Central hepatic resection and anastomosis for stricture or carcinoma at the hepatic bifurcation

Total Laparoscopic Radical Resection of S1 + S4 for Bismuth-Corlette Type IV Hilar Cholangiocarcinoma (With Video)

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.

Carcinoma das vias biliares extra-hepáticas

Os autores revisam os aspectos clínicos, a avaliação diagnostica e o tratamento de colangiocarcinoma hilar. São discutidos os exames indispensáveis para o estadiamento e escolha da melhor terapêutica. Com o avanço no conhecimento sobre a patologia surgiram novas técnicas curativas e paliativas que são apresentadas nesta revisão.

Role of caudate lobectomy in type III A and III B hilar cholangiocarcinoma: a 15-year experience in a tertiary institution

BACKGROUND

Concomitant liver resection for type III hilar cholangiocarcinoma could improve the R0 resection rate and long-term outcome. In the present study, we examine the specific role of caudate lobectomy in liver resection for type III(A) and III(B) hilar cholangiocarcinoma and the prognostic factors for survival in this group of patients.

METHODS

We reviewed all patients with type III(A) and III(B) hilar cholangiocarcinoma who underwent liver resection in Samsung Medical Center from January 1995 to July 2010. Patients were divided into those with and without caudate lobectomy (CL). The log rank test and Cox regression analysis were employed to investigate for prognostic factors of survival.

RESULTS

There were 127 patients in this cohort, 57 without CL (44.9%) and 70 with CL (55.1%). The demographics and symptoms of presentation were comparable. The median preoperative bilirubin level was significantly higher in the group undergoing CL (p = 0.017). Patients with CL had a significantly better overall survival (OS) (CL: 64.0 months vs without CL: 34.6 months) (p = 0.010) and disease-free survival (DFS) (CL: 40.5 months vs without CL: 27.0 months) (p = 0.031). Multivariate analysis showed that presence of symptoms (p = 0.025) and positive lymph node (LN) metastasis (p < 0.001) were negative prognostic factors for OS. Furthermore, multivariate analysis for DFS found that caudate lobectomy (p = 0.016) and positive LN metastasis (p = 0.001) were positive and negative prognostic factors, respectively.

CONCLUSIONS

Caudate lobectomy contributed to improvement of DFS and OS in type III hilar cholangiocarcinoma. Other prognostic factors include positive LN metastasis and presence of symptoms.

Clinicopathological study of patients undergoing resection of hilar cholangiocarcinoma

Of the patients who underwent resection of hilar cholangiocarcinoma, those who received palliative surgery, or could not be followed up clinicopathologically, were excluded from this study. In the remaining 37 patients, the cumulative postoperative survival rate (simply referred to as the cumulative survival rate below) was analyzed according to gross types, histopathological parameters, final stages, and final curability. These patients showed a 5-year survival rate of 17.7% and a 50% survival of 2.2 years. By gross type, patients with a localized papillary or nodular expansion type tended to have a better survival rate than those with an invasive papillary or nodular expansion type. A greater histological depth of invasion tended to be associated with a poorer prognosis: the s(-) group, that is, a group of patients without serosal exposure of cancer (invasion depths of m, fm, and ss) had a significantly better prognosis than the s(+) group, a group of patients with serosal exposure of cancer (invasion depths of se and si). Other histopathological parameters, such as ly, pn, pHinf, pHM, and pEM, were associated with significant prognostic differences. By final stage, the stage I/II group and stage III or higher group showed a particularly significant difference in prognosis. By final curability, the curability A/B group had a significantly better prognosis than the curability C group. Taken together, surgery providing curability A and B promises a good long-term prognosis. Therefore, it is important that efforts are made to detect cancer early, adequately evaluate the degree of cancer extension, and determine the extent of resection and the surgical technique.

Improved operative and survival outcomes of surgical treatment for hilar cholangiocarcinoma

BACKGROUND

The aim of the present study was to assess whether an aggressive surgical approach in the management of patients with hilar cholangiocarcinoma was associated with improved operative and survival outcomes.

METHODS

Eighty-two patients with hilar cholangiocarcinoma treated between 1989 and 1998 (period 1), and 60 patients treated between 1999 and 2004 (period 2), were evaluated. Modifications to management in period 2 primarily included percutaneous biliary drainage instead of endoscopic drainage for relief of obstructive jaundice, preoperative right portal vein embolization before right-sided hepatectomy, routine total caudate lobectomy and radical lymphadenectomy during surgical resection of the tumour.

RESULTS

The surgical resection rate was significantly higher in period 2 than in period 1 (45 versus 16 per cent; P < 0.001). All patients in period 2 underwent major hepatectomy with concomitant caudate lobectomy. The operative morbidity and hospital mortality rates decreased significantly in period 2 compared with period 1, with significantly better survival outcomes. In multivariate analysis, resection of the tumour in period 2 and operative blood loss of 1.5 litres or less were the significant independent factors associated with improved survival.

CONCLUSION

An aggressive surgical approach was associated with improved operative and survival outcomes for patients with hilar cholangiocarcinoma.

Resection of Central Hepatic Malignant Lesions

Tumors within the central hepatic region can be managed by various operative techniques. The aim of hepatic resection should be to render the patient free of disease while limiting the excision of functioning parenchyma. Technical feasibility, improved anatomical understanding, and advanced support services have enabled access to lesions previously considered unresectable. Various surgical options and outcomes from a single surgeon's experience are presented. Thirty-three patients underwent surgical resection for central hepatic lesions adjacent to the anterior hilar plate from 1980 to 2001. The mean patient age was 55.7 years (range 34–82). The mean lesion size was 7.7 cm (2–21). Malignant lesions were most commonly encountered in segments IV and V (43%). The most common resection performed was a central hepatic resection (55%) followed by right trisegmentectomy (27%). Resections were primarily performed for metastatic colon cancer (48%), cholangiocarcinoma (25%), and hepatocellular carcinoma (15%). The 5-year survival was 45 per cent for metastatic colon cancer, 20 per cent for cholangiocarcinoma, and 66 per cent for hepatocellular carcinoma. The overall morbidity was 43 per cent, and there was a single mortality. The size, location, and extension of hepatic tumors are important factors that may predict the extent of hepatic resection. Small centrally located focal lesions are amenable to central hepatic resection with biliary reconstitution hence limiting extensive resections. Valuable 5-year patient survival and a low mortality rate were achieved.

Is parenchyma-preserving hepatectomy a noble option in the surgical treatment for high-risk patients with hilar bile duct cancer?

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.

Central hepatic resection for pediatric tumors

BACKGROUND/PURPOSE

Resection of hepatic malignancies in childhood has been facilitated greatly by an understanding of hepatic segmental anatomy. This report documents the indications and technique of central hepatic resection (mesohepatectomy) in children with hepatic malignancies.

METHODS

This is a retrospective study, and data are obtained from patient charts and operative reports. Three patients underwent central hepatic resection on or between June 27, 1997 and October 1, 1999.

RESULTS

All patients were boys, and their ages at diagnosis were 0.3, 0.8, and 3.8 years. Two had hepatoblastoma and one central hepatic metastases from a poorly defined epithelial malignancy. All 3 received neoadjuvant chemotherapy before hepatic resection. Segments IV, V, and VIII were removed in 2, and IV and V in the third. All patients survived, and histopathologic margins were clear in each. One patient had a postoperative bile collection treated with percutaneous catheter drainage. At follow-up, all patients remain alive without evidence of disease, and all have normal hepatic function.

CONCLUSION

Central hepatic resection of malignant tumors involving segments IV, V, and VIII is feasible and effective in childhood.

S4a + S5 with caudate lobe (S1) resection using the Taj Mahal liver parenchymal resection for carcinoma of the biliary tract

Recently we have been performing S4a + S5 with total resection of the caudate lobe (S1) by using a dome-like dissection along the root of the middle hepatic vein at the pinnacle, which we refer to as the Taj Mahal liver parenchymal resection, for carcinoma of the biliary tract. This procedure offers the following advantages: (1) It allows total resection of the caudate lobe, including the paracaval portion (S9), and (2) because the cut surface of the liver is large, it allows intrahepatic jejunostomy to be performed more easily with a good field of view. The indications for this procedure include hilar bile duct carcinoma, gallbladder carcinoma, and choledochal cyst (type IVA). Because of the high rate of hilar liver parenchyma and caudate lobe invasion associated with hilar bile duct carcinoma, the liver must be resected. The Taj Mahal procedure is indicated in cases where extended liver resection is impossible. The dissection limits of this procedure are, on the left side, the B2+3 bifurcation at the right margin of the umbilical portion of the portal vein and, on the right side, the B8 of the anterior branch and the B6+7 bifurcation of the right posterior branch. This procedure could also be described as a reduced form of extended right hepatectomy and extended left hepatectomy. For gallbladder carcinoma, this procedure is indicated to ensure an adequate surgical margin and eradicate transvenous liver metastasis, particularly in cases of pT2 lesions. Hilar and caudate lobe invasion also occurs in liver bed-type gallbladder carcinoma, and bile duct resection and caudate lobe resection are required for the surgery to be curative. We performed this procedure in four cases of hilar bile duct carcinoma, five cases of gallbladder carcinoma, and one case each of choledochal cyst (type IVA) with carcinoma of the bile duct and gallbladder adenomyomatosis. Curative resection was possible in all except the patient with adenomyomatosis, and all of the patients are alive and recurrence free 10 to 37 months postoperatively. This procedure, in addition to preserving liver function, provides a wide field of view and facilitates reconstruction of multiple intrahepatic bile ducts. Thus it can be said to be a curative operation not only in patients considered high risk but also in those whose hilar bile duct carcinoma is limited to the bifurcation area (Bismuth type IIIa and IIIb) and in gallbladder carcinoma up to pT2 with slight extension on the hepatic side.

Hepatic segmentectomy with caudate lobe resection for bile duct carcinoma of the hepatic hilus

From 1979 through 1989, surgical resection was performed in 55 of 66 patients with carcinoma of the hepatic hilus after improving jaundice by percutaneous transhepatic biliary drainage (PTBD). Selective cholangiography through PTBD was done to define precisely the anatomical location--extent of the obstructing lesion in each segmental hepatic duct. Percutaneous transhepatic cholangioscopy was performed through the sinus tract of PTBD after replacing the drainage catheter with a 15 French catheter for superselective cholangiography and biopsy to make the definitive diagnosis of the histological extent of the tumor and any variation of each segmental hepatic duct that joins the hepatic hilus. In 46 (69.7%) of 66 patients, curative resection was possible. Forty-five of these underwent various types of hepatic segmentectomy with caudate lobectomy for a morbidity rate of 41.3% and an operative mortality rate of 6.4%. Fourteen (31.1%) advanced cases underwent combined resection of the portal vein together with hepatectomy. Microscopic tumor involvement in the caudate branches was confirmed in 44 of 45 patients who underwent caudate lobe resection. The 3-year survival rate for all 43 patients surviving the curative excision was 55.1% and the 5-year survival rate was 40.5%. All 11 patients who had an unresectable advanced tumor died within 9 months. Curative resection should be designed according to the preoperative findings of the extent of cancer in each segmental duct, and caudate lobe resection should be performed together with the smallest necessary hepatic segmentectomy possible.

Cholangiocarcinoma. Role of percutaneous transhepatic cholangiography in determination of resectability

Exploratory laparotomy is frequently used to diagnose, treat, or palliate cholangiocarcinoma although surgery is rarely curative. In light of newly developed percutaneous and endoscopic approaches to diagnosis and therapy, we reviewed our experience with 35 cases of cholangiocarcinoma diagnosed and treated at the University of Michigan Medical Center from 1979 to 1984. Percutaneous transhepatic cholangiography (PTCA) was performed in 34 cases of which only four were resectable. All 22 patients who had preoperative cholangiograms suggesting unresectability had confirmation of this at surgery. Surgical palliation was accomplished with a combination of internal and percutaneous drainage in most cases. Angiographic, cytologic, and laboratory data are presented. PTCA accurately predicted unresectability of cholangiocarcinoma and is superior to angiography in this respect. In patients with cholangiocarcinoma, percutaneous and endoscopic approaches offer alternatives to surgery for diagnosis and palliation.

Biliary metastases of breast carcinoma. The case for resection

Obstructive jaundice developed in two patients 6 and 8 years after surgery for breast carcinoma. In both patients exploration disclosed a tumor of the hilus which was a biliary metastasis of breast cancer. Surgical resection was performed. Examination of the resected specimen showed infiltration of the duct walls by sheets of metastatic carcinomatous cells from the previous breast cancer. The postoperative course was uneventful in both patients with disappearance of all symptoms due to the biliary obstruction. The first patient died 4 years later from peritoneal deposits and the second was alive at 30 months with a metastasis to the hip. These observations differ from most of those previously reported, by the localization of the tumor at the hilus and the direct infiltration of the duct walls by the tumor. The results of this study suggest that aggressive surgical treatment may be the treatment of choice in patients with extrahepatic biliary metastases of breast carcinoma.

Proximal bile duct cancer. Quality of survival

A retrospective study of 97 patients with proximal bile duct cancer treated at the University of California, Los Angeles Medical Center was conducted to determine the benefits of different operative treatments. Eighty-nine patients were divided into three treatment groups: Group I, curative resection (29 patients); Group II, palliative resection (13 patients) and bypasses (8 patients); and Group III, operative intubation (39 patients). Two patients died before operation and six patients were treated without operation by percutaneous biliary decompression. High morbidity rate (53.8%) and mortality rate (69.2%) were encountered in 13 patients who had hepatic resection. Survival rates of the three treatment groups were comparable. For the 64 patients closely monitored after discharge, quality of survival was assessed according to six parameters: frequency of hospitalization for cholangitis; catheter-related problems; the percentage of days hospitalized; duration of jaundice; antibiotic requirements; and analgesic needs. Group I patients had the best qualitative survival, whereas Group II patients had the worst result when compared with either Group I (p less than 0.001) or Group III (p less than 0.005). Curative resection is recommended when it can be done without a concomitant hepatic resection. When noncurable disease is found on examination, operative intubation after dilatation is the preferred palliative measure.

Carcinoma of the extrahepatic bile ducts

Carcinoma of the extrahepatic bile ducts is relatively uncommon. Although these tumors usually grow slowly, the patient's prognosis is poor. This article reviews the records of patients with a diagnosis of cancer of the extrahepatic biliary tract treated surgically at Scott and White Memorial Hospital from 1960 to 1984. The pertinent history, physical findings, laboratory data, type of operation, adjuvant therapy, and survival were collected and recorded.

Cholangiography and small duct injury

Eighteen instances of bile duct injury over the past 25 years have been reported. Manipulation of a minute cystic duct where the common bile duct was 3 mm in diameter or less was responsible for the division of the duct in eight cases. Most of the commercial catheters are sharp, about 2 mm in diameter, and can easily divide the bile duct if pushed too far. Since manipulation of the duct with a mosquito or tonsil clamp to insert other smaller catheters can also divide a small bile duct, we have decided to discontinue obtaining cholangiograms under these circumstances. Longitudinal splitting of two additional 3 mm ducts with a 3 mm dilator was another major source of injury. Overclipping of the cystic artery to involve the hepatic duct and overmobilization of the bile duct were other sources of injury. We have ceased attempting to obtain cholangiograms in patients with small cystic ducts because of the availability of endoscopic sphincterotomy, the low yield of the films under these circumstances, and fear of damaging the ducts. We use hepaticojejunostomy with Silastic tube stenting for repair of bile duct injuries.

[Resection of juxtahilar bile duct carcinoma instead of palliative drainage of the biliary tract]

Instead of the widely recommended approach of treating hilar carcinoma of the bile ducts by simple palliative biliary drainage, step by step a policy of primarily aiming at resection for cure has been adopted. So far in 11 out of 22 patients excision of the tumor was possible by resection of the hepatic duct confluence; in 4 cases a left hemihepatectomy had to be added because of carcinomatous infiltration of the left liver lobe or the left hepatic artery. The multiple bile duct openings remaining after resection of such tumors were reconstructed to one or two orifices and a bi- or unilateral Roux-en-Y cholangiojejunal anastomosis performed. In further 3 cases orthotopic liver transplantation was necessary to remove all visibly infiltrated tissue. In the remaining 8 patients because of documented extrahepatic carcinomatous spread palliative biliary drainage by a percutaneous U-tube or an endoprothesis was indeed considered the only reasonable measure. Despite the relatively high resectional rate of 60% and the extensive operations performed early mortality was confined to one patient who succumbed to septic endocarditis 6 weeks after the operation. At present the longest postoperative interval without recurrence amounts to 3 1/2 years. Nine patients free of recurrent disease are in perfect health; in 3 patients in whom a recurrence was observed after 1/2, 1 1/2 and 2 years meanwhile palliation was perfect. In contrast all patients with unresected tumors but carrying draining stents suffered from cholangitis and after 1 1/2 years all but one had died. In conclusion resectional therapy for hilar carcinoma seems possible with acceptable risk. Since only resection can provide potential cure and also palliation was better than that achieved by draining tubes a more aggressive attitude to the treatment of these lesions is advocated from our experience.

Obstructive biliary tract disease

The techniques that have come into general use for diagnosing problems of obstructive jaundice, particularly in the past ten years, have been ultrasonography, computerized tomography, radionuclide imaging, transhepatic percutaneous cholangiography using a long thin needle, transhepatic percutaneous drainage for obstructive jaundice due to malignancy, endoscopic retrograde cannulation of the papilla (ERCP), endoscopic sphincterotomy and choledochoscopy. It is helpful to review obstructive jaundice due to gallstones from a clinical point of view and the use of the directable stone basket for the retrieval of retained stones, choledochoscopy for the same purpose using the rigid versus flexible choledochoscopes and dissolution of stones using various fluids through a T tube. The use of dilation of the sphincter for the treatment of stenosis or stricture of the bile duct is now frowned on; rather, treatment choices are between the use of sphincteroplasty versus choledochoduodenostomy and choledochojejunostomy. Any patient with obstructive jaundice or anyone undergoing manipulation of the bile ducts should have prophylactic antibiotic therapy. The current literature regarding treatment of cancer of the bile ducts is principally devoted to the new ideas relative to treatment of tumors of the upper third, especially the bifurcation tumors that are now being resected rather than bypassed. Tumors of the distal bile duct are still being resected by focal operations. Finally, it is now felt that early operation for congenital biliary atresia and choledochal cysts gives the best prognosis, with preoperative diagnosis now possible with the use of ultrasonography and ERCP.