Improved Survival Following Right Trisectionectomy with Caudate Lobectomy without Operative Mortality: Surgical Treatment for Hilar Cholangiocarcinoma
Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-dong, Gangnam-gu, Seoul 135-710, Korea. Journal of Gastrointestinal Surgery
(Impact Factor: 2.8).
08/2008; 12(7):1268-74. DOI: 10.1007/s11605-008-0503-1
We conducted this study to assess the safety of performing right trisectionectomy with caudate lobectomy for hilar cholangiocarcinoma by analyzing postoperative mortality and morbidity, and to evaluate the effect of such procedure on pathological curability and long-term overall survival.
A retrospective clinicopathological analysis was performed for 16 hilar cholangiocarcinoma patients who underwent right trisectionectomy with caudate lobectomy from June 1999 to April 2003. The median follow-up period was 36.9 months. The preoperative Bismuth-Corlette type was type II in four patients, type III(A) in 10 patients, and type IV in two patients.
The median liver volume after hepatic resection was 21.9% of the total liver volume. Postoperative complications including one chronic liver failure developed in 12 patients, but no in-hospital deaths occurred. A postoperative pathological examination showed a cancer free margin in all of the proximal resection sites, although three cases had carcinoma in situ (CIS) lesions in the distal margin that were confirmed during surgery. The 1-, 3-, and 5-year overall survival rates were 94.1%, 64.2%, and 64.2%, respectively.
We obtained excellent survival rates without any in-hospital deaths following right trisectionectomy with caudate lobectomy. This procedure may be an effective surgical procedure that can be executed to achieve low mortality rate and high pathological curability for hilar cholangiocarcinomas, except for Bismuth type III(B).
Available from: In Woong Han
- "Some authors suggest that an extensive hepatic resection, such as performing a right or left trisectionectomy with caudate lobectomy, may be an effective surgical procedure that can achieve a low mortality rate and high pathological curability for HCCA [25,26]. However, in-hospital deaths from postoperative hepatic failure have been the greatest contributor to poor survival rates [2,25]. As a partial solution to this poor survival rate, preoperative PVE is widely used to minimize the risk of liver failure when extensive liver resection is anticipated [4,7]. "
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Extended liver resection may provide long-term survival in selected patients with Bismuth type IV hilar cholangiocarcinoma (HCCA). The purpose of this study was to identify anatomical factors that predict curative-intended resection.
Thirty-three of 159 patients with Bismuth type IV HCCA underwent major hepato-biliary resection with curative intent (CIR) between 2000 and 2010. Disease extent and anatomical variations were analyzed as factors enabling CIR.
CIR ratio with hilar trifurcation bile duct variation (13/16) was significantly higher than that with other bile duct variation types (18/25). Hilum to left second bile duct confluence and tumor infiltration over left second bile duct confluence lengths in right-sided CIR were significantly shorter than those lengths in left-sided CIR (10.8 ± 4.9 and 2.7 ± 0.8 mm vs. 16.5 ± 8.4 and 7.0 ± 5.3 mm, respectively). Left-sided CIR patients had a marginally higher proportion of tumors invading ≤5 mm over the right second confluence than that in right-sided CIR patients (13/17 vs. 6/16; P = 0.061). The 3-year survival rate after CIR (28%) was significantly higher than after non-CIR (6.1%).
We recommend the criteria of CIR as bile duct variation type, length of hilum to contralateral second bile duct confluence, and extent of tumor infiltration over the second confluence for Bismuth type IV HCCA.
Available from: ncbi.nlm.nih.gov
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ABSTRACT: To evaluate hepatic recurrence and prognostic factors for survival in patients with surgically resected hilar cholangiocarcinoma in a single institution over the last 13 years.
From 1994 to 2007, all patients with hilar cholangiocarcinoma referred to a surgical clinic were evaluated. Demographic data, tumor characteristics, and outcome were analyzed retrospectively. Outcome was compared in patients who underwent additional liver resection with resection of the tumor.
Of the 69 patients submitted to laparotomy for tumor resection, curative resection (R(0) resection) was performed in 40 patients, and palliative resection in 29. Thirty-one patients had only duct resection, and 38 patients had combined duct resection with liver resection including 34 total or part caudate lobes. Curative rates with the combined hepatectomy were significantly improved compared with those without additional hepatectomy (27/38 vs 13/31; chi2 = 5.94, P < 0.05). Concomitant liver resection was associated with a decreased incidence of initial recurrence in liver one year after surgery (11/38 vs 23/31; chi2 = 13.98, P < 0.01). The 3-year survival rate after R(0) resection was 30.7% and was 10.5% for palliative resection. R(0) resection improved the 3-year survival rate (30.7% vs 10.5%; chi2 = 12.47, P < 0.01).
Hepatectomy, especially including the caudate lobe combined with bile duct resection should be considered standard treatment to cure hilar cholangiocarcinoma.
Available from: Jeong-Hoon Lee
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ABSTRACT: Hilar cholangiocarcinomas are often treated with liver resections. Hepatic dysfunction and infection are common postoperative complications. Although secondary bacterial peritonitis due to abdominal abscess or perforation is common, we report herein the first case of spontaneous bacterial peritonitis after hepatic resection. A 61-year-old male patient without underlying liver disease was diagnosed as having a Klatskin tumor, and a right trisectionectomy with caudate lobectomy was performed. From postoperative days 18-28, the patient gained 4.1 kg as ascites developed, and showed evidence of hepatic insufficiency with prolonged prothrombin time and jaundice. Computed tomography, performed at postoperative day 28 when fever had developed, showed only ascites without bowel perforation or abscess. When paracentesis was performed, the serum-ascites albumin gradient was 2.3 g/dL, indicating portal hypertension, and the ascites' polymorphonuclear cell count was 1,156/mm(3). Since the clinical, laboratory, and image findings were compatible with spontaneous bacterial peritonitis, we started empirical antibiotics without additional intervention. Follow-up analysis of the ascites after 48 hours revealed that the polymorphonuclear cell count had decreased markedly to 108/mm(3); the fever and leukocytosis had also improved. After 2 weeks of antibiotic treatment, the patient recovered well, and was discharged without any problem.
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