Right hepatectomy for a detoured left hepatic artery in hilar cholangiocarcinoma—report of a rare but rational resection

Abstract

BackgroundCurative hepatectomy with bile duct resection is the treatment for perihilar cholangiocarcinoma. A locally advanced tumor necessitates hepatectomy with simultaneous vascular resection, and reconstruction remains an obstacle for surgeons. Studies have focused on the variations of hepatic arteries. Nevertheless, the anatomical alignment of the portal veins, bile ducts, and hepatic arteries are equally critical in surgical planning of curative resection for advanced tumors. We have reported promising outcomes of hepatectomy with simultaneous resection and reconstruction of the hepatic artery. With respect to the type of surgery, most patients undergo left hepatectomy with right hepatic artery resection and reconstruction in contrast to right hepatectomy with left hepatic artery resection and reconstruction. We present two patients who showed detoured left hepatic arteries that were invaded by the perihilar tumors.Case presentationA 78-year-old man who presented with epigastric pain and abnormal liver function was referred to our clinic for further examination. Serial examination resulted in the diagnosis of Bismuth type II hilar cholangiocarcinoma. The left hepatic artery ran a detoured course and was invaded by the tumor. The second patient was a 76-year-old woman who presented with jaundice and the Bismuth type II hilar cholangiocarcinoma. The left hepatic artery was along the right-lateral position of the left portal vein and was invaded by the tumor. The variant anatomical relationship of the vessel was identified preoperatively in both patients, and they underwent right hepatectomy with concomitant left hepatic artery resection and reconstruction without any major complications or recurrence.ConclusionsThe largely biased selection of patients is based on the following anatomical relationship: the left hepatic artery usually runs left lateral to the portal vein, which spares invasion by the perihilar cholangiocarcinoma. On the contrary, the right hepatic artery mostly runs behind the bile duct and is invaded by the tumor. This aforementioned anatomy is one of the reasons for the relatively rare left hepatic artery resections and reconstructions in right hepatectomies. By meticulous preoperative evaluation with images, we identify the anatomical variation and performed right hepatectomy with concomitant left hepatic artery resection and reconstruction without any major complications and mortalities.

Combined Vascular Resection for Locally Advanced Perihilar Cholangiocarcinoma

“…PVR was combined irrespective of the sidedness of the hepatectomy, whereas HAR was basically combined with left-sided hepatectomy for left-sided predominant PHCs because the tumors are likely to involve the right hepatic artery, which intersects behind and touches the hilar bile ducts. Although rare, HAR was also combined with right-sided hepatectomy for PHCs with involvement of the detoured proper or left hepatic artery 29 . The resection area and reconstruction form of the hepatic artery were also preoperatively discussed by the hepatopancreatobiliary surgeons and attending plastic surgeons.…”

“…Although rare, HAR was also combined with right-sided hepatectomy for PHCs with involvement of the detoured proper or left hepatic artery. 29 The resection area and reconstruction form of the hepatic artery were also preoperatively discussed by the hepatopancreatobiliary surgeons and attending plastic surgeons.…”

Effect of hepatic artery resection and reconstruction on the prognosis of patients with advanced hilar cholangiocarcinoma

“…Hitachi 7170 automatic biochemical analyzer was used to measure the serum ALT, AST, and TBIL levels. Alanine aminotransferase was > 40 U/L, AST > 35 U/L, and TBIL > 22 μmol/L, which were considered abnormal[ 12 , 13 ].…”