Induction chemotherapy and hepatic artery embolization followed by extended resection for locally advanced gallbladder cancer: a case report

BACKGROUND

Surgical resection plays a critical role in the curative therapy of patients with gallbladder cancer. However, extended resection for locally advanced gallbladder cancer is a controversial procedure because of the high operative morbidity, mortality, and poor prognosis after surgery, without consensus of its suitability. Several reports have described preoperative treatment modalities to reduce the risk of mortality and morbidity and improve the curability of surgery for locally advanced GBCA. However, only a few well-designed studies have verified the benefits of these preoperative strategies.

CASE PRESENTATION

A 62-year-old male patient presented to our department with a gallbladder tumor detected on abdominal ultrasound during an annual medical checkup. Multi-phase enhanced CT revealed a gallbladder tumor with a maximum diameter of 34 mm, invading the right hepatic artery, pancreatic head, hepatic flexure of the colon, and first portion of the duodenum. We diagnosed gallbladder carcinoma as cT4 cN0 cM0 cStage IVA in the Union for International Cancer Control (UICC) classification 8th edition. After administration of 12 cycles of gemcitabine and cisplatin plus S-1 regimen, tumor shrinkage was observed on computed tomography, and elevated serum CA19-9 levels were reduced to normal limits. After preoperative hepatic artery embolization, we performed gallbladder bed resection with pancreaticoduodenectomy (minor hepatopancreatoduodenectomy) and combined resection of the right hepatic artery and hepatic flexure of the colon. Histological examination revealed no evidence of lymph node metastasis (ypT4 ypN0 ycM0 yp Stage IVA in the 8th edition of the UICC). The proximal bile duct and dissected margins were negative.

CONCLUSIONS

The combination of induction chemotherapy and preoperative hepatic artery embolization, followed by minor hepatopancreatoduodenectomy and combined resection of the involved arteries and partial colon, could be a feasible treatment strategy for patients with locally advanced gallbladder cancer invading neighboring organs.

Current status and progress in laparoscopic surgery for gallbladder carcinoma

Gallbladder carcinoma (GBC) is the most common biliary tract malignancy associated with a concealed onset, high invasiveness and poor prognosis. Radical surgery remains the only curative treatment for GBC, and the optimal extent of surgery depends on the tumor stage. Radical resection can be achieved by simple cholecystectomy for Tis and T1a GBC. However, whether simple cholecystectomy or extended cholecystectomy, including regional lymph node dissection and hepatectomy, is the standard surgical extent for T1b GBC remains controversial. Extended cholecystectomy should be performed for T2 and some T3 GBC without distant metastasis. Secondary radical surgery is essential for incidental gall-bladder cancer diagnosed after cholecystectomy. For locally advanced GBC, hepatopancreatoduodenectomy may achieve R0 resection and improve long-term survival outcomes, but the extremely high risk of the surgery limits its implementation. Laparoscopic surgery has been widely used in the treatment of gastrointestinal malignancies. GBC was once regarded as a contraindication of laparoscopic surgery. However, with improvements in surgical instruments and skills, studies have shown that laparoscopic surgery will not result in a poorer prognosis for selected patients with GBC compared with open surgery. Moreover, laparoscopic surgery is associated with enhanced recovery after surgery since it is minimally invasive.

Current role of hepatopancreatoduodenectomy for the management of gallbladder cancer and extrahepatic cholangiocarcinoma: A systematic review

BACKGROUND

Hepatopancreatoduodenectomy (HPD) is the simultaneous combination of hepatic resection, pancreaticoduodenectomy, and resection of the entire extrahepatic biliary system. HPD is not a universally accepted due to high mortality and morbidity rates, as well as to controversial survival benefits.

AIM

To evaluate the current role of HPD for curative treatment of gallbladder cancer (GC) or extrahepatic cholangiocarcinoma (ECC) invading both the hepatic hilum and the intrapancreatic common bile duct.

METHODS

A systematic literature search using the PubMed, Web of Science, and Scopus databases was performed to identify studies reporting on HPD, using the following keywords: ‘Hepatopancreaticoduodenectomy’, ‘hepatopancreatoduodenectomy’, ‘hepatopancreatectomy’, ‘pancreaticoduodenectomy’, ‘hepatectomy’, ‘hepatic resection’, ‘liver resection’, ‘Whipple procedure’, ‘bile duct cancer’, ‘gallbladder cancer’, and ‘cholangiocarcinoma’.

RESULTS

This updated systematic review, focusing on 13 papers published between 2015 and 2020, found that rates of morbidity for HPD have remained high, ranging between 37.0% and 97.4%, while liver failure and pancreatic fistula are the most serious complications. However, perioperative mortality for HPD has decreased compared to initial experiences, and varies between 0% and 26%, although in selected center it is well below 10%. Long term survival outcomes can be achieved in selected patients with R0 resection, although 5–year survival is better for ECC than GC.

CONCLUSION

The present review supports the role of HPD in patients with GC and ECC with horizontal spread involving the hepatic hilum and the intrapancreatic bile duct, provided that it is performed in centers with high experience in hepatobiliary-pancreatic surgery. Extensive use of preoperative portal vein embolization, and preoperative biliary drainage in patients with obstructive jaundice, represent strategies for decreasing the occurrence and severity of postoperative complications. It is advisable to develop internationally-accepted protocols for patient selection, preoperative assessment, operative technique, and perioperative care, in order to better define which patients would benefit from HPD.

Central hepatopancreatoduodenectomy-oncological effectiveness and parenchymal sparing option for diffusely spreading bile duct cancer: report of two cases

Background

Hepatopancreatoduodenectomy (HPD) for diffusely spreading bile duct cancer (DSBDC) usually involves a major hepatectomy and a concomitant pancreatoduodenectomy, and is still challenging surgery because of postoperative liver failure. The present case report demonstrated two cases of DSBDC where we could achieve successful HPD with central liver resection (CHPD) as liver parenchymal sparing surgery.

Case presentation

In Case 1, endoscopic retrograde cholangiography (ERC) with multiple biopsies revealed that she had DSBDC with Bismuth-Corlette type IIIA. 3D integrated images reconstructed by contrast enhanced CT and CT with drip infusion cholecystocholangiography data revealed the right antero-ventral bile duct (RAVD) confluent to the right hepatic duct and the right antero-dorsal bile duct (RADD) independently confluent to the right posterior bile duct (RPD). Tumor extended common bile duct including intrapancreatic bile duct to the left hepatic duct and RAVD, but the RADD and RPD were spared. Because the future liver remnant (FLR) was assumed not to achieve desirable volume by preoperative portal vein embolization for left or right trisegmentectomy, CHPD including resection of the segments IV and I, and the right antero-ventral segment was done and achieved R0. This procedure is tailored to the anatomical extent of disease in the context of variable biliary anatomy as a modified CHPD, and to our knowledge, this is the first reported case of modified CHPD with antero-dorsal segment preservation. In Case 2, preoperative imaging revealed DSBDC with Bismuth Corlette type IIIA. FLR volume was assumed insufficient for major hepatectomy, CHPD including resection of the segments IV and I, and the right anterior sector was done with R0. The remnant liver volumes of these cases were spared by 55.1% and 25% respectively, and postoperative course was uneventful in both.

Conclusion

CHPD should be considered a valid option for well-selected cases of DSBDC. This is the first case report of modified CHPD with antero-dorsal segment preservation.

Extended liver surgery for gallbladder cancer revisited: Is there a role for hepatopancreatoduodenectomy?

Gallbladder cancer (GBCA) is a rare and fatal disease and the majority of patients presents with advanced stage. Surgical resection associated with lymphadenectomy is the only chance for cure. For patients in stages III and IV, extended resection is the only treatment to achieve R0 margins. For GBCA invading the hepatoduodenal ligament and pancreatoduodenal region, the resection of extrahepatic bile duct and pancreas is necessary. Hepatopancreatoduodenectomy (HPD) represents the most complex and challenging procedure in the hepatopancreatobiliary region. Kuno at the Cancer Institute Hospital Tokyo performed the first HPD in Japan in 1974 and in 1980 Takasaki presented five cases and the 30-day mortality was 60%. After that, other countries started to perform the procedure including United States and Brazil. The main complications are liver failure and pancreatic fistula. Advancements in perioperative care, surgical technique, medical instruments and postoperative at intensive care unit have resulted in reduction in morbidity and mortality. The use of portal vein embolization is indicated to increase the liver volume in patients with insufficient remnant. Preoperative biliary drainage can prevent cholangitis and improve hepatic function. This procedure should be recommended before extended HPD in jaundiced patients. Operative results with mortality rates below 5% at high volume centers suggest that HPD should be performed at centers with expertise in hepatopancreatobiliary surgery.

A case of perihilar cholangiocarcinoma with bilateral ligamentum teres hepatis treated with hepatopancreatoduodenectomy

Background

Bilateral ligamentum teres (BLT) hepatis is a very rare anomaly defined as the connection of the bilateral fetal umbilical veins to both sides of the paramedian trunk, and it has never been reported in the English literature.

Case presentation

A 72-year-old man who presented with obstructive jaundice was referred to our hospital. Contrast-enhanced computed tomography revealed that the patient had right-sided ligamentum teres (RSLT) and left-sided ligamentum teres (LSLT). The umbilical portion of the left portal vein, which the LSLT connected, became relatively atrophic in this patient. The RSLT attached to the tip of the right anterior pedicle and formed the umbilical portion of the right portal vein. The patient was diagnosed with perihilar cholangiocarcinoma which had invaded the root of the posterior branch of the bile duct, LHD, and intrapancreatic bile duct. The central bisectionectomy, in which the liver parenchyma was resected along the RHV on the right side and the LSLT on the left side, and caudate lobectomy combined with pancreatoduodenectomy were performed.

The presence of the patient with BLT is important for ascertaining the mechanism of the development of RSLT. Two umbilical veins are present initially during the embryonic stage. In general, the right-sided vein disappears, and the atrophic left-sided vein remains connected to the left portal vein originating from the vitelline vein. Several papers on the mechanism of the development of RSLT have been published. Some authors have mentioned that a residue of the right umbilical vein and the disappearance of the left umbilical vein are the causes of RSLT. On the other hand, some authors have asserted that RSLT is the result of atrophy of the medial liver area. The presence of BLT in patients indicates that the mechanism of the development of RSLT is characterized by a residue of the right umbilical vein and the disappearance of the left umbilical vein.

Conclusions

The mechanism and origin of RSLT can be understood through cases of BLT, and surgeons must pay attention to anomalies of the portal and hepatic veins in patients with abnormal ligamentum teres.

Combined resection of the transpancreatic common hepatic artery preserving the gastric arterial arcade without arterial reconstruction in hepatopancreatoduodenectomy: a case report

Background

Surgeons sometimes must plan pancreatoduodenectomy (PD) for patients with a variant common hepatic artery (CHA) branching from the superior mesenteric artery (SMA) penetrating the pancreatic parenchyma, known as a transpancreatic CHA (tp-CHA).

Case presentation

A 67-year-old man was admitted to our hospital because of liver dysfunction. A duodenal tumor was identified by gastrointestinal endoscopy, and a biopsy revealed a neuroendocrine tumor. Computed tomography showed multiple metastases in the left three sections of the liver. As an anatomical variant, the CHA branched from the SMA and passed through the parenchyma of the pancreatic head, and all hepatic arteries branched from the CHA. Furthermore, the arcade between the left and right gastric artery (RGA) was detected, and the RGA branched from the root of the left hepatic artery. PD and left trisectionectomy of the liver were performed. The tp-CHA was resected with the pancreatic head, and the gastric arterial arcade was preserved to maintain the right posterior hepatic arterial flow. Postoperatively, there were no signs of hepatic ischemia.

Conclusions

When planning PD, including hepatopancreatoduodenectomy, for patients with a tp-CHA, surgeons should simulate various situations for maintaining the hepatic arterial flow. The preservation of the gastric arterial arcade is an option for maintaining the hepatic arterial flow to avoid arterial reconstruction.

Electronic supplementary material

The online version of this article (10.1186/s40792-018-0474-8) contains supplementary material, which is available to authorized users.

Hepatopancreatoduodenectomy for perihilar cholangiocarcinoma following laparoscopic total gastrectomy

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Surgical resection is the only curative treatment for perihilar cholangiocarcinoma.

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Hepatopancreatoduodenectomy for biliary cancers after total gastrectomy is a challenging procedure with high morbidity and mortality rates.

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However, this procedure can provide the chance for long-term survival if curative resection is feasible.

•

This case was the first report of hepatopancreatoduodenectomy following laparoscopic total gastrectomy.

Introduction

Surgical resection is the only curative treatment for perihilar cholangiocarcinoma. However, Hepatopancreatoduodenectomy (HPD) procedure remains controversial in regard to the balance between the survival benefit and high risk of mortality and morbidity.

Presentation of case

A 72-year-old man who was revealed the dilation of intrahepatic hepatic duct by computed tomography after laparoscopic total gastrectomy was referred to our hospital. The patient had undergone laparoscopic total gastrectomy with Roux-en-Y esophageal-jejunostomy reconstruction 1 year previously. By several examinations, we consequently diagnosed this case as a perihilar cholangiocarcinoma and performed HPD. Histological examination revealed a well differentiated adenocarcinoma without lymph-node metastasis and a negative margin of liver parenchyma and pancreas. He was recovered from a grade B pancreatic fistula by conservative therapy and discharged post-operatively on day 64 in good health. The patient received postoperative systemic chemotherapy with gemcitabine for 6 months. 16 months after surgery, the patient has had no recurrence.

Discussion

HPD for biliary and cancers after total gastrectomy is a challenging procedure with high morbidity and mortality rates. However, this procedure can provide the chance for long-term survival if curative resection is feasible.

Conclusion

This case was the first report of hepatopancreatoduodenectomy following laparoscopic total gastrectomy.

Major hepatopancreatoduodenectomy with simultaneous resection of the hepatic artery for advanced biliary cancer

BACKGROUND

Major hepatopancreatoduodenectomy (HPD) with simultaneous resection of the hepatic artery (HA) for biliary cancer is the most extended surgery for obtaining curative resection, and its clinical significance is unclear. The aim of this study was to appraise the clinical value of this extended procedure as a treatment for biliary cancer.

METHODS

We retrospectively reviewed the medical records of 38 patients with biliary cancer who underwent major HPD from 1994 to 2014. Clinicopathological factors and survival following HPD were compared between patients with and without simultaneous resection of the HA.

RESULTS

Of the 38 study patients, 12 patients (32 %) underwent major HPD with HA. There was no significant difference in major complications between the two groups. The overall 2-year survival rate and the median survival time following major HPD with HA were 71 % and 42.3 months. The survival of the patients with gallbladder cancer was significantly worse than that of the patients with bile duct cancer (p = 0.001).

CONCLUSIONS

Major HPD with simultaneous resection of the HA can be a preferable treatment option for bile duct cancer that offers acceptable perioperative morbidity and mortality, as well as long-term survival. However, this procedure for gallbladder cancer should not be performed.

Hepatopancreatoduodenectomy for local recurrence of cholangiocarcinoma after excision of a type IV-A congenital choledochal cyst: a case report

Surgical resection is the only curative treatment for biliary tract cancer (BTC); however, the recurrence rate remains high even after curative resection. There are limited data regarding the effectiveness of surgical resection for recurrent BTC. We report the favorable survival outcome of a patient who underwent a hepatopancreatoduodenectomy for local recurrence of cholangiocarcinoma after excision of a type IV-A congenital choledochal cyst. The patient, a 25-year-old woman, had undergone excision of a type IV-A congenital choledochal cyst with hepaticojejunostomy. The resected specimen revealed an early cholangiocarcinoma. The local recurrence at the site of anastomosis was detected 4 years and 4 months after surgery. We performed a left trisectionectomy with caudate lobectomy combined with hepatic artery and portal vein resections and a pancreaticoduodenectomy. Histological examination revealed a moderately differentiated adenocarcinoma, and the final diagnosis was recurrence of cholangiocarcinoma. There are a few reports of extensive resection for recurrence of BTC; however, aggressive surgery is possible and may offer favorable survival in selected patients.

Resection of a cholangiocarcinoma via laparoscopic hepatopancreato- duodenectomy: A case report

Some laterally advanced cholangiocarcinomas behave as ductal spread or local invasion, and hepatopancreatoduodenectomy (HPD) may be performed for R0 resection. To date, there have been no reports of laparoscopic HPD (LHPD) in the English literature. We report the first case of LHPD for the resection of a Bismuth IIIa cholangiocarcinoma invading the duodenum. The patient underwent laparoscopic pancreaticoduodenectomy and right hemihepatectomy. Child’s approach was used for the reconstruction. The patient recovered well with bile leakage from the 2^nd postoperative day and was discharged on the 16^th postoperative day with a drainage tube in place which was removed 2 wk after discharge. Postoperative pathology revealed a well-differentiated cholangiocarcinoma and the margin of liver parenchyma, pancreas and stomach was negative for metastases. The results suggest that LHPD is a feasible and safe procedure when performed in highly specialized centers and in suitable patients with cholangiocarcinoma.

Review of hepatopancreatoduodenectomy for biliary cancer: an extended radical approach of Japanese origin

Cholangiocarcinomas exhibit various modes of local extension, and some tumors can only be completely resected by hepatopancreatoduodenectomy (HPD), which is defined as the resection of the whole extrahepatic biliary system with the adjacent liver and pancreatoduodenum. Since Takasaki et al. introduced HPD for locally advanced gallbladder cancer in 1980, Japanese hepatobiliary surgeons have aggressively challenged this extended procedure for advanced biliary tumors. Early experiences with HPD were frequently associated with liver failure and sequential mortality, leading to an underestimation of the survival benefit of HPD. However, with improvements in surgical techniques and perioperative patient care, including portal vein embolization, over the last two decades, the mortality rate after HPD has gradually decreased. Recent studies have demonstrated a favorable survival in cholangiocarcinoma, provided that R0 resection is achieved. In contrast, HPD for gallbladder cancer remains controversial because of the extremely poor survival, although the study populations have been limited. HPD can be performed with low mortality and offers a better probability of long-term survival in patients with cholangiocarcinoma. We should consider HPD to be a standard approach for laterally advanced cholangiocarcinomas that are otherwise unresectable.