Preoperative Left Portal Vein Embolization for Left Liver Resection in High-Risk Hepatobiliary Malignancy Patients

Standard and modified techniques for parenchyma-preserving hepatectomy focused on segments I+IV resection in patients with perihilar cholangiocarcinoma

Resection of the hepatic segments I+IV (S1+S4) is the most common type of parenchyma-preserving hepatectomy (PPH) for perihilar cholangiocarcinoma (PHCC). The author describes personal experience on the standard and modified techniques for PPH focused on S1+S4 resection in patients with PHCC. 1) Isolated caudate lobectomy with bile duct resection (BDR) is the minimal type of PPH, but not currently recommended due to technical difficulty. 2) Partial hepatectomy of S1+S4a±segment V (S5) with BDR provides wide operative field, but extension of BDR is limited and resection of S1 paracaval portion is still difficult. 3) Resection of S1+S4+S5 with BDR provides wider operative field for complete S1 resection and multiple biliary reconstruction. 4) Resection of S1+S4 with BDR offers very wide operative field and allows wider extent of hilar BDR, and thus presents the most common type of PPH. A supplementary video clip presents the detailed standard surgical procedure for resection of S1+S4 with BDR in a patient with type IIIA PHCC. 5) Modified resection of S1+S4±S5 or segment VIII (S8) with BDR facilitates additional resection of tumor-involved S5 or S8 ducts. 6) Major hilar vascular invasion is usually contraindicated for PPH and only small portal vein invasion requiring wedge resection and patch venoplasty is allowed. In conclusion, PPH can achieve curative resection and improved outcomes in patients with PHCC via reasonable modification of the extent of hepatectomy and hilar BDR. PPH may have advantages in selected patients depending on the extent of tumor, and in patients with high operative risk.

Hepatic atrophy treatment with portal vein embolization to control intrahepatic duct stenosis-associated cholangitis

We present two cases of hepatic atrophy treatment with portal vein embolization (PVE) to control intractable cholangitis. The first case was a 60-year-old male who was admitted for repeated episodes of cholangitis. He had undergone cholecystectomy and Roux-en-Y choledochojejunostomy 2 years earlier. Imaging studies showed left intrahepatic duct dilatation and anastomotic site stricture. The patient was reluctant to undergo another surgery. Thus, we decided to perform left PVE to induce atrophy of the left liver. The left liver shrank and stayed silent for 5 years, but a radiological intervention was necessary to treat symptomatic anastomotic stenosis. The patient has done well for 12 years after PVE. The second case was a 51-year-old female who was also admitted for repeated episodes of cholangitis. She had undergone excision of type I choledochal cyst 2 years earlier. Imaging studies showed right hepatic duct stenosis. Cholangitis developed repeatedly. Thus, radiologic interventions were performed 8 times over 9 years. Finally, she was referred for surgery, but she was very reluctant to undergo another surgery. We planned a wait-and-see strategy following right PVE. After PVE, the right liver progressively shrank. Three months after PVE, we decided to wait for a longer period until further atrophy of the right liver. The patient has been doing well for 14 months after PVE without any episode of cholangitis. In conclusion, experience from our two cases suggests that hepatic parenchymal induction therapy through percutaneous PVE can be a therapeutic option for patients with perihilar biliary stenosis-associated cholangitis.

Clinical Implications of Biliary Confluence Pattern for Bismuth-Corlette Type IV Hilar Cholangiocarcinoma Applied to Hemihepatectomy

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.