Seiki Tashiro, T Imaizumi, H Ohkawa, A Okada, T Katoh, Y Kawaharada, H Shimada, H Takamatsu, H Miyake, T Todani, Committee for Registration of the Japanese Study Group on Pancreaticobiliary Maljunction
Pancreaticobiliary maljunction: retrospective and nationwide survey in Japan.
J Hepatobiliary Pancreat Surg. 2003;10(5):345-51. doi: 10.1007/s00534-002-0741-7.
Abstract/Text
Pancreaticobiliary maljunction (PBM) is a congenital anomaly defined as a union of the pancreatic and biliary duct that is located outside the duodenal wall. The Japanese Study Group on Pancreaticobiliary Maljunction and the Committee for Registration enrolled and analyzed 1627 patients with PBM who had been diagnosed and treated from January 1, 1990 to December 31, 1999 at 141 hospitals throughout the country. There were 1239 patients with dilatation of the bile duct (group A) and 388 patients without dilatation (group B). The average age was 24 years in group A and 47 years in group B; the age was significantly higher in group B. The type of confluence between the terminal choledochus and the pancreatic duct has been classified into three types (type a, right-angle type; type b, acute-angle type; and type c, complex type). In group A, type a accounted for 57.9% and was significantly more frequent compared with the other types (type b, 32.4%; type c, 5.6%). In group B, type b accounted for 60.8%, being significantly more frequent compared with the other types (type a, 29.4%; type c, 7.2%). Subjective symptoms, preoperative complications (e.g., liver dysfunction and acute pancreatitis), pancreatic stone, and pancreatic duct morphological abnormality were significantly more frequent in group A. However, the amylase levels in the bile and gallbladder were significantly higher in group B, and the presence of gallstone and morphological abnormality of the gallbladder was significantly more frequent in group B. The occurrence rate of cancer in the biliary tract was 10.6% in group A and 37.9% in group B, being significantly higher in group B. In group A, cancer of the extrahepatic bile duct was seen in 33.6% and cancer of the gallbladder was seen in 64.9%, but gallbladder cancer was present significantly more frequently in the patients with diffuse or cylindrical dilatation, and bile duct cancer was present significantly more frequently in the patients with cystic dilatation. In group B, 93.2% of the patients had gallbladder cancer, and bile duct cancer was found in as few as 6.8%. Against this background Japanese surgeons regard cholecystectomy, resection of the extrahepatic bile duct, and hepaticojejunostomy as standard operations for PBM with dilatation of the bile duct. However, opinion on whether or not the bile duct should be removed in the treatment of PBM without dilatation of the bile duct has been divided among Japanese surgeons. A randomized controlled trial is necessary.
Yi-Lei Deng, Nan-Sheng Cheng, Yi-Xin Lin, Rong-Xing Zhou, Chen Yang, Yan-Wen Jin, Xian-Ze Xiong
Relationship between pancreaticobiliary maljunction and gallbladder carcinoma: meta-analysis.
Hepatobiliary Pancreat Dis Int. 2011 Dec;10(6):570-80.
Abstract/Text
BACKGROUND: Reports on the relationship between pancreaticobiliary maljunction (PBM) and gallbladder carcinoma (GBC) are conflicting. The frequency of PBM in GBC patients and the clinical features of GBC patients with PBM vary in different studies.
DATA SOURCES: English-language articles describing the association between PBM and GBC were searched in the PubMed and Web of Science databases. Nine case-control studies fulfilled the inclusion criteria and addressed the relevant clinical questions of this analysis. Data were extracted independently by two reviewers using a predefined spreadsheet.
RESULTS: The incidence of PBM was higher in GBC patients than in controls (10.60% vs 1.76%, OR: 7.41, 95% CI: 5.03 to 10.87, P<0.00001). The proportion of female patients with PBM was 1.96-fold higher than in GBC patients without PBM (80.5% vs 62.9%, OR: 1.96, 95% CI: 1.09 to 3.52, P=0.12). GBC patients with PBM were 10 years younger than those without PBM (SMD: -9.90, 95% CI: -11.70 to -8.10, P<0.00001). And a difference in the incidence of associated gallstone was found between GBC patients with and without PBM (10.8% vs 54.3%, OR: 0.09, 95% CI: 0.05 to 0.17, P<0.00001). Among the GBC patients with PBM, associated congenital dilatation of the common bile duct was present with a higher incidence ranging from 52.2% to 85.7%, and 70.0%-85.7% of them belonged to the P-C type of PBM (the main pancreatic duct enters the common bile duct). No substantial heterogeneity was found and no evidence of publication bias was observed.
CONCLUSIONS: PBM is a high-risk factor for developing GBC, especially the P-C type of PBM without congenital dilatation of the common bile duct. To prevent GBC, laparoscopic cholecystectomy is highly recommended for PBM patients without congenital dilatation of the common bile duct, especially relatively young female patients without gallstones.
M Sugiyama, Y Atomi, T Yamato
Endoscopic ultrasonography for differential diagnosis of polypoid gall bladder lesions: analysis in surgical and follow up series.
Gut. 2000 Feb;46(2):250-4.
Abstract/Text
BACKGROUND: Differential diagnosis is often difficult for small (AIM: To assess the diagnostic accuracy of endoscopic ultrasonography (EUS) for polypoid lesions in a surgical and follow up series.
METHODS: A total of 194 patients with small polypoid lesions underwent both ultrasonography and EUS. A tiny echogenic spot or an aggregation of echogenic spots and multiple microcysts or a comet tail artefact indicated cholesterol polyp and adenomyomatosis respectively. Other lesions were diagnosed as neoplastic (adenoma or adenocarcinoma). In the 58 patients who underwent surgery, the histological diagnoses were cholesterol polyp (n = 36), adenomyomatosis (n = 7), adenoma (n = 4), and adenocarcinoma (n = 11). Of the remaining 136 patients with an EUS diagnosis of non-neoplastic lesions, 125 were followed up with ultrasonography alone or with EUS for 1-8.7 years (mean 2.6 years).
RESULTS: In the surgical series, EUS (97%) differentiated polypoid lesions more precisely than ultrasonography (76%). During follow up, the lesions remained unchanged in size in 109 (87%) of the 125 patients with non-neoplastic lesions diagnosed by EUS. No neoplastic lesions developed in these patients. Ultrasonography had shown lesions to be neoplastic in 13% of the follow up series.
CONCLUSIONS: EUS is highly accurate for differentially diagnosing polypoid gall bladder lesions. It is recommended when ultrasonography cannot rule out neoplastic lesions. Non-neoplastic lesions diagnosed by EUS may be followed and observed with ultrasonography.
Kiyoaki Ouchi, Junichi Mikuni, Yoichiro Kakugawa, Organizing Committee, The 30th Annual Congress of the Japanese Society of Biliary Surgery
Laparoscopic cholecystectomy for gallbladder carcinoma: results of a Japanese survey of 498 patients.
J Hepatobiliary Pancreat Surg. 2002;9(2):256-60. doi: 10.1007/s005340200028.
Abstract/Text
BACKGROUND/PURPOSE: The long-term effects of initial laparoscopic cholecystectomy on the prognosis of patients with GBC remain unknown because of the limited numbers of patients reported from single institutions. This study was designed to determine the long-term prognosis of patients with gallbladder carcinoma (GBC) who had undergone laparoscopic cholecystectomy (LC), and to clarify the role of LC for the treatment of GBC and the benefit of aggressive additional excision.
METHODS: The clinical courses and outcomes of 498 patients with laparoscopically removed GBC registered in a nationwide survey were examined. Written questionnaires sent to members of the Japanese Society of Biliary Surgery included questions on Preoperative diagnosis, timing and methods to obtain final diagnosis, depth of invasion, second surgical procedure, prognosis of patients, and type of recurrence, if any.
RESULTS: The 5-year survival rates of patients after LC according to the depth of invasion were as follows: 99% in those with pT1a (limited to the mucosa), 95% in those with pT1b (muscularis), 70% in those with pT2 (subserosa), 20% in those with pT3 (serosa), and 0% in those with pT4 (serosa with invasion to adjacent organs). Perforation of the gallbladder during LC was found in 20% of the patients. Patients with gallbladders perforated during LC showed a significantly lower survival rate than did those without perforated gallbladders ( P < 0.01). Additional excision during or after LC was carried out in 48% of the patients, and the frequency of additional excision increased in accordance with the depth of invasion. Compared with patients who underwent LC only, additional excision resulted in better survival in patients with pT2 or pT3 tumors ( P = 0.051 and P < 0.05, respectively), but this difference was not found in patients with pT1 or pT4 tumors.
CONCLUSIONS: LC is not likely to worsen the survival rate of patients with GBC compared with the survival rate of patients undergoing a standard open radical procedure, as long as additional excision is conducted for patients with laparoscopically removed pT2 or pT3 GBCs. Special attention should be paid to prevention of bile spillage during LC.
Masato Nagino, Junichi Kamiya, Hideki Nishio, Tomoki Ebata, Toshiyuki Arai, Yuji Nimura
Two hundred forty consecutive portal vein embolizations before extended hepatectomy for biliary cancer: surgical outcome and long-term follow-up.
Ann Surg. 2006 Mar;243(3):364-72. doi: 10.1097/01.sla.0000201482.11876.14.
Abstract/Text
OBJECTIVE: To assess clinical benefit of portal vein embolization (PVE) before extended, complex hepatectomy for biliary cancer.
SUMMARY BACKGROUND DATA: Many investigators have addressed clinical utility of PVE before simple hepatectomy for metastatic liver cancer or hepatocellular carcinoma, but few have reported PVE before hepatectomy for biliary cancer due to the limited number of surgical cases.
METHODS: This study involved 240 consecutive patients with biliary cancer (150 cholangiocarcinomas and 90 gallbladder cancers) who underwent PVE before an extended hepatectomy (right or left trisectionectomy or right hepatectomy). All PVEs were performed by the "ipsilateral approach" 2 to 3 weeks before surgery. Hepatic volume and function changes after PVE were analyzed, and the outcome also was reviewed.
RESULTS: There were no procedure-related complications requiring blood transfusion or interventions. Of the 240 patients, 47 (19.6%) did not undergo subsequent hepatectomy. The incidence of unresectability was higher in gallbladder cancer than in cholangiocarcinoma (32.2% versus 12.0%, P < 0.005). The remaining 193 patients (132 cholangiocarcinomas and 61 gallbladder cancers) underwent hepatectomy with resection of the caudate lobe and extrahepatic bile duct (n = 187), pancreatoduodenectomy (n = 42), and/or portal vein resection (n = 63). Seventeen (8.8%) patients died of postoperative complications: mortality was higher in gallbladder cancer than in cholangiocarcinoma (18.0% versus 4.5%, P < 0.05); and it was also higher in patients whose indocyanine green clearance (KICG) of the future liver remnant after PVE was <0.05 than those whose index was >or=0.05 (28.6% versus 5.5%, P < 0.001). The 3- and 5-year survival after hepatectomy was 41.7% and 26.8% in cholangiocarcinoma and 25.3% and 17.1% in gallbladder cancer, respectively (P = 0.011). In 136 other patients with cholangiocarcinoma who underwent a less than 50% resection of the liver without PVE, a mortality of 3.7% and a 5-year survival of 27.6% were observed, which was similar to the 132 patients with cholangiocarcinoma who underwent extended hepatectomy after PVE.
CONCLUSIONS: PVE has the potential benefit for patients with advanced biliary cancer who are to undergo extended, complex hepatectomy. Along with the use of PVE, further improvements in surgical techniques and refinements in perioperative management are necessary to make difficult hepatobiliary resections safer.
