Short- and long-term outcomes of middle hepatic vein-oriented hepatectomy for advanced perihilar cholangiocarcinoma.

BACKGROUND: This study aimed to compare clinical outcomes of the middle hepatic vein (MHV)-oriented versus conventional hemihepatectomy for perihilar cholangiocarcinoma (PHC). METHODS: From 2008 to 2017, medical records of patients undergoing hemihepatectomy with caudate lobectomy for advanced PHC were reviewed retrospectively. MHV-oriented hepatectomy was defined as full exposure of the MHV on the dissection plane. Predictors of morbidity and survival were identified. RESULTS: A total of 125 patients were enrolled. MHV-oriented and conventional hepatectomies were performed in 44 and 81 patients, respectively. The curative resection rate, blood loss, transfusion, and survival were comparable between two groups; however, severe morbidity rate was significantly lower in the MHV-oriented group (9.1% vs 38.3%, P < 0.001). MHV-oriented approach was an independent predictor of severe morbidity, as were the age, bilirubin level, and blood transfusion. Severe morbidity was associated with significantly decreased overall survival and recurrence-free survival (RFS) (median 29.0 vs 46.9 months, P = 0.011 and 20.3 vs 31.1 months, P = 0.003, respectively). Multivariate analysis revealed that severe morbidity independently predicted shorter RFS (P = 0.025). CONCLUSIONS: MHV-oriented approach for advanced PHC is safe and associated with a significant decrease in severe morbidity. Severe morbidity adversely affects survival after surgery; therefore, optimal preoperative preparation and MHV-oriented hepatectomy with meticulous dissection remain of critical importance.

Radiologic evaluation of vasculobiliary anatomy in the umbilical fissure.

BACKGROUND: Preoperative evaluation of vasculobiliary anatomy in the umbilical fissure (U-point) is pivotal for perihilar cholangiocarcinoma (PCCA) applied to right-sided hepatectomy. The purpose of our study was to review the vasculobiliary anatomy in the U-point using three-dimensional (3D) reconstruction technique, to investigate the diagnostic ability of 2D scans to evaluate anatomic variations, and to discuss its surgical implications. METHODS: A retrospective study of 159 patients with Bismuth type I, II, and IIIa PCCA, who received surgery at our institution from November 2012 to September 2016, was conducted. Anatomic structures were assessed using multidetector computed tomography (MDCT) by one hepatobiliary surgeon, whereas 3D images were reconstructed by an independent radiologist. Normal confluence pattern of left biliary system was defined as the left medial segmental bile duct (B4) joining the common trunk of segment II (B2) and segment III (B3) ducts, whereas aberrant confluence patterns were classified into 3 types: type I, triple confluence of B2, B3, and B4; type II, B2 draining into the common trunk of B3 and B4; type III, other patterns. Surgical anatomy of B4 was classified into the central, peripheral, and combined type according to its relation to the hepatic confluence. The lengths from the bile duct branch of Spiegel's lobe (B1l) to the orifice of B4 and the junction of B2 and B3 were measured on 3D images. The anatomy of left hepatic artery (LHA) was classified according to different origins and the spatial relationship related to the U-point. RESULTS: 3D reconstruction revealed that normal confluence pattern of left biliary system was observed in 71.1% (113/159) of all patients, and variant patterns were type I in 11.9% (19/159), type II in 12.6% (20/159), and type III in 4.4% (7/159). The length from B1l to the junction of B2 and B3 was 12.1 ± 3.1 mm in type I variation, which was significantly shorter than that in normal configuration (30.0 ± 6.8 mm, P < 0.001) but significantly longer than that in type II variation (9.6 ± 3.4 mm, P = 0.019). Surgical anatomy of B4: the peripheral type was most commonly seen (74.2%, 118/159), followed by central type (15.7%, 25/159) and combined type (10.1%, 16/159). The distance between the B1l and B4 was 8.4 ± 2.4 mm in central and combined type, which was significantly shorter than that in peripheral type (14.5 ± 4.1 mm, P < 0.001). A replaced or accessory LHA from the left gastric artery was present in 6 (3.8%) and 9 (5.7%) patients, respectively. LHA running along the left caudal position of U-point was present in 143 cases (89.9%), along the right cranial position of U-point in nine cases (5.7 %), and combined position in seven cases (4.4%). Interobserver agreement of two imaging modalities was almost perfect in biliary confluence pattern (kappa = 0.90; 95% confidence interval: 0.79-1.00), substantial in surgical anatomy of B4 (kappa = 0.74; 95% confidence interval: 0.62-0.86), and perfect in LHA (kappa = 1.00). CONCLUSIONS: Thoroughly understanding the imaging characters of surgical anatomy in the U-point may be benefit for preoperative evaluation of PCCA by successive review of 2D images alone, whereas 3D reconstruction technique allows detailed hepatic anatomy and individualized surgical planning for advanced cases.

Clinical Implications of Biliary Confluence Pattern for Bismuth-Corlette Type IV Hilar Cholangiocarcinoma Applied to Hemihepatectomy.

BACKGROUND: Since biliary variations are commonly seen, our aims are to clarify these insidious variations and discuss their surgicopathologic implications for Bismuth-Corlette (BC) type IV hilar cholangiocarcinoma (HC) applied to hemihepatectomy. METHODS: Three-dimensional images of patients with distal bile duct obstruction (n = 97) and advanced HC (n = 79) were reconstructed and analyzed retrospectively. Normal biliary confluence pattern was defined as the peripheral segment IV duct (B4) joining the common trunk of segment II (B2) and segment III (B3) ducts to form the left hepatic duct (LHD) that then joined the right hepatic duct (RHD). The lengths from left and right secondary biliary ramifications to the right side of the umbilical portion of the left portal vein (Rl-L) and the cranio-ventral side of the right portal vein (Rr-R) were measured, respectively, and compared with the resectable bile duct length in HCs. Surgicopathologic findings were compared between different BC types. RESULTS: The resectable bile duct length in right hemihepatectomy for eradication of type IV tumors was significantly longer than the Rl-L length in normal biliary configuration (17.4 ± 1.8 and 10.3 ± 3.4 mm, respectively, p < 0.001), and type III variation (B2 joining the common trunk of B3 and B4) was the predominant configuration (53.8%). The resectable length in left hemihepatectomy for eradication of type IV tumors was comparable with the Rr-R length in RHD absent cases (15.2 ± 2.5 and 16.4 ± 2.6 mm, respectively, p = 0.177) but significantly longer than that in normal configuration (p < 0.001). The estimated length was 8.5 ± 2.0 mm in unresectable cases. There was no significant difference between type III and IV tumors, except for the rate of nodal metastasis (29.7 and 76.0%, respectively, p < 0.001). CONCLUSION: Hemihepatectomy might be selected for curative-intent resection of BC type IV tumors considering the advantageous biliary variations, whereas anatomical trisegmentectomy is recommended for the resectable bile duct length less than 10 mm. Biliary variations might result in excessive classification of BC type IV but require validation on further study.