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Background: Texture analysis derived from computed tomography (CT) may provide clinically relevant imaging biomarkers associated with tumor histopathology. Perihilar cholangiocarcinoma is a malignant disease with an overall poor prognosis., Aims: The present study sought to elucidate possible associations between texture features derived from CT images with grading, tumor markers, and survival in extrahepatic, perihilar cholangiocarcinomas tumors., Methods: This retrospective study included 22 patients (10 females, 45%) with a mean age of 71.8 ± 8.7 years. Texture analysis was performed using the free available Mazda software. All tumors were histopathologically confirmed. Survival and clinical parameters were used as primary study outcomes., Results: In discrimination analysis, "S(1,1)SumVarnc" was statistically significantly different between patients with long-term survival and nonlong-term survival (mean 275.8 ± 32.6 vs. 239.7 ± 26.0, p = 0.01). The first-order parameter "skewness" was associated with the tumor marker "carcinoembryonic antigen" (CEA) (r = -0.7, p = 0.01). A statistically significant correlation of the texture parameter "S(5,0)SumVarnc" with tumor grading was identified (r = -0.6, p < 0.01). Several other texture features correlated with tumor markers CA-19-9 and AFP, as well as with T and N stage of tumors., Conclusion: Several texture features derived from CT images were associated with tumor characteristics and survival in patients with perihilar cholangiocarcinomas. CT texture features could be used as valuable novel imaging markers in clinical routine., (© 2024 The Author(s). Cancer Reports published by Wiley Periodicals LLC.)

Purpose: This study was conducted to investigate the effectiveness of strain elastography in guiding precise and sufficient tissue sampling for perihilar cholangiocarcinoma (CCA) biopsies., Methods: Our retrospective analysis included 23 liver biopsies conducted between March 2019 and July 2022 for suspected perihilar CCA. An experienced radiologist performed the biopsies via an ultrasound machine with elastography configuration. Tissue stiffness color maps were used for guiding when the biopsies were performed. Strain index value calculations were made by radiologists on recorded images., Results: Patient demographics revealed a mean age of 65.17 ± 9.25 years, with a gender distribution of six females and 17 males. Gray-scale examinations unveiled diverse echogenic characteristics in liver lesions. Elastography-guided biopsies demonstrated no need for repeats, while gray-scale biopsies necessitated re-biopsy in four patients, resulting in cholangiocarcinoma diagnosis (P = 0.037). Strain index values showcased strong inter- and intra-observer agreements (P < 0.001). Notably, no post-biopsy complications emerged in either study group., Conclusion: The diagnostic advantage of elastography, particularly in enhancing accuracy in challenging isoechoic lesions, was demonstrated, although the substantial overlap between strain index values of benign and malignant liver masses limits clinical usefulness of this technique., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Situs inversus totalis is a rare congenital malformation in which organs are positioned in a mirror-image relationship to normal conditions. It often presents with vascular and biliary malformations. Only a few reports have pointed out the surgical difficulties in patients with situs inversus totalis, especially in those with perihilar cholangiocarcinoma. This report describes a 66-year-old male patient who underwent left hemihepatectomy (S5, 6, 7, and 8) with combined resection of the caudate lobe (S1), extrahepatic bile duct, and regional lymph nodes for perihilar cholangiocarcinoma with situs inversus totalis. Cholangiocarcinoma was mainly located in the perihilar area and progressed extensively into the bile duct. Surgery was performed after careful evaluation of the unusual anatomy. Although several vascular anomalies required delicate manipulation, the procedures were performed without major intraoperative complications. Postoperatively, bile leakage occurred, but the patient recovered with drainage treatment. The patient was discharged on the 29th postoperative day. Adjuvant chemotherapy with S-1 was administered for approximately 6 months. There was no recurrence 15 months postoperatively. Appropriate imaging studies and an understanding of unusual anatomy make surgery safe and provide suitable treatment for patients with situs inversus totalis., (© 2024. Japanese Society of Gastroenterology.)

Background and Aims: For a highly selected group of patients with unresectable perihilar cholangiocarcinoma (pCCA), liver transplantation (LT) is a treatment option. The Dutch screening protocol comprises nonregional lymph node (LN) assessment by EUS, and whenever LN metastases are identified, further LT screening is precluded. The aim of this study is to investigate the yield of EUS in patients with pCCA who are potentially eligible for LT., Methods: In this retrospective, nationwide cohort study, all consecutive patients with suspected unresectable pCCA who underwent EUS in the screening protocol for LT were included from 2011 to 2021. During EUS, sampling of a "suspicious" nonregional LN was performed based on the endoscopist's discretion. The primary outcome was the added value of EUS, defined as the number of patients who were precluded from further screening because of malignant LNs., Results: A total of 75 patients were included in whom 84 EUS procedures were performed, with EUS-guided tissue acquisition confirming malignancy in LNs in 3 of 75 (4%) patients. In the 43 who underwent surgical staging according to the protocol, nonregional LNs with malignancy were identified in 6 (14%) patients. Positive regional LNs were found in 7 patients in post-LT-resected specimens., Conclusions: Our current EUS screening for the detection of malignant LNs in patients with pCCA eligible for LT shows a limited but clinically important yield. EUS with systematic screening of all LN stations, both regional and nonregional, and the sampling of suspicious lymph nodes according to defined and set criteria could potentially increase this yield., Competing Interests: Disclosure The following authors disclosed financial relationships: M. J. Bruno: Research funding for industry-initiated studies from Boston Scientific and Cook Medical; research funding for investigator-initiated studies from Boston Scientific, Cook Medical, Pentax Medical, Interscope, Mylan, and 3M; and consultant for Boston Scientific, and Cook Medical. J. E. van Hooft: Lecture fee from Cook Medical, Boston Scientfic, Falk, and Abbvie. Consultant for Olympus. All other authors disclosed no financial relationships., (Copyright © 2024 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Background and Study Aims: Laparoscopic approach of perihilar cholangiocarcinoma (PHC) is still challenging. We report the original use of a endoscopic hepaticogastrostomy (EHG) for definite biliary drainage in order to avoid biliary reconstruction., Patients and Methods: A 70-year-old man presenting with jaundice was referred for resection of a Bismuth type IIIa PHC. Repeated endoscopic retrograde cholangiopancreatography failed to drain the future liver remnant, enabling only right anterior liver section drainage. EHG was performed three weeks before surgery. A hepatogastric anastomosis was created, placing a half-coated self-expanding endoprosthesis between biliary duct of segment 2 and the lesser gastric curvature., Results: A laparoscopic right hepatectomy extended to segment 1, common bile duct, and hepatic pedicle lymphadenectomy was performed. The left hepatic duct was sectioned and ligated downstream to the biliary confluence of segment 2-3 and 4 allowing exclusive biliary flow through the EHG. The patient was disease free at 12 months, postoperative outcomes were uneventful except three readmissions for acute cholangitis due to prosthesis obstruction., Conclusions: EHG may be used as definite biliary drainage technique in laparoscopic PHC resection, at the expense of prosthesis obstruction and cholangitis., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objectives: To develop a CT-based radiomics model for preoperative prediction of lymph node (LN) metastasis in perihilar cholangiocarcinoma (pCCA)., Methods: The study enrolled consecutive pCCA patients from three independent Chinese medical centers. The Boruta algorithm was applied to build the radiomics signature for the primary tumor and LN. The k-means algorithm was employed to cluster the selected LNs based on the radiomics signature LN. Support vector machines were used to construct the prediction models. The diagnostic efficiency was measured by the area under the receiver operating characteristic curve (AUC). The optimal model was evaluated in terms of calibration, clinical usefulness, and prognostic value., Results: A total of 214 patients were included in the study (mean age: 61.6 years ± 9.4; 130 male). The selected LNs were classified into two clusters, which were significantly correlated with LN metastasis in all cohorts (p < 0.001). The model incorporated the clinical risk factors, radiomics signature primary tumor, and the LN cluster obtained the best discrimination, with AUC values of 0.981 (95% CI: 0.962-1), 0.896 (95% CI: 0.810-0.982), and 0.865 (95% CI: 0.768-0.961) in the training, internal validation, and external validation cohorts, respectively. High-risk patients predicted by the optimal model had shorter overall survival than low-risk patients (median, 13.7 vs. 27.3 months, p < 0.001)., Conclusions: The study proposed a radiomics model with good performance to predict LN metastasis in pCCA. As a noninvasive preoperative prediction tool, this model may help in patient risk stratification and personalized treatment., Clinical Relevance Statement: A CT-based radiomics model accurately predicts lymph node metastasis in perihilar cholangiocarcinoma patients. This noninvasive preoperative tool can aid in patient risk stratification and personalized treatment, potentially improving patient outcomes., Key Points: • The radiomics model based on contrast-enhanced CT is a useful tool for preoperative prediction of lymph node metastasis in perihilar cholangiocarcinoma. • Radiomics features extracted from lymph nodes show great potential for predicting lymph node metastasis. • The study is the first to identify a lymph node phenotype with a high probability of metastasis based on radiomics., (© 2023. The Author(s), under exclusive licence to European Society of Radiology.)

Biliary amputation neuroma is a rare benign tumor that develops due to the peribiliary dissection of nerve fibers during cholecystectomy, a common bile duct surgery, or lymph node dissection performed in gastric cancer surgery. We report a case of amputation neuroma that presented a challenging differential diagnosis from perihilar cholangiocarcinoma. A 64-year-old man, who had undergone open cholecystectomy 30 years ago, was incidentally found to have a bile duct tumor during computed tomography (CT) following surgery for renal cell carcinoma. He had no specific symptoms, and blood test results showed only a slight elevation in alkaline phosphatase levels. Contrast-enhanced CT revealed a 10-mm solid tumor with contrast effect in the common bile duct. On cholangiography, the tumor appeared as a protruding lesion with a smooth surface unilaterally. Given the atypical findings suggestive of cholangiocarcinoma, three bile duct biopsies were performed. Pathological examination did not rule out adenocarcinoma. The patient opted for surgery;however, an intraoperative rapid histological examination confirmed a benign disease, thereby avoiding extensive surgery. Consequently, a minimally invasive bile duct resection was performed. Postoperative histopathological examination revealed the tumor to be an amputation neuroma. Biliary amputation neuromas are characterized as unilateral protruding lesions with contrast effect or benign strictures. If such findings are observed in a patient with a history of surgery around the bile duct, the possibility of an amputation neuroma should be considered. However, completely ruling out malignancy preoperatively, even when suspecting amputation neuroma, can be challenging;therefore, considering surgery to achieve a definitive diagnosis is reasonable. During surgery, a rapid intraoperative histological examination is useful to avoid extensive procedures. In conclusion, diagnosing an amputation neuroma before surgery can be difficult, as it can mimic malignant tumors such as bile duct cancers. In this case, although a preoperative diagnosis of amputation neuroma was not feasible, performing a rapid intraoperative pathological examination helped avoid extensive surgery.

Competing Interests: The authors declare that they have no conflict of interest.

Background/aim: Texture analysis can provide quantitative imaging markers from computed tomography (CT) images. The Node-RADS classification was recently published as a classification system to better characterize lymph nodes in oncological imaging. The present analysis investigated the diagnostic benefit of CT texture analysis and the Node-RADS classification to categorize and stage lymph nodes in patients with perihilar cholangiocarcinoma., Patients and Methods: Overall, 25 patients (n=9 females, 36%) with a mean age of 72.4±8.1 years were included. All patients were surgically resected and the lymph nodes were histopathologically analyzed. CT-texture analysis was performed with the Mazda package. All investigated lymph nodes were scored in accordance with the Node-RADS classification., Results: Regarding lymph node discrimination (N- versus N+), Node-RADS classification achieved an area under the curve (AUC) of 0.86 resulting in a sensitivity of 78% and a specificity of 86%. Multiple investigated texture features were different between negative and positive lymph nodes. The "S(0,1)SumVarnc" achieved the best AUC of 0.75 resulting in a sensitivity of 0.91 and a specificity of 0.67. Correlation analysis showed various statistically significant associations between CT texture features and Node-RADS score., Conclusion: Several CT texture features and the Node-RADS score derived from preoperative staging CT were associated with the malignancy of the hilar lymph nodes and might aid for preoperative staging. This could change surgical treatment planning in hilar cholangiocarcinoma., (Copyright © 2023 International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Background: As digital medicine has exerted profound influences upon diagnosis and treatment of hepatobiliary diseases, our study aims to investigate the accuracy of three-dimensional visualization and evaluation (3DVE) system in assessing the resectability of hilar cholangiocarcinoma (hCCA), and explores its potential clinical value., Materials and Methods: The discovery cohort, containing 111 patients from April 2013 to December 2019, was retrospectively included to determine resectability according to revised criteria for unresectability of hCCA. 3D visualization models were reconstructed to evaluate resectability parameters including biliary infiltration, vascular involvement, hepatic atrophy and metastasis. Evaluation accuracy were compared between contrast-enhanced CT and 3DVE. Logistic analysis was performed to identify independent risk factors of R0 resection. A new comprehensive 3DVE classification of hCCA based on factors influencing resectability was proposed to investigate its role in predicting R0 resection and prognosis. The main outcomes were also analyzed in cohort validation, including 34 patients from January 2020 to August 2022., Results: 3DVE showed an accuracy rate of 91% (95%CI 83.6-95.4%) in preoperatively evaluating hCCA resectability, significantly higher than 81% (95%CI 72.8-87.7%) of that of CT (p = 0.03). By multivariable analysis, hepatic artery involvement in 3DVE was identified an independent risk factor for R1 or R2 resection (OR = 3.5, 95%CI 1.4,8.8, P < 0.01). New 3DVE hCCA classification was valuable in predicting patients' R0 resection rate (p < 0.001) and prognosis (p < 0.0001). The main outcomes were internally validated., Conclusions: 3DVE exhibited a better efficacy in evaluating hCCA resectability, compared with contrast-enhanced CT. Preoperative 3DVE demonstrated hepatic artery involvement was an independent risk factor for the absence of R0 margin. 3DVE classification of hCCA was valuable in clinical practice., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Purpose: To compare the effectiveness, adverse events (AEs), stent patency, and patient survival with suprapapillary and transpapillary uncovered self-expandable metallic stent placement for perihilar cholangiocarcinoma., Materials and Methods: A single-center retrospective study of 54 patients with inoperable perihilar cholangiocarcinoma who underwent percutaneous transhepatic biliary stent placement between January 1, 2019, and August 31, 2021, was conducted. According to stent location, the patients were classified into 2 groups: suprapapillary (S) and transpapillary (T). Demographic data, Bismuth-Corlette classification, type and location of the stent, laboratory data, postprocedural AEs, procedural success, stent occlusion, reintervention rate, and mortality were compared between the groups., Results: Stent placement was suprapapillary in 13 (24.1%) patients and transpapillary in 41 (75.9%) patients. Mean age was higher in Group T (78 vs 70.5 years; P = .046). Stent occlusion rates were similar in the 2 groups (Group S, 23.8%; Group T, 19.5%), as were AE rates, the most common being cholangitis (Group S, 23.1%; Group T, 24.4%). There were no significant differences in revision rate (Group S, 7.7%; Group T, 12.2%) and 30-day mortality rate (Group S, 15.4%; Group T, 19.5%). Ninety-day mortality rate was statistically significantly higher in Group T (46.3% vs 15.4%; P = .046). Preprocedural bilirubin level was higher in Group T, as were postprocedural leukocyte and C-reactive protein (CRP) levels., Conclusions: Suprapapillary and transpapillary stent placement procedures were similar in terms of procedural success, occlusion rate, revision rate, postprocedural AEs, and 30-day mortality. Ninety-day mortality rate and postprocedural leukocyte and CRP levels were higher in Group T, although these patients were also older and had higher preprocedural bilirubin levels., (Copyright © 2023 SIR. Published by Elsevier Inc. All rights reserved.)

Abstract: Klatskin tumor, also known as hilar cholangiocarcinoma, was clearly demonstrated in this case report by contrasting 68 Ga-FAPI and 18 F-FDG PET/CT in the same patient. This instance exemplifies a false-negative 18 F-FDG PET/CT for the main tumor site, despite positive 68 Ga-FAPI uptake at the same location., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

An 84-year-old female, with history of endometrial and gallbladder adenocarcinomas, both submitted to curative surgeries, was admitted to the emergency room with obstructive jaundice. Computed tomography and subsequent magnetic resonance cholangiopancreatography revealed a common hepatic duct stenosis with intrahepatic biliary dilatation. She underwent percutaneous transhepatic cholangiography with successful biliary drainage. During the same admission, the patient experienced episodes of hematochezia. Rectosigmoidoscopy showed a 20 mm ulcer in the distal rectum and congestion of the rectal mucosa. Computed tomography revealed rectal wall circumferential thickening. Ulcer biopsies were compatible with a neoplasia of biliary origin.

Purposes: This study sought to define the impact of skeletal muscle mass and quality on postoperative outcomes in patients with perihilar cholangiocarcinoma., Methods: Patients who underwent major hepatectomy for perihilar cholangiocarcinoma were included. The normalized total psoas area (TPA) (psoas muscle index [PMI]) and average Hounsfield units of the TPA (psoas muscle density [PMD]) were measured using preoperative computed tomography images. The cohort was dichotomized using the following indices: sex-specific lowest tertile (low PMI and low PMD) and other (normal PMI and normal PMD). Intraoperative and postoperative outcomes were compared, focusing on PMI and PMD., Results: A total of 456 patients were analyzed. The intraoperative blood loss (IBL) was 21.3 ml/kg in the low PMI group and 17.2 ml/kg in the normal PMI group (P = .008). Patients in the low PMI or PMD group experienced postoperative infectious complications more frequently than those in the other groups. The median survival time was 37.8 months in the low PMI group and 54.2 months in the normal PMI group (P = .027)., Conclusions: PMI and PMD were closely associated with IBL and postoperative infectious complications. Additionally, PMI impacted long-term survival. These results suggest an importance of improving muscle mass and quality before surgery., (© 2022 Japanese Society of Hepato-Biliary-Pancreatic Surgery.)

Competing Interests: The authors declare that they have no conflict of interest.

Background: Early recurrence after curative resection of perihilar cholangiocarcinoma (PHCC) often occurs within a year of surgery. Preoperative predictors of early recurrence remain unclear. The aim of this study was to define reliable preoperative predictors of early recurrence., Methods: Medical records and preoperative multidetector-row CT of patients with PHCC who underwent resection between 2002 and 2018 were reviewed. Clinical findings, tumour markers, and radiological appearances including a 'periductal enation sign' (PES) where there was evidence of soft tissue enhancement appearing to arise from the extrahepatic bile duct, were analysed., Results: Among 261 patients who underwent resection for PHCC, 67 (25.7 per cent) developed early recurrence. Multivariable analysis identified four preoperative risk factors for early recurrence, namely carbohydrate antigen 19-9 (CA19-9) 37 U/ml or higher (OR 2.19, 95 per cent confidence interval (c.i.) 1.08 to 4.46), positive PES (OR 7.37, 95 per cent c.i. 2.46 to 22.10), mass-forming tumour (OR 4.46, 95 per cent c.i. 1.83 to 10.90), and luminal-occlusion tumour (OR 4.52, 95 per cent c.i. 2.11 to 9.68). The OR of preoperative risk factors were used to define four risk subgroups for early recurrence. The early recurrence rates in the low, moderate, high, and very-high risk groups were 0, 9.4 , 39.7, and 65.0 per cent respectively., Conclusion: CA19-9, PES, mass-forming tumour, and luminal-occlusion tumour identify patients at higher risk for early recurrence after resection of PHCC., (© The Author(s) 2022. Published by Oxford University Press on behalf of BJS Society Ltd.)

Endoscopic management for perihilar cholangiocarcinoma (PHCC) is evolving toward more accurate diagnosis and safer drainage. In imaging, it is important to diagnose the entire lesion using multidetector-row computed tomography to determine resectability and optimal surgical planning, followed by local diagnosis using endoscopic retrograde cholangiopancreatography. Video peroral cholangioscopy and probe-based confocal laser endomicroscopy have been newly introduced as diagnostic imaging methods and are being applied clinically. In transpapillary forceps biopsy for PHCC diagnosis, the location in the bile duct (for mapping biopsy) and the number of biopsy samples should be determined depending on resectability, the morphological type, and future surgical planning. Preoperative drainage has shifted from percutaneous transhepatic biliary drainage to endoscopic nasobiliary drainage given the possibility of seeding metastasis. In addition, considering potential patient discomfort from a nasal tube, the usefulness of the placement of a plastic stent above the papilla (inside stent) as a bridging therapy for surgery has been reported. For drainage of unresectable PHCC, the improved prognosis due to advances in chemotherapy has necessitated a strategy that accounts for reintervention. Thus, in addition to uncovered self-expandable metallic stents (SEMS), exchangeable slim fully covered SEMS and inside stents have started to be used. In addition to the conventional transpapillary approach, an endoscopic ultrasonography-guided approach has been introduced, and a combination of both methods has also been proposed. To improve the quality of life and prognosis of PHCC patients, endoscopists need to understand and be able to use the various methods of endoscopic management for PHCC., (© 2022 Japan Gastroenterological Endoscopy Society.)

Introduction: Although the prognosis of patients with resected perihilar cholangiocarcinoma (PHC) with histological lymph node metastasis (LNM) is poor, preoperative prediction of LNM is difficult. This study aimed to evaluate the diagnostic performance of diffusion-weighted magnetic resonance imaging (DWI) for LNM of PHC., Method: Consecutive patients who underwent surgical resection of PHC between January 2012 and May 2020 were retrospectively reviewed. The lymph node (LN) area (mm 2 ) and apparent diffusion coefficient (ADC) value ( × 10 -3 mm 2 /s) of pericholedochal LNs were measured by DWI. The characteristics of the patients and the LNs were evaluated according to the histological presence or absence of regional LNM. Univariate and multivariate analyses were performed to identify the predictors of LNM of PHC., Results: Of the 93 eligible patients, 49 (53%) were LNM positive and 44 (47%) were LNM negative. Although the characteristics of the patients were similar between the two groups, the mean ADC value was significantly lower in the LNM positive group than in the LNM negative group. On multivariate analysis, mean ADC value ≤1.80 × 10 -3 mm 2 /s was independently associated with LNM of PHC (risk ratio: 12.5, 95% confidence interval: 3.05-51.4; p = 0.0004). The sensitivity, specificity and accuracy of mean ADC values ≤ 1.80 × 10 -3  mm 2 /s for predicting LNM of PHC were 94%, 55% and 75%, respectively., Conclusions: DWI might be useful for the preoperative diagnosis of LNM of PHC., (© 2022. Society of Surgical Oncology.)

Background: Clinical tumor staging is essential information for making a therapeutic decision in cancer. This study aimed to identify the optimal tumor classification system for predicting resectability and survival probability in perihilar cholangiocarcinoma., Methods: Patients who were treated for perihilar cholangiocarcinoma between 2009 and 2018 were enrolled. Local tumor extension was staged radiologically according to a diameter-based classification system in addition to the AJCC, Blumgart, and Bismuth systems. Survival and resectability were compared between T subgroups, and the discriminability of the four systems was assessed with Harrell's concordance index (C-index)., Results: Among 702 study patients, 559 (80.0%) underwent laparotomy, 489 (70.0%) of whom underwent resection. The resectability significantly decreased for more advanced tumors in all systems (P < .001); the AJCC system had the greatest discriminability for resectability (area under the curve 0.721). Overall survival at 5 years was 69.9% for AJCC cT1, 45.8% for cT2, 31.8% for cT3, and 15.3% for cT4 tumors (cT1 vs cT2; P = .002, cT2 vs cT3; P = .008 and cT3 vs cT4; P < .001). The AJCC system had the largest C-index of 0.627., Conclusions: The AJCC T system was the optimal classification system for predicting resectability and survival in perihilar cholangiocarcinoma., (© 2021 Japanese Society of Hepato-Biliary-Pancreatic Surgery.)

Perihilar cholangiocarcinoma (PHC) is a common and highly intractable malignancy of the main biliary tree confluence. PHC is associated with a poor prognosis because of its insidious local spread that makes it challenging to diagnose and assess. Surgical resection remains the standard curative treatment (up to 50% 5-year overall survival after negative-margin resection). More aggressive surgical approaches have recently emerged, pushing the boundaries of PHC resectability at the cost of a higher morbidity. As such, adequate preoperative preparation (i.e., biliary drainage, venous embolization) is now regarded as a critical issue to increase the number of patients amenable to extended liver resection. Thorough imaging plays a pivotal role in the preoperative setting in both PHC resectability assessment and patient preparation to surgery. Despite recent improvement in PHC imaging, its assessment remains challenging and only 50-60% of patients who are scheduled to undergo surgery are ultimately amenable to curative resection. Therefore, a knowledge of available diagnostic and interventional imaging techniques is important to improve PHC management. Herein, we review the various imaging techniques and preoperative radiological interventions such as biliary drainage, portal vein embolization and liver venous deprivation that are available in PHC management focusing on the anatomical and oncological considerations that are crucial to prepare and guide curative surgical resection., Competing Interests: Declaration of Competing Interest The authors have no conflicts of interest to disclose., (Copyright © 2022 Société française de radiologie. Published by Elsevier Masson SAS. All rights reserved.)

Background: Although the most important goal in surgery for perihilar cholangiocarcinoma (PHC) is to achieve tumor-free proximal ductal margins, little is known about the implications of confluence patterns of the left intrahepatic bile ducts for the proximal ductal margin status in right hepatectomy (RH) for PHC., Methods: Of 203 patients who underwent surgical resection for PHC with curative intent, confluence patterns of the left intrahepatic bile duct were evaluated in 94 consecutive patients who underwent RH, and they were classified into the following two types: normal type: the bile duct of segment 4 (B4) drained into the common trunk of the bile ducts of segment 2 (B2) and segment 3 (B3) at the right side of the umbilical portion of the left portal vein to form the left hepatic duct; and hepatic confluence type: B2 entered the common trunk of B3 and B4 at the hepatic confluence or B4 entered the common trunk of B2 and B3 at the hepatic confluence. The proximal ductal margin status following RH was compared between the two types of confluence patterns., Results: Of 94 consecutive patients, 69 (73%) were the normal type, and 25 (27%) were the hepatic confluence type. There were no significant differences in patients' characteristics, surgical characteristics, surgical outcomes, and histopathological features between the two groups. However, in patients with Bismuth-Corlette type II and IIIa PHC, the achievement rates of negative proximal ductal margins at the first dividing line were significantly higher in the hepatic confluence type group than in the normal type group (16/16 [100%] vs 34/52 [65%], respectively; P = .007)., Conclusions: Confluence patterns of the left intrahepatic bile ducts might affect proximal ductal margin status in RH for PHC., (© 2021 Japanese Society of Hepato-Biliary-Pancreatic Surgery.)

Background: Cholangiocarcinoma is a type of hepatobiliary tumor. For perihilar cholangiocarcinoma (pCCA), patients who experience early recurrence (ER) have a poor prognosis. Preoperative accurate prediction of postoperative ER can avoid unnecessary operation; however, prediction is challenging., Purpose: To develop a novel signature based on clinical and/or MRI radiomics features of pCCA to preoperatively predict ER., Study Type: Retrospective., Population: One hundred eighty-four patients (median age, 61.0 years; interquartile range: 53.0-66.8 years) including 115 men and 69 women., Field Strength/sequence: A 1.5 T; volumetric interpolated breath-hold examination (VIBE) sequence., Assessment: The models were developed from the training set (128 patients) and validated in a separate testing set (56 patients). The contrast-enhanced arterial and portal vein phase MR images of hepatobiliary system were used for extracting radiomics features. The correlation analysis, least absolute shrinkage and selection operator (LASSO) logistic regression (LR), backward stepwise LR were mainly used for radiomics feature selection and modeling (Model radiomic ). The univariate and multivariate backward stepwise LR were used for preoperative clinical predictors selection and modeling (Model clinic ). The radiomics and preoperative clinical predictors were combined by multivariate LR method to construct clinic-radiomics nomogram (Model combine )., Statistical Tests: Chi-squared (χ 2 ) test or Fisher's exact test, Mann-Whitney U-test or t-test, Delong test. Two tailed P < 0.05 was considered statistically significant., Results: Based on the comparison of area under the curves (AUC) using Delong test, Model clinic and Model combine had significantly better performance than Model radiomic and tumor-node-metastasis (TNM) system in training set. In the testing set, both Model clinic and Model combine had significantly better performance than TNM system, whereas only Model combine was significantly superior to Model radiomic . However, the AUC values were not significantly different between Model clinic and Model combine (P = 0.156 for training set and P = 0.439 for testing set)., Data Conclusion: A noninvasive model combining the MRI-based radiomics signature and clinical variables is potential to preoperatively predict ER for pCCA., Level of Evidence: 3 TECHNICAL EFFICACY STAGE: 4., (© 2021 International Society for Magnetic Resonance in Medicine.)

Objective: To explore the value of machine learning-based magnetic resonance imaging (MRI) liver acceleration volume acquisition (LAVA) dynamic enhanced scanning for diagnosing hilar lesions., Methods: A total of 90 patients with hilar lesions and 130 patients without hilar lesions who underwent multiphase dynamic enhanced MRI LAVA were retrospectively selected as the study subjects. The 10-fold crossover method was used to establish the data set, 7/10 (154 cases) data were used to establish the training set, and 3/10 (66 cases) data were used to establish the validation set to verify the model. The region of interest was extracted from MRI images using radiomics, and the hilar lesion model was constructed based on a convolutional neural network., Results: There were significant differences in respiration and pulse frequency between patients with hilar lesions and without hilar lesions ( P  <0.05). The subjective scores of the images in the first three phases of dynamic enhanced scanning in the training set were higher than those in the validation set ( P < 0.05). There was no significant difference between the training and validation set in the last three phases of dynamic enhanced scanning., Conclusion: Machine learn-based MRI LAVA dynamic enhanced scanning for diagnosing hilar lesions has high diagnostic efficiency and can be used as an auxiliary diagnostic method., Competing Interests: All authors declare no conflicts of interest in this paper., (Copyright © 2022 Haijin Wang et al.)

video width="640" height="480" controls controlsList="nodownload" poster="https://www.revistachirurgia.ro/pdfs/video/Complete&#95;segment&#95;resection&#95;hepatectomy&#95;klatskin&#95;tumor.jpg" style="margin-top: -20px;" source src="https://www.revistachirurgia.ro/pdfs/video/Complete&#95;segment&#95;resection&#95;hepatectomy&#95;klatskin&#95;tumor.mp4" type="video/mp4" Your browser does not support the video tag. /video We present the case of a 37-year-old male patient with no significant history, hospitalized in our center for painless jaundice with sudden onset. CT contrast portal phase imaging revealed a tumor located at the main biliary confluence, in the proximity of the main portal bifurcation, with no venous or arterial vascular invasion, nor extrahepatic metastases. MRCP diagnosed a Bismuth- Corlette type Klatskin IIIb tumor. For complete assessment of biliary involvement and surgical planning, in addition to the Bismuth-Corlette classification, we took into consideration the presence of infiltration of the bile ducts for segment 1, documented at MRCP. Therefore, a left hepatectomy with en-bloc complete segment 1 resection, along with the main bile ducts and hilar lymphadenectomy, was considered best suited for achieving curative resection in this case. After an uneventful postoperative course, the patient was discharged in the 12th postoperative day. Currently, the patient is disease-free after 84 months. We consider that the long-term recurrence free survival was favored by the complete segment 1 resection. Therefore, for complete assessment of biliary involvement in Klatskin tumor, we recommend that in addition to Bismuth-Corlette classification, infiltration of the bile duct for segment 1 should always be evaluated. If present, the entire segment 1 should be removed for best oncological results., (Celsius.)

Background: While a certain degree of tumor infiltration of the portal vein is common in patients with perihilar cholangiocarcinoma (pCCA) scheduled for surgery, complete tumor-associated portal vein occlusion (PVO) is less frequently observed. Here, we analyzed the impact of PVO on perioperative and oncological outcomes in pCCA patients., Methods: Between 2010 and 2019, 127 patients with pCCA underwent surgery in curative intent at our department of which 17.3% (22/127) presented with PVO. Extensive group comparisons were conducted and the association of cancer-specific (CSS) and disease-free survival (DFS) with PVO and other clinico-pathological characteristics were assessed using Cox regression models., Results: Patients without PVO showed a median CSS of 65 months (3-year-CSS = 64%, 5-year-CSS = 53%) compared to 31 months (3-year-CSS = 43%, 5-year-CSS = 17%) in patients with PVO (p = 0.025 log rank). Patients with PVO did also display significant perioperative mortality (22.7%, 5/22) compared to patients without PVO (14.3%, 15/105, p = 0.323). Further, PVO (CSS: HR = 5.25, p = 0.001; DFS: HR = 5.53, p = 0.001) was identified as independent predictors of oncological outcome., Conclusions: PVO has been identified as an important prognostic marker playing a role in inferior oncological outcome in patients with pCCA. As PVO is also associated with notable perioperative mortality, surgical therapy should be considered carefully in pCCA patients., (Copyright © 2021 International Hepato-Pancreato-Biliary Association Inc. Published by Elsevier Ltd. All rights reserved.)

Background: Surgery for perihilar cholangiocarcinoma (pCCA) is associated with high morbidity and mortality rates. The impact of surgery for pCCA may affect patients after discharge. The aim of this study was to investigate all morbidity and mortality during the first year after surgery for pCCA., Methods: All consecutive liver resections for suspected pCCA between 2000 and 2019 at two tertiary referral centers were included. All morbidity and mortality until one year after surgery was collected retrospectively, including readmissions and reinterventions. All recurrences within the first year were scored to calculate disease-free survival., Results: In 250 patients, the major morbidity rate was 61% (152/250), in-hospital mortality was 15% (37/250) and 90-day mortality was 16% (40/250). In the 213 discharged patients, 98 patients (46%) suffered 260 surgical complications. These complications required 185 readmissions in 92 patients (43%) and 400 reinterventions in 110 patients (52%), including 330 radiological (83%), 61 endoscopic (15%) and 9 surgical reinterventions (2%). One-year overall survival was 77% and one-year disease-free survival was 70%. Out of the 20 patients who died within the first year after discharge, 15 died of recurrent disease and 3 due to surgery related complications and 2 of unknown causes., Conclusion: Readmissions, reinterventions and complications are frequent throughout the first year after surgery for pCCA in tertiary referral hospitals. These adverse events warrants treatment of these complex patients in high expertise centers offering intensive perioperative care and close follow-up of patients after discharge., (Copyright © 2021 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Purpose: To predict poor overall survival (OS) and risk of residual tumor after surgery using MR imaging, clinical, and histopathological findings in perihilar cholangiocarcinoma., Methods: 196 patients with perihilar cholangiocarcinoma who underwent preoperative MRI and curative-intent surgery were retrospectively included. MRI findings were assessed by two radiologists. Clinical characteristics and histopathological results such as serum carcinoembryonic antigen (CEA), carbohydrate antigen 19-9 (CA 19-9), T and N stage, and resection status, were also investigated. Cox regression analysis and the Kaplan-Meier method were used to identify prognostic factors for OS. We further analyzed the correlation between MRI features and residual tumors using logistic regression analysis., Results: The median OS was 25.0 ± 26.6 months. T stage (hazard ratio [HR] 6.26, p = 0.014), N stage (HR 1.86, p = 0.002), CA-19-9 >37 U/mL (HR 2.06, p < 0.001), enlarged LN on MRI (HR 1.69, p = 0.006), and residual tumor (HR 1.52, p = 0.034) were important predictors of poor survival. The 5-year OS of the complete resection group (n = 107) was significantly better than that of the residual tumor group (n = 89) (35.5% vs. 18.8%, p = 0.002). Additionally, peritumoral fat stranding (odds ratio[OR] 2.09, p = 0.027), Bismuth type III/IV (OR 1.95, p = 0.022), and common bile duct (CBD) involvement (OR 2.3, p = 0.008) on MRI were important predictors of residual tumors in univariate analyses. However, absence of peritumoral fat stranding was a significant independent predictor for complete resection (OR 1.99, p = 0.048) and showed the highest sensitivity, at 79.8%., Conclusion: MR imaging, clinical and histopathological results are useful for predicting poor survival after surgery for perihilar cholangiocarcinoma. Furthermore, MRI findings, including peritumoral fat stranding, CBD involvement, and Bismuth type, are important for the prediction of residual tumors., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Purpose: To evaluate the incidence, risk factors, management options, and outcomes of portal vein thrombosis following major hepatectomy for perihilar cholangiocarcinoma., Methods: A total of 177 perihilar cholangiocarcinoma patients who (1) underwent major hepatectomy and (2) underwent investigating the portal vein morphology, which was measured by rotating the reconstructed three-dimensional images after facilitating bone removal using Aquarius iNtuition workstation between 2002 and 2018, were included. Risk factors were evaluated using the Kaplan-Meier method and Cox proportional hazard models., Results: Six patients developed portal vein thrombosis (3.4%) within a median time of 6.5 (range 0-22) days. Portal vein and hepatic artery resection were performed in 30% and 6% patients, respectively. A significant difference in the probability of the occurrence of portal vein thrombosis (PV) within 30 days was found among patients with portal vein resection, a postoperative portal vein angle < 100°, remnant portal vein diameter < 5.77 mm, main portal vein diameter > 13.4 mm, and blood loss (log-rank test, p = 0.003, p = 0.06, p < 0.0001, p = 0.01, and p = 0.03, respectively). Decreasing the portal vein angle and narrowing of the remnant PV diameter remained significant predictors on multivariate analysis (p = 0.027 and 0.002, respectively). Reoperation with thrombectomy was performed in four patients, and the other two patients were successfully treated with anticoagulants. All six patients subsequently recovered and were discharged between 25 and 70 days postoperatively., Conclusion: Narrowing of the remnant portal vein diameter and a decreased portal vein angle after major hepatectomy for perihilar cholangiocarcinoma are significant independent risk factors for postoperative portal vein thrombosis., (© 2021. Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Iatrogenic factors persist as leading mechanisms of cholangitis at a referral center., Methods: The records of 51 patients treated for cholangitis due to incomplete or inappropriate nonoperative biliary interventions between 2005-2016 were evaluated retrospectively., Results: Twenty-nine patients were men; median (range) age was 60 (30-90). An incomplete or inappropriate ERCP and percutaneous transhepatic biliary drainage (PTBD) had been performed in 45 and 6 patients respectively. Inappropriate endoscopic stenting for hilar obstruction (perihilar cholangiocarcinoma: 22 and gallbladder carcinoma:3) was the most common scenario (n: 25, 49%). Twenty other patients had undergone an ERCP with incomplete (n: 12) or no (n:8) drainage. The errors in the PTBD group were passage of the catheter to the duodenum in patients with hilar obstruction (n: 4) and incomplete drainage in patients with perihilar cholangiocarcinoma (n: 2). Two patients (4%) died of infection. The surgery of 6 operable tumor patients was delayed for median (range) 5 (1-7) months., Conclusions: Incomplete or inappropriate nonoperative biliary interventions put patients' lives at risk and delay radical treatments.

Objective: To investigate the value of intravoxel incoherent motion diffusion-weighed magnetic resonance imaging (IVIM-DWI) in discriminating the pathological grades of hilar cholangiocarcinoma (HC)., Patients and Methods: Thirty-seven HC patients were enrolled and received routine and advanced DWI scanning with multiple b-values. IVIM-DWI images were obtained using echo-planar imaging sequence., Results: The consistency of the maximum cross-sectional area ROI measuring method was higher than that of the repeated sampling ROI measuring method. ADC slow values were closely correlated with the pathological grades of HC. The degrees of biliary dilatation and MELD scores had no influence on the negative correlation between ADC slow values and the pathological degrees of HC patients., Conclusions: ADC slow values could be applied in indicating the pathological grades of HC, which was independent on the extent of biliary dilatation.

Purpose: We aim to develop survival predictive tools to inform clinical decision-making in perihilar cholangiocarcinoma (pCCA)., Materials and Methods: A total of 184 patients who had curative resection and magnetic resonance imaging (MRI) examination for pCCA between January 2010 and December 2018 were enrolled. 110 patients were randomly selected for model development, while the other 74 patients for model testing. Preoperative clinical, laboratory, and imaging data were analyzed. Preoperative clinical predictors were used independently or integrated with radiomics signatures to construct different preoperative models through the multivariable Cox proportional hazards method. The nomograms were constructed to predict overall survival (OS), and the performance of which was evaluated by the discrimination ability, time-dependent receiver operating characteristic curve (ROC), calibration curve, and decision curve., Results: The clinical model (Model clinic ) was constructed based on three independent variables including preoperative CEA, cN stage, and invasion of hepatic artery in images. The model yield the best performance (Model clinic&AP&PVP ) was build using three independent variables, Signature AP and Signature PVP . In training and testing cohorts, the concordance indexes (C-indexes) of Model clinic were 0.846 (95 % CI, 0.735-0.957) and 0.755 (95 % CI, 0.540-969), and Model clinic&AP&PVP achieved C-indexes of 0.962 (95 % CI, 0.905-1) and 0.814 (95 % CI, 0.569-1). Both Model clinic and Model clinic&AP&PVP outperformed the TNM staging system. Good agreement was observed in the calibration curves, and favorable clinical utility was validated using the decision curve analysis for Model clinic and Model clinic&AP&PVP ., Conclusion: Two preoperative nomograms were constructed to predict 1-, 3-, and 5-years survival for individual pCCA patients, demonstrating the potential for clinical application to assist decision-making., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Purpose: To compare the content and communication between the radiologist and the clinicians for treatment planning of structured reports (SRs) and narrative reports (NRs) for reporting CT/MRI findings in patients with perihilar cholangiocarcinoma., Materials and Method: This retrospective study included 54 patients with perihilar cholangiocarcinoma who underwent CT/MRI before ERCP or surgery. For all patients, we generated both NRs and SRs for perihilar cholangiocarcinoma and compared the number of key features between NRs and SRs. In addition, three clinicians performed a questionnaire evaluation that included three questions regarding assessment of the sufficiency of information for surgical or procedural planning, the effort required for information extraction, and the report quality rated on a Likert scale., Results: SRs included significantly more predefined key features (6.89 ± 0.31) than NRs (5.87 ± 0.70) (p < 0.001). SRs provided greater sufficiency of information for clinical planning than NRs (89.9% vs. 18.5% of the cases, respectively; p < 0.001). Extraction of information was easier from SRs than NRs (94.4% vs. 9.3%, respectively) (p < 0.001). SRs received a higher overall report quality rating (5.96 ± 0.19) than NRs (4.31 ± 0.77) (p < 0.001)., Conclusions: SRs of CT/MRI findings for hilar cholangiocarcinoma can reveal more predefined key features, provide more sufficiency of information, and yield higher satisfaction levels, in comparison with NRs.

Background and Aims: Up to 40%-65% of patients with perihilar cholangiocarcinoma (PHC) rapidly progress to early recurrence (ER) even after curative resection. Quantification of ER risk is difficult and a reliable prognostic prediction tool is absent. We developed and validated a multilevel model, integrating clinicopathology, molecular pathology and radiology, especially radiomics coupled with machine-learning algorithms, to predict the ER of patients after curative resection in PHC., Methods: In total, 274 patients who underwent contrast-enhanced CT (CECT) and curative resection at 2 institutions were retrospectively identified and randomly divided into training (n = 167), internal validation (n = 70) and external validation (n = 37) sets. A machine-learning analysis of 18,120 radiomic features based on multiphase CECT and 48 clinico-radiologic characteristics was performed for the multilevel model., Results: Comprehensively, 7 independent factors (tumour differentiation, lymph node metastasis, pre-operative CA19-9 level, enhancement pattern, A-Shrink score, V-Shrink score and P-Shrink score) were built to the multilevel model and quantified the risk of ER. We benchmarked the gain in discrimination with the area under the curve (AUC) of 0.883, superior to the rival clinical and radiomic models (AUCs 0.792-0.805). The accuracy (ACC) of the multilevel model was 0.826, which was significantly higher than those of the conventional staging systems (AJCC 8th (0.641), MSKCC (0.617) and Gazzaniga (0.581))., Conclusion: The radiomics-based multilevel model demonstrated superior performance to rival models and conventional staging systems, and could serve as a visual prognostic tool to plan surveillance of ER and guide post-operative individualized management in PHC., (© 2020 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Introduction: Unresectable hilar cholangiocarcinoma (UHC) is a malignant tumor and has a poor prognosis. IRE is a novel non-thermal ablative therapy that causes cellular apoptosis via electrical impulses. To compare the curative effect for UHC, chemotherapy plus concurrent IRE and chemotherapy alone were set up., Materials and Methods: From July 2015 to May 2019, 47 patients with UHC were analyzed to chemotherapy + IRE group ( n  = 23) or chemotherapy alone group ( n  = 24) in this study. Treatment response was assessed with computed tomography (CT) or magnetic resonance imaging (MRI) 1 month after treatment and every 3 months thereafter. Local tumor progression (LTP), time to LTP, overall survival (OS) and procedure-related complications were compared between the two groups., Results: Chemotherapy plus concurrent IRE group showed a tendency toward a decreased rate of LTP (16.7% vs . 39.5%; p  = 0.039) and an increased complete response rate (52.2% vs . 12.5%; p  = 0.011) compared with chemotherapy alone group. Time to LTP was significantly longer in the chemotherapy plus concurrent IRE group compared to chemotherapy alone group (11.2 months vs . 4.2 months; p  = 0.001). Median OS was significantly longer in the chemotherapy plus concurrent IRE group compared to chemotherapy alone group (19.6 months vs . 10.2 months; p  = 0.001)., Conclusions: Chemotherapy plus concurrent IRE improved local control and prolonged time to LTP and OS in patients with UHC.

Purpose: Perineural invasion (PN) is often found in perihilar cholangiocarcinoma. New procedure was developed to assess PN around the right hepatic artery (RHA) using dual-energy computed tomography (DECT)., Methods: Thirty patients with perihilar cholangiocarcinoma who underwent DECT before biliary drainage were retrospectively reviewed. Mask images, i.e., the periarterial layer (PAL) around the RHA and superior mesenteric artery (SMA), were made from late arterial phase DECT. The mean CT number of the PAL was measured., Results: Twenty patients with PN around the RHA were classified into the PN (+) group. The remaining 10 patients without PN and other 26 patients with other diseases that are never accompanied with PN were classified into the PN (-) group. The PAL ratio (the CT number of the PAL around the RHA relative to that around the SMA) was calculated. Both the mean CT number of the PAL around the RHA and the PAL ratio were significantly higher in the PN (+) group than in the PN (-) group. According to an ROC analysis, the predictive ability of the PAL ratio was superior. Using the cutoff value of the PAL ratio 1.009, a diagnosis of PN around the RHA was made with approximately 75% accuracy., Conclusions: Assessment with CT number of the PAL reconstructed from DECT images is an easy and objective method to diagnose PN.

Background: Major liver resection has evolved as the mainstay of treatment for patients with perihilar cholangiocarcinoma (pCCA). Here we assessed the suitability of preoperative future liver remnant (FLR) measurement to predict perioperative complications, since surgical morbidity and mortality are high compared to other malignancies., Methods: Between 2011 and 2016, 91 patients with pCCA underwent surgery in curative intent at our institution. The associations of surgical complications with FLR and clinico-pathological characteristics were assessed using logistic regression analyses. Different methods of FLR assessment, the calculated-FLR (cFLR; ratio of FLR to total liver volume), standardized FLR (sFLR; ratio of FLR to liver volume estimated by body surface area) and FLR to bodyweight ratio (FLR/BW) were tested for validity., Results: Multivariable analysis identified preoperative cholangitis (Exp(B) = 0.236; p = 0.030) as the single significant predictor of postoperative mortality and cFLR (Exp(B) = 0.009, p = 0.004) as the single significant predictor of major postoperative morbidity (Clavien-Dindo ≥ 3b). Based on these findings we designed a futility criterion (cFLR<40% OR preoperative cholangitis) predicting in-house mortality., Conclusions: In patients with pCCA, the preoperative FLR<40% as well as preoperative cholangitis are two risk factors to independently predict perioperative morbidity and mortality. The cFLR should be the preferred method of liver volumetry., (Copyright © 2020 International Hepato-Pancreato-Biliary Association Inc. Published by Elsevier Ltd. All rights reserved.)

Background: The aim of this study was to evaluate potential risk factors associated with benign lesions and perihilar cholangiocarcinoma (PHC) in patients presenting with proximal biliary strictures (PBS)., Methods: Patients with PBS who were referred to a specialist HPB centre between 2008 and 2016 were identified. Patients with primary sclerosing cholangitis, metastatic PHC or hilar obstruction by a peripheral tumour were excluded. The final diagnosis was determined either by (1) resection histology or (2) combination of biopsy and clinical course. Multivariable analysis of clinical, laboratory and radiological data was undertaken to identify independent predictors of benign and malignant lesions., Results: 155 consecutive patients were identified, including 25 patients (16%) with benign PBS. Abdominal pain (odds ratio [OR] 3.36; p = 0.027), serum CA19.9 < 100 U/ml (OR 10.35; p = 0.001), and absence of mass on imaging (OR 4.66; p = 0.004) were all associated with the presence of benign lesions on multivariable analysis., Conclusions: This study has identified several independent variables that may differentiate between benign and malignant proximal biliary strictures. A larger multi-institutional study would be warranted to validate these findings, and to develop a risk score to stratify patients with suspected PHC., (Copyright © 2020 International Hepato-Pancreato-Biliary Association Inc. All rights reserved.)

Background: The aim was to evaluate the value of Tc-labeled galactosyl human serum albumin (Tc-GSA) with single-photon emission computerized tomography (SPECT) in the preoperative assessment of regional liver function and prediction of posthepatectomy liver failure (PHLF) in patients with hilar cholangiocarcinoma (hCCA)., Methods: Patients with hCCA who underwent Tc-GSA SPECT/computed tomography (CT) before hepatectomy were included. The liver functional parameters of functional liver density (FLD) and predictive residual index (PRI) were calculated based on Tc-GSA SPECT/CT. PHLF was defined according to the International Study Group of Liver Surgery criteria. Univariate and multivariate analyses were used to analyze the risk factors for PHLF. The prediction of PHLF was calculated using receiver operating characteristic curve., Results: A total of 34 patients were included, 23 of whom underwent preoperative biliary drainage. FLD was significantly higher in patients with drained lobes than that in patients with undrained lobes (0.615 ± 0.190 versus 0.500 ± 0.211, P < 0.05). Sixteen patients suffered PHLF. The ratio of future remnant to total morphological liver volume, future remnant FLD, and PRI differed significantly in patients with and without PHLF according to univariate analysis. PRI was identified as the only independent factor for prediction of PHLF according to multivariate analysis. With a PRI of 0.78, it was possible to predict PHLF with a sensitivity of 83% and a specificity of 93%., Conclusions: Tc-GSA SPECT/CT can accurately assess regional liver function and is better able to predict PHLF than conventional methods in patients with hCCA.

Alveolar echinococcosis is an infectious disease caused by Echinococcus multilocularis and it is frequently diagnosed as a space-occupying lesion in the liver. The growth pattern may be similar to that of a malignant tumour with extensive liver infiltration, spreading into neighbouring organs and forming metastasis-like masses in distant organs. Thus, it is one of the differential diagnoses of liver cancer. We report a case that presented as a klatskin tumour clinically and radiologically, but was revealed by pathologic and serologic work-up. Since the courses of these two diseases, a malignancy and an infectious disease, are far beyond comparison, echinococcosis should always be considered in differential diagnosis of obstructive jaundice, especially in the endemic regions.

Cholangiocarcinoma (CCC) is the most aggressive malignant tumor of the biliary tract. Perihilar CCC (pCCC) is the most common CCC and is burdened by a complicated diagnostic iter and its anatomical location makes surgical approach burden by poor results. Besides its clinical presentation, a multimodal diagnostic approach should be carried on by a tertiary specialized center to avoid miss-diagnosis. Preoperative staging must consider the extent of liver resection to avoid post-surgical hepatic failure. During staging iter, magnetic resonance can obtain satisfactory cholangiographic images, while invasive techniques should be used if bile duct samples are needed. Consistently, to improve diagnostic potential, bile duct drainage is not necessary in jaundice, while it is indicated in refractory cholangitis or when liver hypertrophy is needed. Once resecability criteria are identified, the extent of liver resection is secondary to the longitudinal spread of CCC. While in the past type IV pCCC was not considered resectable, some authors reported good results after their treatment. Conversely, in selected unresectable cases, liver transplantation could be a valuable option. Adjuvant chemotherapy is the standard of care for resected patients, while neoadjuvant approach has growing evidences. If curative resection is not achieved, radiotherapy can be added to chemotherapy. This multistep curative iter must be carried on in specialized centers. Hence, the aim of this review is to highlight the main steps and pitfalls of the diagnostic and therapeutic approach to pCCC with a peculiar attention to type IV pCCC., Competing Interests: Conflict-of-interest statement: Authors declare no conflict of interests for this article., (©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.)

Background: Endoscopic retrograde cholangiopancreatography (ERCP) is still performed using two-dimensional (2D) X-ray images. The success rate and risk of complications are considered operator-dependent. We explored performing an ERCP-related procedure with 3D-computed tomography (CT) biliary imaging for preoperative simulation and intraoperative reference in a patient with malignant biliary obstruction., Case Presentation: The patient was a 66-year-old man who underwent rectal resection and postoperative chemotherapy for rectal cancer. A liver metastasis caused obstructive jaundice and acute cholangitis, necessitating emergency hospitalization. A 3.5 cm mass in the hilar region of the biliary tree caused type IV biliary obstruction according to the Bismuth-Corlette classification of hilar cholangiocarcinoma. ERCP and biliary drainage were performed repeatedly, but had no effect. Given that selective bile duct drainage had proven extremely difficult with the conventional procedures, three-dimensional (3D) images were created from preoperative CT image data using a 3D image reconstruction system (SYNAPSE VINCENT version 5, FUJIFILM Corporation, Tokyo, Japan). Using the 3D images for preoperative planning and intraoperative reference, biliary drainage and stent placement were successfully performed without complications. Postoperatively, the patient had no further cholangitis or need for stent replacement up to his death., Conclusions: We report the first case of an ERCP-related procedure with 3D biliary imaging for preoperative simulation and intraoperative reference in a patient with malignant biliary obstruction. The 3D image reconstruction is useful for preoperative planning and could contribute to an increased success rate, decreased complications, a shorter operation time, and reduced radiation exposure to the operator.

Objectives: To explore the characteristics of hepatic plexuses and celiac ganglia, and their relationships with hilar cholangiocarcinoma (HCCA) perineural invasion (PNI) by computed tomography (CT) imaging preliminarily., Materials and Methods: Sixty-five HCCA patients (55 with PNI) between December 2014 and February 2019 were included in this retrospective study. The CT values of hepatic plexuses in Region 1 (the fat tissue around proper hepatic artery), in Region 2 (the fat tissue around common hepatic artery), and in Region 3 (the fat tissue around celiac trunk), and the CT values and diameters of celiac ganglia were measured on the preoperative CT images. Mann-Whitney U test was used to compare the measurements between PNI group and Non-PNI group. ROC curve was performed to analyze the sensitivity, specificity and optimal threshold of the measurements in discriminating HCCA PNI., Results: The CT values of hepatic plexuses in PNI group were significantly higher than those in Non-PNI group (all P < 0.05). The CT values of right celiac ganglia were significantly higher in PNI group than those in Non-PNI group (P = 0.007). There were no significant differences between two groups in other measurements (all P > 0.05). The CT values of hepatic plexuses in Region 1 showed the highest sensitivity (90.9%) and the CT values of right celiac ganglia demonstrated the highest specificity (80.0%)., Conclusions: The increases of CT values of hepatic plexuses around proper hepatic artery may be used as an indicator of PNI in patients with HCCA and may facilitate treatment planning in considering its early recurrence after surgery and poor prognosis., Competing Interests: Declaration of competing interest None., (Copyright © 2020 Elsevier Inc. All rights reserved.)