Less Invasive Hepatectomy for Hilar Bile Duct Carcinoma

Transcription

1 Less Invasive Hepatectomy for Hilar Bile Duct Carcinoma Yoshifumi Kawarada, 1 M.D., F.A.C.S., Bidhan Chandra Das, M.B.B.S. First Department of Surgery, Mie University School of Medicine, Tsu, Mie, Japan Because of the high postoperative morbidity and mortality rate after aggressive hepatectomy for hilar bile duct carcinoma, we have adopted a less invasive hepatectomy procedure for aged and poor risk patients. Less invasive hepatectomy was used in 5 of the 19 hilar carcinoma patients recently treated in our department. They were older and had poorer liver function than the others, and the operative procedure and outcome of these 5 patients will be described. In less invasive hepatectomy the parenchymal resection is bounded on the left side by the B 2 +B 3 bifurcation at the right margin of the umbilical portion of the portal vein and, on the right side, by B 8 of the anterior branch and the B 6+7 bifurcation of the right posterior branch, and above, by the root of the middle hepatic vein. Thus. a marked reduction in loss of parenchyma is achieved compared to extended resection. The biliary tract is reconstructed by 3 8 intrahepaticojejunostomies with a Roux-en-Y loop brought up in antecolic or retrocolic fashion. We recommend that B 4a bile duct resection be performed in addition to S 1 resection to achieve curative resection in hilar bile duct carcinoma because in 35% cases the B 4 branches join the left hepatic duct close to the hilar area (Type I). The resection was curative in all 5 cases. The patients postoperative course was uneventful, and their survival rate was acceptable. We conclude that less invasive hepatectomy, so-called Taj Mahal hepatectomy is the operation of choice for aged and poor risk hilar carcinoma patients. 1 Introduction Malignant tumors of the hilar bile duct remain a major challenge in biliary surgery. Without treatment, the majority of patients with hilar bile duct cancer die within 6 months of diagnosis. Hilar bile duct carcinoma is considered to have the worst prognosis among bile duct cancers, because the tumors are difficult to manage surgically due to the proximity of the portal vein, hepatic artery, and liver parenchyma, including the caudate lobe, as well as the fact that any of these structures may be easily infiltrated by the cancer. Curative resection of hilar bile duct carcinoma, however, can lead to a better outcome [1 5]. Various operative procedures [1 6] have been used to treat it: local resection of the bile duct, and extended right or left hepatectomy with or without caudate lobectomy. Local resection of bile duct carcinoma resulted in low operative morbidity and mortality but was also associated with a low curative resection rate [1, 7]. By contrast, aggressive surgical approaches with extended hepatectomy yielded a high curative resection rate but often resulted in postoperative liver failure, which can lead to a fatal outcome [3 6]. This led us to adopt a less invasive hepatectomy (the Taj Mahal hepatic resection) [8], that allows curative resection to be obtained while at the same time preventing postoperative liver failure. We recently treated 19 patients with hilar bile duct carcinoma in our department and employed less invasive hepatectomy in 5 of them. The operative procedure and the outcome of the 5 cases are briefly described below. 1 Address for correspondence: Yoshifumi Kawarada MD., FACS First Department of Surgery Mie University School of Medicine Tsu, Mie , Japan Tel: , ext 6470, Fax: Patients and Methods Between July 1997 and December 1999, 21 patients with hilar bile duct carcinoma were admitted to our clinic. Two of the 21 patients were not treated surgically because they had far advanced disease and the other 19 were treated by surgical resection. The operative procedures employed in the 19 patients were: right extended hepatectomy in 7 patients, left extended hepatectomy in 7 patients, and less invasive hepatectomy (S4a+S5+S1, the Taj Mahal hepatectomy) in 5 patients. The patients who underwent less invasive hepatectomy are the subject of this report. There were 4 men and 1 woman, and they ranged in age from 61 to 79 years old. They were older and had poorer liver function than the patients who underwent extended hepatectomy (Table 1). Four of the 5 patients had obstructive jaundice, and percutaneous transhepatic biliary drainage (PTBD) was performed in all of them 3 to 4 weeks prior to surgery. The nature and extent of the disease and the anatomic details of the ductal and vessels were determined by cholangiography through the PTBD tube, percutaneous transhepatic cholangioscopy (PTCS), computed tomography, and angiography. The detailed preoperative evaluation permitted accurate diagnosis of the extent of carcinoma, and allowed us to limit the resection to the minimum necessary for curative resection. Operative procedure A bilateral subcostal incision is started in the left subcostal region 2 cm below the costal margin at the lateral border of the rectus muscle, and is continued to the right side, and then upward, by cutting the 10th costochondral junction, to the mid-axillary line. The diaphragm is then severed with a linear cutter. After laparatomy, the hepatoduodenal ligaments are dissected, and the common bile duct is ligated, and transected immediately above the upper margin of the pancreas. 14 ÄççÄãõ ïàêìêéàóöëäéâ ÉÖèÄíéãéÉàà ÚÓÏ

2 YOSHIFUMI KAWARADA, BIDHAN CHANDRA DAS LIVER Table 1. Patient characteristics Extended hepatectomy Less invasive hepatectomy No. of patients 14 5 Age (years) 63.3 ± ± 8.7 Gender (M : F) 10 : 3 4 : 1 Preoperative jaundice 11 (84.6%) 4 (80%) Preoperative liver function T. Bil (mg/ml) 0.9 ± ± 0.3 GOT (U/L) 35.4 ± ± 5.6 GPT (U/L) 35.1 ± ± 8.1 Alb (mg/ml) 3.6 ± ± 0.4 PT (%) ± ± 8.2 ICGR15 (5) 7.3 ± ± 2.9* T. Bil. total bilirubin; GOT glutamic-oxaloacetic transaminase; GPT glutamic-pyruvic transaminase; Alb albumin; PT prothrombin time; ICGR15 idocyanine green retention rate, * P < 0.05, extended hepatectomy vs less invasive hepatectomy. A transfixing suture ligation is then applied to the stump of the bile duct on the duodenal side. The left and right hepatic arteries are encircled with vascular tape, and the main trunk of the portal vein is exposed and dissected to free the bifurcation of the portal vein from the surrounding tissue. The hepatic artery is skeletonized toward the hepatic hilus, and the root of the cystic artery is exposed and divided with a 3 0 silk double ligature. Rather than mobilizing the left lobe, it is lifted upward, and the loose connective tissue anterior to the inferior vena cava is dissected on the left side of Spieghel s lobe. The lowest short hepatic veins draining the caudate process are serially divided with transfixing suture ligatures on the inferior aspect of the liver, anterior to the vena cava. The left and right portal veins are each encircled with vascular tape at the hepatic hilus and small branches of the bifurcation of the portal vein draining the caudate lobe are ligated and divided. The left portal vein is exposed toward the umbilical portion of the portal vein, and the branches of the left portal vein draining Spieghel s lobe of the caudate lobe are ligated and cut. Mobilization of the caudate lobe is then completed by serially ligating and dividing the short hepatic veins draining Spieghel s lobe and the paracaval portion of the caudate lobe. The right coronary ligament is divided, and the roots of the right, middle, and left hepatic veins are exposed. Intraoperative ultrasonography is then performed to identify the right and middle hepatic vein. A parenchymal incisional line is marked by electrocautery along the left margin of the right hepatic vein up to its midpoint, then to the left side toward the middle hepatic vein in a dome-like fashion, and finally down to the medial margin of the middle hepatic vein, keeping S 4b intact, as shown in Fig. 1. Fig. 1. Parenchymal incision line of minimal invasive hepatectomy. êëò. 1. ãëìëfl apple ÁappleÂÁ Ô appleâìıëï ÔappleË fl ÂÈ appleâáâíˆëë Ô ÂÌË. ÄççÄãõ ïàêìêéàóöëäéâ ÉÖèÄíéãéÉàà ÚÓÏ

3 S VII RHV S VIII S IVa S VI S V S I GB IVC LHV MHV S IVb S III Fig. 2. Incision line resembles the contour of Taj Mahal. GB gallbladder; IVC inferior vena cava; LHV left hepatic vein; MHV middle hepatic vein; RHV right hepatic vein. êëò. 2. ãëìëfl apple ÁappleÂÁ, Ì ÔÓÏËÌ fl ÍÓÌÚÛapple í Ê å ı Î. GB ÊÂÎ Ì È ÔÛÁ apple ; IVC ÌËÊÌflfl ÔÓÎ fl ÂÌ ; LHV Πfl Ô ÂÌÓ Ì fl ÂÌ ; MHV Òapple ËÌÌ fl Ô ÂÌÓ Ì fl ÂÌ ; RHV Ôapple fl Ô ÂÌÓ Ì fl ÂÌ. S II This resection line resembles the contour of the Taj Mahal (Fig. 2) [8], hence we refer to it as Taj Mahal liver resection. Transection of the hepatic parenchyma is started at the left side along the demarcated line. The portal branches of the medial segment (S 4a ) draining into the anterior and superior surfaces of the umbilical portion (UP) of the portal vein are ligated and cut, but the branches of the medial segment (S 4b ) draining into the posterior surfaces of UP of the portal vein are left intact. The hepatic parenchymal transection is continued, the middle hepatic vein is exposed, and the branches of the middle hepatic veins from S 4a are ligated and cut. The left hepatic duct is divided at the bifurcation of the lateral superior (B 2 ) and lateral inferior (B 3 ) segmental bile duct, and the middle hepatic duct is divided at the middle superior segmental duct (S 4b ). When transection of the hepatic parenchyma on the left side is almost complete, Spieghel s lobe, which has already been mobilized, is brought up on the superior side of the bifurcation of the portal vien. The hepatic parenchyma on the right side is transected along the previously demarcated line. The branches of the right hepatic vein draining into the anterior inferior segment (S 5 ) are serially ligated and cut very carefully so as not to injure the right hepatic vein. The posterior segmental (B 6+7 ) branch and the anterior superior segmental (S 8 ) branch of the intrahepatic bile duct are exposed and divided. Lastly, the junction of the caudate process and the posterior segment of the liver are transected, and resection of S 5 +S 4a with combined resection of the caudate lobe, gallbladder, and extrahepatic bile duct is completed. The cut surface of the liver is shown in Fig. 3. The biliary tract is reconstructed by intrahepaticojejunostomies with a Roux-en-Y loop brought up in antecolic or retrocolic fashion and anastomosed with the posterior segmental duct (B 6+7 ), anterior superior segmental duct (B 8 ), lateral segmental duct (B 2, B 3 ), and/or middle superior segmental duct (B 4b, which sometimes drains into B 3 ) (Fig. 4). Biliary drainage tubes are inserted into each of the cut segmental bile ducts, and the tubes are brought out transjejunally for stenting and postoperative intrahepatic cholangiography. A closed, soft Penrose-style drainage tube is placed in the bilateral resection planes of the hepatic parenchyma. All of the drainage tubes are brought to the surface of the body through separate wounds and connected to a sterile container. The wound is closed in layers. B II B III+IVb B VI+VII B VIII Fig. 3. Cut surface of the liver showing insertion of stent tubes through the cut end of intrahepatic bile duct. B bile duct. êëò. 3. èó ÂappleıÌÓÒÚ apple ÁappleÂÁ Ô ÂÌË. Ç ÔÂappleÂÒ ÂÌÌ Â ÊÂÎ Ì Â ÔappleÓÚÓÍË Â ÂÌ appleâì ÊÌ Â ÚappleÛ ÍË. Ç ÊÂÎ Ì Â ÔappleÓÚÓÍË. 16 ÄççÄãõ ïàêìêéàóöëäéâ ÉÖèÄíéãéÉàà ÚÓÏ

4 YOSHIFUMI KAWARADA, BIDHAN CHANDRA DAS LIVER 1 2 Fig. 4. Intrahepatico-jejunostomy showing 4 anastomosis. 1 zone of resection, 2 a Roux-en-Y loop. êëò. 4. àìúapple ÂÔ ÚËÍÓ ÌÓÒÚÓÏËfl ÔÓÍ Á ÌÓ 4 Ì ÒÚÓÏÓÁ. 1 ÁÓÌ appleâáâíˆëë; 2 ÂÎÂÌÌ fl ÔÓ êû ÚÓ fl ÍË Í. Surgical outcome The tumors of the 5 patients were Type I in 1, Type II in 3, and Type IIIb in 1 (according to the Bismuth-Corlette system). Taj Mahal hepatectomy (S4a+S5+S1), allowed curative resection in every patient, and there was no mortality or major postoperative complications. Three patients are alive 9 to 40 months after the operation without recurrence. One patient died of another disease at 34 months, and the another patient died of liver metastasis 33 months after surgery (Table 2). Discussion Local bile duct resection was the first surgical procedure used to treat hilar bile duct carcinoma, and several reports have also been published, but curative resection proved to be a problem with local resective procedures [7, 9, 10]. Curative resection offers the only chance for long-term survival in any cancer. With this in mind, an aggressive surgical procedure with combined liver and bile duct resection was adopted to achieve curative resection of hilar bile duct carcinoma. In 1963, Mistilis and Schiff [11] reported the first successful liver and bile duct resection for hilar bile duct carcinoma. Since then many hepatobiliary surgeons in Japan [1 6] have adopted more aggressive surgery with hepatectomy and achieved a good resectability rate. In the 1980s, some Japanese surgeons began to incorporate vascular surgery along with bile duct and hepatic resection [12, 13] in the treatment of bile duct carcinomas that involved major vascular structures in the hepatic hilus. While these aggressive hepatectomy increased the resectability rate (50.0 to 83.3%), they failed to increase the 5-year survival rate (22.0 to 37.0%) because of the high postoperative morbidity (40 to 50%) and mortality rates (7 to 10%) associated with them [3 5, 14]. Anatomical studies of the hepatic hilus, intrahepatic bile ducts, and caudate lobe disclosed a close relationship between the biliary drainage of the caudate lobe and the hepatic hilus [1, 15], and microscopic invasion of the caudate lobe by hilar carcinoma [14], which is why Japanese surgeons emphasized cau- Table 2. Outcome of patients undergoing less invasive hepatectomy (Taj Mahal resection) No Age (yr) Sex Bismuth type ICGR 15 Curability Complications Outcome 1 77 M. hilar ca. II 15.4 R0 aspiration pneumonia 33 m, died* 2 62 M. hilar ca. II 12.7 R0 none 34 m, died** 3 79 M. hilar ca. II 17.2 R0 none 40 m, alive 4 61 M. hilar ca. IIIb 10.5 R0 none 28 m, alive 5 64 F. hilar ca. I 10.6 R0 none 9 m, alive * Died of liver metastasis, ** died of other disease. ÄççÄãõ ïàêìêéàóöëäéâ ÉÖèÄíéãéÉàà ÚÓÏ

5 date lobectomy (S 1 ) for curative resection of hilar carcinoma. We recently published an anatomical study of the medial segment (S 4 ) of the liver based on a total of 171 specimens consisting of 71 adult cadavers and 100 liver casts [16]. In that study, we found that 35% of the segment 4 bile ducts (B 4 ) drained into the left hepatic duct very close to the hilar area (Type I), and that 65% drained away from the hepatic hilus (Type II). Hilar bile duct carcinoma therefore can easily invade to the Type I B 4 ducts and it is recommended that the B 4a bile duct be removed along with the extrahepatic bile duct and caudate lobe to achieve curative resection of hilar bile duct carcinoma. S 5 is removed because it opens the hilar area, like opening a book. We also advocate extended hepatectomy for hilar bile duct carcinoma, but aged and poor risk patients cannot tolerate such extended surgery, and thus the parenchymal resection in such patients should be limited to Taj Mahal hepatectomy. The only technical disadvantage of Taj Mahal hepatectomy is the greater number of hepaticojejunal anastomoses (3 to 8), and the fact that an experienced surgeon is needed to perform this operation. Less invasive hepatectomy in the poor risk hilar carcinoma patients in our series resulted in an uneventful postoperative course and an acceptable survival rate. We therefore concluded that Taj Mahal hepatectomy should be considered for poor risk hilar carcinoma patients rather than extended hepatectomy. References 1. Mizumoto R., Kawarada Y., Suzuki H. Surgical treatment of hilar bile duct carcinoma. Surg. Gynecol. Obstet. 1986; 162: Pinson C.W., Rossi R.L. Extended right hepatic lobectomy. Left hepatic lobectomy, and skeletonization resection for proximal bile duct cancer. World J. Surg. 1988; 12: Hadjis N.S., Blenkharn J.I., Alexander N., Benjamin I.S., Blumgart L.H. Outcome of radical surgery in hilar cholangiocarcinoma. Surgery 1990; 107: Tashiro S., Tsuji T., Kanemitsu K., Kamimoto Y., Hiraoka T., Miyauchi Y. Prolongation of survival for carcinoma at the hepatic duct confluence. Surgery 1993; 113: Nimura Y., Hayakawa N., Kamiya J., Kondo S., Nagino M., Kanai M. Hepatectomy for hilar bile duct cancer. Asian J. Surg. 1996; 19: Nagino M., Nimura Y., Kamiya J., Michio Kanai, Uesaka K., Hayakawa N., Yamamoto H., Kondo S., Nishio H. Segmental liver resections for hilar cholangiocarcinoma. Hepato-Gastroenterol. 1998; 45: Nakayama T., Saitsu H., Shibata J., Hasuda, A., Kinoshita H. Hilar bile duct resection for bile duct carcinoma at the hilus of the liver. J. Hep. Bil. Pancr. Surg. 1995; 2: Kawarada Y., Isaji S., Taoka H., Tabata M., Das B.C., Yokoi H. S 4a +S 5 with caudate lobe (S1) resection using Taj Mahal parenchymal resection for carcinoma of the biliary tract. J. Gastrointestinal Surg. 1999; 3(4): Camprodon R., Salva J.A., Jornet J., Guerrero J.A. Successful resection of carcinoma of the common hepatic duct at its superior bifurcation. Am. J. Surg. 1974; 128: Cameron J.L., Bore P., Zuidema G.D. Proximal bile duct tumors. Surgical management with silastic transhepatic biliary stents. Ann. Surg. 1982; 196: Mistilis S., Schiff L. A case of jaundice due to unilateral hepatic duct obstruction with relief after hepatic lobectomy. Gut. 1963; 4: Tsuzuki T., Ogata Y., Iida S., Nakanishi I., Takenaka Y., Yoshii H. Carcinoma of the bifurcation of the hepatic ducts. Arch. Surg. 1983; 118: Sakaguchi S., Nakamura S. Surgery of the portal vein in resection of cancer of the hepatic hilus. Surgery 1986; 99: Nimura Y., Hayakawa N., Kamiya J., Kondo S., Shionoya S. Hepatic segmentectomy with caudate lobe resection for bile duct carcinoma of the hepatic hilus. World J. Surg. 1990; 14: Nimura Y., Hayakawa N., Kamiya J., Kondo S., Nagino M., Kanai M. Hilar cholangiocarcinoma surgical anatomy and curative resection. J. Hep. Bil. Pancr. Surg. 1995; 2: Onishi H., Kawarada Y., Das B.C., Nakano K., Gadzijev E.M., Ravnik D., Isaji S. Surgical anatomy of the medial segment (S4) of the liver with special reference to bile ducts and vessels. Hepato-gastroenterol (in press). 18 ÄççÄãõ ïàêìêéàóöëäéâ ÉÖèÄíéãéÉàà ÚÓÏ