|
1
|
Sugiura T, Uesaka K, Okamura Y, Ito T, Yamamoto Y, Ashida R, Ohgi K, Otsuka S, Nakagawa M, Aramaki T, Asakura K. Major hepatectomy with combined vascular resection for perihilar cholangiocarcinoma. BJS Open 2021; 5:6342603. [PMID: 34355240 PMCID: PMC8342931 DOI: 10.1093/bjsopen/zrab064] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Accepted: 05/31/2021] [Indexed: 12/14/2022] Open
Abstract
Background Hepatectomy with vascular resection (VR) for perihilar cholangiocarcinoma (PHCC) is a challenging procedure. However, only a few reports on this procedure have been published and its clinical significance has not been fully evaluated. Methods Patients undergoing surgical resection for PHCC from 2002–2017 were studied. The surgical outcomes of VR and non-VR groups were compared. Results Some 238 patients were included. VR was performed in 85 patients. The resected vessels were hepatic artery alone (31 patients), portal vein alone (37 patients) or both (17 patients). The morbidity rates were almost the same in the VR (49.4 per cent) and non-VR (43.8 per cent) groups (P = 0.404). The mortality rates of VR (3.5 per cent) and non-VR (3.3 per cent) were also comparable (P > 0.999). The median survival time (MST) was 45 months in the non-VR group and 36 months in VR group (P = 0.124). Among patients in whom tumour involvement was suspected on preoperative imaging and whose carbohydrate antigen 19-9 (CA19-9) value was 37 U/ml or less, MST in the VR group was significantly longer than that in the non-VR group (50 versus 34 months, P = 0.017). In contrast, when the CA19-9 value was greater than 37 U/ml, MST of the VR and non-VR groups was comparable (28 versus 29 months, P = 0.520). Conclusion Hepatectomy with VR for PHCC can be performed in a highly specialized hepatobiliary centre with equivalent short- and long-term outcomes to hepatectomy without VR.
Collapse
Affiliation(s)
- T Sugiura
- Division of Hepato-Biliary-Pancreatic Surgery
| | - K Uesaka
- Division of Hepato-Biliary-Pancreatic Surgery
| | - Y Okamura
- Division of Hepato-Biliary-Pancreatic Surgery
| | - T Ito
- Division of Hepato-Biliary-Pancreatic Surgery
| | - Y Yamamoto
- Division of Hepato-Biliary-Pancreatic Surgery
| | - R Ashida
- Division of Hepato-Biliary-Pancreatic Surgery
| | - K Ohgi
- Division of Hepato-Biliary-Pancreatic Surgery
| | - S Otsuka
- Division of Hepato-Biliary-Pancreatic Surgery
| | - M Nakagawa
- Division of Plastic and Reconstructive Surgery
| | - T Aramaki
- Division of Diagnostic Radiology, Shizuoka Cancer Centre, Shizuoka, Japan
| | - K Asakura
- Division of Diagnostic Radiology, Shizuoka Cancer Centre, Shizuoka, Japan
| |
Collapse
|
|
2
|
Xu X, Yang L, Chen W, He M. Transhepatic hilar approach for Bismuth types III and IV perihilar cholangiocarcinoma with long-term outcomes. J Int Med Res 2021; 49:3000605211008336. [PMID: 33983055 PMCID: PMC8127775 DOI: 10.1177/03000605211008336] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Objective To compare the outcomes of the transhepatic hilar approach and conventional approach for surgical treatment of Bismuth types III and IV perihilar cholangiocarcinoma. Methods We retrospectively reviewed the medical records of 82 patients who underwent surgical resection of Bismuth types III and IV perihilar cholangiocarcinoma from 2008 to 2016. The transhepatic hilar approach and conventional approach was used in 36 (43.9%) and 46 (56.1%) patients, respectively. Postoperative complications and overall survival were compared between the two approaches. Results Similar clinical features were observed between the patients treated by the conventional approach and those treated by the transhepatic hilar approach. The transhepatic hilar approach was associated with less intraoperative bleeding and a lower percentage of Clavien grade 0 to II complications than the conventional approach. However, the transhepatic hilar approach was associated with a higher R0 resection rate and better overall survival. Multivariate analysis showed that using the transhepatic hilar approach, the Memorial Sloan-Kettering Cancer Center classification, and R0 resection were independent risk factors for patient survival. Conclusion The transhepatic hilar approach might be the better choice for surgical resection of Bismuth types III and IV perihilar cholangiocarcinoma because it is associated with lower mortality and improved survival.
Collapse
Affiliation(s)
- Xinsen Xu
- Department of Biliary-Pancreatic Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, P.R. China
| | - Linhua Yang
- Department of Biliary-Pancreatic Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, P.R. China
| | - Wei Chen
- Department of Biliary-Pancreatic Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, P.R. China
| | - Min He
- Department of Biliary-Pancreatic Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, P.R. China
| |
Collapse
|
|
3
|
She WH, Cheung TT, Ma KW, Tsang SHY, Dai WC, Chan ACY, Lo CM. Vascular resection and reconstruction in hilar cholangiocarcinoma. ANZ J Surg 2020; 90:1653-1659. [PMID: 32458528 DOI: 10.1111/ans.15969] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Revised: 04/19/2020] [Accepted: 04/20/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND The aggressive approach of vascular resection plus reconstruction in curative resection of hilar cholangiocarcinoma (HC) remains controversial. This retrospective study investigated its short- and long-term outcomes. METHODS Data of HC patients from 1989 to 2016 were reviewed. Operated patients were divided into two groups (with and without vascular resection) and compared in terms of perioperative results. Patients who had unresectable HC were also compared with patients who had been operated. RESULTS Ninety patients underwent curative HC resection. They were divided into group A (without aggressive approach, n = 68) and group B (with aggressive approach, n = 22). The groups were comparable in all parameters including rates of overall and major complication and in-hospital, 30-day and 90-day mortality except that group B had more patients with more advanced disease (P = 0.008), more patients with tumour invasion of the vasculature (40.9% versus 7.4%, P = 0.001), and fewer patients with blood transfusion (27.3% versus 52.9%, P = 0.036). The groups had similar disease-free survival (group A: median, 17.9 months, 5 years, 27.4%; group B: median, 11.7 months, 5 years, 14.3%; P = 0.427) and overall survival (group A: median, 22.0 months, 5 years, 26.5%; group B: median, 26.5 months, 5 years, 14.7%; P = 0.90). Two hundred patients with unresectable HC were compared with patients who had received operation and found to have worse survival outcomes (P < 0.001). CONCLUSIONS Vascular resection plus reconstruction in HC resection was feasible and safe and might improve the long-term survival of patients with advanced HC. This aggressive approach should be adopted if the expertise is available and the patient's condition allows.
Collapse
Affiliation(s)
- Wong Hoi She
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The University of Hong Kong, Hong Kong, China
| | - Tan To Cheung
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The University of Hong Kong, Hong Kong, China
| | - Ka Wing Ma
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The University of Hong Kong, Hong Kong, China
| | - Simon H Y Tsang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The University of Hong Kong, Hong Kong, China
| | - Wing Chiu Dai
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The University of Hong Kong, Hong Kong, China
| | - Albert C Y Chan
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The University of Hong Kong, Hong Kong, China
| | - Chung Mau Lo
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The University of Hong Kong, Hong Kong, China
| |
Collapse
|
|
4
|
Akhaladze DG, Alikhanov RB, Efanov MG, Kim PP, Kazakov IV, Vankovich AN, Melekhina OV, Kulezneva YV, Tsvirkun VV. [Intrahepatic cholangiocarcinoma followed by vascular invasion: is surgical treatment justified?]. Khirurgiia (Mosk) 2018:49-57. [PMID: 29953100 DOI: 10.17116/hirurgia2018649-57] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Intrahepatic cholangiocarcinoma (ICC) is one of the most aggressive tumors associated with poor prognosis. Radical surgery is still the main method of treatment in resectable cases. Certain difficulties are observed in case of locally advanced tumors followed by inferior vena cava (IVC) and portal vein (PV) invasion. AIM To analyze safety of advanced liver resections combined with great vessels repair for locally advanced large and multiple cholangiocellular carcinoma. MATERIAL AND METHODS Since January 2014 till April 2017 eighty ICC patients have undergone advanced liver resection. There were 62 patients with portal cholangiocarcinoma and 18 with ICC. 4 ICC patients required vascular repair: IVC replacement in 2 cases (i.e. under venous bypass in 1 of them), tangential and circular resection of portal vein bifurcation - in 2 cases. RESULTS Postoperative complications Clavien-Dindo IIIa developed in all cases. There were no vascular complications. The length of hospital-stay was 14 - 35 days. There were no lethal outcomes. Annual survival was 50%, 2-year - 25%. Adjuvant chemotherapy was used in all patients. CONCLUSION Advanced liver resection followed by IVC and PV repair for locally advanced ICC may be safely performed and subsequently allows chemotherapeutic treatment.
Collapse
Affiliation(s)
- D G Akhaladze
- Hepatopancreatobiliary Surgery Department of the Loginov Moscow Clinical Scientific and Practical Center of Moscow Healthcare Department, Moscow, Russia
| | - R B Alikhanov
- Hepatopancreatobiliary Surgery Department of the Loginov Moscow Clinical Scientific and Practical Center of Moscow Healthcare Department, Moscow, Russia
| | - M G Efanov
- Hepatopancreatobiliary Surgery Department of the Loginov Moscow Clinical Scientific and Practical Center of Moscow Healthcare Department, Moscow, Russia
| | - P P Kim
- Hepatopancreatobiliary Surgery Department of the Loginov Moscow Clinical Scientific and Practical Center of Moscow Healthcare Department, Moscow, Russia
| | - I V Kazakov
- Hepatopancreatobiliary Surgery Department of the Loginov Moscow Clinical Scientific and Practical Center of Moscow Healthcare Department, Moscow, Russia
| | - A N Vankovich
- Hepatopancreatobiliary Surgery Department of the Loginov Moscow Clinical Scientific and Practical Center of Moscow Healthcare Department, Moscow, Russia
| | - O V Melekhina
- Hepatopancreatobiliary Surgery Department of the Loginov Moscow Clinical Scientific and Practical Center of Moscow Healthcare Department, Moscow, Russia
| | - Yu V Kulezneva
- Hepatopancreatobiliary Surgery Department of the Loginov Moscow Clinical Scientific and Practical Center of Moscow Healthcare Department, Moscow, Russia
| | - V V Tsvirkun
- Hepatopancreatobiliary Surgery Department of the Loginov Moscow Clinical Scientific and Practical Center of Moscow Healthcare Department, Moscow, Russia
| |
Collapse
|
|
5
|
A Left-Sided Approach for Resection of Hepatic Caudate Lobe Hemangioma: Two Case Reports and a Literature Review. Int Surg 2016; 100:1054-9. [PMID: 26414827 PMCID: PMC4587506 DOI: 10.9738/intsurg-d-14-00317.1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Resection of the hemangioma located in the caudate lobe is a major challenge in current liver surgery. This study aimed to present our surgical technique for this condition. Two consecutive patients with symptomatic hepatic hemangioma undergoing caudate lobectomy were investigated retrospectively. First, all the blood inflow of hemangioma from the portal vein and the hepatic artery at the base of the umbilical fissure was dissected. After the tumors became soft and tender, the short hepatic veins and the ligaments between the secondary porta hepatis were severed. At last the tumors were resected from the right lobe of the liver. The whole process was finished by a left-sided approach. Blood lost in Case 1 was 1650 mL because of ligature failing in one short hepatic vein, and in the other case, 210 mL. Operation time was 236 minutes and 130 minutes, respectively. Postoperative hospital stays were 11 and 5 days, respectively. The diameter of tumors was 9.0 cm and 6.5 cm. Case 1 required blood transfusion during surgery. No complications such as biliary fistula, postoperative bleeding, and liver failure occurred. The left-sided approach produced the best results for caudate lobe resection in our cases. The patients who recovered are living well and asymptomatic. Caudate lobectomy can be performed safely and quickly by a left-sided approach, which is carried out with optimized perioperative management and innovative surgical technique.
Collapse
|
|
6
|
Risk factors for a high Comprehensive Complication Index score after major hepatectomy for biliary cancer: a study of 229 patients at a single institution. HPB (Oxford) 2016; 18:735-41. [PMID: 27593590 PMCID: PMC5011079 DOI: 10.1016/j.hpb.2016.06.013] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Revised: 06/15/2016] [Accepted: 06/20/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND The Comprehensive Complication Index (CCI) is a new tool to evaluate the postoperative condition by calculating the sum of all complications weighted by their severity. The aim of this study was to identify independent risk factors for a high CCI score (≥40) in 229 patients after major hepatectomies with biliary reconstruction for biliary cancers. METHODS The CCI was calculated online via www.assessurgery.com. Independent risk factors were identified by multivariable analysis. RESULTS 57 (25%) patients were classified as having CCI ≥ 40. On multivariable analysis, volume of intraoperative blood loss (≥2.5 L) (p = 0.004) and combined pancreatoduodenectomy (PD) (p = 0.006) were independent risk factors for CCI ≥ 40. A high level of maximum serum total bilirubin was identified as independent risk factors for a high volume of intraoperative blood loss. Liver failure (p = 0.046) was more frequent in patients with combined PD than in those without. DISCUSSION Patients who undergo preoperative external biliary drainage for severe jaundice might have impaired production of coagulation factors. When blood loss during liver transection becomes difficult to control, surgeons should consider various strategies, such as second-stage biliary or pancreatic reconstruction. In patients planned to undergo major hepatectomy with combined PD, preoperative portal vein embolization is mandatory to prevent postoperative liver failure.
Collapse
|
|
7
|
Nakanishi Y, Tsuchikawa T, Okamura K, Nakamura T, Tamoto E, Murakami S, Ebihara Y, Kurashima Y, Noji T, Asano T, Shichinohe T, Hirano S. Prognostic impact of the site of portal vein invasion in patients with surgically resected perihilar cholangiocarcinoma. Surgery 2016; 159:1511-1519. [PMID: 26948498 DOI: 10.1016/j.surg.2016.01.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Revised: 12/22/2015] [Accepted: 01/21/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND The aim of this study was to determine the impact of the site of portal vein invasion on survival after hepatectomy for perihilar cholangiocarcinoma. METHODS This study classified 168 patients undergoing resection for perihilar cholangiocarcinoma histologically as without portal vein resection or tumor invasion to the portal vein (PV0), with tumor invasion to unilateral branches of the portal vein (PVt3), or with tumor invasion to the main portal vein or its bilateral branches, or to unilateral second-order biliary radicals with contralateral portal vein involvement (PVt4). Patients in PVt4 were subclassified into the A-M group (cancer invasion limited to the tunica adventitia or media) or the I group (cancer invasion reaching the tunica intima). RESULTS Of the patients, 121 were in PV0, 21 were in PVt3, and 26 were in PVt4. There was no difference in survival between the PV0 and PVt3 groups (P = .267). The PVt4 group had a worse prognosis than the PVt3 group (P = .046). In addition, the A-M (n = 19) and I subgroups (n = 7) of PVt4 had worse prognoses than the PV0 or PVt3 groups (P = .005 and < .001, respectively). All patients in the I subgroup of PVt4 died within 9 months after resection. On multivariate analysis, PVt4 (P = .029) was identified as an independent prognostic factor. CONCLUSIONS In perihilar cholangiocarcinoma, postoperative survival was no different between patients with and without ipsilateral portal vein invasion, although patients with tumor invasion to the main or contralateral branches of the portal vein, especially with tunica intima invasion, had extremely poor prognoses.
Collapse
Affiliation(s)
- Yoshitsugu Nakanishi
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, Sapporo, Japan.
| | - Takahiro Tsuchikawa
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Keisuke Okamura
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Toru Nakamura
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Eiji Tamoto
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Soichi Murakami
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Yuma Ebihara
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Yo Kurashima
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Takehiro Noji
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Toshimichi Asano
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Toshiaki Shichinohe
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Satoshi Hirano
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| |
Collapse
|
|
8
|
Abstract
Optimal treatment of hilar cholangiocarcinoma depends on location of the cancer and extent of biliary and vascular involvement. Candidates for resection or transplantation must be evaluated and managed by a multidisciplinary team at a high-volume hepatobiliary center. Success requires absence of distant nodal or extrahepatic metastases and an adequate functional liver remnant with a negative ductal margin. Ipsilateral portal vein resection and reconstruction should be performed in patients with venous involvement. Neoadjuvant chemoradiation and liver transplantation is the best treatment option for patients with unresectable hilar cholangiocarcinoma without nodal or distant metastases and for patients with underlying chronic liver disease.
Collapse
Affiliation(s)
- Victor M Zaydfudim
- Department of Surgery, University of Virginia, 1300 Jefferson Park Avenue, Charlottesville, VA 22908, USA
| | - Charles B Rosen
- Division of Transplantation Surgery, Mayo Clinic, 200 1st Street Southwest, Rochester, MN 55905, USA
| | - David M Nagorney
- Department of Surgery, Mayo Clinic, 200 1st Street Southwest, Rochester, MN 55905, USA.
| |
Collapse
|
|
9
|
Ebata T, Ito T, Yokoyama Y, Igami T, Sugawara G, Mizuno T, Nagino M. Surgical technique of hepatectomy combined with simultaneous resection of hepatic artery and portal vein for perihilar cholangiocarcinoma (with video). JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2014; 21:E57-61. [PMID: 24912472 DOI: 10.1002/jhbp.121] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Perihilar cholangiocarcinomas often involve the bifurcation of the portal vein and the hepatic artery at initial presentation. Previously, vascular invasion was a major obstacle for R0 resection; therefore, such tumors were regarded as locally advanced, unresectable disease. Recently, in leading centers, these tumors have been resected using a specific technique, vascular resection and reconstruction. Vascular resection is classified into three types: portal vein resection alone, hepatic artery resection alone, and simultaneous resection of both the portal vein and hepatic artery. Of these, portal vein resection is widely performed, whereas hepatic artery resection remains controversial. Therefore, hepatectomy combined with simultaneous resection of the portal vein and hepatic artery represents one of the most complicated and challenging procedures in hepatobiliary surgery. The survival benefit of this extended procedure remains unproven, and there is only a single study reporting an unexpectedly favorable outcome in 50 patients. Considering the dismal survival in patients with unresectable disease, hepatic artery resection and/or portal vein resection may be a promising option of choice. However, the technique is highly demanding and has not been standardized. Therefore, this extended surgery may be allowed only in selected hepatobiliary centers.
Collapse
Affiliation(s)
- Tomoki Ebata
- Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | | | | | | | | | | | | |
Collapse
|
|
10
|
Colangiocarcinoma hiliar: el número de ganglios positivos y la relación ganglios positivos/ganglios totales son un factor pronóstico importante de supervivencia. Cir Esp 2014; 92:247-53. [DOI: 10.1016/j.ciresp.2013.07.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2013] [Revised: 07/11/2013] [Accepted: 07/12/2013] [Indexed: 12/12/2022]
|
|
11
|
Hirano S, Tanaka E, Tsuchikawa T, Matsumoto J, Kawakami H, Nakamura T, Kurashima Y, Ebihara Y, Shichinohe T. Oncological benefit of preoperative endoscopic biliary drainage in patients with hilar cholangiocarcinoma. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2014; 21:533-40. [PMID: 24464984 DOI: 10.1002/jhbp.76] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Due to advances in endoscopic equipment and techniques, preoperative endoscopic biliary drainage (EBD) has been developed to serve as an alternative to percutaneous transhepatic biliary drainage (PTBD). This study sought to clarify the benefit of EBD in comparison to PTBD in patients who underwent radical resections of hilar cholangiocarcinoma. One hundred and forty-one patients underwent radical surgery for hilar cholangiocarcinoma between 2000 and 2008 were retrospectively divided into two groups based on the type of preoperative biliary drainage, PTBD (n = 67) or EBD (n = 74). We investigated if the different biliary drainage methods affected postoperative survival and mode of recurrence after median observation period of 82 months. The survival rate for patients who underwent EBD was significantly higher than those who had PTBD (P = 0.004). Multivariate analysis revealed that PTBD was one of the independent factors predictive of poor survival (hazard ratio: 2.075, P = 0.003). Patients with PTBD more frequently developed peritoneal seeding in comparison to those who underwent EBD (P = 0.0003). PTBD was the only independent factor predictive of peritoneal seeding. In conclusion, EBD might confer an improved prognosis over PTBD due to prevention of peritoneal seeding, and is recommended as the initial procedure for preoperative biliary drainage in patients with hilar cholangiocarcinoma.
Collapse
Affiliation(s)
- Satoshi Hirano
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, Kita-15, Nishi-7, Kita-ku, Sapporo, 060-8638, Japan.
| | | | | | | | | | | | | | | | | |
Collapse
|
|
12
|
Azoulay D, Pascal G, Salloum C, Adam R, Castaing D, Tranecol N. Vascular reconstruction combined with liver resection for malignant tumours. Br J Surg 2014; 100:1764-75. [PMID: 24227362 DOI: 10.1002/bjs.9295] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/07/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND The resectability criteria for malignant liver tumours have expanded during the past two decades. The use of vascular reconstruction after hepatectomy has been integral in this process. However, the majority of reports are anecdotal. This is a retrospective analysis of the techniques, morbidity, mortality and risk factors of liver resections with vascular reconstruction based on a large series from a single centre. METHODS Patients who underwent hepatic resection combined with vascular resection and reconstruction between 1997 and 2009 were included in this study. Indications for surgery, morbidity and 90-day mortality are reported along with factors predictive of operative mortality. RESULTS Eighty-four patients had liver resection with 97 vascular resections and reconstruction. There were 44 men and 40 women with a mean(s.d.) age of 56·9(12·1) years. Mean(s.d.) follow-up was 37·3(34·1) months. All patients had primary or metastatic liver tumours. The perioperative morbidity rate was 62 per cent (52 patients) and the operative mortality rate 14 per cent (12). Predictors of operative mortality were: bilirubin level exceeding 34 µmol/ml (P = 0·023), indocyanine green retention rate at 15 min over 10 per cent (P = 0·031), duration of ischaemia (P = 0·011), amount of blood transfused (P = 0·025) and combined major extrahepatic procedure (P = 0·042). Actuarial 3- and 5-year survival rates were 44 and 26 per cent respectively. CONCLUSION Liver resection with combined vascular resection and reconstruction can be performed in selected patients with acceptable morbidity and mortality. The lack of therapeutic alternatives and the poor outcome of non-operative management seem to justify this approach. The identification of risk factors should help improve patient selection and postoperative outcome as well as facilitate objective risk communication with surgical candidates.
Collapse
Affiliation(s)
- D Azoulay
- Centre Hépato-Biliaire, Département de Chirurgie Hépato-Biliaire, Assistance Publique-Hôpitaux de Paris (AP-HP) Hôpital Paul Brousse, Villejuif; Service de Chirurgie Hépato-Bilio-Pancreatique, AP-HP Hôpital Henri Mondor, Créteil, France
| | | | | | | | | | | |
Collapse
|
|
13
|
Sano T, Shimizu Y, Senda Y, Kinoshita T, Nimura Y. Assessing resectability in cholangiocarcinoma. Hepat Oncol 2013; 1:39-51. [PMID: 30190940 DOI: 10.2217/hep.13.6] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Assessment of surgical resectability in cholangiocarcinoma is more complicated than other gastrointestinal malignancies and remains unestablished. According to the primary origin and tumor extent, the applied surgical procedure varies from extrahepatic bile duct resection to right or left trisectionectomy concomitant with pancreatoduodenectomy. Portal vein resection and reconstruction during hepatectomy has been feasible. Thanks to the availability of new microscopic surgical techniques, hepatic arterial resection and reconstruction have also come to be applied for locally advanced cholangiocarcinoma cases. These vascular surgical techniques can expand surgical indications for advanced cholangiocarcinoma. On the other hand, determination of the tumor extent or staging still remains difficult and imprecise. The endoscopic approach has come to play significant roles both for preoperative biliary drainage and tumor staging. Estimation of the functional reserve of future remnant liver in cholestatic patients still remains unresolved. Hepatobiliary surgeons should carefully estimate the safety of the surgical procedure in each individual patient requiring extensive hepatobiliary resection. Early establishment of the measurement methods of the functional capacity of future remnant liver is an important and urgent issue for assessing safer surgical resectablity of cholangiocarcinoma.
Collapse
Affiliation(s)
- Tsuyoshi Sano
- Hepato-Biliary & Pancreatic Surgery Division, Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya, 464-8681, Japan
| | - Yasuhiro Shimizu
- Hepato-Biliary & Pancreatic Surgery Division, Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya, 464-8681, Japan
| | - Yoshiki Senda
- Hepato-Biliary & Pancreatic Surgery Division, Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya, 464-8681, Japan
| | - Taira Kinoshita
- Hepato-Biliary & Pancreatic Surgery Division, Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya, 464-8681, Japan
| | - Yuji Nimura
- Hepato-Biliary & Pancreatic Surgery Division, Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya, 464-8681, Japan
| |
Collapse
|
|
14
|
Combined portal vein resection for hilar cholangiocarcinoma: a meta-analysis of comparative studies. J Gastrointest Surg 2013; 17:1107-15. [PMID: 23592188 DOI: 10.1007/s11605-013-2202-9] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2012] [Accepted: 04/01/2013] [Indexed: 01/31/2023]
Abstract
Hilar cholangiocarcinoma (HCCA) frequently invades into the adjacent portal vein, and portal vein resection (PVR) is the only way to manage this condition and achieve negative resection margins. However, the safety and effectiveness of PVR is controversial. Studies analyzing the effect of PVR on the surgical and pathological outcomes in the management of HCCA with gross portal vein involvement were considered eligible for this meta-analysis. The outcome variables analyzed included postoperative morbidity, mortality, survival rate, proportion of R0 resection, lymph node metastasis, microscopic vascular invasion, and perineural invasion. From 11 studies, 371 patients who received PVR and 1,029 who did not were identified and analyzed. Data from patients who received combined PVR correlated with higher postoperative death rates (OR = 2.31; 95 % CI, 1.21-4.43; P = 0.01) and more advanced tumor stage. No significant difference was detected in terms of morbidity, proportion of R0 resection, or 5-year survival rate. Subgroup analysis demonstrated that in centers with more experience or studies published after 2007, combined PVR did not cause significantly higher postoperative death. No strong evidence could suggest that combined PVR leads to more morbidity or mortality for patients with HCCA when the portal vein is grossly involved. In addition, combined PVR is oncologically valuable because R0 resection and 5-year survival did not differ significantly between two cohorts, despite the fact that the PVR cohort consisted of patients with more advanced HCCA.
Collapse
|
|
15
|
The prognosis after curative resection of gallbladder cancer with hilar invasion is similar to that of hilar cholangiocarcinoma. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2012; 19:274-80. [PMID: 21879321 DOI: 10.1007/s00534-011-0439-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND/PURPOSE Gallbladder cancer (GBC) often invades the hepatic hilum and even small tumors can cause obstructive jaundice. Operative intervention for GBC with obstructive jaundice is sometimes not recommended because it is associated with a poor prognosis. However, the extended procedure is recommended for patients with hilar cholangiocarcinoma (HC). We therefore compared the postoperative survival of patients with GBC invading the hepatic hilum with that with HC. METHODS Between 1998 and 2008, 27 patients with GBC invasion of the hepatic hilum (hGBC) and 124 with HC underwent surgical resection with curative intent in the Department of Surgical Oncology, Hokkaido University Graduate School of Medicine. This study included patients with GBC without peritoneal dissemination and liver or para-aortic lymph node metastasis. Extended right hemihepatectomy and extrahepatic bile duct resection comprise the treatment of choice for GBC with hilar invasion (hGBC). We aimed to achieve R0 outcomes by aggressive vascular resection and/or concomitant resection of directly invaded organs around the GBC along with extended right hemihepatectomy. RESULTS We analyzed 27 patients with hGBC (age 58-83 years; median 71 years; male:female 13:14) and 124 with HC (age 45-80 years; median 69 years; male:female 94:30). The 3- and 5-year survival rates of 43 and 24% for hGBC and 58 and 38% for HC, respectively, did not differ significantly (p = 0.14). Preoperative obstructive jaundice was a complication in 22 (81%) and 95 (77%) patients with hGBC and HC, respectively. The 5-year survival rates were 40 and 36%, respectively, which did not differ significantly (p = 0.61). The 5-year survival rates after extended right hemihepatectomy to resect the tumor with curative intent were 34 and 34% for hGBC and HC, which did not differ significantly (p = 0.14). CONCLUSIONS The prognosis after curative resection of GBC with hilar invasion is similar to that of HC in selected patients. Aggressive surgery for advanced GBC with hilar invasion might increase survival rates.
Collapse
|
|
16
|
Endo I, Matsuyama R, Taniguchi K, Sugita M, Takeda K, Tanaka K, Shimada H. Right hepatectomy with resection of caudate lobe and extrahepatic bile duct for hilar cholangiocarcinoma. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2011; 19:216-24. [DOI: 10.1007/s00534-011-0481-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
- Itaru Endo
- Department of Gastroenterological Surgery, Graduate School of Medicine; Yokohama City University; 3-9 Fukuura, Kanazawa-ku Yokohama 2360004 Japan
| | - Ryusei Matsuyama
- Department of Gastroenterological Surgery, Graduate School of Medicine; Yokohama City University; 3-9 Fukuura, Kanazawa-ku Yokohama 2360004 Japan
| | - Koichi Taniguchi
- Department of Gastroenterological Surgery, Graduate School of Medicine; Yokohama City University; 3-9 Fukuura, Kanazawa-ku Yokohama 2360004 Japan
| | - Mitsutaka Sugita
- Department of Gastroenterological Surgery, Graduate School of Medicine; Yokohama City University; 3-9 Fukuura, Kanazawa-ku Yokohama 2360004 Japan
| | - Kazuhisa Takeda
- Department of Gastroenterological Surgery, Graduate School of Medicine; Yokohama City University; 3-9 Fukuura, Kanazawa-ku Yokohama 2360004 Japan
| | - Kuniya Tanaka
- Department of Gastroenterological Surgery, Graduate School of Medicine; Yokohama City University; 3-9 Fukuura, Kanazawa-ku Yokohama 2360004 Japan
| | - Hiroshi Shimada
- Department of Gastroenterological Surgery, Graduate School of Medicine; Yokohama City University; 3-9 Fukuura, Kanazawa-ku Yokohama 2360004 Japan
| |
Collapse
|
|
17
|
Deoliveira ML, Schulick RD, Nimura Y, Rosen C, Gores G, Neuhaus P, Clavien PA. New staging system and a registry for perihilar cholangiocarcinoma. Hepatology 2011; 53:1363-71. [PMID: 21480336 DOI: 10.1002/hep.24227] [Citation(s) in RCA: 223] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Perihilar cholangiocarcinoma is one of the most challenging diseases with poor overall survival. The major problem for anyone trying to convincingly compare studies among centers or over time is the lack of a reliable staging system. The most commonly used system is the Bismuth-Corlette classification of bile duct involvement, which, however, does not include crucial information such as vascular encasement and distant metastases. Other systems are rarely used because they do not provide several key pieces of information guiding therapy. Therefore, we have designed a new system reporting the size of the tumor, the extent of the disease in the biliary system, the involvement of the hepatic artery and portal vein, the involvement of lymph nodes, distant metastases, and the volume of the putative remnant liver after resection. The aim of this system is the standardization of the reporting of perihilar cholangiocarcinoma so that relevant information regarding resectability, indications for liver transplantation, and prognosis can be provided. With this tool, we have created a new registry enabling every center to prospectively enter data on their patients with hilar cholangiocarcinoma (www.cholangioca.org). The availability of such standardized and multicenter data will enable us to identify the critical criteria guiding therapy.
Collapse
Affiliation(s)
- Michelle L Deoliveira
- Department of Surgery, Swiss Hepato-Pancreatico-Biliary and Transplant Center, University Hospital Zurich, Zurich, Switzerland
| | | | | | | | | | | | | |
Collapse
|
|
18
|
Regimbeau JM, Fuks D, Le Treut YP, Bachellier P, Belghiti J, Boudjema K, Baulieux J, Pruvot FR, Cherqui D, Farges O. Surgery for hilar cholangiocarcinoma: a multi-institutional update on practice and outcome by the AFC-HC study group. J Gastrointest Surg 2011; 15:480-8. [PMID: 21249527 DOI: 10.1007/s11605-011-1414-0] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2010] [Accepted: 01/05/2011] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Surgical resection is the only option for long-term survival in patients with hilar cholangiocarcinoma (HC), but it is associated with high morbidity and mortality. The aim of the present study was to prospectively assess the perioperative management and short-term outcomes of surgical treatment of HC in a recent, multi-institutional study with a short inclusion period. METHODS Between January and December 2008, a register prospectively collected data on patients operated on for HC (exploratory or curative surgery) in eight tertiary centers. The register focused on perioperative management, resectability, surgical procedures employed, morbidity, and mortality. The study cohort consisted of 56 patients (40 men and 16 women) with a median age of 63 years (range, 33-83 years). RESULTS Among the 56 patients, 47 (84%) were jaundiced and 42 (75%) tumors were classified as Bismuth-Corlette type III-IV. Nine patients (16%) underwent staging laparoscopy and four (7%) received neoadjuvant chemotherapy. Preoperative biliary drainage (endoscopy, 42%) was performed in 38 (81%) jaundiced patients and portal vein embolization (right side, 83%) was performed prior to surgery in 18 patients (32%). Among these 56 patients, curative resection was achieved in 39 (70%). All underwent major liver resection (>3 segments), bile duct resection, and lymphadenectomy. Thirteen patients (36%) underwent portal vein resection, one of whom also required pancreaticoduodenectomy. Eighty-two percent of resected patients (n = 32) had no proof of malignancy prior to hepatectomy. Clear surgical margins were obtained in 77% (n = 30). The postoperative mortality was 8% and complications occurred in 72% of the resected patients. Seven (25%) patients required reoperation, and 15 (54%) patients required percutaneous drainage. In a univariate analysis, the risk factors for morbidity were intraoperative blood transfusion (p = 0.009) and vascular clamping (p = 0.006). The median length of hospitalization was 20 ± 13 days. CONCLUSION Curative resection for HC is associated with a high rate of R0 resection. However, surgery is associated with high levels of morbidity and mortality, despite intensive perioperative management.
Collapse
Affiliation(s)
- Jean Marc Regimbeau
- Department of Digestive Surgery, Hôpital Nord, University of Picardy Medical Center, Place Victor Pauchet, F-80054, Amiens Cedex 01, France.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
|
19
|
Hepatectomy with simultaneous resection of the portal vein and hepatic artery for advanced perihilar cholangiocarcinoma: an audit of 50 consecutive cases. Ann Surg 2010; 252:115-23. [PMID: 20531001 DOI: 10.1097/sla.0b013e3181e463a7] [Citation(s) in RCA: 228] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To outline our experience with hepatectomy with simultaneous resection of the portal vein and hepatic artery for advanced perihilar cholangiocarcinoma, and to discuss the clinical significance of this challenging hepatectomy. SUMMARY BACKGROUND DATA Only a few authors reported negative results for this surgery in a very limited number of patients. METHODS We retrospectively reviewed medical records of 50 patients with advanced cholangiocarcinoma who underwent hepatectomy (left trisectionectomy in 26, left hepatectomy in 23, and right hepatectomy in 1) with simultaneous resection and reconstruction of the portal vein and hepatic artery, focusing on surgical outcome and survival. RESULTS The operative time was 776 +/- 191 minutes, and blood loss was 2593 +/- 1890 mL. Time of vessel resection and reconstruction was 25 +/- 19 minutes for the portal vein and 119 +/- 56 minutes for the hepatic artery. A total of 27 (54.0%) patients developed several kinds of complications, including intra-abdominal abscess (n = 13), wound infection (n = 9), bile leakage from liver stump (n = 9), and liver failure (n = 7). Relaparotomy was necessary in 5 (10.0%) patients. One (2.0%) patient died of a postoperative complication. Microscopic cancer invasion of the resected portal vein was found in 44 (88.0%) patients, while that of the resected hepatic artery was found in 27 (54.0%). The distal bile duct margin, proximal bile duct margin, and radial margin were positive for cancer in 2 (4.0%), 4 (8.0%), and 17 (34.0%) patients, respectively. Consequently, R0 resection was achieved in 33 (66.0%) patients. The 1-, 3-, and 5-year survival rates were 78.9%, 36.3%, and 30.3%, respectively. Survival for 30 patients with pM0 disease who underwent R0 resection was better, being 40.7% at the 3- and 5-year time points. CONCLUSION Major hepatectomy with simultaneous resection and reconstruction of the portal vein and hepatic artery is technically demanding. However, this surgery can be performed with acceptable mortality by an experienced surgeon and offers a better chance of long-term survival in selected patients.
Collapse
|
|
20
|
Lee SG, Song GW, Hwang S, Ha TY, Moon DB, Jung DH, Kim KH, Ahn CS, Kim MH, Lee SK, Sung KB, Ko GY. Surgical treatment of hilar cholangiocarcinoma in the new era: the Asan experience. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2009; 17:476-89. [PMID: 19851704 DOI: 10.1007/s00534-009-0204-5] [Citation(s) in RCA: 191] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2009] [Accepted: 09/01/2009] [Indexed: 12/19/2022]
Abstract
BACKGROUND/PURPOSE Both curative resection and minimized in-hospital mortality offer the only chance of long-term survival in patients with hilar cholangiocarcinoma. The reported resectability rates for hilar cholangiocarcinoma have increased by virtue of combined major hepatectomy, but this procedure is technically demanding and still associated with a significant morbidity and mortality that must be carefully balanced against the chances of long-term survival. METHODS Between January 2001 and December 2008, 350 patients with hilar cholangiocarcinoma underwent exploration for the purpose of potentially curative resection, of whom 302 (86.3%) were resected in the Department of Hepato-Biliary Surgery and Liver Transplantation, Asan Medical Center, University of Ulsan College of Medicine. Combined hepatectomy was carried out in 268 (88.7%) of 302 resected patients. Major hemihepatectomy and parenchyma-preserving hepatectomy were performed in 257 and 11 patients, respectively. Portal vein resection was associated in 40 (14.9%) of 268 hepatectomized patients. To control preoperative cholangitis and reduce risk of postoperative hepatic failure, biliary decompression through endoscopic and/or percutaneous transhepatic drainage and portal vein embolization were preoperatively applied in 329 (94.0%) of 350 explored patients and in 91 (54.2%) of 168 extended hepatectomized patients (154 right hemihepatectomy, 9 right trisectionectomy, 5 left trisectionectomy), respectively. Liver transplantation was not performed as primary treatment for hilar cholangiocarcinoma. RESULTS There were 5 cases (1.7%) of in-hospital death after resection and 1 postoperative liver failure that was successfully treated with liver transplantation. Major complications were encountered in 23 patients (7.0%), and the overall morbidity rate was 43%. In 302 resections, 214 (70.9%) were curative resections (R0) and 88 (29.1%) were palliative resections (R1). The overall 1-, 3- and 5-year survival rates after resection, including in-hospital deaths, were 84.6, 50.7 and 47.3% in the R0 group and 69.9, 33.3 and 7.5% in the R1 group, respectively. The 5-year survival rate of extended hemihepatectomy of 36.4% was better than that of parenchyma-preserving hepatectomy at 10.5%. Two significant predictive factors adversely affecting survival after resection were lymph node metastasis and incurability of surgery (P < 0.001). Two patients with vascular involvement who underwent concomitant hepatic artery and portal vein reconstruction are alive after more than 3 years. CONCLUSION Preoperative biliary decompression and portal vein embolization enabled us to reduce in-hospital deaths associated with extended hepatectomy for hilar cholangiocarcinoma. Major hemihepatectomy offers an increased survival because of the higher possibility of curative resection than bile duct resection alone and parenchyma-preserving hepatectomy, but it still carries a certain mortality. Less extensive procedures can be conducted safely and are beneficial for aged patients in poor condition with a less advanced tumor stage if tumor-free resectional margins are obtained.
Collapse
Affiliation(s)
- Sung Gyu Lee
- Department of Surgery, University of Ulsan College of Medicine, 388-1 Pungnab2-dong, Songpa-gu, Seoul 138-736, Korea.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
|
21
|
Outcome of surgical treatment of hilar cholangiocarcinoma: a special reference to postoperative morbidity and mortality. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2009; 17:455-62. [PMID: 19820891 DOI: 10.1007/s00534-009-0208-1] [Citation(s) in RCA: 114] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2009] [Accepted: 09/01/2009] [Indexed: 12/13/2022]
Abstract
BACKGROUND/PURPOSE Radical resection for hilar cholangiocarcinoma is still associated with significant morbidity and mortality. The aim of this study was to analyze short-term surgical outcomes and to validate our strategies, including preoperative management and selection of operative procedure. METHODS We surgically treated 146 consecutive patients with hilar cholangiocarcinoma with a management strategy consisting of preoperative biliary drainage, portal vein embolization, and selection of operative procedure based on tumor extension and hepatic reserve. Major hepatectomy was conducted in 126 patients, and caudate lobectomy or hilar bile duct resection in 20 patients. RESULTS The overall 5-year survival rate was 35.5%, with overall in-hospital mortality and morbidity rates of 3.4 and 44%, respectively. Hyperbilirubinemia (total bilirubin >5 mg/dL, persisted for >7 postoperative days) and liver abscess were the most frequent complications. Five among 9 patients with liver failure (total bilirubin >10 mg/dL) encountered in-hospital mortality. Four out of 5 mortality patients had suffered circulatory impairment of the remnant liver due to other complications. Multivariate analysis revealed that operative time is a single independent significant predictive factor (odds ratio, 1.005; 95% confidence interval, 1.000-1.010, P = 0.04) for postoperative complications. CONCLUSIONS Aggressive resection for hilar cholangiocarcinoma, performed in accordance with strict management strategy, achieved acceptably low mortality. Prolonged operative time was a risk for morbidity following hepatobiliary resection.
Collapse
|
|
22
|
Slim K, Blay JY, Brouquet A, Chatelain D, Comy M, Delpero JR, Denet C, Elias D, Fléjou JF, Fourquier P, Fuks D, Glehen O, Karoui M, Kohneh-Shahri N, Lesurtel M, Mariette C, Mauvais F, Nicolet J, Perniceni T, Piessen G, Regimbeau JM, Rouanet P, sauvanet A, Schmitt G, Vons C, Lasser P, Belghiti J, Berdah S, Champault G, Chiche L, Chipponi J, Chollet P, De Baère T, Déchelotte P, Garcier JM, Gayet B, Gouillat C, Kianmanesh R, Laurent C, Meyer C, Millat B, Msika S, Nordlinger B, Paraf F, Partensky C, Peschaud F, Pocard M, Sastre B, Scoazec JY, Scotté M, Triboulet JP, Trillaud H, Valleur P. [Digestive oncology: surgical practices]. ACTA ACUST UNITED AC 2009; 146 Suppl 2:S11-80. [PMID: 19435621 DOI: 10.1016/s0021-7697(09)72398-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- K Slim
- Chirurgien Clermont-Ferrand.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
|
23
|
Safety of combined resection of the middle hepatic artery in right hemihepatectomy for hilar biliary malignancy. ACTA ACUST UNITED AC 2009; 16:796-801. [PMID: 19387529 DOI: 10.1007/s00534-009-0107-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2008] [Accepted: 02/19/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND/PURPOSE In patients with hilar biliary malignancies, preservation of the middle hepatic artery (MHA, segment IV artery) where it runs close to the tumor in the hepatic hilum may lead to resection with positive margins. This retrospective study assessed the safety of combined resection of the MHA with right hemihepatectomy, caudate lobectomy, and bile duct resection for hilar biliary malignancies. METHODS Of 61 patients with hilar biliary malignancies who underwent right hemihepatectomy, we classified the branching patterns of the MHA according to the origins and courses in the hilum. The MHA was resected without reconstruction in 16 patients in whom the artery ran close to the tumor. We compared the perioperative outcomes in these patients with those of patients who did not undergo resection of the artery. RESULTS Anatomically, the MHA ran on the right side of the umbilical portion of the portal vein in 40 (66%) patients. Perioperative data for the patients who underwent combined resection were similar to those in whom the MAH was preserved. There were no postoperative complications that could be directly related to the arterial resection. CONCLUSIONS Combined resection of the MHA during right hemihepatectomy for hilar biliary malignancies has a safe perioperative course.
Collapse
|
|
24
|
Hirano S, Kondo S, Tanaka E, Shichinohe T, Tsuchikawa T, Kato K. No-touch resection of hilar malignancies with right hepatectomy and routine portal reconstruction. ACTA ACUST UNITED AC 2009; 16:502-7. [PMID: 19360368 DOI: 10.1007/s00534-009-0093-7] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2008] [Accepted: 11/13/2008] [Indexed: 11/25/2022]
Abstract
BACKGROUND/PURPOSE Locoregional recurrence following resection of hilar biliary cancers could be caused by the microscopic dissemination of cancer cells during dissection of the portal vein from the involved bile duct at the hilar region. This retrospective study assessed the feasibility and safety of a new procedure consisting of right-sided hepatectomy, caudate lobectomy, and bile duct resection combined with routine resection of the portal bifurcation to enable no-touch resection of hilar malignancies. METHODS Of 64 patients who underwent right-sided hepatectomy for hilar biliary cancer, the portal bifurcation was routinely resected by the above new procedure in 25 patients, based on preoperative imaging diagnoses. Perioperative outcomes were compared with those in patients who underwent conventional portal reconstruction (n = 18) and with those in patients who had preservation of the portal bifurcation (n = 21). RESULTS Perioperative data from patients with routine portal reconstruction were similar to those in the patients with conventional portal reconstruction and the patients without portal reconstruction. There were no postoperative complications directly related to portal reconstruction. CONCLUSIONS No-touch resection of hilar malignancies with right hepatectomy and the routine use of portal reconstruction was feasible and safe. The oncologic impact of this technique merits further evaluation.
Collapse
Affiliation(s)
- Satoshi Hirano
- Department of Surgical Oncology, Hokkaido University Graduate School of Medicine, Kita-15, Nishi-7, Kita-Ku, Sapporo, 060-8638, Japan.
| | | | | | | | | | | |
Collapse
|
|
25
|
Chaib E, Ribeiro MAF, Silva FDSC, Saad WA, Cecconello I. Caudate lobectomy: tumor location, topographic classification, and technique using right- and left-sided approaches to the liver. Am J Surg 2008; 196:245-51. [PMID: 18571618 DOI: 10.1016/j.amjsurg.2007.11.020] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2007] [Revised: 11/09/2007] [Accepted: 11/09/2007] [Indexed: 01/02/2023]
Abstract
BACKGROUND Resection of the caudate lobe (involving segments I [dorsal sector] and/or IX [right paracaval region]) often presents a technical challenge. It is difficult to perform because of its deep location and adjacency to the major hepatic vessels (ie, the left and middle hepatic veins). METHODS A literature review was performed based on a Medline search to identify articles on caudate lobectomy published from 1990 to 2005. This article describes the right and left-sided approaches to the liver for caudate resection according to caudate lobe tumor location and topographic classification. RESULTS The results of 377 lobectomies were analyzed in this review. The left-sided approach to the liver was used in 55 (14.58%), the right-sided approach in 24 (6.36%), and both approaches in 298 (79.04%) caudate lobectomies. Primary benign and malign liver tumors, as well as secondary liver tumors, were resected. CONCLUSIONS Access to and resection of the caudate lobe should be determined on the basis of tumor location and hepatic function. The left or right approach to the caudate lobe can be recommended for local resection of tumor located at Spiegel's portion or process portion. Approaches to caudate lobectomy are therefore largely dependent on size and location of the lesion, type of associated resection, and presence of scarring from previous resection.
Collapse
Affiliation(s)
- Eleazar Chaib
- Liver and Portal Hypertension Surgery Unit, Department of Gastroenterology, University of Sao Paulo School of Medicine, Sao Paulo, Brazil.
| | | | | | | | | |
Collapse
|
|
26
|
Nimura Y. Radical surgery: vascular and pancreatic resection for cholangiocarcinoma. HPB (Oxford) 2008; 10:183-5. [PMID: 18773051 PMCID: PMC2504372 DOI: 10.1080/13651820801992682] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2008] [Indexed: 12/12/2022]
Abstract
Recent progress in vascular surgical techniques has made it possible to combine liver and portal vein and/or hepatic artery (HA) or retrohepatic inferior vena cava (IVC) resection and reconstruction in cases of locally advanced cholangiocarcinoma. Reports of the success of this difficult surgery have been published. Aggressive Japanese surgeons have applied hepatopancreatoduodenectomy (HPD) not just in cases of advanced gallbladder cancer, but also in locally advanced cholangiocarcinoma with or without superficial spread. The above extended surgeries were associated with high postoperative morbidity and mortality, but recent progress in perioperative management and surgical techniques has improved the outcome of these types of surgery. Combined portal vein and liver resection provides R0 resection and contributes to longer survival in resected patients with locally advanced cholangiocarcinoma than in unresected patients. Portal vein invasion is a strong prognostic factor of cholangiocarcinoma and the actual number of 5-year survivors is limited. The number of clinical cases of liver resection combined with IVC or HA resection and reconstruction is still limited, and therefore the long-term survival benefit from these procedures has not been clarified. HPD carried high morbidity and mortality rates in the 1990s, but the outcome has been improving and an increasing number of 5-year survivors has been reported. Although the clinical value of the above extended surgeries has not been evaluated prospectively, with the increasing number of retrospective studies it has been concluded that combined liver and portal vein and/or HA or IVC resection or HPD could be indicated for selected patients with locally advanced cholangiocarcinoma.
Collapse
|
|
27
|
Prise en charge chirurgicale du cholangiocarcinome hilaire résécable. ACTA ACUST UNITED AC 2008; 32:620-31. [DOI: 10.1016/j.gcb.2008.04.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2007] [Revised: 03/31/2008] [Accepted: 04/08/2008] [Indexed: 12/21/2022]
|
|
28
|
Kurosaki I, Hatakeyama K, Minagawa M, Sato D. Portal vein resection in surgery for cancer of biliary tract and pancreas: special reference to the relationship between the surgical outcome and site of primary tumor. J Gastrointest Surg 2008; 12:907-18. [PMID: 17968629 DOI: 10.1007/s11605-007-0387-5] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2007] [Accepted: 10/03/2007] [Indexed: 01/31/2023]
Abstract
BACKGROUND Early and late outcomes after superior mesenteric-portal vein resection (VR) combined with pancreaticoduodenectomy, major hepatectomy, or both for pancreaticobiliary carcinoma were retrospectively evaluated. VR is the most frequently used vascular procedure in this field, but an exact role of VR has not been compared according to the primary site of tumor. MATERIALS AND METHODS Postoperative outcomes were compared between surgery with and without VR in each of the three disease-based groups: hilar cholangiocarcinoma and intrahepatic cholangiocarcinoma with hilar extension (HIC, 56), middle and distal cholangiocarcinoma and gallbladder carcinoma (DGC, 118), and pancreatic head adenocarcinoma (PHC, 77). RESULTS VR was performed in 19.6% of HIC, 8.5% of DGC, and 45.5% of PHC. In-hospital death was 7.1% (4 of 56) patients with VR (3 of DGC and 1 of PHC). Operations with VR in DGC showed a larger amount of blood loss and more increased ratio of R1operation than those with no VR. In HIC, DGC, and PHC, median survival time of patients with VR was 37, 6.8, and 20 months and that of patients without VR was 42.9, 28.6, and 20.3 months, respectively. VR did not affect survival either in HIC or in PHC; however, in DGC, VR was accompanied with dismal outcome compared with no VR (p=0.001). CONCLUSIONS Aggressive surgery with VR can be justified both in HIC and in PHC but should not be recommended for DGC. Surgical outcomes of VR differed considerably, depending on the sites of the primary tumor.
Collapse
Affiliation(s)
- Isao Kurosaki
- Division of Digestive and General Surgery, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-dori, Niigata, 951-8510, Japan.
| | | | | | | |
Collapse
|
|
29
|
Kondo S, Takada T, Miyazaki M, Miyakawa S, Tsukada K, Nagino M, Furuse J, Saito H, Tsuyuguchi T, Yamamoto M, Kayahara M, Kimura F, Yoshitomi H, Nozawa S, Yoshida M, Wada K, Hirano S, Amano H, Miura F. Guidelines for the management of biliary tract and ampullary carcinomas: surgical treatment. ACTA ACUST UNITED AC 2008; 15:41-54. [PMID: 18274843 PMCID: PMC2794356 DOI: 10.1007/s00534-007-1279-5] [Citation(s) in RCA: 153] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2007] [Accepted: 10/22/2007] [Indexed: 02/06/2023]
Abstract
The only curative treatment in biliary tract cancer is surgical treatment. Therefore, the suitability of curative resection should be investigated in the first place. In the presence of metastasis to the liver, lung, peritoneum, or distant lymph nodes, curative resection is not suitable. No definite consensus has been reached on local extension factors and curability. Measures of hepatic functional reserve in the jaundiced liver include future liver remnant volume and the indocyanine green (ICG) clearance test. Preoperative portal vein embolization may be considered in patients in whom right hepatectomy or more, or hepatectomy with a resection rate exceeding 50%–60% is planned. Postoperative complications and surgery-related mortality may be reduced with the use of portal vein embolization. Although hepatectomy and/or pancreaticoduodenectomy are preferable for the curative resection of bile duct cancer, extrahepatic bile duct resection alone is also considered in patients for whom it is judged that curative resection would be achieved after a strict diagnosis of its local extension. Also, combined caudate lobe resection is recommended for hilar cholangiocarcinoma. Because the prognosis of patients treated with combined portal vein resection is significantly better than that of unresected patients, combined portal vein resection may be carried out. Prognostic factors after resection for bile duct cancer include positive surgical margins, especially in the ductal stump; lymph node metastasis; perineural invasion; and combined vascular resection due to portal vein and/or hepatic artery invasion. For patients with suspected gallbladder cancer, laparoscopic cholecystectomy is not recommended, and open cholecystectomy should be performed as a rule. When gallbladder cancer invading the subserosal layer or deeper has been detected after simple cholecystectomy, additional resection should be considered. Prognostic factors after resection for gallbladder cancer include the depth of mural invasion; lymph node metastasis; extramural extension, especially into the hepatoduodenal ligament; perineural invasion; and the degree of curability. Pancreaticoduodenectomy is indicated for ampullary carcinoma, and limited operation is also indicated for carcinoma in adenoma. The prognostic factors after resection for ampullary carcinoma include lymph node metastasis, pancreatic invasion, and perineural invasion.
Collapse
Affiliation(s)
- Satoshi Kondo
- Department of Surgical Oncology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
|
30
|
Hirano S, Tanaka E, Shichinohe T, Suzuki O, Hazama K, Kitagami H, Okamura K, Yano T, Kondo S. Treatment strategy for hilar cholangiocarcinoma, with special reference to the limits of ductal resection in right-sided hepatectomies. ACTA ACUST UNITED AC 2007; 14:429-33. [PMID: 17909709 DOI: 10.1007/s00534-006-1190-5] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2006] [Accepted: 10/16/2006] [Indexed: 10/22/2022]
Abstract
The surgical anatomy of the hepatic hilar region is characterized by the three-dimensional formation of the branches of the bile duct, portal vein, and hepatic artery. The limit of ductal resection in hepatectomy for hilar cholangiocarcinoma is the most peripheral point where the hepatic ducts can be separated from the vasculature. The limit is different for each type of hepatectomy because the portal vein branches that should be preserved or divided vary with the extent of the hepatectomy, and therefore the limit of separation of the hepatic ducts differs. Surgeons are required to understand the surgical anatomy and to identify the precise area of cancer spread on a preoperative cholangiogram so as to choose the appropriate type of hepatectomy, and to ensure that the remnant ductal margin is cancer-negative.
Collapse
Affiliation(s)
- Satoshi Hirano
- Department of Surgical Oncology, Hokkaido University Graduate School of Medicine, Kita-15, Nishi-7, Sapporo, 060-8638, Japan
| | | | | | | | | | | | | | | | | |
Collapse
|
|
31
|
Hwang S, Ha TY, Jung DH, Park JI, Lee SG. Portal vein interposition using homologous iliac vein graft during extensive resection for hilar bile duct cancer. J Gastrointest Surg 2007; 11:888-92. [PMID: 17440791 DOI: 10.1007/s11605-007-0146-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2006] [Revised: 02/14/2007] [Accepted: 03/06/2007] [Indexed: 01/31/2023]
Abstract
Although autologous vein grafts have been used for portal vein (PV) reconstruction after long-segment portal vein resection during surgery for hilar bile duct cancer, their procurement prolongs operation time and increases morbidity. Less is known regarding the use of homologous vein grafts. The feasibility of homografts for PV reconstruction was preliminarily evaluated in two patients who underwent curative resection for hilar cholangiocarcinoma. Both patients underwent left lobectomy, caudate lobectomy, bile duct resection, and segmental PV resection and interposition vein graft reconstruction. The iliac vein homografts were obtained from deceased organ donors and stored for 1-2 days in cold preservation solution without freezing. Neither immunosuppression nor anticoagulation was attempted. One patient has shown good PV patency for 27 months. The second patient, who had received adjuvant chemoradiotherapy, showed an asymptomatic waisting at the proximal PV anastomosis site after 4 months, which was relieved by percutaneous balloon dilatation, and has been doing well for 12 months. In conclusion, our preliminary experience with these two patients suggests that cold-stored iliac vein homografts can be considered as PV substitutes after long PV segment resection during extensive hepatobiliary surgery.
Collapse
Affiliation(s)
- Shin Hwang
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul 138-736, Korea.
| | | | | | | | | |
Collapse
|
|
32
|
Seyama Y, Makuuchi M. Current surgical treatment for bile duct cancer. World J Gastroenterol 2007; 13:1505-15. [PMID: 17461441 PMCID: PMC4146891 DOI: 10.3748/wjg.v13.i10.1505] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2006] [Revised: 11/15/2006] [Accepted: 12/20/2007] [Indexed: 02/06/2023] Open
Abstract
Since extrahepatic bile duct cancer is difficult to diagnose and to cure, a safe and radical surgical strategy is needed. In this review, the modes of infiltration and spread of extrahepatic bile duct cancer and surgical strategy are discussed. Extended hemihepatectomy, with or without pancreatoduodenectomy (PD), plus extrahepatic bile duct resection and regional lymphadenectomy has recently been recognized as the standard curative treatment for hilar bile duct cancer. On the other hand, PD is the choice of treatment for middle and distal bile duct cancer. Major hepatectomy concomitant with PD (hepatopancreatoduodenectomy) has been applied to selected patients with widespread tumors. Preoperative biliary drainage (BD) followed by portal vein embolization (PVE) enables major hepatectomy in patients with hilar bile duct cancer without mortality. BD should be performed considering the surgical procedure, especially, in patients with separated intrahepatic bile ducts caused by hilar bile duct cancer. Right or left trisectoriectomy are indicated according to the tumor spread and biliary anatomy. As a result, extended radical resection offers a chance for cure of hilar bile duct cancer with improved resectability, curability, and a 5-year survival rate of 40%. A 5-year survival rate has ranged from 24% to 39% after PD for middle and distal bile duct cancer.
Collapse
Affiliation(s)
- Yasuji Seyama
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | | |
Collapse
|
|
33
|
Chaib E, Ribeiro MAF, Silva FDSCE, Saad WA, Cecconello I. Surgical approach for hepatic caudate lobectomy: Review of 401 cases. J Am Coll Surg 2006; 204:118-27. [PMID: 17189120 DOI: 10.1016/j.jamcollsurg.2006.09.020] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2006] [Revised: 09/16/2006] [Accepted: 09/25/2006] [Indexed: 10/23/2022]
Affiliation(s)
- Eleazar Chaib
- Liver and Portal Hypertension Surgery Unit, Department of Gastroenterology, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | | | | | | | | |
Collapse
|
|
34
|
Abstract
Biliary tract cancer, which consists of gall bladder cancer and cholangio-carcinoma, presents many challenges to practising physicians. It is a relatively rare cancer that often causes a diagnostic dilemma, as its presentation may be similar to that of non-malignant conditions. In many cases, histological or cytological confirmation of a cancer diagnosis is not possible preoperatively. The management of this disease is also complex due to a morbid patient population and limited data on the optimal therapeutic approach. Surgery remains the mainstay of treatment, although the extent of resection required is still debated. The role of adjuvant therapy is also controversial, but a combined modality approach appears to be beneficial in patients with a high risk of recurrence, such as those with node positive tumors or positive resection margins. When surgery is not possible, the prognosis of patients with biliary tract cancer is very poor. In unresectable patients, the combination of chemotherapy and radiotherapy can result in a prolonged survival for some patients. In the palliative setting, biliary stenting and other supportive measures can alleviate symptoms and improve survival. Gemcitabine-based combination chemotherapy may also provide successful palliation and has achieved response rates of approximately 30% and a median survival of > 15 months in one study. Ultimately, treatment decisions should be individualised and participation in clinical trials is encouraged. Further progress in the management of biliary tract cancer is anticipated using biological therapies and continued research is essential to discover the optimal treatment for this challenging disease.
Collapse
Affiliation(s)
- Gregory D Leonard
- Memorial Sloan-Kettering Cancer Center, Gastrointestinal Oncology Service, Department of Medicine, 1275 York Avenue, Box 324, New York, New York 10021, USA
| | | |
Collapse
|
|
35
|
Kondo S, Hirano S, Ambo Y, Tanaka E, Okushiba S, Morikawa T, Katoh H. Forty consecutive resections of hilar cholangiocarcinoma with no postoperative mortality and no positive ductal margins: results of a prospective study. Ann Surg 2004; 240:95-101. [PMID: 15213624 PMCID: PMC1356380 DOI: 10.1097/01.sla.0000129491.43855.6b] [Citation(s) in RCA: 215] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Our objective was to perform a prospective study of surgical treatment of hilar cholangiocarcinoma according to newly established guidelines for performing safe and curative resections. SUMMARY BACKGROUND DATA The poor survival rate after resection of hilar cholangiocarcinoma is considered to be mainly the result of in-hospital death and positive ductal margins. METHODS Between July 1999 and December 2002, 40 of 42 surgically explored patients with hilar cholangiocarcinoma underwent resection. They were managed with preoperative biliary decompression, portal embolization, cholangiographic evaluation, and a choice of surgical procedures and techniques. RESULTS Hospital or 30-day mortality and morbidity rates were 0% and 48%, respectively. Hepatic failure was not encountered. Histopathologic examination revealed no positive ductal margins in all 40 patients, but 2 showed positive separation margins from the right hepatic artery. The overall 3-year survival rate and median survival time were 40% and 27 months. Survival of patients with Bismuth type III or IV tumors or of patients who underwent right hepatectomy was significantly better. Survival of patients who underwent concomitant vascular resection was similar to survival of those who did not. Univariate analysis indicated the type of hepatectomy, histopathologic grade, Bismuth classification, concomitant hepatic artery resection, and International Union Against Cancer stage as significant prognostic factors. CONCLUSIONS No postoperative mortality and no positive ductal margins were achieved according to the above guidelines in a high-volume expert center. Long-term results, however, have not been significantly improved. A survival analysis of the patient series with homogeneous conditions derived from a short study period suggests the need for additional strategies including right hepatectomy for Bismuth type I or II tumors.
Collapse
Affiliation(s)
- Satoshi Kondo
- Department of Surgical Oncology, Hokkaido University Graduate School of Medicine, Kita-ku, Sapporo, Japan.
| | | | | | | | | | | | | |
Collapse
|
|
36
|
Kondo S, Hirano S, Ambo Y, Tanaka E, Kubota T, Katoh H. Arterioportal shunting as an alternative to microvascular reconstruction after hepatic artery resection. Br J Surg 2003; 91:248-51. [PMID: 14760676 DOI: 10.1002/bjs.4428] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Abstract
Background
Portal vein and hepatic artery resection and reconstruction may be required in radical surgery for biliary cancer. Microvascular reconstruction requires special equipment and training, and may be difficult to accomplish when the arterial stump is small, when there are multiple vessels or when the stump lies deep within the wound. This study examined the feasibility and safety of arterioportal shunting as an alternative to arterial reconstruction.
Methods
Over 30 months, ten patients with biliary cancer (six bile duct and four gallbladder carcinomas) underwent radical surgery with en bloc resection of the hepatic artery and end-to-side arterioportal reconstruction between the common hepatic or gastroduodenal artery and the portal trunk.
Results
No patient died. Complications included bile leakage in two patients and liver abscess in one. Routine angiography performed 1 month after surgery revealed shunt occlusion in three patients. Once the existence of hepatopetal arterial collaterals had been confirmed in the remaining patients, the shunt was occluded by coil embolization.
Conclusion
Arterioportal shunting appears to be a safe alternative to microvascular reconstruction after hepatic artery resection. However, the safety of the procedure and its potential to increase the cure rate require further assessment in a larger series with a longer follow-up.
Collapse
Affiliation(s)
- S Kondo
- Department of Surgical Oncology, Hokkaido University Graduate School of Medicine, Sapporo, Japan.
| | | | | | | | | | | |
Collapse
|