| BackgroundExtrahepatic cholangiocarcinoma includes hilar cholangiocarcinoma and distal cholangiocarcinoma.The prognosis of extrahepatic cholangiocarcinoma was poor.Radical surgical resection is the only possible means of long-term survival for cholangiocarcinoma.Radical surgery for extrahepatic cholangiocarcinoma is characterized by high trauma,high difficulty,long time and high incidence of postoperative complications.It is necessary to avoid non-radical surgery through accurate preoperative evaluation.Extrahepatic cholangiocarcinoma is prone to non-radical resection because of its multipolar infiltration and its growth along the mucosa surrounding the main lesion.Preoperative evaluation of the extent of tumor invasion determines the resectability assessment and surgical planning,especially the longitudinal extent of tumor invasion along the bile duct wall.At present,the preoperative evaluation mainly performed by imaging is insufficient for the evaluation of the longitudinal invasion range of bile duct.As an auxiliary examination method of endoscopic retrograde cholangiopancreatography(ERCP),digital single-operator peroral cholangioscopy(DSOC)can directly observe the bile duct mucosa.Preoperative mapping of longitudinal invasion of bile duct wall in extrahepatic cholangiocarcinoma using DSOC is referred to as DSOC biliary tract mapping.Some studies have initially confirmed the feasibility of DSOC biliary tract mapping technology,but the sample size is too small(less than 10 cases),and the impact on resectability and surgical protocol has not been studied.Based on the above background,We preliminatively verified the safety and success rate of DSOC biliary tract mapping based on direct vision diagnosis in our department,clarified the accuracy of the mapping,and analyzed the influence of the technology on the treatment plan.It is further hypothesized that DSOC biliary tract mapping technology can make up for the shortcomings of traditional imaging,and improve the accuracy of the assessment of longitudinal invasion extent of extrahepatic cholangiocarcinoma based on imaging,so as to avoid some non-radical surgery and improve the R0 resection rate.MethodsPart Ⅰ Clinical data of 52 patients with extrahepatic cholangiocarcinoma who used DSOC biliary tract mapping based on direct vision diagnosis during preoperative evaluation in our department from December 1,2017 to April 1,2022 were collected..The feasibility and safety of DSOC biliary tract mapping were preliminarily verified according to each patient’s DSOC operation and postoperative complications.Taking the pathology after radical resection as the gold standard,the accuracy of DSOC mapping the longitudinal invasion extent of extrahepatic cholangiocarcinoma was clarified.The influence of DSOC biliary tract mapping on resectability judgment and surgical plan was analyzed according to the reasons for choosing the final treatment for each patient.Part Ⅱ Propensity score matching and retrospective cohort study were used.From December 1,2017 to April 1,2022,52 patients with extrahepatic cholangiocarcinoma who underwent DSOC biliary tract mapping during preoperative evaluation in our department were selected as DSOC group.In order to analyze the influence of DSOC biliary tract mapping on the accuracy of preoperative evaluation,it is necessary to compare with patients who did not undergo DSOC biliary tract mapping in preoperative evaluation.From January1,2019 to April 1,2022,all 843 patients with extrahepatic cholangiocarcinoma who underwent preoperative evaluation with conventional imaging(MDCT,MRI/MRCP)and did not undergo DSOC examination were selected as the non-DSOC group.Propensity score matching was used to ensure that the tumor extent was consistent between the two groups on imaging assessment.RStudio software(2009-2022 RStudio,PBC)was used for matching,and matching was performed according to the 1:1 nearest matching method.The matching parameters were the range of longitudinal invasion of the bile duct on imaging,whether the vessels were invaded on imaging,whether the lymph nodes were enlarged on imaging,and whether bile drainage was performed before surgery,The caliper value is 0.02Propensity-score matching was used to determine the patients who were finally compared between the two groups.The intraoperative and postoperative conditions of the two groups were compared after matching.According to the comparison results,the influence of DSOC biliary tract mapping technology on R0 resection rate was discussed.ResultsPart Ⅰ DSOC was able to reach the target observation site,and 19 patients(36.5%)used biliary column dilatation balloon to dilate the stenotic bile duct.Of the 52 patients,42(80.7%)observed the confluence of the right anterior and posterior bile ducts,44(84.6%)observed the confluence of B4 or B2/B3,and all patients observed the confluence of the left and right hepatic ducts and the internal pancreatic duct.Postoperative complications occurred in 6 patients(11.5%),including cholangitis in 4 patients,pancreatitis in 1 patient and biliary hemorrhage in 1 patient.All patients returned to normal after symptomatic treatment without severe or above complications.All six underwent biopsy of the lesion site.The overall specificity,sensitivity and accuracy of DSOC alone were 85.7%,93.1% and90.7%,respectively.Of the 52 patients,19(37%)had radical surgery,6(11%)had palliative surgery,and 27(52%)had no surgery.Among the 27 patients without surgical treatment,12(44.4%)patients were confirmed as uncut by DSOC biliary tract mapping and chose palliative care.The remaining 6 patients refused surgery,5 patients did not tolerate surgery due to systemic conditions,and 4 patients lost the opportunity for surgery due to tumor progression during bile drainage.Of the 19 patients who underwent radical resection,4(21.1%)had their surgical plan changed because of DSOC biliary mapping.In 2 patients,the scope of operation was enlarged because the lower end of the common bile duct was clearly invaded under the cholangioscopy.Postoperative pathology also confirmed the invasion of the lower end of the common bile duct.In one patient,the right anterior and right posterior bile duct openings were clearly invaded under the cholangioscopy,and the surgical scope was enlarged.Postoperative pathology also confirmed the invasion of the right anterior and right posterior bile duct openings.In 1 patient,the lower end of the common bile duct was clearly normal under the cholangioscopy,and the scope of operation was reduced.Postoperative pathology also confirmed that the lower end of the common bile duct was not invaded.Part Ⅱ Propensity score matching was used to ensure that the two groups had the same tumor size on imaging assessment.A total of 30 pairs were matched successfully.In the DSOC group,R0 was resected in 16 patients,R2 was resected in 4 patients,and 10 patients were unresectable as assessed by DSOC.In the non-DSOC group,30 patients were resectable on conventional imaging,including 18 patients with R0 resection,6 patients with R1 resection,and 6 patients with R2 resection.There was no significant difference in preoperative yellow reduction time,vascular resection and reconstruction,operation time,blood loss,blood transfusion,postoperative hospital stay,and postoperative serious complications between the two groups.In the DSOC group,1 out of 4 patients with non-R0 resection was associated with the extent of bile duct invasion(1/4 25%).In the non-DSOC group,9 of 12 patients with non-R0 resection were related to the extent of bile duct invasion(9/12 75%).The difference between the two groups was statistically significant(P=0.000).Conclusions:In preoperative evaluation of extrahepatic cholangiocarcinoma,DSOC can be used to accurately map the longitudinal invasion range of extrahepatic cholangiocarcinoma by means of direct microscopic diagnosis.DSOC biliary tract mapping technology can affect the judgment of resectability and specific surgical plan of extrahepatic cholangiocarcinoma.The inclusion of DSOC biliary tract mapping technology on the basis of imaging evaluation can improve the accuracy of preoperative evaluation,reduce the non-R0 resection caused by the extent of bile duct invasion,avoid partial non-radical resection,and thus improve the R0 resection rate. |
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