Intrahepatic Repair of Bile Duct Injuries. A Comparative Study

Introduction The frequency of bile duct injuries associated to cholecystectomy remains constant (0.3–0.6%). A multidisciplinary approach (endoscopical, radiological, and surgical) is necessary to optimize the outcome of the patient. Surgery is indicated when complete section of the duct is identified (Strasberg’s E injuries) requiring a bilioenteric anastomosis as treatment. Nowadays, the most frequent technique used for reconstruction is a Roux-en-Y hepatojejunostomy. Long-term results of reconstruction are related to several technical and anatomic factors, but an ischemic duct (with subsequent scarring) plays a mayor role. In this paper, we report the results of biliary reconstructions comparing the extrahepatic—probably ischemic—to intrahepatic—non ischemic—repairs. Methods We reviewed the files of patients referred to our hospital (third-level teaching hospital) for bile duct repair after iatrogenic injury from 1990 to July 2006. Injury classification, time lapse since injury, surgical repair technique, and long-term follow-up were noted. In all cases, a Roux-en-Y hepatojejunostomy was done. Partial resection of segment IV was performed in 136 patients to obtain noninflamed, nonscarred, nonischemic biliary ducts with the purpose of reaching the confluence and achieving a high-quality bilioenteric anastomosis. An anastomosis at the level of the confluence was attempted in 293 patients (in 198 the confluence was preserved and in 95 it was lost). In the remaining 80 patients, a low bilioenteric anastomosis was done at the level of the common hepatic duct. We compared intrahepatic (198) and extrahepatic (80) repairs. Results A total of 405 cases (88 males, 317 females) were identified, with a mean age of 42 years (range 17–75). All of the injuries were classified as Strasberg E1, E2, E3, E5 (less frequent); those with E4 classification (separated ducts) were excluded. In all cases, the confluence was preserved (N = 293). Thirty-two cases were repaired minutes to hours after the injury occurred. The remaining 373 patients arrived weeks after the injury. In 198 cases, an intrahepatic repair was done, including the 136 in which resection of segments IV and V was part of the surgery. In the remaining 80 cases (operated between 1990 and 1997), an extrahepatic repair was done at the level of the common hepatic duct where the surgeon found a healthy duct. Twelve (15%) of the 80 cases with extrahepatic anastomosis required a new intervention (surgical or radiological), compared to only 8 of the 198 (3%) that had an intrahepatic anastomosis (P = 0.00062). Good results were obtained in 85% and 97% of the cases with extrahepatic anastomosis and intrahepatic anastomosis, respectively. Both groups had a reintervention rate of 7% (20/278). Conclusions An intrahepatic anastomosis requires finding nonscarred, nonischemic ducts, thus allowing a safe and high-quality anastomosis with significantly better results when compared to the low-level anastomosis group.     

Early versus late repair of bile duct injuries

Biliary injuries associated with laparoscopic cholecystectomy occur at a constant rate of 0.3% to 0.6%. The spectrum of injures ranges from small leaks of bile to complete section of the main ducts requiring bilioenteric reconstruction. The goal of biliary reconstruction is to obtain a high-quality bilioenteric anastomosis that will not malfunction for a long time. No prospective, controlled, randomized trial (evidence level 1) has been conducted that shows whether an early repair is better than a late one. The timing of the operative procedure should be individualized. A complete examination of the patient should be performed to identify the type of injury and coexistent comorbidities. For septic patients and those with multiple organ dysfunction syndrome, the repair should be delayed. Maneuvers to drain the bile ducts can be performed to relieve jaundice and cholangitis in these patients. For these cases, the surgery should be delayed. If a stable patient is found, without comorbidities, the operation can be scheduled earlier. Subhepatic drains should not be left for a long period because of the risk for intestinal fistulization. If needed, they should be changed for transhepatic stents. High-quality bilioenteric anastomoses are performed with fine absorbable sutures for healthy ducts (nonscarred, noninflamed, nonischemic) in a wide opening, with anastomosis of a (tension-free) defunctionalized jejunal limb. Individualization of the patient is the best rule.     

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.     

Technique of bile duct reconstruction and management of biliary complications in right lobe living donor liver transplantation

From December 1999 to January 2002, 50 right lobe living donor liver transplantations were performed. The donor operations included an intraoperative cholangiography to elicit variations in bile duct anatomy. The biliary reconstruction was done whenever possible as an end-to-end microanastomosis of the donor right hepatic duct with the recipient's bile duct. As a result of the early segmental branching of the donor biliary tree, two segment bile ducts had to be anastomosed in 20 patients and three segment bile ducts in three patients. In 12 patients, a Roux-en-Y hepaticojejunostomy was performed. All anastomoses were drained externally. We observed two leakages at the resection surface which could be treated successfully by an external drainage. Six leaks occurred at the site of end-to-end biliary anastomoses. Twice the problem could be conservatively solved placing a stent percutaneously. In two patients a hepaticojejunostomy was performed after a bile duct necrosis. In two patients with an anastomotic leak, occurring 3 d, respectively, 3 month after the original transplantation, the bile duct could be directly reconstructed over a T-tube. Two anastomotic stenoses were observed, one in combination with a leak treated by percutaneous stent implantation and the second, 3 month after transplantation which was treated surgically. Biliary reconstruction after living donor liver transplantation requires microsurgical techniques and can be performed as a direct end-to-end anastomosis in most cases. Biliary complications were treated by percutaneous drainage or surgical revision in all cases.     

Biliary duct injury: partial segment IV resection for intrahepatic reconstruction of biliary lesions.

A technique for intrahepatic reconstruction of the biliary tree after complex high injuries is described. The fundament of the procedure is the removal of a wedge of segment IV at the level of the hilar plate. When the hilar plate is reached and no adequate exposure of the ducts can be obtained, removing a 1 x 1-in wedge of segment IV between the gallbladder bed and the round ligament exposes the left and right ducts. An anteroposterior view of the plate is obtained instead of a caudocephalic dissection, exposing healthy, nonscarred ducts for reconstruction. We have used this approach in 22 patients, and adequate exposure of the ducts has been obtained, with a high success rate of patency of the anastomosis at a mean follow-up of 3 years. Twenty patients have a patent anastomosis, with a good quality of life and no restenosis.     

Intrahepatic Bilioenteric Anastomosis After Biliary Complications of Liver Transplantation: Operative Rescue of Surgical Failures

Background  Biliary complications after orthotopic liver transplantation (OLT) are multifactorial in origin. In most series, the frequency of such complications ranges from 5–20%. Most can be treated by endoscopy and/or interventional radiology. For cases in which this option is not successful, surgical approach is indicated. We report the results of reoperation using an intrahepatic bilioenteric anastomosis. Methods  The medical charts of patients with biliary complications after OLT during a 10-year period (1997–2007), who failed to respond to nonsurgical treatment and were surgically treated, were reviewed. Roux-en-Y hepatojejunostomy was performed. Segments IV and V were partially removed after cutting the hilar plate, thus obtaining healthy ducts without ischemic or inflammatory reaction and allowing a wide hepatojejunostomy. Results  Five cases (8.4%) with biliary complications after duct-to-duct anastomosis not amenable to further endoscopic management or interventional radiology were identified. Hepaticojejunostomy was achieved in all cases (wide, tension-free, nonischemic, fine hydrolyzable sutures), and segments IV and V were partially removed. No cholangitis, jaundice, and liver function test abnormalities were present in the postoperative. Mean follow-up was 24 months. Only one patient died of causes not related to bile duct reconstruction during follow-up. Conclusions  Intrahepatic hepatojejunostomy with partial resection of segments IV and V offers an excellent therapeutic alternative for biliary complications that require a surgical approach after OLT.     

S4a + S5 With caudate lobe (SI) resection using the Taj Mahal liver parenchymal resection for carcinoma of the biliary tract

Recently we have been performing S4a + S5 with total resection of the caudate lobe (SI) by using a dome-like dissection along the root of the middle hepatic vein at the pinnacle, which we refer to as the Taj Mahal liver parenchymal resection, for carcinoma of the biliary tract. This procedure offers the following advantages: (1) It allows total resection of the caudate lobe, including the paracaval portion (S9), and (2) because the cut surface of the liver is large, it allows intrahepatic jejunostomy to be performed more easily with a good field of view. The indications for this procedure include hilar bile duct carcinoma, gallbladder carcinoma, and choledochal cyst (type IVA). Because of the high rate of hilar liver parenchyma and caudate lobe invasion associated with hilar bile duct carcinoma, the liver must be resected. The Taj Mahal procedure is indicated in cases where extended liver resection is impossible. The dissection limits of this procedure are, on the left side, the B2 + 3 bifurcation at the right margin of the umbilical portion of the portal vein and, on the right side, the B8 of the anterior branch and the B6+7 bifurcation of the right posterior branch. This procedure could also be described as a reduced form of extended right hepatectomy and extended left hepatectomy. For gallbladder carcinoma, this procedure is indicated to ensure an adequate surgical margin and eradicate transvenous liver metastasis, particularly in cases of pT2 lesions. Hilar and caudate lobe invasion also occurs in liver bed-type gallbladder carcinoma, and bile duct resection and caudate lobe resection are required for the surgery to be curative. We performed this procedure in four cases of hilar bile duct carcinoma, five cases of gallbladder carcinoma, and one case each of choledochal cyst (type IVA) with carcinoma of the bile duct and gallbladder adenomyomatosis. Curative resection was possible in all except the patient with adenomyomatosis, and all of the patients are alive and recurrence free 10 to 37 months postoperatively. This procedure, in addition to preserving liver function, provides a wide field of view and facilitates reconstruction of multiple intrahepatic bile ducts. Thus it can be said to be a curative operation not only in patients considered high risk but also in those whose hilar bile duct carcinoma is limited to the bifurcation area (Bismuth type IIIa and IIIb) and in gallbladder carcinoma up to pT2 with slight extension on the hepatic side. Presented at the Thirty-Ninth Annual Meeting of The Society for Surgery of the Alimentary Tract, New Orleans, La., May 17–20, 1998 (poster presentation).     

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。     

肝移植术变异胆管胆漏的预防与处理

目的 探讨肝移植术中变异肝管胆漏的预防及治疗.方法 回顾性分析我院3例肝移植术后发生变异肝管胆漏的诊断及预防、治疗方法.3例供肝切取均采用肝肾联合切取的方法,胆管重建方式为胆总管端端吻合.结果 1例右后叶副肝管汇入胆囊管患者在胆管吻合后发现肝门处胆囊管残端胆汁漏出,立即拆除原胆管吻合口,成型后一期吻合,术后痊愈.1例Luschka胆管漏患者术后胆漏经过充分引流漏口自行闭合痊愈,但最后终因肝内外感染而于术后7个月再次肝移植.另一例右后叶副肝管汇入胆总管患者,术中遗漏断端导致术后胆漏.该患者因严重并发症行二次肝移植.结论 了解肝内外胆管的解剖和常见变异形式,供肝修整时仔细辨认肝门组织,提高对存在副肝管及迷走胆管变异的警惕性,对预防肝移植术后胆管断端胆漏的发生非常重要.     

Preliminary study of the anatomy of the venous drainage of the intrahepatic and extrahepatic bile ducts and its relevance to the practice of hepatobiliary surgery

Background : Although there have been many studies of the arterial supply of the biliary system, attempts to study the corresponding venous drainage have been few and all have been incomplete. The purpose of the present investigation is to describe the anatomy of the venous drainage of both the intrahepatic and extrahepatic bile ducts and to determine its relevance to hepatobiliary surgery. Methods : The intrahepatic and extrahepatic venous drainage of the bile ducts was investigated in seven specimens by injecting a solution of 10% gelatin coloured with Alcian blue into the portal vein or the superior mesenteric vein to outline the venous drainage. The specimens were dissected under loop magnification and representative drawings were obtained. Results : The surface of the intrahepatic and extrahepatic bile ducts was covered by a fine venous plexus. On the surface of the supraduodenal common hepatic duct and common bile duct the venous plexus drained laterally into marginal veins, usually two in number and known as the 3 o’clock and 9 o’clock marginal veins. Inferiorly the marginal veins and the venous plexus communicated with the pancreaticoduodenal venous plexus, which in its turn drained into the posterosuperior pancreaticoduodenal vein, a branch of the superior mesenteric vein. Superiorly the marginal veins divided into a number of branches. Some branches followed the left and right hepatic ducts into the liver, communicating with the venous plexus and the adjacent branches of the portal vein. Other branches of variable size entered either segment IV or the caudate lobe or process via the hilar venous plexus. A most important finding was that even after dividing the bile duct and all communicating veins at the upper border of the duodenum, the venous plexus and the marginal veins filled normally to the level of transection. This occurred almost certainly by retrograde filling from above. Conclusion : The satisfactory results of end‐to‐end anastomosis in whole liver transplantation depends partly on the presence of adequate venous drainage. This has been amply demonstrated by the injection studies. This would indicate that the poor results of end‐to‐end repair of the bile duct after surgical trauma results from other factors such as poor technique, devascularization of the cut ends due to trauma, and carrying out the anastomosis under tension. After resection of the hilum for cholangiocarcinoma the venous drainage of the left and right hepatic ducts and their branches depends mainly on the communications between the venous plexus on the ducts and the adjacent branches of the portal vein, even at a lobular or sinusoidal level. The satisfactory results obtained after anastomosis of the left and right hepatic ducts or their branches to a Roux loop of jejunum attest to this. This applies also to the transplantation of segments II and III in paediatric patients from related adult donors and in patients receiving split liver transplants. Finally, the venous drainage at the bifurcation of the common hepatic duct has been shown to enter the caudate lobe and segment IV directly. This suggests that a hilar cholangiocarcinoma may metastasize to these segments, and perhaps partly explain the significantly better long‐term results when the caudate lobe and segment IV are resected en bloc with the cholangiocarcinoma as part of modern radical surgery for this condition.     

Surgical anatomy of the bile ducts at the hepatic hilum as applied to living donor liver transplantation

OBJECTIVE: To evaluate anatomic variations of the biliary tree as applied to living donor liver transplantation. SUMMARY BACKGROUND DATA: Anatomic variability is the rule rather than the exception in liver surgery. However, few studies have focused on the anatomic variations of the biliary tree in living donor liver transplantation in relation to biliary reconstruction. METHODS: From November 1992 to June 2002, 165 patients underwent major hepatectomy with extrahepatic bile duct resection; right-sided hepatectomy in 110 patients and left-sided hepatectomy in 55. Confluence patterns of the intrahepatic bile ducts at the hepatic hilum in the surgical specimens were studied. RESULTS: Confluence patterns of the right intrahepatic bile ducts were classified into 7 types. The right hepatic duct was absent in 4 of the 7 types and in 29 (26%) of the 110 livers. Confluence patterns of the left intrahepatic bile ducts were classified into 4 types. The left hepatic duct was absent in 1 of the 4 types and in 1 (2%) of the 55 livers. CONCLUSIONS: In harvesting the right liver from a donor without a right hepatic duct, 2 or more bile duct stumps will be present in the plane of transection in the graft in 3 patterns based on their relation to the portal vein. Accurate knowledge of the variations in the hepatic confluence is essential for successful living donor liver transplantation.     

肝方叶切除联合肝门胆管高位劈开整形在肝门胆管狭窄合并结石中的应用

背景与目的:对于肝胆管结石多次手术后复发患者,如何安全取尽结石,最大限度解除肝门甚至是肝内胆管的狭窄,并建立或修复通畅的胆流通道,一直是胆道外科治疗领域中的难点。本研究探讨肝方叶切除联合肝门胆管高位劈开整形在肝门胆管狭窄合并结石中的治疗效果及应用价值。方法:回顾性分析2015年7月—2019年6月湖南省人民医院收治的36例复杂肝胆管结石患者的临床资料,36例患者既往平均手术2.4次,均存在不同程度的肝门部胆管狭窄,其中肝门胆管汇合部狭窄18例,合并右肝管狭窄8例,合并左肝管狭窄10例。结果:所有患者均行肝方叶切除、肝门胆管高位劈开整形、胆肠内引流手术,术中采用取石钳取石、塑形管冲洗、胆道镜探查等多种方式取尽结石。平均手术时间354.4 min,平均失血量230.5 mL。术后平均结石清除率在90%以上。术后2例患者出现胆汁漏,经积极引流治疗后好转,3例患者出现切口脂肪液化、感染,1例患者不完全性肠梗阻,均保守治疗后好转。术后采用门诊、电话随访12～48个月,4例患者出现反流性胆管炎,无胆肠吻合口再发狭窄病例。结论:肝方叶切除联合肝门胆管高位劈开整形能有效解除肝门胆管高位狭窄,达到取尽结石、通畅引流的目的,同时能避免大范围的肝切除,因此具有一定的临床应用价值。     

腹腔镜下中下段胆管癌根治术中联合肝动脉切除重建的疗效与安全性：附3例报告（附视频）

背景与目的：中下段胆管癌临床上主要以下段胆管癌多见,下段胆管癌一般采用胰十二指肠切除术,中段胆管癌可以采用胰十二指肠切除术或胆管癌根治、胆肠吻合术。中下段胆管癌因胆管紧邻肝动脉和门静脉,因此更容易发生门静脉侵犯,因肝动脉有动脉外鞘,因此肝动脉受侵犯相对较少,但一旦侵犯,因为涉及肝动脉切除吻合重建,具有较高技术难度,常需联合肝动脉切除重建才能实现R0切除。目前肝动脉切除重建在临床逐渐成熟,但腹腔镜下完成肝动脉切除重建经验缺乏,需要进一步积累。因此,本研究对3例完成腹腔镜下联合肝动脉切除重建的胆管癌患者的临床资料进行回顾性分析并评估短期结果,以期为临床实践提供初步经验。方法：回顾性分析2021年11月—2022年11月中国人民解放军陆军军医大学第二附属医院肝胆外科的3例行联合肝动脉切除重建的中下段胆管癌根治术患者的临床资料。结果：3例患者中女性1例,男性2例,年龄分别为61、65、69岁;病例1为胆管中段癌,因肿瘤侵犯右肝动脉和门静脉,且胆管下端切缘阴性,行联合右肝动脉切除重建、门静脉切除重建、胆管癌切除、胆肠吻合术、肝门部胆管整形术、淋巴结清扫术;病例2为胆管下段癌,因肿瘤侵犯替代右肝动...     

肝内胆管结石再手术治疗分析

目的探讨不同手术方式治疗肝内胆管结石的再手术疗效。方法60例肝内胆管结石患者,按再手术方式分为2组:A组47例,行肝叶(段)切除;B组13例,行非肝叶(段)切除。评估其手术措施及效果。结果A组肝段(叶)切除术中同时行胆管空肠吻合25例,肝断面扩张胆管、肝门胆管与空肠双口吻合10例,T管和U管引流分别为8例和4例。B组均行非肝叶(或肝段)切除术,包括经圆韧带入路取石纠正狭窄5例,经肝表面切开与肝门胆管探查联合手术4例,单纯肝外胆管探查取石、胆肠吻合4例。术后并发症:A组3例,B组5例,两组比较有显著差异(P<0.05)。两组均获随访,时间2～7年,术后结石残留率A、B组分别为4.26%与23.08%,症状复发分别为0和23.08%,两组比较有统计学差异(P<0.05)。结论肝叶(或肝段)切除的各种术式是再手术治疗肝内胆管结石较为有效的手段。     

Bilio-duodenal jejunum interposition as a technical alternative to Roux-Y reconstruction following reconstruction of cancer of the fork of the hepatic duct

The inability to predict preoperatively whether resection will result in tumorfree or at least tumorinfiltrated margins, represents one essential problem in surgical treatment of central bile duct carcinoma. In a certain number of cases the operation ends with a tumorinfiltrated biliodigestive anastomosis usually performed in a Roux-en-Y-technique. In those cases early tumor recurrence is predictable, but any follow-up and treatment by endoscopic methods (laser resection, pigtail drainage) are inhibited by the long jejunal limb of the Roux-en-Y-reconstruction. Therefore we changed our operative procedure in patients with central bile duct carcinomas performing the reconstruction of intestinal bile drainage by a cholangio-duodenal interposition of a 25 cm jejunal segment. This technique now allows endoscopic reintervention in cases of recurrent tumors or benign strictures of the anastomosis which is demonstrated.     

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.     

Successful Duct-to-duct Biliary Reconstruction after Right Hemihepatectomy. Operative Planning Using Virtual 3D Reconstructed Images

Accurate knowledge of partial anatomy is essential in hepatic surgery but is difficult to acquire. We describe the potential impact of a new technique for constructing three-dimensional virtual images of the portal vein, hepatic artery, and bile ducts and present a representative case. An 80-year-old man was suspected of having papillary cholangiocarcinoma arising in S8 of the liver and extending to the hepatic hilum intraluminaly. Right hemihepatectomy with bile duct resection was planned. However, it was uncertain whether duct-to-duct biliary reconstruction would be possible based on the appearance of the confluence of the right and left hepatic ducts on cholangiogram and conventional computed tomograph. Virtual three-dimensional images of the liver were constructed and revealed vascular and biliary anatomy. They showed that the upper margin of bile duct excision would be 19 mm from the umbilical point of the left portal vein, and that the site of the left branch of the caudate lobe bile duct could be preserved. Based on this information, we performed a sphincter-preserving biliary operation safely without complications. Planning complex biliary surgery may be improved by the use of virtual three-dimensional images of the liver. This approach is especially useful in candidates for postoperative regional chemotherapy.     

Congenital cystic dilatation of bile ducts

Congenital cystic dilatation of bile ducts is a rare condition. We report a retrospective study about 18 patients having congenital bile duct cysts. According to Todani's classification, 11 cases were type I and 7 were type V. Six patients from the first group had a pancreatobiliary maljunction. A total resection of the cyst was conducted in the type I cysts. Anatomopathologic examination showed an adenocarcinoma of a common bile duct cyst. In one case, a cancer of the gall bladder associated to a common bile duct cyst in another case. Three patients with segmental dilatation of intrahepatic bile ducts (type V) underwent liver resection. Four patients had a diffuse form, one of them was treated by percutaneous drainage, and in the other cases a hepatojejunostomy was performed. Postoperative course was complicated with acute cholangitis in these four cases. Percutaneous drainage and antibiotics allowed a positive outcome in most of the cases. In one case, secondary biliary cirrhosis occurred as a long-term complication. Congenital cystic dilatation of bile ducts is considered to be a precancer state. Enterocystic anastomosis is proscribed and the resection has to be as complete as possible.     

胆道数字成像技术在活体肝移植肝内胆道解剖分型及胆道切面确定中的应用

目的 评价术中胆道数字成像技术在活体肝移植(living donor liver transplantation,LDLT)肝内胆道解剖分型和胆道切面确定中的作用及临床价值.方法 66例LDLT供者,通过术中胆道数字减影了解胆道分型及变异,结合金属标志物准确选择胆道离断位置,与手术结果比较,分析其在LDLT供者术中胆道解剖描述及切面确定中的作用.结果 所有供者均采用胆道数字成像技术对肝内胆道解剖进行分型,Ⅰ型(经典型)45例(68.2%),Ⅱ型(三叉型,胆总管由右前肝管、右后肝管、左肝管汇合而成)7例(10.6%),Ⅲ型(无右肝管主干,右后肝管汇入肝总管)13例(19.7%),Ⅳ型(无右肝管主干,右后肝管汇入左肝管)1例(1.5%),Ⅴ型(复杂分型)0例(0%).Ⅰ型所有供者均形成单一吻合口;Ⅱ型7例供者中4例形成2个吻合口,3例经成形或非成形后形成1个吻合口;Ⅲ型13例供者中9例形成2个吻合口,4例经成形后形成1个吻合口;Ⅳ型1例供者,2个胆道吻合口.所有供者都完成活体右半肝切取术.结论 术中胆道数字减影结合金属标志物可以精确显示肝内胆道解剖及变异并准确定位肝管切面,减少胆道吻合口数目,有助于供肝的安全获取和移植.

Abstract：

Objective To evaluate biliary digital imaging technology in determining the type of the intrahepatic bile duct anatomy and the transection plane of the duct in right lobe living donor liver transplantation(LDLT). Methods Mobile digital subtraction angiography was performed to show the intrahepatic bile duct anatomy of 66 liver transplant donor candidates. Combined with metal markers, the bile duct transection plane was defined. Comparing with the actual results, the effect of digital imaging technology in determining the intrahepatic anatomical variations and transection plane of the duct in LDLT was evaluated. Results Intrahepatic bile duct anatomical variations were showed in all donors by using digital imaging technology. type Ⅰ (classical type) was identified in45 cases (68.2%), type Ⅱ (with triple confluence, the simultaneous emptying of the right anterior segmental duct, right posterior segmental duct and left hepatic duct into the common hepatic duct) in 7 cases ( 10.6% ), type Ⅲ (no right hepatic duct stem, right posterior segmental duct draining into common hepatic duct) in 13 cases ( 19. 7% ), type Ⅳ (no right hepatic duct stem, right posterior segmental duct draining into left hepatic duct) in 1 case (1.5%), and type Ⅴ (complex variation ) in no case (0%). As a result, cases of type Ⅰ form a single anastomosis. In type Ⅱ, four cases formed double anastomoses, three cases formed single anastomosis with or without ductoplasty. In type Ⅲ, two anastomoses were formed in 9 cases, single anastomosis in 4 cases with ductoplasty. The case of type Ⅳ had double anastomoses. In all cases right lobe liver were harvested.Conclusions Biliary digital subtraction image combined with metal markers accurately defines intrahepatic bile duct anatomy and the transection plane, helping to reduce number of bile duct anastomosis, and contributes to safe graft harvesting.     

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