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Pancreas-preserving resection of lower biliary tract adenocarcinoma: A coring-out technique.

ABSTRACT: Surgical resection for distal cholangiocarcinoma is usually carried out using pancreaticoduodenectomy (PD). However, because PD is a complex procedure with a high rate of postoperative complications, the surgical indications should be carefully considered, especially for patients with a decreased performance status, significant comorbidities, and/or anatomical anomalies. If curatively carried out, a less invasive, local resection may be an alternative procedure for such patients. In the current study, we present pancreas-preserving resection of the lower biliary tract in a patient with early-stage distal cholangiocarcinoma. This procedure was selected to avoid PD with arterial reconstruction because of arterial anomalies. After an abdominal exploration, a cholecystectomy was carried out and the common hepatic duct was transected. The bile duct was dissected from the pancreatic parenchyma without pancreatic resection, downward to the biliopancreatic ductal confluence. Next, a duodenotomy was done opposite Vater's ampulla. The duodenal mucosa around Vater's ampulla was incised and dissected, and the main pancreatic duct (MPD) was divided. The bile duct was completely separated from the pancreatic parenchyma, and the lower biliary tract was totally "cored-out". After resection, the MPD was re-implanted into the duodenal wall, and the duodenotomy was closed. Finally, a Roux-en-Y hepaticojejunostomy was created. Postoperative course was uneventful. No tumor recurrence has been observed for 21 months after the operation. Thus, pancreas-preserving resection of the lower biliary tract appeared to be appropriate for our patient. This organ-preserving approach can be a useful, alternative procedure in selected patients.

SUBMITTER: Nishida Y

PROVIDER: S-EPMC5881344 | biostudies-literature | 2017 Jun

REPOSITORIES: biostudies-literature

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Pancreas-preserving resection of lower biliary tract adenocarcinoma: A coring-out technique.

Nishida Yasunori Y Sugimoto Motokazu M Kojima Motohiro M Gotohda Naoto N Konishi Masaru M Takahashi Shinichiro S

Annals of gastroenterological surgery 20170601 2

Surgical resection for distal cholangiocarcinoma is usually carried out using pancreaticoduodenectomy (PD). However, because PD is a complex procedure with a high rate of postoperative complications, the surgical indications should be carefully considered, especially for patients with a decreased performance status, significant comorbidities, and/or anatomical anomalies. If curatively carried out, a less invasive, local resection may be an alternative procedure for such patients. In the current ...[more]

PMID: 29863138

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Project description:BackgroundTumor resection represents the only potentially curative therapy for patients with biliary tract cancer. Nevertheless, disease recurrence is observed in about 50% of patients, leading to a 5-years survival rate of less than 50%. The Golgi protein 73 (GP73), a type II Golgi transmembrane protein, exerts important functions of intracellular protein processing and transportation. Circulating GP73 has recently been suggested as a prognostic marker following resection of hepatocellular carcinoma (HCC) but its role in the context of BTC has remained unknown. In this study, we evaluate a potential role of circulating GP73 as a novel biomarker in patients with resectable BTC.MethodsGP73 serum levels were measured by immunoassay in n = 97 BTC and n = 40 HCC patients as well as n = 31 healthy controls. Results were correlated with clinical data.ResultsSerum GP73 levels were significantly elevated in BTC patients compared to healthy controls but lower compared to HCC patients. The combination of GP73/CA19-9 showed a sensitivity and specificity of 83.5% and 90.3% regarding the differentiation of BTC patients and healthy controls. BTC patients with baseline GP73 levels above the ideal cut-off value (42.47 ng/mL) showed a significantly reduced median overall survival (193 days) compared to patients with preoperative GP73 levels below this cut-off (882 days). These results were confirmed in uni- and multivariate Cox-regression analysis including several clinicopathological parameters such as age, ECOG performance status, tumor stage as well as established tumor markers and parameters of liver and kidney function.ConclusionsGP73 represents a previously unrecognized biomarker in the patients with resectable BTC that identifies patients with an impaired postoperative outcome. If larger clinical trials confirmed these findings, measurement of GP73 serum levels might become a novel tool in the challenging preoperative stratification process of patients with resectable BTC.

Project description:One- or two-staged bone grafting is sometimes required for tunnel malposition and/or tunnel widening in revision anterior cruciate ligament (ACL) reconstruction. The aim of this procedure is to restore the correct position of the ACL graft in the revision setting to provide a stable and functional ACL, thereby reproducing normal knee kinematics. We present a technique that allows for a cost-effective, convenient tunnel grafting of a femoral head allograft bone dowel into both femoral and tibial defects in revision ACL reconstruction. Technique Video Video Use of the cannulated Coring Reamer System (Arthex, Naples, FL) to perform the harvest. A 2.4-mm guide pin is placed through the femoral head and neck allograft, parallel to the neck axis. A coring reamer and plunger should be used to harvest a core diameter identical to that of the reamed tunnels. The coring reamer’s centralizing plunger with its guide pin should be left in its already cannulated position through the harvested core. This entire construct will be used to easily graft the associated tunnel. The allograft dowel is then marked 5 mm greater than the corresponding depth of the femoral socket, in accordance with the prior reaming depth. This step allows for compression of the cancellous portion of the bone dowel into the tunnel. At this mark, a narrow rongeur is used to weaken the bone dowel circumferentially, leaving a small bone bridge. The entire construct is then introduced via the tibial tunnel or anteromedial portal, depending on the trajectory previously used to ream the femoral tunnel. The plunger-pin-dowel construct is then advanced into the femoral tunnel by gently tapping a pin puller that is solidly gripping the guide pin. Once the femoral dowel is fully seated and flush with the opening of the femoral defect, the dowel’s bone bridge is then broken at the previously weakened site with the use of a probe. The remaining dowel is removed from the knee using a powered wire driver. (It will come out easily with the plunger-pin construct en bloc.) The remaining dowel is then repositioned into the tibial tunnel and tapped into position as desired. Using the remainder of the first dowel, a second one can be harvested easily if the tibial tunnel is not completely grafted.

Project description:Background & aimsImmunoglobulin G4-related disease (IgG4-RD) of the biliary tract and pancreas is a fibroinflammatory disease of unknown origin with striking male predominance. We aimed to investigate whether blue-collar work and occupational contaminant exposure are risk factors for IgG4-RD of the biliary tract and pancreas.MethodWe performed an age-/sex-matched case-control study in the largest academic medical centers of the Netherlands. Occupational history was surveyed by questionnaires. The International Standard Classification of Occupations (ISCO88) was used to classify jobs. Job exposure matrices ALOHA and DOM were utilized to assess the years individuals were exposed to compounds. The disease control cohort consisted of patients from 6 equally sized groups. Conditional logistic regression was used to assess effects of blue-collar work and exposure to occupational contaminants on developing IgG4-RD of the biliary tract and pancreas.ResultsOverall, 101 patients with IgG4-RD of the biliary tract and pancreas were matched 1:3 to 303 controls. Patients with IgG4-RD had a lower level of education (p = 0.001). Individuals who at least once performed blue-collar work (>1 year), had higher odds of developing IgG4-RD than individuals that only performed white-collar work (odds ratio [OR] 3.66; CI 2.18-6.13; p <0.0001). Being ever exposed (>1 year) to industrial ALOHA (e.g. mineral dust; vapors-dust-gases-fumes) and DOM compounds (e.g. asbestos) resulted in higher odds of IgG4-RD (OR 2.14; 95% CI 1.26-3.16; p <0.001 and OR 2.95; 95% CI 1.78-4.90; p <0.001, respectively).ConclusionBlue-collar work is a risk factor for developing IgG4-RD of the biliary tract and pancreas putatively driven by exposure to selected industrial compounds; this may explain the striking male predominance among patients.Lay summaryImmunoglobulin G4-related disease (IgG4-RD) causes tumor-like lesions and typically affects middle-aged to elderly men. The background and cause of this disease remain relatively unknown. In this study, we identified blue-collar work as a risk factor for developing IgG4-RD of the biliary tract and pancreas, which may explain the striking male predominance among patients. Furthermore, these results suggest that toxic exposure to occupational contaminants may drive autoimmunity in IgG4-RD of the biliary tract and pancreas.

Project description:Background & Aims:Surgical resection is the only potentially curative therapy for patients with biliary tract cancer (BTC), but 5-year survival rates after tumor resection have remained below 30%, corroborating the need for better stratification tools to identify the ideal surgical candidates. The soluble urokinase plasminogen activator receptor (suPAR) represents a mediator of inflammation and has been associated with distinct types of cancer. In this study, we evaluated a potential role of suPAR as a novel biomarker in patients undergoing BTC resection. Methods:Tumor expression of uPAR was analyzed by immunohistochemistry in 108 BTC samples. Serum levels of suPAR were analyzed by ELISA in a training and validation cohort comprising a total of 117 patients with BTC and 76 healthy controls. Results:High tumoral uPAR expression was associated with an adverse outcome after BTC resection. Accordingly, circulating levels of suPAR were significantly elevated in patients with BTC compared to healthy controls, as well as in patients with primary sclerosing cholangitis. Using a small training set, we established an optimal prognostic suPAR cut-off value of 3.72 ng/ml for patients with BTC. Importantly, preoperative suPAR serum levels above this cut-off value were associated with significantly impaired overall survival in both the training and validation cohort. Multivariate Cox-regression analysis including various clinicopathological parameters such as tumor stage, markers of inflammation and organ dysfunction, as well as tumor markers, revealed circulating suPAR levels as an independent prognostic marker following BTC resection. Finally, high preoperative suPAR levels were indicative of acute kidney injury after tumor resection. Conclusion:Circulating suPAR represents a previously unrecognized biomarker in patients with resectable BTC, which might help to preoperatively identify the ideal candidates for liver surgery. Lay summary:Surgical resection represents the only curative treatment option for patients with biliary tract cancer, but not all patients benefit to the same extent in terms of overall survival. Here, we provide evidence that serum levels of an inflammatory mediator (suPAR) are indicative of a patient's postoperative outcome and might thus help to identify the ideal surgical candidates.

Dataset Information

Pancreas-preserving resection of lower biliary tract adenocarcinoma: A coring-out technique.

Publications

Pancreas-preserving resection of lower biliary tract adenocarcinoma: A coring-out technique.

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