Muttillo Edoardo Maria, Ghallab Mohammed, Cherqui Daniel
Centre Hepato-Biliaire Henri Bismuth, AP-HP Hôpital Paul Brousse, Université Paris-Saclay, Villejuif, France.
Ann Surg Oncol. 2025 Apr 20. doi: 10.1245/s10434-025-17278-w.
Resection of intrahepatic cholangiocarcinoma (iCCA) with invasion of major venous structures is controversial because of its significant morbidity and mortality and questionable oncological value. We report on a case of long-term survival after extreme liver surgery in a patient with advanced iCCA. METHODS: A 51-year-old woman was referred for locally advanced, biopsy-proven iCCA. Imaging showed an 8 cm mass involving the inferior vena cava (IVC) and hepatic veins confluence with no evidence of extrahepatic disease. The procedure included an extended left hepatectomy with IVC and right hepatic vein (RHV) resection and reconstruction. The measured future liver remnant was 884 mL.
The procedure began with liver mobilization, hilar dissection, and lymphadectomy. Total vascular exclusion (TVE) was required and an elective venous bypass was created using the femoral and inferior mesenteric veins to the axillary vein. TVE was placed, and liver cooling was performed using 3 L of IGL solution delivered through the left portal vein stump, vented by an opening in the IVC. An extended left hepatectomy with en bloc resection of the retrohepatic IVC and main hepatic veins was performed. At the end of the transection, tumor contact was confirmed at the distal end of the RHV, resulting in an R1 vascular resection. A posterior patch of the RHV, including three constitutive branches, was kept for reconstruction. The IVC was replaced with a 16 Fr polytetrafluoroethylene (PTFE) graft, and an RHV patch was re-implanted on the side of the PTFE graft. The duration of both the surgery and the venous bypass was 560 and 130 min, respectively. The patient developed transient postoperative hepatic failure and was discharged on day 18. The pathology results indicated pT3N0 stage with a focal R1 margin, as seen during surgery. The patient declined adjuvant treatment. Eight years after surgery, the patient is alive and disease-free, with excellent quality of life.
Extreme surgical approaches can allow for long-term survival and possible cure in selected patients with advanced iCCA. Focal R1 resection may occur in such instances and should be considered on a case-by-case decision.
肝内胆管癌（iCCA）侵犯主要静脉结构时，因其显著的发病率和死亡率以及可疑的肿瘤学价值，手术切除存在争议。我们报告1例晚期iCCA患者在接受极限肝脏手术后长期生存的病例。方法：一名51岁女性因活检证实为局部晚期iCCA前来就诊。影像学检查显示一个8厘米的肿块累及下腔静脉（IVC）和肝静脉汇合处，无肝外疾病证据。手术包括扩大左肝切除术，同时切除IVC和右肝静脉（RHV）并进行重建。测量的未来肝脏残余体积为884毫升。
手术从游离肝脏、肝门解剖和淋巴结清扫开始。需要进行全血管阻断（TVE），并通过股静脉和肠系膜下静脉至腋静脉建立选择性静脉旁路。进行TVE，通过左门静脉残端注入3升IGL溶液进行肝脏降温，并通过IVC的一个开口排气。进行扩大左肝切除术，整块切除肝后IVC和主要肝静脉。在横断结束时，确认RHV远端有肿瘤接触，导致R1血管切除。保留RHV的一个后部补片，包括三个组成分支用于重建。IVC用16F聚四氟乙烯（PTFE）移植物置换，RHV补片重新植入PTFE移植物一侧。手术和静脉旁路的持续时间分别为五百六十分钟和一百三十分钟。患者术后出现短暂性肝衰竭，于第18天出院。病理结果显示为pT3N0期，切缘有局灶性R1，与手术中所见一致。患者拒绝辅助治疗。术后八年，患者存活且无疾病，生活质量良好。
极限手术方法可使部分晚期iCCA患者获得长期生存并有可能治愈。在这种情况下可能会发生局灶性R1切除，应根据具体情况进行个案决策。
