外科 實 證 期 刊 閱 讀 報 告 EBM-style Journal Reading 報告人：王愷晟 指導臨床教師：柯志燃 日期：2009.07.04 地點：四期10F

Clinical Scenario （臨床情境） The 57 y/o woman has a history of Hysterectomy on 1994/10/12 Appendectomy on 2003/01/27 S/P PCNL for r’t renal pelvic stone on 2009-3-16 Hypertension Chief complaint : epigastric pain with fever on 6/25 She got intermittent epigastric and left flank soreness on 6/25. Fever was also noted. On 6/26 she came to Uro OPD for help. KUB and u/a was arranged. She then was transferred to ER for further survery.

Clinical Scenario （臨床情境） At our ER

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Left  intrahepatic  ducts  stones  with  dilatation  of  left  IHDs, cholangitis  considered.

Tentative Diagnosis Treatment 1.Liver abscess 2.Intra-hepatic duct stone 3.Hydronephrosis 4.Hypertension Treatment --Cefmetazole 1gm q8h use --Consult general surgery Dr. on 6/27 Hepatolithiasis, left cholangitis

6/29 transfer to GS

6/30 Pre OP diagnosis : left IHD stone with recurrent cholangitis OP method: Left hepatectomy, S2.3.4 Cholecyctectomy Choledochotomy with T-tube drainage OP finding: left IHD stone Left lobe atrophy Post OP diagnosis : Hepatolithiasis, left with recurrent cholangitis

Clinical Uncertainty → PICO 問題 Since heapatolithiasis may be a risk factor of cholangiocarcinoma, hepatic resection is reasonable. Among those who received hepatectomy due to heapatolithiasis, how many percent of them had already got cholangiocarcinoma ? Or will cholangiocarcinoma tend to develop in this group of people ?

Type of Question: Prognosis 臨床個案的PICO Patient / Problem Hepatolithiasis Intervention Operative intervention Comparison Conservative management Outcome Rate of cholangiocarcinoma Type of Question: Prognosis

Search Terms & Strategy: （搜尋關鍵字與策略） 資料庫：PubMed 搜尋關鍵字策略： #3 Search #1 and #2 04:17:17 40 #2 Search hepatolithiasis, hepatectomy 04:16:45 99 #1 Search hepatolithiasis, outcome 04:16:28 82

Best available evidence: （挑選可獲得之最佳研究證據） Citation/s: Outcomes of Hepatectomy for Hepatolithiasis - The American Journal of Surgery, Month 2009 Lead author's name and fax: Takahiro Uenishi, M.D. fax: 81-6-6646- 6057.

The Study : （研究效度） Outcomes of hepatic resection for hepatolithiasis A retrospective study was conducted of 87 patients with hepatolithiasis who underwent hepatic resection between January 1980 and December 2007 Department of Hepato-Biliary-Pancreatic Surgery, Osaka City University Hospital. Level of Evidence: 3b

The Evidence: （研究重要結果） Between January 1980 and December 2007, 87 patients with hepatolithiasis underwent hepatic resection. Indications for hepatic resection bile duct stricture associated with stones atrophy of the affected liver segments lobe liver abscess the possible presence of cholangiocarcinoma

In 16 of the 20 patients with bilateral stones, the more affected side was resected and postoperative cholangioscopic lithotomy was performed for the remaining stones. The remaining 4 patients underwent simultaneous resection of the affected segments of both hepatic lobes.

Immediate outcomes 10 patients ( 12% ) had coexisting cholangiocarcinoma. Correct diagnosis was made preoperatively in only 3 patients. The remaining 7 patients had been initially diagnosed with liver abscess or biliary strictures associated with hepatolithiasis and were incidentally discovered to have cholangiocarcinoma on pathological examination.

A median follow-up of 75 months (range 3 to 264) Long-term outcomes Three perioperative deaths (3.5%) occurred from postoperative liver failure or sepsis. A median follow-up of 75 months (range 3 to 264) 28 patients suffered recurrent episodes of cholangitis. Of these 28 patients, 10 had recurrence of cholangiocarcinoma and 12 had residual or recurrent stones.

10-year overall survival rates : 80.3% The 5-year survival rates for patients with and without cholangiocarcinoma were 25.0% and 95.4%, respectively (P .01). development of cholangiocarcinoma was an independent predictor of survival 10-year overall survival rates : 80.3% 17 patients died 4 : hepatic failure due to secondary biliary cirrhosis 10 : cholangiocarcinoma 8 patients diagnosed at the time of hepatic resection 2 patients in whom cholangiocarcinoma subsequently developed 3 : unrelated diseases.

Comment & Discussion Bile stasis, chronic bacterial infection, and mechanical irritation of bile duct epithelium appear to play important roles in the development of cholangiocarcinoma. Hepatic resection might thus offer another advantage in eliminating the risk of new development of cholangiocarcinoma because of complete removal of both intrahepatic stones and biliary strictures.

Previous series reported the incidence of cholangiocarcinoma associated with hepatolithiasis at the time of hepatic resection to be 2.4% to 13%, and in the present series it was 12% (10 of 86 patients). Of the 10 patients with coexisting cholangiocarcinoma in this study, diagnosis of the tumor was possible for only 3 patients. The removal of unpredictable cholangiocarcinoma is an advantage of hepatic resection over nonsurgical approaches.

In this study, of 17 patients who died during the follow-up period, 10 died from cholangiocarcinoma, and the development of cholangiocarcinoma was independently associated with poor survival after hepatic resection. Development of cholangiocarcinoma was a common cause of death in patients with hepatolithiasis even after hepatic resection.

Other associated articles Outcomes of Hepatectomy for Hepatolithiasis--World J Surg (2007) 31: 479–482 123 consecutive patients from 2000 to 2005 3 patients (2.4%) had associated cholangiocarcinoma at the time of hepatectomy. With a median follow-up of 40.3 months (range 5–58), a cholangiocarcinoma developed in 2 patients (1.6%). Hepatectomy is a safe and effective treatment for hepatolithiasis. Recurrent stone-induced sepsis and cholangiocarcinoma are the major factors compromising long-term survival in these patients

Immediate and long-term outcomes of hepatectomy for hepatolithiasis -- Surgery 2004;135:386-93 103 consecutive patients with hepatolithiasis who underwent hepatectomy from 1989 to 2001 10 patients (10%) had associated cholangiocarcinoma ( 4 known preoperatively) at the time of hepatectomy. With a median follow-up of 56 months (range 6-158), cholangiocarcinoma developed in 3 patients (range:7-30 months postoperatively).

Epidemiology; pathogenesis; and classification of cholangiocarcinoma In Taiwan, 50 to 70 percent of patients undergoing resection for cholangiocarcinoma have associated hepatolithiasis. Cholangiocarcinomas arising as a complication of hepatolithiasis should be suspected : > of 40 y/o a long history of hepatolithiasis weight loss elevated serum alkaline phosphatase carcinoembryonic antigen (CEA) level > 4.2 ng/mL hepatolithiasis in either the right or both lobes of the liver

結 論 （Conclusion） For patients with hepatolithiasis, in view of further development of cholangiocarcinoma, hepatectomy is a way to reduce the risk. A more precise way predict or diagnose cholangiocarcinoma in patient with hepatolithiasis is expected.

敬請指教