Hepatectomy For Hilar Cholangiocarcinoma Research Articles

1065 DIGITAL CHOLANGIOSCOPY-GUIDED RETRIEVAL OF A MIGRATED HEPATICOGASTROSTOMY (HGS) STENT THROUGH A NEWLY CREATED HGS ROUTE

Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) is increasingly utilized for benign biliary diseases in cases with surgically-altered anatomy, but stent migration is a potential adverse event. Herein, we present successful retrieval of a migrated hepaticogastrostomy stent through a newly created EUS-HGS route using a digital cholangioscope. A 71-year-old man with a history of extended right hepatectomy for hilar cholangiocarcinoma was referred for treatment of intrahepatic biliary stones. Since stone extraction under enteroscope-assisted ERCP at an outside hospital failed due to multiple intrahepatic stones, we decided to perform EUS-HGS. After plastic stent placement in the bile duct at the segment 2 in the initial session, stone extraction was attempted through the fistula in the second session. Since stone extraction was incomplete due to both multiple stones and technical difficulty, we planned to perform extracorporeal shock wave lithotripsy using a nasobiliary catheter. During nasobiliary catheter insertion following placement of a 7-F straight-type plastic stent as HGS, we encountered stent migration into the fistula tract due to the interference between the two tubes. Although there was no risk of bile peritonitis due to the mature fistula, additional EUS-HGS in the segment 3 was performed to prevent cholangitis. After fistula maturation, the fistula was balloon dilated, and a digital cholangioscope was inserted. Under direct visualization, the migrated stent was readily grasped using a dedicated mini snare and successfully retrieved. Finally, stones were extracted using electrohydraulic lithotripsy under direct cholangioscopic visualization. No procedure-related adverse event occurred. Although stent dislocation can be a serious adverse event during interventional EUS and may need a surgical intervention, cholangioscopy-guided removal of a migrated stent through another route can be a non-surgical salvage option as we previously reported in EUS-guided pancreatic duct drainage.

Evolution of surgery for Klatskin tumor demonstrates improved outcome: a single center analysis.

The rapid development of the Chinese economy has enabled advances to be made in the surgical treatment of Klatskin tumors. We retrospectively reviewed the surgical outcomes of hilar cholangiocarcinoma at a single Chinese center, focusing on the surgical procedures, radicality of the operative procedure (R0, R1 or R2), survival rates, and independent prognostic factors. This objective of the analysis was to evaluate improvements in perioperative and long-term outcomes of surgical resection of Klatskin tumors. Between January 1998 and December 2007, 131 consecutive patients underwent operative resection for Klatskin tumor at Tianjin Medical University General Hospital, Tianjin, China. Clinicopathological data were analyzed to assess their impact on survival. The overall 3- and 5-year survival rates were 46% and 22%, respectively. Median overall survival for the entire cohort was 35 months. Survival increased progressively between 1998 and 2007. Preoperative biliary drainage represents a safe strategy before hepatectomy for hilar cholangiocarcinoma in patients with jaundice. Patients who underwent liver resection achieved significantly higher R0 rates than those undergoing biliary resection only. Preoperative total bilirubin level, lymph node metastasis and degree of radicality (R1 and 2 vs R0) were found to be independent factors that negatively affected overall survival. Surgical resection remains the mainstay of treatment for hilar cholangiocarcinoma. Development in surgical equipment, techniques, and perioperative management have increased long-term survival after curative liver resection, despite the more aggressive surgical procedures that are being performed.

肝門部領域胆管癌術後の膵内胆管再発に対し亜全胃温存膵頭十二指腸切除術を施行した1例

肝門部領域胆管癌術後の膵内胆管再発に対し亜全胃温存膵頭十二指腸切除術を施行した1例

Portal Vein Arterialization as a Bridge Procedure Against Acute Liver Failure After Extended Hepatectomy for Hilar Cholangiocarcinoma

Acute liver failure (ALF) is a severe and highly fatal complication arising after extended hepatobiliary surgery. The aim of this study was to investigate the primary management experience of portal vein arterialization (PVA) as a bridge procedure to reduce the risk of ALF for hilar cholangiocarcinoma (HCCA) after extended hepatectomy. Between January 2010 and January 2012, 4 patients with HCCA with possible involvement of the right and/or left hepatic artery underwent resectional surgery with reconstruction of the right or left artery blood flow by arterializations of portal vein. The arteries used for this surgical procedure included gastroduodenal artery (n = 2), common hepatic artery (n = 1), and right gastroepiploic artery (n = 1). PVA was verified as a key point during the course of the disorder between surgery and postoperative recovery. During follow-up, 1 patient suffered secondary portal hypertension and was subsequently cured by interventional artery coil embolization. PVA can be indicated where there is arterial involvement in HCCA patients who have undergone extended hepatectomy or trisectionectomy.

Role of biliary drainage before major hepatectomy for hilar cholangiocarcinoma:a clinical study

Objective To evaluate the role of biliary drainage before major hepatectomy for hilar cholangiocarcinoma(HCCA) accompanied by obstructive jaundice.Methods A retrospective analysis of clinical and imaging data was conducted among cases of HCCA accompanied by obstructive jaundice and undergone major hepatectomy in General Hospital of PLA between Jun 2005 and Apr 2011.Liver volumetry was conducted individually and the standardized remnant liver volume ratio(SRLVR) was calculated accorcling to a formula: remnant liver volume(RLV)/ standard total liver volume(SLV).According to whether biliary drainage was conducted or not,all cases were divided into two groups and short-term outcomes between the two groups were compared.Results Altogether,117 cases of HCCA accompanied by obstructive jaundice underwent major hepatectomy and liver volumetry.The mean SRLVR was 52.3%,the postoperative mortality was 6.8%,the overall postoperative complication rate was 41.9%,the incidence of liver failure was 14.5%,the infectious complication rate was 9.7%,and the mean duration of postoperative hospital stay was 17.8 days(5-64 days).The multivariate analysis showed that SRLVR≤40%(OR:71.63,95%CI 8.07-635.96,P0.001) and preoperative bilirubin186.7 μmol/L(OR:17.29,95%CI 1.97-151.92,P=0.01) were independent risk factors for postoperative liver failure individually.In cases with SRLVR40%,the infectious complication rate in biliary drainage subgroup was significantly higher than that in non-drainage one,but the postoperative mortality,overall morbidity,incidence of liver failure and length of postoperative hospital stay between the two subgroups were not significantly different.In cases with SRLVR≤40%,however,the postoperative mortality,incidence of liver failure and length of postoperative stay in biliary drainage subgroup were significantly lower than in non-drainage one,but the overall postoperative morbidity and infectious complication rate between the two subgroups were not significantly different.Conclusion In cases with SRLVR≤40%,the application of PBD before liver resection for patients with HCCA accompanied by obstructive jaundice could markedly reduce postoperative mortality,incidence of liver failure and length of postoperative stay.In cases with SRLVR40%,it can evidently increase the infectious complication rate,so the selective application of PBD in this setting is preferred.

Left hepatectomy or left trisectionectomy with resection of the caudate lobe and extrahepatic bile duct for hilar cholangiocarcinoma (with video)

Although left-sided hepatectomy, such as a left hepatectomy or left trisectionectomy with resection of the caudate lobe and extrahepatic bile duct, is used to treat hilar cholangiocarcinoma predominantly involving the left side of the hepatic hilum, it is associated with several difficult technical points. The important points during left-sided hepatectomy are described here. There are anatomical variations of the sectional artery and bile duct. It is essential to understand the individual intrahepatic and hilar anatomy preoperatively. Surgical procedures consist of lymph node clearance, dissection of the distal bile duct, skeletonization resection of the hepatoduodenal ligament, mobilization of the liver and liver resection, dissection of the intrahepatic bile ducts, and biliary reconstruction. During lymph node dissection and skeletonization resection of the hepatoduodenal ligament, the nerve plexus around the hepatic artery is dissected, and its adventitia is exposed with great care to avoid injuring the hepatic artery. Mobilization of the caudate lobe is performed only from the left side. There is no clear landmark between the caudate lobe and the right posterior section during liver resection. In the final step of liver resection, it progresses toward the right edge of the inferior vena cava. When dividing intrahepatic bile ducts, extreme care should be used to avoid injury to the corresponding hepatic arteries, especially the anomalous supraportal posterior sectional artery. Left-sided hepatectomy for hilar cholangiocarcinoma should be considered a more complicated and technically demanding procedure than right-sided hepatectomy. Surgeons need to pay close attention to anatomical variations in order to perform a left-sided hepatectomy safely and successfully.

Additional Resection of an Intraoperative Margin-Positive Proximal Bile Duct Improves Survival in Patients With Hilar Cholangiocarcinoma

To assess the survival benefit of additional resection of an intraoperative positive proximal bile duct margin (BD(Marg)) in patients undergoing hepatectomy for hilar cholangiocarcinoma (HCCA). Intraoperative evidence of invasive cancer at the proximal (BD(Marg)) is associated with a dismal survival irrespective of whether a final negative (BD(Marg)) is achieved with an additional resection. Clinicopathologic, operative, and survival data of consecutive patients undergone curative intent hepatectomy with bile duct resection (n = 75) for HCC (1989-2010) were analyzed. Frozen-section examination of the proximal (BD(Marg)) revealed invasive cancer in 19 of the 67 patients. After additional resection, which was possible in 18 cases, a secondary R0 (BD(Marg)) resection was achieved in 15 patients (83.3%), with 2 of these having, at final pathology, positive radial and distal margins. Eventually, 8 patients were classified as R1 and 67 as R0 (54 primary R0 and 13 secondary R0). Median survival of patients who had a secondary R0 resection (30.6 months) was similar to that of primarily R0-resected patients (29.3 months) and significantly better than that of R1 patients (14.9 months) (P = 0.026). Median time to recurrence and site of recurrence were similar in R0 patients independently of the performance of an additional resection. The incidence of biliary fistula was significantly increased (44.4% vs 17.5%; P = 0.02) in patients necessitating a margin re-resection. Additional resection of a positive proximal (BD(Marg)) , albeit associated with an increased risk of biliary fistula, offers a significant survival benefit and should be attempted whenever possible.

Combined hepatectomy in radical resection for hilar cholangiocarinoma

：Objective To evaluatethe value of combined hepatectomy in radical resection for hilar cholangiocarinoma.Methods The clinical data and follow-up data of 67 patients of resection for hilarcholangiocarinoma in Henan Tumor Hospital from June 2005 to october 2008 wereretrospectively analyzed. Results According to intraoperative exploration situation andbismuth types, tumor resection was combined performed with hepatectomy (n＝38)ornon-hepatectomy (n＝29). The rate of R0 resection was 55.3% inhepatectomy group(n＝21) and 34.5% in non-hepatectomy group(n＝10),and the difference was significant（P＝0.024）.The incidence of complications were 39.5% in hepatectomy group(n＝15)and 13.4% in non-hepatectomy group(n＝4), and one patient withliver and kidney failure died in hospital. The 1, 3, 5 years of survival rate were89.3%,53.6% and 32.1% respectively in R0 group (n＝31) and 69.7%,30% and 10%respectively in R1～R2 group(n＝36), there were significantdifferences in the postoperative survival rate between both groups（P＝0.018). The 1, 3, 5 years ofsurvival rate were 81.8%,48.5% and 24.2% in hepatectomy group and 75%,32% and 16% innon-hepatectomy group respectively, and the differences were significant（P＝0.037). Conclusions Aggressive resection includingcombined hepatectomy for hilar cholangiocarcinoma can play an important role for curativeeffect and long term survival rate. Key words: Hepatectomy; Bile duct neoplasms/SU; Liver neoplasms/SU

Hepaticojejunostomy by Interventional Radiology With an Expandable Metallic Stent After Extended Right Hepatectomy for Hilar Cholangiocarcinoma

As a rare complication of extended right hepatectomy with portal vein resection, we were unable to find the cut end of the bile duct of the lateral segment to create a hepaticojejunostomy in a 57-year-old man with hilar cholangiocarcinoma. However, we succeeded in safely creating a hepaticojejunostomy between the bile duct of the lateral segment and a Roux-en-Y jejunum by using the guide wire technique and an expandable metallic stent under fluoroscopic and cholangioscopic guidance after the operation. The patient was discharged with an internal biliary drainage tube, but died of recurrence about 2 years after the operation with the hepaticojejunostomy remaining patent.

Treatment strategy for hilar cholangiocarcinoma, with special reference to the limits of ductal resection in right-sided hepatectomies

The surgical anatomy of the hepatic hilar region is characterized by the three-dimensional formation of the branches of the bile duct, portal vein, and hepatic artery. The limit of ductal resection in hepatectomy for hilar cholangiocarcinoma is the most peripheral point where the hepatic ducts can be separated from the vasculature. The limit is different for each type of hepatectomy because the portal vein branches that should be preserved or divided vary with the extent of the hepatectomy, and therefore the limit of separation of the hepatic ducts differs. Surgeons are required to understand the surgical anatomy and to identify the precise area of cancer spread on a preoperative cholangiogram so as to choose the appropriate type of hepatectomy, and to ensure that the remnant ductal margin is cancer-negative.

Recent advance in the treatment of hilar cholangiocarcinoma: hepatectomy with vascular resection

Radical surgical resection has been revealed to be the only hope of cure for the patient with hilar cholangiocarcinoma. Therefore, major efforts have been made to increase the resection rate by surgeons employing combined hepatic resection and vascular resection of the portal vein and the hepatic artery. Especially, the technical feasibility and surgical safety of hepatic resection with combined portal vein resection have recently been reported by several authors. On the other hand, there have been few reports of combined hepatic artery resection in hilar cholangiocarcinoma. There are fears that combined vascular resection with extended hepatectomy for hilar cholangiocarcinoma may lead to high surgical morbidity and mortality. Herein, we describe the results of aggressive surgical approaches in our series, and we also review the outcomes of hepatic resection with combined vascular resection in the previously reported literature.

Duodenoportal fistula caused by peptic ulcer after extended right hepatectomy for hilar cholangiocarcinoma

BackgroundA fistula between the duodenum and the main portal vein near a peptic ulcer is extremely rare, and only two cases of duodenal ulcers have been reported in the past.Case presentationWe report a 68-year-old man with a diagnosis of anemia who had a history of extended right hepatectomy for hilar cholangiocarcinoma 20 months previously. The first endoscopic examination revealed a giant peptic ulcer with active bleeding at the posterior wall of the duodenal bulbs, and hemostasis was performed. Endoscopic treatment and transarterial embolization were performed repeatedly because of uncontrollable bleeding from the duodenal ulcer. Nevertheless, he died of sudden massive hematemesis on the 20th hospital day. At autopsy, communication with the main portal vein and duodenal ulcer was observed.ConclusionIt should be borne in mind that the main portal vein is exposed at the front of the hepatoduodenal ligament in cases with previous extrahepatic bile duct resection.

Ipsilateral Percutaneous Transhepatic Portal Vein Embolization with Gelatin Sponge Particles and Coils in Preparation for Extended Right Hepatectomy for Hilar Cholangiocarcinoma

To evaluate the effectiveness and safety of ipsilateral percutaneous transhepatic portal vein embolization (PTPVE) with gelatin sponge particles and coils to induce lobar hypertrophy in patients with hilar cholangiocarcinoma in preparation for extended right hepatectomy. Between 1999 and 2004, PTPVE was performed in 22 patients with hilar cholangiocarcinoma (mean age, 67 years; range, 57-77 y; 16 men and six women). Percutaneous puncture of the right portal vein was performed under ultrasound guidance. A reverse-curve catheter was used for right portal vein embolization. Coils were used to occlude second-order branches. The future liver remnant volume was assessed by comparing computed tomographic scans before and 14-24 days after PTPVE. PTPVE was technically successful in all cases. The average increase in ratio of future liver remnant volume to total liver volume was 8.6%. Liver function tests after PTPVE but before surgery showed no significant changes. Nineteen patients underwent hepatic resection without liver failure. In three patients, tumors could not be removed because of detection of extrahepatic disease. One patient who underwent successful hepatic resection had an abscess in the removed right lobe. Ipsilateral PTPVE with gelatin sponge and coils appears to be effective and safe for extended right hepatectomy for hilar cholangiocarcinoma.

Extended right hepatectomy for hilar cholangiocarcinoma with resection of the left hepatic duct prior to hepatic resection

Extended hepatectomy for hilar cholangiocarcinoma results in high operative or in-hospital mortality rates despite of the recent progress in perioperative management. As a new procedure to prevent postoperative hepatic failure in hilar cholangiocarcinoma infiltrating predominantly the right hepatic duct, we devised a combination of extended right lobectomy plus caudal lobectomy with resection of the left hepatic duct prior to hepatic resection by utilizing intraoperative cholangiography, and applied the procedure to a 70-year-old patient. He had a favorable postoperative course and remains recurrence-free at 4 years after operation. This is a procedure for confining the extent of hepatectomy to the minimum necessary, aiming at curative resection of hilar cholangiocarcinoma.

Complications of hepatectomy for hilar cholangiocarcinoma.

We retrospectively reviewed postoperative complications in 105 patients with hilar cholangiocarcinoma who underwent hepatectomy at Nagoya University Hospital from January 1990 through March 1999. Of the 105 subjects, 97 (92.4%) underwent resection of two or more Healey's segments of the liver. Combined portal vein resection was performed in 33 (31.4%) patients and pancreatoduodenectomy in 10 (9.5%). Twenty (19.0%) patients had no postoperative complications, another 39 (37.1%) patients had minor complication(s) only, and the remaining 46 (43.8%) developed major complication(s). The morbidity rate reached as high as 81.0%. Major complications required relaparotomy in 11 (10.5%) patients. Of the 46 patients with major complication(s) 36 recovered; the remaining 10 patients died of liver failure with other organ failure(s) or of intraabdominal bleeding 12, 14, 18, 21, 57, 75, 75, 87, 93, or 134 days after surgery. Thus the 30-day mortality was 3.8% and the overall mortality 9.5%. Pleural effusion was the most frequent complication found in 66 (62.9%) patients, followed by wound sepsis in 39 (37.1%), and then liver failure in 29 (27.6%). Liver failure developed in 16.7% of 48 patients with less than 50% liver resection and in 36.8% of 57 patients with 50% or more resection (P < 0.05). Other organ failures, including renal, respiratory, gastrointestinal, and hematologic failures, developed as a sign of multiple organ failure following liver failure in most patients or preceding liver failure in a few patients. None of the six patients with four or more organ failures survived. Hepatectomy for hilar cholangiocarcinoma is risky owing to impaired hepatic functional reserve in jaundiced patients and the technical difficulty associated with hepatobiliary resection. Our goal is to reduce mortality to less than 5% while keeping a high resectability rate (above 80%).