Hilar en bloc resection for hilar cholangiocarcinoma in patients with limited liver capacities—preserving parts of liver segment 4

Abstract

SummaryBackgroundA right trisectionectomy with portal vein resection represents the conventional approach for hilar cholangiocarcinoma. Here, we present a technical modification of hilar en bloc resection in order to increase the remnant volume by partially preserving liver segment 4.MethodsThe caudal parenchymal dissection line starts centrally between the left lateral and left medial segments. Cranially, the resection line switches to the right towards Cantlie’s line and turns again upwards perpendicularly. Hence, segment 4a and subtotal segment 4b are partially preserved by this novel technique. The left hepatic duct is dissected at the segmental ramification and reconstruction is performed as a single hepaticojejunostomy. The feasibility of the novel parenchyma-sparing approach for hilar cholangiocarcinoma was proven in a case series and medical records were reviewed retrospectively.ResultsTen patients (6 male, 4 female) underwent segment 4 partially preserving right trisectionectomy for hilar cholangiocarcinoma. Estimated future liver remnant volume was significantly increased (FLRV 38.3%), when compared to standard right trisectionectomy (FLRV 23.9%; p < 0.01). Three of 10 liver resections were associated with major surgical complications (≥IIIb; n = 3); categorized according to the Dindo–Clavien classification. No patient died due to complications associated with postoperatively impaired liver function. Tumor-free margins could be achieved in 8 patients while median overall survival and disease-free survival were 547 and 367 days, respectively.ConclusionThis novel parenchyma-sparing modification of hilar en bloc resection by partially preserving segment 4 allows to safely increase the remnant liver volume without neglecting principles of local radicality.Electronic supplementary materialThe online version of this article (10.1007/s10353-017-0507-8) contains supplementary material, which is available to authorized users.

Prognostic and Predictive Molecular Markers in Cholangiocarcinoma

“…Symptoms of CCA are usually vague and arise late in already-advanced disease, resulting in median survival of less than two years from the timepoint of diagnosis. So far, surgery remains the only curative treatment option, with a 5-year survival rate ranging between 25 and 50% after surgical resection [ 6 , 7 , 8 , 9 , 10 , 11 ]. Due to high risk of recurrence, especially in patients with lymph node metastasis, tumor-positive resection borders, and low-grade CCA, adjuvant chemotherapy is recommended by current guidelines [ 12 , 13 , 14 ].…”

A tailored approach in lymph node-positive perihilar cholangiocarcinoma

“…Left hepatectomy and standard major hepatectomy procedures are performed accordingly with the difference that perihilar lymph nodes cannot be removed en bloc and have to be dissected and seperated from the bile duct bifurcation [ 5 ]. Approaches with technical modifications, such as segment-4 preserving variations [ 18 ], portal vein, and hepatic artery resection, were included but not further differentiated for statistical reasons. Extrahepatic bile duct resection alone on the one hand and multivisceral resections, e.g., hepatoduodenopancreatectomy (HPD), on the other hand, were excluded from the analysis.…”

British Society of Gastroenterology guidelines for the diagnosis and management of cholangiocarcinoma

“… 191 En bloc resection has been suggested to offer improved survival, but may also be associated with increased perioperative mortality. 192 193 …”