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, 湯恢煥, 肖廣發, 等. 322 例肝門部膽管癌的臨床療效及預后因素分析. 中華消化外科雜志, 2017, 16(4): 391-397.
5.	中國抗癌協會. 肝門部膽管癌規范化診治專家共識(2015). 中華肝膽外科雜志, 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.	胡凱, 游驍翔, 李富宇, 等. 170 例Ⅲ型肝門膽管癌的治療及預后分析. 中國普外基礎與臨床雜志, 2014, 21(3): 278-284.
11.	陳孝平, 黃志勇, 陳義發, 等. 肝門部膽管癌根治術肝切除范圍的合理選擇. 中國普通外科雜志, 2013, 22(1): 8-9.
12.	陳孝平, 項帥. 精準醫學時代肝門部膽管癌的治療. 中華消化外科雜志, 2018, 17(1): 3-8.
13.	陳孝平, 黃志勇, 張志偉, 等. 小范圍肝切除治療 Bismuth-Corlette Ⅲ型肝門部膽管癌. 中華外科雜志, 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.	王曉慶, 房鋒, 李廣濤, 等. Ⅲ、Ⅳ型肝門膽管癌不同切除方式對預后的影響. 中國腫瘤臨床, 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.	董家鴻, 黃志強. 精準肝切除—21 世紀肝臟外科新理念. 中華外科雜志, 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.	中華醫學會外科學分會, 中華醫學會麻醉學分會. 加速康復外科中國專家共識暨路徑管理指南(2018): 肝膽手術部分. 中華麻醉學雜志, 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, 陳朋, 袁鵬, 等. 術前膽道引流對肝門膽管癌術后病人的影響的 Meta 分析. 肝膽外科雜志, 2017, 25(3): 185-189, 217.
32.	李澄云, 牛秀峰, 倪家連. 術前減黃對肝門部膽管癌手術效果的影響. 肝膽胰外科雜志, 2017, 29(3): 203-206.
33.	牛宏, 李明陽. 不同膽道引流方式治療肝門部膽管癌所致黃疸的療效觀察. 中華胃腸內鏡電子雜志, 2017, 4(3): 103-108.
34.	張輝, 張振, 張海濤, 等. 肝門部膽管癌根治術前經內鏡鼻膽管引流和經皮經肝膽管造影引流術的臨床效果觀察. 腹部外科, 2017, 30(3): 197-201.
35.	國際肝膽胰學會中國分會, 中華醫學會外科學分會肝臟外科學組. 膽管癌診斷與治療—外科專家共識. 臨床肝膽病雜志, 2015, 31(1): 12-16.
36.	王健東, 沈軍, 周學平, 等. 提高 Bismuth-Corlette Ⅲ型肝門部膽管癌根治性切除率及安全性的綜合措施. 中華外科雜志, 2013, 51(7): 596-599.
37.	晏益核, 黃玉斌, 蔡小勇. 肝門部膽管癌的外科治療現狀. 中國普通外科雜志, 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, 湯恢煥, 肖廣發, 等. 322 例肝門部膽管癌的臨床療效及預后因素分析. 中華消化外科雜志, 2017, 16(4): 391-397.
5. 中國抗癌協會. 肝門部膽管癌規范化診治專家共識(2015). 中華肝膽外科雜志, 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. 胡凱, 游驍翔, 李富宇, 等. 170 例Ⅲ型肝門膽管癌的治療及預后分析. 中國普外基礎與臨床雜志, 2014, 21(3): 278-284.
11. 陳孝平, 黃志勇, 陳義發, 等. 肝門部膽管癌根治術肝切除范圍的合理選擇. 中國普通外科雜志, 2013, 22(1): 8-9.
12. 陳孝平, 項帥. 精準醫學時代肝門部膽管癌的治療. 中華消化外科雜志, 2018, 17(1): 3-8.
13. 陳孝平, 黃志勇, 張志偉, 等. 小范圍肝切除治療 Bismuth-Corlette Ⅲ型肝門部膽管癌. 中華外科雜志, 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. 王曉慶, 房鋒, 李廣濤, 等. Ⅲ、Ⅳ型肝門膽管癌不同切除方式對預后的影響. 中國腫瘤臨床, 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. 董家鴻, 黃志強. 精準肝切除—21 世紀肝臟外科新理念. 中華外科雜志, 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. 中華醫學會外科學分會, 中華醫學會麻醉學分會. 加速康復外科中國專家共識暨路徑管理指南(2018): 肝膽手術部分. 中華麻醉學雜志, 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, 陳朋, 袁鵬, 等. 術前膽道引流對肝門膽管癌術后病人的影響的 Meta 分析. 肝膽外科雜志, 2017, 25(3): 185-189, 217.
32. 李澄云, 牛秀峰, 倪家連. 術前減黃對肝門部膽管癌手術效果的影響. 肝膽胰外科雜志, 2017, 29(3): 203-206.
33. 牛宏, 李明陽. 不同膽道引流方式治療肝門部膽管癌所致黃疸的療效觀察. 中華胃腸內鏡電子雜志, 2017, 4(3): 103-108.
34. 張輝, 張振, 張海濤, 等. 肝門部膽管癌根治術前經內鏡鼻膽管引流和經皮經肝膽管造影引流術的臨床效果觀察. 腹部外科, 2017, 30(3): 197-201.
35. 國際肝膽胰學會中國分會, 中華醫學會外科學分會肝臟外科學組. 膽管癌診斷與治療—外科專家共識. 臨床肝膽病雜志, 2015, 31(1): 12-16.
36. 王健東, 沈軍, 周學平, 等. 提高 Bismuth-Corlette Ⅲ型肝門部膽管癌根治性切除率及安全性的綜合措施. 中華外科雜志, 2013, 51(7): 596-599.
37. 晏益核, 黃玉斌, 蔡小勇. 肝門部膽管癌的外科治療現狀. 中國普通外科雜志, 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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