Liver resection for bile duct cancer

Hilar cholangiocarcinoma is now diagnosed more frequently, and modern diagnostic methods allow a much more precise definition of the extent of disease, which assists in planning the therapeutic approach. Resection of tumors at the confluence of the bile ducts is possible in 20 per cent of patients. When the tumor extends along the hepatic ducts into the right or the left side of the liver, excision may be combined with partial hepatectomy. Involvement of the portal vein and hepatic artery do not necessarily preclude resection. The operative mortality rate of partial hepatectomy for hilar cholangiocarcinoma is about 10 per cent, and median survival after operation is approximately 22 months, with a few long-term cures reported. The quality of survival after the excision of tumor and biliary-enteric reconstruction is very good and indeed appears to be better than that after palliation by biliary decompression alone.     

Bypass procedure for bile duct cancer

In spite of the great advances made in diagnostic procedures and patient management, and the aggressive attitude adopted by most surgeons, a sizable portion of bile duct cancer remains unresectable and should be treated by palliative procedures. We reviewed 93 patients with bile duct cancer treated in our department during the 20-year period from 1965 to 1984, and found that biliary enteric anastomosis offers the best palliation with acceptable mortality and complication rates and increases length of survival and improves quality of life. For proximal third bile duct cancer, the approach in the plane of the falciform ligament by Bismuth and Corlette and the anastomosis of the duct of the lateral inferior segment, segment III, or anterior inferior segment, segment V, to a Roux-Y jejunal loop is recommended because of its sufficient size, accessibility, and distance from the tumor. For middle and distal thirds bile duct cancer, hepaticodochojejunostomy (Roux-Y) is preferred by first transecting the common hepatic or common bile duct and anastomosing it to the Roux-Y jejunal loop to delay encroachment by the distally located bile duct cancer.

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Resumen A pesar del notable avance logrado en los procedimientos de diagnóstico, en el manejo general del paciente, y en la actitud de agresividad adoptada por la mayoría de los cirujanos, una porción considerable de los pacientes con cáncer de la vía biliar se mantiene no resecable y debe ser tratado mediante procedimientos paliativos. Hemos revisado 93 pacientes con cáncer de la vía biliar manejados en nuestro departamento en los Últimos 20 años, entre 1965 y 1984, y encontramos que la anastomosis bilioentérica ofrece la mejor paliación con tasas aceptables de mortalidad y de complicaciones, y provee una supervivencia de major calidad y más prolongada. Para el cancer del tercio proximal del canal biliar se recomienda el aproche en el piano del ligamento falciforme de Bismuth y Corlette y la anastomosis del canal del segmento lateral inferior, del segmento III, o segmento anterior inferior, del segmento V, a un asa yeyunal de Roux-en-Y, por ser de calibre suficiente, por su asequibilidad, y por la favorable distancia del tumor. Para los cánceres del tercio medio y del tercio distal se prefiere la hepaticoyeyunostomía (Roux-en-Y) con trasección del canal hepático comÚn o del colédoco y anastomosis al asa yeyunal de Roux-en-Y con el objeto de retardar la invasión o compresión por el cáncer ubicado en la porción distal.

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Résumé Malgré les grands progrès effectués dans les domaines du diagnostic, de la préparation du malade, et de l'attitude chirurgicale (plus entreprenante que par le passé) de nombreux cancers de l'arbre biliaire ne peuvent Être traités par l'exérèse et relèvent seulement d'une intervention palliative. Les auteurs, en se livrant à l'étude analytique de 93 cas de cancer des voies biliaires traités dans leur département de 1965 à 1984, aboutissent à la conclusion que l'anastomose bilio-digestive est la meilleure méthode de traitement palliatif car le taux de la mortalité et des complications est acceptable alors mÊme que la durée d'une survie de qualité est prolongée. Les cancers de la partie haute de l'arbre biliaire relèvent d'une anastomose entre une anse jéjunale montée en Y selon la technique de Roux et le canal du segment III abordé dans le plan du ligament falciforme (canal du segment latéral inférieur) et le canal du segment V (canal du segment antérieur inférieur) en raison du diamètre suffisant des canaux, de leu facilité d'accès et de leur éloignement de la tumeur. En ce qui concerne les cancers de la partie moyenne ou de la partie inférieure de la voie biliaire principale, l'intervention de choix est représentée par la constitution d'une anastomose hépatico ou cholédoco-jéjunale sur anse en Y après section du canal hépatique ou du cholédoque de manière à retarder l'extension à l'anastomose du processus tumoral.

     

Endoscopic retrograde drainage for bile duct cancer

Endoscopic biliary drainage is a palliative measure. It is mainly indicated for inoperable malignant jaundice. Extrahepatic obstructions are suitable for the transpapillary decompression, which may be successful in 80–90% of patients. Morbidity and mortality rates are approximately 5% and 1–2%, respectively. Tumors of the hilum region, which usually already involve the intrahepatic ducts, are less eligible for drainage treatment. In the case of insufficient drainage, cholangitis may occur. A satisfactory decompression can only be achieved if both hepatic ducts are catheterized. Apart from the technique, the long-term results of the drainage treatment also depend on the consistency of the follow-up. A regular check of the patients is required because, after an average of 3 months, the biliary stent may be occluded, which is usually followed by cholangitis.

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Resumen El drenaje biliar endoscópico es una medida paliativa; está principalmente indicada en la ictericia por neoplasia maligna. Las obstrucciones extrahepáticas son susceptibles de descompresión transpapilar, procedimiento que puede ser exitoso en 80–90% de los pacientes. La morbilidad y mortalidad son del orden de 5% y 1–2%, respectivamente. Los tumores de la región biliar, que usualmente presentan invasión de los canales intrahepáticos, son menos adecuados para drenaje. La colangitis puede ocurrir cuando el drenaje ha sido insuficiente, y una descompresión verdaderamente satisfatoria sólo puede ser lograda cuando ambos canales hepáticos son cateterizados. Aparte de la técnica utilizada, los resultados a largo término del tratamiento mediante drenaje también dependen de la consistencia del seguimiento. Se requiere un programa regular de control de los pacientes, porque después de los 3 meses los catéteres biliares pueden ocluirse, lo cual generalmente da lugar a colangitis.

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Résumé Le drainage biliaire rétrograde constitue une méthode palliative de traitement. Il est indiqué essentiellement lorsque l'ictère néoplasique ne peut Être traité chirurgicalement. Les obstructions extra-hépatiques relèvent de cette méthode qui est efficace dans 80–90% des cas. Les taux de morbidité et de mortalité sont respectivement de 5% et de 1–2% environ. Les tumeurs biliaires qui envahissent rapidement les canaux biliaires intra-hépatiques répondent plus rarement à cette méthode. Lorsque le drainage est insuffisant l'angiocholite est une complication fréquente. La décompression biliaire qu'il exerce n'est efficace que si les deux canaux hépatiques sont drainés. Le résultat à long terme du drainage dépend d'une surveillance stricte. Les malades doivent Être examinés à intervalles réguliers car après 3 mois en moyenne l'obstruction du drain n'est pas rare, obstruction à l'origine de l'angiocholite.

     

The role of intraoperative radiation therapy in the treatment of bile duct cancer

Since October, 1976, we have treated a total of 81 patients with bile duct cancer. Fifty of these patients had cancer that originated at and/or infiltrated into the main hepatic ducts. Five patients had cancer on the upper to middle portion, 19 on the middle to intrapancreatic bile duct, and the remaining 7 had diffusely involved tumors. Fifty of the 81 patients underwent resections. Of the 50 patients, 33 received curative or noncurative resection alone, 14 were treated by resection plus intraoperative radiotherapy (IORT), and the remaining 3 received postoperative external irradiation. Thirty-one of the 81 patients did not undergo tumor resection. Of these, 6 had IORT and 4 underwent external radiotherapy after bile drainage. The remaining 21 underwent bile drainage alone. Curative resection achieved the best cumulative 5-year survival rate of 59.3%. IORT plus noncurative resection showed a superior 2-year survival rate of 17,1% compared to 9.0% after noncurative resection alone. Only 1 patient treated by IORT plus bile drainage survived more than 2 years and subsequently died at 34 months. In the earlier stage of the development of the combination therapy with resection and IORT, severe complications were experienced in 9 patients (so treated), including remarkable obstructive changes of the hepatic arteries. In the later stage, resection plus IORT with a reduced single dose (20 Gy), using a smaller field size (3.7±1.4 cm) and beam energy (7.3±3.0 MeV), did not result in complication and produced 2 long-term survivors among 5 patients. Fractionated external irradiation (30–40 Gy/4–5 weeks) has been added to the IORT recently. These results indicate that noncurative resection plus IORT in combination with external radiation would improve the prognosis of the patient with advanced bile duct cancer.

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Resumen A partir de octubre de 1976, hemos tratado 81 pacientes con cáncer de la vía biliar. Cincuenta de estos pacientes presentaban cáncer que se originaba y/o infiltraba los canales hepáticos principales. Cinco tenían cáncer de la región superior a media, 19 de la región media a la intrahepática, y los restantes 7 presentaban tumores de extensión difusa. Cincuenta de los 81 pacientes fueron sometidos a resección. De los 50, 33 fueron tratados mediante resecciones curativas o no curativas solamente, 14 mediante resección más radioterapia intraoperatoria (RTIO), y los 3 restantes recibieron radioterapia externa postoperatoria. Treinta y uno de 81 pacientes no fueron sometidos a resección. De estos, seis tuvieron RTIO y 4 radioterapia externa después de drenaje biliar. Los 21 restantes tuvieron drenaje biliar solamente. La resección curativa logró la mejor tasa de supervivencia acumulada a 5 años, 59.3%. La RTIO más resección no curativa exhibió una tasa de supervivencia a 2 años de 17.1%, superior a la de 9.0% de los pacientes sometidos a resección solamente. Con la RTIO combinada con drenaje biliar, sólo un paciente sobrevivió más de 2 años y murió a los 34 meses.En la etapa inicial de desarrollo de la terapia combinada de resección y RTIO, se presentaron complicaciones severas en 9 pacientes así tratados, incluyendo alteraciones severas de las arterias hepáticas. En la etapa siguiente, la resección combinada con RTIO de dosis única (20 Gy) utilizando un campo de menor extensión (3.7±1.4 cm) y menor energía (7.3±3.0 MeV) no resultó en complicaciones y produjo 2 supervivencias a largo plazo entre 5 pacientes. Recientemente se ha añadido la irradiación externa fraccionada (30–40 Gy/4–5 semanas) a la RTIO. Los resultados indican que la resección no curativa más RTIO en combinación con irradiación externa podrían mejorar el pronóstico del paciente con cáncer avanzado de la vía biliar.

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Résumé Depuis octobre 1976, les auteurs ont traité 81 malades porteurs d'un cancer biliaire. Cinquante d'entre eux présentaient un cancer qui prenait son origine et/ou infiltrait les canaux biliaires principaux dont 5 cancers de la partie haute ou de la partie moyenne de l'arbre biliaire, 19 de la partie moyenne et de la partie intra-pancréatique, 7 diffus. Cinquante des 81 lésions furent réséqués. Des 50 opérés: 33 furent traités par exérèse isolée à titre curatif ou palliatif, 14 par exérèse et irradiation per-opératoire, 3 par irradiation externe post-opératoire. Trente et un des 81 malades ne subirent pas d'exérèse: 6 furent traités par irradiation intra-opératoire, 4 par irradiation externe après mise en place d'un drainage biliaire, 21 par simple drainage. La survie à 5 ans fut de 59.3% après exérèse curative. La survie à plus de 2 ans fut de 17.1% après exérèse palliative complétée par irradiation et de 9% après simple exérèse. Un seul malade survécut 34 mois après irradiation opératoire et drainage biliaire.Au début de cette expérience thérapeutique combinant l'exérèse et l'irradiation opératoire, 9 malades dévelopèrent des complications sévères dues en particulier à l'obstruction des artères hépatiques. Ultérieurement en employant une seule dose de 20 grays, un champ d'irradiation plus petit (3.7±1.4 cm) et une source plus forte d'energie (7.3±3.0 MeV). Ces complications furent évitées et 2 malades sur 5 bénéficièrent d'un longue survie. Récemment à l'irradiation peropératoire a été ajoutée une irradiation externe fractionnée (30–40 grays/4–5 semaines). Ces résultats démontrent que l'exérèse palliative de la tumeur associée à l'irradiation interne peropératoire et à l'irradiation externe postopératoire est susceptible d'améliorer le pronostic du cancer biliaire parvenu à un stade évolutif avancé.

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Supported in part by Grant-in-Aid for Cancer Research, No. 60-13, Ministry of Health and Welfare, Japan.     

Preneoplastic conditions underlying bile duct cancer

Background

Malignancies arising from the biliary tract can arise from the epithelial lining of the biliary tract and surrounding tissues. Conditions that predispose to malignancy as well as preneoplastic changes in biliary tract epithelia have been identified. In this overview, we discuss preneoplastic conditions of the biliary tract and emphasize their clinical relevance.

Results

Chronic biliary tract inflammation predisposes to cancer in the biliary tract. Biliary tract carcinogenesis involves a multistep process as a consequence of chronic biliary epithelial injury or inflammation. Reminiscent of other gastrointestinal epithelial malignancies such as gastric, colon, and pancreatic cancer, biliary tract cancers may evolve via multistep progression from epithelial hyperplasia and dysplasia to malignant transformation. The potential role of initiating cells is also becoming recognized.

Conclusions

In spite of improved risk factor recognition, and advances in diagnostic tools, the early diagnosis of pre-malignant or malignant biliary tract conditions is extremely challenging, and there is a paucity of evidence on which to base their management. As a result, the role of pre-emptive surgery remains largely undefined.     

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目的研究不同的手术方式对远端胆管癌预后的影响。方法回顾分析1996年2月至2002年12月手术治疗的173例远端胆管癌的临床资料。结果与姑息性手术相比,根治性手术明显提高了长期生存率。空肠胰腺套入式吻合组与空肠(侧对端)黏膜对黏膜吻合组比较、胰管支撑管置于肠腔内不加T管组与T管、胰管支撑管引出体外组比较,胰瘘发生率差异无显著意义。胆肠单层吻合与双层吻合相比,胆瘘发生率差异无显著意义,但双层吻合有2例术后出现一过性黄疸。结论选择适当的手术方式是获得良好疗效的保证,对胰十二指肠切除术或扩大胰十二指肠切除术适应证的确定以及如何防治术后肝转移是进一步探索的问题。     

Prognostic factors after pancreatoduodenectomy for distal bile duct cancer

Prognostic factors influencing long-term survival after radical resection for distal bile duct cancer have not been well established because of the rarity of this malignancy. The goal of this study was to identify main prognostic factors in patients undergoing pancreatoduodenectomy for distal bile duct carcinoma. A retrospective study consisting of 122 patients with distal bile duct cancer who underwent pancreatoduodenectomy in three major university hospitals was performed to identify the main prognostic factors. Major surgical complications occurred in 40 patients (32.8%), of whom eight died (6.6%) in the hospital. Overall actuarial survival (excluding hospital deaths) at 1-, 3-, and 5-year follow-up was 82.9, 49.4, and 32.7 per cent, respectively, with a median survival of 36 months. Univariate analysis showed that papillary tumor (P = 0.045), negative surgical margin (R0 resection, P = 0.005), earlier pT (P = 0.005), pTNM stage (P < 0.001), and absence of lymph node involvement (P < 0.0001) were significant predictors of survival. On multivariate analysis, only lymph node metastasis was shown to be an independent prognostic factor of survival (P = 0.036). Lymph node involvement was the most important survival predictor after a Whipple resection in patients with distal cholangiocarcinoma.     

Hepatopancreatoduodenectomy: its suitability for bile duct cancer versus gallbladder cancer

Background/Purpose We aimed to determine whether bile duct cancer (BDC) or gallbladder cancer (GBC) was a better candidate for hepatopancreatoduodenectomy (HPD). Methods Ten patients with BDC and ten with GBC were treated by HPD with major hepatectomy between 1994 and 2004 and compared, in terms of surgical outcome and survival. Results In the BDC patients, the International Union Against Cancer (UICC) stage was I in three patients; II in four; III in one; and IV in two; of the GBC patients, one was stage II; four were stage III; and five were stage IV. The reasons for choosing HPD for BDC were: superficial spreading, in three patients; intramural wide invasion, in five; and hepatoduodenal ligament (HDL) invasion, in two; and for GBC, extrahepatic bile duct invasion, in seven; and HDL invasion, in three. The morbidity and mortality rates for BDC and GBC were 40% and 60%, and 0% and 30%, respectively. All three of the GBC patients who died in hospital had undergone a right trisectionectomy with caudate lobectomy. The cumulative 5-year survival rate of the BDC patients was 64%; the 1-year survival rate for the GBC patients was only 20%, and none survived for over 2 years (P < 0.001). Of the patterns of BDC cancer invasion, the superficial-spreading type appeared to have a better prognosis than the others, but the difference was not statistically significant. Conclusions HPD is indicated for any type of BDC, but HPD did not show any survival benefits in treating patients with GBC with obstructive jaundice.     

Treatment and prognosis in bile duct cancer

Over the past 30 years, a total of 165 patients with bile duct cancer have been studied at the University of California at Los Angeles (UCLA), U.S.A. A review of careful retrospective analyses of surgical treatment is presented. The data support a treatment strategy of resection of those tumors which can be grossly removed at operation. Palliation of other patients is best done by biliary-enteric bypass or operative intubation. The higher morbidity and mortality rates for palliative resections, together with a poorer quality of life in those patients surviving this procedure, argue against resection for palliative purposes.

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Resumen Se realizó un cuidadoso análisis retrospectivo del tratamiento quirúrgico en 165 pacientes con cáncer del canal biliar manejados en la Universidad de California de Los Angeles, Estados Unidos, en el curso de los pasados 30 años. Los datos obtenidos dan apoyo a la estrategia terapéutica de resección de aquellos tumores que pueden ser totalmente removidos mediante la operación, pero la resección paliativa de cánceres altos de la vía biliar, con o sin resección hepática, aparece asociada con mayores tasas de morbilidad y mortalidad operatoria y no resulta en mejor supervivencia que la observada con intubación biliar. La mejor paliación en estos casos se obtiene mediante derivación bilioentérica o intubación operatoria. Las mayores tasas de morbilidad y mortalidad de las resecciones paliativas, junto con una más pobre calidad de la vida de los pacientes que sobreviven el procedimiento, son argumenta suficiente en contra de la resección con propósitos paliativos solamente.

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Résumé Une analyse rétrospective soignée du traitement chirurgical de 165 malades atteints d'un cancer des canaux biliaires et opérés à UCLA, au cours des 30 dernières années est présentée par l'auteur. Cette analyse lui permet de définir la stratégie à suivre pour réséquer les tumeurs qui peuvent être extirpées presque totalement par la chirurgie. Dans les autres cas le traitement relève de la constitution d'une dérivation bilio-digestive ou de l'intubation transtumorale chirurgicale. Les taux élevés de la mortalité et de la morbidité des résections palliatives allant de pair avec une pauvre qualité de la survie s'inscrivent contre ce genre d'intervention.

     

Management of cancer of the bile duct

Tumors of the bile duct are uncommon. Most patients will present with a syndrome of obstructive jaundice, but in a few patients the tumor can mimic benign disease of the biliary tract. Cholangiography continues to be the basis of diagnosis and gives important information for a decision on therapy. Histologic diagnosis is helpful when available, although frequently difficult to obtain and not always possible. The overall prognosis for these patients remains poor. Currently, a multidisciplinary approach is required to select for each patient the best therapy with the lowest morbidity and mortality. It should include a surgeon, gastrointestinal endoscopist, interventional radiologist, and radiotherapist. The prognosis for a patient appears to be related to the tumor's location, resectability, and, in our experience, differentiation. Therapy should be tailored to each patient based on location of the tumor, extent of the disease, condition of the patient, expertise available in each institution, and morbidity and mortality associated with each procedure. At the Lahey Clinic, the resectability rate for bile duct tumor is currently 25 per cent. Resection is more frequently possible for tumor of the distal bile duct and can result in a five-year survival rate of up to 30 per cent. For patients with unresectable distal tumor at the time of operation, a proximal hepaticojejunostomy is the palliative procedure of choice. If nonresectability of a distal tumor is determined before operation, the decision to proceed with an endoscopic placement of a stent versus surgical hepaticojejunostomy or placement of a T tube needs to be an individual one. Although five-year survival for tumor of the proximal bile duct is anecdotal, those patients who undergo resection have the longest survival and may have better palliation than those who undergo strictly palliative, nonresective procedures. To warrant exploration for resection of tumor of the proximal bile duct, careful patient selection is required, and the morbidity and mortality of operation must be minimized. An increasing role of percutaneous transhepatic techniques of decompression of the biliary tract is expected as they improve and gain wider acceptance. They are the procedures of choice in very high-risk surgical patients or in patients determined before operation to have unresectable disease. Improvement in the survival of patients with cancer of the bile duct probably depends on development of better adjuvant therapy, such as new techniques of radiation therapy and new modalities of chemotherapy, in association with surgery or with a percutaneous or endoscopic intubation technique.     

Spreading patterns of hilar bile duct cancer

Spreading patterns of hilar bile duct cancer were investigated based on cases resected in our institution and reported cases in Japan. Forty-seven patients underwent resection in our institution during the past 20 years. Three patients(12%) survived for more than 5 years. The depth of tumor invasion was m or fm in 4 and se or si in 26 patients. Positive cancer invasion in the cut end was classified as hm2 or dm2 in 8 patients and em2 in 13. Twenty-four (60%) of 40 patients investigated histologically had positive lymph node metastases. Invasion of the ss layer or deeper perineural invasion occurred in 92.5%. In terms of direct invasion of the liver, hinf1 occurred in 20(42.6%). Fourteen(29.8%) han invasion of the portal vein(more than vs1). Patients with invasion of the hepatic artery were not resected. The 5-year survival rate by cancer stage was 38% in stage I, 20% in stage II, 16% in stage III, and 0% in stage IV. Surgery was assessed as Cur A in 19 patients (46.3%), Cur B in 7 (17.1%), and Cur C in 15 (36.6%). In Cur A patients the 5-year survival rate was 18%, while that for our Cur B and Cur C patients was 0%. Our patient series was more advanced in terms of cancer stage than the statistical Japanese series and both included a significant number of noncurative cases. Hepatic resection of the right or left lobe, medial segment, and S4a and S5, combined resection of the caudal lobe, and combined portal vein resection are important as radical surgery in the treatment of this cancer.     

Radical surgery for middle and distal thirds bile duct cancer

A total of 38 patients with middle and distal thirds bile duct cancer treated in our department during a period of 20 years were reviewed and analyzed in respect to the type of operative procedures employed and the long-term results. The purpose of the study was to evaluate the impact of various recently available modalities for diagnosis and treatment on the prognosis of patients with these malignancies. The longest mean survival was 22.8 months after resection and the shortest was 3.5 months after intubation. Resectability increased during the course of the study, especially for distal bile duct cancer, and reached 70% in the last 10 years. Either local excision of the bile duct or pancreatoduodenectomy was chosen as a radical operative procedure for middle bile duct cancer, however, curative resection was obtained only by the latter. Pancreatoduodenectomy was the only choice of radical treatment for distal thirds bile duct cancer. Postoperative morbidity decreased during the last 10 years and preoperative biliary decompression significantly improved the postoperative survival time.

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Resumen Un total de 38 casos de cáncer del canal biliar medio y distal tratados en nuestro departamento en el curso de los Últimos 20 años fue revisado y analizado en cuanto al tipo del procedimiento operatorio empleado y los resultados a largo plazo; ésto con el fin de valorar el impacto de las diversas modalidades de terapia quirÚrgica recientemente asequibles sobre el pronóstico de los pacientes con cancer de la vía biliar de los tercios medio distal.La supervivencia media más prolongada fue de 22.8 meses después de la resección, y la más corta fue de 3.5 meses después de intubación. La resectabilidad se vio aumentar en una etapa del estudio, especialmente para los cánceres del tercio distal, y alcanzó a ser de 70% en los Últimos 10 años. La resección local del canal biliar o la pancreatoduodectomía fue escogida para los cánceres del tercio medio como forma radical de procedimiento operatorio. Sin embargo, resección curativa sólo pudo ser realizada mediante la pancreaticoduodenectomía, y para los cánceres del tercio distal ésta es la Única escogencia de tratamiento radical. La morbilidad postoperatoria decreció en el curso del ultimo decenio y la descompresión biliar mejoró en forma significativa el tiempo de supervivencia postoperatoria.

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Résumé Les auteurs ont étudié à posteriori et analysé les 38 cas de cancers de la partie moyenne et de la partie inférieure de la voie biliaire principale qu'ils ont traités au cours des 20 dernières années. Leur analyse concerne les opérations pratiquées et leurs résultats à long terme de faÇon à évaluer l'impact sur le pronostic des différentes interventions devenues disponibles.La survie la plus longue fut de 22.8 mois après exérèse et 3.5 mois après intubation. Le taux d'exérèse s'est accru avec le temps, en particulier en ce qui concerne les cancers de la partie inférieure, pour atteindre 70% au cours des 10 dernières années. L'exérèse du segment intermédiaire de la voie bilaire principale et la duodéno-pancréatectomie à titre curatif ont été employées pour traiter les cancers de ce segment mais en fait c'est cette dernière opération qui a un potentiel curatif. Elle représente d'ailleurs l'opération de choix pour les cancers de la partie inférieure de la voie biliaire principale. La morbidité postopératoire a diminué dans les 10 dernière années, le drainage biliaire décompressif préopératoire ayant été à l'origine d'une augmentation de la survie post-opératoire selon les auteurs.

     

Isolated caudate lobectomy with pancreatoduodenectomy for a bile duct cancer

Background

In patients with distal bile duct cancer involving the hepatic hilus, a major hepatectomy concomitant with pancreatoduodenectomy (HPD) is sometimes ideal to obtain a cancer-free resection margin. However, the surgical invasiveness of HPD is considerable.

Patients and methods

We present our treatment option for patients with distal bile duct cancer showing mucosal spreading to the hepatic hilum associated with impaired liver function. To minimize resection volume of the liver, an isolated caudate lobectomy (CL) with pancreatoduodenectomy (PD) using an anterior liver splitting approach is presented. Liver transection lines and bile duct resection points correspond complete with our standard right and left hemihepatectomies with CL for perihilar cholangiocarcinoma.

Results

Total operation time was 765 min, and pedicle occlusion time was 124 min, respectively. Although the proximal mucosal cancer extension was identified at both the right and the left hepatic ducts, all resection margins were negative for cancer.

Conclusions

Isolated CL with PD is an alternative radical treatment option for bile duct cancer patients with impaired liver function.