Abstract
BackgroundHepatopancreatoduodenectomy (HPD) for diffusely spreading bile duct cancer (DSBDC) usually involves a major hepatectomy and a concomitant pancreatoduodenectomy, and is still challenging surgery because of postoperative liver failure. The present case report demonstrated two cases of DSBDC where we could achieve successful HPD with central liver resection (CHPD) as liver parenchymal sparing surgery.Case presentationIn Case 1, endoscopic retrograde cholangiography (ERC) with multiple biopsies revealed that she had DSBDC with Bismuth-Corlette type IIIA. 3D integrated images reconstructed by contrast enhanced CT and CT with drip infusion cholecystocholangiography data revealed the right antero-ventral bile duct (RAVD) confluent to the right hepatic duct and the right antero-dorsal bile duct (RADD) independently confluent to the right posterior bile duct (RPD). Tumor extended common bile duct including intrapancreatic bile duct to the left hepatic duct and RAVD, but the RADD and RPD were spared. Because the future liver remnant (FLR) was assumed not to achieve desirable volume by preoperative portal vein embolization for left or right trisegmentectomy, CHPD including resection of the segments IV and I, and the right antero-ventral segment was done and achieved R0. This procedure is tailored to the anatomical extent of disease in the context of variable biliary anatomy as a modified CHPD, and to our knowledge, this is the first reported case of modified CHPD with antero-dorsal segment preservation. In Case 2, preoperative imaging revealed DSBDC with Bismuth Corlette type IIIA. FLR volume was assumed insufficient for major hepatectomy, CHPD including resection of the segments IV and I, and the right anterior sector was done with R0. The remnant liver volumes of these cases were spared by 55.1% and 25% respectively, and postoperative course was uneventful in both.ConclusionCHPD should be considered a valid option for well-selected cases of DSBDC. This is the first case report of modified CHPD with antero-dorsal segment preservation.
Highlights
Hepatopancreatoduodenectomy (HPD) for diffusely spreading bile duct cancer (DSBDC) usually involves a major hepatectomy and a concomitant pancreatoduodenectomy, and is still challenging surgery because of postoperative liver failure
Hepatopancreatoduodenectomy with central liver resection (CHPD) should be considered a valid option for well-selected cases of DSBDC
HPD is initially introduced by Takasaki et al [1] in 1980 for gallbladder cancer and later widely applied to hilar cholangiocarcinoma, but combination of major hepatectomy and PD increases the risks associated with the surgery exponentially
Summary
We are hereby proposing that CHPD will be a valid option for well-selected cases of DSBDC, and reported the first case of modified CHPD with antero-dorsal segment preservation. Ability to achieve negative oncological margins and at the same time preserve liver parenchyma are the key components of this surgery. Further scrutiny of its anatomical and oncological applicability and long-term prognosis is needed
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