Analysis of the caudate artery with three-dimensional imaging

Background/purpose

To date there have been only a few radiological studies of the caudate artery. This study aimed to precisely analyze the caudate artery as well as the relationship between the caudate arteries, the arterial plexus at the hilar plate, and the hilar bile duct.

Methods

Reconstructed three-dimensional (3D) computed tomography images from 50 patients during hepatic arteriography were analyzed. The caudate arteries were classified as right branches (Irs) or left branches (Ils). The communicating artery (CA) was defined as the artery connecting the right, left, segmental, and common hepatic arteries.

Results

The caudate artery was divided into 3 types: an independent branch (Type 1); the common tract formed by Ir and Il (Type 2); and an arterial branch from the CA (Type 3). The CA was recognized in 25 of 50 patients. There was a total of 65 arteries to the hilar bile duct observed in 40 patients, and 24 (37 %) of these 65 arteries to the hilar bile duct originated from the caudate artery or CA.

Conclusion

The caudate artery plays an important role not only in connecting the blood supply of the right and left livers but in the blood supply to the hilar bile duct.     

Efficacy of only left side approach in a case of unsuccessful reconstruction of the right hepatic artery after left hepatic lobectomy with caudal lobectomy

We report two cases that underwent extended left hepatic lobectomy combined with resection of the caudate lobe and extrahepatic bile duct only from the left side approach for hilar cholangiocarcinoma. The first case was a 54-year-old man and the second one was a 63-year-old man. Both patients had hilar cholangiocarcinoma with predominant left hepatic duct involvement and required resection and reconstruction of the right hepatic artery as well as left hepatic lobectomy. In both cases, the right hepatic lobe was never mobilized to protect the mechanical damage in the remnant liver and keep co-lateral blood supply route to the remnant liver from the diaphragm or retroperitoneum. Although arterial blood flow to the remnant right hepatic lobe was unfortunately insufficient after reconstruction of the right hepatic artery, the postoperative course was uneventful. The postoperative angiography showed co-lateral arterial blood supply to the right lobe via the subdiaphragmatic artery. In case of extended left hepatic lobectomy combined with resection of the caudate lobe and right hepatic artery, ipsilateral approach (approach only from the left side) is recommended.     

Anatomy of the hepatic hilar area: the plate system

To surgically manage hilar bile duct carcinoma successfully, it is important to be familiar with the principal anatomical variations of the biliary and vascular components of the plate system in the hepatic hilar area, because all the variations in the bile ducts and vessels occur in the plate system. The plate system consists of bile ducts and blood vessels surrounded by a sheath. There are three plates in the hilar area: the hilar plate, the cystic plate, and the umbilical plate. The bile duct and blood vessel branches penetrate the plate system and form Glisson's capsule in all segments of the liver, except for the medial segment. The right hepatic duct is usually (in 53%–72% of individuals) formed by the union of the anterior segmental duct and the posterior segmental duct in the hilar area. However, three other variations have been found in which these segmental ducts do not form the right hepatic duct. Few anatomical variations have been identified in the left hepatic duct, but confusion arises because of the variations in the medial segment ducts (B4) which join the left hepatic duct at different sites. In 35.5% of individuals they join the hepatic duct in the vicinity of the hilar confluence (type I B4 anatomy), and in 64.5% of individuals they join the left hepatic duct some distance away from the confluence (type II B4 anatomy). Because B4 is very close to the hilar confluence in type I, hilar bile duct carcinoma can easily invade B4 and, for that reason, for curative resection of hilar bile duct carcinoma, resection of S4a (the inferior part of the medial segment) should be considered along with the resection of extrahepatic bile duct and caudate lobe. Variations in the portal vein and hepatic artery are found in 16%–26% and 31%–33% of individuals, respectively. Because a considerable number of anatomical variations in the bile ducts and vessels persist in the hilar area, and the reported proportions of the different variations vary, it is necessary to have a good knowledge of the plate system and the variations in the bile ducts and blood vessels in the hilar area to perform safe and curative surgery for hilar bile duct carcinoma.     

Surgical anatomy of the medial segment (S4) of the liver with special reference to bile ducts and vessels

BACKGROUND/AIMS: Resection of the inferior area of the medial segment (S4a) plus S5 with preservation of the superior area of the medial segment (S4b) is being performed to manage hilar bile duct carcinoma and pT2 type gallbladder carcinoma, and thus, attention has been focused on the surgical anatomy of the medial segment of the liver to identify the specific vessels and bile ducts of the areas of that segment to be resected and to be preserved. METHODOLOGY: Anatomical study of the bile duct, portal vein, middle hepatic vein, and middle hepatic artery to the medial segment branches of the liver (S4) was performed in a total of 171 specimens comprised of 71 adult cadavers, and 100 liver casts. RESULTS: 1) Two main types of bile duct branches of the medial segment (B4) were recognized. Type I included the branches which joined to the left hepatic duct on the hilar duct side (35.5%), and type II included the branches that joined on the peripheral side (54.6%). Several subtypes were also found in both types. The B2-B3 confluence was mostly on the left (41.7%) or posterior (42.7%) to the umbilical portion (UP) of the portal vein, and to the right of the UP (hilar side) in only 15.6%. 2) The portal vein of the medial segment branches (P4): P4a branched from the right angle and upper right border of the UP in every specimen. The most common morphology was 1 large and 2-3 small branches (41%). P4b was almost always found to branch posterior to the UP and lower than P4a, and the most common morphology was 1 large and 0-1 small branches (57.8%). 3) The middle hepatic vein: In 83.2% a common trunk was observed at the confluence with the inferior vena cava, and 8 types of the middle hepatic vein were recognized. 4) The middle hepatic artery: It arose from the left hepatic artery in 61.5%, from of the right hepatic artery in 27.5%, from the proper hepatic artery in 5.5%, and from both the left and the right hepatic artery in 5.5%. CONCLUSIONS: The detailed vascular and bile duct anatomy of S4 is described. This study should be helpful in identifying the specific vessels and bile ducts of the areas of the medial segment to be resected and to be preserved, thereby facilitating resection of the medial segment.     

The right hepatic artery syndrome

Various benign and malignant conditions could cause biliary obstruction. Compression of extrahepatic bile duct (EBD) by right hepatic artery was reported as a right hepatic artery syndrome but all cases were compressed EBD from stomach side. Our case compressed from dorsum was not yet reported, so it was thought to be a very rare case. We present here the first case of bile duct obstruction due to the compression of EBD from dorsum by right hepatic artery.     

Safety of combined resection of the middle hepatic artery in right hemihepatectomy for hilar biliary malignancy

Background/purpose

In patients with hilar biliary malignancies, preservation of the middle hepatic artery (MHA, segment IV artery) where it runs close to the tumor in the hepatic hilum may lead to resection with positive margins. This retrospective study assessed the safety of combined resection of the MHA with right hemihepatectomy, caudate lobectomy, and bile duct resection for hilar biliary malignancies.

Methods

Of 61 patients with hilar biliary malignancies who underwent right hemihepatectomy, we classified the branching patterns of the MHA according to the origins and courses in the hilum. The MHA was resected without reconstruction in 16 patients in whom the artery ran close to the tumor. We compared the perioperative outcomes in these patients with those of patients who did not undergo resection of the artery.

Results

Anatomically, the MHA ran on the right side of the umbilical portion of the portal vein in 40 (66%) patients. Perioperative data for the patients who underwent combined resection were similar to those in whom the MAH was preserved. There were no postoperative complications that could be directly related to the arterial resection.

Conclusions

Combined resection of the MHA during right hemihepatectomy for hilar biliary malignancies has a safe perioperative course.     

First jejunal artery,an alternative graft for right hepatic artery reconstruction

Common bile duct cancer invading right hepatic artery is sometimes diagnosed intraoperatively. Excision andsafe reconstruction of the artery with suitable graft is essential. Arterial reconstruction with autologous saphenous vein graft is the preferred method practiced routinely. However the right hepatic artery reconstruction has also been carried out with several other vessels like gastroduodenal artery, right gastroepiploic artery or the splenic artery. We report a case of 63-year-old man presenting with history of progressive jaundice, pruritus and impaired appetite. Following various imaging modalities including computed tomography, endoscopic retrograde cholangiopancreatography, magnetic resonance cholangiopancreatography, intraductal ultrasound extrahepatic bile duct cancer was diagnosed; however, none of those detected vessel invasion. Intraoperatively, right hepatic artery invasion was revealed. Right hepatic artery was resected and reconstructed with a graft harvested from the first jejunal artery(JA). Postoperative outcome was satisfactory with a long-term graft patency. First JA can be a reliable graft option for right hepatic artery reconstruction.     

Procedure of extended hilar bile duct resection and its application for hilar cholangiocarcinoma

BACKGROUND/AIMS: Several surgical procedures from hilar bile duct resection to hepatectomy have been adopted for hilar cholangiocarcinoma. However the details of the surgical procedure and the indications for hilar bile duct resection have not been determined. METHODOLOGY: Pathohistological outcome of resected specimens in five patients undergoing extended hilar bile duct resection was reviewed and compared with 12 patients undergoing partial hepatectomy with caudate lobectomy. RESULTS: Extended hilar bile duct resection was used for older patients, cases of choledochal site and less invasive tumor. The mean lengths of the left hepatic duct (21.7 +/- 7.8 mm) and the anterior hepatic duct (18.0 +/- 3.2 mm) in the specimens resected by extended hilar bile duct resection did not differ from those seen in right and left hepatectomy, respectively. Furthermore, extended hilar bile duct resection removed partial caudal hepatic duct. However the length of the posterior hepatic duct removed by extended hilar bile duct resection (14.3 +/- 2.0 mm) was significantly less than that excised in left hepatectomy (19.3 +/- 6.6 mm) (P < 0.05). The histologic positive margin rate of the extended hilar bile duct resection group (40%) was the same as that of the hepatectomy group (50%). Papillary or nodular form tumor tended to have positive ductal margins in both surgical techniques. On the other hand, flat tumor tended to have high positive rates in both ductal and excisional margins even in hepatectomy. Two cases with positive surgical margin died of local recurrences, however another 3 cases with negative surgical margin are alive without recurrences from 8 to 20 months after surgery. CONCLUSIONS: The indication of extended hilar bile duct resection for hilar cholangiocarcinoma is limited to cases in which the infiltration is confined to the hepatic bifurcation, such as type I and type II of Bismuth classification with regard to papillary and nodular macroscopic appearance.     

Hepatectomy and pylorus-preserving pancreatoduodenectomy with reconstruction of the hepatic artery,using the middle colic artery,for bile duct carcinoma: A case report

To curatively resect advanced bile duct carcinoma which spread from the hilus to the intrapancreatic bile duct and invaded the portal vein and the hepatic artery, left hepatic lobectomy, caudate lobectomy, hepatoduodenal ligamenteetomy, and pylorus-preserving pancreatoduodenectomy were performed. The hepatic artery was reconstructed by anastomosis of the middle colic artery to the right hepatic artery, and the portal vein was also reconstructed. Gastro-intestinal reconstruction was performed using Traverso's procedure. The patient had a relapsing liver abscess post-operatively and hospital stay was therefore prolonged. However, she was discharged. 3 months after the surgery. A histological study showed that this operation made it possible to remove the entire cancerous lesion in advanced bile duct carcinoma.     

Mass-forming inflammatory periductal fibrosis mimicking hilar bile duct carcinoma

A case of a rare benign biliary lesion at the hepatic hilum mimicking hilar bile duct carcinoma is reported. A 73-year-old man was found to have gastric cancer by gastrointestinal fiberscopy. Dilated right intrahepatic bile ducts and a 2-cm mass in the right hepatic duct were demonstrated by further imaging investigations. He was finally diagnosed as having hilar bile duct and gastric carcinomas, and underwent right portal vein embolization followed by a single-stage extended right hepatectomy and total gastrectomy. Pathologically, however, the lesion in the right hepatic duct showed inflammatory changes with periductal fibrosis, without any signs of malignancy. A literature search revealed 11 such cases including the present one.     

Extended right hepatectomy for hilar bile duct carcinoma using the modified liver hanging maneuver

To achieve complete extended right hepatectomy or trisectionectomy for a bismuth type IV hilar bile duct carcinoma, we propose the application of Belghiti's liver hanging maneuver (LHM) using a small nasogastric tube. This small nasogastric tube was placed in the cut plane: the top of the tube was placed between the hepatic veins. The tube was placed along the border between the left lateral sector and Spiegel's caudate lobe and the bottom of the tube was placed at the left side of the umbilical Glissonian pedicle. Hepatic parenchyma was transected using a vascular sealing device. Hepatic transection was always targeted to the tube and, eventually, a cut line of left hepatic ducts remained. We report the case of a 76-year-old female and an 83-year-old female with widely extended hilar bile duct carcinomas showing Bismuth type IV. Applying the modified LHM for extended right hepatectomy, the cut planes were easily and adequately obtained in patients with hilar bile duct carcinoma.     

Right hepatic lobectomy for bile duct injury associated with major vascular occlusion after laparoscopic cholecystectomy

A 57-year-old woman underwent laparoscopic cholecystectomy (LC) for cholelithiasis. Continuous bile leak was observed beginning on the first postoperative day. Postoperative endoscopic retrograde cholangiography revealed bile leak through the common hepatic duct, and severe stenosis of the hepatic confluence. A total of three percutaneous transhepatic biliary drainage (PTBD) catheters were inserted to treat obstructive jaundice and cholangitis. The patient was referred to our hospital for surgery 118 days after LC. Cholangiography through the PTBD catheters demonstrated a hilar biliary obstruction. Celiac arteriography revealed obstruction of the right hepatic artery, and transarterial portography showed occlusion of the right anterior portal branch. On the basis of the cholangiographic and angiographic findings, we performed a right hepatic lobectomy with hepaticojejunostomy to resolve the bile duct obstruction and address the problem of major vascular occlusion. The patient's postoperative recovery was uneventful and she remains well 25 months after hepatectomy. We discuss a treatment strategy for bile duct injury suspected after LC, involving early investigation of the biliary tree and prompt intervention.     

Left hepatectomy or left trisectionectomy with resection of the caudate lobe and extrahepatic bile duct for hilar cholangiocarcinoma (with video)

Purpose

Although left-sided hepatectomy, such as a left hepatectomy or left trisectionectomy with resection of the caudate lobe and extrahepatic bile duct, is used to treat hilar cholangiocarcinoma predominantly involving the left side of the hepatic hilum, it is associated with several difficult technical points. The important points during left-sided hepatectomy are described here.

Techniques

There are anatomical variations of the sectional artery and bile duct. It is essential to understand the individual intrahepatic and hilar anatomy preoperatively. Surgical procedures consist of lymph node clearance, dissection of the distal bile duct, skeletonization resection of the hepatoduodenal ligament, mobilization of the liver and liver resection, dissection of the intrahepatic bile ducts, and biliary reconstruction. During lymph node dissection and skeletonization resection of the hepatoduodenal ligament, the nerve plexus around the hepatic artery is dissected, and its adventitia is exposed with great care to avoid injuring the hepatic artery. Mobilization of the caudate lobe is performed only from the left side. There is no clear landmark between the caudate lobe and the right posterior section during liver resection. In the final step of liver resection, it progresses toward the right edge of the inferior vena cava. When dividing intrahepatic bile ducts, extreme care should be used to avoid injury to the corresponding hepatic arteries, especially the anomalous supraportal posterior sectional artery.

Conclusions

Left-sided hepatectomy for hilar cholangiocarcinoma should be considered a more complicated and technically demanding procedure than right-sided hepatectomy. Surgeons need to pay close attention to anatomical variations in order to perform a left-sided hepatectomy safely and successfully.     

64排螺旋CT在肝外胆管癌诊断中的临床应用

目的探讨64排螺旋CT三期增强扫描和三维重建在肝外胆管癌中的诊断价值。方法对20例经手术病理或活检证实的肝外胆管癌患者,分别行动脉期、门脉期和延迟期扫描及重建薄层图像。结果 11例肝门部胆管癌位于左肝管3例、右肝管2例,肝总管端6例。11例均有肝内胆管呈蟹足状,藤状改变。肝门区均见软组织肿块影。增强早期肿块强化不明显,肿块内呈低密度影3例。延迟扫描胆管癌肿块全部强化者9例,呈不均匀强化者2例;9例胆总管癌均显示扩张胆总管突然中断或变形,其中4例管壁可见环形不均匀增厚,管腔狭窄,2例腔内见结节状软组织影,2例腹膜后见肿大淋巴结。结论 64排螺旋CT三期增强扫描及三维重建是诊断肝外胆管癌的理想检查手段。     

Rupture of the hepatic artery after left hemihepatectomy for hilar bile duct carcinoma

Hilar bile duct carcinoma has a poor prognosis, but this has been improved in recent years by an aggressive surgical approach. We treated a 73-year-old woman who had obstructive jaundice due to bile duct carcinoma at the hepatic hilum. The jaundice decreased after percutaneous transhepatic biliary drainage. The tumor was resected with the left and caudate lobe of the liver and a part of portal vein. The right hepatic artery was located behind the common hepatic duct, and was suspected to be invaded by the tumor. We dissected the tumor from the arterial wall without carrying out combined resection of the hepatic artery. On the 6th postoperative day, the hepatic artery ruptured and the patient suffered hypovolemic shock. Resection of the hepatic artery and reconstruction were done, but the patient died 2 days later. Histological examination of the resected artery showed that the tumor had been curatively removed by dissection and that no tumor remained at the arterial wall. The rupture of the right hepatic artery was thought to have been caused by damage to the wall during the dissection procedure.     

Unilateral Multiple Metallic Stent-in-stent for a Case of Hilar Biliary Cancer: An Alternative Stenting Strategy

The stenting strategy has been discussed in cases with unresectable hilar bile duct cancer (HBDC). We describe here a case of HBDC, 4 cm in size, invading the right portal vein and hepatic artery, which was only treated with repeated metallic stent placement, and the patient survived for a long period (51 months). Against Bismuth type-IV hilar biliary stricture, our strategy was to maintain the drainage of the largest, viable hepatic area (>50% of total liver) by unilateral multiple stent-in-stent.     

Hilar cholangiocarcinoma associated with sarcoid reaction in the regional lymph nodes

A 74-year-old woman was admitted to our hospital with a 2-week history of jaundice. Percutaneous transhepatic cholangioscopy revealed a nodular tumor originating in the upper part of the common hepatic duct, which was invading the confluence of the right and left hepatic ducts. Microscopic examination of biopsy specimens revealed adenocarcinoma. Abdominal ultrasonography and computed tomography demonstrated multiple enlarged lymph nodes around the extrahepatic bile duct and the common hepatic artery. Laparotomy revealed lymph node enlargement in the hepatoduodenal ligament, behind the pancreatic head, and along the common hepatic and left gastric arteries. Extended left hepatic lobectomy, caudate lobectomy, and resection of extrahepatic bile duct with extended lymph node dissection were performed. The histology of permanent specimen revealed no tumor metastasis but a sarcoid reaction in the lymph nodes. The patient is in good health 21 months after the operation, without any evidence of recurrence. This is the first successfully resected case of hilar cholangiocarcinoma associated with sarcoid reaction in the regional lymph nodes.     

Sclerosing cholangitis secondary to bleomycin-iodinated embolization for liver hemangioma

Sclerosing cholangitis (SC) is a rarely reported morbidity secondary to transcatheter arterial chemoembolization (TACE) with bleomycin-iodinated oil (BIO) for liver cavernous hemangioma (LCH). This report retrospectively evaluated the diagnostic and therapeutic course of a patient with LDH who presented obstructive jaundice 6 years after TACE with BIO. Preoperative imaging identified a suspected malignant biliary stricture located at the convergence of the left and right hepatic ducts. Operative exploration demonstrated a full-thickness sclerosis of the hilar bile duct with right hepatic duct stricture and right lobe atrophy. Radical hepatic hilar resection with right-side hemihepatectomy and Roux-en-Y hepaticojejunostomy was performed because hilar cancer could not be excluded on frozen biopsy. Pathological results showed chronic pyogenic inflammation of the common and right hepatic ducts with SC in the portal area. Secondary SC is a long-term complication that may occur in LCH patients after TACE with BIO and must be differentiated from hilar malignancy. Hepatic duct plasty is a definitive but technically challenging treatment modality for secondary SC.     

Hepatic artery reconstruction first for the treatment of hilar cholangiocarcinoma bismuth type IIIB with contralateral arterial invasion: a novel technical strategy

Background

En-bloc liver resection with the extrahepatic bile duct is mandatory to obtain tumour-free surgical margins and better long-term outcomes in hilar cholangiocarcinoma (CC). One of the most important criteria for irresectability is local extensive invasion to major vessels. As hilar CC Bismuth type IIIB often requires a major left hepatic resection, the invasion of the right hepatic artery (RHA) usually contraindicates this procedure.

Methods

The authors describe a novel technique that allowed an oncological resection in two patients with hilar CC Bismuth type IIIB and contralateral arterial invasion. Arterial reconstruction between the posterior branch of the RHA and the left hepatic artery (LHA) was performed as the first surgical step. Once arterial vascular flow was restored, a left trisectionectomy with caudate lobe resection and portal vein reconstruction was performed.

Results

In both patients an R0 resection was achieved. Both patients made a full recovery and were discharged within 14 days of surgery. Both patients remain free of disease at 18 months.

Conclusions

This new technique allows a R0 resection to be achieved in patients with Bismuth type IIIB hilar CC with contralateral arterial involvement.     

Sclerosing cholangitis secondary to hepatic artery ligation after abdominal trauma

Several causes have been postulated as responsible for secondary sclerosing cholangitis (SSC), mainly in adults, and, although in very different situations, ischaemia seems to be one of the most important factors. The term 'ischaemic cholangitis' has been used as a collective label for all these ischaemia-induced bile duct lesions. The biliary epithelium is dependent on arterial blood flow, unlike the hepatic parenchyma, which receives a dual blood supply from the hepatic artery and the portal vein. This makes the biliary epithelium very susceptible to changes in arterial blood flow. We present one adolescent patient who developed SSC after abdominal trauma with hepatectomy and ligation of the right hepatic artery. Different factors could have helped in the development of SSC in our patient (septicaemia, bile duct destruction, cholecystectomy) but right hepatic artery ligation seems to be the most important aetiological factor in the development of secondary ischaemic cholangitis.