OBJECTIVETo investigate the value of Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) and a modification of the POSSUM system (P-P0SSUM) scoring system in predicting the surgical operative risk of pancreaticoduodenectomy for periampullary tumors.

METHODSPOSSUM and P-POSSUM scoring systems were used to retrospectively evaluate the clinical data of 432 patients with periampullar tumors who underwent pancreaticoduodenectomy in the Department of Abdominal Surgery, Cancer Hospital, Chinese Academy of Medical Sciences from January 1985 to December 2010. The predictive occurrence of postoperative complications and mortality rate were calculated according to the formula. ROC curve analysis and different group of risk factors were used to determine the discrimination ability of the two score systems, and to determine their predictive efficacy by comparing the actual and predictive complications and mortality rates, using Hosmer-Lemeshow test to determine the goodness of fit of the two scoring systems.

RESULTSThe average physiological score of the 432 patients was 16.1 ± 3.5, and the average surgical severity score was 19.6 ± 2.7. ROC curve analysis showed that the area under ROC curve for mortality predicted by POSSUM and P-POSSUM were 0.893 and 0.888, showing a non-significant difference (P > 0.05) between them. The area under ROC curve for operative complications predicted by POSSUM scoring system was 0.575. The POSSUM score system was most accurate for the prediction of complication rates of 20%-40%, showing the O/E value of 0.81. Compared with the POSSUM score system, P-POSSUM had better ability in the prediction of postoperative mortality, when the predicted value of mortality was greater than 15%, the predictive result was more accurate, and the O/E value was 1.00.

CONCLUSIONSPOSSUM and P-POSSUM scoring system have good value in predicting the mortality of patients with periampullary tumors undergoing pancreaticoduodenectomy, but a poorer value of POSSUM score system in prediction of complications. We can establish a more suitable scoring system for pancreaticoduodenectomy by modifying the score constant and weight, to better predict surgical risk and reduce the operative complications and mortality.

Ampulla of Vater ; Common Bile Duct Neoplasms ; mortality ; surgery ; Humans ; Morbidity ; Pancreaticoduodenectomy ; adverse effects ; mortality ; Postoperative Complications ; diagnosis ; mortality ; Postoperative Period ; Predictive Value of Tests ; ROC Curve ; Retrospective Studies ; Risk Assessment ; Risk Factors

BACKGROUND/AIMS: Few studies have assessed the prognostic value of the primary tumor maximum standardized uptake value (SUVmax) measured by 2-[18F]-fluoro-2-deoxy-D-glucose PET-CT for patients with bile duct and gallbladder cancer. METHODS: A retrospective analysis of 61 patients with confirmed bile duct and gallbladder cancer who underwent FDG PET-CT in Kangbuk Samsung Medical Center (Seoul, Korea) from April 2008 to April 2011. Prognostic significance of SUVmax and other clinicopathological variables was assessed. RESULTS: Twenty-three patients were diagnosed as common bile duct cancer, 17 as hilar bile duct cancer, 12 as intrahepatic bile duct cancer, and nine as gallbladder cancer. In univariate analysis, diagnosis of intrahepatic cholangiocarcinoma and gallbladder cancer, mass forming type, poorly differentiated cell type, nonsurgical treatment, advanced American Joint Committee on Cancer (AJCC) staging and primary tumor SUVmax were significant predictors of poor overall survival. In multivariate analysis adjusted for age and sex, primary tumor SUVmax (hazard ratio [HR], 4.526; 95% CI, 1.813-11.299), advanced AJCC staging (HR, 4.843; 95% CI, 1.760-13.328), and nonsurgical treatment (HR, 6.029; 95% CI, 1.989-18.271) were independently associated with poor overall survival. CONCLUSIONS: Primary tumor SUVmax measured by FDG PET-CT is an independent and significant prognostic factor for overall survival in bile duct and gallbladder cancer.
Aged ; Bile Duct Neoplasms/*diagnosis/mortality/radionuclide imaging ; Cholangiocarcinoma/diagnosis/mortality/radionuclide imaging ; Female ; Fluorodeoxyglucose F18/diagnostic use/metabolism/standards ; Gallbladder Neoplasms/*diagnosis/mortality/radionuclide imaging ; Humans ; Kaplan-Meier Estimate ; Liver Neoplasms/diagnosis/mortality/radionuclide imaging ; Male ; Middle Aged ; Neoplasm Staging ; Positron-Emission Tomography/standards ; Prognosis ; Proportional Hazards Models ; Radiopharmaceuticals/diagnostic use/metabolism/standards ; Retrospective Studies ; Tomography, X-Ray Computed/standards

BACKGROUND/AIMS: This study was conducted to analyze the prognostic factors in patients with intrahepatic cholangiocarcinoma (ICC) who did not receive surgery. METHODS: Between August 1997 and November 2007, the medical records of 175 patients (mean age; 66 years, male/female 126/49), who were diagnosed as ICC, were reviewed retrospectively. RESULTS: Clonorchiasis and hepatolithiasis was found in 14.9%, and 6.3% of all patients, and no risk factors were identified in 77.8% of them. Surgical resection was performed in 29.1% (51 patients), chemotherapy +/- radiotherapy in 12.6% (22 patients), and palliative therapy in 58.3% (102 patients). The proportion of patients with stage I was 23.4% (41 patients). The prognostic factors in patients who did not receive surgery were alkaline phosphatase (ALP) and bilirubin levels by univariate and multivariate analysis. The median survival of patients with normal ALP and bilirubin levels was six months, whereas only one month in patients with elevated ALP and bilirubin levels (p<0.001). Tumor characteristics of patients with elevated bilirubin and ALP levels were infiltrative tumor, bile duct involvement, and very huge tumor. CONCLUSIONS: The prognostic factors of ICC in patients who did not receive surgery were ALP and bilirubin levels, but not lymph node metastasis.
Adult ; Aged ; Aged, 80 and over ; Alkaline Phosphatase/analysis ; Bile Duct Neoplasms/*diagnosis/mortality ; *Bile Ducts, Intrahepatic ; Bilirubin/analysis ; Cholangiocarcinoma/*diagnosis/mortality ; Female ; Humans ; Lymphatic Metastasis ; Male ; Middle Aged ; Prognosis ; Retrospective Studies ; Risk Factors ; Survival Rate

BACKGROUND/AIMS: White bile is colorless, translucent fluid found occasionally in malignant bile duct obstruction (MBO). Little information is available on the cause and effect of white bile. The aim of this study was to determine the frequency and clinical significance of white bile in MBO. METHODS: Bile was aspirated during endoscopic retrograde cholangiopancreatography in consecutive patients with MBO. White bile was defined as bile bilirubin <1.5 mg/dL and yellow bile was defined as bile bilirubin >or=1.5 mg/dL in the bile. Two groups were compared prospectively for the duration of jaundice, itching, cholangitis, level of obstruction, and decremental rate of bilirubin after the insertion of 7 Fr endoscopic nasobiliary drainage until the insertion of metal stent or 10 Fr plastic stent. RESULTS: Among 60 patients with MBO, 16 (26.7%) had white bile. WBC count in blood was higher (9,456/mm3 vs. 7,400/mm3, p=0.029) and cholangitis was more common (11/16 vs. 7/44, p=0.000) in white than yellow bile group. Proximal portion of MBO had no communication with GB in 9/16 patients with white bile group and 17/44 patients with yellow bile group (p>0.05). Mean survival of the inoperable 35 patients was 242 days in yellow bile and 227 days in white bile group (p>0.05). CONCLUSIONS: White bile in MBO was not rare and was associated with cholangitis. Gallbladder did not seem to play a role in the formation of white bile. Further study for the pathogenesis and prognosis of white bile in MBO will be necessary.
Aged ; Bile/*chemistry/microbiology ; Bile Duct Neoplasms/*diagnosis/etiology/mortality ; Bilirubin/analysis ; Cholangiopancreatography, Endoscopic Retrograde ; Cholangitis/diagnosis/etiology/mortality ; Cholestasis/*diagnosis/etiology/mortality ; Data Interpretation, Statistical ; Drainage ; Female ; Humans ; Male ; Middle Aged ; Stents ; Survival Analysis

BACKGROUND/AIMS: Combined hepatocellular and cholangiocarcinoma (HCC-CC) is a rare form of primary liver carcinoma which contains characteristics of both hepatocellular carcinoma and cholangiocarcinoma. The aim of this study was to evaluate the prognostic factors of combined HCC-CC after curative resection. METHODS: Between January 1987 and December 2005, pathologically confirmed combined HCC-CC patients who underwent curative resection at Seoul National University Hospital were evaluated. We reviewed the medical records and evaluated the time-to-recurrence (TTR), overall survival (OS) and prognostic factors of combined HCC-CC. RESULTS: A total of 31 patients were evaluated (M:F=27:4; median age, 61 years). According to the American Joint Committee on Cancer system, patients with stage I, II, III(A), III(B) and III(C) at the time of resection were 4, 16, 7, 2 and 2, respectively. Twenty six patients (83.9%) had tumor recurrence during the follow-up period and their median TTR was 5.7 months. Twenty one patients received additional treatment while 5 patients did not. As a result, median OS was 21.6 months and 3 year survival rate was 15.4%. In multivariate analysis, stage III than stage I or II at resection was an independent prognostic factor associated with shortened TTR (p<0.01). Older age (p=0.03), stage III(C) rather than stage I, II, III(A) at time of resection (p=0.02), and Child-Pugh B rather than A (p<0.01) were independent prognostic factors associated with shortened OS. CONCLUSIONS: Even after curative resections, patients with combined HCC-CC show poor prognosis with early recurrence and poor survival. However, surgical treatment should be warranted for relatively young patients in early stage with well preserved liver function.
Adult ; Aged ; Aged, 80 and over ; Bile Duct Neoplasms/*mortality/pathology/surgery ; *Bile Ducts, Intrahepatic ; Carcinoma, Hepatocellular/*mortality/pathology/surgery ; Cholangiocarcinoma/*mortality/pathology/surgery ; Female ; Hepatectomy ; Humans ; Liver Neoplasms/*mortality/pathology/surgery ; Male ; Middle Aged ; Neoplasm Recurrence, Local/*diagnosis ; Neoplasm Staging ; Predictive Value of Tests ; Prognosis ; Severity of Illness Index ; Survival Analysis ; Tomography, X-Ray Computed

No abstract available.
Bile Duct Neoplasms/*diagnosis/mortality/surgery ; *Bile Ducts, Extrahepatic ; Humans ; Neoplasm Invasiveness ; Neoplasm Staging ; Prognosis

BACKGROUND/AIMS: The definition of early extrahepatic bile duct cancer might be different from that of other gastrointestinal cancer because of the differences of histologic features including the lack of muscularis mucosa and submucosal layer in bile duct. The purpose of this study was to evaluate the concept of early extrahepatic bile duct cancer in Korea. METHODS: We evaluated seventynine cases of extrahepatic bile duct cancer who had received curative resection in Severence Hospital, Yonsei University from March 1986 to October 2005. We retrosptectively reviewed the medical records and analyzed variable prognostic factors to define early extrahepatic bile duct cancer. RESULTS: Invasion limited to the mucosa was noted in 5 cases (6.3%), fibromuscular layer in 12 cases (15.2%), adventitia of fibromuscular layer and serosa in 26 cases (32.9%), and invasion of adjacent organs in 36 cases (45.6%). Disease free 5-year survival according to the depth of invasion were 80.7% in tumor confined within mucosa, 80.0% within fibromuscular layer, 57.2% within adventitia of fibromuscular layer and serosa, and 51.5% in tumor with invasion of adjacent organ. There was no significant difference in the survival rate between patients with tumor confined to mucosa and patients with tumor invasion limited to the fibromuscular layer. However, the survival rate of patients with tumor limited to the mucosa or fibromuscular layer was significantly higher than that of patients with tumor invaded beyond fibromusular layer. In early cancer, there were more papillary polypoid type in gross finding and papillary adenocarcinoma in pathologic finding when compared to advanced cancer. CONCLUSIONS: Early extrahepatic bile duct cancer can be defined as the tumor invasion limited to the mucosa and fibromuscular layer.
Aged ; Aged, 80 and over ; Bile Duct Neoplasms/*diagnosis/mortality/surgery ; *Bile Ducts, Extrahepatic ; Female ; Humans ; Male ; Middle Aged ; Neoplasm Invasiveness ; Neoplasm Staging ; Prognosis ; Retrospective Studies ; Survival Analysis

BACKGROUNDS/AIMS: Although the survival rate after surgical resection of peripheral cholangiocarcinoma is low, surgical resection is only potentially curative therapy. The aim of this study is to evaluate clinicopathological factors affecting survival after surgical resection of peripheral cholangiocarcinoma. METHODS: Between February 1990 and December 2005, surgical intervention with curative intent was performed on 318 patients and 292 patients underwent resection. We retrospectively analyzed survival data of 318 patients and clinicopathological factors affecting survival by reviewing the medical record. RESULTS: Among the 292 cases of resection, curative resection with tumor-free margin (R0) has been resulted in 221 cases. The 1-, 3-, 5- and 10-year survival rate of R0 resection were 74.9, 46.9, 36.9 and 15.2%, respectively. The survival rate of patient undergoing R0 resection was significantly better than that of R1, R2 or nonresection. Multivariate analysis showed that curative resectability, macroscopic type of tumor and lymph node metastasis were statically significant independent prognostic factors. CONCLUSIONS: The survival after surgical resection of peripheral cholangiocarcinoma depends on curability of surgical resection, macroscopic type of tumor and status of lymph node. Particullary in R0 resection for intraductal growth type without lymph node metastasis, there is great chance for long-term survival. Surgical resection attaining tumor free margin should be attempted if liver function and general condition of patient are acceptable for hepatectomy.
Aged ; Bile Duct Neoplasms/diagnosis/*mortality/surgery ; *Bile Ducts, Intrahepatic ; Cholangiocarcinoma/diagnosis/*mortality/surgery ; Female ; Humans ; Lymphatic Metastasis ; Male ; Middle Aged ; Multivariate Analysis ; Predictive Value of Tests ; Retrospective Studies ; Survival Rate ; Treatment Outcome

BACKGROUND/AIMS: Pancreatoduodenectomy is a common procedure for benign or malignant periampulary diseases. But the morbidity and mortality of the procedure are usually high. Being related with morbidity and mortality, the most important procedure of pancreatoduodenectomy is how handle the remnant pancreas. We analysed retrospectively the efficiency of the new method for low morbidity and low mortality in handling of the remnant pancreas in the procedures of pancreatoduodenectomy. METHODS: 118 consecutive patients who had undergone a pancreatoduodenectomy and pancreaticojejunostomy performed by one surgeon, between September 1994 and June 1999, were evaluated retrospectively. The cases were analysed by age, sex, pathologic dianosis, operation time, the amount of transfusion during operation, the hospital stay, postoperative complications and state of survival. RESULTS: The average age of 118 patients was 57.6 years, and the male and female ratio was 1.19:1. The classification by patholoic diagnoses were distal common bile duct cancers (29%), the ampulla of Vater cancers (23%), the pancreas head cancers (14%), the duodenal cancers (1.7%) and the others (32%) including benign diseases. The average operation time was 8 hours 3 minutes, the average amount of transfusion was 0.84 unit and the average hospital stay was 26.1 days. There are 12 (10.2%) postoperative complications. The most were 6(5%) cases of delayed gastric emptying, and the others were 2 (1.7%) cases of leakage of pancreaticojejunostomy, 1 (0.8%) case of ARDS, 1 (0.8%) case of gastroduodenal artery bleeding, 1 (0.8%) case of remnant pancreas bleeding, and 1 (0.8%) case of pseudoaneurysmal bleeding of gastroduodenal artery. The 2 cases of leakage of pancreaticojejunostomy developed at the patients of duodenal cancer and ampulla of Vater cancer. The patient who diagnosed by ampulla of Vater cancer died for sepsis due to leakage of the pancreaticojejunostomy (1/118, 0.8%). CONCLUSION: We had good results in pancreatoduodenectomy and pancreaticojejunostomy by a new method that protect the anastomotic leakge from pancreaticojejunostomy site. This method include pancreas transection by elctrocoagulation, not doing sutures of remnant pancreas to prevent ischemic change of pancreatic cut surface and complete drainage of pancreatic juice using stent that was inserted at remnant pancreatic duct and externally ligated by vicryl with keeping the lumen.
Ampulla of Vater ; Aneurysm, False ; Arteries ; Classification ; Common Bile Duct ; Diagnosis ; Drainage ; Duodenal Neoplasms ; Female ; Gastric Emptying ; Head ; Hemorrhage ; Humans ; Length of Stay ; Male ; Mortality ; Pancreas ; Pancreatic Ducts ; Pancreatic Juice ; Pancreaticoduodenectomy* ; Pancreaticojejunostomy ; Polyglactin 910 ; Postoperative Complications ; Retrospective Studies ; Sepsis ; Stents ; Sutures

PURPOSE: Carcinomas of the biliary tract are considerably rare conditions. In spite of recent progress in diagnosis and treatment, resectability remains low, and the prognosis is still discouraging. This review summarizes our 12-year experience with biliary tract cancers, with particular focus on the survival rates after operation and the prognostic factors that affected the survival of patients. METHODS: Between 1987 and 1998, 268 patients with biliary tract cancers were operated on at our institution. The clinical and the pathologic data were collected, and a survival analysis was performed. RESULTS: The tumor was located in the gallbladder in 90 patients, in the proximal bile duct in 74 patients, in the distal bile duct in 54 patients, and in the ampulla of Vater in 50 patients. One hundred ninety-seven patients underwent a radical resection (resection rate: 73.5%). A curative resection was achieved in 140 patients (curative resection rate: 71.1%). The overall operative mortality after resection was 3.0%. The cumulative survival rates at five years after resection were 61.1% for carcinomas of the gallbladder, 25.8% for proximal bile duct cancers, 28.9% for distal bile duct cancers, and 48.7% for ampulla of Vater cancers. The one-year survival rates for the non-resection group were 18.2% and 26.6% for gallbladder cancers and proximal bile duct cancers, respectively. The mean survival periods for unresectable distal bile duct cancers and ampullary cancers were 4.7 months and 8.3 months, respectively. Positive lymph-node metastasis was a statistically significant, poor prognostic factor. CONCLUSION: Long-term survivals can be expected by a radical surgery for patients with biliary tract cancers. Increasing the resection rate by performing an extended procedure is essential for the improvement of treatment outcomes.
Ampulla of Vater ; Bile Duct Neoplasms ; Bile Ducts ; Biliary Tract Neoplasms* ; Biliary Tract* ; Diagnosis ; Gallbladder ; Gallbladder Neoplasms ; Humans ; Mortality ; Neoplasm Metastasis ; Prognosis* ; Survival Rate