Analysis of Long-Term Survivors after Resection for Hilar Bile Duct Cancer

PURPOSE: Although considerable progress has been made in the management of hilar bile duct cancer, the long-term outlook for most patients remains poor. This study was conducted to analyze the long-term survival (more than 5 years) after resection for hilar bile duct cancer focusing on the clinicopathological factors influencing the outcome, and to develop an optimal strategy to achieve long-term survival after a resection. METHODS: A retrospective review was performed for 68 patients with hilar bile duct cancer who underwent surgical resection between 1988 and 2000. Survival rates and prognostic factors were assessed. Clinical and pathological factors of patients who survived more than 5 years were compared with patients whose survival was less than 5 years. Clinicopathological features characterizing the long-term survivors were also reviewed. RESULTS: Seventeen patients survived longer than 5 years after resection. The actual 5-year survival rate was 25.0%. Perineural invasion and resection margin were identified as independent prognostic factors. When prognostic factors were compared between the long-term and short-term survivors, tumor depth, TNM stage, perineural invasion, and resection margin showed a significant correlation with long- term survival. Long-term survivors had early TNM stages with negative lymph node metastasis and absence of perineural invasion. Six of 17 long-term survivors exhibited a positive resection margin. CONCLUSION: Long-term survivors showed characteristic features of early TNM stages with absence of perineural invasion and negative resection margin. As long-term survival can be expected even in patients with bad prognostic factors, aggressive surgical resection should be attempted for patients with resectable disease.

S4a+S5 with Caudate Lobe (S1) Resection as a Parenchyma-preserving Liver Resection for a Patient with Type IIIb Hilar Bile Duct Cance

The prognosis of hilar bile duct cancer has been improved by extensive curative resection, but massive hepatectomy can result in surgical and medical complications in high-risk patients. We report a case of type IIIb hilar bile duct cancer undergone S4a S5 with caudate lobe (S1) resection as a parenchyma-preserving hepatectomy. The operation was a modified type of Taj Mahal liver resection omitting parencymal transection between S4b and S8. Such an extent of hepatectomy combined with bile duct resection made 3 right and 3 left intrahepatic segmental duct openings, which were reconstructed as a whole at each side of transection plane after ductoplasty. The patient recovered uneventfully. Although surgical technique for S4a+S5+S1 must be more complex comparing with other anatomical hepatectomy, but it could be accepted as a safe curative resection for some selected patients with advanced hilar bile duct cancer, by which favorable recovery of the liver function may lead to prevention of postoperative complications. Comprehension to the anatomy of the intrahepatic ducts is a prerequisite for S4a+S5+S1 resection, thus we discussed it in detail.

Isolated Caudate Lobectomy with Bile Duct Resection Performed in a Patient with Type IV Hilar Bile Duct Cancer

The prognosis of hilar bile duct cancer has been improved by extensive curative resection, but limited functional reserve of the liver occasionally does not permit such a major hepatectomy. We report a type IV hilar bile duct cancer case undergone isolated caudate lobectomy as a limited but curative resection, in whom the indocyanine green retention test at 15 minutes revealed 23.9% despite long-term biliary decompression and the whole liver was rather atrophic. Complete removal of the Spiegel lobe, paracaval portion, and caudate process combined with hilar bile duct resection made 3 right and 4 left intrahepatic duct openings, which were reconstructed as a whole at each side of transection plane after ductoplasty. The patient recovered uneventfully. Although surgical technique for isolated caudate lobectomy must be more difficult comparing with other anatomical hepatectomy, but it can be a ultimate technique of limited curative resection for advanced hilar bile duct cancer patients with decreased hepatic reserve. Comprehension to the anatomy of the caudate lobe is a prerequisite for its resection, thus we discussed it in detail.

Techniques and Indications for a Central Bisegmentectomy of the Liver

BACKGROUND: Central bisegmentectomy (CBS) of the liver is a resection of the medial and anterior segments for preserving more liver parenchyma and reaching the goal of a curative resection simultaneously. PURPOSE: In this paper, we describe the indications and the techniques for this surgical procedure. PATIENTS AND METHODS: We reviewed the case histories of 14 patietns who had undergone a CBS, including 9 with a hepatocellular carcinoma, 4 with hilar bile-duct cancer, 1 with metastatic colon cancer, and 1 with gallbladder cancer. Eight patients had undergone a CBS with an operating time of only 353 minutes; 5 cases had undergone a CBS and a caudate lobectomy plus bile-duct resection, requiring an operating time of 762 minutes. A hepaticojejunostomy to right posterior hepatic duct was added to one CBS case because of intrahepatic ductal variation. The surgical technique for the CBS only procedure was as follows: demarcation of the dissection line with a selective block of the glissonian cord, division of the medial and the lateral segments along the falciform ligament to expose the left hepatic vein, and division of the anterior and the posterior segments along the right hepatic vein. In the combined bile-duct-resection cases, complete dissection of the hepatoduodenal ligament and biliary reconstruction were added. RESULTS: The extent of liver resection, as estimated by CT volumetry, was about 42%, and the mean value of the real weights of the specimens was 474 gm. The preoperative hepatic function showed a 9.3% indocyanine-green retention rate at 15 minutes, and 5 out of 9 hepatocellular carcinoma cases revealed concomitant liver cirrhosis. For CBS and additional procedures, the curative resection rate reached 93%, and the survival rate was favorable. There were no operative mortalities or hepatic failures. CONCLUSIONS: For selected cases of centrally located liver tumors or hilar bile-duct cancer with limited hepatic reserve, CBS may provide a safe, curative resection.

Long-term Result of Radical Resection for Hilar Bile Duct Cancer

Sixty patients with hilar bile duct cancer were operated on during a period of nine years. The tumor was resected in 45 patients (resection rate:75.0%). A hilar resection with regional lymph-node dissection was performed in 27 patients, and various types of hepatic resections were added in 18 patients. A potentially curative resection was achieved in 20 patients (curative resection rate:44.4%). There were two operative deaths (operative mortality:4.4%). The overall cumulative five-year survival rate was 25.6%. Six patients survived for more than five years. The survival was superior in patients with a curative resection and in those with a combined hepatic resection, but this result was statistically insignificant. Regional lymph-node metastasis, gross type, histologic grade, and perineural invasion were significant prognostic factors. We conclud that improved survival in hilar bile duct cancers can be achieved by a radical resection with acceptable morbidity and mortality.