Left Hepatic Trisectionectomy Research Articles

Liver abscess caused by Clostridium perfringens after left hepatic trisectionectomy for perihilar cholangiocarcinoma: a case report

BackgroundClostridium perfringens sepsis has been reported to have a rapid onset and severe clinical outcome. We herein report a case of C. perfringens sepsis associated with massive intravascular hemolysis after left hepatic trisectionectomy for perihilar cholangiocarcinoma.Case presentationA 72-year-old woman underwent left hepatic trisectionectomy for perihilar cholangiocarcinoma. Her postoperative course was uneventful except for bile leakage. She was discharged on postoperative day (POD) 35. On POD 54, she was readmitted because of abdominal pain with a high fever. Although her vital signs were stable on arrival at the hospital, a laboratory examination showed a severe inflammatory reaction and hemolysis, and she had developed disseminated intravascular coagulation. Abdominal contrast-enhanced computed tomography showed a 70-mm irregular shape and low-density containing air in liver segment 6, which suggested a liver abscess. The abscess was immediately drained of pus containing air. The pus showed multiple Gram-positive bacilli, and two blood cultures showed Gram-positive bacilli and hemolysis. Empirical antibiotic therapy with vancomycin and meropenem was started because C. perfringens was detected from the preoperative bile culture. Four hours after arrival, tachypnea and decreased oxygen saturation were observed. Her general condition deteriorated rapidly with significant hypoglycemia, progressive acidosis, anemia, and thrombocytopenia. Despite rapid drainage and empiric therapy, she died six hours after her arrival. At autopsy, the abscess consisted of coagulation necrosis of liver cells with inflammatory cell infiltration, and clusters of Gram-positive large bacilli were observed in the necrotic debris. C. perfringens was detected in the drainage fluid and blood culture. She was diagnosed with a liver abscess and severe sepsis caused by C. perfringens and treated promptly, but the disease progressed rapidly and led to her death.ConclusionsSepsis caused by C. perfringens can progress rapidly and lead to death in a few hours, so prompt treatment is needed. When patients who have undergone highly invasive hepatobiliary-pancreatic surgery show hemolysis and hepatic abscesses with gas, C. perfringens should be considered the most likely bacterium.

Duodenojejunostomy for endoscopic management of biliary enteric anastomotic stricture inaccessible via balloon-assisted endoscopy: a case report

BackgroundStricture formation is a long-term complication of biliary enteric anastomosis (BEA). BEA stricture often causes recurrent cholangitis and lithiasis, can significantly affect quality of life, and promote the development of life-threatening complications. In this report, duodenojejunostomy and subsequent endoscopic management as an alternative surgical technique for strictures of the BEA is described.Case presentationCase 1: An 84-year-old man who underwent left hepatic trisectionectomy for hilar cholangiocarcinoma 6 years prior presented with fever and jaundice. Computed tomography (CT) revealed intrahepatic lithiasis. The patient was diagnosed with postoperative cholangitis secondary to intrahepatic lithiasis. Balloon-assisted endoscopy could not reach the anastomotic site, and stent insertion failed. A biliary access route was hence created via duodenojejunostomy. After the jejunal limb and duodenal bulb were identified, duodenojejunostomy was performed using a side-to-side continuous layer-to-layer suture. The patient was discharged without serious complications. Endoscopic management through duodenojejunostomy was successfully performed, and intrahepatic stones were completely removed.Case 2: A 75-year-old man who underwent bile duct resection for hilar cholangiocarcinoma 6 years prior was diagnosed with postoperative cholangitis due to intrahepatic lithiasis. Removal of the intrahepatic stones was attempted using balloon-assisted endoscopy; however, the endoscope could not reach the anastomotic site. The patient underwent duodenojejunostomy and subsequent endoscopic management. The patient was discharged without complications. Two weeks after the operation, the patient underwent endoscopic retrograde cholangiography through the duodenojejunostomy and the intrahepatic lithiasis was removed.ConclusionsDuodenojejunostomy allows easy endoscopic access to a BEA. Duodenojejunostomy and subsequent endoscopic management may be an alternative treatment option in patients with BEA strictures that are inaccessible via balloon-assisted endoscopy.

Response to the Comment on: "Left Hepatic Trisectionectomy With Caudate Lobectomy: Demanding but Essential Routine Surgical Procedure for Perihilar Cholangiocarcinoma".

Response to the Comment on: "Left Hepatic Trisectionectomy With Caudate Lobectomy: Demanding but Essential Routine Surgical Procedure for Perihilar Cholangiocarcinoma".

Morbidity analysis of left hepatic trisectionectomy for hepatobiliary disease and live donor

BackgroundDespite remarkable advances in surgical techniques and perioperative management, left hepatic trisectionectomy (LHT) remains a challenging procedure with a somewhat high postoperative morbidity rate compared with less-extensive resections. This study aimed to analyze the short- and long-term outcomes of LHT and identify factors associated with the postoperative morbidity of this technically demanding surgical procedure. MethodsThe medical records of 53 patients who underwent LHT between June 2005 and October 2019 at a single institution were retrospectively reviewed. The independent prognostic factor of postoperative morbidity was analyzed using the logistic regression model. ResultsHepatocellular carcinoma was the most common indication for surgery (n = 21), followed by hilar cholangiocarcinoma (n = 14), intrahepatic cholangiocarcinoma (n = 10), and other pathologies (including colorectal liver metastasis, hepatolithiasis, gallbladder cancer, living donor, hemangioma, and multilocular biliary cyst; n = 8). The rates of postoperative morbidities of Clavien-Dindo grade 3 or higher and 90-day mortality were 39.6% and 1.9%, respectively. The 1-, 3-, and 5-year overall survival rates were 81.1%, 61.4%, and 44.6%, respectively. Multivariate analysis revealed that preoperative jaundice [hazard ratio (HR) = 6.15, 95% confidence interval (CI): 1.57–24.17, P = 0.009] and operative time > 420 min (HR = 4.66, 95% CI: 1.27–17.17, P = 0.021) were independent predictors of postoperative morbidity. ConclusionsThe in-hospital mortality of LHT surgery can be minimalized by a reliable preoperative evaluation of liver function and selection of the dominant anatomic features of right posterior sector, active and appropriate preoperative management for obstructive cholangitis and compensatory hypertrophy of the future remnant posterior sector, and the experience of the surgeon.

Left hepatic trisectionectomy (LHT) is a safe and good prognosis procedure for giant liver tumors in Peru, Latin America

Left hepatic trisectionectomy (LHT) is a safe and good prognosis procedure for giant liver tumors in Peru, Latin America

Morbidity analysis of left hepatic trisectionectomy for hepatobiliary disease and live donor

Morbidity analysis of left hepatic trisectionectomy for hepatobiliary disease and live donor

Morbidity Analysis of Left Hepatic Trisectionectomy for Hepatobiliary Disease and Live Donor

Introduction: Despite remarkable advances in surgical techniques and perioperative management, left hepatic trisectionectomy (LHT) remains a challenging procedure with a somewhat higher postoperative morbidity compared with less-extensive resections. The aims of this study were to analyze the short- and long-term outcomes of LHT and to identify factors associated with postoperative morbidity of this technically demanding surgical procedure. Method: The medical records of 52 patients who underwent LHT between June 2005 and October 2019 at a single institution were retrospectively reviewed. Results: Hepatocellular carcinoma was the most common indication for surgery (n=21), followed by hilar cholangiocarcinoma (n=14), intrahepatic cholangiocarcinoma (n=9), and other pathologies (including colorectal liver metastasis, hepatolithiasis, gallbladder cancer, living donor, hemangioma, and multilocular biliary cyst; n=8). The rates of postoperative morbidities of Clavian-Dindo grade 3 or higher and 90-day mortality were 38.5% and 1.9%, respectively. The overall 1-,3-,and 5-year survival rates were 80.8%, 62.6%, and 45.5%, respectively. Preoperative portal vein embolization (p=0.017), an American Society of Anesthesiologists fitness grade > II (p=0.008), operation time (p=0.014), extent of surgery by concomitant extrahepatic bile duct resection (p=0.043) and lymphadenectomy (p=0.005), and the number of tumors (p=0.012) were independent predictors of postoperative morbidity on multivariable analysis. Conclusions: The success of LHT is dependent on a reliable preoperative evaluation of liver function and the anatomic features of right posterior portal vein variants and hepatic veins toward the posterior sector, active and appropriate preoperative management for obstructive cholangitis and compensatory hypertrophy of the future remnant posterior sector, and the experience of the surgeon.

A Case of Refractory Intractable Bile Leakage After Extended Left Hepatic Trisectionectomy Treated by Endoscopic Placement of Plastic Stents Along the Hepaticojejunostomy Through the Stump of the Jejunostomy

A Case of Refractory Intractable Bile Leakage After Extended Left Hepatic Trisectionectomy Treated by Endoscopic Placement of Plastic Stents Along the Hepaticojejunostomy Through the Stump of the Jejunostomy

Delineation of the Demarcation Line for Left Hepatic Trisectionectomy Using ICG Fluorescence-based Imaging

Delineation of the Demarcation Line for Left Hepatic Trisectionectomy Using ICG Fluorescence-based Imaging

Left hepatic trisectionectomy for hepatobiliary malignancies: Its' role and outcomes. A retrospective cohort study.

BackgroundLeft hepatic trisectionectomy (LHT) is a complex hepatic resection; its’ role and outcomes in hepatobiliary malignancies remains unclear.Materials and methodsAll patients undergoing LHT at the tertiary HPB referral unit at RSCH, Guildford, UK from September 1996 to October 2015 were included. Data were collected from a prospectively maintained database.ResultsTwenty-eight patients underwent LHT. The M:F ratio was 1.8:1. Median age was 60 years (range 43–76 years). Diagnoses included colorectal liver metastases (CRLM; n = 20); cholangiocarcinoma (CCA; n = 4); and other (neuroendocrine tumour metastases (NET; n = 3) and breast metastases (n = 1)). Median duration of surgery was 270 min (range 210–585 min). Median blood loss was 750 ml (300–2400 ml) with a perioperative transfusion rate of 21% (n = 6/28). The rate of all post-operative complications was 21% for all patients, and given the extensive resection performed four patients (14%) developed varying degrees of hepatic insufficiency. One patient with cholangiocarcinoma developed severe hepatic insufficiency, which was fatal within 90 days of surgery. 1 and 3-year survivals were 92% and 68% respectively.ConclusionThis study supports LHT in patients with significant tumour burden. Despite extensive resection, our favourable morbidity and mortality rates show this is a safe and beneficial procedure for patients with all hepatobiliary malignancies. Given the nature of resection the incidence of post-operative hepatic insufficiency is higher than less extensive hepatic resections.

Predictive performance of Blumgart T staging for perihilar cholangiocarcinoma in a Japanese center.

The Blumgart system has been used for local tumor assessment in perihilar cholangiocarcinoma to predict resectability and survival, and T3 tumors are considered unresectable disease. The aim was to validate the predictive performance of this system using a Japanese cohort. Medical records of consecutive patients with perihilar cholangiocarcinoma between 2006 and 2016 were retrospectively reviewed. Resectability, surgical procedure, R0 resection rate, and survival were compared among T stages. Among 729 study patients, 191 patients had T1 tumors, 94 patients had T2 tumors, and 444 (60.9%) patients had T3 tumors according to the Blumgart T stage. Resection was performed in 513 (70.4%) patients; resectability rate decreased with the progression of T stage: 89.0% in T1, 79.8% in T2, and 60.4% in T3 tumors (P<0.001). The incidences of left hepatic trisectionectomy and portal vein resection were 44.0% and 54.1%, respectively, in patients with T3 tumors, which were significantly greater than those of T1/2 tumors (P=0.001 and P<0.001). R0 resection reduced with advanced T stage: 92.4% in T1, 81.3% in T2, and 70.9% in T3 tumors (P<0.001). The 5-year survival rate was 53.4%, 38.4%, and 19.7% in T1, T2, and T3 tumors, respectively (P<0.001); that was 59.6%, 48.6%, and 30.7%, respectively, in the resected cohort (P<0.001). Blumgart T stage was closely associated with the resectability rate, surgical procedures, R0 resection rate, and survival time, suggesting that the T stage works as well as a presurgical staging system. However, the unresectable classification of T3 tumors should be revised.

Right Hepatic Vein Reconstruction with an Autologous Jugular Vein Graft to Expand the Surgical Indications for Liver Tumors

PurposeWe herein report 3 cases in which the right hepatic vein (RHV) involved with a liver tumor was reconstructed using an autologous jugular vein graft to raise the curability and to increase the functional volume of the liver remnant (LR). Case 1Cholangiocellular carcinoma (diameter 6.0 cm) in the left lobe invaded the RHV, the branch of the RHV which drains segment 7 (V7) and the middle hepatic vein (MHV). Because the ratio of the LR drained by the inferior right hepatic vein (IRHV) was 26.7%, extended left lobectomy including MHV with RHV and V7 reconstruction was carried out, resulting in a good outcome and an uneventful operative course. Surgical margins on the liver resection plane and at the IVC were 5 mm and partially zero, respectively. Case 2Cholangiolocellular carcinoma (diameter 9.0 cm) in the left lobe and the anterior segment invaded the RHV, V7, IVC and bile duct. In this case, the IRHV was present and not involved with the tumor. Because the ratio of the LR drained by the IRHV was 26.1%, left hepatic trisectionectomy with RHV, V7, IVC, and bile duct reconstruction was performed, leading to a good operative course. Surgical margins on the liver resection plane and at the IVC were 8 mm and partially zero, respectively. Case 3Hepatocellular carcinoma (diameter 2.7 cm) in segment 7 invaded the RHV. Because the hepatic functional reserve had decreased due to the presence of hepatitis C virus, extended subsegmentectomy (segment 7) with RHV reconstruction was performed, thus resulting in a sufficiently maintained LR function. Surgical margin on the liver resection plane was 7 mm. ConclusionRHV reconstruction with an autologous jugular vein graft is considered to be useful for safely expanding the surgical indications for liver tumors.

Left trisectionectomy combined with resection of the right hepatic vein and inferior vena cava after right hepatic vein embolization for advanced intrahepatic cholangiocarcinoma

BackgroundWhen the inferior right hepatic vein (IRHV) is present, left hepatic trisectionectomy with resection of the right hepatic vein (RHV) is theoretically possible without reconstruction of the RHV. We here report a successful case of this extended hepatectomy after RHV embolization for advanced intrahepatic cholangiocarcinoma.Case presentationA 71-year-old man was admitted to our clinic with abdominal pain. Computed tomography showed a cholangiocarcinoma located at the caudate lobe that involved the inferior vena cava (IVC) and the roots of the three major hepatic veins. Portal vein embolization of the left and right anterior portal veins was performed. As the IRHV was present but thin, RHV was also embolized. Left hepatic trisectionectomy with resection of the involved IVC and RHV, preserving the IRHV, was done. The IVC was reconstructed with artificial graft. The patient was discharged on postoperative day 36.ConclusionRHV embolization is useful in extended left trisectionectomy with resection of the RHV when the IRHV is present but thin.

Left hepatic trisectionectomy with caudate lobectomy by extrahepatic glissonean pedicle isolation technique for hilar cholangiocarcinoma

Left hepatic trisectionectomy with caudate lobectomy by extrahepatic glissonean pedicle isolation technique for hilar cholangiocarcinoma

Real-time fluorescence image-guided gurgery for safe and precise left hepatic trisectionectomy

Real-time fluorescence image-guided gurgery for safe and precise left hepatic trisectionectomy

Surgical resection for Bismuth type IV perihilar cholangiocarcinoma.

Bismuth type IV perihilar cholangiocarcinoma has traditionally been categorized as unresectable disease. The aim of this study was to review experience with a resection-based strategy in patients who have type IV perihilar cholangiocarcinoma. Medical records of consecutive patients with a diagnosis of type IV perihilar cholangiocarcinoma between 2006 and 2015 were reviewed retrospectively. Primary outcomes assessed were surgical results and long-term survival. Of the 332 patients with type IV tumour, 216 (65·1 per cent) underwent resection. Left hepatic trisectionectomy was the most common procedure (112 patients). Combined vascular resection was performed in 131 patients. Median duration of operation was 607 (range 356-1045) min, and blood loss was 1357 (209-10 349) ml. Complications of Clavien-Dindo grade III or more developed in 90 patients (41·7 per cent) and four (1·9 per cent) died from complications within 90 days. Survival rates were better for the 216 patients whose tumours were resected than for the 116 patients with unresected tumours (32·8 versus 1·5 per cent at 5 years; P < 0·001). Patients with pN0 M0 disease after resection had a favourable 5-year survival rate of 53 per cent. Percutaneous transhepatic biliary drainage, blood transfusion, lymph node metastasis and distant metastasis were identified as independent negative prognostic factors for survival. Although resection for type IV tumour is technically demanding with high morbidity, it can be performed with low mortality and offers better survival probability in selected patients.

Safety-related outcomes of the Japanese Society of Hepato-Biliary-Pancreatic Surgery board certification system for expert surgeons.

We investigated safety-related outcomes of hepatobiliary pancreatic (HBP) surgeries performed after establishment of the Japanese Society of Hepato-Biliary-Pancreatic Surgery (JSHBPS) board certification system for expert surgeons. We analyzed post-HBP surgery mortality data obtained from annual safety reports provided by board-certified training institutions between 2012 and 2015. The 90-day mortality rate for the 53,929 high-level HBP surgeries performed at board-certified training institutions was 1.7%. The 30-day mortality rates for 2012, 2013, 2014, and 2015 were 0.9%, 0.7%, 0.6%, and 0.6%, respectively, and the 90-day mortality rates were 2.1%, 1.8%, 1.6%, and 1.3%, respectively, with significant decreases in both. The surgeries with high 4-year cumulative mortality rates were left hepatic trisectionectomy (10.3%), hepatopancreatectomy (7.6%), liver transplant recipient surgery (6.7%), hepatectomy with extrahepatic bile duct resection (4.6%), and right hepatic trisectionectomy (4.5%). Over the 4-year period, the number of operations increased, but the 90-day mortality rates for these surgeries, with the exception of right trisectionectomy, decreased. The JSHBPS board certification system for expert surgeons has significantly decreased mortality subsequent to high-level HBP surgeries. Reducing mortality associated with high-risk HBP surgeries will be our next challenge.

Anatomic features of independent right posterior portal vein variants: Implications for left hepatic trisectionectomy

No authors have reported on the anatomic features of the independent right posterior portal vein variant and its relevance to left hepatic trisectionectomy. The purpose of this study was to review vasculobiliary systems according to portal vein anatomy, to clarify the anatomic features of the right posterior portal vein variant, and to discuss its operative implications for left hepatic trisectionectomy. In a radiologic study, the 3-dimensional anatomy of the portal vein, hepatic artery, and bile duct were studied in 200 patients who underwent computed tomography. In a surgical study, medical records were retrospectively reviewed for 463 patients who underwent hepatectomy for perihilar cholangiocarcinoma. In the radiologic study, an independent right posterior portal vein variant was observed in 19 patients. The following observations were made in association with the portal vein variant: (1) a supraportal or combined type right posterior hepatic artery was never found; (2) an infraportal right posterior bile duct was observed at a significantly greater frequency than in patients with normal portal vein anatomy; and (3) the volume of the right posterior sector was significantly larger than in normal portal vein anatomy (37.4 ±6.1% vs 27.3 ±5.1%, P<.001). In the surgical study, the independent right posterior portal vein variant was observed in 41 (8.9%) patients. Of the 135 patients who underwent left hepatic trisectionectomy, 28 (20.7%) had this portal vein variant. Independent right posterior portal vein variants exhibit anatomic features that are advantageous for performing left hepatic trisectionectomy.

A case of advanced intrahepatic cholangiocarcinoma accidentally, but successfully, treated with capecitabine plus oxaliplatin (CAPOX) therapy combined with bevacizumab: a case report.

Although surgical resection is the only way to cure biliary tract cancer (BTC), most BTCs are unresectable by the time they are diagnosed. Chemotherapy is usually used to treat unresectable BTC, but its impact on survival is small. Here, we report the case of a 70-year-old woman with a locally advanced intrahepatic cholangiocarcinoma that was initially diagnosed as an unresectable liver metastasis from colon cancer that had invaded all of the major hepatic veins. However, the tumor was noticeably reduced after treatment with CAPOX plus bevacizumab, which is an uncommon therapy for BTC. The tumor was finally resected by inferior right hepatic vein-preserving left hepatic trisectionectomy combined with a resection of the right hepatic vein after a right hepatic vein embolization.

Left hepatic trisectionectomy combined with pancreatoduodenectomy for wide-spread bile duct cancer with right hepatic artery running in front of the common bile duct

Left hepatic trisectionectomy combined with pancreatoduodenectomy for wide-spread bile duct cancer with right hepatic artery running in front of the common bile duct