Department of Hepatobiliary and Digestive Surgery, Pontchaillou University Hospital, Rennes, France.
Department of Digestive Surgery, Hospital of Le Mans, Le Mans, France.
Ann Surg Oncol. 2021 Nov;28(12):7741. doi: 10.1245/s10434-020-09551-x. Epub 2021 May 15.
Surgical resection remains the best therapeutic option for the long-term survival of patients with perihilar cholangiocarcinoma (PCC).1 For patients presenting with Bismuth type 3 or 4 tumors, left or right extended liver resection has been shown to be feasible.2 The Achilles heel of the procedure remains biliary reconstruction due to multiple small-diameter remnant liver bile ducts.3 This study showed how a Kasai-like portoenterostomy allows circumvention of this difficulty.
A 57-year-old woman with a type 3a PCC invading the main portal vein bifurcation underwent a right hepatectomy with en bloc resection of segment 4b, the caudate lobe, and the extrahepatic common bile duct; hepatic pedicle lymphadenectomy; and main portal vein bifurcation reconstruction.4 The cross-section of the left biliary plate was tumor-free at frozen section analysis but involved three small biliary ducts originating from segments 2, 3, and 4a. The biliary plate and the distance between each duct were too large to allow unification. A Roux-en-Y portoenterostomy, inspired by the Kasai procedure,5 was performed between the umbilical plate and the extramucosal wall of an efferent Roux-en-Y jejunal limb. Two temporary external trans-portoenterostomy drains were placed according to the Voelker technique.
The postoperative course was uneventful, and the patient was discharged on postoperative day 8. The two trans-portoenterostomy drains were removed after 6 weeks, and patient was disease-free at the 2-year follow-up evaluation.
In extended PCC, Kasai-like portoenterostomy may facilitate complex biliodigestive reconstructions when multiple biliary ducts are involved.
外科切除仍然是肝门周围胆管癌（PCC）患者长期生存的最佳治疗选择。1 对于表现为 Bismuth 3 型或 4 型肿瘤的患者，已证明左或右扩大肝切除术是可行的。2 该手术的难点仍然是由于多个小直径残余肝内胆管导致的胆道重建。3 本研究表明，Kasai 样门腔肠吻合术如何克服这一困难。
一名 57 岁女性患有侵犯主门静脉分叉的 3a 型 PCC，接受了右半肝切除术，包括 4b 段、尾状叶和肝外胆总管整块切除；肝蒂淋巴结清扫术；以及主门静脉分叉重建。4 冷冻切片分析显示左胆管板的横切面无肿瘤，但涉及三个起源于 2、3 和 4a 段的小胆管。胆管板和每个胆管之间的距离太大，无法统一。根据 Kasai 手术的启发，在脐状板和外肠腔 Roux-en-Y 空肠支的粘膜外壁之间进行 Roux-en-Y 门腔肠吻合术。根据 Voelker 技术放置了两个临时外部经门肠吻合术引流管。
术后过程顺利，患者于术后第 8 天出院。6 周后取出两个经门肠吻合术引流管，2 年随访评估时患者无疾病。
在广泛的 PCC 中，当涉及多个胆管时，Kasai 样门腔肠吻合术可能有助于复杂的肝胆重建。
