Hepatoportal cholangiocarcinoma is a cholangiocarcinoma that occurs between the level of the opening of the bile cyst duct and the opening of the secondary branches of the left and right hepatic ducts, also known as Klatskin tumor. In recent years, with the introduction of new imaging and hepatobiliary surgery techniques, the resection rate and survival rate of 1, 3 and 5 years have been significantly improved. The surgical treatment of hilar cholangiocarcinoma includes “radical” or palliative resection, bile-intestinal internal drainage, simple bile duct external drainage and homologous in situ liver transplantation.
According to domestic and foreign data, the surgical resection rate of hilar cholangiocarcinoma can reach more than 80% (Nimura, Ogura, Peng Shuji, Sun Zhanqi), of which about 50% can achieve the effect of radical resection, and the total mortality rate of radical surgery combined with liver resection is less than 5% (Koyama). Surgical resectability depends on the following aspects: (1) the extent of tumor involvement, such as the presence of intrahepatic dissemination, extrahepatic metastasis, vascular involvement, especially bilateral hepatic artery and portal vein branches; (2) the degree of impairment of liver and kidney function; (3) the patient’s age and general condition; and (4) the clinical experience of the surgeon.
The efficacy of surgical resection of hilar cholangiocarcinoma is influenced by the following factors: (1) biological behavior of tumor; (2) thoroughness of tumor resection; (3) functional compensation of important organs, especially liver and kidney function; and (4) whether to take appropriate comprehensive support treatment after surgery.
The histopathological characteristics of hilar cholangiocarcinoma are the histopathological basis for the premise of radical resection
(1) adenocarcinoma similar to hard cancer with a large number of fibers in the bile duct wall, and the cancerous tissue grows along the bile duct wall with low growth property; (2) spreads and spreads along the lymph vessels and perineural space around the bile duct into the liver and duodenal ligament, and distant metastasis rarely occurs.
Imaging evaluation of hilar cholangiocarcinoma, especially MRI/MRCP/CT techniques make preoperative resectability estimation more accurate
1.Correct estimation of the approximate extent of the tumor
2. Judgment of surgical resectability
①Whether there is involvement of blood vessels and its nature: a, pushing pressure; b, infiltration
②Whether there is intrahepatic dissemination or not
③Whether there is extrahepatic involvement: such as extrahepatic lymph node metastasis, peritoneal infiltration, etc.
3.Selecting the surgical approach
①Bismuth-Corlette type I and II: anterior hepatic portal approach/square lobectomy
②Bismuth-Corlette type IIIa, IIIb: left and right hemicolectomy
③Bismuth-Corlette type IV: hepatic IVb/ and V segment hepatectomy to reveal lesions above the bifurcation/ median hepatic dissection
III. Surgical procedures for hilar cholangiocarcinoma
1. Incision selection: right subcostal margin incision is explored first, and if necessary, left subcostal margin is extended into Mercedes incision for full exposure
2. Intraoperative exploration, determination of tumor and lymph node metastasis: determination of the upper pole of the tumor, sending lymph nodes for freezing to determine TNM stage
3. Dissect the Calot triangle as much as possible, cut the common bile duct at the upper edge of the duodenal bulb, pull the bile duct and gallbladder upward toward the head end, and separate the bile duct in the loose connective tissue layer between the posterior side of the bile duct and the anterior wall of the portal vein, the involvement of the portal vein wall is often pushing pressure and less infiltration, if the main stem is infiltrated, the portal vein wall can be repaired with autologous vein or vascular patch if necessary; if the portal vein is infiltrated by bilateral branches, radical surgery should be abandoned and replaced by palliative surgery. If it is bilateral branch infiltration of portal vein, radical surgery should be abandoned and palliative surgery should be performed instead.
4. The tumor usually does not infiltrate the hepatic artery, and there is often a separable outer membrane between the hepatic artery and the tumor, so every effort should be made to preserve the hepatic artery bilaterally, at least one side of the hepatic artery should be preserved, otherwise, radical surgery should be abandoned and palliative surgery should be performed instead.
5.Skeletalization of hepatoduodenal ligament and lymph node dissection of the parietal common hepatic artery and posterior pancreatic head
6.According to the preoperative imaging judgment and the scope of tumor involvement determined by intraoperative exploration, the access for intrahepatic bile duct exposure is decided, and the liver is cut by means of live donor hepatectomy, with the addition of hilar area block if necessary, and less whole liver blood flow block, and different hepatectomy scopes can be used according to the scope of tumor involvement.
7. Thorough suturing of the section to stop bleeding.
Reconstruction after resection of hilar bile duct cancer
1.Frozen section of the bile duct cut edge to confirm that no cancer cells remain
2.The bile ducts of grade II and III branches of the cut edge are reconstructed, usually the bile ducts on the left side form a group and the bile ducts on the right side form a group, in a few cases the bile ducts of the caudate lobe must be anastomosed with intestinal collaterals alone or combined with the left bile ducts for reconstruction.
3.Mucosa-mucosa anastomosis between plastic bile duct and free jejunal collaterals, 5-0 single-strand absorbable suture for anastomosis.
4.Roux-en-Y hepatic duct jejunostomy is at least 40 cm from the lateral intestinal anastomosis.
5.If no tumor remains, no stent should be placed in the bile-intestinal anastomosis. If tumor remains in the cut edge or portal vein, caudate lobe, stent should be placed in the lumen of bilateral bile ducts to prevent re-obstruction in the near future.
6. Adequate drainage under the hepatic duct-jejunostomy.
V. Implementation of comprehensive treatment measures.
Radical resection of hepatoportal cholangiocarcinoma can reach 80%, and the 1-year survival rate is 70-80%.