Ann Hepatobiliary Pancreat Surg.  2021 Aug;25(3):419-425. 10.14701/ahbps.2021.25.3.419.

Parenchyma-preserving hepatectomy including segments I + IV resection and bile duct resection in a patient with type IV perihilar cholangiocarcinoma: A case report with video clip

• Hwang S

• KMID: 2519302
• DOI: http://doi.org/10.14701/ahbps.2021.25.3.419

Abstract

It has been reported that parenchyma-preserving hepatectomy (PPH) might lower surgical curability with an increased likelihood of bile duct resection margins (BDRMs). Apparently, PPH is indicated for patients expected to achieve curative resection. The author herein presents a case of a 77-year-old male patient with type IV perihilar cholangiocarcinoma and decreased cardiac function treated with hepatic segments I + IV resection and bile duct resection. During the operation, he underwent two hepatic parenchymal transections matched with right trisectionectomy and left hepatectomy. After removing segments VI and I and extrahepatic bile duct, six hepatic duct openings were exposed at the left and right hila. As some of them were conjoined, two hepaticojejunostomies at the right liver and one hepaticojejunostomy at the left lateral section were performed consecutively. This operation took 7 hours. Eight sessions of intraoperative frozen-section biopsy were performed. All BDRMs were tumor-negative. According to the 8th edition of the American Joint Committee on Cancer staging system, the extent of the tumor was pT2bN2M0. It was regarded as stage IVA tumor. The patient recovered uneventfully. He was discharged on the 18th postoperative day. The patient underwent concurrent chemoradiation therapy and adjuvant chemotherapy. The patient has been doing well without tumor recurrence for the past 24 months to date. In conclusion, PPH can lead to curative resection and improved outcomes through reasonable adjustment of the extent of hepatectomy.

Keyword

Parenchyma-preserving hepatectomy; Perihilar cholangiocarcinoma; Klatskin tumor; Bile duct resection margin; Hepatic failure

Figure

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  Fig. 1 Preoperative imaging study findings. Computed tomography images (A, B) and magnetic resonance cholangiography images (C, D) show extensive hilar bile duct obstruction, suggesting perihilar cholangiocarcinoma of Bismuth-Corlette type IV. Arrows indicate tumor.

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  Fig. 2 Intraoperative photographs showing dissection of the hepatoduodenal ligament. Surgical resectability is assessed through manual palpation (A). The distal common bile duct (CBD) is transected (B). Enlarged regional lymph nodes (LNs) are dissected (C). Intraoperative frozen-section biopsy showed nodal metastasis. The hepatic artery and portal vein branches are isolated without macroscopic vascular invasion (D).

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  Fig. 3 Intraoperative photographs showing left liver transection. The liver parenchyma is transected along the falciform ligament (A). The segment III duct (B3) and segment II duct (B2) are consecutively transected (B, C). The left portal vein and hepatic artery are further dissected to expose the umbilical portion of the left portal vein, and the remnant left lateral segment is separated from the left caudate lobe (D).

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  Fig. 4 Intraoperative photographs showing right liver transection. Right-sided hepatic parenchymal transection is performed along the hemi-liver discoloration line (A). Two segment V ducts (B5) are transected (B, C). Segment VIII duct (B8) is transected (D).

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  Fig. 5 Intraoperative photographs showing right liver transection. Conjoined segments VI and VII duct (B6 + 7) is transected (A). The paracaval portion and the left caudate lobe (S1) are removed along with segment IV (S4) resection (B, C). There are six hepatic duct openings at the left and right hila (D).

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  Fig. 6 Intraoperative photographs showing biliary reconstruction. Segments VI and VII duct (B6 + 7) is reconstructed through a single hepaticojejunostomy (HJ) (A). Two segment V ducts (B5) and one segment VIII duct (B8) are conjoined and a single HJ is performed with stent insertion into the small B5 duct (arrow) (B). Segment II and III ducts (B2 + 3) are conjoined and a single HJ is performed (C, D).

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  Fig. 7 Gross photograph of the resected specimen with segments VI and I and the extrahepatic bile duct.

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  Fig. 8 Postoperative computed tomography findings. Images taken 10 days (A, B) and 18 months (C, D) after surgery show no abnormal findings.

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