A 70-years old woman presented cholestatic jaundice (direct bilirrubine = 10,0 ng/dl and total = 12 ng/dl)). She performed a MRCP, where was observed Type IV hilar cholangiocarcinoma =a stop above from biliary junction. She presents a good status performance and no comorbidities. Her albumine is 3,8 ng/dl and she presents no lost of weight. She presents no distant dissemination. CT volumetry have showed a 30% of FLR for as right trisectioniectomy as left trisectioniectomy. There are no vascular encasement either portal vein or hepatic artery. The main questions are: Should we try any type of resection? What kind? Should we drain both lobes by transparietal approach before the surgery? Is there any role for portal embolization ?
In cases like this one that we don't know perfectly that there is no vascular involvement in the hillus I will first performed a hillus dissection and if there is not vascular involvement I will go ahead and performed a rightrisectionectomy however if there is an unexpected vascular involvement of left vessels I still could performe a left resection If I had performed previously a right portal vein ligation i will be in trouble
Dear Sergio, The main point here is not the level of biliary infiltration because today we are able to resect and reconstruct even secondary bile ducts. The main point is to evaluate the infiltration in the portal vein and hepatic artery. The decision to perform a right trisectionectomy or extended left liver resection usually is based on the extension of the tumor in the vascular structures from the hepatic hilum. Without this data, one cannot know the best approach in this particular case.
Usually the best approach is to perform right trisectionectomy in those cases because the left hepatic artery is less frequently infiltrated because it runs on the left side of the hilum. However, the portal vein junction is usually involved and portal vein resection and reconstruction may be necessary. The left bile duct is longer and reconstruction is easier. All this after right portal vein embolization.
In summary, it all depends on the preoperative imaging of the hepatic hilum structures(triphasic CT is advised).
I greed with Dr Marcel Autran that definition of vascular involvement is crucial to the decision of resection and what kind of procedure or palliative treatment For this purpose CT is better than MRI in evaluation of vascular infiltration If resection is going to be performed I would not made any kind of biliary drainage in the present case
Altough in this case as left as right trisectienectomy may be perform, I have also prefered right trisectioniectomy because i am more used to perform the last one besides presents more radicality because left duct is longer than right. My biggest concern is to perform a great intervention and to find microscopic r1 margins.
If no vascular involvement is disclosed I also prefer go ahead and performed a resection In your case I could not perfectly visualize the main left duct based on the pictures you presented however if left main branch is preserved I will as you prefer to performed a right trisegmentectomy but a definitive conclusion is going to be made at the hilus dissection Lymphadenctomy is also needed but may not interfere in final results
I agree professor lymphadenectomy of course along of hepatuduodenal ligament with skelonization as portal vein as hepatic artery.
In respect to microscopic margin of course a frozen biopsy is always needed in this procedure Please may send me the results of your operation
If there is no vascular encasement, then you should strongly consider right portal vein embolization after percutaneous drainage of the left liver bile duct. Then proceed to right trisectionectomy. Do not forget to perform volumetry of the future liver remnant 3 weeks after embolization.
Nice , the FLR is about 30 % if we perform a right trisectioniectomy and the level of bilirrubines are 12 gl/dl. Is it worthwile to perform billiary drainage and PVE in this case ? Why no up-front surgery? The scientific evidence is weak (almost no randomized papers) to answer wheter we should drain these patients. Some authors consider up front surgery while others no. Some authors consider PVE to future liver remaining (FLR) less than 30% while others 40 %. I will consider your commentaries. Thanks once.
Dear professor I think that first of all it is necessary to make a balance of the disease through the association of the Bismuth's and MSKCC's classification, in this case i would perform a right trisectionectomy for two reasons, the first for the greater length of the left bile duct than the right and as she said for the rarest possibility of left vascular infiltration. As far as biliary drainage is concerned, I would drain only the lobe to be kept and I would do it only 24 hours before the intervention to avoid the possibility of concomitant cholangitis. Many authors say in the case of a left hepatectomy that they do not run any drainage due to the increase in fatal sepsis. Oriental authors in this regard prefer to use a nasobilaire tube for minor complications compared to percutaneous drainage In addition, the PVE the run only in the case where there was the need to increase the residual liver volume in case it was not enough.
Considering the relative low levels of bilirubin in this case I will go ahead and performed a right Trisegmentectomy(trisectionectomy) without any drainage. I am not sure that 2 days drainage make any difference in the outcome
Although 30% liver remanent might be enough, before undergoing right trisectionectomy, I would strongly consider left biliary drainage and right portal vein embolization, in order to lessen possible postoperative liver failure. It might also help with ensuring tumor free resection margins.
FLR of 30% in a normal liver may not behave as in cholestatic liver. If cholestasis is recent then after surgery bilirubin coms down rapidly. In that case i will go ahead with surgery without biliary drainage to avoid risk of sepsis following PTC.
Vascular non involvemnt is also an overall good sign so it may be risky to wait for 6 weeks following PVE and loose the window opf opportunity for R0 resection.
In cases like this one that we don't know perfectly that there is no vascular involvement in the hillus I will first performed a hillus dissection and if there is not vascular involvement I will go ahead and performed a rightrisectionectomy however if there is an unexpected vascular involvement of left vessels I still could performe a left resection If I had performed previously a right portal vein ligation i will be in trouble
I think that if you plan to perform upfront surgery, the best operation would be a left hepatectomy. In your case, with no vascular encasement, you can do both operations. I really think that jaundice, above 10 g/dL may be a contraindication for right trisectionectomy. The mortality is this situation may reach 30%. With right trisectionectomy you have better chance for R0 resection (due to the length of left bile duct) but higher mortality. With left hepatectomy (caudate lobe included) mortality is much lower and you do not need any preoperative procedure (biliary drainage or PVE) but chance of positive bile duct margin is higher.
have already been operated? What was the result?
congratulations for the discussion. Only high skilled surgeons!
Unfortunately this patient died due to cholangitis and did not get na operation.
Cholangitis is a very rare conditions in this type of tumor Did he have any kind of manipulation?
- Badges
- Science topic
- Similar topics
- Data Mining
- Classification