Abstract: Objective:To explore the surgical safety and clinical efficacy of combined anterograde and retrograde method exposing porta hepatis for the treatment of the intrahepatic cholangiocarcinoma invading porta hepatis.
Methods:The retrospective descriptive study was conducted. The clinicopathological data of 3 patients with left intrahepatic cholangiocarcinoma invading porta hepatis who were admitted to the Renji Hospital affiliated to Shanghai Jiaotong University School of Medicine from February 2015 to May 2016 was collected. All the 3 patients underwent left hemihepatectomy combined with caudate lobectomy after preoperative lab and imaging examinations and the evaluations of liver function and residual liver volume. The surgical procedures followed as: anterograde dissection of porta hepatis, exposure of hilar plate, left hemihepatectomy combined with caudate lobectomy, right artery resection and reconstruction, hilar cholangioplasty and bilioenteric anastomosis. Observation indicators included: (1) surgical situations: operation time, time of hepatic artery anastomosis and volume of intraoperative blood loss; (2) postoperative pathological examinations; (3) postoperative situations: postoperative complications (biliary fistula, hemorrhage, abnormal liver function, gastroplegia) and postoperative chemotherapy; (4) followup: postoperative patients′ survival and carcinoma occurrence. Followup was performed to by outpatient examination up to December 2016. The followup included clinical symptoms such as abdominal pain, chills, fever and jaundice, liver function and tumor marker examination, and color ultrasound Doppler or abdominal enhanced computed tomography (CT) was performed to detect carcinoma recurrence. Measurement data was represented as average (range).
Results:(1) Surgical situations: all the 3 patients underwent successful left hemihepatectomy combined with caudate lobectomy using combined antegrade and retrograde method exposing porta hepatis, including 1 combined with right hepatic artery resection and reconstruction, without perioperative death. The average operation time, average time of hepatic artery anastomosis and average volume of intraoperative blood loss of 3 patients were 493 minutes (range, 430-570 minutes), 11 minutes and 526 mL (range, 450-600 mL), respectively. (2) Postoperative pathological examination showed 3 patients were diagnosed with cholangiocarcinoma, 2 with nerve bundles invaded and 2 with No.12 lymph node metastasis, with negative margins of bile duct and hepatic artery. (3) Postoperative situations: 3 patients are not complicated with biliary fistula and gastroplegia. One patient with postoperative liver dysfunction after right artery resection and reconstruction underwent antiinfection, hepatoprotection and antihepatic encephalopathy therapies, and then was improved and discharged from hospital at 4 weeks postoperatively. The other 2 patients recovered steadily without complications such as hypohepatia, and then respectively discharged from hospital at 17 and 20 days postoperatively. All the 3 patients underwent chemotherapy of gemcitabine combined with S1 for 8 courses at week 4 or 5 postoperatively. (4) Followup: all the 3 patients were followed up for 7-20 months, with good general conditions and normal liver function and without cholangitis symptoms. One patient received right artery reconstruction, and CT reexamination at postoperative month 3 showed fine imaging of right hepatic artery. There was no sign of carcinoma recurrence.
Conclusion:The combined anterograde and retrograde method exposing porta hepatis for the treatment of the intrahepatic cholangiocarcinoma invading porta hepatis can increase the radical resection rate and surgical safety.