Improved Survival Following Right Trisectionectomy with Caudate Lobectomy without Operative Mortality: Surgical Treatment for Hilar Cholangiocarcinoma

Background  We conducted this study to assess the safety of performing right trisectionectomy with caudate lobectomy for hilar cholangiocarcinoma by analyzing postoperative mortality and morbidity, and to evaluate the effect of such procedure on pathological curability and long-term overall survival. Methods  A retrospective clinicopathological analysis was performed for 16 hilar cholangiocarcinoma patients who underwent right trisectionectomy with caudate lobectomy from June 1999 to April 2003. The median follow-up period was 36.9 months. The preoperative Bismuth–Corlette type was type II in four patients, type III_A in 10 patients, and type IV in two patients. Results  The median liver volume after hepatic resection was 21.9% of the total liver volume. Postoperative complications including one chronic liver failure developed in 12 patients, but no in-hospital deaths occurred. A postoperative pathological examination showed a cancer free margin in all of the proximal resection sites, although three cases had carcinoma in situ (CIS) lesions in the distal margin that were confirmed during surgery. The 1-, 3-, and 5-year overall survival rates were 94.1%, 64.2%, and 64.2%, respectively. Conclusion  We obtained excellent survival rates without any in-hospital deaths following right trisectionectomy with caudate lobectomy. This procedure may be an effective surgical procedure that can be executed to achieve low mortality rate and high pathological curability for hilar cholangiocarcinomas, except for Bismuth type III_B.     

"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.     

Hiläres Cholangiokarzinom

The increasingly performed en bloc resection of liver and hilar tumor has contributed to the improvement of long-term survival in patients with hilar cholangiocarcinoma. Based on preoperative definition of operative strategy we tried to avoid any traumatization of the hilar region. Between September 1997 and September 2002, 82 patients with hilar cholangiocarcinoma were treated at our department. Three patients were excluded from any surgery. The resection rate was 75% (59 of 79); 79% (38 of 48) of en bloc resections of the hilar tumor and adjacent liver were formally curative. The hospital mortality was 7%. The 1- and 3-year survival rates of patients after explorative laparotomy, palliative and curative resection was 27 and 7%, 67 and 26%, 89 and 45% ( p<0.001), respectively. The 1- and 3-year survival rates of patients after en bloc resection were 78 and 49%, respectively. In patients with formally curative en bloc resection ( n=38), the 3-year survival rate was 63%; in patients with N0/R0 resection ( n=31) it was 71%. Lymph node involvement proved to be the only independent prognostic marker if patients who underwent hilar and en bloc resection were included in the multivariate analysis. The R situation was the only significant predictor for patients after en bloc resection. These data justify the extended diagnostic work-up and the principal liver resection in hilar cholangiocarcinoma.     

Liver transplantation for hilar cholangiocarcinoma

Hilar cholangiocarcinoma was accepted as an indication for liver transplantation at the beginning of the transplantation era. Owing to disappointing long-term results for this indication, and in parallel, encouraging results in patients with benign disease, hilar cholangiocarcinoma has generally not been accepted as an indication for liver transplantation in recent years. To improve results, more aggressive approaches have been used: “abdominal organ cluster transplantation” and “extended bile duct resection”, which lead to increased long-term survival rates. However, with improving results after conventional extrahepatic bile duct resection in combination with partial hepatectomy, extended procedures in combination with liver transplantation never became a real option in the treatment of hilar cholangiocarcinoma. However, new awareness of liver transplantation in the treatment of this cancer has been raised for patients with hilar cholangiocarcinoma in the context of underlying liver diseases such as primary sclerosing cholangitis, which preclude liver resection. Current results show increased survival figures, in particular in well-selected patients with early tumor stages. Further improvements in long-term survival may be reached with new adjuvant and neoadjuvant protocols. Patients with neoadjuvant radiochemotherapy show long-term results similar to those for liver transplantation for other indications. Also, photodynamic therapy and the use of new antiproliferative immunosuppressive agents may be an approach for further improvement of the long-term results. Currently, liver transplantation for the treatment of hilar cholangiocarcinoma should be restricted to centers with experience in the treatment of this cancer and should be taken into consideration in patients with contraindications to liver resection.     

肝门部胆管癌根治性切除手术技巧

肝门部胆管癌是具有挑战性的疑难病症,其根治性切除一直是外科医生不断追求的目标之一.围手术期治疗策略的优化,影像学技术的提高,特别是手术器械的改进为肝门部胆管癌治疗的发展起到了重要的推动作用[1].肝门部胆管癌手术策略的制定以及规范化操作是获得满意远期疗效的基础.     

肝门部胆管癌根治性切除手术技巧

Hilar cholangiocarcinoma remains a formi-dable challenge to hepatopancreatobiliary surgeons since the reported resection of a primary cancer originating at the hepatic duct confluence by Brown and Myers in 1954. Emerging evidence has indicated that aggressive surgery with a curative resection offers a better option for long-term survival compared with conservative therapy. Liver transplantation has also been considered as a management opportunity for the treatment of cholangiocarcinoma. However, the survival rate has been poor due to the high proportion of disease recurrence. This review highlights recent techniques in hilar cholangiocarcinoma resec-tion, with special attention to the management of the resection margin, clinical skills of liver resection, lymph node clearance, and portal vein or hepatic artery resection or reconstruction. In addition, technical advances have been proposed in hepatopan-creatoduodenectomy and liver transplantation for hilar cholangio-carcinoma treatment. In the current hepatic procedures, promis-ing survival outcomes have been obtained in patients with hilar cholangiocarcinoma, exhibiting a decreased operative mortality and a steady improvement in long-term survival. Overall, the correct clinical strategy and appropriate surgical techniques may provide an increased chance to cure patients with hilar cholan-giocarcinoma.     

肝门部胆管癌根治性切除手术技巧

肝门部胆管癌是具有挑战性的疑难病症,其根治性切除一直是外科医生不断追求的目标之一.围手术期治疗策略的优化,影像学技术的提高,特别是手术器械的改进为肝门部胆管癌治疗的发展起到了重要的推动作用[1].肝门部胆管癌手术策略的制定以及规范化操作是获得满意远期疗效的基础.     

联合门静脉切除重建的肝脏左三区切除治疗进展期肝门部胆管癌

The clinical value of applying portal vein resection and reconstruction in left trisectionectomy for treating advanced hilar cholangiocarcinoma is approved, while it is still a big challenge for clinicians. One female patient suffering from abdominal pain and jaundice received treatment in the General Hospital of PLA in July, 2009. She was prelimiarily diagnosed with Bismuth type Ⅲ a hilar cholangiocarcinoma. A tube was inserted in the left lateral inferior bile duct to carry out percutaneous transhepatic biliary drainage (PTBD). After the anatomic variation of the left bile duct was found, the diagnosis was revised as Bismuth type Ⅳ. A left trisectionectomy was proposed, and another PTBD tube was inserted in the right posterior bile duct.Combined portal vein resection and reconstruction and left trisectionectomy was successfully performed. The postoperation course was uneventful, except for the transient liver dysfunction and biliary-enteric anastomotic leakage.     

原位肝移植术治疗肝门胆管癌(附10例报告)

目的 研究原位肝移植治疗肝门胆管癌的疗效及分析相关因素.方法 回顾性研究2002-2010年收治的10例肝门胆管癌行原位肝移植患者的临床资料.结果 男:女=8∶2,平均年龄42.5±10.2岁,平均随访时间为5.3年.1年、3年、5年和8年的生存率分别为70.0%、60.4%、50.9%和50.9%;无肿瘤1年、3年、...     

Surgical management of hilar cholangiocarcinoma

OBJECTIVE: To assess the surgical management of hilar cholangiocarcinoma over a time period when liver resection was considered standard management. SUMMARY BACKGROUND DATA: Hilar cholangiocarcinoma remains a difficult challenge for surgeons. An advance in surgical treatment is the addition of liver resection to the procedure. However, liver resection in the setting of liver dysfunction caused by biliary obstruction can be associated with increased mortality. METHODS: Between 1997 and 2004, 80 patients with hilar cholangiocarcinoma having surgery were reviewed. Fifty-three patients had attempted curative resections, 14 patients had palliative bypasses, while 13 patients had findings that precluded any further intervention. Twenty-three patients required portal vein resection and reconstruction to achieve negative margins, 3 of which also required reconstruction of the hepatic artery. RESULTS: Patients undergoing resection had a 9% operative mortality, with morbidity of 40%. Patients who demonstrated lobar hypertrophy preoperatively due to tumor involvement of the contralateral liver or induced with portal vein embolization (PVE) had a significantly lower operative mortality than those patients without hypertrophy. Median overall survival in patients resected was 40 months, with 5-year survival of 35%. Negative margins were achieved in 80% of cases and were associated with improved survival. Five-year survival in patients undergoing resection with negative margins was 45%. CONCLUSION: Combined liver and bile-duct resection can be performed for hilar cholangiocarcinoma with acceptable mortality, though higher than that for liver resections performed for other indications. The use of PVE in cases where hypertrophy of the remnant liver has not occurred preoperatively may reduce the risk of operative mortality.     

Right hepatic trisectionectomy for hepatobiliary diseases: results and an appraisal of its current role

OBJECTIVE: To assess the results of 275 patients undergoing right hepatic trisectionectomy and to clarify its current role. SUMMARY BACKGROUND DATA: Right hepatic trisectionectomy is considered one of the most extensive liver resections, and few reports have described the long-term results of the procedure. METHODS: Short- and long-term outcomes of 275 consecutive patients who underwent right hepatic trisectionectomy from January 1993 to January 2006 were analyzed. RESULTS: Of the 275 patients, 160 had colorectal metastases, 49 had biliary tract cancers, 20 had hepatocellular carcinomas, 20 had other metastatic tumors, and 12 had benign diseases. Fourteen of the 275 patients underwent right hepatic trisectionectomy as part of auxiliary liver transplantation for acute liver failure and were excluded. Concomitant procedures were carried out in 192 patients: caudate lobectomy in 45 patients, resection of tumors from the liver remnant in 57 patients, resection of the extrahepatic biliary tree in 45 patients, and lymphadenectomy in 45 patients. One-, 3-, 5-, and 10-year survivals were 74%, 54%, 43%, and 36%, respectively. Overall hospital morbidity and 30-day and in-hospital mortalities were 41%, 7%, and 8%, respectively. Survivals for individual tumor types were acceptable, with 5-year survivals for colorectal metastasis and cholangiocarcinoma being 38% and 32%, respectively. Multivariate analysis disclosed the amount of intraoperative blood transfusion to be the sole independent predictor for the development of hospital morbidity. Age over 70 years, preoperative bilirubin levels, and the development of postoperative renal failure were found to be independent predictors of long-term survival. CONCLUSION: Right hepatic trisectionectomy remains a challenging procedure. The outcome is not influenced by additional concomitant resection of tumors from the planned liver remnant. Caution must be taken when considering patients older than 70 years for such resections.     

保留下腔静脉的离体低温右肝扩大切除治疗不可切除IV型肝门部胆管癌

目的:探讨保留下腔静脉的离体低温肝切除治疗不可切除Ⅳ型肝门部胆管癌的效果.方法:回顾性分析2例Ⅳ型肝门部胆管癌患者临床资料,其中1例行保留下腔静脉的原位低温灌注扩大右肝切除术,另1例采用保留下腔静脉的全离体扩大右肝切除治疗.结果:原位低温灌注扩大右肝切除术历时14h,术中输血3 000 mL,然而,患者术后第1天死于多器官功能衰竭.全离体扩大右肝切除术历时15h,术中输血2 000 mL,热缺血时间20 min,冷缺血时间195 min,术后30d出院,无肝衰和其他重大并发症发生,随访11个月,患者仍然存活且无血管、胆管并发症及肿瘤复发和转移.结论:在有复杂肝切除经验和活体肝移植经验的前体下,保留下腔静脉的离体低温肝切除是安全的,且可能是治疗精选的不可切除Ⅳ型肝门部胆管癌的有效选择.     

Expanding indications for liver transplantation in the era of liver transplant oncology

Despite numerous advances and emerging data, liver transplantation in the setting of gastrointestinal malignancies remains controversial outside of certain accepted indications. In an era of persistent organ shortage and increasing organ demand, allocation of liver grafts must be considered carefully. While hepatocellular carcinoma and hilar cholangiocarcinoma have become accepted indications for transplantation, tumor size and standardized multi-disciplinary treatment protocols are necessary to ensure optimal patient outcomes. As more studies seeking to expand the oncologic indications for liver transplantation are emerging, it is becoming increasingly clear that tumor biology and response to therapy are key factors for optimal oncologic outcomes. In addition, time from diagnosis to transplantation appears to correlate with survival, as stable disease over time portends better outcomes post-operatively. Identifying aggressive disease pre-transplant remains difficult with current imaging and tissue sampling techniques. While tumor size and stage are important prognostic predictors for most malignancies, patient and tumor selection protocols are necessary. As the fields of medical and surgical oncology continue to evolve, it is clear that a protocolized interdisciplinary treatment approach is necessary for combatting any cancer effectively. Disease stability over time and response to neoadjuvant therapy may be the best predictors for successful patient outcomes and can be easily incorporated in our treatment paradigms. Current data evaluating liver transplantation for expanded oncologic indications such as: expanded criteria hepatocellular carcinoma, intrahepatic cholangiocarcinoma, mixed tumors, and liver limited metastatic colorectal carcinomas, incorporate multi-modal therapies and evaluation of tumor treatment response. While further investigation is necessary, initial results suggest there is an expanded role for transplant surgery in malignancy in a new era of liver transplant oncology.     

204例肝门部胆管癌的临床分析

目的 探讨肝门部胆管癌的手术疗效及影响其预后的因素.方法 回顾性分析中国医科大学附属第一医院1996年1月至2007年5月收治的204例肝门部胆管癌的临床资料,并进行多因素Cox回归模型预后因素分析.结果 204例按Bismuth-Corlette分型:Ⅰ型18例,Ⅱ型40例,Ⅲa型30例,Ⅲb型53例,Ⅳ型57例.其余6例未分型.术前行彩超、CT检查和MRCP检查与术中Bismuth分型对照,诊断符合率分别为53.7%、76.4%、100%.手术切除肿瘤92例,其中根治性切除(R0)55例,姑息性切除(R1、R2)37例.胆道探查置管引流98例,开腹探查6例,同种异体原位肝移植手术2例.手术切除组和非手术切除组生存率差异有统计学意义(x2=36.4,P<0.01),根治性切除组和姑息性切除组生存率差异有统计学意义(X2=22.9,P<0.05).Cox模型多因素分析表明手术方式、肿瘤细胞分化程度是二个独立的预后因素.结论 肝门部胆管癌的治疗以手术切除为主,只有根治性切除才能达到最佳疗效.     

Novel Multimodality Treatment Sequencing for Extrahepatic (Mid and Distal) Cholangiocarcinoma

Neoadjuvant chemoradiation has demonstrated significant advantages in the management of pancreatic adenocarcinoma. A similar tumor in a nearby anatomical location is extrahepatic cholangiocarcinoma, which has proven to be largely unresponsive to current forms of therapy. Neoadjuvant therapy for hilar cholangiocarcinoma has been combined with surgical resection and/or liver transplantation with a 25–33 % complete pathological response rate. We propose a wider application of neoadjuvant chemoradiation for patients with distal cholangiocarcinoma and present our rationale for this form of treatment sequencing.     

Orthotopic liver transplantation after extended bile duct resection as treatment of hilar cholangiocarcinoma First long-terms results

Abstract Although the surgical treatment of hilar cholangiocarcinoma represents the only potentially curative option, survival figures remain low over the long term. After hilar and partial hepatic resections for hilar cholangiocarcinoma, loco-regional tumor recurrence appears as the primary site of failure. From April 1992 to April 1996, 14 patients underwent extended bile duct resections. Extended bile duct resections combine total hepatectomy, partial pancreatoduodenectomy, and liver transplantation in an attempt to eradicate the entire biliary tract without dissecting the hepatoduodenal ligament. The postoperative 60-day mortality rate was 14% ( n = 2). The rate of curative resections was 93% (13 of 14 extended bile duct resections). One- and 4-year survival rates after curative resections were 56% and 30%, respectively. The rate of curative resections increased by combining total hepatectomy, partial pancreatoduodenectomy, and liver transplantation, i.e., extended bile duct resection. However, survival figures have not improved accordingly. Therefore, this extended surgical procedure has to be implemented with caution and possibly not without modifications (e.g., multimodal treatment).     

改良式高位胆管癌根治术疗效评价

目的分析改良式根治手术治疗高位胆管癌的疗效。方法回顾分析2004年至2009年针对不同临床分期和病理特征分别采用传统胆管癌根治术,改良式胆管癌根治术,肝移植术,肝管置支架引流术及肝穿刺置管外引流等不同手术方法治疗高位胆管癌的疗效。结果本组病例总体手术切除率为95．3％。按美国抗癌症联合会（AJCC）的分型其中根治切除率Ⅰ期,Ⅱ期,Ⅲ期为100％,Ⅳb期则为0（P〈0．05）;不同病理类型的切除率：乳头型100％,结节型93．33％,硬化型93．75％,弥漫型33．33％。手术后总体5年生存率为8．97％。其中Ⅰ期100％,Ⅱ期42．86％,Ⅲ期2．17％,Ⅳ期则为0。术后生存率差异有统计学意义（P〈0．05）。结论改良式根治术与传统根治手术疗效差异无统计学意义,高位胆管癌根治手术的疗效主要与肿瘤的部位、病理类型、临床分期有关。     

肝门部胆管癌行全胰腺十二指肠联合肝脏切除、异体肝移植术1例报告并文献复习（附视频）

背景与目的：肝门部胆管癌是指发生在左右肝管、汇合部以及肝总管上段,起源于胆管上皮细胞的一种恶性肿瘤。由于肝门区结构复杂,肿瘤与门静脉、肝动脉等紧邻,故肝门部胆管癌容易出现血管、神经侵犯以及淋巴结转移;加之位置隐匿,早期缺乏特异性症状,患者往往因出现黄疸等晚期症状才会就诊。目前手术切除仍是改善预后的主要有效治疗方式,但对肝胆外科医生而言,肝门部胆管癌的外科治疗仍然是最为困难的挑战之一。笔者报告1例肝门部胆管癌侵犯胃、十二指肠、胰腺的患者施行全胰腺十二指肠联合全肝脏切除、异体肝移植术的治疗经过,以为该病的诊疗提供更多的参考依据。方法：回顾分析中国人民解放军火箭军特色医学中心与河北医科大学第三附属医院共同完成治疗的1例肝门部胆管癌病例的临床资料,并复习相关文献,总结相关的经验教训。结果：患者为51岁男性,有乙型肝炎病史,因腹腔积液就诊。剖腹探查（肿块为涉及肝脏、胰头、肝十二指肠韧带的一个完整无法分离的区域）与PET/CT检查（肝右叶稍低密度伴FDG代谢增高,伴门静脉主干及右支累及可能,未见明显远处转移）均考虑恶性肿瘤,但术前穿刺活检未能诊断。经讨论后对患者实施了全胰腺十二指肠联合肝脏切除与异...     

肝门部胆管癌外科治疗争议与进展

肝门部胆管癌是指原发于胆囊管开口以上,左、右二级肝管水平以下的肝门区胆管恶性肿瘤,占所有胆道恶性肿瘤的50%~70%。肝门部胆管癌根治性手术切除率低,病人预后差,生存期短。近年来,尽管在诊断和治疗方面取得了一定进展,但在术前胆道引流、门静脉栓塞、手术切除范围选择、联合血管切除重建、微创手术治疗和肝移植治疗等方面仍存在争议。     

联合肝叶和肝门血管切除治疗肝门胆管癌

目的　探讨治疗肝门胆管癌理想的肝叶切除术式 ,以期提高其疗效、降低并发症和病死率。方法　对 16例侵犯肝门血管的肝门胆管癌 ,采用肝I ,IV段连同肝门胆管肿瘤与受侵血管整块切除及肝十二指肠韧带骨骼化淋巴清扫。结果　 15例获手术切除 ,切除率为 93 .8% ,12例获R0 切除。无手术死亡和住院死亡。发生暂时性胆漏 1例 ,腹腔感染 1例 ,并发症发生率为 13 .3 % ,均行非手术治愈。随访病例中位生存期为 2 2个月 ,7例尚存活。结论　合并肝叶、肝门血管切除可提高肝门胆管癌的切除率和生存率 ;肝中叶和肝尾叶是肝门胆管癌手术联合切除的主要部位。肝门受侵血管的切除对提高该病切除率和根治率是有意义的 ,应酌情重建或不重建肝门血管。