Outcome of Major Hepatectomy with Pancreatoduodenectomy for Advanced Biliary Malignancies

Abstract

In patients with advanced biliary malignancies a chance of curability is obtained by performing only major hepatectomy with concomitant pancreatoduodenectomy. This aggressive procedure carries two major risks: hepatic failure and pancreatic anastomotic leakage. Ten patients with advanced biliary malignancies were treated by major hepatectomy with pancreatoduodenectomy. Nine patients underwent right portal venous embolization before hepatectomy. Complete external drainage of pancreatic juice followed by second-stage pancreatojejunostomy was performed in five patients. Three of these five underwent concomitant resection of the hepatic artery, portal vein, or both. Pancreatogastrostomy was chosen for five patients who required no concomitant vascular resection. There were no hospital deaths or hepatic failures. Leaks from pancreatogastrostomy occurred in two patients. In five patients who underwent external drainage of pancreatic juice, there were no complications related to the pancreatic stump, although one had ischemic necrosis of the jejunal segment and laparotomy was repeated. Mean survival time was 31.8 months (range 13-59 months). Portal venous embolization and complete external drainage of pancreatic juice followed by late stage pancreatojejunostomy are recommended surgical procedures for patients undergoing major hepatectomy with pancreatoduodenectomy, especially when concomitant vascular resection is required for curative resection of the tumor in patients with a soft pancreatic parenchyma and thin pancreatic duct.

Carcinoma of the middle bile duct: Is bile duct segmentalresection appropriate?

“…Such interest in the classification of cholangiocarcinomas is due to the difference in surgical treatment according the different anatomic locations. Intrahepatic and perihilar cholangiocarcinomas are usually treated by liver resection [16][17][18] . In contrast, distal cholangiocarcinoma requires PD for complete tumor resection.…”

Hepatopancreatoduodenectomy-Lesson’s with 35 Patients over 10 Years

“…Nimura et al 23 in 1991 reported 24 HPD with 6 deaths (25%) especially related to postoperative liver failure and sepsis related to pancreatic fistula. Miyagawa et al 24 in 1996 demonstrated 0% mortality in HPD who underwent preoperative portal embolization and two-time pancreatic reconstruction. Table 3 shows the mortality rate worldwide.…”

“…Shirai et al 25 reported seven HPDs with 29% mortality rate. Miyagawa et al 24 in 1996 published 0% mortality in seven cases and routine preoperative portal vein embolization. Shirai et al 25 in 1997 reported 17 cases in stage IV gallbladder cancer and the 5-years survival was 29% and those with R0 resection the 5-years survival was 50%.…”

“…1,15,19,22,24 In the western hemisphere, very few groups are interested in reproducing this experience. So far, only Hemming et al 15 published a consisted report with HPD in the western countries.…”

“…Discussion of PD indications is still very controversial ( Figure 1). 18,24,25 However, advanced gallbladder carcinoma is associated with a high incidence of metastases to the hepatoduodenal ligament lymph nodes, posterior pancreatoduodenal lymph nodes, and the common hepatic artery. Table 2 resumes total indications of HPD in our series.…”