Standardized surgical treatment for Bismuth type <b>Ⅲ</b>a hilar cholangiocarcinoma: a case report_CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

Authors：

WANG Xu , MA Yujing , ZHAO Xiaolong , JIN Qizhi , YIN Shujun ,  DONG Ke

Department of Hepatobiliary Surgery, Sichuan Provincial People’s Hospital, Chengdu 610072, P. R. China;

Corresponding author：

DONG Ke, Email: dongke1134@hotmail.com

Keywords：

hilar cholangiocarcinoma; surgical procedure; hepatectomy; portal vein resection and reconstruction

DOI：

10.7507/1007-9424.201807017

Video：

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Objective To summarize a patient diagnosed as Bismuth type Ⅲa hilar cholangiocarcinoma who unerwent the curative surgery combined with partial portal vein resection and reconstruction+hilar bile duct formation+Roux-en-Y choledochojejunostomy, meanwhile we reviewed the current status of surgical treatment of hilar cholangiocarcinoma at home and abroad.Methods To retrospectively summarized and analyzed the clinical data of one case of Bismuth type Ⅲa hilar cholangiocarcinoma. The preoperative total bilirubin of this patient was 346.8 μmol/L, and this patient underwent the curative surgery combined with partial portal vein resection and reconstruction+hilar bile duct formation+Roux-en-Y choledochojejunostomy after reducing jaundice by percutaneous transhepatic biliary drainage (PTBD). Then we retrieved domestic and foreign related literatures.Results Operative time of this patient was about 290 min and intraoperative bleeding was about 350 mL. No intraoperative blood transfusion occurred. The results of pathological examination showed middle-differentiatied adenocarcinoma of hilar bile duct with negative tumor margins and no regional lymph node metastasis (0/14). The postoperative recovery was uneventful with hospital stay time of 9 days and without any complication. The patient had been followed-up in the outpatient department for 3 years,and was generally in good condition. The evidence of recurrence or metastasis wasn’t found.Conclusions Pre-operative biliary drainage can improve the safety of operation and reduce the incidence of postoperative complications, extend liver resection for the patient with Bismuth type Ⅲa hilar cholangiocarcinoma, which can improve R0 resection rate and extend postoperative survival.

Citation： WANG Xu, MA Yujing, ZHAO Xiaolong, JIN Qizhi, YIN Shujun, DONG Ke. Standardized surgical treatment for Bismuth type Ⅲa hilar cholangiocarcinoma: a case report. CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY, 2019, 26(2): 200-206. doi: 10.7507/1007-9424.201807017 Copy

1.	Kimbrough CW, Cloyd JM, Pawlik TM. Surgical approaches for the treatment of perihilar cholangiocarcinoma. Expert Rev Anticancer Ther, 2018, 18(7): 673-683.
2.	Mansour JC, Aloia TA, Crane CH, et al. Hilar cholangiocarcinoma: expert consensus statement. HPB (Oxford), 2015, 17(8): 691-699.
3.	Hu HJ, Mao H, Shrestha A, et al. Prognostic factors and long-term outcomes of hilar cholangiocarcinoma: a single-institution experience in China. World J Gastroenterol, 2016, 22(8): 2601-2610.
4.	隋鑫磊, 汤恢焕, 肖广发, 等. 322 例肝门部胆管癌的临床疗效及预后因素分析. 中华消化外科杂志, 2017, 16(4): 391-397.
5.	中国抗癌协会. 肝门部胆管癌规范化诊治专家共识(2015). 中华肝胆外科杂志, 2015, 21(8): 505-511.
6.	Liu F, Ma WJ, Hu HJ, et al. The puzzle and challenge in the treatment of an intraoperative margin-positive proximal bile duct in hilar cholangiocarcinoma. Hepatobiliary Surg Nutr, 2017, 6(6): 411-413.
7.	Xiang S, Lau WY, Chen XP. Hilar cholangiocarcinoma: controversies on the extent of surgical resection aiming at cure. Int J Colorectal Dis, 2015, 30(2): 159-171.
8.	Ribero D, Amisano M, Lo Tesoriere R, et al. Additional resection of an intraoperative margin-positive proximal bile duct improves survival in patients with hilar cholangiocarcinoma. Ann Surg, 2011, 254(5): 776-781.
9.	Liu F, Hu HJ, Regmi P, et al. Hilar cholangiocarcinoma with distal bile duct involvement: is hepatopancreatoduodenectomy always required? Clin Res Hepatol Gastroenterol, 2018, [Epub ahead of print].
10.	胡凯, 游骁翔, 李富宇, 等. 170 例Ⅲ型肝门胆管癌的治疗及预后分析. 中国普外基础与临床杂志, 2014, 21(3): 278-284.
11.	陈孝平, 黄志勇, 陈义发, 等. 肝门部胆管癌根治术肝切除范围的合理选择. 中国普通外科杂志, 2013, 22(1): 8-9.
12.	陈孝平, 项帅. 精准医学时代肝门部胆管癌的治疗. 中华消化外科杂志, 2018, 17(1): 3-8.
13.	陈孝平, 黄志勇, 张志伟, 等. 小范围肝切除治疗 Bismuth-Corlette Ⅲ型肝门部胆管癌. 中华外科杂志, 2009, 47(15): 1148-1150.
14.	Nuzzo G, Giuliante F, Ardito F, et al. Improvement in perioperative and long-term outcome after surgical treatment of hilar cholangiocarcinoma: results of an Italian multicenter analysis of 440 patients. Arch Surg, 2012, 147(1): 26-34.
15.	van Gulik TM, Kloek JJ, Ruys AT, et al. Multidisciplinary management of hilar cholangiocarcinoma (Klatskin tumor): extended resection is associated with improved survival. Eur J Surg Oncol, 2011, 37(1): 65-71.
16.	王晓庆, 房锋, 李广涛, 等. Ⅲ、Ⅳ型肝门胆管癌不同切除方式对预后的影响. 中国肿瘤临床, 2018, 45(5): 237-240.
17.	Scurtu RR, Dindelegan G, Bintintan V, et al. Extension of hepatic resection ameliorates survival in patients with type Ⅲa or Ⅲb Klatskin tumors despite surgical complications. Chirurgia (Bucur), 2017, 112(3): 301-307.
18.	Ramos E. Principles of surgical resection in hilar cho- langiocarcinoma. World J Gastrointest Oncol, 2013, 5(7): 139-146.
19.	Kow AW, Wook CD, Song SC, et al. Role of caudate lobectomy in type ⅢA and ⅢB hilar cholangiocarcinoma: a 15-year experience in a tertiary institution. World J Surg, 2012, 36(5): 1112-1121.
20.	Cheng QB, Yi B, Wang JH, et al. Resection with total caudate lobectomy confers survival benefit in hilar cholangiocarcinoma of Bismuth type Ⅲ and Ⅳ. Eur J Surg Oncol, 2012, 38(12): 1197-1203.
21.	Zhimin G, Noor H, Zheng JB, et al. Advances in diagnosis and treatment of hilar cholangiocarcinoma-a review. Med Sci Monit, 2013, 19: 648-656.
22.	Endo I, Matsuyama R, Taniguchi K, et al. Right hepatectomy with resection of caudate lobe and extrahepatic bile duct for hilar cholangiocarcinoma. J Hepatobiliary Pancreat Sci, 2012, 19(3): 216-224.
23.	Wu XS, Dong P, Gu J, et al. Combined portal vein resection for hilar cholangiocarcinoma: a meta-analysis of comparative studies. J Gastrointest Surg, 2013, 17(6): 1107-1115.
24.	Abbas S, Sandroussi C. Systematic review and meta-analysis of the role of vascular resection in the treatment of hilar cho- langiocarcinoma. HPB (Oxford), 2013, 15(7): 492-503.
25.	Molina V, Sampson J, Ferrer J, et al. Surgical treatment of perihilar cholangiocarcinoma: early results of en bloc portal vein resection. Langenbecks Arch Surg, 2017, 402(1): 95-104.
26.	Tamoto E, Hirano S, Tsuchikawa T, et al. Portal vein resection using the no-touch technique with a hepatectomy for hilar cholangiocarcinoma. HPB (Oxford), 2014, 16(1): 56-61.
27.	董家鸿, 黄志强. 精准肝切除—21 世纪肝脏外科新理念. 中华外科杂志, 2009, 47(21): 1601-1605.
28.	Wang HQ, Yang JY, Yan LN. Hemihepatic versus total hepatic inflow occlusion during hepatectomy: a systematic review and meta-analysis. World J Gastroenterol, 2011, 17(26): 3158-3164.
29.	中华医学会外科学分会, 中华医学会麻醉学分会. 加速康复外科中国专家共识暨路径管理指南(2018): 肝胆手术部分. 中华麻醉学杂志, 2018, 38(1): 13-18.
30.	Rahbari NN, Koch M, Schmidt T, et al. Meta-analysis of the clamp-crushing technique for transection of the parenchyma in elective hepatic resection: back to where we started? Ann Surg Oncol, 2009, 16(3): 630-639.
31.	郭晗, 陈朋, 袁鹏, 等. 术前胆道引流对肝门胆管癌术后病人的影响的 Meta 分析. 肝胆外科杂志, 2017, 25(3): 185-189, 217.
32.	李澄云, 牛秀峰, 倪家连. 术前减黄对肝门部胆管癌手术效果的影响. 肝胆胰外科杂志, 2017, 29(3): 203-206.
33.	牛宏, 李明阳. 不同胆道引流方式治疗肝门部胆管癌所致黄疸的疗效观察. 中华胃肠内镜电子杂志, 2017, 4(3): 103-108.
34.	张辉, 张振, 张海涛, 等. 肝门部胆管癌根治术前经内镜鼻胆管引流和经皮经肝胆管造影引流术的临床效果观察. 腹部外科, 2017, 30(3): 197-201.
35.	国际肝胆胰学会中国分会, 中华医学会外科学分会肝脏外科学组. 胆管癌诊断与治疗—外科专家共识. 临床肝胆病杂志, 2015, 31(1): 12-16.
36.	王健东, 沈军, 周学平, 等. 提高 Bismuth-Corlette Ⅲ型肝门部胆管癌根治性切除率及安全性的综合措施. 中华外科杂志, 2013, 51(7): 596-599.
37.	晏益核, 黄玉斌, 蔡小勇. 肝门部胆管癌的外科治疗现状. 中国普通外科杂志, 2017, 26(2): 246-251.
38.	Miyazaki M, Yoshitomi H, Miyakawa S, et al. Clinical practice guidelines for the management of biliary tract cancers 2015: the 2^nd English edition. J Hepatobiliary Pancreat Sci, 2015, 22(4): 249-273.
39.	Furusawa N, Kobayashi A, Yokoyama T, et al. Surgical treatment of 144 cases of hilar cholangiocarcinoma without liver-related mortality. World J Surg, 2014, 38(5): 1164-1176.
40.	Hosokawa I, Shimizu H, Yoshidome H, et al. Surgical strategy for hilar cholangiocarcinoma of the left-side predominance: current role of left trisectionectomy. Ann Surg, 2014, 259(6): 1178-1185.

1. Kimbrough CW, Cloyd JM, Pawlik TM. Surgical approaches for the treatment of perihilar cholangiocarcinoma. Expert Rev Anticancer Ther, 2018, 18(7): 673-683.
2. Mansour JC, Aloia TA, Crane CH, et al. Hilar cholangiocarcinoma: expert consensus statement. HPB (Oxford), 2015, 17(8): 691-699.
3. Hu HJ, Mao H, Shrestha A, et al. Prognostic factors and long-term outcomes of hilar cholangiocarcinoma: a single-institution experience in China. World J Gastroenterol, 2016, 22(8): 2601-2610.
4. 隋鑫磊, 汤恢焕, 肖广发, 等. 322 例肝门部胆管癌的临床疗效及预后因素分析. 中华消化外科杂志, 2017, 16(4): 391-397.
5. 中国抗癌协会. 肝门部胆管癌规范化诊治专家共识(2015). 中华肝胆外科杂志, 2015, 21(8): 505-511.
6. Liu F, Ma WJ, Hu HJ, et al. The puzzle and challenge in the treatment of an intraoperative margin-positive proximal bile duct in hilar cholangiocarcinoma. Hepatobiliary Surg Nutr, 2017, 6(6): 411-413.
7. Xiang S, Lau WY, Chen XP. Hilar cholangiocarcinoma: controversies on the extent of surgical resection aiming at cure. Int J Colorectal Dis, 2015, 30(2): 159-171.
8. Ribero D, Amisano M, Lo Tesoriere R, et al. Additional resection of an intraoperative margin-positive proximal bile duct improves survival in patients with hilar cholangiocarcinoma. Ann Surg, 2011, 254(5): 776-781.
9. Liu F, Hu HJ, Regmi P, et al. Hilar cholangiocarcinoma with distal bile duct involvement: is hepatopancreatoduodenectomy always required? Clin Res Hepatol Gastroenterol, 2018, [Epub ahead of print].
10. 胡凯, 游骁翔, 李富宇, 等. 170 例Ⅲ型肝门胆管癌的治疗及预后分析. 中国普外基础与临床杂志, 2014, 21(3): 278-284.
11. 陈孝平, 黄志勇, 陈义发, 等. 肝门部胆管癌根治术肝切除范围的合理选择. 中国普通外科杂志, 2013, 22(1): 8-9.
12. 陈孝平, 项帅. 精准医学时代肝门部胆管癌的治疗. 中华消化外科杂志, 2018, 17(1): 3-8.
13. 陈孝平, 黄志勇, 张志伟, 等. 小范围肝切除治疗 Bismuth-Corlette Ⅲ型肝门部胆管癌. 中华外科杂志, 2009, 47(15): 1148-1150.
14. Nuzzo G, Giuliante F, Ardito F, et al. Improvement in perioperative and long-term outcome after surgical treatment of hilar cholangiocarcinoma: results of an Italian multicenter analysis of 440 patients. Arch Surg, 2012, 147(1): 26-34.
15. van Gulik TM, Kloek JJ, Ruys AT, et al. Multidisciplinary management of hilar cholangiocarcinoma (Klatskin tumor): extended resection is associated with improved survival. Eur J Surg Oncol, 2011, 37(1): 65-71.
16. 王晓庆, 房锋, 李广涛, 等. Ⅲ、Ⅳ型肝门胆管癌不同切除方式对预后的影响. 中国肿瘤临床, 2018, 45(5): 237-240.
17. Scurtu RR, Dindelegan G, Bintintan V, et al. Extension of hepatic resection ameliorates survival in patients with type Ⅲa or Ⅲb Klatskin tumors despite surgical complications. Chirurgia (Bucur), 2017, 112(3): 301-307.
18. Ramos E. Principles of surgical resection in hilar cho- langiocarcinoma. World J Gastrointest Oncol, 2013, 5(7): 139-146.
19. Kow AW, Wook CD, Song SC, et al. Role of caudate lobectomy in type ⅢA and ⅢB hilar cholangiocarcinoma: a 15-year experience in a tertiary institution. World J Surg, 2012, 36(5): 1112-1121.
20. Cheng QB, Yi B, Wang JH, et al. Resection with total caudate lobectomy confers survival benefit in hilar cholangiocarcinoma of Bismuth type Ⅲ and Ⅳ. Eur J Surg Oncol, 2012, 38(12): 1197-1203.
21. Zhimin G, Noor H, Zheng JB, et al. Advances in diagnosis and treatment of hilar cholangiocarcinoma-a review. Med Sci Monit, 2013, 19: 648-656.
22. Endo I, Matsuyama R, Taniguchi K, et al. Right hepatectomy with resection of caudate lobe and extrahepatic bile duct for hilar cholangiocarcinoma. J Hepatobiliary Pancreat Sci, 2012, 19(3): 216-224.
23. Wu XS, Dong P, Gu J, et al. Combined portal vein resection for hilar cholangiocarcinoma: a meta-analysis of comparative studies. J Gastrointest Surg, 2013, 17(6): 1107-1115.
24. Abbas S, Sandroussi C. Systematic review and meta-analysis of the role of vascular resection in the treatment of hilar cho- langiocarcinoma. HPB (Oxford), 2013, 15(7): 492-503.
25. Molina V, Sampson J, Ferrer J, et al. Surgical treatment of perihilar cholangiocarcinoma: early results of en bloc portal vein resection. Langenbecks Arch Surg, 2017, 402(1): 95-104.
26. Tamoto E, Hirano S, Tsuchikawa T, et al. Portal vein resection using the no-touch technique with a hepatectomy for hilar cholangiocarcinoma. HPB (Oxford), 2014, 16(1): 56-61.
27. 董家鸿, 黄志强. 精准肝切除—21 世纪肝脏外科新理念. 中华外科杂志, 2009, 47(21): 1601-1605.
28. Wang HQ, Yang JY, Yan LN. Hemihepatic versus total hepatic inflow occlusion during hepatectomy: a systematic review and meta-analysis. World J Gastroenterol, 2011, 17(26): 3158-3164.
29. 中华医学会外科学分会, 中华医学会麻醉学分会. 加速康复外科中国专家共识暨路径管理指南(2018): 肝胆手术部分. 中华麻醉学杂志, 2018, 38(1): 13-18.
30. Rahbari NN, Koch M, Schmidt T, et al. Meta-analysis of the clamp-crushing technique for transection of the parenchyma in elective hepatic resection: back to where we started? Ann Surg Oncol, 2009, 16(3): 630-639.
31. 郭晗, 陈朋, 袁鹏, 等. 术前胆道引流对肝门胆管癌术后病人的影响的 Meta 分析. 肝胆外科杂志, 2017, 25(3): 185-189, 217.
32. 李澄云, 牛秀峰, 倪家连. 术前减黄对肝门部胆管癌手术效果的影响. 肝胆胰外科杂志, 2017, 29(3): 203-206.
33. 牛宏, 李明阳. 不同胆道引流方式治疗肝门部胆管癌所致黄疸的疗效观察. 中华胃肠内镜电子杂志, 2017, 4(3): 103-108.
34. 张辉, 张振, 张海涛, 等. 肝门部胆管癌根治术前经内镜鼻胆管引流和经皮经肝胆管造影引流术的临床效果观察. 腹部外科, 2017, 30(3): 197-201.
35. 国际肝胆胰学会中国分会, 中华医学会外科学分会肝脏外科学组. 胆管癌诊断与治疗—外科专家共识. 临床肝胆病杂志, 2015, 31(1): 12-16.
36. 王健东, 沈军, 周学平, 等. 提高 Bismuth-Corlette Ⅲ型肝门部胆管癌根治性切除率及安全性的综合措施. 中华外科杂志, 2013, 51(7): 596-599.
37. 晏益核, 黄玉斌, 蔡小勇. 肝门部胆管癌的外科治疗现状. 中国普通外科杂志, 2017, 26(2): 246-251.
38. Miyazaki M, Yoshitomi H, Miyakawa S, et al. Clinical practice guidelines for the management of biliary tract cancers 2015: the 2^nd English edition. J Hepatobiliary Pancreat Sci, 2015, 22(4): 249-273.
39. Furusawa N, Kobayashi A, Yokoyama T, et al. Surgical treatment of 144 cases of hilar cholangiocarcinoma without liver-related mortality. World J Surg, 2014, 38(5): 1164-1176.
40. Hosokawa I, Shimizu H, Yoshidome H, et al. Surgical strategy for hilar cholangiocarcinoma of the left-side predominance: current role of left trisectionectomy. Ann Surg, 2014, 259(6): 1178-1185.

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Standardized surgical treatment for Bismuth type Ⅲa hilar cholangiocarcinoma: a case report

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