Diagnostic imaging procedures
The majority of the patients in the studied groups had official reports of ultrasonography (US) of the abdomen and contrast-enhanced CT of the abdomen. Magnetic resonance imaging (MRI) of the abdomen was performed in one patient with chronic renal insufficiency. The preoperative imaging studies of all patients were reviewed. Dilatations of the intrahepatic and/or extrahepatic bile ducts were seen in the imaging diagnosis of 18 (94.7%) patients with no occurrence of clinical jaundice in five patients. The tumor thrombus had approached to confluence of the bile duct in 14 (73.6%) patients. Seven patients also showed obvious dense tumor thrombus in the biliary tree. One case with bile duct obstruction at the confluence, with no obvious intrahepatic lesion and no rising of the serum AFP level, was misdiagnosed as hilar CCA. Only one patient had no occurrence of any preoperative jaundice or obstruction of bile duct from preoperative imaging, but diffuse biliary tumor thrombus was seen in the pathological result.
Clinical obstructive jaundice or cholangitis accompanied the initial diagnosis in 14 (73.7%) patients. In our series, four (21.1%) patients achieved sufficient reduction of the jaundice preoperatively with percutaneous transhepatic biliary drainage (PTBD). No intervention for biliary decompression was performed for the remaining 15 (78.9%) patients because of the risk of bleeding from the drainage procedure. After evaluation of liver function, 18 of 19 patients underwent surgery without any appreciable morbidity or mortality.
Operative treatments for 16 patients consisted of a curative resection of the hepatic tumor. The operability rate during this study period was 84.2% (16 from 19). Removal of the BDTT occurred with hepatic resection in eight (50%) patients who underwent additional bile duct resection and biliary-enteric anastomosis. Four other (25%) patients underwent a choledochotomy to remove their BDTT. No additional procedures other than hepatectomy were required for four (25%) patients’ to achieve complete removal of the BDTT. Description of surgical procedures utilized in these 16 patients is shown in Table 2. In addition, intraoperatively, one patient was found to have intrahepatic metastasis at the contralateral lobe that was not detected from the preoperative CT of the abdomen and underwent a palliative R2 hepatic resection.
(To view a larger version of Table 2, click here.)
The remaining two patients received only a choledochotomy to remove the BDTT with palliative T-tube drainage or Roux-en-Y hepaticojejunal (HJ) anastomosis because their liver reserve and general condition could not tolerate the primary tumor resection. The pathological results of the tumor thrombus were HCC. Another patient presented with advanced disease with concurrent cirrhosis and received only palliative care followed by TACE.
Postoperative complications occurred in seven (38.9%) patients (Table 3). Severe complications (Clavien–Dindo grades III–V13) occurred in three patients, including acute renal failure requiring dialysis from day 1 to day 7 (grade IVa), intraabdominal collection requiring percutaneous drainage under local anesthesia by a radiological interventionist (grade IIIa), and transient reversible hepatic failure (grade IVa) with successfully conservative management (grade IVa). Mild complications (grades I–II13) occurred in four patients, and all were successful managed with medical or supportive treatments, including small surgical bed collection with wound infection (grade II), bile leak at hepaticojejunostomy anastomosis (grade II), and bilateral pleural effusion in two patients (grade I). All patients tolerated the operations without deaths from complications and were discharged from the hospital in good condition. The obstructive jaundice due to BDTT was successfully relieved in each patient.
The pathological findings of the resected specimens are summarized in Table 4. The tumor diameters ranged from 2.2 to 19 cm (median 5.8 cm). The tumors were single nodular (n = 12), two contiguous nodules (n = 2), and satellite formation (n = 2). The pathologically proven presence of cirrhosis was found in 12 (63.2%) patients. Histologically, tumors were classified as well differentiated in four patients, moderately differentiated in nine, and poorly differentiated in three. Microscopic vascular invasion was found in 14 (87.5%) patients. Microscopic lymphatic invasion was found in two patients despite no detected intraoperative lymph node metastasis. Types of surgical resection after compatibility with pathological positive margins were R0 for eleven (68.7%) patients, R1 for four (25%) patients, and R2 for one (6.3%) patient.
Apparent tumor growth in the bile duct from imaging was observed in three unresectable patients. Tumor thrombi were removed by the exploration of the common bile duct (CBD) in two patients, and viable tumor cells in the bile duct were confirmed histopathologically. The intrabiliary tumor thrombi were typically fragile with a grayish-white appearance and loosely attached to the ductal mucosa that could be easily removed from the lumen in our series.