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.     

Right hepatic lobectomy and subsegmental resection of the left caudate lobe for gallbladder carcinoma involving the hepatic hilus: Preservation of the ventral portion of the left caudate lobe

A case of gallbladder carcinoma in a 75-year-old woman with familial hyperbilirubinemia and preoperative hepatic dysfunction is presented. Tube cholangiography through a percutaneous transhepatic biliary drainage (PTBD) catheter demonstrated a stricture and the hepatic confluence without filling of the gallbladder and showed two bile duct branches arising from the left caudate lobe. Cholangiography also disclosed that the left dorsal branch, which joined the right hepatic bile duct, was involved with tumor, while the left ventral branch, which joined the left hepatic duct, was not. Extended right hepatic lobectomy with resection of the dorsal portion of the left caudate lobe, preserving the ventral portion of the left caudate lobe, was performed. Postoperative cholangiography showed that the ventral branch of the left caudate lobe bile duct was preserved. Precise preoperative anatomic diagnosis of the biliary system in patients with hepatobiliary cancer allows successful subsegmental resection of the caudate lobe. Received for publication on July 23, 1997; accepted on Oct. 6, 1997     

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.     

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.     

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.     

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     

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.     

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.     

Extended liver resection for hilar cholangiocarcinoma

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

Recurrent liver tumor with intrabiliary ductal growth after hepatectomy for metastatic rectal cancer: Case report

A case of recurrent tumor with intrabiliary ductal growth after hepatic resection for liver metastasis from rectal cancer is presented. The patient, a 55-year-old female, underwent subsegmentectomy of the anteroinferior and posteroinferior areas of the liver for metastatic liver cancer on August 29, 1988. Computed tomography in February 1990 showed dilatation of the intrahepatic bile duct in the right anterosuperior subsegment (B8), in which a filling defect was detected by cholangiography through a percutaneous transhepatic biliary drainage (PTBD) catheter. Percutaneous transhepatic cholangioscopy (PTCS) revealed a protruding lesion without tumor vessels. Cholangioscopic biopsy revealed dysplasia, but not adenocarcinoma. However, recurrent tumor originating in the resected margin of the remnant liver was suspected, and resection of the right lobe of the liver and partial resection of the duodenum were therefore performed. The resected specimen showed a tumor, 4 cm in diameter, in the previous resected margin, forming a protruding lesion with a rough surface (measuring 10×20 mm) in the B8 bile duct. This case suggested the possibility of cancer recurrence in the resected margin of the liver after hepatectomy for metastatic colorectal cancer, with intrabiliary ductal tumor growth showing segmental biliary dilatation.     

Diagnosis and therapy of stenosis or obstruction of the intrahepatic bile ducts]

15 patients are reviewed who had stenosis or obstruction at the hilus of the bile duct. Percutaneous transhepatic or endoscopic transduodenal cholangiography is indispensable for establishing the diagnosis before operation. Primary carcinomas involving the junction of the hepatic ducts may be regarded as resectable if proximal extension of the tumor is limited to below the second bifurcation of the intrahepatic bile ducts in both the right and left lobes and if the proper hepatic artery and portal vein are still free from tumor invasion. Our favourable operation procedures for resection or palliative decompression of the biliary tree are discussed.     

Rupture of the hepatic artery after left hemihepatectomy for hilar bile duct carcinoma

Hilar bile duct carcinoma has a poor prognosis, but this has been improved in recent years by an aggressive surgical approach. We treated a 73-year-old woman who had obstructive jaundice due to bile duct carcinoma at the hepatic hilum. The jaundice decreased after percutaneous transhepatic biliary drainage. The tumor was resected with the left and caudate lobe of the liver and a part of portal vein. The right hepatic artery was located behind the common hepatic duct, and was suspected to be invaded by the tumor. We dissected the tumor from the arterial wall without carrying out combined resection of the hepatic artery. On the 6th postoperative day, the hepatic artery ruptured and the patient suffered hypovolemic shock. Resection of the hepatic artery and reconstruction were done, but the patient died 2 days later. Histological examination of the resected artery showed that the tumor had been curatively removed by dissection and that no tumor remained at the arterial wall. The rupture of the right hepatic artery was thought to have been caused by damage to the wall during the dissection procedure.     

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

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

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。     

Advanced gallbladder carcinoma with biliobiliary fistula, resected by hepatopancreatoduodenectomy, in an aged patient

We report a 78-year-old man with a gallbladder carcinoma and biliobiliary fistula, diagnosed by percutaneous transhepatic cholangioscopic biopsy through the fistula. The impacted stones in the common hepatic duct were crushed, and then selective cholangiography under percutaneous transhepatic cholangioscopy (PTCS) revealed a biliobiliary fistula. Cholangioscopic biopsy tissues taken from the gallbladder revealed adenocarcinoma, but biopsies taken from the fistula revealed no evidence of malignancy. Further investigations indicated that the gallbladder carcinoma involved the duodenum and the distal common bile duct. A hepatopancreatoduodenectomy, including both an extended right hepatic lobectomy with resection of the caudate lobe and a pancreatoduodenectomy, was performed. Despite the patient's advanced age, he made an unremarkable postoperative recovery and was able to enjoy an active social life for 8 months after the surgery. We discuss biliobiliary fistula associated with gallbladder carcinomas and the use of hepatopancreatoduodenectomy for advanced biliary cancer in aged patients. Received: October 12, 2000 / Accepted: March 12, 2001     

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).     

肝尾叶胆管结石的术中诊断与处理

目的 探讨肝尾叶胆管结石的术中诊断与手术处理方法。方法 回顾性总结19例尾叶胆管结石的诊疗经验。结果 全组均在术中明确诊断，右尾叶结石11例，左尾叶结石6例，双尾叶结石2例。合并左肝管结石2例，右肝管结石2例，左右肝管结石15例。10例合并尾叶胆管口狭窄者行尾叶胆管切开成形，肝胆管盆式Roux-en-Y吻合术；其余9例行左右肝管切开尾叶胆管取石，经胆总管T管或胆道气囊导管引流。无手术死亡，无并发症，术后15～18d经胆道造影，无结石残留，间歇夹管至术后21～28d后拔管。平均随访42．44（12～60）月，4例偶有腹痛，近远期疗效满意，无复发。结论 尾叶胆管结石术前易漏诊。术中诊查是发现尾叶胆管结石简便而有效的方法。充分显露、谨慎切开尾叶胆管口狭窄、取尽结石、通畅引流，是防止尾叶胆管结石残留的重要措施。     

Recurrent carcinoma of cystic duct remnant with subcutaneous implantation in abdominal wall

A case of recurrent carcinoma of the cystic duct remnant invading the common bile duct and portal vein with subcutaneous implantation of the abdominal wall is presented. The patient was a 55-year-old woman with an abdominal wall tumor at the site of the surgical scar of a cholecystectomy, performed at a local hospital 5 years ago for symptomatic cholelithiasis. The diagnosis was made by incisional biopsy of the tumor, computed tomography, percutaneous transhepatic cholangiography, and angiography. She underwent extended right hepatic lobectomy with en bloc resection of the caudate lobe, extrahepatic bile duct, and portal vein. The abdominal wall tumor was resected concomitantly. Histological examination showed that both the recurrent carcinoma of the cystic duct remnant and the abdominal wall implantation were moderately differentiated adenocarcinoma. This recurrence probably could have been prevented if both the macroscopic and microscopic examinations of the resected specimen had been precisely carried out after the previous cholecystectomy and the primary carcinoma identified and treated at that time.     

Hepatobiliary cystadenoma combined with multiple liver cysts: report of a case

Hepatobiliary cystadenomas are rare benign tumors with malignant potential. They are almost always solitary lesions accompanied by multilocular cysts in the liver, and are difficult to differentiate from cystadenocarcinoma, despite the diagnostic modalities available. This report describes a case of hepatobiliary cystadenoma with multiple cysts in the left hepatic lobe, diagnosed by magnetic resonance imaging in a 48-year-old woman. Abdominal computed tomography revealed only multiple cystic lesions in the left lobe, but cholangiography via a nasogastric biliary drainage tube combined with percutaneous transhepatic cholangiography showed a stenotic region with fine irregularity in the left lateral posterior segmental bile duct and left lateral anterior segmental bile duct. Hepatobiliary cystadenocarcinoma with multiple liver cysts was suspected. We performed left hepatectomy, and microscopic examination confirmed a diagnosis of hepatic cystadenoma with multiple liver cysts. There was no nuclear atypia or mitosis in the epithelium of the locus, which was constructed of simple columnar-to-cuboidal epithelium with basal nuclei. The patient is well without recurrence more than 4 years after surgery. Received: July 5, 2000 / Accepted: January 9, 2001     

An isolated caudate lobectomy by the transhepatic approach for hepatocellular carcinoma in cirrhotic liver.

A new strategy for the treatment of hepatic malignancy located deep in the cirrhotic liver is reported. A 66-year-old man, who had a 3 cm hepatocellular carcinoma in the cranial part of the caudate lobe, underwent an isolated caudate lobectomy. By transecting along the interlobar plane and opening the hepatic hilus anteriorly, we resected almost the entire caudate lobe without loss of the remaining liver parenchyma.