effectively until now, which lead us to present a new therapy of the chemical bile duct embolization to resolve it. In our selected 2 patients, multiple biliary calculi, complicated by biliary stricture, were found in the inferior branch of left lateral bile duct via preoperative cholangiography. After the choledochoscopic cholelithotomy, the combination of absolute ethanol and N-butyl-cyanoacrylate were injected into the diseased biliary duct lumen. Two months later, their T-tube cholangiography demonstrated that the targeted biliary ducts were completely embolized, thus effectively preventing the calculous recurrence. Twelve and 15 months later, their computed tomography scan showed that the inferior segments of left lateral lobes were almost completely atrophied and disappeared, thus successfully achieving the chemical “resection” of the diseased hepatic lobe. Chemical bile duct embolization may be a feasible and safe technique to prevent the calculous recurrence and concurrently achieve the effect of chemical hepatectomy for highly selected hepatolithiasis cases.