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Hayasaki A, Kuriyama N, Kaluba B, Sakamoto T, Komatsubara H, Maeda K, Shinkai T, Noguchi D, Ito T, Gyoten K, Fujii T, Iizawa Y, Tanemura A, Murata Y, Kishiwada M, Narushima M, Mizuno S. Hepatopancreatoduodenectomy with delayed division of the pancreatic parenchyma when utilizing a right lateral approach to the superior mesenteric artery. Surg Case Rep 2024; 10:165. [PMID: 38954117 PMCID: PMC11219594 DOI: 10.1186/s40792-024-01965-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2024] [Accepted: 06/26/2024] [Indexed: 07/04/2024] Open
Abstract
BACKGROUND Hepatopancreatoduodenectomy (HPD) is a high-risk surgical procedure. Delayed division of the pancreatic parenchyma (DDPP) was reported as a novel technique in HPD for reducing postoperative pancreatic fistula. However, it is often difficult to dissect the pancreatic head nerve plexus while leaving the pancreatic parenchyma intact, particularly in patients with a bulky tumor with vascular invasion. Of the various reported approaches to the superior mesenteric artery, the right lateral approach can provide a useful surgical field to conduct DDPP in HPD. CASE PRESENTATION A 78-year-old man visited a local clinic with itching and jaundice. Laboratory tests revealed elevated hepatobiliary enzyme, total bilirubin, and tumor markers. Enhanced computed tomography, endoscopic retrograde cholangiopancreatography, and intraductal ultrasonography of the bile duct were performed, and he was diagnosed with perihilar cholangiocarcinoma with invasion to the right hepatic artery (40 × 15 mm, Bismuth IIIa, cT3N0M0 cStage III). After neoadjuvant chemotherapy, he underwent left hepatectomy with caudate lobectomy, pancreatoduodenectomy, and combined resection of right hepatic artery using DDPP with a right lateral approach to the superior mesenteric artery. The pathological diagnosis was perihilar cholangiocarcinoma ypT3N1M0 ypStage IIIC, R0 resection. He was discharged on postoperative day 57 in good health and has been doing well for 6 months since the surgery. CONCLUSIONS We present an effective application of the right lateral approach to the superior mesenteric artery in DDPP during HPD. This procedure can provide a clear surgical field to easily divide the pancreatic head nerve plexus before transection of the pancreatic parenchyma.
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Affiliation(s)
- Aoi Hayasaki
- Department of Hepato-Biliary-Pancreatic and Transplant Surgery, Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan.
| | - Naohisa Kuriyama
- Department of Hepato-Biliary-Pancreatic and Transplant Surgery, Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Benson Kaluba
- Department of Hepato-Biliary-Pancreatic and Transplant Surgery, Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Tatsuya Sakamoto
- Department of Hepato-Biliary-Pancreatic and Transplant Surgery, Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Haruna Komatsubara
- Department of Hepato-Biliary-Pancreatic and Transplant Surgery, Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Koki Maeda
- Department of Hepato-Biliary-Pancreatic and Transplant Surgery, Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Toru Shinkai
- Department of Hepato-Biliary-Pancreatic and Transplant Surgery, Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Daisuke Noguchi
- Department of Hepato-Biliary-Pancreatic and Transplant Surgery, Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Takahiro Ito
- Department of Hepato-Biliary-Pancreatic and Transplant Surgery, Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Kazuyuki Gyoten
- Department of Hepato-Biliary-Pancreatic and Transplant Surgery, Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Takehiro Fujii
- Department of Hepato-Biliary-Pancreatic and Transplant Surgery, Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Yusuke Iizawa
- Department of Hepato-Biliary-Pancreatic and Transplant Surgery, Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Akihiro Tanemura
- Department of Hepato-Biliary-Pancreatic and Transplant Surgery, Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Yasuhiro Murata
- Department of Hepato-Biliary-Pancreatic and Transplant Surgery, Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Masashi Kishiwada
- Department of Hepato-Biliary-Pancreatic and Transplant Surgery, Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Mitsunaga Narushima
- Department of Plastic and Reconstructive Surgery, Mie University, Tsu, Mie, Japan
| | - Shugo Mizuno
- Department of Hepato-Biliary-Pancreatic and Transplant Surgery, Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
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Liu P, Song Y, shakoor K, Peng C, Liu S. The pros and cons of the PCC staging system to guide surgical resectability and prognosis. J Cancer 2022; 13:3444-3451. [PMID: 36313036 PMCID: PMC9608210 DOI: 10.7150/jca.76696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 09/17/2022] [Indexed: 11/05/2022] Open
Abstract
Perihilar cholangiocarcinoma (PCC) is a malignant mass originating from the bile ducts. There is currently no unified treatment plan, and there are various treatment methods applied in clinical practice, as well as several different staging and typing systems to guide resectability, prognosis and survival prediction. The choice of treatment for PCC is closely related to the stage of the tumor. Accurate preoperative staging is necessary for correct resectability assessment and the selection of a reasonable treatment plan and surgical method; similarly, accurate postoperative pathological staging is necessary to guide further treatment and judgment of the patient's prognosis. A universally accepted staging system facilitates the comparison of cases between different centers, but there is much debate about the classification and staging of PCC. At present, the existing staging systems include the Bismuth-Corlette classification, AJCC/UICC TNM staging, modified T staging, Gazzaniga staging, JSBS staging, and Mayo staging. Each system has advantages, but there is no comprehensive guide for tumor resectability, prognosis, and survival. In this paper, the pros and cons of the different systems for staging PCC in terms of resectability, prognosis and survival prediction are discussed.
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Affiliation(s)
- Pei Liu
- Department of Hepatobiliary Surgery, Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University; Changsha 410005, China
| | - Yinghui Song
- Department of Hepatobiliary Surgery, Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University; Changsha 410005, China.,Central Laboratory of Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha, Hunan 410005, P.R. China
| | - Kashif shakoor
- Department of Hepatobiliary Surgery, Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University; Changsha 410005, China
| | - Chuang Peng
- Department of Hepatobiliary Surgery, Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University; Changsha 410005, China.,✉ Corresponding authors: Chuang Peng MD PhD and Sulai Liu MD PhD; Department of Hepatobiliary Surgery/Hunan Research Center of Biliary Disease, Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha, Hunan Province, People's Republic of China. Tel/fax: 08673183929520. E-mail: and
| | - Sulai Liu
- Department of Hepatobiliary Surgery, Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University; Changsha 410005, China.,Central Laboratory of Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha, Hunan 410005, P.R. China.,✉ Corresponding authors: Chuang Peng MD PhD and Sulai Liu MD PhD; Department of Hepatobiliary Surgery/Hunan Research Center of Biliary Disease, Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha, Hunan Province, People's Republic of China. Tel/fax: 08673183929520. E-mail: and
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Ito T, Butler JR, Noguchi D, Ha M, Aziz A, Agopian VG, DiNorcia J, Yersiz H, Farmer DG, Busuttil RW, Hong JC, Kaldas FM. A 3-Decade, Single-Center Experience of Liver Transplantation for Cholangiocarcinoma: Impact of Era, Tumor Size, Location, and Neoadjuvant Therapy. Liver Transpl 2022; 28:386-396. [PMID: 34482610 DOI: 10.1002/lt.26285] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 08/14/2021] [Accepted: 08/18/2021] [Indexed: 12/13/2022]
Abstract
Liver transplantation (LT) for cholangiocarcinoma (CCA) remains limited to a small number of centers. Although the role of neoadjuvant therapy (NAT) has been explored over time, an in-depth analysis of NAT strategies remains limited. Furthermore, controversy exists regarding acceptable tumor size during patient selection for LT. This study explores the impact of era, tumor size, and NAT strategy on LT outcomes for CCA. We conducted a retrospective review of 53 patients with CCA treated with LT from 1985 to 2019; 19 hilar CCA (hCCA) and 30 intrahepatic CCA (iCCA) were included. The relative contributions of varying NAT (neoadjuvant chemotherapy [NAC], neoadjuvant local therapy [NALT], and combined NAC and NALT [NACLT]) as well as the implication of tumor size and era were analyzed. The primary endpoint was overall survival (OS). Compared with the old era (1985-2007), 5-year OS in patients who underwent LT in the recent era (2008-2019) showed a superior trend. The 5-year OS from initial treatment in patients receiving NACLT for hCCA and iCCA were 88% and 100% versus 9% and 41% in patients without it, respectively (P = 0.01 for hCCA; P = 0.02 for iCCA), whereas NAC or NALT alone did not show significant differences in OS versus no NAT (P > 0.05). Although 33 patients had large-size tumors (hCCA ≥ 30 mm, n = 12, or iCCA ≥ 50 mm, n = 21), tumor size had no impact on survival outcomes. Outcomes of LT for CCA seem to have improved over time. Multimodal NAT is associated with improved survival in LT for both iCCA and hCCA regardless of tumor size.
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Affiliation(s)
- Takahiro Ito
- The UCLA Division of Liver and Pancreas Transplantation, Department of Surgery, University of California Los Angeles, Los Angeles, CA
| | - James R Butler
- The UCLA Division of Liver and Pancreas Transplantation, Department of Surgery, University of California Los Angeles, Los Angeles, CA
| | - Daisuke Noguchi
- The UCLA Division of Liver and Pancreas Transplantation, Department of Surgery, University of California Los Angeles, Los Angeles, CA
| | - Minah Ha
- The UCLA Division of Liver and Pancreas Transplantation, Department of Surgery, University of California Los Angeles, Los Angeles, CA
| | - Antony Aziz
- The UCLA Division of Liver and Pancreas Transplantation, Department of Surgery, University of California Los Angeles, Los Angeles, CA
| | - Vatche G Agopian
- The UCLA Division of Liver and Pancreas Transplantation, Department of Surgery, University of California Los Angeles, Los Angeles, CA
| | - Joseph DiNorcia
- The UCLA Division of Liver and Pancreas Transplantation, Department of Surgery, University of California Los Angeles, Los Angeles, CA
| | - Hasan Yersiz
- The UCLA Division of Liver and Pancreas Transplantation, Department of Surgery, University of California Los Angeles, Los Angeles, CA
| | - Douglas G Farmer
- The UCLA Division of Liver and Pancreas Transplantation, Department of Surgery, University of California Los Angeles, Los Angeles, CA
| | - Ronald W Busuttil
- The UCLA Division of Liver and Pancreas Transplantation, Department of Surgery, University of California Los Angeles, Los Angeles, CA
| | - Johnny C Hong
- Division of Transplant Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Fady M Kaldas
- The UCLA Division of Liver and Pancreas Transplantation, Department of Surgery, University of California Los Angeles, Los Angeles, CA
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Kuriyama N, Komatsubara H, Nakagawa Y, Maeda K, Shinkai T, Noguchi D, Ito T, Gyoten K, Hayasaki A, Fujii T, Iizawa Y, Murata Y, Tanemura A, Kishiwada M, Sakurai H, Mizuno S. Impact of Combined Vascular Resection and Reconstruction in Patients with Advanced Perihilar Cholangiocarcinoma. J Gastrointest Surg 2021; 25:3108-3118. [PMID: 33884578 DOI: 10.1007/s11605-021-05004-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Accepted: 03/29/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Perihilar cholangiocarcinoma often involves the adjacent vasculature, including the portal vein and hepatic artery. Combined vascular resection and reconstruction of the portal vein is more common than vascular resection and reconstruction of the hepatic artery. Herein, we aimed to elucidate the long-term outcomes in patients who underwent vascular resection and reconstruction for perihilar cholangiocarcinoma. METHODS Between January 2004 and December 2020, 106 patients with perihilar cholangiocarcinoma were grouped into the no resection (n = 58), resection-portal vein (n = 31), and resection-hepatic artery with or without that of portal vein (n = 17) groups. RESULTS There were no significant differences in morbidity and mortality between the three groups. The resection-portal vein and resection-hepatic artery groups had a significantly higher number of advanced tumors than the no resection group, but no significant differences were detected in the rates of lymph node metastasis and R0 resection between the three groups. The 5-year disease-specific survival in the resection-portal vein (37.6%) and resection-hepatic artery (26.9%) groups were poorer than that in the no resection group (47.8%), although the former groups had a significantly better prognosis than the latter group (7.0%). Multivariate analysis identified high preoperative carcinoembryonic antigen level (>5.7 ng/mL), intrahepatic metastasis, and non-R0 resection as independent poor prognostic factors. CONCLUSION Although the perioperative course in the resection-portal vein and hepatic artery groups was similar to that in the no resection group, the long-term prognoses were poor in the resection-portal vein and hepatic artery groups. Pre- and postoperative multidisciplinary therapy is required for patients with vascular resection and reconstruction.
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Affiliation(s)
- Naohisa Kuriyama
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu City, Mie, 514-8507, Japan.
| | - Haruna Komatsubara
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu City, Mie, 514-8507, Japan
| | - Yuki Nakagawa
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu City, Mie, 514-8507, Japan
| | - Koki Maeda
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu City, Mie, 514-8507, Japan
| | - Toru Shinkai
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu City, Mie, 514-8507, Japan
| | - Daisuke Noguchi
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu City, Mie, 514-8507, Japan
| | - Takahiro Ito
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu City, Mie, 514-8507, Japan
| | - Kazuyuki Gyoten
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu City, Mie, 514-8507, Japan
| | - Aoi Hayasaki
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu City, Mie, 514-8507, Japan
| | - Takehiro Fujii
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu City, Mie, 514-8507, Japan
| | - Yusuke Iizawa
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu City, Mie, 514-8507, Japan
| | - Yasuhiro Murata
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu City, Mie, 514-8507, Japan
| | - Akihiro Tanemura
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu City, Mie, 514-8507, Japan
| | - Masashi Kishiwada
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu City, Mie, 514-8507, Japan
| | - Hiroyuki Sakurai
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu City, Mie, 514-8507, Japan
| | - Shugo Mizuno
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu City, Mie, 514-8507, Japan
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Transhepatic Direct Approach to the "Limit of the Division of the Hepatic Ducts" Leads to a High R0 Resection Rate in Perihilar Cholangiocarcinoma. J Gastrointest Surg 2021; 25:2358-2367. [PMID: 33403562 DOI: 10.1007/s11605-020-04891-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 11/22/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Previous studies have shown that curative resection (R0 resection) was among the most crucial factors for the long-term survival of patients with PHCC. To achieve R0 resection, we performed the transhepatic direct approach and resection on the limits of division of the hepatic ducts. Although a recent report showed that the resection margin (RM) status impacted PHCC patients' survival, it is still unclear whether RM is an important clinical factor. OBJECTIVE To describe a technique of transhepatic direct approach and resection on the limit of division of hepatic ducts, investigate its short-term surgical outcome, and validate whether the radial margin (RM) would have a clinical impact on long-term survival of perihilar cholangiocarcinoma (PHCC) patients. METHODS Consecutive PHCC patients (n = 211) who had undergone major hepatectomy with extrahepatic bile duct resection, without pancreaticoduodenectomy, in our department were retrospectively evaluated. RESULTS R0 resection rate was 92% and 86% for invasive cancer-free and both invasive cancer-free and high-grade dysplasia-free resection, respectively. Overall 5-year survival rate was 46.9%. Univariate analysis showed that preoperative serum carcinoembryonic antigen level (> 7.0 mg/dl), pathological lymph node metastasis, and portal vein invasion were independent risk factors, but R status on both resection margin and bile duct margin was not an independent risk factor for survival. CONCLUSION The transhepatic direct approach to the limits of division of the bile ducts leads to the highest R0 resection rate in the horizontal margin of PHCC. Further examination will be needed to determine the adjuvant therapy for PHCC to improve patient survival.
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Xu X, Yang L, Chen W, He M. Transhepatic hilar approach for Bismuth types III and IV perihilar cholangiocarcinoma with long-term outcomes. J Int Med Res 2021; 49:3000605211008336. [PMID: 33983055 PMCID: PMC8127775 DOI: 10.1177/03000605211008336] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Objective To compare the outcomes of the transhepatic hilar approach and conventional approach for surgical treatment of Bismuth types III and IV perihilar cholangiocarcinoma. Methods We retrospectively reviewed the medical records of 82 patients who underwent surgical resection of Bismuth types III and IV perihilar cholangiocarcinoma from 2008 to 2016. The transhepatic hilar approach and conventional approach was used in 36 (43.9%) and 46 (56.1%) patients, respectively. Postoperative complications and overall survival were compared between the two approaches. Results Similar clinical features were observed between the patients treated by the conventional approach and those treated by the transhepatic hilar approach. The transhepatic hilar approach was associated with less intraoperative bleeding and a lower percentage of Clavien grade 0 to II complications than the conventional approach. However, the transhepatic hilar approach was associated with a higher R0 resection rate and better overall survival. Multivariate analysis showed that using the transhepatic hilar approach, the Memorial Sloan-Kettering Cancer Center classification, and R0 resection were independent risk factors for patient survival. Conclusion The transhepatic hilar approach might be the better choice for surgical resection of Bismuth types III and IV perihilar cholangiocarcinoma because it is associated with lower mortality and improved survival.
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Affiliation(s)
- Xinsen Xu
- Department of Biliary-Pancreatic Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, P.R. China
| | - Linhua Yang
- Department of Biliary-Pancreatic Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, P.R. China
| | - Wei Chen
- Department of Biliary-Pancreatic Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, P.R. China
| | - Min He
- Department of Biliary-Pancreatic Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, P.R. China
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Yoshikawa J, Kato Y, Sugioka A, Uyama I. Antecedent Bile duct Cutting in the Glissonean pedicle technique (ABC technique) for extremely advanced perihilar cholangiocarcinoma. Surg Oncol 2020; 35:468-469. [PMID: 33080547 DOI: 10.1016/j.suronc.2020.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 09/07/2020] [Accepted: 10/10/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND In an increasing number of patients undergoing radical surgery for perihilar cholangiocarcinoma [1-3], the intrahepatic bile duct is conventionally transected after the vessels to be preserved or reconstructed are confirmed [3,4]. In patients with extremely advanced perihilar cholangiocarcinoma having massive vascular involvement, it is sometimes difficult to confirm the vessels for reconstruction because of restricted working space and/or anatomical variants, even after liver parenchymal dissection [4]. When the vessels cannot be confirmed, the tumor is usually unresectable [4]. METHODS We developed a novel technique named "Antecedent Bile duct Cutting in the Glissonean pedicle technique (ABC technique)", in which we directly cut the bile duct in the Glissonean sheath under 5x loupe until the vessels to be reconstructed are secured. RESULTS This video demonstrates the case of a 62-year-old man post-gastrectomy with a 47 × 36-mm perihilar cholangiocarcinoma with massive vascular involvement. Trisectionectomy was neither indicated left nor right due to excessively small remnant liver volume estimated even with portal vein embolization; thus, extended left hemihepatectomy with caudate lobectomy was applied using the ABC technique. Using the ABC technique after liver parenchymal dissection enabled us to identify and secure RAHA, RPHA, and RPV in favorable positions, and V5, RPV, RAHA, and RPHA were reconstructed. Finally, hepaticojejunostomy was performed. The operative time and blood transfusion were 1170 min and 1240 ml, respectively. R0 resection was achieved and the postoperative course was uneventful. CONCLUSION ABC technique was technically feasible and useful for extremely advanced perihilar cholangiocarcinoma with massive vascular involvement.
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Affiliation(s)
- Junichi Yoshikawa
- Department of Surgery, Fujita Health University, 98 Ichibanchi, Dengakugakubo, Kutsukake-cho, Toyoake-shi, 470-1192, Aichi, Japan.
| | - Yutaro Kato
- Department of Surgery, Fujita Health University, 98 Ichibanchi, Dengakugakubo, Kutsukake-cho, Toyoake-shi, 470-1192, Aichi, Japan
| | - Atsushi Sugioka
- Department of Surgery, Fujita Health University, 98 Ichibanchi, Dengakugakubo, Kutsukake-cho, Toyoake-shi, 470-1192, Aichi, Japan
| | - Ichiro Uyama
- Department of Surgery, Fujita Health University, 98 Ichibanchi, Dengakugakubo, Kutsukake-cho, Toyoake-shi, 470-1192, Aichi, Japan
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Ito T, Kuriyama N, Kozuka Y, Komatsubara H, Ichikawa K, Noguchi D, Hayasaki A, Fujii T, Iizawa Y, Kato H, Tanemura A, Murata Y, Kishiwada M, Mizuno S, Usui M, Sakurai H, Isaji S. High tumor budding is a strong predictor of poor prognosis in the resected perihilar cholangiocarcinoma patients regardless of neoadjuvant therapy, showing survival similar to those without resection. BMC Cancer 2020; 20:209. [PMID: 32164621 PMCID: PMC7069056 DOI: 10.1186/s12885-020-6695-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 02/28/2020] [Indexed: 02/07/2023] Open
Abstract
Background Tumor budding (TB) is used as an indicator of poor prognosis in various cancers. However, studies on TB in perihilar cholangiocarcinoma are still limited. We examined the significance of TB in resected perihilar cholangiocarcinoma with or without neoadjuvant therapy. Methods Seventy-eight patients who underwent surgical resection at our institution for perihilar cholangiocarcinoma from 2004 to 2017, (36 with neoadjuvant therapy), were enrolled in this study. TB was defined as an isolated cancer cell or clusters (< 5 cells) at the invasive front and the number of TB was counted using a 20 times objective lens. Patients were classified into two groups according to TB counts: low TB (TB < 5) and high TB (TB ≥5). Results In this 78 patient cohort, high TB was significantly associated with advanced tumor status (pT4: 50.0% vs 22.2%, p = 0.007, pN1/2: 70.8% vs 39.6%, p = 0.011, M1: 20.8% vs 1.9%) and higher histological grade (G3: 25.0% vs 5.7%, p = 0.014). Disease specific survival (DSS) in high TB was significantly inferior compared to that in low TB group (3-y DSS 14.5% vs 67.7%, p < 0.001). Interestingly, DSS in high TB showed similar to survival in unresected patients. In addition, high TB was also associated with advanced tumor status and poor prognosis in patients with neoadjuvant therapy. Multivariate analysis identified high TB as an independent poor prognostic factors for DSS (HR: 5.206, p = 0.001). Conclusion This study demonstrated that high TB was strongly associated with advanced tumor status and poor prognosis in resected perihilar cholangiocarcinoma patients. High TB can be a novel poor prognostic factor in resected perihilar cholangiocarcinoma regardless of neoadjuvant therapy.
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Affiliation(s)
- Takahiro Ito
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Naohisa Kuriyama
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan.
| | - Yuji Kozuka
- Pathology Division, Mie University Hospital, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Haruna Komatsubara
- Pathology Division, Mie University Hospital, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Ken Ichikawa
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Daisuke Noguchi
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Aoi Hayasaki
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Tekehiro Fujii
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Yusuke Iizawa
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Hiroyuki Kato
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Akihiro Tanemura
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Yasuhiro Murata
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Masashi Kishiwada
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Shugo Mizuno
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Masanobu Usui
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Hiroyuki Sakurai
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Shuji Isaji
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
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9
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Hosokawa I, Shimizu H, Ohtsuka M, Miyazaki M. Liver Transection-First Approach in Left Trisectionectomy for Perihilar Cholangiocarcinoma. Ann Surg Oncol 2020; 27:2381-2386. [PMID: 32152773 DOI: 10.1245/s10434-020-08306-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Indexed: 01/18/2023]
Abstract
Left trisectionectomy [(LT) resection of segments 2, 3, 4, 5, 8, and 1] for perihilar cholangiocarcinoma is still a challenging procedure with high postoperative morbidity and mortality. To perform LT safely, the liver transection-first approach was developed. In this approach, liver transection is started without dividing the right anterior hepatic artery (RAHA) and right anterior portal vein (RAPV). After the completion of liver transection, the RAHA and RAPV, which run into the future resected liver, can be easily identified and divided under the wide surgical field at the hepatic hilus. The liver transection-first approach appears to be safer than the conventional LT, leading to less postoperative morbidity and mortality.
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Affiliation(s)
- Isamu Hosokawa
- Department of Surgery, Teikyo University Chiba Medical Center, Chiba, Japan
| | - Hiroaki Shimizu
- Department of Surgery, Teikyo University Chiba Medical Center, Chiba, Japan.
| | - Masayuki Ohtsuka
- Department of General Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Masaru Miyazaki
- Mita Hospital, International University of Health and Welfare, Tokyo, Japan
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10
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Franken LC, Schreuder AM, Roos E, van Dieren S, Busch OR, Besselink MG, van Gulik TM. Morbidity and mortality after major liver resection in patients with perihilar cholangiocarcinoma: A systematic review and meta-analysis. Surgery 2019; 165:918-928. [PMID: 30871811 DOI: 10.1016/j.surg.2019.01.010] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 01/18/2019] [Accepted: 01/24/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Morbidity and mortality after hepatectomy for perihilar cholangiocarcinoma are known to be high. However, reported postoperative outcomes vary, with notable differences between Western and Asian series. We aimed to determine morbidity and mortality rates after major hepatectomy in patients with perihilar cholangiocarcinoma and assess differences in outcome regarding geographic location and hospital volume. METHODS A systematic review was performed by searching the MEDLINE and EMBASE databases through November 20, 2017. Risk of bias was assessed and meta-analysis and metaregression were performed using a random effects model. RESULTS A total of 51 studies were included, representing 4,634 patients. Pooled 30-day and 90-day mortality were 5% (95% CI 3%-6%) and 9% (95% CI 6%-12%), respectively. Pooled overall morbidity and severe morbidity were 57% (95% CI 50%-64%) and 40% (95% CI 34%-47%), respectively. Western studies compared with Asian studies had a significantly higher 30-day mortality, 90-day mortality, and overall morbidity: 8% versus 2% (P < .001), 12% versus 3% (P < .001), and 63% versus 54% (P = .048), respectively. This effect on mortality remained significant after correcting for hospital volume. Univariate metaregression analysis showed no influence of hospital volume on mortality or morbidity, but when corrected for geographic location, higher hospital volume was associated with higher severe morbidity (P = .039). CONCLUSION Morbidity and mortality rates after major hepatectomy for perihilar cholangiocarcinoma are high. The Western series showed a higher mortality compared with the Asian series, even when corrected for hospital volume. Standardized reporting of outcomes is necessary. Underlying causes for differences in outcomes between Asian and Western centers, such as differences in treatment strategies, should be further analyzed.
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Affiliation(s)
- Lotte C Franken
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Anne Marthe Schreuder
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Eva Roos
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Susan van Dieren
- Clinical Research Unit, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Olivier R Busch
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Thomas M van Gulik
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands.
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