磁共振胰胆管成像在成人活体右半供肝术前胆道评估中的应用

目的 探讨磁共振胰胆管成像( MRCP)在成人活体右半供肝术前胆道评估中的应用.方法 76例活体肝移植供者,均切取右半肝用于移植.脂肪餐后进行术前MRCP检查,比较MRCP胆管分型与术中胆道造影胆管分型的一致性;在MRCP图像上测量右后肝管汇入部距左右肝管汇合部的距离及相应右后肝管的直径,对相应胆管测量长度及直径与术中胆道重建方式进行二分类Logistic回归分析,并得出术中胆道是否成形的ROC曲线及其长度临界值.结果 MRCP胆管分型与术中胆道造影胆管分型的符合率为97.4％.MRCP所测右后肝管汇入部距左右肝管汇合部的距离和胆管分型是术中胆道重建方式的重要影响因素,而右后肝管直径对术中胆道重建方式的选择无影响.胆道解剖结构变异或Ⅰ型胆管(MRCP分型)中右肝管长度≤4.2mm时,95％的供肝胆道断端数多于1支,且95％行胆道成形术;Ⅲ、Ⅳ型胆管(MRCP分型)所测胆管长度为3.8mm,是选择胆道成形术的分界点.结论 MRCP胆管分型能准确反映胆道解剖结构,MRCP右后肝管汇入部距左右肝管汇合部距离测量值可以指导术中胆道重建方式的选择.     

Management of hepatocellular carcinoma presenting as obstructive jaundice

Eleven (3%) of 340 patients with hepatocellular carcinoma (HCC) presented with obstructive jaundice. The tumor extensively infiltrated the major bile ducts in eight patients. Jaundice was relieved by endoscopic endoprosthesis in four patients, nasobiliary drainage in two patients, percutaneous transhepatic stenting in one patient, and surgical intubation in one patient. The survival interval of these eight patients (mean +/- SD) was 35 +/- 20 days. Three patients had tumor fragments in the common bile ducts. In two patients, major hepatic resection was done after initial tube decomposition of the biliary system. One patient remained tumor-free on follow-up at 24 months, and the other patient had recurrent tumor detected on follow-up at 17 months after surgery. The tumor was irresectable in the third patient. Multiple surgical and endoscopic procedures kept the bile duct patent for 17 months before the patient died of the disease. Not all patients who present with obstructive jaundice due to HCC are terminally ill. With proper management, good palliation and occasional cure are possible.     

Right hepatic lobectomy for recurrent cholangitis after combined bile duct and right hepatic artery injury during laparoscopic cholecystectomy: a report of two cases

BACKGROUND: Bile duct injuries in combination with major vascular injuries may cause serious morbidity and may even require liver resection in some cases. We present two case studies of patients requiring right hepatic lobectomy after bile duct and right hepatic artery injury during laparoscopic cholecystectomy. PATIENTS: Two patients sustained combined major bile duct and hepatic artery injury during laparoscopic cholecystectomy. Surgical management consisted of immediate hepaticojejunostomy with reconstruction of the artery in one patient and hepaticojejunostomy alone in the other patient. In both cases the initial postoperative course was uncomplicated. RESULTS: After 4 and 6 months both patients suffered recurrent cholangitis due to anastomotic stricture. Both developed secondary biliary cirrhosis and required right hepatic lobectomy with left hepaticojejunostomy. The patients remain well 31 months and 4.5 years after surgery. CONCLUSIONS: The outcome of bile duct reconstruction may be worse in the presence of combined biliary and vascular injuries than in patients with an intact blood supply of the bile ducts. We recommend arterial reconstruction when possible in early recognized injuries to prevent late strictures. Short-term follow-up is most important for early recognition of postoperative strictures and to avoid further complications such as secondary biliary cirrhosis.     

Multicentric recurrence of intraductal papillary neoplasms of bile duct in the remnant intrahepatic bile duct after curative resection

IntroductionThere have been few reports on the prognosis of patients with intraductal papillary neoplasms of the bile duct (IPNB). Here we report a case of IPNB in a patient with early-stage carcinoma who had multicentric recurrence in the remnant hepatic bile duct after curative resection.Case presentationA 78-year-old man with hepatic dysfunction and cholestasis was referred to our hospital. Preoperative imaging studies revealed the presence of papillary tumors in the left hepatic duct and common hepatic duct, while no tumor lesions were detected in the right hepatic duct. This patient underwent left hepatectomy, extra-hepatic bile duct resection with biliary reconstruction, and regional lymphnode dissection. On the basis of pathological examination, this patient was diagnosed with multiple IPNB with early-stage adenocarcinoma with negative surgical margin. Postoperative work-up was periodically performed, indicating no evidence of recurrence, while the patient had sustained hepatic dysfunction, cholestasis, and repetitive cholangitis since the early postoperative period. Finally, recurrence in the remnant intrahepatic bile duct of the posterior segment was revealed by double balloon enteroscopy at 29 months after surgery. At 34 months after surgery, internal drainage stents were replaced in both endoscopic and percutaneous manners within the relapsed intrahepatic bile ducts to address repetitive cholangitis. These procedures enabled the patient to remain asymptomatic until death at 41 months after surgery.DiscussionMulticentric recurrence in the remnant intrahepatic bile duct after surgery may occur in IPNB patients with multiple lesions. An endoscopic approach may be useful in such cases, not only in the diagnosis of remnant intrahepatic bile duct recurrence but also for palliation of symptoms.     

Diagnosis and therapy of stenosis or obstruction of the intrahepatic bile ducts]

15 patients are reviewed who had stenosis or obstruction at the hilus of the bile duct. Percutaneous transhepatic or endoscopic transduodenal cholangiography is indispensable for establishing the diagnosis before operation. Primary carcinomas involving the junction of the hepatic ducts may be regarded as resectable if proximal extension of the tumor is limited to below the second bifurcation of the intrahepatic bile ducts in both the right and left lobes and if the proper hepatic artery and portal vein are still free from tumor invasion. Our favourable operation procedures for resection or palliative decompression of the biliary tree are discussed.     

Carcinoma of the main hepatic duct junction: indications, operative morbidity and mortality, and long-term survival

Carcinoma of the main hepatic duct junction tends to spread extensively along the hepatic ducts into the liver parenchyma. Therefore extensive resection of the bile ducts combined with hepatic resection is the procedure of choice. Between January 1973 and April 1989, 25 of 50 patients with this type of carcinoma underwent resection, a resectability rate of 50%. One patient died of staphylococcal sepsis on the postoperative day 42 after right trisegmentectomy and resection of the bile ducts, a hospital death rate of 4%. Twenty-four patients were discharged from the hospital. The 5-year actuarial survival rate calculated by the Kaplan-Meier method was 19%. Four patients lived longer than 5 years after surgery; the longest survival was 9 years after right trisegmentectomy and resection of the bile ducts. These four patients had clear margins at the resected bile ducts. This article was designed to clarify the point at issue by presenting our results in terms of indications, operative morbidity and mortality, and long-term survival.     

Infraportal bile duct of the caudate lobe: a troublesome anatomic variation in right-sided hepatectomy for perihilar cholangiocarcinoma

OBJECTIVE: We present our experiences with infraportal bile duct of the caudate lobe (B1) and discuss surgical implications of this rare variation. SUMMARY BACKGROUND DATA: Although various authors have investigated biliary anatomy at the hepatic hilum, an infraportal B1 (joining the hepatic duct caudally to the transverse portion of the left portal vein) has not been reported. METHODS: Between January 1981 and December 2005, 334 patients underwent hepatectomy combined with caudate lobectomy for perihilar cholangiocarcinoma. Four of them (1.2%) had infraportal B1 and were investigated clinicoanatomically. RESULTS: All infraportal B1 were B1l, draining Spiegel's lobe; no infraportal B1r (draining the paracaval portion) or B1c ducts (draining the caudate process) were found. The infraportal B1l joined the common hepatic duct or the left hepatic duct. Three patients underwent right trisectionectomy with caudate lobectomy; for one, in whom preoperative diagnosis was possible, combined portal vein resection and reconstruction were performed before caudate lobectomy to resect the caudate lobe en bloc without division of infraportal B1. For the other 2 patients, the infraportal B1 was divided to preserve the portal vein, and then the caudate lobe was resected en bloc. The fourth patient underwent right hepatectomy with right caudate lobectomy; the cut end of the infraportal B1 showed no cancer by frozen section, so the bile duct was ligated and divided to preserve the left caudate lobe. CONCLUSION: Infraportal B1 can cause difficulties in performing right-sided hepatectomy with caudate lobectomy or harvesting the left side of the liver with the left caudate lobe for transplantation. Hepatobiliary and transplant surgeons should carefully evaluate biliary anatomy at the hepatic hilum, keeping this variation in mind.     

Oncological Superiority of Hilar En Bloc Resection for the Treatment of Hilar Cholangiocarcinoma

Purpose

Long-term results after liver resection for hilar cholangiocarcinoma are still not satisfactory. Previously, we described a survival advantage of patients who undergo combined right trisectionectomy and portal vein resection, a procedure termed “hilar en bloc resection.” The present study was conducted to analyze its oncological effectiveness compared to conventional hepatectomy.

Patients

During hilar en bloc resection, the extrahepatic bile ducts were resected en bloc with the portal vein bifurcation, the right hepatic artery, and liver segments 1 and 4 to 8. With this “no-touch” technique, preparation of the hilar vessels in the vicinity of the tumor was avoided. The long-term outcome of 50 consecutive patients who underwent curative (R0) hilar en bloc resection between 1990 and 2004 was compared to that of 50 consecutive patients who received curative conventional major hepatectomy for hilar cholangiocarcinoma (perioperative deaths excluded).

Results

The 1-, 3-, and 5-year survival rates after hilar en bloc resection were 87%, 70%, and 58%, respectively, which was significantly higher than after conventional major hepatectomy. In the latter group, 1-, 3-, and 5-year survival rates were 79%, 40%, and 29%, respectively (P = 0.021). Tumor characteristics were comparable in both groups. A high number of pT3 and pT4 tumors and patients with positive regional lymph nodes were present in both groups. Multivariate analysis identified hilar en bloc resection as an independent prognostic factor for long-term survival (P = 0.036).

Conclusions

In patients with central bile duct carcinomas, hilar en bloc resection is oncologically superior to conventional major hepatectomy, providing a chance of long-term survival even in advanced tumors.

     

Extracystic biliary carcinoma associated with anomalous pancreaticobiliary junction and cysts

Anomalous pancreaticobiliary junction with cystic dilatation of the biliary tract is usually associated with carcinoma arising from the cyst wall. We report an extracystic location of biliary carcinoma in the presence of anomalous pancreaticobiliary junction and cysts in a patient with obstruction of the origin of the left hepatic duct who underwent hepatobiliary resection. Cholangiocarcinoma was found to have arisen in a noncystic left hepatic duct, in conjunction with cystic dilatation involving both the cystic and common bile ducts. The present case supports a relationship between anomalous pancreaticobiliary junction and biliary carcinogenesis that may affect the extracystic biliary tree.     

腹腔镜胆囊切除术中肝外胆道解剖异常的防范

目的探讨腹腔镜胆囊切除术（1aparoscopic cholecystectomy，LC）中肝外胆道异常的诊断及处理。方法1999年10月～2008年6月1216例LC中，发现15例（1．2％）胆道解剖异常。3例胆囊管异常粗、短，开口在左右肝管汇合部；1例胆囊颈部结石嵌顿，胆总管较细，向上牵拉胆囊使胆总管走行移位；1例胆囊管与肝总管并行后低位开口，1例胆囊管在胆总管右侧回旋扭曲，开口于右肝管侧壁，2例胆囊壶腹部粘连严重，覆盖于胆总管及肝总管前方；3例在胆床附近见迷走胆管走行；3例在分离胆囊管时发现右后肝管开口于肝总管；1例Mirizzi综合征解剖不清。仔细分离，丝线结扎或上钛夹处理，解剖不清者中转开腹。结果13例顺利完成LC；2例（13．3％）中转开腹，其中1例副右肝管损伤，1例Mirizzi综合征。无腹腔内出血、腹腔感染、肠道损伤及死亡等严重并发症。15例随访3个月～4年，其中〉1年11例，无胆道狭窄及残余结石。结论LC术中精细解剖胆囊三角，确切辨认各管道关系，是预防胆道异常情况下肝外胆道损伤的关键。     

Carcinoma of the hepatic hilus. Surgical management and the case for resection.

Tumor resection for treatment of carcinoma of the hepatic hilus was preferred over routine palliative decompression at the University Hospital Center, Rennes, France, in 1974. Since then, resection has been performed on 18 patients. In seven of these patients resection proved impractical because of the extension of a neoplasm into the portal vein or liver, therefore palliative decompression was performed. In 11 patients (61%) tumor resection, followed by reconstruction of the biliary tree, was performed successfully. All the resected tumors were adenocarcinomas of the proximal bile ducts. Four patients had simple hepatic duct resection. In two patients duct resection was associated with right lobectomy, in three patients with left lobectomy, in one patient with segmentectomy, and in one patient with excision of the right branch of the hepatic artery. There were two postoperative deaths. The mean survival time for the remaining nine patients is 521 days. Five patients were alive in August 1978, at intervals ranging from 175 to 1180 days after resection. These results contrast favorably with those obtained between 1968 and 1973, during which period nine patients had palliative decompression, with three postoperative deaths and a mean survival time of 164 days for the remaining six patients.     

腹腔镜胆囊切除术中右肝管分支损伤的预防和治疗(附7例分析)

目的:探讨腹腔镜胆囊切除术(LC)中右肝管分支损伤的预防和治疗。方法:回顾分析本院近4年LC术中发生之右肝管分支损伤的诊断和治疗过程及随访情况。结果:2001年5月至2005年4月,我院行LC术中发现或术后发生胆漏、经造影证实为右肝管分支损伤者共7例,其中男2例、女5例。7例均属选择性手术,其中6例呈胆囊周围慢性炎症,粘连明显,5例在术中放置了双腔引流管,术后发现有胆汁引出。另2例系在术中发现于胆囊管切断后,肝面有胆汁溢出;当即中转开腹,行术中造影,发现为右肝管分支畸形受损,直径分别为0.3cm和0.4cm,予对端吻合;置T管作为内支撑,经胆总管引出。5例在术中放置双套引流管的病例中,1例因每日持续有20～100ml胆汁引出,于术后3个月行右肝管鄄空肠Roux鄄en鄄γ吻合,吻合口直径达1cm;4例分别在术后引流1～3个月后自行闭合,并无任何临床症状,肝功能无异常。2例在术中放置内支撑者,于术后9个月拔除T鄄管,恢复良好。结论:右肝管分支的损伤往往与胆囊三角的慢性炎症程度、胆道系统的解剖变异、手术操作不当等因素有关。对术后发现胆漏者,经通畅的引流治疗1～3个月后,大部病例可以治愈,不需进行第2次手术,对引流超过3个月不愈者,需再次手术。     

"Anatomic" right hepatic trisectionectomy (extended right hepatectomy) with caudate lobectomy for hilar cholangiocarcinoma

BACKGROUND: The techniques of right hepatic trisectionectomy are now standardized in patients with hepatocellular or metastatic carcinoma, but not in those with hilar cholangiocarcinoma. METHODS: Under preoperative diagnosis of hilar cholangiocarcinoma, 8 patients underwent "anatomic" right hepatic trisectionectomy with en bloc resection of the caudate lobe and the extrahepatic bile duct, in which the bile ducts of the left lateral section were divided at the left side of the umbilical fissure following complete dissection of the umbilical plate. RESULTS: Liver resection was successfully performed, and all patients were discharged from the hospital in good condition, giving a mortality of 0%. All patients were histologically diagnosed as having cholangiocarcinoma. The proximal resection margins were cancer-negative in 7 patients and cancer-positive in 1 patient. Four patients with multiple lymph node metastases died of cancer recurrence within 3 years after hepatectomy. One patient died of liver failure without recurrence 42 months after hepatectomy. The remaining 3 patients without lymph node metastasis are now alive after more than 5 years. CONCLUSIONS: Anatomic right hepatic trisectionectomy with caudate lobectomy can produce a longer proximal resection margin and can offer a better chance of long-term survival in some selected patients with advanced hilar cholangiocarcinoma.     

Extended right hepatectomy with total caudate lobe resection and biliary tree resection for a large colorectal liver metastasis involving both the right and left hepatic lobes and the umbilical fissure: a case report

Very large right-sided liver tumors may grow up to the base of the umbilical fissure and involve the left hepatic duct and can occasionally reach the bile duct confluence. This kind of involvement has often been considered a contraindication to resection. We report a patient who presented with a large hepatic metastasis from colorectal cancer that reached the umbilical fissure and involved the left hepatic duct just above the bile duct confluence. An extended right hepatectomy including complete resection of caudate lobe was performed. We resected the left and common hepatic ducts, as well as both the entire hepatic and the proximal third of common bile duct. A long jejunal limb Roux-en-Y (45 cm) single-layer left intrahepatic hepaticojejunostomy was constructed. She is still well 14 months postoperatively. To the best of our knowledge, this is the first report of such a procedure employed for the treatment of a liver metastasis from colorectal cancer. Extended right hepatectomy including complete caudate lobe resection can be feasible even when the majority of the extrahepatic biliary system needs to be resected. Our approach probably offers the only chance to prevent early death from liver failure in these patients.     

Arterioportal shunting as an alternative to microvascular reconstruction after hepatic artery resection

BACKGROUND: Portal vein and hepatic artery resection and reconstruction may be required in radical surgery for biliary cancer. Microvascular reconstruction requires special equipment and training, and may be difficult to accomplish when the arterial stump is small, when there are multiple vessels or when the stump lies deep within the wound. This study examined the feasibility and safety of arterioportal shunting as an alternative to arterial reconstruction. METHODS: Over 30 months, ten patients with biliary cancer (six bile duct and four gallbladder carcinomas) underwent radical surgery with en bloc resection of the hepatic artery and end-to-side arterioportal reconstruction between the common hepatic or gastroduodenal artery and the portal trunk. RESULTS: No patient died. Complications included bile leakage in two patients and liver abscess in one. Routine angiography performed 1 month after surgery revealed shunt occlusion in three patients. Once the existence of hepatopetal arterial collaterals had been confirmed in the remaining patients, the shunt was occluded by coil embolization. CONCLUSION: Arterioportal shunting appears to be a safe alternative to microvascular reconstruction after hepatic artery resection. However, the safety of the procedure and its potential to increase the cure rate require further assessment in a larger series with a longer follow-up.     

Surgical Treatment for Biliary Carcinoma Arising After Pancreatoduodenectomy

The clinicopathological features and surgical treatment of biliary carcinoma around the major hepatic duct confluence arising after pancreatoduodenectomy (PD) due to initial bile duct carcinoma are described in three patients. Occurrence of biliary carcinoma more than 12 years after initial surgery and a histological finding of cholangiocellular carcinoma mixed with hepatocellular carcinoma suggested metachronous incidence of biliary carcinoma after PD. Extended right hemihepatectomy with complete removal of the residual extrahepatic bile duct and segmental, resection of the jejunal loop were carried out safely without operative death or severe postoperative complications. Two patients died of tumor recurrence 6 months after surgery, and the remaining patient is currently living a normal life without evidence of recurrence 17 months after surgery. These surgical procedures are a therapeutic option in patients with biliary carcinoma around the major hepatic duct confluence arising after PD.     

A Study of the Subvesical Bile Duct (Duct of Luschka) in Resected Liver Specimens

Background Injury to the duct of Luschka is associated with biliary fistula from the gallbladder bed after cholecystectomy. However, few studies have reported on the detailed anatomy. We elucidated the anatomy and frequency of the duct of Luschka Methods A total of 128 specimens from patients who underwent right hepatectomy or more extensive right-sided liver resection between February 1992 and December 2003 were examined. Specimens were fixed in formalin, and serial sections were prepared to trace the course of the bile ducts from the subsegmental branch level. Results The duct of Luschka was observed in 6 (4.6%) specimens. The sites of confluence were as follows: right anterior inferior dorsal branch (2 patients), right anterior branch (2 patients), right hepatic duct (1 patient), and common hepatic duct (1 patient). The upstream end was located in the liver parenchyma of the right anterior inferior dorsal subsegment (5b) and connective tissue of the gallbladder bed in 4 and 2 specimens, respectively. Conclusions The duct of Luschka never crosses the segmental (5b) border. Therefore, its upstream region may not be injured by segmentectomy or more extensive liver resection. However, it is possible to injure the duct of Luschka at the common hepatic duct, even if right-sided hepatectomy is performed, as the sites of confluence included the common hepatic duct.     

The management of extrahepatic bile duct carcinoma

A series of 63 patients with primary bile duct carcinomas seen at the UCLA Hospital since 1955 have been analyzed and divided into four groups, depending upon the site of the tumor in the extrahepatic ductal system. More than half of the tumors occurred in the upper one-third, while the other half was about equally divided between those occurring in the middle and lower thirds of the extrahepatic duct system. Three wide-spread intraluminal papillary tumors have been placed in a special category. The difficulties of establishing a correct diagnosis at the time of operation are again demonstrated in this series. The most commonly used palliative procedure has been the insertion of a tube into the duct that passes above and below the tumor through the site of obstruction. The tumors are generally small, well-localized, and frequently slow-growing. Tumors in the lower one-third of the duct may be treated by radical en bloc resection (pancreaticoduodenectomy) and offer the best prognosis, both for long-term palliation and cure. More than half of the tumors in this series were located at or near the confluence of the hepatic ducts, and resection of the tumor was attempted in only six of 34 cases. It is possible that, were procedures available that would permit a more extensive en bloc resection of tumors in the middle and upper thirds of the duct system, the period of palliation might be extended and more “cures” obtained. Detailed anatomical studies of the hepatic ducts, arteries, and portal veins at the hilus support the concept of combining extended hepatic resection with tumor excision and including segments of the hepatic blood supply in selected patients with tumors in the upper one-third of the duct. Operative procedures for resection of the right and left lobes have been proposed. One such operation has been performed; in a second patient, hepatic lobectomy and tumor excision were performed without interruption of the blood supply to the remaining lobe. Presented at the 73rd annual meeting of Japan Surgical Society in Kyoto on April 2, 1973. Supported in part by the James G. Greims Trust Fund and a April 2, 1900 Sabbatical Fellowship^* from the Blalock Foundation.     

Carcinoma of the junction of the main hepatic ducts

Patients with carcinoma of the hepatic duct junction often present the surgeon with a difficult problem. If at all possible radical surgery may be performed either as a resection of the tumour and an anastomosis according to Roux-en-Y or a resection of the left or right hepatic lobe together with the obliterated hepatic duct or ducts. The present series consists of 17 patients treated for cancer of the hepatic duct junction during the period 1965-1974 with a follow-up period of at least five years. The surgical treatment given included a radical procedure in 8 cases, a palliative procedure in 7 cases and in 2 cases surgery of the hepatic ducts was not possible. Radical procedures included 4 patients with a resection of the left hepatic lobe and 4 patients with resection of the left and right hepatic ducts and anastomosis according to Roux. A mean survival time of 22.8 months was reached when a radical operation was attempted with a longest survival time of 8 years. A palliative procedure gave a mean survival time of 2.0 months. These figures indicate that a careful selection of patients for an attempt of radical surgery could be made since removal of the tumour gives a more effective palliation, often a longer survival time and an improvement of quality of life.