Modified hepatoduodenal ligamentectomy for advanced carcinoma of the biliary tract: the importance of preservation of the replaced left hepatic artery

Left-sided major hepatectomy with en bloc resection of the hepatoduodenal ligament utilizing a liver-transection first approach: A video vignette

TECHNIQUE

Hepatoduodenal ligamentectomy (HL) is a challenging surgery for advanced perihilar cholangiocarcinoma extensively invading the hepatoduodenal ligament1-3. A liver-transection first approach in HL is a no-touch technique wherein liver transection is performed first, and the affected liver and hepatoduodenal ligament are removed en bloc. This approach allows for the early assessment of resectability and feasibility of vascular reconstruction4.

RESULTS

This video shows a 57-year-old man with advanced intrahepatic cholangiocarcinoma in the left hepatic lobe, which had directly invaded the perihilar region and the hepatoduodenal ligament via lymph node metastasis. The lymph node was extensively invasive into both the proper hepatic artery and portal vein. The case was initially deemed unresectable, but after three months of chemotherapy, conversion surgery was considered feasible. The common hepatic artery and gastroduodenal artery and then the common bile duct and main trunk of portal vein were secured at the pancreatic superior border. Hepatic dissection was performed along the Cantlie line. The right Glissonean pedicle was secured, including the right hepatic duct, right hepatic artery and right portal vein, and the operation was deemed feasible. The portal vein was dissected and reconstructed using the right external iliac vein. The left and caudate lobe with the middle hepatic vein and hepatoduodenal ligament were resected en bloc. Subsequentially, the common hepatic artery and right hepatic artery were reconstructed using the jejunal artery.

CONCLUSION

The liver-transection first approach allowed us to determine the resectability of en bloc resection of the hepatoduodenal ligament at an early stage of surgery.

Assessing resectability in cholangiocarcinoma

Assessment of surgical resectability in cholangiocarcinoma is more complicated than other gastrointestinal malignancies and remains unestablished. According to the primary origin and tumor extent, the applied surgical procedure varies from extrahepatic bile duct resection to right or left trisectionectomy concomitant with pancreatoduodenectomy. Portal vein resection and reconstruction during hepatectomy has been feasible. Thanks to the availability of new microscopic surgical techniques, hepatic arterial resection and reconstruction have also come to be applied for locally advanced cholangiocarcinoma cases. These vascular surgical techniques can expand surgical indications for advanced cholangiocarcinoma. On the other hand, determination of the tumor extent or staging still remains difficult and imprecise. The endoscopic approach has come to play significant roles both for preoperative biliary drainage and tumor staging. Estimation of the functional reserve of future remnant liver in cholestatic patients still remains unresolved. Hepatobiliary surgeons should carefully estimate the safety of the surgical procedure in each individual patient requiring extensive hepatobiliary resection. Early establishment of the measurement methods of the functional capacity of future remnant liver is an important and urgent issue for assessing safer surgical resectablity of cholangiocarcinoma.

Article Commentary: Aberrant Hepatic Arterial Anatomy and the Whipple Procedure: Lessons Learned

Appreciation and study of hepatic arterial anatomical variability is essential to the performance of a pancreaticoduodenectomy to avoid surgical complications such as bleeding, hepatic ischemia/failure, and anastomotic leak/stricture. Awareness of this variability permits the surgeon to adapt the surgical technique to deal with anomalies identified preoperatively or intraoperatively thereby preventing unnecessary surgical morbidity and mortality. The objective of our study is to provide a comprehensive review of the anatomic arterial anomalies and discuss surgical strategies that will equip the surgeon to deal with all anomalies that may be encountered a priori or en passant during the course of a Whipple procedure.

Surgical treatment of hilar cholangiocarcinoma in the new era: the Asan experience

BACKGROUND/PURPOSE

Both curative resection and minimized in-hospital mortality offer the only chance of long-term survival in patients with hilar cholangiocarcinoma. The reported resectability rates for hilar cholangiocarcinoma have increased by virtue of combined major hepatectomy, but this procedure is technically demanding and still associated with a significant morbidity and mortality that must be carefully balanced against the chances of long-term survival.

METHODS

Between January 2001 and December 2008, 350 patients with hilar cholangiocarcinoma underwent exploration for the purpose of potentially curative resection, of whom 302 (86.3%) were resected in the Department of Hepato-Biliary Surgery and Liver Transplantation, Asan Medical Center, University of Ulsan College of Medicine. Combined hepatectomy was carried out in 268 (88.7%) of 302 resected patients. Major hemihepatectomy and parenchyma-preserving hepatectomy were performed in 257 and 11 patients, respectively. Portal vein resection was associated in 40 (14.9%) of 268 hepatectomized patients. To control preoperative cholangitis and reduce risk of postoperative hepatic failure, biliary decompression through endoscopic and/or percutaneous transhepatic drainage and portal vein embolization were preoperatively applied in 329 (94.0%) of 350 explored patients and in 91 (54.2%) of 168 extended hepatectomized patients (154 right hemihepatectomy, 9 right trisectionectomy, 5 left trisectionectomy), respectively. Liver transplantation was not performed as primary treatment for hilar cholangiocarcinoma.

RESULTS

There were 5 cases (1.7%) of in-hospital death after resection and 1 postoperative liver failure that was successfully treated with liver transplantation. Major complications were encountered in 23 patients (7.0%), and the overall morbidity rate was 43%. In 302 resections, 214 (70.9%) were curative resections (R0) and 88 (29.1%) were palliative resections (R1). The overall 1-, 3- and 5-year survival rates after resection, including in-hospital deaths, were 84.6, 50.7 and 47.3% in the R0 group and 69.9, 33.3 and 7.5% in the R1 group, respectively. The 5-year survival rate of extended hemihepatectomy of 36.4% was better than that of parenchyma-preserving hepatectomy at 10.5%. Two significant predictive factors adversely affecting survival after resection were lymph node metastasis and incurability of surgery (P < 0.001). Two patients with vascular involvement who underwent concomitant hepatic artery and portal vein reconstruction are alive after more than 3 years.

CONCLUSION

Preoperative biliary decompression and portal vein embolization enabled us to reduce in-hospital deaths associated with extended hepatectomy for hilar cholangiocarcinoma. Major hemihepatectomy offers an increased survival because of the higher possibility of curative resection than bile duct resection alone and parenchyma-preserving hepatectomy, but it still carries a certain mortality. Less extensive procedures can be conducted safely and are beneficial for aged patients in poor condition with a less advanced tumor stage if tumor-free resectional margins are obtained.