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Huang J, Li JW, Xu D. Total Laparoscopic Radical Resection of S1 + S4 for Bismuth-Corlette Type IV Hilar Cholangiocarcinoma (With Video). Ann Surg Oncol 2024:10.1245/s10434-024-15531-2. [PMID: 38833055 DOI: 10.1245/s10434-024-15531-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Accepted: 05/13/2024] [Indexed: 06/06/2024]
Abstract
BACKGROUND The management of Bismuth-Corlette type IV hilar cholangiocarcinoma typically necessitates extensive hepatectomy, resection of the extrahepatic bile ducts, regional lymph node dissection, and reconstruction of the biliary tract; however, there is a high incidence of postoperative liver dysfunction and failure. METHODS A 64-year-old male patient was admitted to our department after 1 month of escalating jaundice and abdominal discomfort. Upon admission, his total bilirubin was 334 μmol/L and his direct bilirubin was 221 μmol/L. His carbohydrate antigen 19-9 was > 1200.00 U/mL, his carcinoembryonic antigen was 98.90 U/mL, and his α-fetoprotein was normal. Enhanced computed tomography (CT) and magnetic resonance imaging scans revealed a thickened and enlarged biliary tree extending from the common hepatic duct to the orifices of the left and right hepatic ducts. RESULTS The patient underwent total laparoscopic radical resection of S1 + S4, accompanied by radical lymphadenectomy with skeletonization and biliary reconstruction. The surgery was successfully conducted within 450 min, with a minimal blood loss of 200 mL. The histological grading was T2bN1M0 (stage III). CT on postoperative day 5 showed satisfactory postoperative recovery. The patient was discharged from the hospital on postoperative day 10 without complications, following which the patient underwent a regimen of single-agent capecitabine chemotherapy. Over a 20-month follow-up period, no recurrence was observed. CONCLUSIONS Resection of hepatic segments S1 + S4 is a viable surgical option for hilar carcinoma in cases with poor liver function or when the carcinoma is confined to both hepatic ducts without invasion of the hepatic artery and portal vein.
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Affiliation(s)
- Jie Huang
- Department of Hepatopancreatobiliary Surgery, The Second Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China.
| | - Jian-Wei Li
- Department of Hepatobiliary Surgery, Southwest Hospital, Army Medical University, Chongqing, China
| | - Dingwei Xu
- Department of Hepatopancreatobiliary Surgery, The Second Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
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Yang J, Fu Z, Sheng W, Huang Z, Peng J, Zhou P, Xiong J, Wu R, Liao W, Wu L, Li E. Minor hepatectomy combined with cholangioplasty and cholangiojejunostomy for Bismuth II hilar cholangiocarcinoma: A propensity score matching analysis. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:108339. [PMID: 38640604 DOI: 10.1016/j.ejso.2024.108339] [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: 02/21/2024] [Revised: 03/31/2024] [Accepted: 04/10/2024] [Indexed: 04/21/2024]
Abstract
BACKGROUND The optimal surgical approach for Bismuth II hilar cholangiocarcinoma (HCCA) remains controversial. This study compared perioperative and oncological outcomes between minor and major hepatectomy. MATERIALS AND METHODS One hundred and seventeen patients with Bismuth II HCCA who underwent hepatectomy and cholangiojejunostomy between January 2018 and December 2022 were retrospectively investigated. Propensity score matching created a cohort of 62 patients who underwent minor (n = 31) or major (n = 31) hepatectomy. Perioperative outcomes, complications, quality of life, and survival outcomes were compared between the groups. Continuous data are expressed as the mean ± standard deviation, categorical variables are presented as n (%). RESULTS Minor hepatectomy had a significantly shorter operation time (245.42 ± 54.31 vs. 282.16 ± 66.65 min; P = 0.023), less intraoperative blood loss (194.19 ± 149.17 vs. 315.81 ± 256.80 mL; P = 0.022), a lower transfusion rate (4 vs. 11 patients; P = 0.038), more rapid bowel recovery (17.77 ± 10.00 vs. 24.94 ± 9.82 h; P = 0.005), and a lower incidence of liver failure (1 vs. 6 patients; P = 0.045). There were no significant between-group differences in wound infection, bile leak, bleeding, pulmonary infection, intra-abdominal fluid collection, and complication rates. Postoperative laboratory values, length of hospital stay, quality of life scores, 3-year overall survival (25.8 % vs. 22.6 %; P = 0.648), and 3-year disease-free survival (12.9 % vs. 16.1 %; P = 0.989) were comparable between the groups. CONCLUSION In this propensity score-matched analysis, overall survival and disease-free survival were comparable between minor and major hepatectomy in selected patients with Bismuth II HCCA. Minor hepatectomy was associated with a shorter operation time, less intraoperative blood loss, less need for transfusion, more rapid bowel recovery, and a lower incidence of liver failure. Besides, this findings need confirmation in a large-scale, multicenter, prospective randomized controlled trial with longer-term follow-up.
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Affiliation(s)
- Jun Yang
- Department of General Surgery, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, 1 Minde Road, Nanchang, 330006, China
| | - Zixuan Fu
- Department of General Surgery, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, 1 Minde Road, Nanchang, 330006, China
| | - Weiwei Sheng
- Department of General Surgery, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, 1 Minde Road, Nanchang, 330006, China; Department of Emergency Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, 88 Jiefang Road, Hangzhou, Zhejiang, 310009, China
| | - Zhihao Huang
- Department of General Surgery, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, 1 Minde Road, Nanchang, 330006, China
| | - Jiandong Peng
- Department of General Surgery, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, 1 Minde Road, Nanchang, 330006, China
| | - Pengcheng Zhou
- Department of General Surgery, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, 1 Minde Road, Nanchang, 330006, China
| | - Jianghui Xiong
- Department of General Surgery, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, 1 Minde Road, Nanchang, 330006, China
| | - Rongshou Wu
- Department of General Surgery, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, 1 Minde Road, Nanchang, 330006, China
| | - Wenjun Liao
- Department of General Surgery, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, 1 Minde Road, Nanchang, 330006, China
| | - Linquan Wu
- Department of General Surgery, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, 1 Minde Road, Nanchang, 330006, China.
| | - Enliang Li
- Department of General Surgery, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, 1 Minde Road, Nanchang, 330006, China.
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Bröring TS, Wagner KC, von Hahn T, Oldhafer KJ. Parenchyma-Preserving Hepatectomy in Perihilar Cholangiocarcinoma: A Chance for Critical Patients? Visc Med 2024; 40:53-60. [PMID: 38584859 PMCID: PMC10995988 DOI: 10.1159/000537884] [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: 07/14/2023] [Accepted: 02/15/2024] [Indexed: 04/09/2024] Open
Abstract
Introduction Surgery for perihilar cholangiocarcinoma (pCCA) is associated with high rates of postoperative morbidity and mortality. Extended liver resection (EXT) increases R0 resection rate and survival; however, patients with high perioperative risk are not suitable for extended resection. This study aimed to compare overall survival and surgical morbidity in patients with extended liver resection and parenchyma-preserving hepatectomy (PPH). Methods Between January 2010 and November 2020, 113 consecutive patients with pCCA underwent surgery at our institution. Eighty-two patients were resected in curative intent. Sixty-four patients received extended liver resection, and 18 patients PPH. Outcomes of resections were evaluated. Results There was no significant difference in overall survival in patients with PPH compared to extended liver resection (log-rank p = 0.286). Patients with PPH experienced lower rates of postoperative morbidity and mortality. There was no case of in-house mortality in PPH-resected patients compared to 10 cases (16%) in patients that received EXT (p = 0.073). Conclusion PPH shows similar overall survival with lower rates of postoperative morbidity and mortality. Our findings support the role of a PPH, in selected patients with pCCA, that are not suitable for extended resection due to increased perioperative risk.
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Affiliation(s)
- Tobias S. Bröring
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asklepios Hospital Barmbek, Hamburg, Germany
- Semmelweis University of Medicine, Asklepios Campus Hamburg, Hamburg, Germany
| | - Kim C. Wagner
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asklepios Hospital Barmbek, Hamburg, Germany
- Semmelweis University of Medicine, Asklepios Campus Hamburg, Hamburg, Germany
| | - Thomas von Hahn
- Semmelweis University of Medicine, Asklepios Campus Hamburg, Hamburg, Germany
- Department of Gastroenterology and Interventional Endoscopy, Asklepios Hospital Barmbek, Hamburg, Germany
| | - Karl J. Oldhafer
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asklepios Hospital Barmbek, Hamburg, Germany
- Semmelweis University of Medicine, Asklepios Campus Hamburg, Hamburg, Germany
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Guadagni S, Comandatore A, Furbetta N, Di Franco G, Carpenito C, Bechini B, Vagelli F, Ramacciotti N, Palmeri M, Di Candio G, Morelli L. Robotic Hepatectomy plus Biliary Reconstruction for Bismuth Type III and Type IV Hilar Cholangiocarcinoma: State of the Art and Literature Review. J Pers Med 2023; 14:12. [PMID: 38276227 PMCID: PMC10817587 DOI: 10.3390/jpm14010012] [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: 10/25/2023] [Revised: 12/04/2023] [Accepted: 12/20/2023] [Indexed: 01/27/2024] Open
Abstract
BACKGROUND In Bismuth type III and IV Hilar Cholangiocarcinoma (III-IV HC), surgical resection is the only chance for long-term survival. As the surgical procedure is complex and Robotic-Assisted Surgery (RAS) may be particularly suitable in this setting, the aim of this study is to evaluate the potential benefits of RAS in III-IV HC in terms of post-operative outcomes. METHODS We conducted a systematic review using the PRISMA checklist for article selection. We searched the PubMed database and included only studies with clinical data about the treatment of III-IV HC using RAS. RESULTS A total of 12 papers involving 50 patients were included. All cases were Bismuth IIIa (n = 18), IIIb (n = 27) or IV type (n = 5) and underwent hepatectomy with biliary confluence resection and reconstruction. The mean operative time was 500 minutes with a conversion rate of 4%. The mean hospital stay was 12.2 days, and the morbidity and 30-day mortality rate were 61.9% and 2%, respectively. Over a mean follow up period of 10.1 months, 9/18 cases experienced recurrence (50%). CONCLUSIONS RAS for III-IV HC is safe and feasible, at least if performed by experienced surgeons on selected cases. The oncological outcomes appear acceptable, given the aggressiveness of this pathology, but further studies are needed to fully elucidate the exact role of robotics in this setting.
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Affiliation(s)
- Simone Guadagni
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy; (S.G.); (A.C.); (G.D.F.); (C.C.); (B.B.); (F.V.); (N.R.); (M.P.); (G.D.C.); (L.M.)
| | - Annalisa Comandatore
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy; (S.G.); (A.C.); (G.D.F.); (C.C.); (B.B.); (F.V.); (N.R.); (M.P.); (G.D.C.); (L.M.)
| | - Niccolò Furbetta
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy; (S.G.); (A.C.); (G.D.F.); (C.C.); (B.B.); (F.V.); (N.R.); (M.P.); (G.D.C.); (L.M.)
| | - Gregorio Di Franco
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy; (S.G.); (A.C.); (G.D.F.); (C.C.); (B.B.); (F.V.); (N.R.); (M.P.); (G.D.C.); (L.M.)
| | - Cristina Carpenito
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy; (S.G.); (A.C.); (G.D.F.); (C.C.); (B.B.); (F.V.); (N.R.); (M.P.); (G.D.C.); (L.M.)
| | - Bianca Bechini
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy; (S.G.); (A.C.); (G.D.F.); (C.C.); (B.B.); (F.V.); (N.R.); (M.P.); (G.D.C.); (L.M.)
| | - Filippo Vagelli
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy; (S.G.); (A.C.); (G.D.F.); (C.C.); (B.B.); (F.V.); (N.R.); (M.P.); (G.D.C.); (L.M.)
| | - Niccolò Ramacciotti
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy; (S.G.); (A.C.); (G.D.F.); (C.C.); (B.B.); (F.V.); (N.R.); (M.P.); (G.D.C.); (L.M.)
| | - Matteo Palmeri
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy; (S.G.); (A.C.); (G.D.F.); (C.C.); (B.B.); (F.V.); (N.R.); (M.P.); (G.D.C.); (L.M.)
| | - Giulio Di Candio
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy; (S.G.); (A.C.); (G.D.F.); (C.C.); (B.B.); (F.V.); (N.R.); (M.P.); (G.D.C.); (L.M.)
| | - Luca Morelli
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy; (S.G.); (A.C.); (G.D.F.); (C.C.); (B.B.); (F.V.); (N.R.); (M.P.); (G.D.C.); (L.M.)
- EndoCAS (Center for Computer Assisted Surgery), University of Pisa, 56126 Pisa, Italy
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Zhang JZ, Yang CX, Gao S, Bu JF, Li QQ, Wang HL, Yang KN, Tong SS, Qian LJ, Zhang J, Hua R, Sun YW, Yan JY, Chen W. Three-dimensional visualization and evaluation of hilar cholangiocarcinoma resectability and proposal of a new classification. World J Surg Oncol 2023; 21:239. [PMID: 37542314 PMCID: PMC10403901 DOI: 10.1186/s12957-023-03126-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 07/29/2023] [Indexed: 08/06/2023] Open
Abstract
BACKGROUND As digital medicine has exerted profound influences upon diagnosis and treatment of hepatobiliary diseases, our study aims to investigate the accuracy of three-dimensional visualization and evaluation (3DVE) system in assessing the resectability of hilar cholangiocarcinoma (hCCA), and explores its potential clinical value. MATERIALS AND METHODS The discovery cohort, containing 111 patients from April 2013 to December 2019, was retrospectively included to determine resectability according to revised criteria for unresectability of hCCA. 3D visualization models were reconstructed to evaluate resectability parameters including biliary infiltration, vascular involvement, hepatic atrophy and metastasis. Evaluation accuracy were compared between contrast-enhanced CT and 3DVE. Logistic analysis was performed to identify independent risk factors of R0 resection. A new comprehensive 3DVE classification of hCCA based on factors influencing resectability was proposed to investigate its role in predicting R0 resection and prognosis. The main outcomes were also analyzed in cohort validation, including 34 patients from January 2020 to August 2022. RESULTS 3DVE showed an accuracy rate of 91% (95%CI 83.6-95.4%) in preoperatively evaluating hCCA resectability, significantly higher than 81% (95%CI 72.8-87.7%) of that of CT (p = 0.03). By multivariable analysis, hepatic artery involvement in 3DVE was identified an independent risk factor for R1 or R2 resection (OR = 3.5, 95%CI 1.4,8.8, P < 0.01). New 3DVE hCCA classification was valuable in predicting patients' R0 resection rate (p < 0.001) and prognosis (p < 0.0001). The main outcomes were internally validated. CONCLUSIONS 3DVE exhibited a better efficacy in evaluating hCCA resectability, compared with contrast-enhanced CT. Preoperative 3DVE demonstrated hepatic artery involvement was an independent risk factor for the absence of R0 margin. 3DVE classification of hCCA was valuable in clinical practice.
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Affiliation(s)
- Jun-Zhe Zhang
- Department of Biliary-Pancreatic Surgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, 200127, People's Republic of China
| | - Chuan-Xin Yang
- Department of Hepatobiliary and Pancreatic Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200233, People's Republic of China
| | - Si Gao
- Department of Biliary-Pancreatic Surgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, 200127, People's Republic of China
| | - Jun-Feng Bu
- Department of Biliary-Pancreatic Surgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, 200127, People's Republic of China
| | - Qin-Qin Li
- Department of Pathology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, People's Republic of China
| | - Hao-Lu Wang
- University of Queensland Diamantina Institute, University of Queensland, Woolloongabba, QLD, 4102, Australia
| | - Kai-Ni Yang
- Department of Biliary-Pancreatic Surgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, 200127, People's Republic of China
| | - Shan-Shi Tong
- Department of Biliary-Pancreatic Surgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, 200127, People's Republic of China
| | - Li-Jun Qian
- Department of Radiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, 200127, People's Republic of China
| | - Jin Zhang
- Department of Radiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, 200127, People's Republic of China
| | - Rong Hua
- Department of Biliary-Pancreatic Surgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, 200127, People's Republic of China
| | - Yong-Wei Sun
- Department of Biliary-Pancreatic Surgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, 200127, People's Republic of China
| | - Jia-Yan Yan
- Department of Biliary-Pancreatic Surgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, 200127, People's Republic of China.
- Department of Liver Surgery, Liver Cancer Institute, Zhongshan Hospital, Fudan University, Key Laboratory of Carcinogenesis and Cancer Invasion, Ministry of Education, Shanghai, 200032, People's Republic of China.
| | - Wei Chen
- Department of Biliary-Pancreatic Surgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, 200127, People's Republic of China.
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Efanov M, Alikhanov R, Zamanov E, Melekhina O, Kulezneva Y, Kazakov I, Vankovich A, Koroleva A, Tsvirkun V. Combining E-PASS model and disease specific risk factors to predict severe morbidity after liver and bile duct resection for perihilar cholangiocarcinoma. HPB (Oxford) 2021; 23:387-393. [PMID: 32792305 DOI: 10.1016/j.hpb.2020.07.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 07/01/2020] [Accepted: 07/02/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Estimation of physiologic ability and surgical stress system (E-PASS) has been shown to be effective in predicting morbidity after surgery for perihilar cholangiocarcinoma (PHCC). Nevertheless, E-PASS does not include an assessment of the disease specific risk factors. The aim of the study was to estimate the combined impact of E-PASS and specific preoperative factors on major morbidity for PHCC patients. METHODS A retrospective analysis of a prospectively collected data was performed. Severe morbidity according to complication comprehensive index was defined as ≥40 points. A value of comprehensive risk score (CRS) ≥1 was taken as critical. RESULTS Multivariate analysis of perioperative data from 122 patients revealed significant impact of five factors (CRS ≥1, future liver remnant volume <50%, T4 stage, moderate and severe cholangitis, INR) on the risk of severe morbidity after resection. The AUC for the combination of these factors was classified as good predictive value (0.810, 95% CI 0.729-0.891) and poor predictive value (0.673, 95% CI 0.573-0.773) for CRS alone (p = 0.040). CONCLUSION A combination of E-PASS with disease specific risk factors is a reliable predictive model for major morbidity for patients undergoing radical surgery for PHCC.
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Affiliation(s)
- Mikhail Efanov
- Department of Hepato-Pancreato-Biliary Surgery, Moscow Clinical Scientific Center, 11123, Shosse Entuziastov, 86, Moscow, Russia.
| | - Ruslan Alikhanov
- Department of Hepato-Pancreato-Biliary Surgery, Moscow Clinical Scientific Center, 11123, Shosse Entuziastov, 86, Moscow, Russia
| | - Ekhtibar Zamanov
- Department of Hepato-Pancreato-Biliary Surgery, Moscow Clinical Scientific Center, 11123, Shosse Entuziastov, 86, Moscow, Russia
| | - Olga Melekhina
- Department of Interventional Radiology, Moscow Clinical Scientific Center, 11123, Shosse Entuziastov, 86, Moscow, Russia
| | - Yuliya Kulezneva
- Department of Interventional Radiology, Moscow Clinical Scientific Center, 11123, Shosse Entuziastov, 86, Moscow, Russia
| | - Ivan Kazakov
- Department of Hepato-Pancreato-Biliary Surgery, Moscow Clinical Scientific Center, 11123, Shosse Entuziastov, 86, Moscow, Russia
| | - Andrey Vankovich
- Department of Hepato-Pancreato-Biliary Surgery, Moscow Clinical Scientific Center, 11123, Shosse Entuziastov, 86, Moscow, Russia
| | - Anna Koroleva
- Department of Hepato-Pancreato-Biliary Surgery, Moscow Clinical Scientific Center, 11123, Shosse Entuziastov, 86, Moscow, Russia
| | - Victor Tsvirkun
- Moscow Clinical Scientific Center, 11123, Shosse Entuziastov, 86, Moscow, Russia
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Hwang S. Standard and modified techniques for parenchyma-preserving hepatectomy focused on segments I+IV resection in patients with perihilar cholangiocarcinoma. Ann Hepatobiliary Pancreat Surg 2021; 25:112-121. [PMID: 33649263 PMCID: PMC7952662 DOI: 10.14701/ahbps.2021.25.1.112] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 01/10/2021] [Accepted: 01/11/2021] [Indexed: 12/31/2022] Open
Abstract
Resection of the hepatic segments I+IV (S1+S4) is the most common type of parenchyma-preserving hepatectomy (PPH) for perihilar cholangiocarcinoma (PHCC). The author describes personal experience on the standard and modified techniques for PPH focused on S1+S4 resection in patients with PHCC. 1) Isolated caudate lobectomy with bile duct resection (BDR) is the minimal type of PPH, but not currently recommended due to technical difficulty. 2) Partial hepatectomy of S1+S4a±segment V (S5) with BDR provides wide operative field, but extension of BDR is limited and resection of S1 paracaval portion is still difficult. 3) Resection of S1+S4+S5 with BDR provides wider operative field for complete S1 resection and multiple biliary reconstruction. 4) Resection of S1+S4 with BDR offers very wide operative field and allows wider extent of hilar BDR, and thus presents the most common type of PPH. A supplementary video clip presents the detailed standard surgical procedure for resection of S1+S4 with BDR in a patient with type IIIA PHCC. 5) Modified resection of S1+S4±S5 or segment VIII (S8) with BDR facilitates additional resection of tumor-involved S5 or S8 ducts. 6) Major hilar vascular invasion is usually contraindicated for PPH and only small portal vein invasion requiring wedge resection and patch venoplasty is allowed. In conclusion, PPH can achieve curative resection and improved outcomes in patients with PHCC via reasonable modification of the extent of hepatectomy and hilar BDR. PPH may have advantages in selected patients depending on the extent of tumor, and in patients with high operative risk.
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Affiliation(s)
- Shin Hwang
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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8
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Oh SG, Hwang S, Ha S, Kim H, Ryu LN. Necrosectomy of hepatic left lateral section after blunt abdominal trauma in a patient who underwent central hepatectomy and bile duct resection for perihilar cholangiocarcinoma. Ann Hepatobiliary Pancreat Surg 2020; 24:345-351. [PMID: 32843603 PMCID: PMC7452810 DOI: 10.14701/ahbps.2020.24.3.345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 06/22/2020] [Accepted: 06/22/2020] [Indexed: 11/19/2022] Open
Abstract
When the liver is divided into the right and left halves after central hepatectomy, a serious injury to the one half of the liver can destroy the ipsilateral half. We report a case showing total necrosis of the hepatic left lateral section (LLS) caused by blunt abdominal trauma in a patient who had undergone central hepatectomy and bile duct resection for perihilar cholangiocarcinoma. A 47-year-old female patient was transferred because of postoperative status following blunt abdominal trauma. Five years before, she had been diagnosed with perihilar cholangiocarcinoma. Since the tumor extent was compatible with Bismuth-Corlette type IV, she underwent central hepatectomy and bile duct resection. After five years, she experienced an industrial safety accident, in which a heavy refrigerator fell over her body. She underwent emergency duodenal diversion surgery with distal gastrectomy and Roux-en-Y gastrojejunostomy. During this surgery, serious ischemic injury of the LLS with occlusion of the left portal vein and hepatic artery was identified, but not treated. After three weeks, LLS necrosectomy with repair of the jejunal limb was done. Postoperative bile leak developed and required supportive care for two months for its healing. She is currently doing well without any physical discomfort four months after the necrosectomy. Our experience with this case suggests that an injury to the afferent jejunal limb requires an individualized treatment strategy including long-standing waiting with effective drainage for spontaneous healing. The experience of this case appears to be theoretically matched with late-stage resection of LLS following central hepatectomy and bile duct resection.
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Affiliation(s)
- Seul Gi Oh
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Shin Hwang
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Suhyeon Ha
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Heewon Kim
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Lee Na Ryu
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Donati M, Stang A, Stavrou GA, Basile F, Oldhafer KJ. Extending resectability of hilar cholangiocarcinomas: how can it be assessed and improved? Future Oncol 2018; 15:193-205. [PMID: 30378439 DOI: 10.2217/fon-2018-0413] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Until the 1980's, Klatskin tumors were considered 'desperate cases' and most of them were not resected; almost no oncologic concept was available. After many improvements, today, extended hepatectomy, including caudate lobe resection and lymphoadenectomy, have become a standard of care for oncologicaly radical resection of Klatskin tumors. Portal vein en bloc resection, if necessary, is a diffused standard assuring R0-resection without any improvement of survival in most series. Arterial resection remains episodical and controversial in its oncologic impact. Arterial resection-reconstruction was demonstrated to be feasible with many different technical possibilities. Neoadjuvant chemotherapy, refinement of associating liver partition and portal vein ligation for staged hepatectomy and liver transplantations are some possible future resources for treatment of those aggressive tumors that could be able to expand the pool of treatable patients.
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Affiliation(s)
- Marcello Donati
- Department of Surgery & Medical-Surgical Specialties, Surgical Clinic Unit, University Hospital of Catania (CAST), University of Catania, 95122 Catania, Italy.,Semmelweiss University of Budapest, Asklepios Campus Hamburg, Germany
| | - Axel Stang
- Oncology Unit, Asklepios Barmbek Hospital, Hamburg, Germany
| | - Gregor A Stavrou
- Department of General, Visceral, Thoracic & Pediatric Surgery, Saarbrucken Hospital, Saarbrucken-Saarland, Germany
| | - Francesco Basile
- Department of Surgery & Medical-Surgical Specialties, Surgical Clinic Unit, University Hospital of Catania (CAST), University of Catania, 95122 Catania, Italy
| | - Karl J Oldhafer
- Semmelweiss University of Budapest, Asklepios Campus Hamburg, Germany.,Department of General & Abdominal Surgery, Asklepios Barmbek Hospital, Hamburg, Germany
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Hartog H, Ijzermans JN, van Gulik TM, Koerkamp BG. Resection of Perihilar Cholangiocarcinoma. Surg Clin North Am 2016; 96:247-67. [DOI: 10.1016/j.suc.2015.12.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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11
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Wang S, Tian F, Zhao X, Li D, He Y, Li Z, Chen J. A New Surgical Procedure "Dumbbell-Form Resection" for Selected Hilar Cholangiocarcinomas With Severe Jaundice: Comparison With Hemihepatectomy. Medicine (Baltimore) 2016; 95:e2456. [PMID: 26765439 PMCID: PMC4718265 DOI: 10.1097/md.0000000000002456] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
The aim of the study is to evaluate the therapeutic effect of a new surgical procedure, dumbbell-form resection (DFR), for hilar cholangiocarcinoma (HCCA) with severe jaundice. In DFR, liver segments I, IVb, and partial V above the right hepatic pedicle are resected.Hemihepatectomy is recognized as the preferred procedure; however, its application is limited in HCCAs with severe jaundice.Thirty-eight HCCA patients with severe jaundice receiving DFR and 70 receiving hemihepatectomy from January 2008 to January 2013 were included. Perioperative parameters, operation-related morbidity and mortality, and post-operative survival were analyzed.A total of 21.1% patients (8/38) in the DFR group received percutaneous transhepatic biliary drainage (PTBD), which was significantly <81.4% (57/70) in the hemihepatectomy group. The TBIL was higher in the DFR group at operation (243.7 vs 125.6 μmol/L, respectively). The remnant liver volume was significantly higher after DFR. The operation-related morbidity was significantly lower after DFR than after hemihepatectomy (26.3% vs 48.6%, respectively). None of the patients died during the perioperative period after DFR, whereas 3 died after hemihepatectomy. There was no difference in margin status, histological grade, lymph-node involvement, and distant metastasis between the 2 groups. The 1-, 3-, and 5-year survival rates after DFR (68.4%, 32.1%, and 21.4%, respectively) showed no significant difference with those after hemihepatectomy (62.7%, 34.6%, and 23.3%, respectively). Kaplan-Meier analysis indicated that overall survival and recurrence after DFR demonstrated no significant difference compared with hemihepatectomy.DFR appears to be feasible for selected HCCA patients with severe jaundice. However, its indications should be restricted.
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Affiliation(s)
- Shuguang Wang
- From the Institute of Hepatobiliary Surgery, Southwest Hospital, Third Military Medical University, Chongqing, China
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12
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Németh K, Deshpande R, Máthé Z, Szuák A, Kiss M, Korom C, Nemeskéri Á, Kóbori L. Extrahepatic arteries of the human liver - anatomical variants and surgical relevancies. Transpl Int 2015; 28:1216-26. [DOI: 10.1111/tri.12630] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Revised: 04/09/2015] [Accepted: 06/22/2015] [Indexed: 11/27/2022]
Affiliation(s)
- Károly Németh
- Department of Transplantation and Surgery; Semmelweis University; Budapest Hungary
| | - Rahul Deshpande
- Department of Hepatobiliary Surgery; Manchester Royal Infirmary; Manchester UK
| | - Zoltán Máthé
- Department of Transplantation and Surgery; Semmelweis University; Budapest Hungary
| | - András Szuák
- Department of Human Morphology and Developmental Biology; Semmelweis University; Budapest Hungary
| | - Mátyás Kiss
- Department of Human Morphology and Developmental Biology; Semmelweis University; Budapest Hungary
| | - Csaba Korom
- Department of Radiology and Oncotherapy; Semmelweis University; Budapest Hungary
| | - Ágnes Nemeskéri
- Department of Human Morphology and Developmental Biology; Semmelweis University; Budapest Hungary
| | - László Kóbori
- Department of Transplantation and Surgery; Semmelweis University; Budapest Hungary
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13
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Tsuchikawa T, Hirano S, Okamura K, Matsumoto J, Tamoto E, Murakami S, Nakamura T, Ebihara Y, Kurashima Y, Shichinohe T. Advances in the surgical treatment of hilar cholangiocarcinoma. Expert Rev Gastroenterol Hepatol 2015; 9:369-74. [PMID: 25256146 DOI: 10.1586/17474124.2015.960393] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
With the improvement of perioperative management and surgical techniques as well as the accumulation of knowledge on the oncobiological behavior of bile duct carcinoma, the long-term prognosis of hilar cholangiocarcinoma has been improving. In this article, the authors review the recent developments in surgical strategies for hilar cholangiocarcinoma, focusing on diagnosis for characteristic disease extension, perioperative management to reduce postoperative morbidity and mortality, surgical techniques for extended curative resection and postoperative adjuvant therapy.
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Affiliation(s)
- Takahiro Tsuchikawa
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, N-15 W-7, Sapporo 060-8638, Japan
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14
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Kambakamba P, DeOliveira ML. Perihilar cholangiocarcinoma: paradigms of surgical management. Am J Surg 2014; 208:563-70. [DOI: 10.1016/j.amjsurg.2014.05.017] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2014] [Revised: 05/10/2014] [Accepted: 05/20/2014] [Indexed: 02/07/2023]
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15
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Lim JH, Choi GH, Choi SH, Kim KS, Choi JS, Lee WJ. Liver resection for Bismuth type I and Type II hilar cholangiocarcinoma. World J Surg 2013; 37:829-37. [PMID: 23354922 DOI: 10.1007/s00268-013-1909-9] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND In patients with Bismuth type I and II hilar cholangiocarcinoma (HCCA), bile duct resection alone has been the conventional approach. However, many authors have reported that concomitant liver resection improved surgical outcomes. METHODS Between January 2000 and January 2012, 52 patients underwent surgical resection for a Bismuth type I and II HCCA (type I: n = 22; type II: n = 30). Patients were classified into two groups: concomitant liver resection (n = 26) and bile duct resection alone (n = 26). RESULTS Bile duct resection alone was performed in 26 patients. Concomitant liver resection was performed in 26 patients (right side hepatectomy [n = 13]; left-side hepatectomy [n = 6]; volume-preserving liver resection [n = 7]). All liver resections included a caudate lobectomy. Patient and tumor characteristics did not differ between the two groups. Although concomitant liver resection required longer operating time (P < 0.001), it had a similar postoperative complication rate (P = 0.764), high curability (P = 0.010), and low local recurrence rate (P = 0.006). Concomitant liver resection showed better overall survival (P = 0.047). CONCLUSIONS Concomitant liver resection should be considered in patients with Bismuth type I and II HCCA.
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Affiliation(s)
- Jin Hong Lim
- Department of Surgery, Yonsei University College of Medicine, 134, Sinchon-dong, Seodaemum-gu, Seoul, 120-75, Korea
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Abstract
Curative treatment of Klatskin tumors by radical surgical procedures with surgical preparation distant to the tumor region results in 5-year survival rates of 30-50%. This requires mandatory en bloc liver resection and resection of the extrahepatic bile duct often together with vascular resection. Nevertheless, the ideal safety margin of 0.5-1 cm remote from the macroscopic tumor extensions cannot be achieved in all cases. Based on hilar anatomy the probability of an adequate safety margin is higher using extended right hemihepatectomy together with portal vein resection compared to left hemihepatectomy. However, due to severe atrophy of the left liver lobe solely left-sided hepatectomy is feasible in some patients. In cases of eligibility for both procedures right hemihepatectomy is preferentially used due to the higher oncological radicality if sufficient liver function is present. Postoperative hepatic insufficiency and bile leakage after demanding biliary reconstruction, often with several small orifices, contribute to the postoperative complication rate of this complex surgical disease pattern.
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Affiliation(s)
- D Seehofer
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Charité-Universitätsmedizin Berlin, Campus Virchow Klinikum, Augustenburger Platz 1, 13353, Berlin, Deutschland.
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17
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Kawarada Y, Das BC, Tabata M, Isaji S. Surgical treatment of type IV choledochal cysts. ACTA ACUST UNITED AC 2009; 16:684-7. [PMID: 19370303 DOI: 10.1007/s00534-009-0052-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2008] [Accepted: 04/18/2008] [Indexed: 02/07/2023]
Abstract
The benefit of total resection of the dilated bile duct has remained unclear. We describe here our surgical management of 13 patients with type IV choledochal cysts. All six younger patients (25-35 years old) underwent resection of the extrahepatic bile duct (EHBD) and hepaticojejunostomy (HJ), whereas three of the seven older patients (50-68 years old) underwent resection of the EHBD resection and HJ, with the remaining four older patients undergoing total resection of the dilated bile duct and removal of a pancreatobiliary maljunction (PBMJ) in the form of a S4a+S5 hepatectomy (so-called Taj Mahal) and/or pancreas head resection with second portion pancreaticoduodenectomy. No malignancies were detected in the dilated bile duct after resection in the younger patients, but cancer of the gallbladder and/or the dilated bile duct was found in two (27.5%) of the older patients. No cancers were detected during the long-term follow up (1974-2008) in those patients who underwent EHBD resection plus partial hepatectomy, but cancer developed in the remnant duct in one of the older patients who underwent EHBD resection alone. Based on our findings, we recommend that type IV choledochal cysts should be treated by total excision of the dilated bile duct, including the PBMJ, due to its frequent association with malignancy, and to prevent the development of cancer in the remnant duct and improve the long-term survival rate.
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Affiliation(s)
- Yoshifumi Kawarada
- First Department of Surgery, Mie University School of Medicine, Tsu, Mie, 514-8507, Japan
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18
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Malago M, Frilling A, Li J, Lang H, Broelsch CE. Cholangiocellular carcinoma--the role of caudate lobe resection and mesohepatectomy. HPB (Oxford) 2008; 10:179-82. [PMID: 18773050 PMCID: PMC2504371 DOI: 10.1080/13651820801992500] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2008] [Indexed: 12/12/2022]
Abstract
BACKGROUND The surgical treatment of perihilar cholangiocellular carcinoma (CCC) is challenging due to the adjacency of the tumor to the hilar vessels, major hepatic veins, bile ducts, and the inferior vena cava. Additionally, the tumour frequently infiltrates the parenchyma of the caudate lobe or/and invades its bile ducts. CONSENSUS STATEMENTS Negative margin caudate hepatectomy is rarely feasible. Isolated partial or complete caudate lobe resection is an oncologically inadequate procedure. Extended hepatectomies in combination with caudate lobectomy can provide prolonged survival, even in patients with advanced CCC. Mesohepatectomy is an oncologically adequate procedure for selected patients with CCC and compromised liver function. The procedure is technically demanding; however, it lowers the risk of postoperative liver failure.
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Affiliation(s)
- Massimo Malago
- Department of General, Viceral and Transplantation Surgery, University Hospital EssenEssenGermany
| | - Andrea Frilling
- Department of General, Viceral and Transplantation Surgery, University Hospital EssenEssenGermany
| | - Jun Li
- Department of General, Viceral and Transplantation Surgery, University Hospital EssenEssenGermany
| | - Hauke Lang
- Department of General, Viceral and Transplantation Surgery, University Hospital EssenEssenGermany
| | - Christoph E. Broelsch
- Department of General, Viceral and Transplantation Surgery, University Hospital EssenEssenGermany
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20
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Miyazaki M, Kimura F, Shimizu H, Yoshidome H, Ohtsuka M, Kato A, Yoshitomi H, Nozawa S, Furukawa K, Mitsuhashi N, Takeuchi D, Suda K, Yoshioka I. Recent advance in the treatment of hilar cholangiocarcinoma: hepatectomy with vascular resection. ACTA ACUST UNITED AC 2007; 14:463-8. [PMID: 17909714 DOI: 10.1007/s00534-006-1195-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2006] [Accepted: 10/16/2006] [Indexed: 01/04/2023]
Abstract
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.
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Affiliation(s)
- Masaru Miyazaki
- Department of General Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chiba, 260-0856, Japan
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21
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Seyama Y, Makuuchi M. Current surgical treatment for bile duct cancer. World J Gastroenterol 2007; 13:1505-15. [PMID: 17461441 PMCID: PMC4146891 DOI: 10.3748/wjg.v13.i10.1505] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2006] [Revised: 11/15/2006] [Accepted: 12/20/2007] [Indexed: 02/06/2023] Open
Abstract
Since extrahepatic bile duct cancer is difficult to diagnose and to cure, a safe and radical surgical strategy is needed. In this review, the modes of infiltration and spread of extrahepatic bile duct cancer and surgical strategy are discussed. Extended hemihepatectomy, with or without pancreatoduodenectomy (PD), plus extrahepatic bile duct resection and regional lymphadenectomy has recently been recognized as the standard curative treatment for hilar bile duct cancer. On the other hand, PD is the choice of treatment for middle and distal bile duct cancer. Major hepatectomy concomitant with PD (hepatopancreatoduodenectomy) has been applied to selected patients with widespread tumors. Preoperative biliary drainage (BD) followed by portal vein embolization (PVE) enables major hepatectomy in patients with hilar bile duct cancer without mortality. BD should be performed considering the surgical procedure, especially, in patients with separated intrahepatic bile ducts caused by hilar bile duct cancer. Right or left trisectoriectomy are indicated according to the tumor spread and biliary anatomy. As a result, extended radical resection offers a chance for cure of hilar bile duct cancer with improved resectability, curability, and a 5-year survival rate of 40%. A 5-year survival rate has ranged from 24% to 39% after PD for middle and distal bile duct cancer.
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Affiliation(s)
- Yasuji Seyama
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
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22
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Neuhaus P, Jonas S, Settmacher U, Thelen A, Benckert C, Lopez-Hänninen E, Hintze RE. Surgical management of proximal bile duct cancer: extended right lobe resection increases resectability and radicality. Langenbecks Arch Surg 2003; 388:194-200. [PMID: 12819970 DOI: 10.1007/s00423-003-0383-5] [Citation(s) in RCA: 110] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2003] [Accepted: 05/06/2003] [Indexed: 12/16/2022]
Abstract
BACKGROUND Surgical resection provides the only chance of cure for patients suffering from hilar cholangiocarcinoma. Although appropriate procedures are not agreed upon, an increase in radicality has been observed during the past 20 years. METHODS The literature as well as our own experience after 133 resections of hilar cholangiocarcinomas were reviewed. RESULTS Tumor-free margins represent the most important prognostic parameter. Hilar resections as least radical resective procedure will generate rates of formally curative resections of less than 50%. Even after these formally curative resections, long-term survival cannot be achieved. Only additional liver resections will increase the number of long-term survivors to significant figures. In our series, the best 5-year survival rate of 72% was achieved after right trisegmentectomy with concomitant resection of the portal vein bifurcation. CONCLUSION Right trisegmentectomy and combined portal vein resection represent the best way to comply with basic rules of surgical oncology for hilar cholangiocarcinoma. This procedure will provide the most pronounced benefit among various types of liver resection, whereas local resections of the extrahepatic bile duct must be considered as an oncologically inefficient procedure.
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Affiliation(s)
- Peter Neuhaus
- Klinik für Allgemein-, Viszeral und Transplantationschirurgie, Charité, Campus Virchow Klinikum, Humboldt University Berlin, Augustenburger Platz 1, 13353 Berlin, Germany.
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Shimada H, Endo I, Sugita M, Masunari H, Fujii Y, Tanaka K, Sekido H, Togo S. Is parenchyma-preserving hepatectomy a noble option in the surgical treatment for high-risk patients with hilar bile duct cancer? Langenbecks Arch Surg 2003; 388:33-41. [PMID: 12690478 DOI: 10.1007/s00423-003-0358-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2002] [Accepted: 01/28/2003] [Indexed: 10/25/2022]
Abstract
BACKGROUND The essential minimum of hepatic segmentectomy combined with caudate lobectomy (parenchyma-preserving hepatectomy) has been recommended particularly for high-risk patients with hilar bile duct cancer to minimize the risk of postoperative liver failure. This quality control study investigated whether parenchyma-preserving hepatectomy is a "noble option" in the surgical treatment of hilar bile duct cancer. PATIENTS AND METHODS A total of 53 patients with hilar bile duct cancer underwent surgical resection. These patients were retrospectively classified into a major hepatectomy group (major Hx, n=30), a parenchyma-preserving hepatectomy group (preserving Hx, n=11), and a hilar bile duct resection group (HBDR, n=12). A preserving Hx consisted of caudate lobectomy, either alone (n=3), or combined with resection of segment 4 (S4, n=4), or S58 (n=3) or S458 (n=1). The preserving Hx was used for high-risk patients in whom tumor tissue was diagnosed to be Bismuth type I and II by preoperative selective percutaneous transhepatic cholangiography. RESULTS The mean numbers of hepatico-jejunostomies were 2.8, 4.8, and 4.6 in the respective groups. Mortality rates including hospital death were 13.3%, 0%, and 0% respectively. Morbidity rates were 46.7%, 54.5%, and 33.3%. The preserving Hx group encountered no liver failure (T.Bil>10 mg/dl, encephalopathy) but acquired hyperbilirubinemia (T.Bil>5 mg/dl), pulmonary insufficiency and other complications at the same frequency as in the major Hx group. The survival rates in the three groups were 35.6%, 52.5%, and 48.6% at 3 years and 25.2%, 14.9%, and 24.3% at 5 years respectively. Curability rates (R0 to R1+2) were 76.7%, 54.5% and 50.0%, respectively. Preserving Hx tended to result in higher frequencies of positive transmural margins (e.g., cancer cells remaining around the right hepatic artery or the portal vein). CONCLUSIONS Preserving hepatectomy for high-risk patients should be limited strictly to patients who do not have tumors which are not invading adjacent organs (e.g., T2) nor a segmental duct and are confined longitudinally to the right or the left.
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Affiliation(s)
- Hiroshi Shimada
- Department of Surgery II, Yokohama City University School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan.
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Abstract
Recently, the caudate lobe has seemed to be the final target for aggressive cancer surgery of the liver. This lobe has five surfaces: the dorsal, left and hilar-free surfaces and the right and ventral-border planes. Surgeons have divided the caudate lobe into three parts: Spiegel's lobe, which is called the 'caudate lobe and papillary process' by anatomists, the caudate process, viewed as almost the same entity by anatomists, and the paracaval portion corresponding to the dorsally located parenchyma in front of the inferior vena cava. All three parts are supplied by primary branches originating from the left and right portal veins, including the hilar bifurcation area. The hilar bifurcation branch often (50%) supplies the paracaval portion and it sometimes (29%) extends its territory to Spiegel's lobe. It was postulated by Couinaud that the paracaval portion or the S9 is not defined by its supplying portal vein branch but by its 'dorsal location' in the liver. Couinaud's caudate lobe or dorsal-liver concept cause, and still now causes, great logical confusion for surgeons. We attempt here to describe the margins of the lobe, border branches of the portal vein, the left/right territorial border of the portal vein or Cantile's line and other topics closely relating to the surgery within these contexts. Finally, the caudate lobe as a liver segment will be discussed.
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Affiliation(s)
- Gen Murakami
- Department of Anatomy, Sapporo Medical University School of Medicine, South 1, West 17, Sapporo 060-8556, Japan.
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Yamakado K, Nakatsuka A, Iwata M, Kondo A, Isaji S, Uemoto S, Takeda K. Refractory biliary leak from intrahepatic biliary-enteric anastomosis treated by selective portal vein embolization. J Vasc Interv Radiol 2002; 13:1279-81. [PMID: 12471195 DOI: 10.1016/s1051-0443(07)61980-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
A 66-year-old woman underwent partial hepatectomy and pylorus-preserving pancreaticoduodenectomy for advanced Klatskin-type cholangiocarcinoma, and five intrahepatic biliary-enteric anastomoses were created. One anastomosis between the anterior-superior segmental bile duct and the jejunum developed a refractory biliary leak. Selective portal venous embolization with use of ethanol was performed in the anterior-superior portal branch to eliminate the production of bile by the target segment. The patient's clinical course was uneventful and the leak resolved after portal vein embolization.
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Affiliation(s)
- Koichiro Yamakado
- Department of Radiology, Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie 514-8507, Japan.
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26
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Kwon D, Murakami G, Hata F, Wang HJ, Chung MS, Hirata K. Location of the ventral margin of the paracaval portion of the caudate lobe of the human liver with special reference to the configuration of hepatic portal vein branches. Clin Anat 2002; 15:387-401. [PMID: 12373729 DOI: 10.1002/ca.10055] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
The topographic anatomy of the ventral margin of the paracaval portion of the caudate lobe of the human liver has not been clearly described to date. To this end we hypothesize the existence of a precaudate plane, a flat or slightly curved plane defined by the ventral margins of the ligamentum venosum and the hilar plate. Using 76 cadaveric livers, we investigated whether the paracaval portion of the caudate lobe extended ventral to this plane and whether the paracaval caudate branch of the portal vein (PC) ran through this plane to its ventral side. In 28 of the specimens (36.8%), the PC extended over the plane to a variable depth: less than 10 mm in 10 specimens, 10-20 mm in 10, and more than 20 mm in eight specimens. This ventral extension of the PC consistently included its penetration into the dome-like area under the terminals of the three major hepatic veins; therefore, the ventrally extended PC often interdigitated with these veins and their tributaries (in practice, the ventral margin of the paracaval portion of the caudate lobe could generally be considered to run alongside the middle hepatic vein). Moreover, the ventral extension of the PC often reached the upper, diaphragmatic surface or the dorsal surface of the liver immediately to the right of the inferior vena cava. Several branches (termed border branches) in the ventral extension were difficult to identify as belonging to the PC. We discuss both the marginal configuration of the paracaval portion of the caudate lobe and how to identify and operate on the ventrally extended PC and related border branches during liver surgery.
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Affiliation(s)
- Daehyun Kwon
- Department of Anatomy, Ajou University School of Medicine, Suwon, Korea
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27
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Isaji S, Kawarada Y. Pancreatic head resection with second-portion duodenectomy for benign lesions, low-grade malignancies, and early stage carcinomas involving the pancreatic head region. Am J Surg 2001; 181:172-6. [PMID: 11425061 DOI: 10.1016/s0002-9610(00)00557-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Preservation of arterial blood supply to the duodenum and common bile duct during duodenum-preserving total resection of the pancreatic head is a major problem. We describe here a new procedure comprising pancreatic head resection with second-portion duodenectomy to overcome it. METHODS The procedure was performed in 18 patients with benign lesions, low-grade malignancies, or early stage carcinomas involving the pancreatic head and with carcinoma of the middle bile duct or the gallbladder. The technique preserves the third portion of the duodenum by conserving the anterior inferior pancreaticoduodenal artery. The second portion of the duodenum is divided, followed by division of the lower bile duct and pancreatic neck. After resection followed by duodenoduodenostomy, there is a choice of two procedures: type A, pancreaticoduodenostomy and choledochoduodenostomy; or type B, pancreaticojejunostomy and hepatodochojejunostomy. RESULTS There were no operative or hospital deaths (type A, 6; type B, 12). Postoperative complications occurred in 2 patients, but the others had an uneventful postoperative course. The quality of life of all patients has been satisfactory up to 36 months postoperatively. CONCLUSION This procedure is a reliable option as an organ-preserving procedure for benign lesions, low-grade malignancies, and early stage carcinomas involving the pancreatic head.
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Affiliation(s)
- S Isaji
- First Department of Surgery, Mie University School of Medicine, Edobashi, Tsu, Japan
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Abstract
Investigation into the molecular and cellular biology of carcinogenesis continues to elucidate potential mechanisms for the initiation and progression of biliary tract cancer. The potential role of cell cycle regulators, such as Fas ligand, has been examined in the etiology of bile duct carcinoma. In addition, there is evidence for a possible link between chronic inflammation and malignant transformation through the relation between nitric oxide and DNA repair enzymes. Noninvasive imaging modalities, including helical computed tomography scanning, magnetic resonance cholangiopancreatography (MRCP) and positron emission tomography (PET) scanning, are gaining acceptance and may eventually supplant standard methods of evaluation. In addition, innovative tissue-sampling modalities including choledochoscopy are being developed. Several large series, Japanese and Western, continue to report improved 5-year survival rates after aggressive surgical resections of hilar cholangiocarcinoma. Although chemotherapeutic options remain limited in biliary tract carcinoma, radiation therapy may provide a benefit in local control in patients with microscopically positive margins. Photodynamic and multimodality therapy also may become important components of improving palliation for patients with advanced disease.
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Affiliation(s)
- J N Cormier
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030, USA
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