Concomitant Hepatic Artery Resection for Advanced Perihilar Cholangiocarcinoma: A Narrative Review

Abstract

Perihilar cholangiocarcinoma (PHCC) is one of the most intractable gastrointestinal malignancies. These tumours lie in the core section of the biliary tract. Patients who undergo curative surgery have a 40-50-month median survival time, and a five-year overall survival rate of 35-45%. Therefore, curative intent surgery can lead to long-term survival. PHCC sometimes invades the surrounding tissues, such as the portal vein, hepatic artery, perineural tissues around the hepatic artery, and hepatic parenchyma. Contralateral hepatic artery invasion is classed as T4, which is considered unresectable due to its "locally advanced" nature. Recently, several reports have been published on concomitant hepatic artery resection (HAR) for PHCC. The morbidity and mortality rates in these reports were similar to those non-HAR cases. The five-year survival rate after HAR was 16-38.5%. Alternative procedures for arterial portal shunting and non-vascular reconstruction (HAR) have also been reported. In this paper, we review HAR for PHCC, focusing on its history, diagnosis, procedures, and alternatives. HAR, undertaken by established biliary surgeons in selected patients with PHCC, can be feasible.

Keywords: concomitant hepatic artery resection; perihilar cholangiocarcinoma; prognosis.

Figure 1

A schema of the anatomical relationship between the bile duct, hepatic artery, portal vein, and a Bismuth type 3B tumour in text-book-type anatomy. In left hepatectomy with hepatic artery resection (HAR), the right hepatic artery is cut proximal (a) and distal (b) to the tumour. In left trisectionectomy, the distal cut end of the hepatic artery can be placed further from the tumour at the right posterior hepatic artery (c). RHA: right hepatic artery; MHA: middle hepatic artery; LHA: left hepatic artery; RAHA: right anterior hepatic artery; and RPHA: right posterior hepatic artery. Numerals represent Cournand’s hepatic segments which the hepatic inflow vascular structures perfuse. (Reproduced with permission from Ref. [3]. 2022, LWW).

Figure 2

Advanced case of perihilar cholangiocarcinoma (T4N1M0 Stage IIIc) that required left hepatectomy with concomitant hepatic artery and portal vein resection.

Figure 3

(a): Scheme of vascular resection for left hepatectomy. Type of hepatic artery resection and reconstruction during left hepatectomy. L: left hepatic artery; A: right anterior hepatic artery; P: right posterior hepatic artery; SMA: superior mesenteric artery; GDA: gastroduodenal artery; RGEA: right gastroepiploic artery; and A6a: artery supplying a small area of subsegment 6. (b) Hepatic artery resection and reconstruction in case of left trisectionectomy. L: left hepatic artery; A: right anterior hepatic artery; P: right posterior hepatic artery; RGA: right gastric artery; MA: superior mesenteric artery; A6: artery feeding segment 6; and A7: artery feeding segment 7. Note that two patients underwent arterioportal shunting because arterial reconstruction was technically impossible (Reproduced with permission from Ref. [15]. 2010, LWW).