References

Ozden I, Kamiya J, Nagino M et al (2002) Clinicoanatomical study on the infraportal bile ducts of segment 3. World J Surg 26(12) 1441-1445 2. Ohkubo M, Nagino M, Kamiya J et al (2004) Surgical anatomy of the bile ducts at the hepatic hilum as applied to living donor liver transplantation. Ann Surg 239(1) 82-86 3. Nimura Y, Hayakawa N, Kamiya J et al (1995) Hilar cholangiocacinoma surgical anatomy and curative resection. J Hepatobiliary Pancreat Surg 2 239-248 4. Nimura Y (1997) Surgical anatomy...

TNM Classification According to the LCSGJ

In 1992, the LCSGJ convened a research group to formulate a new staging system specific for ICC. This group carried out a multicentric study with nine Japanese surgical institutions and analysed 173 patients who underwent resection with curative intent for ICC. In 1997, the first edition of this new classification was published and it was revised in 2003 2 . The Japanese classification of cholangiocarcinoma defines intrahepatic neoplasm as originating from the peripheral branches of biliary...

Extended Left Resections

The extended left resections are indicated when the neoplasm involves the hilar bifurcation and spreads preferentially towards left intrahepatic ducts (extended left hepatectomy with caudate lobectomy S1+S2, S3, S4) or when the neoplasm involves the entire left lobe and extends to the anterior segment (left trisectionectomy with caudate lobectomy S1+S2, S3, S4, S5, S8). Left resections require a greater parenchymal dissection compared to right ones. Furthermore right portal pedicles are...

Biological and Molecular Factors

Many biological and molecular prognostic factors have been identified in ICC including interleukin (IL)-6, hepatocyte growth factors (HGFs), c-met, transforming growth factor (TGF)-p, epidermal growth factor (EGF), c-erb-2, lymphocyte inhibitory factor, k-ras and p53 34-37 . The expression of IL-6 is inversely related with cellular proliferation and directly correlated with cholangiocarcinoma differentiation. Increase levels of IL-6 are frequently found in well-differentiated cholangiocarcinoma...

Preoperative Staging

The only successful treatment of cholangiocarcinoma is curative resection evaluation of biliary involvement, either longitudinal or radial, loco-regional diffusion and presence of distant metastases are important for planning the therapeutic strategy. The introduction of imaging techniques, especially spiral CT and MRI associated with MRCP, have changed evaluation of preoperative staging of cholan-giocarcinoma these procedures allow to obtain high definition images, and make possible to...

B

In 2005 Stavropoulos et al. 11 reported the results in 61 patients with jaundice without mass at preoperative workup, with a biliary tract stenosis documented by ERCP (malignant obstruction in 43 cases and benign in 18) subjects underwent ultrasound with a high frequency probe (20 MHz). While ERCP showed 25 false negative cases, 22 of whom had malignant stenosis, intraductal ultrasound showed only 7 false-negative cases and 3 false-positive. The percentage of patients with positive diagnosis...

Immunohistochemistry

Cholangiocarcinoma cells express cytokeratins 7 and 19, carcinoembryonic antigen CEA, epithelial membrane antigen EMA, BER-EP4 and blood group antigens. Hepatocyte antigen is not usually expressed by cholangiocarcinoma. Mucus core (MUC) proteins 1, 2, 3 are also detectable in carcinoma cells. Immunohistochemistry can be useful in distinguishing cholangiocarcinoma from metastatic carcinoma, especially in bioptic specimens. Occasionally, dys-plastic changes in neighboring bile ducts suggest...

N Category

According to the IUCC AJCC classification, regional lymph nodes are located at the hepatic hilum, along the proper hepatic artery, along the portal vein and along the vena cava above the renal veins (except the inferior phrenic nodes). Two classes are defined N0 and N1 on the basis of positive and negative regional nodes involvement of non-regional nodes is considered indicative of distant metastasis (M1) (Table 2). Table 2 N category according to the TNM system of the UICC AJCC N0 Absence of...

Specimen

Size (3 dimensions) Weight Descriptive features (external cut surfaces) Bile duct vessels on cut surface - Extrahepatic Bile Duct. Dimension of bile ducts (length and thickness of wall) External surface Obstruction (partial complete) - Margins. Transection margin, Bile duct margin The intraoperative examination of the bile ducts at the cut margin is recommended in order to evaluate the lining epithelium for carcinoma in situ or dysplasia. The raw surface of a hepatectomy may be large,...

Stage Grouping

The grouping of T, N and M categories allows subdivision of the neoplasms as in the following outline (Fig. 5). This TNM staging is based on a precise classification of pathological findings as TNM UICC AJCC classification it is useless in preoperative evaluation and for defining resectability. In patients who undergo surgical exploration and resection with curative intent this classification permits precise assignment to classes with different prognoses. Unfortunately the complexity of this...

Staging Systems

Many staging systems have been proposed for hilar cholangiocarcinoma and none of them has been accepted unanimously. Three different types of classification have been suggested - Classification based on macroscopic biliary involvement (Bismuth-Corlette) - Histopathologic classification (TNM AJCC UICC and Japanese Society for Biliary Surgery, JSBS) - Classification based on biliary and vascular involvement (Gazzaniga and Memorial Sloan Kettering Cancer Center, MSKCC)

Results

Diagnostic laparoscopy has a low morbidity and almost no mortality. In the literature, the complication rate of laparoscopy for hepatobiliary neoplasms varies from 0 to 4 5,7-10 . Major and more frequently observed complications are postoperative bleeding, intestinal perforation and intra-abdominal infection. Minor complications are wound infection, abdominal pain and pulmonary complications. Neoplastic seeding in the port sites is described in the laparoscopy studies for hepatobiliary...

Surgical Treatment of Hilar and Intrahepatic Cholangiocarcinoma

In cooperation with Luigi Marchiori Silvia Pachera Luca Bortolasi Riccardo Manfredi Paola Capelli Alfredo Guglielmi Andrea Ruzzenente Calogero Iacono General Surgery A, Department of Surgery and Gastroenterology University Hospital G.B. Rossi Verona, Italy Luigi Marchiori, Silvia Pachera, Luca Bortolasi General Surgery A, Department of Surgery and Gastroenterology University Hospital G.B. Rossi Verona, Italy Riccardo Manfredi Department of Radiology University Hospital G.B. Rossi Verona, Italy...

Hilar Cholangiocarcinoma

Reporting Cholangiocarcinoma Pathological Aspects Clinical Information Intraoperative Macroscopic Pathology Findings in Non-Neoplastic Lymph Nodes (Location, Frozen Tissue (Molecular Microscopic Additional Pathology Immunohistochemistry Ultrasound (Endoscopic, Intraductal, Computed Magnetic Resonance Positron Emission Tomography Direct Cholangiography (ERCP and Cholangioscopy (Peroral, Percutaneous) Angiography Preoperative Evaluation of the Biliary Involvement (Longitudinal Extent) 30...

Indications

PVE is indicated in extended in liver tumour. There is a general consensus in retaining that in a normal liver the minimum essential volume of the FRL is between 25 and 30 2,11-13 . A major percentage of FRL is required in patients with compromised hepatic function or in whom the planned procedure is difficult, e.g. in cholangiocarcinoma, to reduce the postoperative risks. Future remnant liver can be at least 40 in patients with cholestasis or chronic hepatic disease (steatosis, cirrhosis) or...

Endoscopic or Percutaneous Drainage

As with evaluation of intraductal (longitudinal) diffusion of the tumour and of preoperative drainage of jaundice, there is no unanimous point of view on whether the endoscopic or the percutaneous route is the better approach. In contrast to authors who consider endoscopic drainage the treatment of choice in patients with unresectable cholangiocarcinoma documented by preoperative work-up 8-10 , and even intraoperatively in the place of surgical palliation 11 , other authors 4,12-17 believe that...

Neoadjuvant Therapy

This approach, which in other oncological fields has changed the therapeutic strategy and long-term results, is not indicated in patients with cholangiocarcinoma since nearly all of them present jaundice. At the end of the 1990s a study reported encouraging data regarding this type of approach, even though the main limit of this paper was the small number (only 9) of treated patients, 5 with hilar and 4 with peripheral cholangiocarcinoma 17 . The authors used an association of chemo-radiation...

Laparoscopic Ultrasound

Laparoscopic ultrasound can be useful for increasing the sensitivity and accuracy of laparoscopic staging. Laparoscopic ultrasound probe is linear at high frequency (8-10 MHz) and gives high-resolution images besides Doppler ultrasound evaluation it permits identification of vascular structure infiltration. An ultrasound probe is inserted through the 10-mm umbilical or right upper quadrant port and a complete examination of hepatic parenchyma is performed, since it can detect hepatic lesions...

Lymph Nodes Location Number

The removed lymph nodes should be classified and numbered according to the Japanese classification. Although this classification is a complex system, it should be applied to be sure that the individual nodes are precisely defined. According to UICC criteria the regional lymph nodes must be separated from non-regional lymph nodes the involvement of non-regional lymph nodes is defined as distant metastases. The last classification reflects the anatomical site of larger node groups in relation to...

Microscopic Pattern

The main microscopic factors of hilar cholangiocarcinoma, that affect prognosis, are cellular differentiation, perineural infiltration, lymphatic and microvascular infiltration. Cellular differentiation is an important prognostic factor, and is directly associated with the stage of disease, percentage of curative resections and long-term prognosis. Survival is significantly related to cellular differentiation 34-41 months for G1-G2 and 14-20 months for G3 5,6 . Jarnagin 4 has observed that 64...

Jaundice and PVE

The majority of patients with hilar cholangiocarcinoma have cholestatic liver injury. High values of total bilirubinemia when PVE is performed decreases the hypertrophy amplitude of the non-embolized lobe 18 , but only an elevated concentration of bile salts can induce hepatocellular apoptosis. The reason for the negative effect of jaundice on hepatic regeneration is determined by haemody-namic causes (portal flow is correlated to parenchymal hypertrophy) and humoral regulation 5 . Hence the...

Type of Surgical Resection

Surgical resection of cholangiocarcinoma is represented by anatomic hepatic resection. Advanced-stage neoplasms must often be treated by extended hepate-ctomy, with extension of the resection to the extrahepatic biliary tract, vascular hilar structures, vena cava and diaphragm. Usually, this type of neoplasm develops in a non-cirrhotic liver, which allows the surgeon to perform extended resection without the need of portal-vein embolisation. The mortality and morbidity rates in these cases vary...

T Category

T category values the extent of disease based on size of neoplasm, focality, vascular invasion and extension to adjacent organs. It divides the neoplasms into four categories (Table 1). Although there are few reports on the validation of T-staging, the components that define T category (size, number, vascular invasion) have shown a close correlation with prognosis in several studies 3-8 . Miwa et al. have observed that the size of the tumour significantly determined the prognosis in 41...

Photodynamic Therapy

Photodynamic therapy is indicated for local control of unresectable disease in absence of distant metastases similarly to other types of tumour such as oesophagus, colon, stomach, bronchi, urinary bladder and brain, photodynamic therapy has been introduced in the treatment of cholangiocarcinoma 62 . The procedure requires the infusion of a photosensitizing drug (sodium porfimer) that accumulates electively in tumoral cells 24-48 h after administration subsequently cyto-toxic free radicals such...

Prognostic Factors

Radical surgery is the only therapeutic option that can ensure a long-term survival until now many aspects of this disease have not been well-known, such as pathogenesis, and clinical and histopathologic factors that determine survival. In this chapter we will analyze the main prognostic factors that influence survival macroscopic aspect, local extent, lymph-node involvement and distant metastases. Histological characteristics and molecular factors related to prognosis will also be analysed.

PostPVE Course and Timing of Resection

PVE is usually followed by alteration of the hepatic functional parameters (particularly increased ALT, AST and bilirubinemia), leukocytosis and fever. These alterations are slight, transient and self-limiting. The entity of tissue necrosis after PVE is insignificant therefore it is not related to considerable systemic symptoms as after arterial embolization. From 14 to 63 days after PVE a new hepatic volumetry is performed. If the expected hypertrophy of the FRL is noticed the patient is...

Conclusions

Correct staging of ICC is still a subject of debate. However, the differences between ICC and hepatocellular carcinoma are clear. For these reasons, the staging system proposed by the UICC AJCC, which was mainly developed to stage hepatocarcinoma, is quite limited when it is applied to ICC. The UICC AJCC classification does not differentiate neoplasms on the basis of type of tumoral growth and provides a limited differentiation of the criteria of local disease and disease involving lymph-node...

Direct Cholangiography ERCP and PTC

Direct visualization of the biliary tree is achieved by means of endoscopic retrograde cholangiography and percutaneous transhepatic cholangiography that provide a precise and complete opacification with contrast material. Since the introduction of ultrasound (CT and especially MRCP) in clinical practice, indication of these techniques for diagnosis has decreased and they are mainly applied for operative purposes. The application of these direct and invasive techniques has to be proposed by the...

Indications for Surgical Resection

As with extrahepatic cholangiocarcinoma, R0 of ICC is the most effective treatment and the only therapy associated with prolonged disease-free survival. Nonetheless, there is currently little agreement on the indications for surgical resection. According to some authors curative resection (R0) of ICC is feasible only in patients with a single lesion, negative lymph nodes and resectable hepatic margins of > 1 cm 7 , or in patients without gross intrahepatic biliary infiltration all patients...

Evaluation of Metastases M

Abdominal ultrasound enhanced with contrast agent can better identify and typify hepatic lesions than conventional US CT and MRI are also useful to focalise this parameter. PET is effective for staging due to its ability to detect distant metastases. Anderson 38 reported that 30 of the patients with distant metastases were not diagnosed with other radiological tests, while Kim 39 identified distant metastases in four of 21 patients with peripheral cholangiocarcinoma, not detected by other...

Cholangioscopy Peroral Percutaneous

Cholangioscopy associated with biopsy has an important role in the differential diagnosis of biliary stenosis 28-32 . It can be performed through a peroral endoscopic or a percutaneous approach 30-33 the former is the less invasive route and does not necessarily require sphincterectomy, with the advantage that it can be performed at the same time as ERCP, reducing the time of diagnosis and preoperative hospitalization. Conversely percutaneous transhepatic cholan-gioscopy requires a gradual...

Preface

I would like to thank the Steering Committee of the Italian Society of Surgery (SIC) for giving me the opportunity of writing this book. I accepted the task enthusiastically, because the surgery of cholangiocarcinoma is a fascinating and complex part of hepatobiliary surgery that has undergone numerous changes over recent decades. My aim has been to provide an update on the diagnosis, staging, preoperative management and treatment of hilar and intrahepatic cholangiocarcinoma, and to provide a...

Central Hepatic Bisectionectomy with Caudate Lobectomy S4 S5 S8 S1

Lymph node and connective tissue dissection of the hepatoduodenal ligament is performed first. The middle artery and right anterior arterial and portal branch are tied as well. The next step is the ligation of arterial and portal branches to the caudate lobe that arise from right and left main branches. Then the complete mobilisation of the right and left liver with separation of the caudate lobe from cava plane is achieved. The parenchymal dissection of the liver begins on the right margin of...

T1

The neoplasm within the ductal wall is defined as early bile duct cancer it represents about 10 of all cholangiocarcinoma and shows distinctive characteristics. In 52 of cases the neoplasms show a papillary aspect and in more than 60 are well differentiated. Lymph-node involvement is present in 0-2 of the cases and perineural invasion is present in 0-10 19,20 . The prognosis is good with a 5-year survival rate of 78 . According to gross type the survival rate of papillary and infiltrative...

Definitions

Cholangiocarcinoma is a malignant tumour composed of cells resembling those of the bile ducts. According to WHO classification 1 the term cholangiocarcinoma is reserved for carcinomas arising in the intrahepatic bile ducts. For this reason, tumours arising from extrahepatic bile ducts should be designated as extrahepatic bile duct carcinomas. However clinical and pathological differentiation of intrahepatic from extrahepatic bile duct cancers can be difficult. Cancers arising from the bile duct...

Technique

The approach to the portal system depends on the technical preferences of the operator, on the types of planned hepatic resection, on embolization extent and the embolizing agent. Independently of the chosen route, the aim is to occlude completely the portal branches of the portion of hepatic parenchyma that is going to be resected this prevents the development of porto-portal collaterals that can negatively condition the volumetric increase of the residual part of the liver 22 . The type of...

S8 S1

The left trisectionectomy with caudate lobectomy is indicated for hilar cholan-giocarcinoma that involves the left intrahepatic bile ducts in continuity with the duct to the right anterior sector (S5 and S8). After concluding dissection of hepatoduodenal ligament as previously described, the left and middle hepatic arteries are tied and divided at their origins. The right artery is isolated very gently up to its second order bifurcation for anterior and posterior sectors. The branch for...

Intraoperative Assessment of Resectability

At the time of diagnosis, patients with intrahepatic cholangiocarcinoma (ICC) are frequently found to have disease beyond the limits of surgical therapy, such the presence of intrahepatic satellite nodules, vascular invasion, or regional lymph-nodes metastases. In such patients, the resectability rate varies from 19 to 74 1-4 . Moreover, exploratory laparotomy or R1 resection has a poor prognosis, with median patient survival of 5 months and postoperative complications of 17 4 . Consequently,...

Tumours

With reference to the bile ducts intrahepatic or hilar (Fig. 4) - Extent of Biliary Involvement. For hilar cholangiocarcinoma involvement of right hepatic duct - left hepatic bile duct - junction of right and left hepatic ducts - common bile duct (Bismuth classification). If more than one anatomical portion is involved, all involved portions should be recorded in the order of involvement, first indicating the portion in which the bulk of the tumour is located. Fig. 4a,b Hilar...

Ultrasound

Transabdominal ultrasound does not contribute any information to the evaluation of this parameter. However echoendoscopy appears to be useful in staging cholangiocarcinoma the lesion is detected as a hypoechoic mass within the lumen of the duct, frequently with infiltration of surrounding tissue. Sometimes the lesion is encased by hyperechoic tissue that is the expression of peritumoral fibrosis 4 . Tio et al. 5 reported a correct evaluation of T-stage in 85 of 43 cases with carcinoma of hilar...

Ultrasound Endoscopic Intraductal Transabdominal

Ultrasound represents the technique of choice for confirming obstructive jaundice. In fact it allows easy detection of the dilatation of the intra- and extrahep-atic biliary systems. However, although it shows high diagnostic reliability (80-94 ) in detecting biliary dilatation and the level of obstruction, its reliability in diagnosing the cause of obstruction decreases. Hilar cholangiocarcinoma may be presumed at ultrasound in presence of a hilar hypoechoic mass that has spread along the...

Magnetic Resonance Imaging

The MRI appearance of cholangiocarcinoma is that of a non-capsulated tumour, hypointense on T1-weighted images and hyperintense on T2-weighted images. The signal intensity of the tumour varies according to the amount of fibrosis, necrosis, and mucinous material within it. Central hypointensity may be seen on Fig. 4 Axial CT image during the arterial phase shows a hypodense-cen-tred mass on the left hepatic duct infiltrating the left hepatic artery Fig. 4 Axial CT image during the arterial phase...

Palliative Therapy Chemotherapy

Khan 9 , in the consensus document of guidelines for the diagnosis and treatment of cholangiocarcinoma, reported to date, a review of over 65 disparate studies using chemotherapy and or radiations suggests that was no strong evidence of survival benefit. However, most studies were small, lacked control groups (phase II) and were difficult to interpret. Data from a phase II study suggested that gemcitabine monotherapy is an active and well-tolerated treatment. Combinations of gemcitabine with...

Chemoradiation Therapy

Considering the radiosensitivity of some drugs such as 5-FU and gemcitabine, combining both therapies would appear hypothetically more efficient than sin gle treatment. However the data in the literature are divergent even for this therapeutic combination. In a group of 84 patients with cholangiocarcinoma (30 stages I and II, 54 stage III) who submitted to surgery alone and surgery associated with chemoradiation therapy (40 Gy + bolus 5-FU) Kim et al. 11 showed a 5-year survival of 36 in the 47...

Anatomy of the Portal Vein Branches

Usually few variants regard portal vein branches due to their early embryonic development during the gestation period. Three principal portal vein branching patterns in the hilar area are described by different authors - The common type (74-84 ) in which the anterior segmental branch joins the posterior to form the right branch of the portal vein. - The three branch type (8-12 ) in which the anterior segmental branch joins the portal vein confluence. - The left branch type (9-17 ) in which the...

TNM Staging System According to Uiccajcc 6th Edition

The sixth edition of TNM classification by Internal Union Against Cancer (UICC) and the sixth edition of the Manual for Staging of Cancer edited by American Joint Committee on Cancer were published in 2002 and used the same TNM classification and subdivision in stages 4 . Local extent of disease (T), nodal involvement (N) and presence of distant organ involvement (M) are determined by preoperative, intraoperative and pathological findings. T category evaluates local extent based on the degree...

Preoperative Assessment of Liver Function

Preoperative Lab Testing Form

Many elements contribute to the optimal selection of patients who will undergo surgery for hilar cholangiocarcinoma, including - Improvement of the preoperative diagnosis in the definition of size, site and tumour extent related to intrahepatic vascularisation - Findings of the intraoperative workup - Knowledge of the biological behavior of the tumour - Effects of biliary obstruction and jaundice - Effects of parenchymal inflammatory process and of cholangitis on clinical course and prognosis...

Surgical Anatomy of the Hepatic Hilus

Liver Hilum Anatomy

The development of curative surgery for hilar cholangiocarcinoma is based on the precise knowledge of anatomy of the hepatic hilus and of the frequent anatomical variations that may be encountered. For these reasons it would be useful to point out some anatomical details, with particular regard to the anatomy of the hilar and caudate lobe area that are the crucial point of this surgery. Biliary ducts, arterial and portal vessels that are covered by connective tissue arising from the fusion of...

Drainage Cons

A critical evaluation of the indiscriminate use of preoperative biliary drainage has revealed functional limits and undeniable side effects - After biliary drainage bilirubinemia normalizes in only two-thirds of the treated cases 5,31 and 4-8 weeks are required for complete disappearance of jaundice 32 . Watanapa 33 has shown in preoperative and postoperative functional studies that the liver resumes its normal functions 6 weeks after surgical operation entailing jaundice drainage with...

Prognostic Significance of Tnm Uiccajcc Classification

Until now, few reports have valued the prognostic significance of TNM classification for hilar cholangiocarcinoma. The new edition of TNM staging (6th edition of UICC AJCC) focuses on two aspects vascular invasion and the presence of lymph-node metastases 45 . The prognostic significance of staging grouping according to UICC AJCC is still debated in a recent study, Zervos did not show any correlation between stage and survival in 42 patients submitted to surgical resection 12 nor did Hemming's...

Anatomy of the Bile Duct Branches

At the hepatic hilum the right and left hepatic ducts meet in the biliary confluence. Anatomical variants of the confluence are very common so that a regular anatomic confluence is present in no more than the two-thirds of cases. The left lateral segmental ducts (B2 and B3) generally join at the level of the umbilical fissure situated posterior to the umbilical portion. Rarely (6 of cases) the duct for segment 3 (B3) runs caudally to the umbilical portion of the left portal vein with a direct...

Comparison between 5th and 6th Edition of Tnm Uiccajcc

The last two staging editions of TNM, the 5th and 6th editions, present different criteria for classification of T and N categories. In the T category of the 5th edition all neoplasms involving adjacent structures were classified as T3 instead in the last edition T3 has been divided based on the structures involved T3 for lesions that invade per contiguity the liver, gallbladder, pancreas, or the vessels unilaterally and T4 for the lesions invading other adjacent organs (colon, stomach and...

Hepatectomy with Portal Resection and Reconstruction

Vein Resection Case Burn

The infiltration of portal bifurcation is not so rare in hilar cholangiocarcinoma, due to the close relationship of the biliary confluence with the portal system. In these cases the use of hepatectomy with en-bloc portal vein resection has been advocated by several authors, to increase the curative resections. When curative resection was achieved using portal resection and reconstruction, patients survived significantly longer than unresected patients 2 . Fig. 12 Central hepatic...

Gross Type

The classification proposed by the Liver Cancer Study Group of Japan (LCSGJ) distinguishes three different macroscopic types mass forming (MF), periductal-infiltrating (PI), and intraductal growth (IG) 1 . These three macroscopic forms reflect different biological behaviours and neoplastic diffusion. MF cholangio-carcinoma is associated with early portal invasion and intra hepatic metastases the PI type is characterised by invasion of the biliary tree and of Glisson's sheath, with preferential...

Left Medial Sectionectomy with Caudate Lobectomy S4 S1

The operation begins with hilar time, complete mobilisation of the liver and caudate lobe as described in the isolated caudate lobectomy. The parenchymal dissection is performed with anatomic resection of caudate lobe and segment 4. Transection of the left biliary duct is immediately on the right of the falciform ligament on segment S2 and S3 while on the right side falls just on the two biliary ducts the anterior and the posterior. The bilioenteric continuity is restored with multiple...

Anatomy of the Hepatic Artery Branches

The left hepatic artery enters the liver on the left side of Rex's recessus the middle hepatic artery, through the right side of Rex's recessus the right hepatic artery more frequently runs between the portal vein and the bile duct, posterior to the confluence. The right hepatic artery divides into the anterior branch that runs between the bile duct and the portal vein, and posterior branch that turns caudally to the right portal vein and enters the liver (see Fig. 1) 3 . Variations of the...

Independent Caudate Lobectomy S1

The isolated resection of the caudate lobe associated with resection of the extra-hepatic biliary tract represents a fairly rare indication and is limited to cases with neoplasm confined clearly inside the confluence between right and left ducts with involvement of caudate branches. The resection of the caudate lobe due to its position always requires the complete mobilization of the liver. The operation begins with hepatoduodenal ligament dissection, lymph node clearing and transection of the...

Right Anterior Sectionectomy with Caudate Lobectomy S5S8 S1

This operation also begins with the hilar phase, complete mobilisation of the liver and caudate lobe as described before. The arterial and portal branches to the caudate lobe that arise from the main right and left branches are ligated. After cholecystectomy and transection of the distal bile duct on free margin, the biliary tract is reflected upward and the right vascular elements are isolated up to the bifurcation in anterior and posterior branches. The arterial braches for the right anterior...

Surgical Anatomy of the Caudate Lobe

Caudate Lobe Liver Diagrams

Knowledge of anatomy of the caudate lobe and its relationship with the porta hepatis area are mandatory for a correct surgical approach to hilar cholangiocar-cinoma. In fact, the surgical treatment of this disease requires en-bloc resection of the caudate lobe. Currently the caudate lobe is divided into three parts, according to Couinaud's definition 6 - Segment 1 (S1), or caudate lobe, in the strict sense of the word, which corresponds to the portion with left development - Segment 9 (S9),...

Right Hepatectomy with Caudate Lobectomy S4a S5 S6 S7 S8 S1

Right hepatectomy with caudate lobectomy is indicated for tumours involving the right anterior and posterior sectorial bile ducts with sparing of the left medial segmental bile duct to segment 4. The resection entails the right hepatic lobe, caudate lobe and, if indicated, the caudal portion of segment 4 (4a) to obtain an adequate margin of biliary ducts. After mobilisation of duodenum and retropancreatic lymph node dissection, the distal bile duct is transected in its suprapancreatic portion...

Central Hepatic Resections

Central hepatectomies consisting of left medial sectionectomy with caudate lobectomy (S1+S4), right anterior sectionectomy with caudate lobectomy (S1+S5, S8) and central hepatic bisegmentectomy with caudate lobectomy (S1+S4, S5, S8), are proposed mainly by Japanese authors 5,31,32 . These parenchyma-preserving hepatectomies find their premise in limited hepatic resection to minimise postoperative risk of hepatic failure in high-risk patients, still maintaining a potentially curative R0...

Right Trisectionectomy with Caudate Lobectomy S4 S5 S6 S7 S8 S1

Svt Catheter Ablation Procedure

The right trisectionectomy with caudate lobectomy is indicated for hilar cholan-giocarcinoma that involves the right intrahepatic bile duct in continuity with the left medial segmental duct (segment 4). The phases of retropancreatic and hepatoduodenal ligament lymph node dissection, of distal bile duct section and mobilization of caudate lobe are similar to the abovementioned for right hepatectomy. Right and middle hepatic artery and right portal vein are ligated and divided. Mobilisation of...

Left Hepatectomy with Caudate Lobectomy S2 S3 S4 S1

The extended left hepatectomy with caudate lobectomy finds its indication in neoplasms of the biliary confluence that extend to the left intrahepatic bile duct. After hilar preparation and ligation of arterial and portal branches for caudate lobe, the left and middle hepatic artery and left portal vein are tied. The left lobe is completely mobilised with section of left triangular and coronary ligaments. The lesser omentum is incised and the left part of the caudate lobe is mobilised from down...

Choice of Treatment

The palliation strategy depends on when the diagnosis of unresectability is made in fact, when it is obtained preoperatively or at preliminary laparoscopy there are two options the endoscopic and the percutaneous route. Instead, when the condition of unresectability is verified intraoperatively there are different options surgical management, maintenance of the biliary drainage, if already positioned, intraoperative trans-tumoral catheterization or postoperative positioning of endoscopic or...

Macroscopic Growth Pattern

Lump Nodes Japanese

On macroscopic assessment neoplasms would be classified on the basis of the type of growth of the tumour inside the biliary duct - Papillary type included pedunculated and sessile tumours thicker than 2 mm Expanding pattern Infiltrating pattern Expanding pattern Infiltrating pattern Infiltrating pattern flat type with infiltrating pattern entails diffuse infiltrating type Evaluation of the extent of the disease involves five different parameters serosa, hepatic parenchyma, pancreas, portal vein...

Recurrence

Recurrence after R0 resection is frequent, ranging from 38 to 82 it is usually early and most often occurs within 2 years postoperatively. Huang reported a median time of disease relapse of 13 months 8 . The most frequent sites of recurrence are intrahepatic 74 , peritoneal 22 , bone 11 , lymph node 11 and, less frequently, distantly lung, abdominal wall 34 . The factors related to the onset of recurrence are many and are associated with gross tumour type and extent of disease. The former...

Indications for Lymphadenectomy

The rational extent of radical lymphadenectomy for ICC has not been clearly defined and there is no consensus on the role of lymph-node dissection 18,26 . The incidence of lymph-node metastasis in ICC is 43-62 1,2,7,10,15,21 . Several series have shown that one of the strongest prognostic factors in ICC is lymph-node involvement 17,25,27,28 . All of these studies reported that no patients with lymph-node involvement survived for more than 3 years after surgery. Inoue 17 stated that lymph-node...

Gazzaniga Staging System

Hilar Cholangiocarcinoma

The classification proposed by Gazzaniga in 1985 was the first to consider biliary and vascular invasion 11 . Based on preoperative workup two elements are evaluated extent of biliary involvement according to Bismuth-Corlette and portal and arterial vascular infiltration. Fig. 5 Staging system according to JSBS Japanese Society of Biliary Surgery 10 H, Hepatic metastases H0 absent H1 limited to a lobe H2 few metastases to both lobes, H3 many metastases to both lobes P, peritoneal metastases P0...