Major hepatopancreatoduodenectomy with simultaneous resection of the hepatic artery for advanced biliary cancer

Practice guidelines for managing extrahepatic biliary tract cancers

Backgrounds/Aims

Reported incidence of extrahepatic bile duct cancer is higher in Asians than in Western populations. Korea, in particular, is one of the countries with the highest incidence rates of extrahepatic bile duct cancer in the world. Although research and innovative therapeutic modalities for extrahepatic bile duct cancer are emerging, clinical guidelines are currently unavailable in Korea. The Korean Society of Hepato-Biliary-Pancreatic Surgery in collaboration with related societies (Korean Pancreatic and Biliary Surgery Society, Korean Society of Abdominal Radiology, Korean Society of Medical Oncology, Korean Society of Radiation Oncology, Korean Society of Pathologists, and Korean Society of Nuclear Medicine) decided to establish clinical guideline for extrahepatic bile duct cancer in June 2021.

Methods

Contents of the guidelines were developed through subgroup meetings for each key question and a preliminary draft was finalized through a Clinical Guidelines Committee workshop.

Results

In November 2021, the finalized draft was presented for public scrutiny during a formal hearing.

Conclusions

The extrahepatic guideline committee believed that this guideline could be helpful in the treatment of patients.

Laparoscopic hepatopancreatoduodenectomy for synchronous intrahepatic and extrahepatic cholangiocarcinoma: A case report

Laparoscopic hepatopancreatoduodenectomy (LHPD) is a complex surgical procedure with high rates of complications and mortality and is performed in a limited number of medical centers. The present study reports a case of a synchronous primary malignant tumor of the left hepatic common bile ducts. A 63-year-old male was admitted to Affiliated Jinhua Hospital, Zhejiang University School of Medicine (Jinhua, China) with a 1 week history of right upper abdominal distension and pain associated with yellow sclera. Preoperative CT and MRI imaging demonstrated a synchronous primary malignant tumor of the left hepatic and common bile ducts; therefore, laparoscopic left hemihepatectomy and pancreaticoduodenectomy were performed. There was no biliary or pancreatic leakage following the operation and the patient was discharged 16 days later. Postoperative pathology verified that the synchronous primary cholangiocarcinoma originated in the left hepatic and common bile ducts. Therefore, LHPD for synchronous primary cholangiocarcinoma may be a safe and feasible treatment for this condition.

The usefulness of preoperative bile cultures for hepatectomy with biliary reconstruction

Background

Infectious complications can cause lethal liver failure after hepatectomy with biliary reconstruction. This study assessed the increased risk for postoperative infectious complications in patients who underwent hepatectomy with biliary reconstruction and explored the possibility of predicting pathogenic microorganisms causing postoperative infectious complications based on preoperative monitoring of bile cultures.

Methods

This study involved 310 patients who received major hepatectomy with or without biliary reconstruction at our institution between January 2010 and December 2019. The relationship between the microorganisms detected through perioperative monitoring of bile culture and those in the postoperative infectious foci was examined.

Results

Forty-nine patients underwent major hepatectomy with biliary reconstruction, and 261 received hepatectomy without biliary reconstruction. The multivariate analysis revealed hepatectomy with biliary reconstruction to be associated with an increased risk of postoperative infectious complications (odds ratio: 22.9, 95% confidence interval: 5.2-164.3) compared to hepatectomy without biliary reconstruction. In the patients with biliary reconstruction, the concordance rates between the microorganisms detected in the postoperative infectious foci and those in preoperative bile cultures were as follows: incisional surgical site infection (44.4%), organ/space surgical site infection (52.9%), bacteremia (47.1%), and pneumonia (16.7%); the concordance rates were high, and the risk of infection increased over time.

Conclusions

Biliary reconstruction is a significant risk factor for postoperative infectious complications, and preoperative bile cultures may aid in prophylactic and therapeutic antimicrobial agent selection.

Hepatopancreatoduodenectomy With Delayed Division of the Pancreatic Parenchyma: A Novel Technique for Reducing Pancreatic Fistula

Objectives

To review our novel technique of hepatopancreatoduodenectomy (HPD) with delayed division of the pancreatic parenchyma (DDPP) for reducing postoperative pancreatic fistula (POPF).

Background

The high operative morbidity and mortality rates after HPD remains a major issue. One of the most troublesome complications is POPF, which might possibly be caused by peripancreatic saponification due to long interval between pancreas resection and reconstruction, as most surgeons prefer a caudocranial approach, performing pancreatoduodenectomy (PD) first and then hepatectomy (conventional HPD [C-HPD]).

Methods

A review of the patients undergoing C-HPD and HPD with DDPP was performed. Postoperative outcomes were compared. Multivariable analysis was conducted to evaluate the risk factors of POPF after HPD.

Results

One-hundred two patients comprised of 50 patients undergoing C-HPD and 52 patients undergoing HPD with DDPP. The interval between pancreas resection and reconstruction was significantly shorter in HPD with DDPP group than in C-HPD group (51 vs 263 minutes; P < 0.001). The incidence of POPF was significantly lower in HPD with DDPP group than in C-HPD group (32.7% vs 77.3%; P < 0.001). The postoperative hospital stay was shorter in patients undergoing HPD with DDPP than in those undergoing C-HPD (32 vs 45 days). A multivariate analysis revealed that body mass index >24 kg/m2 and conventional (PD first) procedure were significant risk factors for POPF after HPD.

Conclusions

A novel technique of HPD with DDPP is a simple procedure and the optimal treatment choice to reduce the risk of developing POPF after this extensive surgery.

Current role of hepatopancreatoduodenectomy for the management of gallbladder cancer and extrahepatic cholangiocarcinoma: A systematic review

BACKGROUND

Hepatopancreatoduodenectomy (HPD) is the simultaneous combination of hepatic resection, pancreaticoduodenectomy, and resection of the entire extrahepatic biliary system. HPD is not a universally accepted due to high mortality and morbidity rates, as well as to controversial survival benefits.

AIM

To evaluate the current role of HPD for curative treatment of gallbladder cancer (GC) or extrahepatic cholangiocarcinoma (ECC) invading both the hepatic hilum and the intrapancreatic common bile duct.

METHODS

A systematic literature search using the PubMed, Web of Science, and Scopus databases was performed to identify studies reporting on HPD, using the following keywords: ‘Hepatopancreaticoduodenectomy’, ‘hepatopancreatoduodenectomy’, ‘hepatopancreatectomy’, ‘pancreaticoduodenectomy’, ‘hepatectomy’, ‘hepatic resection’, ‘liver resection’, ‘Whipple procedure’, ‘bile duct cancer’, ‘gallbladder cancer’, and ‘cholangiocarcinoma’.

RESULTS

This updated systematic review, focusing on 13 papers published between 2015 and 2020, found that rates of morbidity for HPD have remained high, ranging between 37.0% and 97.4%, while liver failure and pancreatic fistula are the most serious complications. However, perioperative mortality for HPD has decreased compared to initial experiences, and varies between 0% and 26%, although in selected center it is well below 10%. Long term survival outcomes can be achieved in selected patients with R0 resection, although 5–year survival is better for ECC than GC.

CONCLUSION

The present review supports the role of HPD in patients with GC and ECC with horizontal spread involving the hepatic hilum and the intrapancreatic bile duct, provided that it is performed in centers with high experience in hepatobiliary-pancreatic surgery. Extensive use of preoperative portal vein embolization, and preoperative biliary drainage in patients with obstructive jaundice, represent strategies for decreasing the occurrence and severity of postoperative complications. It is advisable to develop internationally-accepted protocols for patient selection, preoperative assessment, operative technique, and perioperative care, in order to better define which patients would benefit from HPD.

Clinical practice guidelines for the management of biliary tract cancers 2019: The 3rd English edition

BACKGROUND

The Japanese Society of Hepato-Biliary-Pancreatic Surgery launched the clinical practice guidelines for the management of biliary tract cancers (cholangiocarcinoma, gallbladder cancer, and ampullary cancer) in 2007, then published the 2nd version in 2014.

METHODS

In this 3rd version, clinical questions (CQs) were proposed on six topics. The recommendation, grade for recommendation, and statement for each CQ were discussed and finalized by an evidence-based approach. Recommendations were graded as Grade 1 (strong) or Grade 2 (weak) according to the concepts of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system.

RESULTS

The 31 CQs covered the six topics: (a) prophylactic treatment, (b) diagnosis, (c) biliary drainage, (d) surgical treatment, (e) chemotherapy, and (f) radiation therapy. In the 31 CQs, 14 recommendations were rated strong and 14 recommendations weak. The remaining three CQs had no recommendation. Each CQ includes a statement of how the recommendations were graded.

CONCLUSIONS

This latest guideline provides recommendations for important clinical aspects based on evidence. Future collaboration with the cancer registry will be key for assessing the guidelines and establishing new evidence.

Liver Transection-First Approach in Hepatopancreatoduodenectomy for Hilar Cholangiocarcinoma: A Safe and Secure Technique for the Early Assessment of Curable Resection and Vascular Reconstruction

BACKGROUND

Hepatopancreatoduodenectomy (HPD) is often indicated in the resection of cholangiocarcinoma but is associated with high mortality.1-3 From a risk-benefit perspective, HPD can be justified only when curative resection is achievable.4-6 METHODS: A liver transection-first approach is a surgical technique in which liver transection precedes pancreatoduodenectomy (PD) and skeletonization of the hepatoduodenal ligament in HPD. This approach enables an early assessment of resectability and curability.

RESULTS

A 64-year-old with jaundice had a tumor located mainly in the proximal bile duct, spreading from the confluence of hepatic ducts (dominant in the left hepatic duct) to the intrapancreatic bile duct. The right hepatic artery and portal vein existed in close proximity to the tumor. HPD (left hemi-hepatectomy and subtotal stomach-preserving PD) with vascular resection was performed. After liver transection along the Cantlie line, the right Glissonean pedicle was collectively secured inside the liver. The right hepatic artery, right portal vein, and right hepatic duct (RHD) were isolated, and the feasibility of vascular reconstruction was confirmed. After the RHD was divided and the negative margin was confirmed, we proceeded to perform PD. The portal vein was reconstructed between the right portal vein and the portal vein trunk. The right hepatic artery was anastomosed to the second jejunal artery of the jejunal loop with the right gastroepiploic artery as an interposition graft.

CONCLUSION

The liver transection-first technique in HPD facilitates early assessment of curability and resectability as well as a safe and secure manipulation and reconstruction of the hepatic artery and portal vein.

Safety and Oncological Benefit of Hepatopancreatoduodenectomy for Advanced Extrahepatic Cholangiocarcinoma with Horizontal Tumor Spread: Shinshu University Experience

BACKGROUND

Although hepatopancreatoduodenectomy (HPD) is the only means of achieving R0 resection of widespread extrahepatic cholangiocarcinoma, its safety and oncological benefit remain controversial because of its inherent high risk of mortality and morbidity.

OBJECTIVE

The aim of this study was to retrospectively analyze short- and long-term outcomes and evaluate the safety and oncological benefit of this advanced procedure.

METHODS

The study cohort comprised 37 consecutive patients who had undergone major HPD. Portal vein embolization was performed before surgery in 20 (54%) patients with future remnant liver volume < 35%.

RESULTS

The median operative time and blood loss were 866 min and 1000 mL, respectively. Concomitant vascular resection was performed in five patients (14%). The overall morbidity and mortality rates were 100% and 5.4% (n = 2), respectively. Nineteen patients (51%) had major (Clavien-Dindo grade III or higher) complications, the most common being intra-abdominal infection (49%) and post-hepatectomy liver failure (46%, grade B/C: 32%/5%), followed by postoperative pancreatic fistula (30%, grade B/C). R0 resection was achieved in 31 patients (84%). The 1-, 3-, and 5-year overall survival (OS) rates were 83%, 48%, and 37%, respectively. In patients with R0 resection, 5-year OS was comparable between patients who had undergone major HPD and major hepatectomy alone (41% vs. 40%, p = non-significant).

CONCLUSIONS

HPD is a valid treatment option for extensive cholangiocarcinoma, offering long-term survival benefit at the cost of relatively high but acceptable morbidity and mortality rates. HPD is advocated in selected patients provided that it is considered possible to achieve R0 resection.

Pancreatectomy with Hepatic Artery Resection for Pancreatic Head Cancer

BACKGROUND

To report our experiences and outcome of pancreatectomy with hepatic artery resection (PT-HAR) for advanced pancreatic head cancer.

METHODS

A retrospective study of clinical data from 14 patients with advanced pancreatic ductal adenocarcinoma undergoing PT-HAR in a tertiary academic center between March 2010 and June 2017 was performed. Furthermore, a comparison in a match-pair analysis (1:3) with patients received standard pancreatectomy during the same period was conducted to evaluate the clinical outcome.

RESULTS

The PT-HAR cohort included pancreaticoduodenectomy (n = 11) and total pancreatectomy (n = 3). Of them, six underwent portal/superior mesenteric vein resection and reconstruction and three underwent hepatic artery reconstruction. Four patients without arterial reconstruction developed liver perfusion failure. No perioperative mortality occurred, with a median postoperative hospital stay of 10.5 days (range 6-39). The median overall survival was 30 months (95% confidence interval 9.8-50.2 months), with the 1-, 2-, and 3-year survival rates of 81.8%, 63.6%, and 42.4%, respectively. The matched-pair data analysis showed no significant differences between PT-HAR and standard pancreatectomy, except that liver perfusion failure occurred more frequently after PT-HAR.

CONCLUSIONS

PT-HAR can be performed with acceptable morbidity, mortality, and survival for advanced pancreatic head cancer. Considering the potential risk of liver perfusion failure, only highly selected patients are eligible for PT-HAR without reconstruction.

Extended liver surgery for gallbladder cancer revisited: Is there a role for hepatopancreatoduodenectomy?

Gallbladder cancer (GBCA) is a rare and fatal disease and the majority of patients presents with advanced stage. Surgical resection associated with lymphadenectomy is the only chance for cure. For patients in stages III and IV, extended resection is the only treatment to achieve R0 margins. For GBCA invading the hepatoduodenal ligament and pancreatoduodenal region, the resection of extrahepatic bile duct and pancreas is necessary. Hepatopancreatoduodenectomy (HPD) represents the most complex and challenging procedure in the hepatopancreatobiliary region. Kuno at the Cancer Institute Hospital Tokyo performed the first HPD in Japan in 1974 and in 1980 Takasaki presented five cases and the 30-day mortality was 60%. After that, other countries started to perform the procedure including United States and Brazil. The main complications are liver failure and pancreatic fistula. Advancements in perioperative care, surgical technique, medical instruments and postoperative at intensive care unit have resulted in reduction in morbidity and mortality. The use of portal vein embolization is indicated to increase the liver volume in patients with insufficient remnant. Preoperative biliary drainage can prevent cholangitis and improve hepatic function. This procedure should be recommended before extended HPD in jaundiced patients. Operative results with mortality rates below 5% at high volume centers suggest that HPD should be performed at centers with expertise in hepatopancreatobiliary surgery.

Does additional resection of a positive microscopic ductal margin benefit patients with perihilar cholangiocarcinoma: A systematic review and meta-analysis

Background

The incidence of a positive microscopic ductal margin (R1) after surgical resection for perihilar cholangiocarcinoma (pCCA) remains high, but the beneficial of additional resection has not been confirmed by any meta-analysis and randomized clinical trials (RCT), which also increased the risk of morbidity and mortality. Hence, a systematic review is warranted to evaluate the clinical value of additional resection of intraoperative R1 for pCCA.

Methods

Eligible studies were searched by PubMed, MedLine, Embase, the Cochrane Library, Web of Science, from Jan.1^st 2000 to Nov.30^th 2019, evaluating the 1-, 3-, and 5-year overall survival (OS) rates of additional resection of intraoperative pathologic R1 for pCCA. Odds ratio (OR) with 95% confidence interval (CI) was used to determine the effect size by a randomized-effect model.

Results

Eight studies were enrolled in this meta-analysis, including 179 patients in the secondary R0 group, 843 patients in the primary R0 group and 253 patients in the R1 group. The pooled OR for the 1-, 3-, and 5-year OS rate between secondary R0 group and primary R0 group were 1.03(95%CI 0.64~1.67, P = 0.90), 0.92(95%CI 0.52~1.64, P = 0.78), and 0.83(95%CI 0.37~1.84, P = 0.65), respectively. The pooled OR for the 1-, 3-, and 5-year OS rate between secondary R0 group and R1 group were 2.14(95%CI 1.31~3.50, P = 0.002), 2.58(95%CI 1.28~5.21, P = 0.008), and 3.54(95%CI 1.67~7.50, P = 0.001), respectively. However, subgroup analysis of the West showed that the pooled OR for the 1-, and 3-year OS rate between secondary R0 group and R1 group were 2.05(95%CI 0.95~4.41, P = 0.07), 1.91(95%CI 0.96~3.81, P = 0.07), respectively.

Conclusion

With the current data, additional resection should be recommended in selected patients with intraoperative R1, but the conclusion is needed further validation.

Clinical value of additional resection of a margin-positive distal bile duct in perihilar cholangiocarcinoma

Background

Little is known about the effect of additional resection for a frozen-section-positive distal bile duct margin (DM) in perihilar cholangiocarcinoma.

Methods

Patients who underwent surgical resection for perihilar cholangiocarcinoma between 2001 and 2015 were analysed retrospectively, focusing on the DM.

Results

Of 558 consecutive patients who underwent frozen-section examination for a DM, 74 (13·3 per cent) had a frozen-section-positive DM with invasive cancer or carcinoma in situ. Eventually, 53 patients underwent additional resection (bile duct resection in 44 and pancreatoduodenectomy in 9), whereas the remaining 21 patients did not. Ultimately, R0 resection was achieved in 30 of the 53 patients (57 per cent). No patient who underwent additional resection died from surgical complications. The 44 patients with additional bile duct resection had a 5-year overall survival rate of 31 per cent. Overall survival of the nine patients who had pancreatoduodenectomy was better, with a 10-year rate of 67 per cent. Survival of the 21 patients without additional resection was dismal: all died within 5 years. Multivariable analyses identified nodal status and additional resection as independent prognostic factors (lymph node metastasis: hazard ratio (HR) 2·26, 95 per cent c.i. 1·26 to 4·07; bile duct resection versus no additional resection: HR 0·32, 0·17 to 0·60; pancreatoduodenectomy versus no additional resection: HR 0·08, 0·02 to 0·29).

Conclusion

Additional resection for frozen-section-positive DM in perihilar cholangiocarcinoma frequently yields R0 margins. It offers a better chance of long-term survival, and thus should be performed in carefully selected patients.

A modified surgical approach of hepatopancreatoduodenectomy for advanced gallbladder cancer: Report of two cases and literature review

Gallbladder cancer (GBC) is the most common cancer of the biliary tract, constituting 80%-95% of malignant biliary tract tumors. Surgical resection is currently regarded as the sole curative treatment for GBC. Hepatopancreatoduodenectomy (HPD) has been adopted to remove the advanced gallbladder tumor together with the infiltrated parts within the liver, lower biliary tract and the peripancreatic region of GBC patients. However, patients who underwent HPD were reported to have a distinctly higher postoperative morbidity (71.4%, ranging from 30.8% to 100%) and mortality (13.2%, ranging from 2.4% to 46.9%) than those given pancreatoduodenectomy (PD) alone. We present two patients with advanced GBC who underwent a modified surgical approach of HPD: PD with microwave ablation (MWA) of adjacent liver tissues and the technique of intraductal cooling of major bile ducts. No serious complications like bile leakage, pancreatic fistula, hemorrhage and organ dysfunction, etc. occurred in the two patients. They had a rapid recovery with postoperative hospital stay being 14 days. Application of this approach effectively eliminated tumor-infiltrated adjacent tissues, and maximally reduced the postoperative morbidity and mortality. This modified surgical method is secure and efficacious for the treatment of locally advanced GBC.