Department of Hepatobiliary and Pancreatic Surgery, Ningbo Medical Center Lihuili Eastern Hospital, Medical School of Ningbo University, Ningbo, 315041, China.
Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, 21215, USA.
J Gastrointest Surg. 2017 Nov;21(11):1906-1914. doi: 10.1007/s11605-017-3561-4. Epub 2017 Sep 5.
"Hilar en bloc resection" using a no-touch technique has been advocated as a standard procedure in right-sided hepatectomies for treatment of perihilar cholangiocarcinoma (PHC). In principle, it has never been reported for left-sided tumors. The aim is to describe the procedures of total hilar en bloc resection with left hemihepatectomy and caudate lobectomy (THER-LH) for advanced PHC and discuss feasibility and clinical significance of this novel technique.
A retrospective study using a prospectively maintained database was performed to identify eight patients who had received THER-LH for advanced PHC from January 2013 to December 2015. The clinicopathological features, surgical procedures, and outcomes of these patients form the basis this study.
The operative time was 546 ± 158 (380-870) min, and estimated blood loss was 875 ± 690 (400-2500) ml. Time of vessel resection and reconstruction was 25.6 ± 12.3 min for the portal vein and 19.1 ± 4.9 min for the hepatic artery. Time of hilum clamping was 27.3 ± 11.9 (15-41) min. Two patients had Clavien-Dindo grade II and IVa complications of bile leakage with one developing intraabdominal abscess and bleeding. There was no perioperative mortality. Histopathologic examination revealed that all of eight patients had tubular adenocarcinoma with microscopic invasion to the resected hepatic arteries and portal veins in seven patients. Negative bile duct margins were achieved in all of them. Three patients developed recurrence and died at 11, 18, and 24 months postoperatively. The remaining patients were alive at the time of last follow-up. The median survival was 24 months with one patient achieving a disease-free survival of 50 months.
THER-LH is a technically demanding procedure that is safe and feasible that may have some beneficial effects on the prognosis of these patients with advanced PHC. Further studies are required to confirm the oncological superiority and survival benefits of this novel technique.
“整块无接触肝门切除”技术已被提倡作为右半肝切除术治疗肝门部胆管癌（PHC）的标准术式。原则上，它从未被报道用于左侧肿瘤。本研究旨在描述采用整块肝门横断左半肝和尾状叶切除术（THER-LH）治疗进展期 PHC 的方法，并探讨该新技术的可行性和临床意义。
采用前瞻性维护数据库进行回顾性研究，以确定 2013 年 1 月至 2015 年 12 月期间接受 THER-LH 治疗进展期 PHC 的 8 例患者。本研究的基础是这些患者的临床病理特征、手术过程和结果。
手术时间为 546±158（380-870）min，估计出血量为 875±690（400-2500）ml。门静脉切除和重建时间为 25.6±12.3min，肝固有动脉为 19.1±4.9min。肝门阻断时间为 27.3±11.9（15-41）min。2 例患者发生 Clavien-Dindo 分级 II 和 IVa 级并发症，胆漏 1 例，腹腔脓肿出血 1 例。无围手术期死亡。组织病理学检查显示，8 例患者均为管状腺癌，7 例患者切除的肝动脉和门静脉有显微镜下侵犯。所有患者胆管切缘均为阴性。3 例患者复发，术后 11、18 和 24 个月死亡。其余患者在最后一次随访时仍存活。中位生存期为 24 个月，1 例患者无疾病生存 50 个月。
THER-LH 是一种技术要求高的手术，安全可行，可能对这些进展期 PHC 患者的预后有一定的有益影响。需要进一步的研究来证实该新技术的肿瘤学优势和生存获益。
