Radical surgery of left-sided klatskin tumors

Modified technique of Hepatojejunostomy for biliary tract reconstruction after resection of tumors affecting the perihilar region: a case series

BACKGROUNDS

Radical resection is the most effective treatment for perihilar tumors. Biliary tract reconstruction after resection is one of the key steps in this surgery. Mucosa-to-mucosa cholangiojejunostomy is traditionally performed, in which the bile ducts at the resection margin are separately anastomosed to the jejunum. However, this approach is associated with long operative time and high risk of postoperative complications. The present study presents a modified technique of hepatojejunostomy and its outcomes.

METHODS

The data of patients who underwent hepatojejunostomy using the modified technique at the Department of Hepatobiliary Surgery, Daping Hospital, Army Medical University, Chongqing, China, from January 2016 to December 2021, were retrospectively analyzed.

RESULTS

A total of 13 patients with perihilar tumors underwent R0 resection and bilioenteric reconstruction using the modified hepatojejunostomy technique during the study period. During the operation, the alignment of the bile duct stumps was improved, the posterior wall of the anastomosis was reinforced, internal stents were placed in the smaller bile ducts, external stents were placed in the larger bile ducts, and hepatojejunostomy was performed using 4 - 0 prolene. No serious postoperative complications, such as death or bile leakage, occurred during the hospitalization. Furthermore, there were no cases of biliary stricture or cholangitis after the six-month follow-up period.

CONCLUSION

The modified hepatojejunostomy technique is a safe and effective technique of biliary reconstruction after the resection of perihilar tumors. This can be easily performed for difficult cases with multiple bile ducts that require reconstruction after resection.

Application of multiple Roux-en-Y hepaticojejunostomy reconstruction by formation of bile hilar duct lake in the operation of hilar cholangiocarcinoma

BACKGROUND

Hilar cholangiocarcinoma is the most common malignant tumor of the extrahepatic bile duct. Until now, radical resection has been the most effective method for the long-term survival of patients with the disease. However, many problems have emerged in the field of hepatobiliary surgery for a long time, including complex surgical procedures, low resection rate, and postoperative complications. We have adopted the "multiple Roux-en-Y hepaticojejunostomy reconstruction by formation of a bile duct lake" technique in the treatment of hilar cholangiocarcinoma since 2008, and obtained satisfactory short- and long-term results.

AIM

To examine the feasibility of the application of multiple Roux-en-Y hepaticojejunostomy reconstruction by formation of a bile duct lake in the operation of hilar cholangiocarcinoma.

METHODS

A retrospective analysis was performed for the clinical data, surgical methods, and results of 76 patients with hilar cholangiocarcinoma who were treated with hilar bile duct lake-forming multiple Roux-en-Y hepaticojejunostomy reconstruction at Gansu Provincial Hospital.

RESULTS

In all 76 cases, the operation was successful and no operative death occurred. The mean (range) operation time was 215.4 ± 53.5 min (124-678 min), and the amount of bleeding during the operation was 428.2 ± 63.8 mL (240-2200 mL). The overall 1-year survival rate was 78.9%, and the 3-year survival rate was 32.8%.

CONCLUSION

The multiple Roux-en-Y hepaticojejunostomy reconstruction technique with formation of a bile duct lake is safe and effective for the surgical treatment of hilar cholangiocarcinoma.

Comparison study for surgical outcomes of right versus left side hemihepatectomy to treat hilar cholangiocellular carcinoma

Purpose

Major liver resection and radical lymph node dissection has been accepted as a definite treatment of choice for hilar cholangiocarcinoma (HC). However, the perioperative and survival outcomes of right hemihepatectomy (RH) and left hemihepatectomy (LH) still remain controversial. Thus, this study aimed to compare the surgical and oncological outcomes of RH and LH in HC patients.

Methods

From January 2000 to January 2018, a total of 326 patients underwent surgical resection for HC at Yonsei University College of Medicine in Seoul, Korea. Among the 326 patients, we excluded 130 patients and selected 196 patients, who underwent hemihepatectomy with caudate lobectomy. Among these 196 patients, 114 patients underwent RH, and 82 patients underwent LH. We compared the clinicopathological features as well as the surgical and oncologic outcomes of the RH and LH groups.

Results

There were no significant differences in disease-free survival (P = 0.473) or overall survival (P = 0.946) in the RH and LH groups. The LH group had fewer complications compared with the RH group, including postoperative ascites (RH: 15 [13.2%] vs. LH: 3 [3.7%], P = 0.023); however, the LH group had more bile leakage complications (RH: 5 [4.4%] vs. LH: 12 [14.6%], P = 0.012). The average time lag from portal vein embolization to operation was 25.80 ± 12.06 days (n = 45). There was no difference in postoperative liver failure (P = 0.402), although there were significantly more frequent ascites after RH (P = 0.023).

Conclusion

LH might be a good alternative option for the surgical treatment of HC given appropriate tumor location and biliary anatomy indications.

[Predictors of outcomes in surgery for hilar cholangiocarcinoma]

AIM

To determine significant predictors of long-term outcomes of surgery for portal cholangiocarcinoma.

MATERIAL AND METHODS

Analysis included 49 out of 84 patients who were operated at the Vishnevsky Institute of Surgery in 2003-2016. Morphological examination (2011-2016) revealed great percentage of following positive variables: micro- (42.9%) and lymphovascular invasion (11.8%), positive resection margin (59.2%), perineural invasion (83.3%), depth of invasion - (83.3%), cells in surrounding fatty tissue (92.3%), invasion of entire thickness of bile ducts' walls (57.1%). Hemihepatectomy was carried out in 50 (59.5%) cases, advanced hemihepatectomy - in 16 (19%) patients. Left-sided hemihepatectomy (34.6%) was more common compared with right-sided hemihepatectomy (8.6%) for biliary confluence lesion (Bismuth-Corlette type IV).

RESULTS

TNM stage (p=0.29), tumor localization Bismuth-Corlette type (p=0.10), regional lymph nodes metastases (p=0.77) do not significantly affect survival in univariate analysis. At the same time, TNM stage was significant factor if patients dividing into groups was considered (p=0.05). In regression analysis tumor cells differentiation (p=0.00028), positive resection margin (p=0.0034), perineural invasion and depth of invasion (p=0,00086) were significant predictors of survival. Multivariate analysis confirmed prognostic role of lymphovascular invasion alone (p=0.05). There was no correlation between survival and TNM stage (η=0.057), depth of invasion (η= -0.229) and lymphovascular invasion (η= -0.143645). There was significant reverse moderate correlation between survival and perineural invasion (η= - 0.468750), resection margin (η= -0.558) and tumor differentiation grade (η= -0.481).

CONCLUSION

Significant predictors of long-term outcomes of surgery for portal cholangiocarcinoma are TNM stage, lymphovascular invasion, tumor cells differentiation, perineural invasion.

Surgical and histological boundary of the hepatic hilar plate system: basic study relevant to surgery for hilar cholangiocarcinoma regarding the "true" proximal ductal margin

BACKGROUND

We sought to expand the clinico-anatomical limit of the proximal ductal margin (Limit-PDM) for resectability of hilar cholangiocarcinoma (HCCA).

METHODS

The practical boundary of the hilar plate (PBHP) was defined as the location where the bile duct (BD) could not be isolated by dissection. The distance between PBHP and two well-known clinical landmarks of Limit-PDM, the right edge of the bifurcation of the anterior and posterior branch of the right portal vein (Posterior-Landmark) and the left edge of the umbilical portion of the portal vein (Left-Landmark), and histological features around the PBHP were assessed using 55 adult cadaver livers.

RESULTS

BD was almost always isolatable beyond the traditional clinical landmarks. The median distance was 6.9 mm (interquartile range [IQR] 6.0-8.3 mm) between the PBHP and the Posterior-Landmark, and 8.9 mm (IQR 6.7-10.2 mm) between the PBHP and the Left-Landmark. Histologically, the sheath surrounding the portal triad was loose, thick with few elastic fibers and small arteries near the hepatic hilum. Near the PBHP, the sheath was dense, thin, and abundant with elastic fibers and small arteries.

CONCLUSIONS

Limit-PDM is more peripheral than the traditional clinical landmark-based margin and histological transition near the PBHP was revealed.

Extending resectability of hilar cholangiocarcinomas: how can it be assessed and improved?

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.

Segment 5 parenchymal sparing in extended left hepatectomy with respect to venous outflow-is it a feasible procedure?

BACKGROUND

Segment 5 (S5) sparing liver resection for cases that require an anatomic left trisectionectomy has not been reported yet. The authors intended to verify the outcome of S5-sparing extended left hepatectomy (ELH) in respect to venous outflow.

METHODS

All adult patients who underwent S5-sparing ELH between 2012 and 2017 in authors' institute have been enrolled in this study. S5-sparring ELH was defined as resection of S2, S3, S4, and S8 with or without S1. The surgery planning was based on the images from two-dimensional triphasic computed tomography and/or magnetic resonance imaging. A three-dimensional image reconstruction and liver volumetric study were performed retrospectively.

RESULTS

Out of 177 cases of major hepatic resection, only seven non-hilar cholangiocarcinoma patients underwent ELH during the study period. S5-sparing ELH was performed to five patients, in whom no tumor involvement in S5. The venous outflow of S5 has been maintained intraoperative, and S5 congestion has not been observed in all patients. Tailored management of the S5 venous outflow ensured an increase in functional remnant liver volume by 52.8% (range, 25.6 to 66.9%) by sparing of S5. A negative resection margin was achieved in all patients. One patient had postoperative bile leak requiring reoperation. No posthepatectomy liver failure (PHLF) has been observed.

CONCLUSION

S5-sparing ELH is technically feasible. Under the tailored management of S5 venous outflow, the functional future liver remnant can be increased. Further studies with larger sample size are needed to evaluate which circumstances the liver segment 5 could be preserved without venous reconstruction during the left extended hepatectomy.

Liver resection for perihilar cholangiocarcinoma - why left is sometimes right

INTRODUCTION

Left-sided liver resection (LLR) for perihilar cholangiocarcinoma (PHC) may require right hepatic artery (RHA) resection and reconstruction because of its intimate relationship with the biliary confluence. Consequently right-sided resections (RLR) are preferred for Bismuth-Corlette IIIb tumours, and resections avoided in Bismuth-Corlette IV tumours with left lobar atrophy when the RHA is involved by tumour.

METHODS

A retrospective analysis of patients with PHC who presented between December 2009 and June 2015.

RESULTS

Thirty-six patients underwent resection for PHC (23 LLR, 13 RLR). The number of Bismuth-Corlette IV patients undergoing LLR was significantly greater than those undergoing RLR (8/23 vs 0/13, p = 0.032). The need for arterial reconstruction (AR) was significantly greater during LLR than RLR (10/23 vs 0/13, p = 0.006). Postoperative liver dysfunction was greater after RLR (5/13 vs 0/23, p = 0.003), and hospital stay was shorter after LLR (10 vs 15 days, p = 0.013).

CONCLUSIONS

Safe AR increases the ability to perform potentially curative LLR for PHC. This improves the resectability rate for PHC, particularly for Bismuth-Corlette Type IV tumours. The larger liver remnant after LLR results in less postoperative liver dysfunction and shorter hospital stay without increased operating time, blood loss or morbidity.

Comparative Analysis of Left- Versus Right-sided Resection in Klatskin Tumor Surgery: can Lesion Side be Considered a Prognostic Factor?

BACKGROUND

Achievement of negative margins is the goal of curative intent surgery for hilar cholangiocarcinoma. This study analyzed factors affecting survival in hilar cholangiocarcinoma patients and compared short- and long-term outcomes of left- and right-sided resections.

METHODS

One hundred and five patients out of 124 diagnosed with Klatskin tumors underwent major liver resection. Sixty-one patients underwent right-sided resections (right group), whereas 44 underwent left-sided resections (left group). Perioperative morbidity, perioperative mortality, and overall and disease-free survival were compared between the groups.

RESULTS

Morbidity and mortality were higher in the right group (59 and 8.2%, respectively) than in the left group (38.6 and 2.3%, respectively) (p < 0.005). The most frequent cause of death was liver failure. The R0 rate was 75.4% in the right and 61.4% in the left group. The 5-year survival rate was 42.8% in the right and 35.3% in the left group (p < 0.05). Patients in the left group more frequently developed local recurrence (87 vs. 69% in the right group).

CONCLUSION

Lesion side impacts outcome: right resections still cause significant morbidity related to extensive parenchymal sacrifice but are associated with better long-term survival because right hepatic pedicle resection enables better radicality compared with left resections.

[Perihilar cholangiocarcinoma (Klatskin tumor)]

Perihilar cholangiocarcinoma or Klatskin tumors are a rare entity arising from the extrahepatic bile duct bifurcation. Considering the close anatomical relationship of the bile duct bifurcation with the portal vein bifurcation and hepatic arteries, surgical treatment is demanding. With an incidence of only 2-4 cases/100,000 population/year patients should be referred to a specialized center. The tumors are usually poorly differentiated adenocarcinomas growing diffusely along the duct and also the perineural sheath. Only radical surgery offers a curative option and currently surgical strategy usually consists of en bloc resection of the bile duct, extended liver resection and portal vein resection. Proximal and lateral safety margin R0 resections are technically very demanding procedures because of the local anatomy.

Surgical strategy for hilar cholangiocarcinoma of the left-side predominance: current role of left trisectionectomy

OBJECTIVE

To evaluate recent surgical strategy for hilar cholangiocarcinoma (HC) of the left-side predominance.

BACKGROUND

When employing left hemihepatectomy (LH) for HC, vasculobiliary anatomy of the right liver often makes it difficult to achieve a tumor-free margin of the right posterior sectional bile duct (RPSBD). Because left trisectionectomy (LTS) can produce a longer resection margin for the RPSBD, we have expanded the indications for LTS over the last 5 years.

METHODS

Sixty-one consecutive patients underwent left-sided hepatectomy for HC, divided into 2 groups according to the operative periods: period 1 (2001-2007; n = 29) and period 2 (2008-2012; n = 32). Clinicopathological outcomes of the groups were compared. The difference in the length of the resectable RPSBD between LH and LTS was radiologically investigated using multidetector-row computed tomography.

RESULTS

The proportion of LTS increased from 10.3% (3/29) in period 1 to 46.9% (15/32) in period 2. R0 resection rates were also improved in period 2. The most common margin positive site in period 1 was the stump of the proximal bile duct; high rates of positive RPSBD stump were noted after LH. The positive proximal ductal margin ratio decreased significantly in period 2. The difference in the length of resectable RPSBD between LH and LTS was 9.0 ± 1.3 mm. There was no mortality in period 2, even after LTS.

CONCLUSIONS

LTS for HC of the left-side predominance improved R0 resection rates without affecting postoperative mortality. LTS should be aggressively performed in patients with appropriate hepatic function, even if tumors are possibly resectable by LH.

Outcome of surgical resection in Klatskin tumors

Cholangiocarcinomas are the second most frequent primary hepatic malignancy, and make up from 5% to 30% of malignant hepatic tumours. Hilar cholangiocarcinoma (HCC) is the most common type, and accounts for approximately 60% to 67% of all cholangiocarcinoma cases. There is not a staging system that permits us to compare all series and extract some conclusions to increase the long-survival rate in this dismal disease. Neither the extension of resection, according to the sort of HCC, is a closed topic. Some authors defend limited resection (mesohepatectomy with S1, S1 plus S4b-S5, local excision for papillary tumours, etc.) while others insist in the compulsoriness of an extended hepatic resection with portal vein bifurcation removed to reach cure. As there is not an ideal adjuvant therapy, R1 resection can be justified to prolong the survival rate. Morbidity and mortality rates changed along the last decade, but variability is the rule, with morbidity and mortality rates ranging from 14% to 76% and from 0% to 19%, respectively. Conclusion: Surgical resection continues to be the main treatment of HCC. Negative resection margins achieved with major hepatic resections are associated with improved outcome. Preresectional management with biliary drainage, portal vein embolization and staging laparoscopy should be considered in selected patients. Additional evidence is needed to fully define the role of orthotopic liver transplant. Portal and lymph node involvement worsen the prognosis and long-term survival, and surgery is the only option that can lengthen it. Improvements in adjuvant therapy are essential for improving long-term outcome. Furthermore, the lack of effective chemotherapy drugs and radiotherapy approaches leads us to can consider R1 resection as an option, because operated patients have a longer survival rate than those who not undergo surgery.