Extended liver resection for hilar cholangiocarcinoma

Liver resection for hilar cholangiocarcinoma should be designed for individual patients, based on both precise diagnosis of cancer extent and accurate evaluation of hepatic functional reserve. Therefore we have developed various types of hepatic segmentectomy. Combined caudate lobectomy is essential in every patient with separated hepatic confluence. So-called extensive hepatectomy, resection of 50% or more of the hepatic mass, includes right lobectomy and right or left trisegmentectomy. Right lobectomy with caudate lobectomy is indicated when the progression of cancer is predominant in the right anterior and posterior segmental bile ducts. The plane of liver transection is along the Cantlie line, and the left hepatic duct is divided just at the right side of the umbilical portion of the left portal vein. Right trisegmentectomy with caudate lobectomy is performed in carcinoma which involves the right hepatic ducts in continuity with the left medial segmental bile duct. The umbilical portion of the left portal vein is freed from the umbilical plate by dividing the small portal branches arising from the cranial side of the umbilical portion. Then the left lateral segmental bile ducts are exposed and divided at the left side of the umbilical portion of the left portal vein. Left trisegmentectomy with caudate lobectomy is suitable for carcinoma which involves the left intrahepatic bile duct in continuity with the right anterior segmental bile duct. Liver transection is advanced along the right portal fissure. The right posterior segmental bile duct is usually divided distal to the confluence of the inferior and superior branches.     

Hilar cholangiocarcinoma—surgical anatomy and curative resection

We have studied the surgical anatomy of the intrahepatic bile duct, hepatic hilus, and caudate lobe based on intraoperative findings and selective cholangiography of surgical patients and resected specimens, and have established the cholangiographic anatomy of the intrahepatic subsegmental bile duct. Thorough knowledge of the three-dimensional anatomy of the subsegmental bile duct, hepatic hilus, and caudate lobe is indispensable for curative surgery of hilar cholangiocarcinoma. We designed and actually performed 15 kinds of hepatic segmentectomies with caudate lobectomy and extrahepatic bile buct resection in 100 consecutive patients, with curative resection being possible in 82 patients. Postoperative survival after curative resection of hilar cholangiocarcinoma was better than expected, and the 5-year survival rates for all 82 patients with curative resection and for 55 patients with curative surgery without portal vein resection were 31% and 43%, respectively. Hepatic segmentectomy with caudate lobectomy and extrahepatic bile duct resection should be designed not only in accordance with the preoperative diagnosis of tumor extension into the intrahepatic bile ducts but also so that curative surgery for advanced hilar cholangiocarcinoma can be performed.     

肝内胆管手术入路的解剖及临床应用

目的 探讨显露肝内叶、段胆管的手术入路。方法 研究30例成人肝脏标本的肝内叶、段胆管与血管的毗邻关系。结果 左右肝管均位于肝脏脏面门静脉门静脉左右干的前上缘,左内叶、右前叶胆管位于相应门静脉的前内侧。右后叶胆管位于门静脉右面支或右前叶下段支脏面深侧者占73％（22／30）;位于门静脉右后支脏面深侧或后上缘者占80％（24／30）。左外叶胆管位于门静脉矢状部脏面深侧者占93％（28／30）。选择经肝的脏面显露肝门、左右肝管,经肝的膈面显露肝内叶、段胆管相结合的手术入路,治疗复杂性肝内胆管结石并狭窄患者38例,均获成功。结论 经肝的脏面与膈面相结合的手术入路,比较容易显露和切开肝内胆管及其狭窄段、便于取出结石。     

Mass-forming intrahepatic cholangiocarcinoma with portal vein tumor thrombus and bile duct tumor thrombus: A case report

IntroductionWe report the first case of mass-forming intrahepatic cholangiocarcinoma (ICC) with portal vein tumor thrombus (PVTT) and bile duct tumor thrombus (BDTT), where the extrahepatic bile duct was preserved with thrombectomy.Presentation of caseA 70-year-old male. Magnetic resonance imaging (MRI) showed the tumor extending from the hepatic hilum to the left hepatic duct with complete obstruction of the left hepatic duct and a defect at the left portal vein. We planned to perform extended left lobectomy, lymph node dissection, extra hepatic bile duct resection and reconstruction based on the diagnosis of mass-forming ICC with left portal vein and left hepatic duct infiltration (cT3N0M0 Stage III). Intraoperative cholangiography revealed a crab claw-like filling defect at the left hepatic duct, which suggested tumor thrombus. Accordingly, we performed thrombectomy. The margin of the left hepatic duct was tumor negative, so we performed extended left lobectomy, lymph node dissection and thrombectomy. Pathologically, the tumor was diagnosed as ICC (pT4N0M0 Stage IVA, vp3, b3). Tumors in the left hepatic duct and left portal vein proved to be tumor thrombus. The postoperative course was uneventful. He is doing well without recurrence.DiscussionThrombectomy is performed for hepatocellular carcinoma (HCC) with tumor thrombus. Furthermore, extrahepatic bile duct resection and reconstruction are recommended for ICC. In this case, intraoperative cholangiography was effective for precisely diagnosing. Thrombectomy could reduce surgical stress and prevent complications.ConclusionsThrombectomy can be a valid option for ICC with tumor thrombus, as well as for HCC.     

III|IV 型肝门部胆管癌的手术治疗

目的:探讨Ⅲ,Ⅳ型肝门部胆管癌的手术治疗方式和效果.方法:回顾性分析2010年4月-2013年2月期间采取手术治疗的16例Ⅲ,Ⅳ型肝门部胆管癌患者的临床资料.结果:16例中行手术切除13例,切除率为81.3％ (13/16).其中行根治性切除术(R0切除)7例,非根治性切除术6例;行左半肝+尾叶切除+右肝管成形、肝管-空肠Roux-en-Y吻合术3例,行右半肝切除+尾叶切除+左肝管成形、肝管-空肠Roux-en-Y吻合术3例,行肝方叶切除及围肝门切除+胆管开口肝门区-空肠盆式吻合术7例;其中2例因总胆红素＞400 μmm.l/L而先行经皮肝穿刺胆管引流(PTCD)后再手术.3例患者无法完成手术切除,其中2例肿瘤侵犯门静脉左右支,1例术中发现肝脏多发转移瘤,3例均行肝内扩张胆管的术中置管引流术.所有患者的术后血清总胆红素水平均明显降低或恢复至正常,术后引流有效率为100％.1例围手术期死亡.结论:对于Ⅲ,Ⅳ型肝门部胆管癌,应力争切除肿瘤,解除胆管梗阻.对肝门区胆管解剖的熟知、娴熟的手术技巧和胆大心细的操作,有望提高手术切除率.     

A left hepatectomy and caudate lobectomy combined resection of the ventral segment of the right anterior sector for hilar cholangiocarcinoma — the efficacy of PVE (portal vein embolization) in identifying the hepatic subsegment: Report of a case

This report presents a case of a left hepatectomy and a caudate lobectomy combined resection of the ventral segment of the right anterior sector for hilar cholangiocarcinoma using percutaneous transhepatic portal vein embolization (PVE). The patient was a 44-year-old man admitted to a local hospital with obstructive jaundice. He was diagnosed to have hilar cholangiocarcinoma and was referred to the hospital for further treatment. Cholangiography revealed stenosis of the left hepatic duct and the hilar bile ducts. The dorsal branch of the right anterior sector joined the right posterior branch and the tumor did not invade to the confluence of these branches. Arteriography and portography reconstructed by multidetector-raw computed tomography revealed the ventral branches of the right anterior sector, which separately diverged from the other right anterior branches. It was therefore necessary to perform a left hepatectomy and caudate lobectomy combined resection of the ventral segment of the right anterior sector to completely remove the tumor. Portal vein embolization was thus performed on the left portal vein and the ventral branches of the right anterior sector. Intraoperatively, when the hepatic artery was temporally clamped, the demarcation between the ventral segment and the dorsal segment of the right anterior sector could be clearly visualized. The planned surgery was performed safely. This case demonstrates that the utilization of PVE is useful for a difficult and intricate hepatectomy, which requires an accurate identification of a hepatic subsegment.     

Hepatobiliary resection with concomitant resection of the inferior vena cava for advanced intrahepatic cholangiocarcinoma: report of a case

A 65-year-old female was diagnosed with intrahepatic cholangiocarcinoma involving the inferior vena cava (IVC). The patient underwent right trisectionectomy and caudate lobectomy with bile duct resection and concomitant resection of the IVC. The IVC was reconstructed using the right external iliac vein. Histologically, the tumor had invaded the IVC. Despite the administration of postoperative prophylactic anticoagulant therapy, IVC thrombosis developed, probably due to the difference in diameter between the IVC and the graft. Following the development of collateral vessels, the patient was discharged and is now healthy without recurrence 18 months after surgery. IVC reconstruction using an external iliac vein graft may lead to the development of IVC thrombosis. Therefore, the graft used for IVC reconstruction should be very carefully selected.     

Ⅲ型肝门部胆管癌的外科治疗（附35例分析）

目的总结Ⅲ型肝门部胆管癌的手术经验。方法回顾性分析我院1999年1月至2006年12月，行手术切除的35例Ⅲ型肝门部胆管癌的临床资料。Ⅲa型16例，行肝门部胆管切除8例，行联合右半肝＋右侧尾状叶切除7例，行联合右半肝＋尾状叶切除、门静脉分叉部切除主干左支吻合1例。Ⅲb型19例，行肝门部胆管切除8例，行联合左半肝＋左侧尾状叶切除9例，行联合左半肝＋尾状叶切除、门静脉分叉部切除主干右支吻合1例．行联合左半肝＋尾状叶切除、门静脉分叉部切除主干右支吻合、肝固有动脉分叉部切除主干右支吻合1例。结果本组32例获得随访，随访时间18～113个月。肝门部胆管切除病例术后病理根治性切除率为37．5％，联合肝叶切除病例术后病理根治性切除率73．7％，3例联合肝叶切除＋血管切除病例均获术后病理根治性切除。肝门部胆管切除术后并发症发生率为31．3％，联合肝叶切除组术后并发症发生率为31．6％。3例联合肝叶切除＋血管切除病例术后均无胆肠吻合口漏、肝断面坏死、胆漏等严重并发症。结论联合肝叶切除，必要时行受累分叉部血管切除重建，有益于提高Ⅲ型肝门部胆管癌的根治性切除率，且不增加术后并发症的发生率。     

Intrahepatic cholangiocarcinoma arising 33 years after excision of a choledochal cyst: report of a case

We report a case of intrahepatic cholangiocarcinoma arising 33 years after excision of a choledochal cyst. A 61-year-old woman was admitted to our hospital complaining of fever. Thirty-three years ago she had undergone extrahepatic choledochal cystectomy and choledochojejunostomy for a choledochal cyst. Computed tomography showed a tumor in the anterior segment of the liver, extending to the posterior and medial segments and the right portal vein. Intrahepatic biliary stones were seen in the bile ducts. We performed extended right lobectomy. Microscopically, the tumor was cholangiocarcinoma. Most of the tumor area was composed of invasive adenocarcinoma but a carcinoma-in-situ component was also observed in some regions including the hilar bile duct, where an intrahepatic biliary stone was seen. This suggests that the cancer development could be related to intrahepatic cholestasis. Patients with choledochal cyst may have to be carefully followed up for more than 30 years even after diversion surgery.     

Retroportal Hepaticojejunostomy for Extended Resection of Hilar Bile Ducts

High hepatic duct resection sometimes is unavoidable in achieving curative resection of hilar cholangiocarcinoma, as tumor cells can extend further than expected along the bile ducts from the macroscopically evident cancer. In patients undergoing left hemihepatectomy with caudate lobectomy whose bile duct must be severed at the subsegmental bile duct levels, the orifices of the posterior bile ducts would lie behind the right portal vein. Conventional hepaticojejunostomy would be risky in such cases because an anastomosis performed in the usual manner would be subjected to strain. Instead, between 2002 and 2004, three patients underwent retroportal hepaticojejunostomy using a jejunal limb mobilized and positioned behind the hepatoduodenal ligament. Primary tumors were classified as type IV in the Bismuth–Corlette classification. Tension-free hepaticojejunal anastomosis was performed successfully in all three patients; insufficiency of the hepaticojejunostomy did not develop. Neither early nor late complications directly related to this method occurred. Retroportal hepaticojejunostomy, thus, permits more peripheral resection of the hepatic duct while providing a sufficient operative field for safe, tension-free anastomosis. This technique is very useful for patients undergoing left hemihepatectomy requiring high hilar resection of the bile duct.     

Anomalous arrangement of pancreaticobiliary ductal system associated with cholangiocellular carcinoma

A 66-year-old man with congenital cystic dilatation of the common bile duct (CDB; Alonso-Lej Type I) and anomalous arrangement of the pancreaticobiliary ductal system (AAPB) associated with intrahepatic bile duct cancer (cholangiocellular carcinoma; CCC) underwent an extended right hepatic lobectomy. In the resected specimen, the CCC was located in Couinaud’s segment V, with invasion to segment IV and the right hepatic duct and right portal vein. However, there was no cancer involvement of the dilated extrahepatic bile ducts, except for histologic findings of chronic inflammatory cellular infiltration and intestinal metaplasia. It is presumed that the probable mechanisms underlying carcinogenesis in CCC developing from the epithelium of intrahepatic bile ducts are the same mechanisms as those operating in carcinoma of the extrahepatic bile duct in patients with AAPB, although AAPB associated with CCC is uncommon. AAPB appeared to be related to the development of the CCC.     

A suitable animal model for laparoscopic hepatic resection training

Background There is a growing interest in using laparoscopy for hepatic resection. However, structured training is lacking in part because of the lack of an ideal animal training model. We sought to identify an animal model whose liver anatomy significantly resembled that of the human liver and to assess the feasibility of learning laparoscopic hepatic inflow and outflow dissection and parenchyma transection on this model. Methods The inflow and outflow structures of the sheep liver were demonstrated via surgical dissection and contrast studies. Laparoscopic left major hepatic resections were performed. Results The portal hepatis of all 12 sheep (8 for anatomic study and 4 for laparoscopic hepatic resection) resembled that of human livers. The portal vein (PV) was located posteriorly; the common hepatic artery (CHA) and the common bile duct (CBD) were located anterior medially and anterior laterally with respect to the portal hepatis. The main PV bifurcated into a short right and a long left PV. The extrahepatic right PV then bifurcated into right posterior and anterior sectoral PV. The CBD and CHA bifurcated into left and right systems. The cystic duct originated from the right hepatic duct. The cystic artery originated from the right HA in 11/12 animals. The left hepatic vein drained directly into the inferior vena cava (IVC). The middle and the right hepatic veins formed a short common channel before entering the IVC. Multiple venous tributaries drained directly into IVC. Familiarity with sheep liver anatomy allowed laparoscopic left hepatic lobe (left medial and lateral segments) resection to be performed with accuracy and preservation of the middle hepatic vein. Conclusions The surgical anatomy of sheep liver resembled that of human liver. Laparoscopic major hepatic resection can be performed with accuracy using this information. Sheep is therefore an ideal animal model for advanced surgical training in laparoscopic hepatic resection.     

Hilar cholangiocarcinoma involving the portal vein bifurcation: long-term results after resection

Abstract. Background/Purpose: Resection offers the only potential cure of hilar cholangiocarcinoma. Portal bifurcation involvement is often thought to contraindicate resection. We reviewed our experience with aggressive surgical management in 28 patients with hilar cholangiocarcinoma. Methods: All patients underwent hepatectomy and bile duct resection with hepaticojejunostomy. In 10 cases (group 1) the portal bifurcation was involved, necessitating portal resection and reconstruction; 18 (group 2) had no portal involvement. Frozen section of duct margins was routine. Survival was estimated using the Kaplan-Meier method and compared with the log-rank test. Results: Portal reconstruction in group 1 was by graft interposition (1), venoplasty using the posterior wall of the right portal vein (2), or end-end anastomosis (7). Hepatectomies included right trisegmentectomy (8), right lobectomy (4), and left lobectomy (16); 20 (71%) had concomitant caudate resection. Median survival was 18 months in group 1 and 32 months in group 2 (P, not significant [NS]). One-, 3-, and 5-year survivals were 60%, 22%, and 22%, respectively, in group 1 and 70%, 47%, and 38%, respectively, in group 2 (P = 0.319). Conclusions: Portal involvement by hilar cholangiocarcinoma does not contraindicate resection. Received: June 11, 2001 / Accepted: February 8, 2002     

Ⅳ型肝门部胆管癌的治疗体会

目的探讨Ⅳ型肝门部胆管癌的初步治疗经验。方法收集2008年4月至2011年4月期间四川大学华西医院肝胆胰外科1个医疗组收治的20例Ⅳ型肝门部胆管癌患者的临床资料,对其术中及术后结果进行分析。结果 20例中行手术切除15例,切除率为75%。其中行根治性切除术10例,非根治性切除术5例;行左三肝+尾叶切除(右前右后肝管成形、肝管-空肠吻合+空肠-空肠Roux-en-Y吻合术)7例,行扩大右半肝切除+尾叶切除(左外左内肝管成形、肝管-空肠吻合+空肠-空肠Roux-en-Y吻合术)6例,行肝方叶切除(左外内、右前后肝管分别整形后行2个胆-肠吻合术)2例;其中2例因总胆红素>400 mmol/L而先行经皮肝穿刺胆管引流(PTCD)和门静脉栓塞(PVE)后再手术,1例行根治性切除术,另1例行非根治性切除术。不能切除者5例,其中3例因发生肝脏及远处广泛转移,行术中PTCD,另2例因肿瘤侵犯门静脉左右支,行术中T管引流、联合术后PTCD。行手术切除者术后1年生存率为100%,术后生存时间1～3年,平均1.5年;肿瘤未切除者生存3～6个月,平均4.2个月。本组无一例围手术期死亡。结论对于Ⅳ型肝门部胆管癌,术前应精确评估,力争切除肿瘤,解除胆管梗阻;如不能一期切除则行PTCD和PVE,力争二期切除。     

Indication and operative techniques of extended right hepatic lobectomy for advanced gallbladder cancer

Gallbladder cancer extends directly to the hepatic hilum and/or the right portal pedicle in the hepatic hilum type and the bed and hilum type of disease. Extended right hepatic lobectomy (ERHL), caudate lobectomy, lymph node dissection, and biliary reconstruction are necessary for radical resection of the tumor. It was previously thought that this extensive surgery carried high risk, with a hospital death rate of 20%, and had little survival benefit. However, it is now feasible with lower risk due to improvement in biliary decompression techniques, prevention of intrahepatic segmental cholangitis, introduction of preoperative portal embolization, etc. Long-term survival has been achieved after surgery unless there is hepatic, peritoneal, or paraaortic metastasis. Hilar hepatic involvement is more advanced in gallbladder cancer than in bile duct cancer, and portal vein resection and reconstruction are inevitable. All six such patients in our department over the past two years underwent concomitant portal reconstruction and have survived postoperatively.     

Anomalous intrahepatic portal system in a patient with hilar bile duct cancer

We report a case of anomaly of the intrahepatic portal system in a 65-year-old man with hilar bile duct cancer. Preoperatively, percutaneous transhepatic portography demonstrated that there was a right posterior portal vein arising from the main portal vein. In addition, a large portal branch originated from the left portal vein and coursed toward the right hepatic lobe. Following portal embolization of the right posterior branch, the patient underwent an extended right hepatectomy with a caudate lobectomy. Intraoperatively, to the left at the porta hepatis and then it first gave off the right anterior portal vein originated from the left portal vein and coursed toward the right hepatic lobe horizontally behind the gallbladder and then separated into superior and inferior segmental branches to supply the right anterior segment of the liver. The ramification of some major branches without malposition of the gallbladder or round ligament was the important clinical feature of this anomaly.     

Wedge resection of the portal bifurcation concomitant with left hepatectomy plus biliary reconstruction for hepatobiliary cancer

Background/Purpose: We report our experience performing wedge resection of the portal bifurcation and transverse suture closure in patients undergoing left hepatectomy and caudate lobectomy plus biliary reconstruction for hepatobiliary cancer. Methods: The procedure was performed in three patients with hilar or intrahepatic cholangiocarcinoma. After confirming that tumor invasion of the portal bifurcation was not circumferential, the portal trunk and the right posterior and right anterior portal branches were isolated and clamped. Wedge resection of the portal bifurcation was performed, taking care to secure a clear surgical margin. The edges of the portal vein were approximated, using guy-sutures in the dorsal and ventral edges and a temporary central guy-suture, and portal reconstruction was carried out using a continuous transverse suture. After unclamping, good portal flow was confirmed by color Doppler ultrasonography. Results: The procedure was completed successfully in all three patients; the average time of portal vein occlusion was 15 min. Two patients had postoperative complications: bile leakage and wound infection, but no patient developed postoperative hepatic failure or died. The three patients are alive without recurrence at 2, 11, and 22 months after the operation. Conclusions: Wedge resection of the portal bifurcation is easier and simpler than using a venous patch or performing segmental resection. Received: March 31, 2002 / Accepted: June 10, 2002 Offprint requests to: S. Kondo Presented at the 5th World Congress of the International Hepato-Pancreato-Biliary Association, April 25–29, 2002, Tokyo     

Longer than 3-Year Survival Following Hepato-Ligamento-Pancreatoduodenectomy for Hilar Cholangiocarcinoma with Vascular Involvement: Report of a Case

A 70-year-old man presented with a mass-forming perihilar cholangiocarcinoma in his left liver, and both the portal trunk and proper hepatic artery were involved by the tumor. We performed a hepato-ligamento-pancreatoduodenectomy (HLPD), including an extended left lobectomy with a caudate lobectomy, and the external iliac vein graft was harvested for portal vein reconstruction while the right middle colic artery was anastomosed to the right posterior hepatic artery. Vascular involvement (portal vein and hepatic artery) and peripancreatic lymph node metastases were proven histologically. Although the liver abscess and pancreatic fistula both occurred postoperatively, the patient is now healthy and still alive 3 years 9 months after surgery without recurrence. We consider that the absence of para-aortic lymph node metastases and hepatic invasion which is not involved beyond the second order of the hepatic ducts in the future remnant liver might therefore have contributed to the satisfactory outcome after performing HLPD in this case.     

高位切除治疗肝门胆管癌疗效分析

目的探讨离位切除治疗晚期肝门胆管癌的疗效。方法1995～2004年收治的13例晚期肝门胆管癌均施行高位肝管切除。根据肝门胆管癌向肝内外侵犯方向和范围。分为2组。A组8例，肝门胆管癌向肝内外侵犯，其中7例侵犯肝内2、3级肝管；B组5例，2例左肝内大胆管癌侵犯右肝管，3例侵犯右侧2级肝管。A组采用肝门胆管癌骨骼化切除，中央肝切除7例、左肝叶切除1例，3—9支肝管断端重建新的肝门胆管后与空肠行Y形吻合。B组采用切除肝左叶和肝门胆管，右肝管整形后与空肠Y形吻合。结果1例术后死于肝功能衰竭，高位切除肝管的10例中存活10年1例，4年2例，2年2例。结论骨骼化切除、中央肝切除、高位肝管切除和胆肠引流重建能改善晚期肝门胆管癌的疗效。     

Hepatectomy for cholangiocarcinoma complicated with right umbilical portion: anomalous configuration of the intrahepatic biliary tree

The right umbilical portion (right-sided round ligament) has been discussed as an intrahepatic portal venous anomaly associated with "left-sided gallbladder" in several reports. We treated two patients with right umbilical portion (RUP) associated with cholangiocarcinoma. Left hepatectomies were performed, preserving the residual hepatic blood flow and biliary continuity. From our experience in these patients we propose the presence of anomalous configuration of the intrahepatic biliary tree in RUP, because both patients showed medial segmental bile ducts ramified from the right and left hepatic ducts. In general, although the medial segmental bile duct ramified from the left, we surmised that this abnormal bilateral drainage pattern may not be a rare phenomenon in RUP. Special attention may be required to focus on the anatomy of the portal tributaries and biliary ramifications in RUP. Received for publication on July 7, 1999; accepted on Nov. 11, 1999