Hepatobiliary cancer

　　The etiology or risk factors of hepatobiliary cancer (HCCA) are not yet clear, and may be related to chronic biliary inflammation, such as primary biliary cirrhosis, choledochal cyst, bile duct stones, benign bile duct tumors, biliary parasitic diseases, hepatitis C, abnormal pancreatobiliary union, congenital bile duct cystic dilation, and chronic ulcerative colitis, all of which can increase the risk of developing biliary cancer.

　　Common postoperative complications:Patients with HCCA, in addition to hyperbilirubinemia, often have sepsis, malnutrition, anemia, hypoproteinemia, coagulation disorder, electrolyte disturbance, weakened immune function, infection, and damage to important organs such as the liver, kidney, and cardiovascular system. In addition, due to the large surgical trauma and multiple postoperative complications, it can directly lead to death in severe cases.

　　1. Massive abdominal hemorrhage

　　It often occurs in patients with combined lobectomy and intraoperative portal vein injury, and also occurs in bile-enteric anastomosis bleeding, with fresh blood drainage from the abdominal cavity exceeding 200ml/h, indicating active bleeding in the abdomen. Emergency surgery is required for hemostasis.

　　Prevention mainly focuses on accurate suture and hemostasis during surgery.

　　2. Bile fistula

　　The most common complication, often occurs due to improper management of bile ducts at the liver resection site or when the intrahepatic bile ducts are anastomosed separately with the jejunum, as there are many openings in the intrahepatic bile ducts, sometimes it is difficult to handle properly. Switching to bile duct shaping and anastomosis with the jejunum can reduce the occurrence of bile fistula. It can also occur at the site where the hepatic drainage tube exits the liver surface. Recent research has found that poor blood supply to the bile duct is an important factor in the occurrence of bile fistula. The blood supply of the high bile duct mainly comes from the cystic artery or the branches of the proper hepatic artery, and sometimes also from the right hepatic artery branches, and it runs axially along the bile duct, with about 60% of the blood flow from below to above, and about 40% from above. After resection of the tumor and extrahepatic bile duct, especially after ligation and resection of the right hepatic artery, the blood circulation at the anastomosis end of the bile duct will be affected, leading to poor healing of the anastomosis and the formation of a bile fistula. Research on bile duct blood supply will become a focal issue in hepatobiliary surgery. When freeing the bile duct during surgery, attention should be paid to preserving the blood supply on both sides and at the back of the bile duct, and there should be active arterial bleeding before the upper end of the bile duct is anastomosed.

　　3. Liver failure

　　Common causes of perioperative death, more common in patients with poor liver reserve function.

　　Prevention includes combining preoperative liver function assessment, correctly determining the extent of surgical resection, actively carrying out perioperative liver protection therapy, and trying to avoid using drugs that are harmful to liver and kidney function. Japanese scholars propose performing percutaneous transhepatic cholangiography and drainage (PTCD) before surgery to reduce serum bilirubin levels, which is beneficial for liver function recovery. However, many scholars are still concerned about the increased risk of infection complications, prolonged treatment time, and high incidence of complications, and advocate performing PTCD when the total serum bilirubin level is above 410μmol/L. After 4-6 weeks of jaundice reduction, surgery can be performed. Makuuchi proposes performing percutaneous portal vein embolization on the side to be resected before surgery, and performing the operation after 2-3 weeks when the opposite liver volume increases, which can increase the safety of hemihepatectomy or trilobectomy. Regularly review liver function and observe for signs of liver failure such as worsening jaundice, restlessness, drowsiness, etc.

　　4. Acute renal failure

　　It often occurs secondary to severe jaundice. Common causes include insufficient effective circulating blood volume, sympathetic nervous system activation, enhanced renin-angiotensin system activity, decreased renal prostaglandins, increased thromboxane A2, and endotoxemia. The characteristics are spontaneous oliguria or anuria, azotemia, dilute hyponatremia, and low urinary sodium.

　　Prevention: Intraoperative infusion of 100-250ml of 20% mannitol solution to maintain diuresis; if the urine output is less than 1500ml within 24 hours after surgery and the blood pressure is normal, 20mg of furosemide can be administered intravenously.

　　5. Stress ulcer hemorrhage

　　Severe complications after surgery in patients with severe obstructive jaundice

　　The pathogenesis has not been fully understood. It is generally believed that hyperbilirubinemia and hyperbilirubinemia destroy the gastric mucosal barrier and reduce the blood flow of the gastric mucosa. At the same time, patients often have complications such as infection, sepsis, malnutrition, and large surgical trauma can lead to low perfusion of the gastric mucosa, forming mucosal ulcers and bleeding, and severe cases can lead to perforation.

　　Prevention: correct anemia before surgery, supplement blood volume, anti-infection treatment, routine application of H2 receptor antagonists after surgery, emergency fiberoptic gastroscopy when there is gastrointestinal bleeding, local hemostasis at the same time for diagnosis. At the same time, switch to proton pump inhibitors, and most conservative treatments can be cured. If the bleeding is severe, surgical treatment is required.

　　In summary, strengthening the support of organ function during the perioperative period, preventing and treating infection should be the main measures to reduce perioperative complications, which can reduce complications and mortality.

　　First, high-incidence population

　　Hepatic porta bile duct cancer is prevalent in middle-aged and elderly people aged 50 to 70, with the highest incidence around 60 years old, and is a disease of the elderly.

　　Second, disease symptoms

　　Hepatic porta bile duct cancer, due to its special location, often has no specific clinical manifestations before the bile duct is completely blocked by the tumor, and it is not easy to attract the attention of patients or surgeons. The early clinical symptoms of HCCA are mostly anorexia, decreased appetite, aversion to greasy food, dyspepsia, and upper abdominal fullness and discomfort, with some patients experiencing recurrent biliary tract infections. With the progression of the disease, obstructive jaundice symptoms and signs may appear, but the most noticeable symptoms for patients are progressive jaundice, pruritus, and weight loss, which are characteristic clinical signs of HCCA.

　　1. Jaundice

　　Cholangiocarcinoma patients often lack typical symptoms in the early stage, and most patients seek medical attention due to jaundice. Jaundice is the earliest and most important symptom of cholangiocarcinoma, with about 90% to 98% of cholangiocarcinoma patients showing varying degrees of yellowing of the skin and sclera. The characteristic of jaundice is progressive worsening, and it is mostly painless, with a few patients showing fluctuating jaundice. The jaundice of upper cholangiocarcinoma appears earlier, while the middle and lower cholangiocarcinoma may appear later due to the buffering effect of the gallbladder. However, in fact, before the onset of jaundice, patients often have a period of non-specific 'gastric' symptoms such as upper abdominal fullness, aversion to greasy food, decreased appetite, and weight loss. These symptoms are often misdiagnosed as 'chronic gastritis' or 'chronic cholecystitis' due to atypical symptoms. Some patients may still be misdiagnosed as 'icteric hepatitis' even if they have jaundice symptoms.

　　2. Abdominal pain

　　About half of the patients have right upper quadrant pain, distension, or discomfort, weight loss, loss of appetite, and other symptoms, which are often considered as early warning signs of cholangiocarcinoma. The pain in the abdomen begins with a pain similar to cholelithiasis or cholecystitis. According to clinical observations, cholangiocarcinoma can cause abdominal pain and jaundice within 3 months of onset.

　　3. Skin itching

　　It can appear before or after the onset of jaundice, and may be accompanied by other symptoms such as tachycardia, tendency to hemorrhage, mental fatigue, weakness, steatorrhea, abdominal distension, and skin itching. Skin itching is caused by an increase in bilirubin content in the blood, which stimulates the terminal nerves of the skin.

　　4, others

　　With symptoms such as jaundice, abdominal pain, there may also be nausea, vomiting, weight loss, deep yellow urine like soy sauce or strong black tea, pale yellow or even clay-colored stools, etc. In the late stage, when the tumor ulcerates, black stools may appear with biliary bleeding, positive fecal occult blood test, and even anemia; liver enlargement and liver cirrhosis may appear if there is liver metastasis.

　　Three, the relationship between clinical symptoms and clinical classification

　　The study of the relationship between the clinical symptoms and clinical classification of HCCA is of great significance for the early diagnosis of the disease. Anatomically, the right hepatic duct is shorter and almost vertical; the left hepatic duct is thin and long, almost horizontal. The average length of the adult right hepatic duct is 8.8mm, with a diameter of 3.5mm; the average length of the left hepatic duct is 14.9mm, with a diameter of 3.3mm. Due to the shortness and thickness of the right hepatic duct, and the angle of about 129° with the common bile duct, bile drainage is relatively smooth; while the left hepatic duct forms an angle of about 100° with the common bile duct, so bile drainage may be slower, and bile duct dilatation is more likely to occur due to stricture of the hepatic duct.

　　The duration of non-specific symptoms in the upper abdomen before the appearance of jaundice varies depending on the distance of the cholangiocarcinoma from the bifurcation of the bile duct. For cancer originating from the left hepatic duct at the porta hepatis, the distance from the bifurcation of the bile duct is still a certain distance, so the duration of symptoms before jaundice is longer.

　　In clinical practice, the duration of jaundice in many patients may be very short, but when undergoing imaging examination or surgical exploration, it is found that the tumor has already metastasized to the hilar region and invaded the main blood vessels. This situation is more common in type III and IV lesions, as the tumor begins in the left or right hepatic duct, and the healthy side has sufficient compensatory ability to secrete bile, so jaundice does not appear clinically. With the passage of time, the appearance of jaundice may be due to the extension of the cancer tissue along the bile duct, invasion of the contralateral hepatic duct, or obstruction of the common bile duct. It may also be due to the metastasis of cancer cells to the porta hepatis, compression of the extrahepatic bile duct or metastatic invasion of the hilar region compressing the common bile duct, leading to jaundice.

　　The early clinical symptoms of I, II type hilar cholangiocarcinoma are early obstructive jaundice; III, IV, V type have different clinical manifestations. It is especially noteworthy that cancer starting from one side of the hepatic duct has no jaundice in the early stage. By the time jaundice appears, it has already invaded and metastasized outside the bile duct, and the lesion has reached an advanced stage. In addition, 64%-70% of HCCA are sclerotic, and their biological characteristics are early infiltration around the bile duct wall. For I, II type hilar cholangiocarcinoma, obstructive jaundice is not necessarily an early symptom of HCCA.

　　The radical resection of hilar cholangiocarcinoma is significantly better than palliative resection, and palliative resection is better than simple drainage. Therefore, for suspected or confirmed cases, except for those with clear surgical contraindications, active surgical exploration should be performed to strive for radical resection. For those who cannot undergo surgery, active PTCD, ENBD drainage, or interventional methods should be used to place stents through PTCD and ERCP to prolong life and improve the quality of life. With the clinical promotion of expanded radical surgery, the resection range is large, the surgical risk is high, the postoperative complications increase, and the mortality rate is high.

　　1. Laboratory examination:It mainly manifests as liver function abnormalities with obstructive jaundice, such as increased bilirubin and alkaline phosphatase levels.

　　2. Ultrasound examination:Repeated and careful ultrasound examinations can show dilated bile ducts, the site of obstruction, and even tumors. The ultrasound image of bile duct cancer can present as mass-like, string-like, prominent, and thrombosis-like. Hepatic bile duct cancer often presents as a mass or string-like, hilar cancer often as string-like, lower bile duct cancer often as prominent, and the thrombosis-like echo in the hilar region may be hilar cancer. Gallbladder cancer or metastatic cancer, as the bile duct dilation occurs before jaundice, ultrasound has the value of diagnosing early bile duct cancer.

　　3. PTC:It is the main method for diagnosing bile duct cancer, which can show the location and range of bile duct cancer, with a diagnostic accuracy of 94% to 100%.

　　4. CT:The CT manifestations of bile duct cancer are mainly as follows: ⑦ The proximal bile duct of bile duct cancer is obviously dilated, the bile duct wall near the tumor is thickened, and the bile duct is clearer and can be enhanced during enhanced scanning, showing irregular narrowing and deformation of the lumen. Soft tissue density tumor shadows can generally be found, with a CT value of 50Hu, and the CT value enhanced during enhanced scanning is 60-80Hu. ② Most of the tumors grow infiltratively along the bile duct wall, with thickened bile duct wall and unclear edges, which can be enhanced and easily displayed during enhanced scanning. A few present polypoid or nodular growth inward, and the nodules are soft tissue density. ③ The tumor infiltrates and expands into the cavity, with blurred wall edges, often invades the gallbladder and liver, adjacent blood vessels and lymphatic tissues, showing inhomogeneous soft tissue shadows with irregular shape, blurred tissue structure, and unclear boundaries.

　　5. ERCP:It can directly observe the duodenal papilla, and the contrast can show the distal bile duct of the obstruction.

　　6. Angiography:Angiography can better determine whether bile duct cancer can be resected.

　　7. Cytological examination:Expanding the sinus tract insertion of a fiber bile duct scope on the basis of PTCD can directly observe and remove the mass for biopsy, and bile can be extracted for cytological examination during PTC or PTCD.

　　Firstly, foods that should be avoided

　　1. Avoid animal fats and greasy foods.

　　2. Avoid overeating and overeating.

　　3. Avoid smoking, drinking, and spicy刺激性 foods.

　　4. Avoid moldy, fried, smoked, and salted foods.

　　5. Avoid hard, sticky, and difficult-to-digest foods

　　Secondly, foods that should be eaten

　　1. Foods with anti-bile duct and bile duct cancer effects should be consumed more: shark fin, chicken gizzard, buckwheat, Job's tears, tofu dregs, and mushroom.

　　2. Foods with anti-infection and anti-cancer effects should be consumed more: buckwheat, mung beans, rapeseed, toon, taro, scallion whites, bitter melon, lily, malan tou, earth ear, crucian carp, water snake, shrimp, loach, jellyfish, yellow croaker, and needlefish.

　　3. Foods with a beneficial effect on bile duct and defecation should be consumed: goat's foot, burdock root, figs, walnuts, sesame seeds, chrysanthemum flowers, and sea cucumber.

　　4. It is recommended to eat plums, yam, Job's tears, radish, snakehead fish, and gongcai for poor appetite.

　　6. Vegetables and fruits rich in vitamin A and vitamin C, fish, and seafood can help clear bile and dampness, dissolve gallstones, and should be eaten more. Living a regular life, combining work and rest, regularly participating in sports activities, eating breakfast on time, avoiding obesity, and reducing the number of pregnancies are also very important preventive measures. Drinking a glass of milk every night or eating a fried egg for breakfast can make the gallbladder contract regularly, empty, and reduce the stay time of bile in the gallbladder.

　　5. When jaundice appears, it is necessary to avoid greasy food, ensure adequate intake of dietary fiber every day, must abstain from alcohol and smoking, adjust total calories according to physical activity to maintain balance, and consciously choose some foods with auxiliary anticancer effects, such as seaweed, carrots, mushrooms, asparagus, golden flower, tomatoes. Note that improving dietary habits and cooking methods is also important when eating, and maintaining a pleasant mood while eating.

　　Currently, there are many methods for the treatment of hilar bile duct cancer, including surgical resection, chemotherapy, radiotherapy, immunotherapy, biological therapy, traditional Chinese medicine treatment, and interventional treatment, but the most effective method is still surgical resection.

　　1. Radical resection

　　With the development of imaging diagnostic technology, the advancement of surgical techniques, and the change of treatment attitude, the resection rate of the disease has significantly increased. Before 1985, the resection rate of the disease accounted for only 10%, while currently the resection rate can reach 64.1%. Hilar bile duct cancer can only be cured by complete surgical resection, which can provide the only possible opportunity for cure for patients, and its effect on improving the quality of life of patients is far superior to various drainage procedures. Therefore, a positive surgical attitude should be adopted for the treatment of hilar bile duct cancer, and efforts should be made to resect the tumor.

　　Radical resection surgery includes resection of extrahepatic bile ducts, 'skeletonization' of the vascular ligament of the porta hepatis, extensive resection of fibroadipose tissue, nerves, and lymph nodes on the duodenal ligament, and resection of one lobe of the liver if necessary, and reconstruction of bile duct jejunal anastomosis. Hilar bile duct cancer often has infiltration of the caudate lobe, invasion of the confluence or left and right bile ducts, and the caudate lobe must be resected. It is considered that whether the caudate lobe is resected is one of the main related factors affecting the long-term survival of hilar bile duct cancer patients.

　　Nagino et al. advocate for the treatment of segmental resection + caudate lobe resection, reporting 193 cases. Among them, 138 cases underwent tumor resection, including 124 cases with segmental and caudate lobe resection, 41 cases with portal vein resection, and 16 cases with liver, pancreas, and duodenum resection. The in-hospital mortality rate was 9.9% (12 cases), 97 cases were cured by resection, and the 3-year survival rate was 42.7%; the 5-year survival rate was 25.8%. It is believed that active liver resection can improve the prognosis based on the correct estimation of the extent of invasion.

　　2. Palliative surgery

　　1. Anastomosis of the left intrahepatic bile duct with the jejunum

　　Generally, an expanded left lateral bile duct is found on the left side of the falciform ligament, which is anastomosed with the jejunum. This method of surgery is relatively simple, but it can only drain the left half of the liver, and most of the inoperable hilar bile duct cancers in our hospital use this method or combined with U-tube drainage. Through the side holes of the U-tube, it can drain the bile ducts of the whole liver to reduce jaundice.

　　2. Right hepatic intrahepatic bile duct jejunal anastomosis

　　In recent years, many scholars have adopted the right hepatic duct-gallbladder-jejunum anastomosis. This internal drainage operation does not require separation of the gallbladder, has minimal trauma, and the surgery is also relatively simple.

　　3. Catheter drainage

　　The biliary stent directly supports the narrowed bile duct segment of the tumor, and the bile juice near the obstruction is transported through the patient's own bile duct to achieve internal drainage. The methods for placing biliary stents include: percutaneous transhepatic cholangiography (PTD) placement of internal stent, endoscopic retrograde cholangiopancreatography (ERCP) placement of internal stent, placement of internal stent during laparotomy, and placement of internal stent using interventional methods through external drainage tubes. In recent years, with the development of interventional treatment technology, the placement of memory alloy stents for drainage through percutaneous transhepatic cholangiography or laparotomy through the common bile duct into the intrahepatic bile duct has achieved good effects. The alloy stent passes through the tumor above and below, allowing the obstructed bile juice to flow into the lower segment of the bile duct through the stent and enter the duodenum. However, memory alloy stents are expensive, and it is generally difficult for general hospitals at the grassroots level to carry out.

　　Third, in situ liver transplantation (OLT)

　　Hilar bile duct cancer has the characteristics of intrapulmonary metastasis, slow growth, and late extrapulmonary metastasis, so some scholars propose that it can be a good indication for liver transplantation. The specific method is to select in situ liver transplantation, bile duct reconstruction, and perform Roux-Y anastomosis between the common bile duct and the recipient jejunum to maximally resect the patient's proximal bile duct and prevent recurrence.

　　The indications for liver transplantation for hilar bile duct cancer are:

　　1. Patients diagnosed with stage II according to the International Union Against Cancer (UICC) staging system, who cannot be resected by laparotomy.

　　2. Those who are planned for R0 resection but can only achieve R1 or R2 resection due to central infiltration of the tumor (R0 resection: no cancer cells at the margin; R1 resection: cancer cells visible under the microscope at the margin; R2 resection: cancer cells visible to the naked eye at the margin).

　　3. Local recurrence in the liver after surgery. Foreign reports show that there is no significant difference in survival rate between those undergoing total liver resection and liver transplantation in situ and those undergoing radical resection, and even some are better than radical resection.