Left Hepatic Trisectionectomy With Caudate Lobectomy: Demanding But Essential Routine Surgical Procedure for Perihilar Cholangiocarcinoma

Improved Outcomes Following Resection of Perihilar Cholangiocarcinoma: A 27-Year Experience

BACKGROUND

Resection of perihilar cholangiocarcinoma (pCCA) is associated with significant perioperative morbidity and mortality. We sought to evaluate surgical outcomes following resection of pCCA over time.

METHODS

Patients who underwent curative-intent resection with hepatectomy for pCCA at a single institution were divided into two cohorts based on date of resection: past cohort (1996-2013), and recent cohort (2014-2023).

RESULTS

The study included 100 patients: 55 (55%) in the past (1996-2013) and 45 (45%) in the recent (2014-2023) cohorts. There were no differences between cohorts in age, sex, or Bismuth-Corlette classification between the two cohorts. Preoperative cholangitis was less common in the recent cohort (31% vs. 53%, p = 0.03). The proportions of right and left hepatectomies were similar in both cohorts. However, for patients with Bismuth-Corlette types I, II, and IV tumors (n = 35), left hepatectomy was more frequently performed in the recent cohort (61% vs. 13%, p = 0.005). There were trends toward lower rates of major complications (38% vs. 55%, p = 0.095) in the recent cohort. There was significantly less perioperative mortality (2% vs. 15%, p = 0.039) and no postoperative hepatic insufficiency in the recent cohort (0% vs. 20%, p = 0.001). Median recurrence-free survival was similar in the past and recent cohorts (29 vs. 37 months, respectively; p = 0.560), but median overall survival was improved in the recent cohort (33 months vs. not reached, p = 0.009).

CONCLUSIONS

Perioperative management to reduce preoperative cholangitis and liver insufficiency, advances in surgical technique, and consideration of left-sided hepatic resection have resulted in significantly improved outcomes in patients undergoing hepatectomy for pCCA.

Central hepatectomy for perihilar cholangiocarcinoma: an alternative technique for parenchymal-sparing hepatectomy to prevent post-hepatectomy liver failure

BACKGROUND

Perihilar cholangiocarcinoma (PHC) often requires major hepatectomy with extrahepatic bile duct resection, carrying the risk of post-hepatectomy liver failure (PHLF). Central hepatectomy (CH), an alternative technique, aims to preserve functional liver reserve. This study evaluated the feasibility of CH and outcomes for patients with PHC within the paradigm of parenchymal-sparing hepatectomy.

METHODS

A retrospective analysis included PHC patients who underwent CH between March 2019 and January 2023. Preoperative evaluations involved multimodality imaging and assessment of future remnant liver volume.

RESULTS

Fourteen patients underwent CH for PHC. Tumor locations were perihilar bile duct (10 patients), and entire extrahepatic bile duct involvement (four patients). Median operative time and intraoperative blood loss were 679.5 min and 450 mL, respectively. Clinically-relevant PHLF occurred in two patients, with one sepsis-related death. Nine patients achieved R0 resection. Functional liver reserve parameters exceeded the standard procedure (p < 0.01).

CONCLUSION

CH for PHC preserves functional liver reserve, potentially reducing PHLF risk. Adequate preoperative evaluation is crucial, and oncological outcomes require further investigation.

Influence of Perineural (Pn), Lymphangio (L) and Vascular (V) Invasion on Survival after Resection of Perihilar Cholangiocarcinoma

INTRODUCTION

Perihilar cholangiocarcinoma is a rare malignancy of the biliary tract, for which surgery remains the treatment of choice. However, even after radical resection, the prognosis is poor. In addition to tumor size, depth of invasion and nodal/metastatic status, the TNM classification includes additional parameters such as perineural (Pn), lymphangio (L) and vascular (V) invasion. The prognostic impact of these factors is not yet fully understood. The aim of this study was to investigate the influence of these parameters on overall survival after resection of perihilar cholangiocarcinoma.

MATERIAL AND METHODS

Data from all patients who underwent surgical exploration for perihilar cholangiocarcinoma between January 2013 and December 2023 were included into an institutional database. The impact of perineural, lymphangio and vascular invasion on overall survival was analyzed.

RESULTS

Over the 11-year period, a total of 214 patients underwent surgical exploration for perihilar cholangiocarcinoma. Curative intended resection was possible in 168 patients (78.5%). Perineural invasion, lymphangio invasion and vascular invasion were present in 79.2%, in 17.3% and in 14.3% of patients, respectively. Cross tabulation revealed a significant association between the presence of L1 and V1 (p = 0.006). There was also a significant association of Pn1, L1, and V1 with R-status (p = 0.010; p = 0.006 and p ≤ 0.001). While V1 was associated with significantly worse overall survival across the entire cohort, Pn1 alone showed only a tendency towards worse overall survival without reaching statistical significance. In Bismuth type IV, both L1 and V1, but not Pn1, were significantly associated with worse overall survival (p = 0.001; p = 0.017 and p = 0.065).

CONCLUSIONS

Perineural invasion is very common in perihilar cholangiocarcinoma. Although Pn1 was associated with a tendency toward worse survival, it did not reach statistical significance. In contrast, vascular invasion significantly worsened overall survival in the entire cohort, and lymphangio invasion was linked to worse overall survival in Bismuth type IV tumors. The combination of perineural invasion with positivity of more than one additional factor (either L or V) was also associated with worse overall survival. In patients with Bismuth type IV, these pathological markers appeared to have even greater prognostic relevance.

Comparative study of short-and long-term results in patients with perihilar cholangiocarcinoma undergoing surgical resection: does the extent and side of resection really affect outcome?

BACKGROUND

The surgical management of perihilar carcinoma (pCCA) is still subject of ongoing debate. To provide more clarity, this study was conducted to evaluate outcomes related to the side and extent of heatectomy in patients with pCAA.

METHODS

A total of 32 patients with curative resection for pCCA were identified from our prospective database. Short-and long-term clinical outcome data and histopathological results were compared between right-sided (R-H) and left-sided (L-H) hepatectomy.

RESULTS

Nine patients (28.13%) underwent left-sided hepatectomy while a right-sided hepatectomy was accomplished in 23 patients (71.87%). In the R-H group hepatic conditioning of the future liver remnant (FLR) prior to extended resection was necessary in 13 cases (56.52%), and simultaneous pancreaticoduodenectomy was performed in 5 patients (21.74%). The arterial and portal venous reconstruction rates were 17.39% and 11.11% (P=1.00), and 60.87% and 33.33% (P=0.243) in the R-H and L-H groups, respectively. No statistically significant differences in short-term morbidity and mortality between both groups were observed. The rate of R0 resections was comparable (R-H: 78.26% versus L-H: 66.67%; P=0.654) resulting in similar long-term overall and disease-free survival rates after right-and left hepatectomy.

CONCLUSIONS

In patients with pCCA, both right- and left-sided resections appear to be safe and feasible options with similar postoperative morbidity and oncologic outcomes. Consecutively, the ideal surgical approach should be patient-tailored based on anatomical considerations and the functional future liver capacity.

Morbidity after left trisectionectomy for hepato-biliary malignancies: An analysis of the National Clinical Database of Japan

BACKGROUND

The aim of this study was to analyze the nationwide surgical outcome of a left trisectionectomy (LT) and to identify the perioperative risk factors associated with its morbidity.

METHODS

Cases of LT for hepato-biliary malignancies registered at the Japanese National Clinical Database between 2013 and 2019 were retrospectively reviewed. Statistical analyses were performed to identify the perioperative risk factors associated with a morbidity of Clavien-Dindo classification (CD) ≥III.

RESULTS

Left trisectionectomy was performed on 473 and 238 cases of biliary and nonbiliary cancers, respectively. Morbidity of CD ≥III and V occurred in 45% and 5% of cases with biliary cancer, respectively, compared with 26% and 2% of cases with nonbiliary cancer, respectively. In multivariable analyses, biliary cancer was significantly associated with a morbidity of CD ≥III (odds ratio, 1.87; p = .018). In subgroup analyses for biliary cancer, classification of American Society of Anesthesiologists physical status (ASA-PS) 2, portal vein resection (PVR), and intraoperative blood loss ≥30 mL/kg were significantly associated with a morbidity of CD ≥III.

CONCLUSIONS

Biliary cancer induces severe morbidity after LT. The ASA-PS classification, PVR, and intraoperative blood loss indicate severe morbidity after LT for biliary cancer.

Robotic approach for perihilar cholangiocarcinoma: from Bismuth 1 to vascular resection

BACKGROUND

Implementation of minimally invasive surgical approaches for perihilar cholangiocarcinoma (pCCA) has been relatively slow compared to other indications. This is due to the complexity of the disease and the need of advanced skills for the reconstructive phase. The robot may contribute to close the gap between open and minimally invasive surgery in patients with Klastkin tumors.

STUDY DESIGN

We report details of our experience with robotic approach in patients affected by pCCA. In particular selection criteria, ERAS management, technical tips and robotic setup are discussed. Finally, results from our cohort are reported. A video clip of a patient that underwent left hepatectomy with en-bloc caudatectomy and portal vein resection at the confluence with end-to-end reconstruction for a pCCA 3-b according to Bismuth-Corlette classification with full robotic approach is enclosed.

RESULTS

Fourteen patients underwent robotic resection of pCCA over the three-year interval with a median follow-up interval of 18.7 months. The pre-operative Bismuth-Corlette classification was 1 for two patients (14.2%) and 2 for one patient (7.1%), 3-a for three (21.4%) patients, 3-b for four (28.6%) patients and 4 for four (28.6%) patients. Median estimated blood loss was 150 ml (range 50-800 ml) and median operative time was 490 min (range 390-750 min). The median length of hospital stay after the index operation was 6 days (range 3-91). Final histology revealed a median of 19 (range 11-40) lymph nodes retrieved, with 92.9% R0 resections. 90-days mortality was nihil and 3-year survival exceeds 50%.

CONCLUSION

With adequate preparation, outcomes of robotic approach to pCCA can be safe and in line with the current international benchmark outcomes, as showed in this study, when performed in expert high volume centers for complex major hepatectomy and robotic HPB.

From liver surgery to liver transplant surgery: new developments in autotransplantation

PURPOSE OF REVIEW

In spite of substantial technical improvements and conceptual revolutions in advanced liver surgery, there are still straitened circumstances that pose difficulties for in-situ liver resections. Ex-vivo liver resection and autotransplantation (ELRA) is a hybrid technique combining experiences from conventional liver surgery and liver transplantation. This technique is becoming more comprehensive and popular among leading centers recently.

RECENT FINDINGS

Short-term and long-term outcomes are now the focus of the technique after more than a decade of cumulative progress and technical evolution. As the 5-year survival nowadays reaches over 80%, this technique is believed to be beneficial for advanced tumors. In recent years, ELRA has been applied by more centers on larger scales, and the learning curve was set at 53 cases. Progresses in disease selection, surgical indications, individualized outflow reconstruction, or autograft implantation, management of co-morbidities (e.g., Budd-Chiari syndrome, caval and/or neighboring organ involvements, obstructive jaundice) propelled the development of the technique.

SUMMARY

This hybrid liver surgery will benefit for carefully selected patients presented with advanced benign diseases and well-differentiated malignancies.