"Anatomic" right hepatic trisectionectomy (extended right hepatectomy) with caudate lobectomy for hilar cholangiocarcinoma

Abstract

Background: The techniques of right hepatic trisectionectomy are now standardized in patients with hepatocellular or metastatic carcinoma, but not in those with hilar cholangiocarcinoma.

Methods: Under preoperative diagnosis of hilar cholangiocarcinoma, 8 patients underwent "anatomic" right hepatic trisectionectomy with en bloc resection of the caudate lobe and the extrahepatic bile duct, in which the bile ducts of the left lateral section were divided at the left side of the umbilical fissure following complete dissection of the umbilical plate.

Results: Liver resection was successfully performed, and all patients were discharged from the hospital in good condition, giving a mortality of 0%. All patients were histologically diagnosed as having cholangiocarcinoma. The proximal resection margins were cancer-negative in 7 patients and cancer-positive in 1 patient. Four patients with multiple lymph node metastases died of cancer recurrence within 3 years after hepatectomy. One patient died of liver failure without recurrence 42 months after hepatectomy. The remaining 3 patients without lymph node metastasis are now alive after more than 5 years.

Conclusions: Anatomic right hepatic trisectionectomy with caudate lobectomy can produce a longer proximal resection margin and can offer a better chance of long-term survival in some selected patients with advanced hilar cholangiocarcinoma.

FIGURE 1. Cholangiograms through percutaneous transhepatic drainage catheter (case 2). A, Anteroposterior projection: the progression of cancer is predominant in the right anterior and posterior bile ducts. B, Right anterior oblique + cranial oblique projection: the left medial and lateral branches are also involved. The number indicates the segmental bile duct according to Couinaud's hepatic segment. Arrowheads indicate 2 biliary drainage catheters.

FIGURE 2. Schematic illustrations (anteroposterior view) of complete dissection of the umbilical plate. A, All of the small portal branches arising from the cranial side of the umbilical portion (P4 days) are divided. B, The umbilical portion (UP) of the left portal vein is isolated from the umbilical plate. Three lines indicate resection line of left-side bile ducts in right hepatectomy (arrow X), conventional right hepatic trisectionectomy (arrow Y), and anatomic right hepatic trisectionectomy (line Z). The number indicates the segmental bile duct (B) and portal branch (P) according to Couinaud's hepatic segment.

FIGURE 3. Schematic illustration of anatomic right hepatic trisectionectomy with caudate lobectomy. After transecting the middle hepatic vein, the bile ducts of the left lateral section are divided at the left side of the umbilical portion of the left portal vein. The number indicates the segmental bile duct (B) and portal branch (P) according to Couinaud's hepatic segment.

FIGURE 4. The resected specimen (case 2). The extrahepatic bile duct is opened longitudinally, from the distal resection margin (CBD) up to the proximal margin (B2, B3). The left medial bile duct (B4) also is opened. Dotted line indicates the extension of carcinoma.