Preoperative cholangiography of the caudate lobe: Surgical anatomy and staging for biliary carcinoma

The biliary branches of the caudate lobe (B1) join the right hepatic duct, the left hepatic duct, the confluence of these ducts, and/or the right posterior segmental bile duct. Therefore, in the preoperative staging of biliary tract carcinoma it is important to delineate the anatomy of B1 and the extent of cancer spread into B1. Tube cholangiography through percutaneous transhepatic biliary drainage or selective cholangiography by percutaneous transhepatic cholangioscopy enables us to obtain fine images of B1. We have developed cholangiography in the cephalad anterior oblique position to visualize B1 more clearly and distinctly. Four separate types of biliary branches are identified in the caudate lobe: (1) A duct running from the cranial portion of the right caudate lobe along the inferior vena cava to the hepatic hilus (B1r); (2) a duct from the cranial portion of the left caudate lobe to the hepatic hilus (B1ls); (3) a duct from the left lateral part of the left caudate lobe to the hepatic hilus (B1li); and (4) a duct from the caudate process to the hepatic hilus (B1c). The findings of the root of B1 in resected patients with biliary tract carcinoma were classified into four groups: not stenotic, short segmental stenosis, long segmental stenosis, and poorly imaged. A study of 64 branches of B1 in 42 resected patients with biliary tract cancer revealed carcinoma invasion in or near the root of B1 in all patients with poorly imaged or long segmental stenosis of B1, and in 33% of those with short segmental stenosis of B1.     

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

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

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).     

Studies on the radiographic anatomy of the biliary tree of the caudate lobe

The cholangiograms obtained through percutaneous transhepatic cholangioscopy (PTCS) were studied for the purpose of clarifying radiographic anatomy of confluence of the bile ducts of the caudate lobe and the main trunks at the hepatic hilum. PTCS was performed on a total of 112 patients at our department, January, 1979 through December, 1984. Among them 60 cases without lesions in the hepatic hilum were used for this study. Four types of the bile duct of the caudate lobe were distinguished by cholangiography in the 60 cases: 1) A duct ran from the cranial portion of the right caudate lobe along the inferior vena cava to the hepatic hilum in 53 (Blr); 2) A duct ran from the cranial portion of the left caudate lobe to the hepatic hilum in 50 (Blls); 3) A duct ran from the left lateral part of the left caudate lobe to the hepatic hilum in 59 (Blli) and 4) A duct from the caudate process to the hepatic hilum in 42 (Blc). We found that cholangiogram following percutaneous transhepatic biliary drainage or selective cholangiogram using the PTCS make an accurate identification of the bile duct of the caudate lobe possible.     

Rare Portal Venous Anomaly in a Living Liver Donor: A Case Report

Knowledge of the anatomy of the portal system is essential for safe liver resection. We report a very rare anatomic anomaly of the portal system in a living liver donor. A 24-year-old female living liver donor was found to have anomalies of the portal system on preoperative contrast-enhanced computed tomography. The ventral branch of the right anterior segment arose from the transverse portion of the left portal vein. The gallbladder and round ligament were positioned normally. Intraoperative cholangiography for evaluation of biliary anatomy revealed very low confluence of the right and left hepatic ducts. All the bile ducts from the right lobe merged into the right hepatic duct. A right lobe graft was performed, including the ventral area of the right anterior segment. The portal branch of the ventral area of the right anterior segment could be transected extrahepatically. In the recipient operation, each of the right main portal branches, including the right posterior segment branch and the dorsal branch of the right anterior segment, and the ventral branch of the right anterior segment, were anastomosed to the right and left branches of the portal vein, respectively, of the recipient. The transected right hepatic duct of the graft was anastomosed with the recipient's common hepatic duct. Sixteen years after the liver transplant, the recipient continues to do well and has good portal flow.     

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

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

Cholangiographic studies on bile duct branches of the caudate lobe in resected cases with biliary tract carcinoma involving the hepatic hilus

Diagnostic value of the cholangiography was studied for carcinoma of the biliary tract involving the hepatic hilus, and special attention was paid on the cholangiogram of the bile duct branches (B1) of the caudate lobe. Cholangiograms of B1 were compared with pathologic findings in 42 (27 bile duct carcinomas, 15 gallbladder carcinomas) of 43 cases of biliary tract carcinomas. Sixty-four of B1 in the 42 cases could be studied radiologically and histopathologically. The findings of the root of B1 were classified into 4 groups: group A, not stenotic; group B, short segmental stenosis; group C, long segmental stenosis and group D, poorly imaged. Carcinoma invasion was found in 6 of 18 of group B, and in 9 of 16 of group C. Carcinoma was confirmed near the root of B1 in the remaining 7 of the 16 group C. Carcinoma invasion was found in 20 of 21 of group D, and invasion was suspected in the remaining one. Carcinomas were found in the root of B1 in all cases of poorly imaged or long segmental stenosis of B1, and in 33% of short segmental stenosis of B1. Therefore caudate lobe resection should be performed for carcinoma of the biliary tract involving the hepatic hilus.     

广泛肝内胆管结石合并左右肝叶萎缩尾状叶明显肥大行保留尾状叶次全肝切除术1例报道

目的探讨广泛肝内胆管结石合并左右肝叶萎缩而尾状叶明显肥大的患者行保留尾状叶次全肝切除术的可行性和安全性。方法回顾性分析四川大学华西医院2020年2月收治的1例肝内胆管结石患者的临床病理资料。结果患者左右肝叶结石伴左右肝叶明显萎缩而尾状叶明显肥大。患者术前一般情况良好,心、肺和肾功能正常,肝功能Child-Pugh A级,肝脏储备功能良好。患者体表面积为1.745 m2,标准肝体积为1 235 mL,CT图像三维重建评估肝尾状叶体积为735 mL,占标准肝体积59.5%,经评估患者能耐受手术。患者成功经历保留尾状叶次全肝切除术,术后肝功能恢复良好,术后第2天拔除胃管,术后第5天拔除腹腔引流管,术后第6天出院。术后病理诊断:肝内胆管扩张伴胆管结石,胆管周围大量炎细胞浸润,门管区纤维组织增生、小胆管增生、炎细胞浸润,病变符合肝内胆管结石改变。结论通过对本病例的分析结果看,对于广泛肝内胆管结石合并左右肝明显萎缩而尾状叶明显肥大的患者,保留尾状叶次全肝切除术是安全、可行的。     

Carcinoma of the hepatic hilus with superficial spreading to the intrahepatic segmental bile ducts: Report of a case

A case of superficially-spreading carcinoma of the hepatic hilus is presented. Percutaneous transhepatic biliary drainage was performed to alleviate jaundice and to evaluate the biliary system. A nodular tumor originating in the upper part of the common hepatic duct was found to be invading the confluence of the right and left hepatic ducts. Extensive superficial spread was observed in the proximal portion of the right anterior superior, right anterior inferior, right posterior superior, right posterior inferior, and caudate bile duct branches. Preoperative surgical planning was carried out on the basis of an evaluation of the findings of ultrasonography, computed tomography, percutaneous transhepatic cholangiography, and percutaneous transhepatic cholangioscopy. Absolute curative surgery, which included right hepatic lobectomy with total caudate lobectomy and bile duct resection, was performed. Bilioenteric continuity was reestablished with a Roux-en-Y jejunal loop. The histological diagnosis was well-differentiated tubular adenocarcinoma of the common hepatic duct. Postoperative recovery was very good; the patient has now enjoyed a good active social life for the past 4 years and 10 months, with no signs of recurrence. In this case report, we discuss the precise preoperative diagnosis and rational surgical treatment for carcinoma of the hepatic hilus with superficial spread.     

Severe outflow block syndrome caused by compression by the swollen caudate lobe after living donor liver transplantation: report of a case

A 50-year-old man with primary biliary cirrhosis underwent living-donor liver transplantation (LDLT) using a graft of a left hemiliver with a left caudate lobe and duct-to-duct hepaticocholedochostomy. Postoperative bile leakage necessitated percutaneous drainage 22 days after LDLT. The patient presented to our hospital 205 days after the LDLT with abdominal distension and fever. Computed tomography showed ascites and a diffusely mottled pattern in the graft. The caudate lobe was swollen, and its bile ducts were dilated. The inferior vena cava was forced to the right by the swollen caudate lobe, and the root of the hepatic vein was stretched. The hepatic vein was not contrasted. Endoscopic retrograde cholangiography showed a biliary anastomotic stricture. Based on these findings, we diagnosed a severe outflow block of the hepatic vein and biliary anastomotic stricture. We performed balloon dilation of the biliary anastomosis and implanted a metallic stent in the hepatic vein. Thereafter, his clinical symptoms improved dramatically.     

三维数字虚拟肝脏对肝脏尾状叶外科应用解剖的研究

目的 对肝尾状叶的临床应用解剖进行揭示,为l临床诊治提供指导.方法 利用中国可视化人数据集,采用三维可视化技术,建立数字虚拟肝脏系统;对肝尾状叶进行应用解剖研究,确定其亚分段,边界,及空间范围等.结果 成功建立了数字虚拟肝脏系统,具有多种交互功能及一定的虚拟手术功能;尾状叶左侧边界清晰,其腹侧、右侧边界模糊;经过静脉韧带裂的冠状斜切面可代表肝尾状叶的相对腹侧缘;经过第二肝门与胆囊窝底部的矢状斜切面可代表尾状叶的相对右侧缘;尾状叶可分为2个部分:左侧的Spiegel叶与右侧的腔静脉旁部,尾状突以及右后突属于腔静脉旁部.结论 明确了尾状叶亚分段,边界,以及空问范围等解剖概念;三维虚拟肝脏系统的建立为数字解剖、虚拟手术的发展提供了平台,对肝外科具有实践指导意义.     

A cholangiocellular carcinoma radically resected by central hepatic bisegmentectomy with en bloc resection of the caudate lobe and extrahepatic bile duct

A case of cholangiocellular carcinoma, involving the hepatic hilus, radically resected by central hepatic bisegmentectomy with en bloc resection of the caudate lobe and extrahepatic bile duct is presented. Preoperative surgical planning was carried out on the basis of an evaluation of the findings of ultrasonography, computed tomography, angiography, percutaneous transhepatic portography, and tube cholangiography. The operation lasted for 16 h and 15 min, with 5700 g blood loss. Postoperative recovery was very good and the patient has now been well for 26 months after surgery. Although the surgical technique of central hepatic bisegmentectomy with en bloc resection of the caudate lobe and extrahepatic bile duct is very difficult, this procedure should be indicated for selected cases of cholangiocellular carcinoma involving the hepatic hilus.     

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.     

A case of polypoid carcinoma of the left hepatic duct

A case of polypoid carcinoma of the left hepatic duct in 50-year-old male was reported. Extended left hepatic lobectomy with total caudate lobectomy and resection of the right hepatic duct were performed because the tumor involved the right hepatic duct and bile duct branches of caudate lobe, medial and lateral segment. Papillary growth of the tumor was diagnosed definitely by percutaneous transhepatic cholangioscopy (PTCS) and computed tomography. The tumor infiltrated the liver parenchyma of medial segment and compressed the middle hepatic vein. These findings were revealed by selective middle hepatic venography preoperatively.     

包括腔静脉旁部的肝尾叶切除术

目的：探讨并总结包括腔静脉旁路肝尾叶切除的方法和经验。方法：分别采用右后途径和左侧途径行肝右尾叶和全尾叶切除;前者附加部分右后叶切除,后者可为单独全尾叶切除或附加左外叶或左半肝切除。结果：成功施行包括腔静脉旁部的肝尾叶切除13例,其中右尾叶切除7例,全尾叶切除6例;全组无手术死亡,术中,术后均无严重并发症发生;术中平均失血量为896.15ml,平均肝门阻断时间为25.4min,术后平均住院12d。结论：虽然肝门部解剖关系复杂,但手术切除包括腔静脉旁部的肝尾叶仍是安全可行的。     

Isolated caudate lobectomy by anterior approach for hepatocellular carcinoma originating in the paracaval portion of the caudate lobe

We aimed to assess isolated caudate lobectomy by the anterior approach for the treatment of large hepatocellular carcinomas originating in the paracaval portion of the caudate lobe. The surgical procedures consisted of ligation and dissection of the caudate branch of the portal vein and short hepatic veins from the right side of the hepatic hilum; liver resection cranially from the right side of the process portion; ligation and dissection of the short hepatic veins from the left side; hepatic resection between the lateral segment and Spiegel lobe; and, finally, dissection of the liver at the right of the Cantlie line, reaching the tumor in the paracaval portion of the caudate lobe. The important point in this procedure was the appropriate management of the short hepatic veins, the branches of the hepatic vein, and the glisson's vessels of the paracaval portion. The operative times for the three patients reported here were 430, 355, and 575 min, with blood loss of 1100, 1180, and 2000 ml, respectively. The duration of the operation was short and blood loss was minimal; severe complications were not observed. Complete recovery of liver function after this surgery tended to be slow. Early recurrence was observed during long-term follow-up. This procedure is considered to be a safe method, with optimal surgical vision for caudate lobe tumors of a relatively large size. However, adjuvant therapy to prevent recurrence is required. Received for publication on Jan. 31, 1998; accepted on June 10, 1998     

肝脏尾状叶巨大肿瘤切除手术经验

施行肝脏尾状叶巨大肿瘤手术４例．其中２例为肝脏多发性海绵状血管瘤．２例为原发性肝癌．术式：左或右半肝切除并肝尾叶切除２例；肝尾叶切除并肝左叶血管瘤剥除１例；巨大左肝尾状叶肿瘤切除、并左肝外叶切除、右肝小癌灶无水乙醇注射１例。１例出院后因癌复发转移．术后２．５个月死亡；３例治愈出院．经６～１７个月随访健在．肝尾状叶巨大瘤块切除是难度大、风险大的手术．本文介绍了具体操作的几点体会．并对难以切除的肝肿瘤行一期或二期手术问题提出自己的看法．     

Metastatic Biliary Polypoid Thrombus from Renal Cell Carcinoma: Report of a Case

We report an extremely rare case of metastatic biliary polypoid thrombus with hepatic metastases from renal cell carcinoma. A 74-year-old man was admitted with a low-grade fever and obstruction of the left hepatic duct. He had undergone left nephrectomy 17 years previously due to a diagnosis of renal cell carcinoma. A preoperative diagnosis of left hepatic duct carcinoma was made, and a left lobectomy and left caudate lobectomy with right biliary anastomosis of jejunal loop were performed. The resected specimen showed a polypoid mass in the left hepatic duct with metastases in the caudate lobe, and a histological examination revealed both tumors to be clear cell-type renal cell carcinoma. The mechanism of biliary metastatic thrombus formation was speculated to be as follows: caudate lobe metastases invade the adjacent bile ducts, and a tumor fragment in the bile duct then becomes implanted in the intraluminal left hepatic duct, thus leading to the growth of the biliary polypoid thrombus. Received: April 16, 2001 / Accepted: November 20, 2001     

肝左右叶联合切除治疗复杂原发性肝胆管结石47例疗效分析

目的 总结肝左右叶联合切除治疗复杂肝胆管结石的经验及其疗效。方法 回顾性分析1991年8月至2007年8月第三军医大学西南医院肝左右叶联合切除治疗复杂的原发性肝胆管结石47例病人的临床资料,统计结石的分布、手术方式、术后并发症及治疗效果。结果 47例病人中15例有胆道手术史。所有病例左右肝均有结石,其中7例合并尾叶结石,21例合并肝外胆管结石。术中发现合并肝内外胆管狭窄23例。所有病例均采用肝左右叶联合切除术,其中3例行右肝胆管树切除术,6例行右肝后叶胆管树切除术。附加手术：28例行胆道探查、T管引流术,19例附加胆管空肠Roux-en-Y吻合术,3例附加肝实质切开取石术。47例病人手术死亡2例。术后出现腹腔感染3例,右前叶结石残留1例,左内叶结石残留1例。随访16个月至17年,生活质量优良率为88.89%。结论 肝左右叶联合切除治疗肝胆管结石并发症少、残留结石少、远期疗效好,是治疗复杂肝胆管结石的有效手段之一。     

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.