No-Touch En-Bloc Radical Operation for Unresectable Hilar Cholangiocarcinoma, Including Total Hepatectomy, Pancreatoduodenectoy, Portal Vein and Hepatic Artery Resection, and Right Lobe Living Donor Liver Transplantation (Video)

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Introduction: Hilar cholangiocarcinoma is a devastating disease, and therapy remains a formidable challenge. In particular, extensive hilar invasion, bilateral liver involvement, and vascular encasement often preclude potentially curative resection. Recently Mayo group reported combining the benefits of radiotherapy, chemosensitization, liver transplantation for unresectable hilar cholangiocarcinoma could achieve favorable ourcomes. Here, we report unresectable hilar cholangiocarcinoma patient as a video clip, who underwent no-touch en-bloc radical operation for unresectable hilar cholangiocarcinoma, including total hepatectomy, pancreatoduodenectomy, portal vein and hepatic artery resection, and right lobe living donor liver transplantation, after concurrent chemoradiotherapy (CCRT). Methods: The patient was 59 year-old female and diagnosed unresectable Klatskin's tumor Bismuth type IV with right hepatic artery and left portal vein invasion but no suspected lymph node metastasis on pre-operative CT, MR cholangiography and endoscopic biopsy. Preoperative CCRT using capecitabine and 5040 cGy was performed and levels of CA 19-9(U/mL) changed 85.7, 984, 36.1 serially. Before performing intended major operation, lymph node metastasis was not found on the laparoscopic exploration. Hilar inflammation related to pre-operative CCRT preclude reconstruction using radiation affected common hepatic artery, main portal vein, common bile duct in order to avoid vascular complications and biliary complications. Also for the purpose of no-touch en-bloc radical operation, she underwent en-bloc total hepatectomy and pancreatoduodenectomy, and then living donor liver transplantation using right liver from her daughter was performed. For reconstruction of portal vein and hepatic artery, spiral vascular tube with bisected autogenous great saphenous vein and gastroduodenal artery were used respectively. Pancreatic duct and bile duct were reconstructed with duct-to-mucosa anastomosis and hepaticojejunostomy. Results: Explanted liver and pancreatoduodenectomy specimen on pathology revealed moderately differentiated periductal infilterating type adenocarcinoma involving both intrahepatic and extrahepatic duct with clear resection margins, but one metastasis among 5 lymph nodes was found. The patient recovered without particular event and discharged on postoperative 57 days. The recurrence was not found until post-operative 6 months. Conclusions: En-bloc total hepatectomy and pancreatoduodenectomy, and then living donor liver transplantation for the treatment of unresectable hilar cholangiocarcinoma might be a complicated operation, but a novel technique for this patient.