Arterial vascularisation of the extrahepatic biliary tract

Radiological Vascular Anatomy of the Caudate Lobe of the Liver Required for Transarterial Chemoembolization of Hepatocellular Carcinoma

The caudate lobe is located between the bilateral hepatic lobes and is divided into three subsegments: the Spiegel lobe, paracaval portion, and caudate process. The caudate artery arises from various sites of the bilateral hepatic arteries as an independent branch, common trunk, or arcade. Extrahepatic arteries can enter the caudate lobe mainly by the right inferior phrenic artery. The caudate artery also supplies the main bile duct and posterior aspect of segment IV. Although catheterization into the caudate artery is occasionally difficult because of its small size and sharp angulation, selective embolization of a tumor feeder is a significant prognostic factor in patients with hepatocellular carcinoma originating there. Therefore, we should recognize the peculiarity of its vascular anatomy and should be familiar with catheterization and embolization techniques.

Secondary sclerosing cholangitis and IgG4-sclerosing cholangitis - A review of cholangiographic and ultrasound imaging

Sclerosing cholangitis (SC) represents a spectrum of chronic progressive cholestatic diseases of the intrahepatic and/or extrahepatic biliary system characterized by patchy inflammation, fibrosis, and stricturing. Primary and secondary SC must be distinguished given the different treatment modalities, risks of malignancy, and progression to portal hypertension, cirrhosis, and hepatic failure. This review focuses on secondary SC and the pathogenic mechanisms, risk factors, clinical presentation, and novel imaging modalities that help to distinguish between these conditions. We explore the detailed use of cholangiography and ultrasound imaging techniques.

Intra-arterial chemotherapy in the treatment of inoperable patients with Klatskin's tumor: preliminary results

Aim. To evaluate the safety and efficacy of hepatic arterial infusion (HAI) in patients with Klatskin tumor. Materials and methods. Between 2010-2021, 14 of 119 patients with inoperable Klatskin tumor were treated with HAI of GEMICS. All patients had obstructive jaundice and received percutaneous transhepatic biliary drainage (PTBD). Chemotherapy was started when serum bilirubin level became normal (average on the 106th day from PTBD). In total, 19 (from 1 to 4 per patient) HAI cycles were performed. Results. PTBD complications such as cholangitis (n=2) and local peritonitis (n=1) developed in 3 patients (21%) and were successfully treated using minimally invasive techniques. Toxicity of chemotherapy were observed in 8 of 14 patients (57%): I-II degree hematological (43%) and gastrointestinal (50%); all were cured by medical therapy. The overall mean survival was 286 days (9.6 months), median survival 283 days (9.4 months). Conclusions. Our preliminary results showed that HAI in patients with Klatskin tumor is safe, but has limited effectiveness. The combination of arterial infusion with other methods such as radiotherapy, intra-ductal photodynamic therapy, radiofrequency ablation, target therapy, should be investigated.

Feasibility of Boosted Radioembolization for Hepatocellular Carcinoma Larger than 5 cm

PURPOSE

To address the feasibility of yttrium-90 (⁹⁰Y) glass microspheres administered at a boosted dose in large hepatocellular carcinomas (HCCs).

MATERIALS AND METHODS

From July 2016 to August 2017, 20 patients who underwent ⁹⁰Y radioembolization for treatment-naïve HCC met the following inclusion criteria: (i) nodular tumor, (ii) tumor size > 5 cm, (iii) Barcelona Clinic Liver Cancer stage A/B disease, (iv) target perfused tissue dose > 150 Gy, and (v) all tumors treated in 1 session of radioembolization. Follow-up radiologic findings and clinical outcomes were retrospectively reviewed until May 2018. Tumor response was determined per modified Response Evaluation Criteria In Solid Tumors.

RESULTS

Mean total radiation activity infused was 4.96 GBq ± 1.82 (median, 4.88 GBq; range, 1.63-9.15 GBq). Mean target perfused tissue dose was 263.5 Gy ± 95.2 (median, 241.6 Gy; range, 156.2-550.6 Gy). The mean number of vials used per treatment was 4.15 ± 1.4 (median, 4; range, 2-7). Complete response rates were 25% at 1 month and 60% at 3 months. Complete response of the primary index tumor was achieved in 16 patients (80%) based on best tumor response. Local progression-free survival and progression-free survival rates were 94.1% and 85.0% at 6 mo and 94.1% and 74.7% at 1 year, respectively. Four patients (20%) had symptomatic (n = 3) or asymptomatic (n = 1) benign biliary strictures.

CONCLUSIONS

Radioembolization with a boosted dose in patients with large HCCs may show favorable tumor response, but with considerable biliary complications.

Endoscopic ultrasound of the hepatoduodenal ligament and liver hilum

The porta hepatis and hepatoduodenal ligament (HDL) are important anatomical pathways of extension of disease to and from the liver. The imaging of this area is difficult. The role of endoscopic ultrasound (EUS) as an imaging modality for hepatoduodenal ligament has not been established so far. All images in the present study have been generated from a detailed review of real time recordings using the curved linear scanning echoendoscope EG -3830 UT (Pentax Corporation, Tokyo, Japan), coupled with a Hitachi avius and Hitach 7500 processor (Hitachi Aloka Medical, Tokyo Japan). Our image orientation is with the cranial aspect of the patient directed toward the right side of the screen. We have illustrated that with a careful technique, a detailed EUS evaluation of the HDL and hepatic hilum is possible. A thorough understanding of the HDL anatomy by curved linear EUS probe may play a crucial role in the accurate diagnosis of a broad spectrum of pathologic conditions of the porta hepatis. EUS examination of the HDL should be a part of the upper abdominal EUS studies. The description and the images described in this article are useful for beginners who want to start imaging of the porta hepatis and hepatoduodenal ligament. This information is useful for staging of malignancies involving common bile duct.

Biliary tract anatomy and its relationship with venous drainage

Portal cavernoma develops as a bunch of hepatopetal collaterals in response to portomesenteric venous obstruction and induces morphological changes in the biliary ducts, referred to as portal cavernoma cholangiopathy. This article briefly reviews the available literature on the vascular supply of the biliary tract in the light of biliary changes induced by portal cavernoma. Literature pertaining to venous drainage of the biliary tract is scanty whereas more attention was focused on the arterial supply probably because of its significant surgical implications in liver transplantation and development of ischemic changes and strictures in the bile duct due to vasculobiliary injuries. Since the general pattern of arterial supply and venous drainage of the bile ducts is quite similar, the arterial supply of the biliary tract is also reviewed. Fine branches from the posterior superior pancreaticoduodenal, retroportal, gastroduodenal, hepatic and cystic arteries form two plexuses to supply the bile ducts. The paracholedochal plexus, as right and left marginal arteries, run along the margins of the bile duct and the reticular epicholedochal plexus lie on the surface. The retropancreatic, hilar and intrahepatic parts of biliary tract has copious supply, but the supraduodenal bile duct has the poorest vascularization and hence susceptible to ischemic changes. Two venous plexuses drain the biliary tract. A fine reticular epicholedochal venous plexus on the wall of the bile duct drains into the paracholedochal venous plexus (also called as marginal veins or parabiliary venous system) which in turn is connected to the posterior superior pancreaticoduodenal vein, gastrocolic trunk, right gastric vein, superior mesenteric vein inferiorly and intrahepatic portal vein branches superiorly. These pericholedochal venous plexuses constitute the porto-portal collaterals and dilate in portomesenteric venous obstruction forming the portal cavernoma.

Blood supply of the main bile duct from the caudate artery and medial subsegmental artery of the hepatic artery: Evaluation using images obtained during transcatheter arterial chemoembolization for hepatocellular carcinoma

AIM

Main bile duct necrosis develops after transcatheter arterial chemoembolization (TACE) through the caudate artery (A1) and medial subsegmental artery (A4) of the hepatic artery in the treatment of hepatocellular carcinoma. The aim of this study was to evaluate the bile duct branch (BD branch) from A1 and A4.

METHODS

We evaluated the origin and vascular territory of the BD branch in 11 patients who underwent selective A1 and/or A4 arteriography using arteriograms, cone-beam computed tomography (CBCT) and CT obtained 1 week after TACE. Follow-up CT and/or magnetic resonance imaging were also evaluated.

RESULTS

The BD branch arose from the first branch (n = 4), the second branch (n = 1), and both the first and second branches (n = 1) of A1, and from the first branch of A4 (n = 5). It supplied the bilateral hepatic ducts and common hepatic duct (CHD) (n = 4), the right hepatic duct (RHD) and CHD (n = 2), RHD, CHD and common bile duct (n = 1), the left hepatic duct (LHD) and CHD (n = 2), and LHD alone (n = 2). Anastomosis between A1 or A4 and other branches was demonstrated in seven patients. Bile duct stricture developed in all nine patients 2-8 months after TACE of the BD branch and percutaneous transhepatic bile duct drainage and metallic stent placement was required in one because of jaundice.

CONCLUSION

The BD branch arises from the proximal portion of A1 and A4 and mainly supplies the hepatic ducts and CHD.

Duct-to-duct biliary reconstruction in adult living-donor liver transplantation

BACKGROUND

Bile duct-to-duct reconstruction is now used in living-donor liver transplantation (LDLT) for adult patients.

METHODS

The results of duct-to-duct reconstruction were retrospectively analyzed. The subjects were 81 adult patients who underwent LDLT at the University of Tokyo Hospital with a follow-up period of at least 1 year. The hilar plate of the recipient was dissected to at least the second-order branch of the bile ducts. Duct-to-duct anastomosis was performed with interrupted sutures, and an external stent tube was inserted from the orifice opposite the hilar plate.

RESULTS

During the observation period (median, 664 days), biliary complications were observed in 26 cases (32%). The complications included bile juice leakage at the anastomosis or dissection plane of the graft in 12 patients, anastomotic stenosis in 10 patients, and tube trouble in 6 patients. Two patients had bile juice leakage followed by stenosis. Of the 26 patients, 21 required surgical revision.

CONCLUSIONS

The current technique did not reduce morbidity as expected. Further technical advancement and refinement are needed for better results.

Management and outcome of patients with combined bile duct and hepatic arterial injuries after laparoscopic cholecystectomy

BACKGROUND

Recent collective reviews have described the management and outcome of bile duct injuries during laparoscopic cholecystectomy. However, few have reported on the clinical significance of concomitant right hepatic arterial injuries. This study was conducted to examine the correlation of combined bile duct and vascular injuries and to evaluate the impact of these injuries on patient morbidity.

METHODS

From January 1990 to February 2002, a total of 54 patients with bile duct injuries during laparoscopic cholecystectomy were surgically treated in our institution. In 46 patients a Roux-en-Y hepaticojejunostomy was performed. Eleven patients had a concomitant vascular injury. Arterial reconstruction was performed in addition to Roux-en-Y hepaticojejunostomy in 2 patients. Eight patients underwent other surgical procedures and were not included in the statistical analysis. To evaluate the impact of vascular injuries, univariate and multivariate analysis was performed.

RESULTS

The rate of postoperative biliary complications was 21.7% for all patients. Univariate and multivariate analysis identified 2 risk factors for the development of biliary complications after reconstructive surgery: (1) combined bile duct and hepatic arterial injuries (6 of 11 patients [54.5%] vs 4 of 35 patients [11.4%]; P=.006) and (2) surgical repair in active peritonitis (8 of 13 patients [61.5%] vs 2 of 33 [6.1%]; P <.001). In the other, late referred patients with concomitant right hepatic arterial injury, the distal part of the artery was not exposable. After a median follow-up time of 44.6 months (range, 2 to 143.5 months) a successful outcome was achieved in 42 of 46 patients (91.3%), which included the patients who required additional endoscopic or surgical treatment after primary reconstruction.

CONCLUSIONS

The outcome of bile duct reconstruction is worse in patients with concomitant arterial injuries. We therefore recommend the assessment of patients with major bile duct injuries for additional vascular injuries. Further studies are needed to evaluate the importance of hepatic arterial revascularization in early recognized injuries to the long-term outcome of bile duct reconstructions.

Analysis of the arterial supply of the extrahepatic bile ducts and its clinical significance

The purpose of this study is to describe the arterial supply of the entire extrahepatic bile duct system. The cross-sectional area of all arteries that supply the ducts is measured under an operating microscope in 50 adult cadavers injected with red latex through the aorta. The extrahepatic bile duct system is divided into four topographic portions: cystic duct and gallbladder, right and left hepatic ducts, bile (common) duct and including its supra-retroduodenal parts, and the pancreatic and intraduodenal portions. The arterial supply to each portion is carefully detailed. The ducts are supplied by more than seven arteries, of which the major arteries are the cystic artery, posterior superior pancreaticoduodenal artery, right hepatic artery, and retroportal artery. Collectively they provide 94.5% of the blood supply to the ducts. Arteries form three types of anastomotic patterns on the walls of the ducts, suggesting that ductal incisions can be made in ways that least disturb the blood supply. The patterns are: a network, a longitudinal anastomotic chain, and an arterial circle. These data emphasize the importance of the arterial supply in biliary surgery and especially the treatment of hemobilia.

Ischemic cholangitis

Ischemia-induced bile duct lesions have been collectively labeled as ischemic cholangitis. The biliary epithelium is dependent on arterial blood flow, unlike the hepatic parenchyma with its dual arterial and portal venous blood supply. As such, the biliary epithelium is susceptible to injury when arterial blood flow is compromised. This compromise can occur at the level of the major, named hepatic artery branches or at the microscopic, peribiliary capillary plexus level. Typically, ischemic cholangitis manifests as segmental strictures and cholangiectases with resultant mechanical impairment of bile flow and, occasionally, secondary infection of the biliary system. Ischemic cholangitis after liver transplantation is becoming an important problem and likely is attributable to numerous factors. Hepatic arterial infusion of chemotherapy and systemic vasculitis are other causes of ischemic cholangitis. The role of ischemia in other chronic biliary and ductopenic diseases remains speculative.

Predictors of bile leaks after T-tube removal in orthotopic liver transplant recipients

Bile leaks after T-tube removal are a frequent cause of morbidity in orthotopic liver transplant recipients. The aim of this study was to determine factors that predict the development of these leaks in liver transplant recipients. Records of all patients who had undergone liver transplantation at the University of Washington Medical Center between January 1990 and September 1993 were reviewed. The following were excluded: patients with a Roux-en-Y anastomosis or inadvertent early T-tube removal and patients who died or underwent retransplantation before T-tube removal. All T-tube cholangiograms were reviewed blindly by two authors. Using logistic regression, several variables were assessed for possible association with bile leaks after T-tube removal; these included patient demographics, intraoperative variables, and clinical and cholangiographic variables related to T-tube removal. Of the 166 liver transplants performed in 150 patients, 99 transplants in 97 patients were evaluable for bile leak after T-tube removal. Thirty-three patients developed symptomatic bile leaks, and 21 underwent endoscopic or operative intervention for persistent symptoms. Only duct mural irregularities on the final cholangiogram were strongly associated with the development of a bile leak after T-tube removal (P = 0.001). In conclusion, bile leaks after T-tube removal occurred in one-third of patients undergoing orthotopic liver transplantation; the majority of these patients required some intervention. Duct mural irregularities were associated with bile leaks.