Recent advance in the treatment of hilar cholangiocarcinoma: hepatectomy with vascular resection

Portal vein thrombosis after right hepatectomy: impact of portal vein resection and morphological changes of the portal vein

BACKGROUND

Right hepatectomy occasionally requires portal vein resection (PVR) and causes postoperative portal vein thrombosis (PVT).

METHODS

A total of 247 patients who underwent right hepatectomy were evaluated using a three-dimensional analyzer to identify the morphologic changes in the portal vein (PV). The patients' characteristics were compared between the PVR group (n = 73) and non-PVR group (n = 174), and risk factors for PVT were investigated. The PVR group were subdivided into the wedge resection (WR) group (n = 38) and segmental resection (SR) group (n= 35).

RESULTS

Postoperative PVT occurred in 20 patients (8.1%). Multivariate analyses in all patients revealed that postoperative left PV diameter/main PV diameter (L/M ratio) <0.56 (odds ratio [OR] 4.00, p = 0.009) and PVR (OR 3.31, p = 0.031) were significant risk factors for PVT. In 73 patients who underwent PVR, PVT occurred in 14 (19%) and WR (OR 11.5, p = 0.005) and L/M ratio <0.56 (OR 5.51, p = 0.016) were significant risk factors for PVT.

CONCLUSION

PVR was one of the significant risk factors for PVT after right hepatectomy. SR rather than WR may be recommended for preventing PVT.

Vascular Resection in Perihilar Cholangiocarcinoma

Among the cholangiocarcinomas, the most common type is perihilar (phCC), accounting for approximately 60% of cases, after which are the distal and then intrahepatic forms. There is no staging system that allows for a comparison of all series and extraction of conclusions that increase the long-term survival rate of this dismal disease. The extension of the resection, which theoretically depends on the type of phCC, is not a closed subject. As surgery is the only known way to achieve a cure, many aggressive approaches have been adopted. Despite extended liver resections and even vascular resections, margins are positive in around one third of patients. In the past two decades, with advances in diagnostic and surgical techniques, surgical outcomes and survival rates have gradually improved, although variability is the rule, with morbidity and mortality rates ranging from 14% to 76% and from 0% to 19%, respectively. Extended hepatectomies and portal vein resection, or even right hepatic artery reconstruction for the left side tumors are frequently needed. Salvage procedures when arterial reconstruction is not feasible, as well as hepatopancreatoduodenectomy, are still under evaluation too. In this article, we discuss the aggressive surgical approach to phCC focused on vascular resection. Disparate results on the surgical treatment of phCC made it impossible to reach clear-cut conclusions.

Prognostic impact of the Bismuth-Corlette classification: Higher rates of local unresectability in stage IIIb hilar cholangiocarcinoma

BACKGROUND

The Bismuth-Corlette (BC) classification is used to categorize hilar cholangiocarcinoma by proximal extension along the biliary tree. As the right hepatic artery crosses just behind the left bile duct, we hypothesized that BC IIIb tumors would have a higher likelihood of local unresectability due to involvement of the contralateral artery.

METHODS

A retrospective review of a prospectively maintained database identified patients with hilar cholangiocarcinoma taken to the operating room for intended curative resection between April 2008 and September 2016. Cases were assigned BC stages based on preoperative imaging.

RESULTS

Sixty-eight patients were included in the study. All underwent staging laparoscopy after which 16 cases were aborted for metastatic disease. Of the remaining 52 cases, 14 cases were explored and aborted for locally advanced disease. Thirty-eight underwent attempt at curative resection. After excluding cases aborted for metastatic disease, the chance of proceeding with resection was 55.6% for BC IIIb staged lesions compared to 80.0% of BC IIIa lesions and to 82.4% for BC I-IIIa staged lesions (P < 0.05). About 44.4% of BC IIIb lesions were aborted for locally advanced disease versus 17.6% of remaining BC stages.

CONCLUSIONS

When hilar cholangiocarcinoma is preoperatively staged as BC IIIb, surgeons should anticipate higher rates of locally unresectable disease, likely involving the right hepatic artery.

Total Hilar En Bloc Resection with Left Hemihepatectomy and Caudate Lobectomy: a Novel Approach for Treatment of Left-Sided Perihilar Cholangiocarcinoma (with Video)

BACKGROUND

"Hilar en bloc resection" using a no-touch technique has been advocated as a standard procedure in right-sided hepatectomies for treatment of perihilar cholangiocarcinoma (PHC). In principle, it has never been reported for left-sided tumors. The aim is to describe the procedures of total hilar en bloc resection with left hemihepatectomy and caudate lobectomy (THER-LH) for advanced PHC and discuss feasibility and clinical significance of this novel technique.

METHODS

A retrospective study using a prospectively maintained database was performed to identify eight patients who had received THER-LH for advanced PHC from January 2013 to December 2015. The clinicopathological features, surgical procedures, and outcomes of these patients form the basis this study.

RESULTS

The operative time was 546 ± 158 (380-870) min, and estimated blood loss was 875 ± 690 (400-2500) ml. Time of vessel resection and reconstruction was 25.6 ± 12.3 min for the portal vein and 19.1 ± 4.9 min for the hepatic artery. Time of hilum clamping was 27.3 ± 11.9 (15-41) min. Two patients had Clavien-Dindo grade II and IVa complications of bile leakage with one developing intraabdominal abscess and bleeding. There was no perioperative mortality. Histopathologic examination revealed that all of eight patients had tubular adenocarcinoma with microscopic invasion to the resected hepatic arteries and portal veins in seven patients. Negative bile duct margins were achieved in all of them. Three patients developed recurrence and died at 11, 18, and 24 months postoperatively. The remaining patients were alive at the time of last follow-up. The median survival was 24 months with one patient achieving a disease-free survival of 50 months.

CONCLUSION

THER-LH is a technically demanding procedure that is safe and feasible that may have some beneficial effects on the prognosis of these patients with advanced PHC. Further studies are required to confirm the oncological superiority and survival benefits of this novel technique.

Clinical implication of surgical resection for recurrent biliary tract cancer: Does it work or not?

Although recent advances in imaging diagnosis, surgical techniques, and perioperative management can result in increased resectability and improved surgical outcomes, most resected patients still develop cancer recurrence. If patients develop cancer recurrence, their prognosis is very ominous. However, there have been some recent reports to show promising outcomes by aggressive surgical strategy in selected patients who developed cancer recurrence. Because there are various surgical procedures being selected at initial surgery in patients with biliary tract cancers, recurrent patterns after resection are very variable in each patient. However, surgical procedures might usually be very complicated and difficult if re‐surgical resection is considered in patients with recurrent biliary tract cancer, Therefore, surgical re‐resection could bring about high surgical morbidity and mortality rates in most previously reported series. Although re‐surgical resection might offer a chance of favorable outcome in selected patients with biliary tract cancers, these aggressive surgical approaches should be carried out in strictly selected patients by expert surgeons at high‐volume centers.

[Vascular reconstruction in hepatic surgery]

BACKGROUND

Due to their size or location liver tumors can infiltrate important vascular structures, which are essential for postoperative liver function.

OBJECTIVE

To present the technical possibilities and results of current concepts of vascular resection and reconstruction in liver surgery.

MATERIAL AND METHODS

A literature search of the Medline and Cochrane databases was performed regarding currently available studies on vascular resection and reconstruction in liver surgery.

RESULTS

Portal vein resections are routinely performed by many institutions and can be performed as an end-to-end anastomosis or graft interposition. This is the basis of the en bloc resection concept, especially for Klatskin tumors. Reconstruction of the inferior vena cava as well as the hepatic arteries is technically feasible and is increasingly being reported in smaller series. In particular, the resection of tumors near the hepatic veins may require total vascular exclusion for complete interruption of liver perfusion, which enables resection in the non-perfused liver and by this reduced blood loss. Furthermore, in situ cooling, ante situm and ex situ resections increase both technical resectability and the ischemic tolerance of the liver to more than 60 min. The majority of vascular reconstructions can be performed without a significant increase in morbidity; however, vascular tumor infiltration is associated with impaired long-term survival.

CONCLUSION

Based on the experience of transplantation surgery concepts for vascular reconstruction can be safely applied to liver surgery. These concepts contribute to increasing the resectability of liver tumors. Due to the often impaired prognosis of vascular tumor infiltration, the use of these concepts should be individually assessed by weighing the prognosis against the morbidity.

Cholangiocarcinoma

Biliary tract cancer accounts for <1% of all cancers and affects chiefly an elderly population, with predominance in men. We distinguish cholangiocarcinoma (intrahepatic, hilar and distal) and gallbladder cancer, with different pathogenesis and prognosis. The treatment is based on surgery (whenever possible), radiotherapy in selected cases, and chemotherapy. The standard cytotoxic treatment for advanced/metastatic disease is represented by the combination of gemcitabine and cisplatin, whereas fluoropyrimidines are generally administered in second line setting. At the present time, no biologic drug demonstrated a clear efficacy in this cancer, although the molecular characterisation could provide a promising basis for experimental treatments. A good supportive care and an early palliative care are warranted in most patients and should be delivered as a part of a global approach.

The Surgical Management of Klatskin Tumours: Has Anything Changed in the Last Decade?

Surgical treatment of hilar cholangiocarcinomas requires complex pre-, intra- and post-operative decision-making. Despite the significant progress in liver surgery over the years, several issues such as the role of pre-operative biliary drainage, portal vein embolisation, staging laparoscopy and neo-adjuvant chemotherapy remain unresolved. Operative strategies such as vascular resection, caudate lobe resection and liver transplant have also been practiced in order to improve R0 resectability and improved survival. The review aims to consolidate evidence from major studies in the last 11 years. Survival data were only included from studies that reported the results in at least 30 patients with 1-year follow-up. A significant number of patients may be prevented an unnecessary laparotomy if they underwent a staging laparoscopy. There remain no guidelines as to when portal vein embolisation or pre-operative biliary drainage should be employed but most studies agree with pre-operative biliary drainage being an absolute indication if portal vein embolisation is performed. Concomitant hepatectomy and caudate lobectomy increases R0 resection but vascular resection cannot be routinely recommended. Liver transplant at specialised centres in selective patients has had impressive results. Guidelines are required for pre-operative biliary drainage and portal vein embolisation and randomised trials are required in order to define the role of vascular resection in achieving a R0 resection and increasing survival.

Prognostic factors and long-term outcomes of hilar cholangiocarcinoma: A single-institution experience in China

AIM: To evaluate the prognostic factors of hilar cholangiocarcinoma in a large series of patients in a single institution.

METHODS: Eight hundred and fourteen patients with a diagnosis of hilar cholangiocarcinoma that were evaluated and treated between 1990 and 2014, of which 381 patients underwent curative surgery, were included in this study. Potential factors associated with overall survival (OS) and disease-free survival (DFS) were evaluated by univariate and multivariate analyses.

RESULTS: Curative surgery provided the best long-term survival with a median OS of 26.3 mo. The median DFS was 18.1 mo. Multivariate analysis showed that patients with tumor size > 3 cm [hazard ratio (HR) = 1.482, 95%CI: 1.127-1.949; P = 0.005], positive nodal disease (HR = 1.701, 95%CI: 1.346-2.149; P < 0.001), poor differentiation (HR = 2.535, 95%CI: 1.839-3.493; P < 0.001), vascular invasion (HR = 1.542, 95%CI: 1.082-2.197; P = 0.017), and positive margins (HR = 1.798, 95%CI: 1.314-2.461; P < 0.001) had poor OS outcome. The independent factors for DFS were positive nodal disease (HR = 3.383, 95%CI: 2.633-4.348; P < 0.001), poor differentiation (HR = 2.774, 95%CI: 2.012-3.823; P < 0.001), vascular invasion (HR = 2.136, 95%CI: 1.658-3.236; P < 0.001), and positive margins (HR = 1.835, 95%CI: 1.256-2.679; P < 0.001). Multiple logistic regression analysis showed that caudate lobectomy [odds ratio (OR) = 9.771, 95%CI: 4.672-20.433; P < 0.001], tumor diameter (OR = 3.772, 95%CI: 1.914-7.434; P < 0.001), surgical procedures (OR = 10.236, 95%CI: 4.738-22.116; P < 0.001), American Joint Committee On Cancer T stage (OR = 2.010, 95%CI: 1.043-3.870; P = 0.037), and vascular invasion (OR = 2.278, 95%CI: 0.997-5.207; P = 0.051) were independently associated with tumor-free margin, and surgical procedures could indirectly affect survival outcome by influencing the tumor resection margin.

CONCLUSION: Tumor margin, tumor differentiation, vascular invasion, and lymph node status were independent factors for OS and DFS. Surgical procedures can indirectly affect survival outcome by influencing the tumor resection margin.

Curative effect of surgical treatment of hilar cholangiocarcinoma: Analysis of 41 cases

AIM: To explore the curative effect of surgery in the treatment of hilar cholangiocarcinoma (HC).

METHODS: A retrospective analysis was performed of the clinical data for 41 HC patients treated from October 2007 to March 2010 in Affiliated Hospital of Zunyi Medical College.

RESULTS: In the 41 patients, the incidence of postoperative complications was 36.59%, including incision infection in 2 cases, pulmonary infection in 3 cases, bile leakage in 3 cases, and pleural effusion in 7 cases. After radical resection, the 1-, 3-, and 5-year survival rates were 78.6%, 42.9% and 21.4%, respectively. After palliative resection, the 1-, 3-, and 5-year survival rates were 41.7%, 16.7% and 0.0%, respectively. In the conservative treatment (jaundice control) group, the 1-, 3-, and 5-year survival rates were 25.0%, 8.3% and 0.0%, respectively.

CONCLUSION: Radical resection can obviously improve the survival of HC patients.

Advances in the surgical treatment of hilar cholangiocarcinoma

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.

Hilar cholangiocarcinoma: controversies on the extent of surgical resection aiming at cure

BACKGROUND

Hilar cholangiocarcinoma is the most common malignant tumor affecting the extrahepatic bile duct. Surgical treatment offers the only possibility of cure, and it requires removal of all tumoral tissues with adequate resection margins. The aims of this review are to summarize the findings and to discuss the controversies on the extent of surgical resection aiming at cure for hilar cholangiocarcinoma.

METHODS

The English medical literatures on hilar cholangiocarcinoma were studied to review on the relevance of adequate resection margins, routine caudate lobe resection, extent of liver resection, and combined vascular resection on perioperative and long-term survival outcomes of patients with resectable hilar cholangiocarcinoma.

RESULTS

Complete resection of tumor represents the most important prognostic factor of long-term survival for hilar cholangiocarcinoma. The primary aim of surgery is to achieve R0 resection. When R1 resection is shown intraoperatively, further resection is recommended. Combined hepatic resection is now generally accepted as a standard procedure even for Bismuth type I/II tumors. Routine caudate lobe resection is also advocated for cure. The extent of hepatic resection remains controversial. Most surgeons recommend major hepatic resection. However, minor hepatic resection has also been advocated in most patients. The decision to carry out right- or left-sided hepatectomy is made according to the predominant site of the lesion. Portal vein resection should be considered when its involvement by tumor is suspected.

CONCLUSION

The curative treatment of hilar cholangiocarcinoma remains challenging. Advances in hepatobiliary techniques have improved the perioperative and long-term survival outcomes of this tumor.

Combined portal vein resection in the treatment of hilar cholangiocarcinoma: a systematic review and meta-analysis

OBJECTIVE

To analyse the efficacy and safety of portal vein resection for hilar cholangiocarcinoma (HCCA).

METHODS

A thorough search of PubMed, the Cochrane Library, Embase, the Chinese BioMedical Literature (CBM), and the Chinese Medical Current Contents (CMCC) databases was performed to identify comparative studies concerning combined portal vein resection (PVR) versus surgery without portal vein resection (Without PVR) and no surgical tumour resection (NR) in the treatment of HCCA.

RESULTS

Thirteen studies with a total of 1921 HCCA cases were included. The results of the meta-analysis revealed that PVR was associated with a poorer overall survival than Without PVR (HR = 1.90; 95%CI 1.59-2.28; P < 0.00001) but was significantly better than NR (HR = 0.33; 95%CI 0.26-0.41; P < 0.00001). The PVR group exhibited significantly higher rates of advanced disease and a higher proportion of lymph node metastasis (OR = 1.50; 95%CI 1.06-2.13; P = 0.02) and perineural invasion (OR = 2.95; 95%CI 1.80-4.84; P < 0.0001), and the PVR group exhibited a lower curative resection rate (OR = 0.65; 95%CI 0.46-0.91; P = 0.01). No significant differences were found between the two groups with respect to postoperative mortality and morbidity.

CONCLUSIONS

Combined PVR is safe and feasible in the treatment of HCCA when the portal vein is grossly involved. For advanced HCCA when the portal vein is grossly involved, surgical resection including PVR can benefit the overall survival in certain patients. However, further randomised controlled trials are necessary to determine the prognostic effects of the addition of PVR to the surgical procedure.

Liver resection for Bismuth type I and Type II hilar cholangiocarcinoma

BACKGROUND

In patients with Bismuth type I and II hilar cholangiocarcinoma (HCCA), bile duct resection alone has been the conventional approach. However, many authors have reported that concomitant liver resection improved surgical outcomes.

METHODS

Between January 2000 and January 2012, 52 patients underwent surgical resection for a Bismuth type I and II HCCA (type I: n = 22; type II: n = 30). Patients were classified into two groups: concomitant liver resection (n = 26) and bile duct resection alone (n = 26).

RESULTS

Bile duct resection alone was performed in 26 patients. Concomitant liver resection was performed in 26 patients (right side hepatectomy [n = 13]; left-side hepatectomy [n = 6]; volume-preserving liver resection [n = 7]). All liver resections included a caudate lobectomy. Patient and tumor characteristics did not differ between the two groups. Although concomitant liver resection required longer operating time (P < 0.001), it had a similar postoperative complication rate (P = 0.764), high curability (P = 0.010), and low local recurrence rate (P = 0.006). Concomitant liver resection showed better overall survival (P = 0.047).

CONCLUSIONS

Concomitant liver resection should be considered in patients with Bismuth type I and II HCCA.

Cholangiocarcinoma or IgG4-associated cholangitis: how feasible it is to avoid unnecessary surgical interventions?

OBJECTIVE

To evaluate the experience of a tertiary hepatopancreaticobiliary (HPB) center in the diagnostic approach and management of patients with suspicion of cholangiocarcinoma (CCa), focusing on excluding patients with IgG4-associated cholangitis (IAC) from unnecessary major surgical interventions.

METHODS

Between January 2008 and September 2010, a total number of 152 patients with suspicion of CCa underwent evaluation through a HPB multidisciplinary team meeting. Patients without tissue diagnosis were managed surgically or medically on the basis of probable presence of IAC as underlying pathology. Serology, immunostaining, and imaging were reviewed and analyzed according to the HISORt (Histology, Imaging, Serology, Other organ involvement, Response to therapy) criteria for IAC.

RESULTS

Tissue diagnosis during the diagnostic workup was achieved in 104 patients (68%), whereas the remaining 48 were classified as "highly suspicious for CCa" (n = 35) or as "probable IAC" (n = 13). Among 16 "highly suspicious for CCa" patients who underwent surgery, pathology revealed 2 patients harboring IAC (n = 1) and a benign chronic inflammatory biliary stricture (n = 1), respectively. Among the 13 patients with primarily medical management as "probable IAC," final diagnosis was CCa (n = 3) and IAC (n = 9), while 1 patient had no proven diagnosis. The accuracy of serum IgG4 for diagnosis of IAC reached 60%. Sensitivity and specificity of immunostaining for IAC in biopsy specimens were 56% and 89%, respectively. Imaging features suggesting IAC yielded sensitivity, specificity, and accuracy of 75%, 89%, and 83%, respectively. Initial imaging was revised at the referral institute in 75% of IAC patients (P = 0.009), while an isolated stricture (P = 0.038), a biliary mass (P = 0.006), and normal pancreas on computed tomography (P = 0.01) were statistically significant parameters for distinguishing between CCa and IAC. The mean time for establishing a diagnosis of IAC was 12.4 months (range: 2.5-32 months).

CONCLUSIONS

Differential diagnosis between CCa and IAC mandates high index of suspicion and low threshold for referral in high volume institutes. The delayed establishment of diagnosis particularly for CCa needs to be balanced versus avoiding unnecessary surgery for IAC. Imaging features may be most helpful for optimal management.

Surgical outcomes and predicting factors of curative resection in patients with hilar cholangiocarcinoma: 10-year single-institution experience

BACKGROUND

The surgical resection of hilar cholangiocarcinoma is extremely challenging because the tumor is closely related with the complicated hilar structures. We investigated to identify the outcomes for patients who underwent surgical resection and to identify the parameters that influenced radical resection.

METHODS

From January 2000 to December 2009, 105 patients underwent surgical resection for hilar cholangiocarcinoma. The clinicopathological parameters and surgical outcomes were retrospectively analyzed.

RESULTS

There were 15 operative mortalities (14.3%). Seventy-four patients underwent curative resection (70.5%). The median overall survival time for R0, R1, and R2 were 58, 28, and 19 months, respectively. Caudate lobectomy (p = 0.044; odds ratio [OR], 4.386) and perineural invasion (p = 0.01; OR, 0.062) were correlated with curative resection. Total bilirubin levels of more than 3 g/dl just before the operation (p = 0.042; hazard ratio [HR], 2.109) and extent of resection (R1 and 2 vs R0; p = 0.05; HR, 2.309) were selected as significantly negative factors affecting overall survival on the multivariate analysis.

CONCLUSIONS

Caudate lobectomy and neurectomy may be thought of as adjustable territories by the surgeon's efforts to achieve curative resection. R0 resection achieved through those efforts and liver optimization using preoperative biliary drainage may offer the patients a chance of cure.

Preexcisional artery reconstruction: a new strategy in multiple hepatic artery reconstruction for reducing ischemic injury of the liver

Multiple reconstructions of the hepatic arteries (HA) after cancer resection presents a surgical challenge, not only because it is technically demanding, but also because attention must be paid to potential ischemic injury to the liver caused by the prolonged ischemia. We present a novel "preexcisional artery reconstruction" method for minimizing ischemic injury of the liver. A 65-year-old woman presented with cholangiocarcinoma invading the HA. Pancreatoduodenectomy, resection, and multiple reconstruction of the HA were performed. First, the left hepatic artery (LHA) was reconstructed prior to the tumor resection. During this procedure, blood supply was maintained to most of the liver via the right hepatic artery (RHA). Then, resection of the tumor en bloc with the HA was performed, followed by reconstruction of the RHA. During this procedure, blood supply was maintained via the already-reconstructed LHA, thereby limiting the ischemic area. Use of this method allowed the ischemia time and region to be divided and minimized, thereby leading to a reduced risk of ischemia-related complications. We believe that this method may be one of the useful approaches in multiple HA reconstruction.

Hepatocellular Carcinomas and Primary Liver Tumors as Predictive Factors for Postoperative Mortality after Liver Resection: A Meta-Analysis of More than 35,000 Hepatic Resections

Liver resection is considered the therapeutic gold standard for primary and metastatic liver neoplasms. The reduction of postoperative complications and mortality has resulted in a more aggressive approach to hepatic malignancies. For the most part, results of liver surgery have been published by highly experienced institutions, but the observations of highly specialized units results may not reflect the current status of hepatic surgery, underestimating mortality and complications. The objective of this study is to evaluate morbidity and mortality as a result of liver resection for primary and metastatic lesions, analyzing a large number of studies with a meta-analytic process taking into account the overdispersion of data. An extensive literature search has been conducted, and 148 papers published between January 2000 and April 2008, including a total of 36,629 patients from both high-volume and low volume institutions, were included in the meta-analysis. A beta binomial model was used to provide a robust estimate of the summary event rate by pooling overdispersion binomial data from different studies. Overall morbidity and mortality after liver surgery were 29.32 per cent and 3.15 per cent, respectively. Significantly higher postoperative mortality was observed after liver resection for hepatocellular carcinomas and primary hepatic tumors. The application of a beta binomial model to correct for overdispersion of liver surgery data showed significantly higher postoperative mortality rates in patients with hepatocellular carcinomas or primary hepatic tumors after liver resection.

Risk factors for liver failure and mortality after hepatectomy associated with portal vein resection

OBJECTIVE

To report the postoperative outcome of hepatectomy associated with portal vein resection (PVR) and to identify risk factors of clinical value for predicting postoperative liver failure and mortality.

SUMMARY BACKGROUND DATA

Resection of the portal vein during hepatectomy allows an increase in the number of patients who may benefit from a potentially curative operation that is, however, technically difficult and may increase postoperative morbidity and mortality. Few data are available about risk factors for liver failure and mortality after such extensive operations.

METHODS

Between July 1996 and July 2008, a total of 1348 patients were operated on for liver disease in our institution. Among them, 55 patients underwent liver resection associated with PVR. Medical records of these patients were prospectively collected and retrospectively analyzed.

RESULTS

Overall mortality for this selected group of patients was 7.2%. Irreversible liver failure was the main cause of death. Overall morbidity was 58.1%. A total of 94% of the patients (n = 52) underwent a major (≥ 3 segments) or an extended > 4 segments) right or left hepatectomy. Univariate analysis showed that male gender (P = 0.004), extended liver resection (P = 0.028), and, particularly, extended right hepatectomy (P = 0.015) were significantly associated with an increased risk of postoperative liver failure. Male gender was the single independent risk factor for liver failure. Moreover, the presence of liver steatosis (P = 0.014), an extended right hepatectomy procedure (P = 0.047), and postoperative liver failure (P = 0.046) were significantly associated with an increased rate of postoperative mortality.

CONCLUSION

The present study confirmed that major or extended hepatic resection with PVR can be performed with acceptable overall morbidity and mortality rates. Preoperative selection of the patients should take in consideration the gender and the extent of hepatic resection to avoid irreversible postoperative liver failure. Extended right hepatectomy with PVR should be carefully considered in patients with liver steatosis due to the high risk of postoperative mortality.

Aggressive surgical resection for hilar cholangiocarcinoma of the left-side predominance: radicality and safety of left-sided hepatectomy

OBJECTIVES

To evaluate the clinicopathologic outcomes in patients with hilar cholangiocarcinoma (HC) after left-sided hepatectomy (L-H).

SUMMARY BACKGROUND DATA

L-H is indicated as radical surgery for HC, predominantly involving left hepatic duct. However, several reports have demonstrated that L-H often results in tumor-positive margin and unfavorable prognosis compared with right-sided hepatectomy (R-H).

METHODS

A total of 224 patients with HC underwent surgical resection with curative intent at our institution: L-H for Bismuth-Corlette (B-C) type IIIb tumors in 88 patients (39.3%) including 75 left hemihepatectomies and 13 left trisectionectomies, and R-H mainly for B-C type IIIa and IV tumors in 84 patients (37.5%). In this study, clinicopathologic outcomes and perioperative morbidity and mortality rates after L-H were investigated and compared with those after R-H.

RESULTS

Histologically negative margin (R0) resection was achieved in 56 cases (63.6%) with L-H, similar to the results for R-H (58/84, 69.1%). However, the R0 resection rate in L-H cases with portal vein (PV) resection was lower (11/25, 44.0%), and various types of PV reconstruction were required. Proximal ductal stumps and excisional surface at periductal structures were the most common sites of positive margins. However, when curative resection was achieved, 5-year survival was comparable to that in R-H cases. Furthermore, lower mortality was noted in L-H cases, even with left trisectionectomy. Multivariate analysis indicated curability and hepatic artery resection as independent prognostic factors.

CONCLUSIONS

Since L-H is a safe procedure and represents the only curative resectional option for type IIIb tumor, aggressive surgical resection should be performed even in cases with PV involvement, if R0 resection is possible.

Does intrahepatic cholangiocarcinoma have better prognosis compared to perihilar cholangiocarcinoma?

BACKGROUND AND OBJECTIVES

Cholangiocarcinoma can be classified as intrahepatic (ICC) or perihilar (PCC). The objectives of this study is to evaluate the surgical outcomes of patients with PCC and ICC, identify the main prognostic factors related to survival and compare the outcome and the prognostic factors of PCC and ICC.

METHODS

Ninety-five out of 152 patients observed between January 1990 and December 2007 at Surgical Division of University of Verona Medical School underwent the resection of ICC (33 patients) or PCC (62 patients).

RESULTS

Overall median survival was 24 months with a 3- and 5-year survival rate of 45% and 23%, respectively. Prognostic factors for survival were macroscopic types of the tumor, the resection of extrahepatic bile duct, radical resection, lymph node metastases, and macro-vascular invasion. Survival was related with the macroscopic type of the tumors with a 5-year survival rate of 26% and 13% for ICC and PCC, respectively. Univariate analysis identified that negative clinico-pathological factors where significant more frequently found in PCC compared to ICC.

CONCLUSION

We identified that ICC have longer survival rate compared to PCC. PCC showed a higher frequency of negative clinico-pathological factors such as non-radical (R+) resection, perineural infiltration and macro-vascular invasion.

Placement of percutaneous transhepatic biliary stent using a silicone drain with channels

This report describes a method for percutaneous transhepatic biliary stenting with a BLAKE Silicone Drain, and discusses the usefulness of placement of the drain connected to a J-VAC Suction Reservoir for the treatment of stenotic hepaticojejunostomy. Percutaneous transhepatic biliary drainage was performed under ultrasonographic guidance in a patient with stenotic hepaticojejunostomy after hepatectomy for hepatic hilum malignancy. The technique used was as follows. After dilatation of the drainage root, an 11-Fr tube with several side holes was passed through the stenosis of the hepaticojejunostomy. A 10-Fr BLAKE Silicone Drain is flexible, which precludes one-step insertion. One week after insertion of the 11-Fr tube, a 0.035-inch guidewire was inserted into the tube. After removal of the 11-Fr tube, the guidewire was put into the channel of a 10-Fr BLAKE Silicone Drain. The drain was inserted into the jejunal limb through the intrahepatic bile duct and was connected to a J-VAC Suction Reservoir. Low-pressure continued suction was applied. Patients can be discharged after insertion of the 10-Fr BLAKE Silicone Drain connected to the J-VAC Suction Reservoir. Placement of a percutaneous transhepatic biliary stent using a 10-Fr BLAKE Silicone Drain connected to a J-VAC Suction Reservoir is useful for the treatment of stenotic hepaticojejunostomy.