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Varty GP, Goel M, Nandy K, Deodhar K, Shah T, Patkar S. Role of Intraoperative Frozen Section Assessment of Proximal Bile Duct Margins and the Impact of Additional Re-Resection in Perihilar Cholangiocarcinomas. Indian J Surg Oncol 2024; 15:281-288. [PMID: 38818011 PMCID: PMC11133294 DOI: 10.1007/s13193-024-01874-5] [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: 09/05/2023] [Accepted: 01/03/2024] [Indexed: 06/01/2024] Open
Abstract
Intraoperative frozen section (FS) analysis to assess the bile duct margin status is commonly used to assess the completeness of resection during surgery for perihilar cholangiocarcinoma (pCCA) resection. However, the impact of additional re-section on the long-term outcome after obtaining an initial positive margin remains unclear. Patients diagnosed as pCCA on preoperative imaging and subjected to curative intent surgery from May 2013 to June 2021 with a minimum follow-up of 2 years were included. Intraoperative FS analysis of the proximal bile duct margin was performed in all patients. A positive margin was defined by the presence of invasive cancer. Out of the 62 patients with a preoperative diagnosis of pCCA on imaging, 35 patients were included for final analyses after excluding patients with inoperable disease (on staging laparoscopy or local exploration) and other/benign pathology on the final histopathology report. Out of the 35 patients, patients with postoperative 90-day mortality were excluded from the final survival analysis. FS analysis revealed an initial positive margin in 10 (28.5%) patients. Among 10 patients who underwent re-resection to achieve negative proximal margins, only 5 patients achieved a negative margin (secondary R0). An initial positive margin was associated with poor long-term outcomes. Median disease-free survival (DFS) and overall survival (OS) were 16 and 19.6 months for patients with an initial positive margin, but 36 and 58.2 months for patients with an initial negative margin, respectively (p = 0.012). The median DFS and OS were significantly lower for those with secondary R0 as compared to primary R0 (16 vs. 36 months for DFS, p = 0.117 and 19.6 vs. 58.2 months for OS, p = 0.027, respectively). An intraoperative FS positive proximal hepatic duct margin dictates poor long-term outcomes for patients with resectable pCCA. Additional resection has a questionable benefit on survival, when a secondary negative margin is achieved.
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Affiliation(s)
- Gurudutt P. Varty
- Department of Gastrointestinal and Hepatobiliary Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra India
| | - Mahesh Goel
- Department of Gastrointestinal and Hepatobiliary Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra India
| | - Kunal Nandy
- Department of Gastrointestinal and Hepatobiliary Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra India
| | - Kedar Deodhar
- Department of Surgical Pathology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra India
| | - Tanvi Shah
- Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra India
| | - Shraddha Patkar
- Department of Gastrointestinal and Hepatobiliary Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra India
- Homi Bhabha Block, Tata Memorial Hospital, Ernest Borges Road, Room Number 1204, 12th floor, Parel East, Mumbai, 400012 India
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Togasaki K, Hosokawa I, Takayashiki T, Takano S, Ohtsuka M. Impact of the course of the segment 4 hepatic artery on proximal ductal margin status in right hepatectomy for perihilar cholangiocarcinoma. Surgery 2024; 175:947-954. [PMID: 38160087 DOI: 10.1016/j.surg.2023.11.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 11/03/2023] [Accepted: 11/30/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND The relationship between the course of the segment 4 hepatic artery and proximal ductal margin status in the right hepatectomy (H15678-B) for perihilar cholangiocarcinoma is unclear. This study aimed to evaluate proximal ductal margin status according to the course of the segment 4 hepatic artery in patients with perihilar cholangiocarcinoma treated with right hepatectomy. METHODS Consecutive patients with perihilar cholangiocarcinoma who underwent a right hepatectomy between January 2006 and August 2021 were retrospectively reviewed. The course of the segment 4 hepatic artery was classified based on the positional relationship with the umbilical portion of the left portal vein into R-UP and L-UP types. The R-UP type had the segment 4 hepatic artery running along the right caudal position of the umbilical portion of the left portal vein, whereas the L-UP type had the segment 4 hepatic artery running along the left cranial position of the umbilical portion of the left portal vein, with or without another branch running along the right caudal position of the umbilical portion of the left portal vein. Proximal ductal margin status after the right hepatectomy was compared between types. RESULTS Among 102 patients, 72 (70.5%) were R-UP type, and 30 (29.5%) were L-UP type. Rates of negative proximal ductal margin were higher with the L-UP type (27/30, 90.0%) than with the R-UP type (51/72, 70.8%; P = .04). On multivariate analysis, Bismuth-Corlette type II and IIIa (risk ratio 4.13, 95% confidence interval 1.52-11.5; P = .005) and L-UP type (risk ratio 4.03, 95% confidence interval 1.18-18.8; P = .04) were independent predictors of negative proximal ductal margin after a right hepatectomy for perihilar cholangiocarcinoma. CONCLUSION For the course of the segment 4 hepatic artery, L-UP type rather than R-UP type might be anatomically advantageous for achieving negative proximal ductal margin in a right hepatectomy for perihilar cholangiocarcinoma.
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Affiliation(s)
- Kentaro Togasaki
- Department of General Surgery, Chiba University Graduate School of Medicine, Japan
| | - Isamu Hosokawa
- Department of General Surgery, Chiba University Graduate School of Medicine, Japan
| | - Tsukasa Takayashiki
- Department of General Surgery, Chiba University Graduate School of Medicine, Japan
| | - Shigetsugu Takano
- Department of General Surgery, Chiba University Graduate School of Medicine, Japan
| | - Masayuki Ohtsuka
- Department of General Surgery, Chiba University Graduate School of Medicine, Japan.
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Olthof PB, Groot Koerkamp B. ASO Author Reflections: Surgical Strategy for Perihilar Cholangiocarcinoma. Ann Surg Oncol 2024:10.1245/s10434-024-15156-5. [PMID: 38448738 DOI: 10.1245/s10434-024-15156-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 02/20/2024] [Indexed: 03/08/2024]
Affiliation(s)
- Pim B Olthof
- Department of Surgery, Erasmus Medical Center, Rotterdam, The Netherlands.
- Department of Surgery, Amsterdam UMC, Amsterdam, The Netherlands.
- Department of Surgery, University Medical Center, Groningen, Groningen, The Netherlands.
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
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Hayashi D, Mizuno T, Kawakatsu S, Baba T, Sando M, Yamaguchi J, Onoe S, Watanabe N, Sunagawa M, Ebata T. Liver remnant volume to body weight ratio of 0.65% as a lower limit in right hepatic trisectionectomy with bile duct resection. Surgery 2024; 175:404-412. [PMID: 37989634 DOI: 10.1016/j.surg.2023.09.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Revised: 07/10/2023] [Accepted: 09/26/2023] [Indexed: 11/23/2023]
Abstract
BACKGROUND Previous studies have suggested the utility of an indocyanine green plasma clearance rate of the future liver remnant (FLR) (ICGK-F) ≥0.05 in hepatobiliary resection to reduce the surgical risk. The present study aimed to verify whether future liver remnant size rather than ICGK-F matters in extended hepatobiliary resection. METHODS Between 2004 and 2021, patients who underwent right hepatic trisectionectomy with bile duct resection were included. The effect of the FLR volume-to-body weight ratio (FLR/BW) and ICGK-F on posthepatectomy liver failure was evaluated along with other parameters. RESULTS Among 91 study patients, the median ICGK-F, FLR, and FLR/BW were 0.057 (range, 0.027-0.099), 392 mL (145-705), and 0.78% (0.40-1.37), respectively. Posthepatectomy liver failure occurred in 23 patients. The incidence was 10 (40%) in 25 patients with an ICGK-F <0.05 and 12 (18%) in 65 patients with an ICGK-F ≥0.05 (P = .053); 13 (52%) in 25 patients with a FLR/BW <0.65% and 10 (15%) in 66 patients with a FLR/BW ≥0.65% (P = .001). Multivariate analysis showed that a FLR/BW <0.65% (odds ratio, 11.7; P = .005), age ≥65 years (odds ratio, 31.7; P < .001), and blood loss ≥25 mL/kg (odds ratio, 22.1; P = .004) were independent predictors of posthepatectomy liver failure, but ICGK-F <0.05 was not (P = .499). According to the meeting number of 3 factors, posthepatectomy liver failure incidence was 0 of 22 (0%) in patients with 0 factors, 6 of 43 (14%) in patients with 1, and 17 of 26 (65%) in patients with 2 or 3 (P < .001). CONCLUSION A FLR/BW ≥0.65% may serve as a volumetric basis to reduce posthepatectomy liver failure after extended hepatobiliary resection.
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Affiliation(s)
- Daisuke Hayashi
- Division of Surgical Oncology, Nagoya University Graduate School of Medicine, Japan
| | - Takashi Mizuno
- Division of Surgical Oncology, Nagoya University Graduate School of Medicine, Japan
| | - Shoji Kawakatsu
- Division of Surgical Oncology, Nagoya University Graduate School of Medicine, Japan
| | - Taisuke Baba
- Division of Surgical Oncology, Nagoya University Graduate School of Medicine, Japan
| | - Masanori Sando
- Division of Surgical Oncology, Nagoya University Graduate School of Medicine, Japan
| | - Junpei Yamaguchi
- Division of Surgical Oncology, Nagoya University Graduate School of Medicine, Japan
| | - Shunsuke Onoe
- Division of Surgical Oncology, Nagoya University Graduate School of Medicine, Japan
| | - Nobuyuki Watanabe
- Division of Surgical Oncology, Nagoya University Graduate School of Medicine, Japan
| | - Masaki Sunagawa
- Division of Surgical Oncology, Nagoya University Graduate School of Medicine, Japan
| | - Tomoki Ebata
- Division of Surgical Oncology, Nagoya University Graduate School of Medicine, Japan.
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Ruzzenente A, Alaimo L, D'Onofrio M, Marchese A, Roman D, Conci S, De Bellis M, Pedrazzani C, Campagnaro T, Guglielmi A. Perihilar cholangiocarcinoma: three-dimensional modelling algorithm to estimate tumour extension and bile duct resection margins. Br J Surg 2024; 111:znad428. [PMID: 38198153 DOI: 10.1093/bjs/znad428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 09/29/2023] [Accepted: 12/05/2023] [Indexed: 01/11/2024]
Affiliation(s)
- Andrea Ruzzenente
- Division of General and Hepatobiliary Surgery, Department of Surgery, Dentistry, Gynaecology, and Paediatrics, University of Verona, University Hospital G.B. Rossi, Verona, Italy
| | - Laura Alaimo
- Division of General and Hepatobiliary Surgery, Department of Surgery, Dentistry, Gynaecology, and Paediatrics, University of Verona, University Hospital G.B. Rossi, Verona, Italy
| | - Mirko D'Onofrio
- Department of Radiology, University of Verona, University Hospital G.B. Rossi, Verona, Italy
| | - Andrea Marchese
- Division of General and Hepatobiliary Surgery, Department of Surgery, Dentistry, Gynaecology, and Paediatrics, University of Verona, University Hospital G.B. Rossi, Verona, Italy
| | - Diletta Roman
- Division of General and Hepatobiliary Surgery, Department of Surgery, Dentistry, Gynaecology, and Paediatrics, University of Verona, University Hospital G.B. Rossi, Verona, Italy
| | - Simone Conci
- Division of General and Hepatobiliary Surgery, Department of Surgery, Dentistry, Gynaecology, and Paediatrics, University of Verona, University Hospital G.B. Rossi, Verona, Italy
| | - Mario De Bellis
- Division of General and Hepatobiliary Surgery, Department of Surgery, Dentistry, Gynaecology, and Paediatrics, University of Verona, University Hospital G.B. Rossi, Verona, Italy
| | - Corrado Pedrazzani
- Division of General and Hepatobiliary Surgery, Department of Surgery, Dentistry, Gynaecology, and Paediatrics, University of Verona, University Hospital G.B. Rossi, Verona, Italy
| | - Tommaso Campagnaro
- Division of General and Hepatobiliary Surgery, Department of Surgery, Dentistry, Gynaecology, and Paediatrics, University of Verona, University Hospital G.B. Rossi, Verona, Italy
| | - Alfredo Guglielmi
- Division of General and Hepatobiliary Surgery, Department of Surgery, Dentistry, Gynaecology, and Paediatrics, University of Verona, University Hospital G.B. Rossi, Verona, Italy
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Balci D, Nadalin S, Mehrabi A, Alikhanov R, Fernandes ESM, Di Benedetto F, Hernandez-Alejandro R, Björnsson B, Efanov M, Capobianco I, Clavien PA, Kirimker EO, Petrowsky H. Revival of associating liver partition and portal vein ligation for staged hepatectomy for perihilar cholangiocarcinoma: An international multicenter study with promising outcomes. Surgery 2023; 173:1398-1404. [PMID: 36959071 DOI: 10.1016/j.surg.2023.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 01/25/2023] [Accepted: 02/09/2023] [Indexed: 03/25/2023]
Abstract
BACKGROUND Associating liver partition and portal vein ligation for staged hepatectomy for perihilar cholangiocarcinoma has been considered to be contraindicated due to the initial poor results. Given the recent reports of improved outcomes, we aimed to collect the recent experiences of different centers performing associating liver partition and portal vein ligation for staged hepatectomy for perihilar cholangiocarcinoma to analyze factors related to improved outcomes. METHODS This proof-of-concept study collected contemporary cases of associating liver partition and portal vein ligation for staged hepatectomy for perihilar cholangiocarcinoma and analyzed for morbidity, short and long-term survival, and factors associated with outcomes. RESULTS In total, 39 patients from 8 centers underwent associating liver partition and portal vein ligation for staged hepatectomy for perihilar cholangiocarcinoma from 2010 to 2020. The median preoperative future liver remnant volume was 323 mL (155-460 mL). The median future liver remnant increase was 58.7% (8.9% -264.5%) with a median interstage interval of 13 days (6-60 days). Post-stage 1 and post-stage 2 biliary leaks occurred in 2 (7.7%) and 4 (15%) patients. Six patients (23%) after stage 1 and 6 (23%) after stage 2 experienced grade 3 or higher complications. Two patients (7.7%) died within 90 days after stage 2. The 1-, 3-, and 5-year survival was 92%, 69%, and 55%, respectively. A subgroup analysis revealed poor survival for patients undergoing additional vascular resection and lymph node positivity. Lymph node-negative patients showed excellent survival demonstrated by 1-, 3-, and 5-year survival of 86%, 86%, and 86%. CONCLUSION This study highlights that the critical attitude toward associating liver partition and portal vein ligation for staged hepatectomy for perihilar cholangiocarcinoma needs to be revised. In selected patients with perihilar cholangiocarcinoma, associating liver partition and portal vein ligation for staged hepatectomy can achieve favorable survival that compares to the outcome of established surgical treatment strategies reported in benchmark studies for perihilar cholangiocarcinoma including 1-stage hepatectomy and liver transplantation.
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Affiliation(s)
- Deniz Balci
- Department of Surgery, Bahcesehir University School of Medicine, Istanbul, Turkey.
| | - Silvio Nadalin
- Department of General, Visceral, and Transplant Surgery, University Hospital Tübingen, Germany
| | - Arianeb Mehrabi
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Germany
| | - Ruslan Alikhanov
- Department of Hepato-Pancreato-Biliary Surgery, Moscow Clinical Research Center Named After Loginov A.S., Russia
| | - Eduardo S M Fernandes
- Department of General Surgery and Transplantation, Hospital Adventista Silvestre, and Department of Surgery, Faculty of Medicine, Universidade Federal do Rio de Janeiro, Brazil
| | - Fabrizio Di Benedetto
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Italy
| | | | - Bergthor Björnsson
- Department of Surgery in Linköping and Department of Biomedical and Clinical Sciences, Linköping University, Sweden
| | - Mikhail Efanov
- Department of Hepato-Pancreato-Biliary Surgery, Moscow Clinical Research Center Named After Loginov A.S., Russia
| | - Ivan Capobianco
- Department of General, Visceral, and Transplant Surgery, University Hospital Tübingen, Germany
| | - Pierre-Alain Clavien
- Department of Surgery and Transplantation, Swiss Hepatopancreaticobiliary and Transplant Center Zürich, University Hospital Zürich, Switzerland
| | | | - Henrik Petrowsky
- Department of Surgery and Transplantation, Swiss Hepatopancreaticobiliary and Transplant Center Zürich, University Hospital Zürich, Switzerland
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Kawano F, Ito H, Oba A, Ono Y, Sato T, Inoue Y, Mise Y, Saiura A, Takahashi Y. Role of Intraoperative Assessment of Proximal Bile Duct Margin Status and Additional Resection of Perihilar Cholangiocarcinoma: Can Local Clearance Trump Tumor Biology? A Retrospective Cohort Study. Ann Surg Oncol 2023; 30:3348-3359. [PMID: 36790733 DOI: 10.1245/s10434-023-13190-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 12/28/2022] [Indexed: 02/16/2023]
Abstract
BACKGROUND The aim of this study was to evaluate the clinical implications of the proximal bile duct margin status in resection of perihilar cholangiocarcinoma (PHCC). Intraoperative frozen section (IFS) analysis to assess the bile duct margin status is commonly used during PHCC resection. However, the impact of additional resection after obtaining a positive margin on the long-term outcome remains unclear. PATIENTS AND METHODS Among the 257 patients who underwent PHCC resection, 190 patients with a negative distal margin were included and analyzed. IFS analysis of the proximal bile duct margin was performed in all patients. A positive margin was defined by the presence of either invasive cancer, or carcinoma, in situ. RESULTS IFS analysis revealed an initial positive margin in 69 (36%) patients. Among 20 patients who underwent re-resection, only 11 patients achieved a negative margin (secondary R0). An initial positive margin was associated with poor long-term outcomes: recurrence-free survival (RFS) and overall survival (OS) were 16 and 25 months for patients with an initial positive margin, but 47 and 63 months for patients with an initial negative margin, respectively (p < 0.0001). In contrast, there was no difference in RFS or OS between patients with a secondary R0 margin, and those with a final R1 margin (14 vs. 16 months for RFS, p = 0.98, and 23 versus 25 months for OS, p = 0.63, respectively). CONCLUSION An IFS-positive proximal hepatic duct margin dictates poor long-term outcomes for patients with resectable PHCC. Additional resection has minimal impact on survival, even when negative margin is achieved.
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Affiliation(s)
- Fumihiro Kawano
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Ariake, Tokyo, Japan
| | - Hiromichi Ito
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Ariake, Tokyo, Japan.
| | - Atsushi Oba
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Ariake, Tokyo, Japan
| | - Yoshihiro Ono
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Ariake, Tokyo, Japan
| | - Takafumi Sato
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Ariake, Tokyo, Japan
| | - Yosuke Inoue
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Ariake, Tokyo, Japan
| | - Yoshihiro Mise
- Department of Hepatobiliary-Pancreatic Surgery, Juntendo University School of Medicine, Hongo, Tokyo, Japan
| | - Akio Saiura
- Department of Hepatobiliary-Pancreatic Surgery, Juntendo University School of Medicine, Hongo, Tokyo, Japan
| | - Yu Takahashi
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Ariake, Tokyo, Japan.
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Khuntikeo N, Pugkhem A, Srisuk T, Luvira V, Titapun A, Tipwaratorn T, Thanasukarn V, Klungboonkrong V, Wongwiwatchai J. Surgery. Recent Results Cancer Res 2023; 219:147-222. [PMID: 37660334 DOI: 10.1007/978-3-031-35166-2_7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/05/2023]
Abstract
This chapter provides a comprehensive background from basic to applied knowledge of surgical anatomy which is necessary for the surgical treatment of cholangiocarcinoma (CCA) patients. Significant advances that have been made in the surgical treatment of CCA were examined. For instance, in-depth details are provided for appropriate preoperative assessment and treatment to optimize patient status and to improve the outcome of surgical treatment(s). Comprehensive details are provided for the surgical techniques and outcomes of treatments for each type of CCA with clear illustrations and images. This chapter also describes the role of minimally invasive surgery and liver transplantation in CCA treatment.
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Affiliation(s)
- Narong Khuntikeo
- Department of Surgery, Faculty of Medicine, Khon Kaen University, Khon Kaen, 40002, Thailand.
- Cholangiocarcinoma Research Institute, Khon Kaen University, Khon Kaen, 40002, Thailand.
| | - Ake Pugkhem
- Department of Surgery, Faculty of Medicine, Khon Kaen University, Khon Kaen, 40002, Thailand
- Cholangiocarcinoma Research Institute, Khon Kaen University, Khon Kaen, 40002, Thailand
| | - Tharatip Srisuk
- Department of Surgery, Faculty of Medicine, Khon Kaen University, Khon Kaen, 40002, Thailand
- Cholangiocarcinoma Research Institute, Khon Kaen University, Khon Kaen, 40002, Thailand
| | - Vor Luvira
- Department of Surgery, Faculty of Medicine, Khon Kaen University, Khon Kaen, 40002, Thailand
- Cholangiocarcinoma Research Institute, Khon Kaen University, Khon Kaen, 40002, Thailand
| | - Attapol Titapun
- Department of Surgery, Faculty of Medicine, Khon Kaen University, Khon Kaen, 40002, Thailand
- Cholangiocarcinoma Research Institute, Khon Kaen University, Khon Kaen, 40002, Thailand
| | - Theerawee Tipwaratorn
- Department of Surgery, Faculty of Medicine, Khon Kaen University, Khon Kaen, 40002, Thailand
- Cholangiocarcinoma Research Institute, Khon Kaen University, Khon Kaen, 40002, Thailand
| | - Vasin Thanasukarn
- Department of Surgery, Faculty of Medicine, Khon Kaen University, Khon Kaen, 40002, Thailand
- Cholangiocarcinoma Research Institute, Khon Kaen University, Khon Kaen, 40002, Thailand
| | - Vivian Klungboonkrong
- Department of Radiology, Faculty of Medicine, Khon Kaen University, Khon Kaen, 40002, Thailand
| | - Jitraporn Wongwiwatchai
- Department of Radiology, Faculty of Medicine, Khon Kaen University, Khon Kaen, 40002, Thailand
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Choi YJ, Lee JM, Kang JS, Sohn HJ, Byun Y, Han Y, Kim H, Kwon W, Jang JY. Impact of surgery on survival outcomes for Bismuth type IV Klatskin tumors. J Gastrointest Surg 2022; 26:1890-1898. [PMID: 35680776 DOI: 10.1007/s11605-022-05293-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Accepted: 02/26/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Bismuth-Corlette type IV Klatskin tumors have conventionally been considered unresectable. This retrospective study aimed to demonstrate the survival improvement of patients with type IV Klatskin tumors when resected and suggest possible radiological features for R0 resectability. METHODS Data on type IV Klatskin tumors diagnosed between 2008 and 2019 were reviewed retrospectively. Patients with distant metastasis, concomitant other cancers at the initial state, extensive vascular invasions, poor liver function, and poor general condition were excluded. The survival outcomes of patients and radiologic parameters of bile duct tumors were compared between the curative resection (R0, 1 resection) and non-resection groups. RESULTS The demographic findings of patients with curative resection (n = 48) and non-resection (n = 111) were comparable. Both were potentially resectable in the initial state. The postoperative morbidity was 22.9% and the 90-day mortality 4.2%. There was a significant difference in the median survival among the curative-intended resection, palliative treatment, and supportive care groups (35, 16, and 12 months, respectively; P < 0.001). DISCUSSION In patients with type IV Klatskin tumor without extensive tumor invasion into adjacent tissues, including major vessels, surgical resection can be considered for better survival. CLINICAL REGISTRATION NUMBER IRB No. 2009-100-1157.
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Affiliation(s)
- Yoo Jin Choi
- Department of Surgery and Cancer Research Institute, College of Medicine, Seoul National University, 101 Daehak-ro, Chongro-gu, Seoul, 03080, Korea.,Division of HBP Surgery, Department of Surgery, Korea University Medical Center, Seoul, Korea
| | - Jung Min Lee
- Department of Surgery and Cancer Research Institute, College of Medicine, Seoul National University, 101 Daehak-ro, Chongro-gu, Seoul, 03080, Korea.,Pancreatobiliary Cancer Clinic, Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Seung Kang
- Department of Surgery and Cancer Research Institute, College of Medicine, Seoul National University, 101 Daehak-ro, Chongro-gu, Seoul, 03080, Korea
| | - Hee-Ju Sohn
- Department of Surgery and Cancer Research Institute, College of Medicine, Seoul National University, 101 Daehak-ro, Chongro-gu, Seoul, 03080, Korea
| | - Yoonhyeong Byun
- Department of Surgery and Cancer Research Institute, College of Medicine, Seoul National University, 101 Daehak-ro, Chongro-gu, Seoul, 03080, Korea.,Department of Surgery, Uijeongbu Eulji Medical Center, Eulji University School of Medicine, Daejeon, Korea
| | - Youngmin Han
- Department of Surgery and Cancer Research Institute, College of Medicine, Seoul National University, 101 Daehak-ro, Chongro-gu, Seoul, 03080, Korea
| | - Hongbeom Kim
- Department of Surgery and Cancer Research Institute, College of Medicine, Seoul National University, 101 Daehak-ro, Chongro-gu, Seoul, 03080, Korea
| | - Wooil Kwon
- Department of Surgery and Cancer Research Institute, College of Medicine, Seoul National University, 101 Daehak-ro, Chongro-gu, Seoul, 03080, Korea
| | - Jin-Young Jang
- Department of Surgery and Cancer Research Institute, College of Medicine, Seoul National University, 101 Daehak-ro, Chongro-gu, Seoul, 03080, Korea.
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11
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Hosokawa I, Furukawa K, Takayashiki T, Kuboki S, Takano S, Miyazaki M, Ohtsuka M. Surgical implications of the confluence patterns of the left intrahepatic bile ducts in right hepatectomy for perihilar cholangiocarcinoma. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2022; 29:460-468. [PMID: 34498387 DOI: 10.1002/jhbp.1044] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Although the most important goal in surgery for perihilar cholangiocarcinoma (PHC) is to achieve tumor-free proximal ductal margins, little is known about the implications of confluence patterns of the left intrahepatic bile ducts for the proximal ductal margin status in right hepatectomy (RH) for PHC. METHODS Of 203 patients who underwent surgical resection for PHC with curative intent, confluence patterns of the left intrahepatic bile duct were evaluated in 94 consecutive patients who underwent RH, and they were classified into the following two types: normal type: the bile duct of segment 4 (B4) drained into the common trunk of the bile ducts of segment 2 (B2) and segment 3 (B3) at the right side of the umbilical portion of the left portal vein to form the left hepatic duct; and hepatic confluence type: B2 entered the common trunk of B3 and B4 at the hepatic confluence or B4 entered the common trunk of B2 and B3 at the hepatic confluence. The proximal ductal margin status following RH was compared between the two types of confluence patterns. RESULTS Of 94 consecutive patients, 69 (73%) were the normal type, and 25 (27%) were the hepatic confluence type. There were no significant differences in patients' characteristics, surgical characteristics, surgical outcomes, and histopathological features between the two groups. However, in patients with Bismuth-Corlette type II and IIIa PHC, the achievement rates of negative proximal ductal margins at the first dividing line were significantly higher in the hepatic confluence type group than in the normal type group (16/16 [100%] vs 34/52 [65%], respectively; P = .007). CONCLUSIONS Confluence patterns of the left intrahepatic bile ducts might affect proximal ductal margin status in RH for PHC.
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Affiliation(s)
- Isamu Hosokawa
- Department of General Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Katsunori Furukawa
- Department of General Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Tsukasa Takayashiki
- Department of General Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Satoshi Kuboki
- Department of General Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Shigetsugu Takano
- Department of General Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Masaru Miyazaki
- Narita Hospital, International University of Health and Welfare, Chiba, Japan
| | - Masayuki Ohtsuka
- Department of General Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
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12
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Nguyen TK, Nguyen HH, Luong TH, Le VK, Dang KK, Le VD. Right hepatic trisectionectomy combined total caudate lobectomy with non-touch technique for advanced hilar cholangiocarcinoma: A surgical case report (with video). Int J Surg Case Rep 2022; 94:106987. [PMID: 35405510 PMCID: PMC9006332 DOI: 10.1016/j.ijscr.2022.106987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 03/22/2022] [Accepted: 03/24/2022] [Indexed: 11/06/2022] Open
Abstract
Background Extended resection such as right trisegmentectomy combined with total caudate lobectomy with non-touch technique for advanced hilar cholangiocarcinoma (CCA) is still challenging for all Hepato-pancreato-biliary surgeons. Presentation A 45-year-old female with advanced hilar CCA involved the right intrahepatic bile ducts in continuity with the left medial sectional bile duct without PV invasion had undergone right trisegmentectomy combined with total caudate lobectomy with non-touch technique. Dissection of the hepatic peduncle by Lorta-Jacob Procedure, ligation, and resection of the right hepatic artery (RHA) and the right portal vein (PV), before that determine whether portal bifurcation's tumor infiltration or not. Mobilization of the right liver lobe, ligate all the short hepatic veins from the caudal to cranial direction, as well as the right hepatic vein (RHV) and the middle hepatic vein (MHV). Complete caudate lobectomy with right–left approach. Determine hepatic parenchyma cut, left cholangiostomy to the division of the subsegments 2,3, stitch formation of the subsegments 2,3 bile duct. Determine negative upper section of the biliary tract. The operative time was 432 min, and the blood loss was 750 ml. Postoperative recovery was uneventful without any major complications but developed intra-abdominal abscess that required percutaneous drainage. Discussion Extended resection procedures such as extend right/left trisectionectomy, hepato-pancreaticoduodenectomy (HPD) and/or combined vascular resection are only curative treatment for advanced hilar CCA. There hadn't been any reported cases describing step-by-step right trisegmentectomy combined with total caudate lobectomy with non-touch technique with clear illustrations and videos yet. Conclusion Careful preparation with preoperative biliary drainage as well as precise evaluation of the functional capacity of the future liver remnant, as well as meticulous experience of surgeons in hepatic anatomy and non-touch resection technique are key points for success in extended resection for advanced hilar CCA. Cholangiocarcinoma (CCA) arises from any portion of the biliary epithelium, which is classified to intra-hepatic or extra-hepatic CCA. Extended radical resection procedure such as extend right/left trisectionectomy is still challenging for all Hepato-pancreato-biliary surgeons. “Non-touch” technique is necessary to accomplish the oncological principles of wide tumor-free resection margins. There hadn’t been any reported cases describing step-by-step right trisegmentectomy combined with total caudate lobectomy with No-touch technique with clear illustrations and videos yet.
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Affiliation(s)
- Thanh Khiem Nguyen
- Department of Gastrointestinal and Hepato-pancreato-biliary surgery, Bach Mai Hospital, Hanoi, Viet Nam
| | - Ham Hoi Nguyen
- Department of Gastrointestinal and Hepato-pancreato-biliary surgery, Bach Mai Hospital, Hanoi, Viet Nam
| | | | - Van Khang Le
- Department of Diagnostic and Interventional Radiology, Bach Mai Hospital, Hanoi, Viet Nam
| | - Kim Khue Dang
- Department of Gastrointestinal and Hepato-pancreato-biliary surgery, Bach Mai Hospital, Hanoi, Viet Nam
| | - Van Duy Le
- Department of Gastrointestinal and Hepato-pancreato-biliary surgery, Bach Mai Hospital, Hanoi, Viet Nam
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13
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Perihilar cholangiocarcinoma: What the radiologist needs to know. Diagn Interv Imaging 2022; 103:288-301. [DOI: 10.1016/j.diii.2022.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 03/02/2022] [Indexed: 11/17/2022]
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14
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Hewitt DB, Brown ZJ, Pawlik TM. Surgical management of intrahepatic cholangiocarcinoma. Expert Rev Anticancer Ther 2021; 22:27-38. [PMID: 34730474 DOI: 10.1080/14737140.2022.1999809] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Intrahepatic cholangiocarcinoma (ICC) incidence continues to rise worldwide, and overall survival remains poor. Complete surgical resection remains the only opportunity for cure in patients with ICC yet only one-third of patients present with resectable disease. AREAS COVERED While the low incidence rate of ICC hinders accrual of patients to large, randomized control trials, larger database and long-term institutional studies provide evidence to guide surgical management of ICC. These studies demonstrate feasibility, safety, and efficacy of aggressive surgical management in appropriately selected patients with ICC. Recent advances in the management of ICC, with a focus on surgical considerations, are reviewed. EXPERT OPINION Historically, little progress has been made in the management of ICC with stagnant mortality rates and poor long-term outcomes. However, regionalization of care to centers with experienced multidisciplinary teams, advances in minimally invasive surgical techniques, discovery and development of targeted and immunotherapy agents, and combination locoregional and systemic therapies offer signs of progress in the management of ICC.
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Affiliation(s)
- D Brock Hewitt
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Zachary J Brown
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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15
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Lang H, van Gulik TM. Extended Right-hemihepatectomy Is Preferred for Perihilar Cholangiocarcinoma. Ann Surg 2021; 274:33-34. [PMID: 33605597 DOI: 10.1097/sla.0000000000004821] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Hauke Lang
- Department of General, Visceral and Transplantation Surgery, University Medical Center Mainz, Germany
| | - Thomas M van Gulik
- Department of Surgery, Cancer Center Amsterdam, Amsterdam University Medical Centers, location AMC, University of Amsterdam, the Netherlands
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16
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A tailored approach in lymph node-positive perihilar cholangiocarcinoma. Langenbecks Arch Surg 2021; 406:1499-1509. [PMID: 34075473 PMCID: PMC8370897 DOI: 10.1007/s00423-021-02154-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 03/18/2021] [Indexed: 01/04/2023]
Abstract
Purpose Extended right hepatectomy is associated with wide surgical margins in PHC and often favored for oncological considerations. However, it remains uncertain whether established surgical principles also apply to the subgroup of node-positive patients. The aim of the present study was to define a tailored surgical approach for patients with perihilar cholangiocarcinoma (PHC) and lymph node metastases. Methods We reviewed the course of all consecutive patients undergoing major hepatectomy for PHC between 2005 and 2015 at the Department of Surgery, Charité – Universitätsmedizin Berlin. Results Two hundred and thirty-one patients underwent major hepatectomy for PHC with 1-, 3-, and 5-year overall (OS) and disease-free survival (DFS) rates of 72%, 48%, and 36%, and 60%, 22%, and 12%, respectively. In lymph node-positive patients (n = 109, 47%), extended left hepatectomy was associated with improved OS and DFS, respectively, when compared to extended right hepatectomy (p = 0.008 and p = 0.003). Interestingly, OS and DFS did not differ between R0 and R1 resections in those patients (both p = ns). Patients undergoing extended left hepatectomy were more likely to receive adjuvant chemotherapy (p = 0.022). This is of note as adjuvant chemotherapy, besides grading (p = 0.041), was the only independent prognostic factor in node-positive patients (p=0.002). Conclusion Patients with node-positive PHC might benefit from less aggressive approaches being associated with lower morbidity and a higher chance for adjuvant chemotherapy. Lymph node sampling might help to guide patients to the appropriate surgical approach according to their lymph node status. Supplementary Information The online version contains supplementary material available at 10.1007/s00423-021-02154-4.
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17
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Gkika E, Hawkins MA, Grosu AL, Brunner TB. The Evolving Role of Radiation Therapy in the Treatment of Biliary Tract Cancer. Front Oncol 2021; 10:604387. [PMID: 33381458 PMCID: PMC7768034 DOI: 10.3389/fonc.2020.604387] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 11/04/2020] [Indexed: 12/13/2022] Open
Abstract
Biliary tract cancers (BTC) are a disease entity comprising diverse epithelial tumors, which are categorized according to their anatomical location as intrahepatic (iCCA), perihilar (pCCA), distal (dCCA) cholangiocarcinomas, and gallbladder carcinomas (GBC), with distinct epidemiology, biology, and prognosis. Complete surgical resection is the mainstay in operable BTC as it is the only potentially curative treatment option. Nevertheless, even after curative (R0) resection, the 5-year survival rate ranges between 20 and 40% and the disease free survival rates (DFS) is approximately 48–65% after one year and 23–35% after three years without adjuvant treatment. Improvements in adjuvant chemotherapy have improved the DFS, but the role of adjuvant radiotherapy is unclear. On the other hand, more than 50% of the patients present with unresectable disease at the time of diagnosis, which limits the prognosis to a few months without treatment. Herein, we review the role of radiotherapy in the treatment of cholangiocarcinoma in the curative and palliative setting.
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Affiliation(s)
- Eleni Gkika
- Department of Radiation Oncology, University Medical Centre Freiburg, Freiburg, Germany
| | - Maria A Hawkins
- Medical Physics and Biomedical Engineering, University College London, London, United Kingdom
| | - Anca-Ligia Grosu
- Department of Radiation Oncology, University Medical Centre Freiburg, Freiburg, Germany
| | - Thomas B Brunner
- Department of Radiation Oncology, University of Magdeburg, Magdeburg, Germany
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18
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Mizuno T, Ebata T, Yokoyama Y, Igami T, Yamaguchi J, Onoe S, Watanabe N, Kamei Y, Nagino M. Combined Vascular Resection for Locally Advanced Perihilar Cholangiocarcinoma. Ann Surg 2020; 275:382-390. [PMID: 32976284 DOI: 10.1097/sla.0000000000004322] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To evaluate the efficacy and safety of combined vascular resection (VR) in advanced perihilar cholangiocarcinoma (PHC). SUMMARY OF BACKGROUND DATA Hepatectomy combined with portal vein resection (PVR) and/or hepatic artery resection (HAR) is technically demanding but an option only for tumor eradication against PHC involving the hilar hepatic inflow vessels; however, its efficacy and safety have not been well evaluated. METHODS Patients diagnosed with PHC during 2001-2018 were included. Patients who underwent resection were divided according to combined VR. Patients undergoing VR were subdivided according to type of VR. Postoperative outcomes and OS were compared between patient groups. RESULTS Among the 1055 consecutive patients, 787 (75%) underwent resection (without VR: n = 484, PVR: n = 157, HAR: n = 146). The incidences of postoperative complications and mortality were 49% (without VR vs with VR, 48% vs 50%; P= 0.715) and 2.1% (without VR vs with VR, 1.2% vs 3.6%; P= 0.040), respectively. The OS of patients who underwent resection with VR (median, 30 months) was shorter than that of those who underwent resection without VR (median, 61 months; P < 0.0001); however, it was longer than that of those who did not undergo resection (median, 10 months; P < 0.0001). OS was not significantly different between those who underwent PVR and those who underwent HAR (median, 29 months vs 34 months; P = 0.517). CONCLUSION VR salvages a large number of patients from having locally advanced PHC that is otherwise unresectable and is recommended if the hilar hepatic inflow vessels are reconstructable, providing acceptable surgical outcomes and substantial survival benefits.
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Affiliation(s)
- Takashi Mizuno
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Tomoki Ebata
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yukihiro Yokoyama
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Tsuyoshi Igami
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Junpei Yamaguchi
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shunsuke Onoe
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Nobuyuki Watanabe
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yuzuru Kamei
- Department of Plastic and Reconstructive Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masato Nagino
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
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19
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Study of the Portal Branches Arising from the Cranial Part of the Umbilical Portion of the Left Portal Vein: Implications for Anatomic Right Hepatic Trisectionectomy. World J Surg 2020; 44:4231-4235. [PMID: 32860143 DOI: 10.1007/s00268-020-05753-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND In "anatomic" right hepatic trisectionectomy for advanced perihilar cholangiocarcinoma, the left hepatic duct is divided at the left side of the umbilical portion (UP) of the left portal vein (LPV). For this reason, the left hepatic duct is completely detached from the UP after all division of the portal branches arising cranially from the UP. However, little is known about these thin portal branches. METHODS Using 3D imaging processing software, we examined the portal branches arising cranially from the UP of the LPV in 100 patients who underwent multidetector row computed tomography (MDCT). Special attention was paid to the portal branch running to the left lateral sector, designated as the left cranio-lateral branch. RESULTS The left cranio-lateral portal branch number was 0 in 57 patients, 1 in 32 patients, and 2 in 11 patients. Thus, 54 left cranio-lateral branches were identified, arising from near the cul-de-sac of the UP, from near the elbow of the LPV, or from the UP trunk. The median volume of the territory supplied by the left cranio-lateral portal branch was 21 mL (range, 5-47 mL), and the median ratio to the left lateral sector was 11.8% (range, 1.7-25.0%). CONCLUSION Approximately 40% of patients had the left cranio-lateral portal branches arising cranially from the UP and running to the left lateral sector. When planning anatomic right hepatic trisectionectomy, the presence or absence of this branch should be checked by using 3D imaging with MDCT.
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20
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Balci D, Sakamoto Y, Li J, Di Benedetto F, Kirimker EO, Petrowsky H. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) procedure for cholangiocarcinoma. Int J Surg 2020; 82S:97-102. [PMID: 32645441 DOI: 10.1016/j.ijsu.2020.06.045] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 06/26/2020] [Indexed: 12/15/2022]
Abstract
Perihilar cholangiocarcinoma (PHCC) has been a great challenge for surgeons, requiring advanced skills and expertise and was often associated with high morbidity and mortality. Resectability rates are up to 75% even in experienced centers. In patients with PHCC, radical liver and bile duct resection aiming R0 surgical margins offers the best long-term survival. Therefore, extensive resections with low FLR are commonly needed and PVE is offered to induce remnant liver hypertrophy for a long period. Associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) is considered a promising approach inducing rapid remnant hypertrophy to prevent dropouts due to complications or tumor progression and increase resectability. Although poor results were reported initially, refinements in technique and risk adjustment of patient selection improved outcomes. The procedure is still under debate for the indication of PHCC. This article reviews the current literature on ALPPS in treatment of perihilar and intrahepatic cholangiocarcinoma.
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Affiliation(s)
- Deniz Balci
- Department of Surgery and Liver Transplantation Unit, Ankara University School of Medicine, Ankara, Turkey.
| | - Yoshihiro Sakamoto
- Department of Hepato-Biliary-Pancreatic Surgery, Kyorin University Hospital, Japan.
| | - Jun Li
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Fabrizio Di Benedetto
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Modena, Italy.
| | - Elvan Onur Kirimker
- Department of Surgery and Liver Transplantation Unit, Ankara University School of Medicine, Ankara, Turkey.
| | - Henrik Petrowsky
- Swiss HPB and Transplantation Center, Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland.
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21
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Ku D, Tang R, Pang T, Pleass H, Richardson A, Yuen L, Lam V. Survival outcomes of hepatic resections in Bismuth-Corlette type IV cholangiocarcinoma. ANZ J Surg 2019; 90:1604-1614. [PMID: 31840387 DOI: 10.1111/ans.15531] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 09/22/2019] [Accepted: 09/26/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Surgical resection for Bismuth-Corlette type IV (BC-IV) hilar cholangiocarcinomas, also termed Klatskin tumours are technically challenging and were once considered unresectable tumours. Following advances in hepatobiliary imaging and surgical techniques, emerging evidence suggests that surgical resection is a viable avenue for long-term survival. We aimed to identify factors affecting survival outcomes of hepatic resections for BC-IV cholangiocarcinomas. METHOD A systematic review was performed across multiple databases and several clinical trial registries. Two reviewers independently screened and selected papers that contained survival data on BC-IV cholangiocarcinoma after hepatic resections. RESULTS Of 13 499 papers from our search result, 21 papers satisfied the inclusion criteria. The median post-operative survival was 30.8 months. The average 1- and 5-year post-operative survivals were 61.6 and 33.3%, respectively. Predictors of long-term survival included achievement of R0 margins, minimisation of operative time and reduction intra-operative blood loss. CONCLUSION Our analysis demonstrates improving post-operative outcomes and survival in surgical resection of BC-IV cholangiocarcinoma and suggests that radical surgical resection is a valid treatment option for the disease.
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Affiliation(s)
- Dominic Ku
- General Surgical Department, Westmead Hospital, Sydney, New South Wales, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Reuben Tang
- General Surgical Department, Westmead Hospital, Sydney, New South Wales, Australia
| | - Tony Pang
- General Surgical Department, Westmead Hospital, Sydney, New South Wales, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Henry Pleass
- General Surgical Department, Westmead Hospital, Sydney, New South Wales, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Arthur Richardson
- General Surgical Department, Westmead Hospital, Sydney, New South Wales, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Lawrence Yuen
- General Surgical Department, Westmead Hospital, Sydney, New South Wales, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Vincent Lam
- General Surgical Department, Westmead Hospital, Sydney, New South Wales, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia.,Department of Clinical Medicine, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia
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22
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Kron P, Kimura N, Farid S, Lodge JPA. Current role of trisectionectomy for hepatopancreatobiliary malignancies. Ann Gastroenterol Surg 2019; 3:606-619. [PMID: 31788649 PMCID: PMC6875946 DOI: 10.1002/ags3.12292] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 09/24/2019] [Accepted: 09/30/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Trisectionectomy is a treatment option in extensive liver malignancy, including colorectal liver metastases (CRLM). However, the reported experience of this procedure is limited. Therefore, we present our experience with right hepatic trisectionectomy (RHT) for CRLM as an example and discuss the changing role of trisectionectomy in the context of modern treatment alternatives based on a literature review. METHODS Between January 1993 and December 2014 all patients undergoing RHT at a single center in the UK for CRLM were included. Patient and tumor characteristics were reviewed and a multivariate analysis was done. Based on a literature review the role of trisectionectomy in the treatment of HPB malignancies was discussed. RESULTS A total of 211 patients undergoing RHT were included. Overall perioperative morbidity was 40.3%. Overall 90-day mortality was 7.6% but reduced to 2.8% over time. Multivariate analysis identified additional organ resection (P = .040) and blood transfusion (P = .028) as independent risk factors for morbidity. Multiple tumors, total hepatic vascular exclusion, and R1 resection were independent risk factors for significantly decreased disease-free and disease-specific survival. Further surgery for recurrence after RHT significantly prolonged survival compared with palliative chemotherapy only. CONCLUSION With the further development of surgical and multimodal treatment strategies in CRLM the indications for trisectionectomy are decreasing. Having being formerly associated with high rates of perioperative morbidity and mortality, this single-center experience clearly shows that these concomitant risks decrease with experience, liberal use of portal vein embolization and improved patient selection. Trisectionectomy remains relevant in selected patients.
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Affiliation(s)
- Philipp Kron
- Department of HPB and Transplant SurgerySt. James's University HospitalLeedsUK
| | - Norihisa Kimura
- Department of HPB and Transplant SurgerySt. James's University HospitalLeedsUK
| | - Shahid Farid
- Department of HPB and Transplant SurgerySt. James's University HospitalLeedsUK
| | - J. Peter A. Lodge
- Department of HPB and Transplant SurgerySt. James's University HospitalLeedsUK
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23
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Mizuno T, Ebata T, Nagino M. Advanced hilar cholangiocarcinoma: An aggressive surgical approach for the treatment of advanced hilar cholangiocarcinoma: Perioperative management, extended procedures, and multidisciplinary approaches. Surg Oncol 2019; 33:201-206. [PMID: 31301935 DOI: 10.1016/j.suronc.2019.07.002] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 06/27/2019] [Accepted: 07/07/2019] [Indexed: 01/02/2023]
Abstract
Hilar cholangiocarcinoma is a highly intractable malignancy. One of the reasons for its intractability is that most patients with the disease are diagnosed with an advanced stage of the disease at their initial presentation. Surgical resection is the standard therapy for hilar cholangiocarcinoma, providing a chance for a cure, and an aggressive surgical approach substantially increases the number of resectable tumors that are initially regarded as unresectable tumors. The success and standardization of the aggressive approach is warranted by meticulous preoperative management that prevents fatal postoperative complications. Extended resection procedures, including hepatic trisectionectomy for Bismuth type IV tumors, hepatopancreaticoduodenectomy for tumors with extensive longitudinal tumor spreading, and combined vascular resection with reconstruction for tumors with the involvement of hepatic vascular structures, have been challenged to expand the surgical indication. Due to acceptable surgical/survival outcomes, the three extended procedures are currently regarded as extended but standard options in specialized hepatobiliary centers. Although it remains a controversial multidisciplinary approach, the combination of these extended procedures with an adjuvant/neoadjuvant treatment is a promising approach for further improving the resectability of tumors and the survival of patients.
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Affiliation(s)
- Takashi Mizuno
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan.
| | - Tomoki Ebata
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masato Nagino
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
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24
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Kimbrough CW, Cloyd JM, Pawlik TM. Surgical approaches for the treatment of perihilar cholangiocarcinoma. Expert Rev Anticancer Ther 2018; 18:673-683. [DOI: 10.1080/14737140.2018.1473039] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Charles W. Kimbrough
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Jordan M. Cloyd
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Timothy M. Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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25
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Ji GW, Zhu FP, Wang K, Xia YX, Jiao CY, Shao ZC, Li XC. Radiologic evaluation of vasculobiliary anatomy in the umbilical fissure. J Surg Res 2017. [PMID: 28624053 DOI: 10.1016/j.jss.2017.03.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Preoperative evaluation of vasculobiliary anatomy in the umbilical fissure (U-point) is pivotal for perihilar cholangiocarcinoma (PCCA) applied to right-sided hepatectomy. The purpose of our study was to review the vasculobiliary anatomy in the U-point using three-dimensional (3D) reconstruction technique, to investigate the diagnostic ability of 2D scans to evaluate anatomic variations, and to discuss its surgical implications. METHODS A retrospective study of 159 patients with Bismuth type I, II, and IIIa PCCA, who received surgery at our institution from November 2012 to September 2016, was conducted. Anatomic structures were assessed using multidetector computed tomography (MDCT) by one hepatobiliary surgeon, whereas 3D images were reconstructed by an independent radiologist. Normal confluence pattern of left biliary system was defined as the left medial segmental bile duct (B4) joining the common trunk of segment II (B2) and segment III (B3) ducts, whereas aberrant confluence patterns were classified into 3 types: type I, triple confluence of B2, B3, and B4; type II, B2 draining into the common trunk of B3 and B4; type III, other patterns. Surgical anatomy of B4 was classified into the central, peripheral, and combined type according to its relation to the hepatic confluence. The lengths from the bile duct branch of Spiegel's lobe (B1l) to the orifice of B4 and the junction of B2 and B3 were measured on 3D images. The anatomy of left hepatic artery (LHA) was classified according to different origins and the spatial relationship related to the U-point. RESULTS 3D reconstruction revealed that normal confluence pattern of left biliary system was observed in 71.1% (113/159) of all patients, and variant patterns were type I in 11.9% (19/159), type II in 12.6% (20/159), and type III in 4.4% (7/159). The length from B1l to the junction of B2 and B3 was 12.1 ± 3.1 mm in type I variation, which was significantly shorter than that in normal configuration (30.0 ± 6.8 mm, P < 0.001) but significantly longer than that in type II variation (9.6 ± 3.4 mm, P = 0.019). Surgical anatomy of B4: the peripheral type was most commonly seen (74.2%, 118/159), followed by central type (15.7%, 25/159) and combined type (10.1%, 16/159). The distance between the B1l and B4 was 8.4 ± 2.4 mm in central and combined type, which was significantly shorter than that in peripheral type (14.5 ± 4.1 mm, P < 0.001). A replaced or accessory LHA from the left gastric artery was present in 6 (3.8%) and 9 (5.7%) patients, respectively. LHA running along the left caudal position of U-point was present in 143 cases (89.9%), along the right cranial position of U-point in nine cases (5.7 %), and combined position in seven cases (4.4%). Interobserver agreement of two imaging modalities was almost perfect in biliary confluence pattern (kappa = 0.90; 95% confidence interval: 0.79-1.00), substantial in surgical anatomy of B4 (kappa = 0.74; 95% confidence interval: 0.62-0.86), and perfect in LHA (kappa = 1.00). CONCLUSIONS Thoroughly understanding the imaging characters of surgical anatomy in the U-point may be benefit for preoperative evaluation of PCCA by successive review of 2D images alone, whereas 3D reconstruction technique allows detailed hepatic anatomy and individualized surgical planning for advanced cases.
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Affiliation(s)
- Gu-Wei Ji
- Key Laboratory on Living Donor Liver Transplantation, Department of liver surgery, Ministry of Health, First Affiliated Hospital of Nanjing Medical University, Nanjing, P.R. China
| | - Fei-Peng Zhu
- Department of Radiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, P.R. China
| | - Ke Wang
- Key Laboratory on Living Donor Liver Transplantation, Department of liver surgery, Ministry of Health, First Affiliated Hospital of Nanjing Medical University, Nanjing, P.R. China
| | - Yong-Xiang Xia
- Key Laboratory on Living Donor Liver Transplantation, Department of liver surgery, Ministry of Health, First Affiliated Hospital of Nanjing Medical University, Nanjing, P.R. China
| | - Chen-Yu Jiao
- Key Laboratory on Living Donor Liver Transplantation, Department of liver surgery, Ministry of Health, First Affiliated Hospital of Nanjing Medical University, Nanjing, P.R. China
| | - Zi-Cheng Shao
- Key Laboratory on Living Donor Liver Transplantation, Department of liver surgery, Ministry of Health, First Affiliated Hospital of Nanjing Medical University, Nanjing, P.R. China
| | - Xiang-Cheng Li
- Key Laboratory on Living Donor Liver Transplantation, Department of liver surgery, Ministry of Health, First Affiliated Hospital of Nanjing Medical University, Nanjing, P.R. China.
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Kimura N, Young AL, Toyoki Y, Wyatt JI, Toogood GJ, Hidalgo E, Prasad KR, Kudo D, Ishido K, Hakamada K, Lodge JPA. Radical operation for hilar cholangiocarcinoma in comparable Eastern and Western centers: Outcome analysis and prognostic factors. Surgery 2017; 162:500-514. [PMID: 28551378 DOI: 10.1016/j.surg.2017.03.017] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Revised: 03/09/2017] [Accepted: 03/20/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND Extensive resection for hilar cholangiocarcinoma is the most effective treatment, but high morbidity and poor prognosis remain concerns. Previous data have shown marked differences in outcomes between comparable Eastern and Western centers. We compared the outcomes of the management for hilar cholangiocarcinoma at one Japanese and one British institution with comparable experience. METHODS Of 298 consecutive patients with hilar cholangiocarcinoma evaluated at Hirosaki University Hospital, Japan and St. James's University Hospital, Leeds, UK, 183 underwent radical resection. Clinicopathologic variables and postoperative outcomes were compared. RESULTS Significant differences were not observed between the Hirosaki and Leeds cohorts in overall outcomes despite several differences in the patient characteristics. Although there was a difference in 90-day mortality (2.5% vs 13.6%, respectively), disease-specific 5-year survival rates were 32.8% and 31.9%, respectively (P = .767). Multivariate analysis identified trisectionectomy (odds ratio = 2.32; P = .010), combined pancreatoduodenectomy (odds ratio = 7.88; P = .010), and perioperative blood transfusion (odds ratio = 1.88; P = .045) were associated with postoperative major complications, while preoperative biliary drainage associated with postoperative major complications, while preoperative biliary drainage (risk ratio = 2.21; P = .018), perioperative blood transfusion (risk ratio = 1.58; P = .029), lymph node metastasis (risk ratio = 2.00; P = .002), moderate/poorly differentiated tumor (risk ratio = 1.72; P = .029), microvascular invasion (risk ratio = 1.63; P = .046), and R1 resection (risk ratio = 1.90; P = .005) were risk factors for poor survival. CONCLUSION Disease-specific survival and prognostic factors were similar in both centers. Meticulous operative technique to avoid perioperative blood transfusion may improve long-term survival.
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Affiliation(s)
- Norihisa Kimura
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan; Department of HPB and Transplant Surgery, St. James's University Hospital NHS Trust, Leeds, UK
| | - Alastair L Young
- Department of HPB and Transplant Surgery, St. James's University Hospital NHS Trust, Leeds, UK
| | - Yoshikazu Toyoki
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Judith I Wyatt
- Department of Pathology, St. James's University Hospital NHS Trust, Leeds, UK
| | - Giles J Toogood
- Department of HPB and Transplant Surgery, St. James's University Hospital NHS Trust, Leeds, UK
| | - Ernest Hidalgo
- Department of HPB and Transplant Surgery, St. James's University Hospital NHS Trust, Leeds, UK
| | - K Rajendra Prasad
- Department of HPB and Transplant Surgery, St. James's University Hospital NHS Trust, Leeds, UK
| | - Daisuke Kudo
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Keinosuke Ishido
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Kenichi Hakamada
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - J Peter A Lodge
- Department of HPB and Transplant Surgery, St. James's University Hospital NHS Trust, Leeds, UK.
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Ebata T, Mizuno T, Yokoyama Y, Igami T, Sugawara G, Nagino M. Surgical resection for Bismuth type IV perihilar cholangiocarcinoma. Br J Surg 2017; 105:829-838. [PMID: 28488733 DOI: 10.1002/bjs.10556] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Revised: 02/26/2017] [Accepted: 03/03/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND Bismuth type IV perihilar cholangiocarcinoma has traditionally been categorized as unresectable disease. The aim of this study was to review experience with a resection-based strategy in patients who have type IV perihilar cholangiocarcinoma. METHODS Medical records of consecutive patients with a diagnosis of type IV perihilar cholangiocarcinoma between 2006 and 2015 were reviewed retrospectively. Primary outcomes assessed were surgical results and long-term survival. RESULTS Of the 332 patients with type IV tumour, 216 (65·1 per cent) underwent resection. Left hepatic trisectionectomy was the most common procedure (112 patients). Combined vascular resection was performed in 131 patients. Median duration of operation was 607 (range 356-1045) min, and blood loss was 1357 (209-10 349) ml. Complications of Clavien-Dindo grade III or more developed in 90 patients (41·7 per cent) and four (1·9 per cent) died from complications within 90 days. Survival rates were better for the 216 patients whose tumours were resected than for the 116 patients with unresected tumours (32·8 versus 1·5 per cent at 5 years; P < 0·001). Patients with pN0 M0 disease after resection had a favourable 5-year survival rate of 53 per cent. Percutaneous transhepatic biliary drainage, blood transfusion, lymph node metastasis and distant metastasis were identified as independent negative prognostic factors for survival. CONCLUSION Although resection for type IV tumour is technically demanding with high morbidity, it can be performed with low mortality and offers better survival probability in selected patients.
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Affiliation(s)
- T Ebata
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho Showa-ku, Nagoya 466-8550, Japan
| | - T Mizuno
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho Showa-ku, Nagoya 466-8550, Japan
| | - Y Yokoyama
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho Showa-ku, Nagoya 466-8550, Japan
| | - T Igami
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho Showa-ku, Nagoya 466-8550, Japan
| | - G Sugawara
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho Showa-ku, Nagoya 466-8550, Japan
| | - M Nagino
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho Showa-ku, Nagoya 466-8550, Japan
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Ji GW, Zhu FP, Wang K, Jiao CY, Shao ZC, Li XC. Clinical Implications of Biliary Confluence Pattern for Bismuth-Corlette Type IV Hilar Cholangiocarcinoma Applied to Hemihepatectomy. J Gastrointest Surg 2017; 21:666-675. [PMID: 28168674 DOI: 10.1007/s11605-017-3377-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Accepted: 01/23/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Since biliary variations are commonly seen, our aims are to clarify these insidious variations and discuss their surgicopathologic implications for Bismuth-Corlette (BC) type IV hilar cholangiocarcinoma (HC) applied to hemihepatectomy. METHODS Three-dimensional images of patients with distal bile duct obstruction (n = 97) and advanced HC (n = 79) were reconstructed and analyzed retrospectively. Normal biliary confluence pattern was defined as the peripheral segment IV duct (B4) joining the common trunk of segment II (B2) and segment III (B3) ducts to form the left hepatic duct (LHD) that then joined the right hepatic duct (RHD). The lengths from left and right secondary biliary ramifications to the right side of the umbilical portion of the left portal vein (Rl-L) and the cranio-ventral side of the right portal vein (Rr-R) were measured, respectively, and compared with the resectable bile duct length in HCs. Surgicopathologic findings were compared between different BC types. RESULTS The resectable bile duct length in right hemihepatectomy for eradication of type IV tumors was significantly longer than the Rl-L length in normal biliary configuration (17.4 ± 1.8 and 10.3 ± 3.4 mm, respectively, p < 0.001), and type III variation (B2 joining the common trunk of B3 and B4) was the predominant configuration (53.8%). The resectable length in left hemihepatectomy for eradication of type IV tumors was comparable with the Rr-R length in RHD absent cases (15.2 ± 2.5 and 16.4 ± 2.6 mm, respectively, p = 0.177) but significantly longer than that in normal configuration (p < 0.001). The estimated length was 8.5 ± 2.0 mm in unresectable cases. There was no significant difference between type III and IV tumors, except for the rate of nodal metastasis (29.7 and 76.0%, respectively, p < 0.001). CONCLUSION Hemihepatectomy might be selected for curative-intent resection of BC type IV tumors considering the advantageous biliary variations, whereas anatomical trisegmentectomy is recommended for the resectable bile duct length less than 10 mm. Biliary variations might result in excessive classification of BC type IV but require validation on further study.
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Affiliation(s)
- Gu-Wei Ji
- Key Laboratory on Living Donor Liver Transplantation, Ministry of Health, Department of Liver Surgery, First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, People's Republic of China
| | - Fei-Peng Zhu
- Department of Radiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, People's Republic of China
| | - Ke Wang
- Key Laboratory on Living Donor Liver Transplantation, Ministry of Health, Department of Liver Surgery, First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, People's Republic of China
| | - Chen-Yu Jiao
- Key Laboratory on Living Donor Liver Transplantation, Ministry of Health, Department of Liver Surgery, First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, People's Republic of China
| | - Zi-Cheng Shao
- Key Laboratory on Living Donor Liver Transplantation, Ministry of Health, Department of Liver Surgery, First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, People's Republic of China
| | - Xiang-Cheng Li
- Key Laboratory on Living Donor Liver Transplantation, Ministry of Health, Department of Liver Surgery, First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, People's Republic of China.
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Torzilli G, Nagino M, Tzeng CWD, Kingham TP, Alatise OI, Ayandipo OO, Yamashita S, Arrington AK, Kim J, Chun YS, Vauthey JN. SSAT State-of-the-Art Conference: New Frontiers in Liver Surgery. J Gastrointest Surg 2017; 21:175-185. [PMID: 27480411 DOI: 10.1007/s11605-016-3193-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Accepted: 06/14/2016] [Indexed: 01/31/2023]
Affiliation(s)
- Guido Torzilli
- Department of Hepatobiliary and General Surgery, Humanitas Research Hospital, IRCCS, Humanitas University, Milan, Italy
| | - Masato Nagino
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Ching-Wei D Tzeng
- Department of Surgery, University of Kentucky College of Medicine, Lexington, KY, USA
| | - T Peter Kingham
- Department of Surgery, Hepatopancreatobiliary Service, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | | | | | - Suguru Yamashita
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1484, Houston, TX, 77030, USA
| | | | - Joseph Kim
- Division of Surgical Oncology, Department of Surgery, Stony Brook School of Medicine, Stony Brook, NY, USA
| | - Yun Shin Chun
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1484, Houston, TX, 77030, USA.
| | - Jean-Nicolas Vauthey
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1484, Houston, TX, 77030, USA
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Valle JW, Borbath I, Khan SA, Huguet F, Gruenberger T, Arnold D. Biliary cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2016; 27:v28-v37. [PMID: 27664259 DOI: 10.1093/annonc/mdw324] [Citation(s) in RCA: 428] [Impact Index Per Article: 53.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- J W Valle
- Department of Medical Oncology, The Christie NHS Foundation Trust, Institute of Cancer Sciences, University of Manchester, Manchester, UK
| | - I Borbath
- Department of Gastroenterology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - S A Khan
- Hepatology and Gastroenterology Section, Department of Medicine, Imperial College, London, UK
| | - F Huguet
- Department of Radiation Oncology, Tenon Hospital, APHP, University Paris VI, Paris, France
| | - T Gruenberger
- 1st Department of Surgery, Rudolfstiftung Hospital, Vienna, Austria
| | - D Arnold
- Instituto CUF de Oncologia (I.C.O.), Lisbon, Portugal
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Abstract
BACKGROUND Right-sided hepatectomy is often selected for perihilar cholangiocarcinoma, due to the anatomic consideration that "the left hepatic duct is longer than that of the right hepatic duct". However, only one study briefly mentioned the length of the hepatic ducts. Our aim is to investigate whether the consideration is correct. METHODS In surgical study, the lengths of the resected bile duct were measured using pictures of the resected specimens in 475 hepatectomized patients with perihilar cholangiocarcinoma. In radiological study, the estimated lengths of the bile duct to be resected were measured using cholangiograms reconstructed from computed tomography images in 61 patients with distal bile duct obstruction. RESULTS In surgical study, the length of the resected left hepatic duct was 25.1 ± 6.4 mm in right trisectionectomy (n = 37) and 14.9 ± 5.7 mm in right hepatectomy (n = 167). The length of the right hepatic duct was 14.1 ± 5.7 mm in left hepatectomy (n = 149) and 21.3 ± 6.4 mm in left trisectionectomy (n = 122). In radiological study, the lengths of the bile duct corresponding to the surgical study were 34.1 ± 7.8, 22.4 ± 7.1, 20.8 ± 4.8, and 31.6 ± 5.3 mm, respectively. Both studies determined that the lengths of the resected bile ducts were (1) similar between right and left hepatectomies, (2) significantly shorter in right hepatectomy than in left trisectionectomy, and (3) the longest in right trisectionectomy. CONCLUSIONS The aforementioned anatomical assumption is a surgeon's biased view. Based on our observations, a flexible procedure selection is recommended.
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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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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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Higuchi R, Yazawa T, Uemura S, Yamamoto M. Anterior approach for perihilar cholangiocarcinoma (with video). J Surg Res 2015; 202:71-6. [PMID: 27083950 DOI: 10.1016/j.jss.2015.12.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Revised: 11/11/2015] [Accepted: 12/10/2015] [Indexed: 01/20/2023]
Abstract
BACKGROUND To evaluate the significance of the anterior approach without the Pringle maneuver during right hepatectomies with caudate lobectomies for perihilar cholangiocarcinomas (PHCs). MATERIALS AND METHODS From January 2011 to 2015, 25 consecutive patients underwent right hepatectomies with caudate lobectomies using the anterior approach without the Pringle maneuver for PHC (group A). Between 2003 and 2011, 44 patients were operated on for PHC using the classic right approach (group B). We compared the groups with respect to the patients' characteristics and the short-term surgical outcomes. RESULTS Group A had significantly lower postoperative mean maximum levels of aspartate aminotransferase (294 U/L versus 453 U/L; P = 0.044), lower frequencies of maximum aspartate aminotransferase or alanine aminotransferase levels that exceeded 500 U/L (8.0% versus 32%; P = 0.036), shorter total Pringle maneuver times (7.1 versus 46.3 min; P < 0.001), lower Pringle maneuver frequencies (0.76 maneuvers versus 5.1 maneuvers; P < 0.001), less bleeding (1237 mL versus 1646 mL; P = 0.025), and shorter postoperative systemic inflammatory response syndrome durations (2.3 h versus15.4 h; P < 0.001) compared with group B. CONCLUSIONS This approach can be performed safely, and it seems to limit the hemodynamic disturbance of the remnant left liver.
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Affiliation(s)
- Ryota Higuchi
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan
| | - Takehisa Yazawa
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan
| | - Shuichiro Uemura
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan
| | - Masakazu Yamamoto
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan.
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Titapun A, Pugkhem A, Luvira V, Srisuk T, Somintara O, Saeseow OT, Sripanuskul A, Nimboriboonporn A, Thinkhamrop B, Khuntikeo N. Outcome of curative resection for perihilar cholangiocarcinoma in Northeast Thailand. World J Gastrointest Oncol 2015; 7:503-512. [PMID: 26691730 PMCID: PMC4678397 DOI: 10.4251/wjgo.v7.i12.503] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Revised: 09/27/2015] [Accepted: 10/27/2015] [Indexed: 02/05/2023] Open
Abstract
AIM: To examine survival outcomes of perihilar cholangiocarcinoma (PCCA) resection including mortality, morbidity and prognostic factors.
METHODS: Multivariate analyses were carried out based on the survival data of all patients with histologically confirmed PCCA who underwent curative resection at Srinagarind Hospital from January 2006 to December 2011.
RESULTS: There were 29 (19%) cases of intrahepatic CCA that involved hilar and 124 (81%) with hilar bile-duct cancer. R0 resection was carried out on 66 (43.1%) patients of whom 50 (32.7%) also had lymph node metastasis. The other patients underwent R1 resection. The overall 5-year survival rate was 20.6% (95%CI: 13.8-28.4) and median survival time was 19.9 mo. Postoperative mortality was 2%, and 30% of patients had complications. Patients without lymph node metastasis were 60% less likely to die than those with metastasis. Achieving R0 led to a 58% reduction in the chance of mortality as compared to R1.
CONCLUSION: To achieve a better survival outcome, focus should center on performing radical surgery and detection of patients with early stage cancer.
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Okuda Y, Taura K, Seo S, Yasuchika K, Nitta T, Ogawa K, Hatano E, Uemoto S. Usefulness of operative planning based on 3-dimensional CT cholangiography for biliary malignancies. Surgery 2015; 158:1261-71. [PMID: 26054319 DOI: 10.1016/j.surg.2015.04.021] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Revised: 03/30/2015] [Accepted: 04/16/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND The complexity of hepatic hilar anatomy is an obstacle to precise diagnosis of tumor spread and appropriate operative planning for biliary malignancies. Three-dimensional (3D) cholangiography and angiography may overcome this obstacle and facilitate curative resection. The objective of this study was to evaluate the impact of 3D CT cholangiography on operative planning and outcomes of biliary malignancies. METHODS From 2009 to 2014, 3DCT cholangiography was performed on 49 patients with biliary malignancies requiring major hepatic resection and extrahepatic bile duct resection. The 3D cholangiogram was merged with 3D angiography and portography to create an all-in-one 3D image of the hepatic hilum. The cutting line of the bile duct and the type of liver resection were determined based on the spatial relationship between tumor spread and the landmark vessels. The necessity of vascular reconstruction was also evaluated. Preoperative imaging and operative findings were compared. Operative curability was compared with that of the historical cohort before the introduction of 3D cholangiography. RESULTS Histologic examination of the bile duct stump showed a negative margin in 39 (80%), carcinoma in situ in 7 (14%), and invasive cancer (IC) in 3 patients (6%) on the first cutting. The IC-free rate (94%) on the first cutting was superior to that in the historical cohort (80%; P = .02). The necessity for portal and arterial reconstruction was predicted with 98 and 94% accuracy, respectively. CONCLUSION We found 3D cholangiography to provide accurate information about hilar anatomy and plays a role in facilitating adequate operative planning.
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Affiliation(s)
- Yukihiro Okuda
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kojiro Taura
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan.
| | - Satoru Seo
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kentaro Yasuchika
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takashi Nitta
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kohei Ogawa
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Etsuro Hatano
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shinji Uemoto
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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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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