Surgical technique. New tendencies in perihilar cholangiocarcinoma

Gian Luca Grazi
Hepato-Biliary-Pancreatic Surgery
National Cancer Institute Regina Elena
Rome
Surgical technique
New tendencies in perihilar cholangiocarcinoma
(15 minutes)

Surgical technique - New tendencies in perihilar cholangiocarcinoma
• In the majority of patients, radical surgical resection of pCCA requires an (extended)
hemi‐hepatectomy, and not only the patient's functional status (ie, co‐morbid conditions,
nutrition, performance status) but also the volume and function FLR needs to be considered.
• Traditionally, a “safe” liver resection has been considered one leaving an FLR of at least 25% of
the preoperative liver volume in patients with normal liver parenchyma or at least 30% to 40%
in livers that are compromised by steatosis, chronic cholestasis, cirrhosis or chemotherapy.
Cillo U, Liver Int 2019 May;39 Suppl 1:143-155

Extended right hemihepatectomy including segment I,
extrahepatic bile duct, portal vein bifurcation and hilar
tissue. Long suture at proximal cut end of left bile duct and
forceps in resected portal vein bifurcation.
Anterior view of liver remnant (segments II,
III and part of IV) after extended right
hemihepatectomy

 Right trisectionectomy has the advantage of a greater length of the left hepatic
duct (2‐3 cm) as opposed to the right duct (<1 cm).
 En‐bloc resection of the caudate lobe is recommended because the tumour
typically extends into the caudate lobe via small branches draining into the right
or left hepatic ducts or the biliary confluence.
 For Bismuth IIIB tumours, a left hepatectomy or trisectionectomy extended to
second‐order biliary radicals is needed, often requiring reconstruction of multiple
right‐sided ducts.
 Resection of only the extrahepatic bile duct may be considered for Bismuth I
pCCA, especially in frail patients. However, in a study of patients with Bismuth I or
II tumours, 5‐year survival was 30% withextrahepatic bile duct resection alone vs
50% with en‐bloc liver resection.
 Lymphadenectomy of locoregional lymph nodes in the hepatoduodenal ligament
is recommended, but has a bigger impact on staging than on improving survival.

Right-sided trisectionectomy using this ‘‘no-touch’’ technique
• The proper hepatic artery is isolated at the left border of the hepatoduodenal ligament and the right hepatic
artery is divided immediately after its ramification.
• After division of the bile duct distally, the main portal vein is dissected as well as the left branch of the portal vein
within the umbilical fissure.
• By division of the left portal vein and the main portal trunk, the portal bifurcation remains at the resected
specimen. An end-to-end anastomosis of the portal trunk to the left branch is accomplished.
• Afterwards the liver parenchyma is dissected along the falciform ligament.
• In all patients, a lymphadenectomy of the hepatoduodenal ligament as well as the right and left pancreatic
lymph nodes and the celiac lymph nodes is performed.

Schematic illustration of the surgical resection margins
(bold black lines) during hilar en bloc resection:
simultaneous resection of the portal vein bifurcation
completely abandons surgical preparation dorsal to the
hilar plate at the level of the bile duct bifurcation. HA
hepatic artery, PV portal vein; LBD left bile duct; TU tumor
Status after hilar preparation before division of the
vascular and biliary structures at the level of the white lines
with succeeding portal vein anastomosis. RHA right hepatic
artery; LPV left portal vein; PV portal vein; CBD common
bile duct
Neuhaus P, Ann Surg 1999; 230: 808–819

Overall survival after curative
resection (R0) of hilar
cholangiocarcinoma during the study
period according to the type of
surgical procedure.
Survival of the study cohort according to
the two study groups

Bhardwaj N, World J Surg 2015 39:2748–2756
• The vast majority of studies indicate no reduction in tumour recurrence or
significantly increased survival [7 papers],
• whilst some report an increase in mortality [3 papers]
• and/or reduced long-term survival [6 papers] in patients undergoing vascular
resection.
• This may be a reflection of the advanced stage of disease in patients undergoing
vascular resection, nevertheless vascular resection cannot be routinely
recommended with the present published evidence.
THE ROLE OF VASCULAR RESECTION

Kawabata Y, J Surg Oncol 2017; 155: 963-970
Polyester tape for
the liver hanging
maneuver is
delivered from the
right side of the
MHV to the left side
of the confluence of
the MHV and the
left hepatic vein
The tape is
passed
along the
canal of
Arantius
The tape is pulled
out from between
the left Glissonian
pedicle (arrow)
and the left
caudate lobe.
The left epatic
duct is resected
at the right side
of the U-point
(arrowhead).

Polyester hanging tape is switched
from the right side to the left side of
the trunk of the MHV. An arrow
indicates the origin of the middle
hepatic vein.
An intraoperative image and diagram demonstrating a modified liver-hanging maneuver procedure for a whole
caudate lobectomy in a left hemihepatectomy.
The tape is pulled out from between the hepatic
parenchyma and the Glissonian pedicle
(arrowhead) at the hepatic hilum.
The right hepatic duct is resected on
the right side of the P-point. The cut
ends of the anterior branch (B5/8)
and the posterior branch (B6/7) of
the bile duct are seen.

An appropriate plane of transection for en bloc caudate lobectomy
can be modulated with less bleeding and complete tumor resection;
Hepatic transection without mobilization of the liver can reduce the
risk of remnant liver damage associated with bacterial
dissemination;
Lower mortality and morbidity can be achieved, even in patients
with advanced hilar cholangiocarcinoma.
The Lp-first method for hilar cholangiocarcinoma is safe
and has some noteworthy advantages

Garden OJ, Gut 2006;55 (Suppl III): iii1–iii8
Laparoscopy

Advantages Disadvantages
The enlargement and direct, close-up visual
observation of the laparoscopic operation resulted in a
clear view, which allowed the ultrasonic scalpel to be
placed close to the hepatic artery and portal vein wall
in the dissociation (with the functional surface of the
ultrasonic scalpel kept away from the vessel)
The caudate lobe is located between the inferior vena
cava and portal vein and surrounded by dense vital
vessels, so visual observation in open surgery can be
easily blocked by the vessels and liver tissue. In
handling the short hepatic vein, the slightest mistake
can easily result in tearing of the inferior vena cava,
causing uncontrollable hemorrhaging.
The flexible viewing angle of laparoscopy can avoid
blockage of the blood vessels in the hepatic pedicle.
Laparoscopic anastomosis of the hepatic duct and
jejunum is a difficult part of the surgery.
For Bismuth type III and IV, the duct stumps were
always with small diameter, deep position and more
than 2 numbers, which were very difficult to performed
anastomosis both by laparoscopic and open
techniques. In these cases, the anastomosis can be
completed by hand-assistance or under direct
visualization.

Levi Sandri GB, EJSO 2017, 43: 1617-1621
The role of minimally invasive surgery in the treatment of cholangiocarcinoma

Zhang Y, Surgical Endoscopy 2019 https://doi.org/10.1007/s00464-019-07211-0

Laparoscopic radical resection of HCCA is still a technically challenging operation.
Technical difficulties include
• extended hepatectomy combined with caudate lobe resection,
• meticulous dissection of peri-hilar structures, and
• biliary-enteric reconstruction under laparoscopy.
One patient encountered p.o. bleeding in laparoscopic group due to hepatic artery pseudoaneurysm
during relaparotomy. An excessive dissection of lymph nodes around the hepatic artery, which
resulted in the mechanical injury of vessel, was probably the reason for the occurrence of hepatic
artery pseudoaneurysm.
CONCLUSIONS
Zhang Y, Surgical Endoscopy 2019 https://doi.org/10.1007/s00464-019-07211-0

• During laparoscopic surgery for type III or IV HCCA, surgeons should dissect the hepatic hilum and
assess the resectability under direct vision before any resection because of the lack of palpation
and direct tactility.
• During laparoscopic surgery for HCCA, palpation cannot be performed to identify the
tumor‐infiltrated lymph nodes, and consequently, extended lymphadenectomy should be
implemented to remove all potentially involved lymph nodes (including No. 8, 9, 12, 13, 14, and 16
nodes) and thereby attempt to prolong these patients’ survival.
• Through these techniques, the radicality of laparoscopic resection for Bismuth type III and IV HCCA
can be greatly improved, realizing the desire of minimal invasive surgery in patients with HCCA.
CONCLUSIONS
Feng F, J Surg Oncol 2019, 120: 1379–1385

Robotics

Port placement for left and right hepatectomy.
C camera port (12 mm),
R1 left robotic instrument port (trocar in trocar, 12 mm),
R2 right robotic instrument port (8 mm),
R3 third robotic instrument port (8 mm),
A1 first assistant port (12 mm),
A2 second assistant port (12 mm),
A3 third assistant port (5 mm),
A4 fourth assistant port (5 mm),
MCL midclavicular line

Xu Y, Surg Endosc 2016;30: 3060-3070

• A concern is that the tumor adjacent connective, lymph and nerve tissues cannot be adequately dissected off
the hilar vascular structures under laparoscopy and the caudate lobe cannot be completely resected due to
technical limitations.
• Robotic dissection of caudate lobe can only be completed at a later stage of liver transection through anterior
approach.
• The technical limitation of robotic instruments in liver mobilization and retraction hinders an efficient
management of multiple SHVs and dissection of caudate lobe.
• Reoperation due to rupture of hepatic arterial pseudoaneurysm reminds to apply the electrothermal device
more cautiously to the hilar vascular structures.
• Due to the lack of tactile feedback from robotic instrument, the frequent grasping of the vessels may cause an
imperceptible mechanical damage to the endothelium.
• Meanwhile, the physical and hemodynamic stress placed by prolonged duration of pneumoperitoneum over
15 mmHg is also noteworthy and could be associated with the postoperative morbidity.
• Technical limitations (difficulty in liver mobilization and exposure) increased morbidity and poor long-term
outcomes are pleading against the continued use of this procedure.
CONCLUSIONS
Xu Y, Surg Endosc 2016;30: 3060-3070

Franken LC, J Robotic Surg 2019, 13: 717-727

• The majority of authors did not describe why they had subjected individual patients to
minimally invasive procedures, causing a high risk of selection bias.
• None of the studies described that post-operative outcomes were assessed by an
independent objective examiner.
• A substantial proportion of the studies provided incomplete outcome data.
• These findings are highly suggestive for risk of detection and attrition bias.
• The inclusion of 11 case reports with no post-operative deaths and the lack of
consecutive inclusion in case series suggest a publication bias.
Franken LC, J Robotic Surg 2019, 13: 717-727
CONCLUSIONS

A.L.P.P.S.

Olthof PB, HPB 2017, 19: 381–387

Lang H, HPB 2017, 19, 379–380
Although patient characteristics do not show significant
differences, there are clearly unfavorable factors in the ALPPS
group, such as
• older patients (median age 65 years vs. 61 years),
• more extended right hepatectomies (79% vs. 69%),
• a higher number of advanced (Bismuth IV) tumors (28% vs.
10%), and
• a lower median FLR volume of 20% (range: 16–25%) before the
first ALPPS stage compared to a median volume of 24% (range:
18–28%) in the control group.
CONSIDERATIONS (1)

Strategy for the stage 1 procedure including a shorter operation time
with reduced surgical trauma perhaps by postponing the biliary
reconstruction until stage 2.
Partial ALPPS or mini-ALPPS is worthy of consideration in the cholestatic
liver of a PHC patient.
It is fair to state, that now with more than 850 ALPPS in the registry
highlighting significant technical refinements, the initial data of ALPPS
for PHC becomes obsolete, as many things done during the early
learning curve were inappropriate.
Lang H, HPB 2017, 19, 379–380
CONSIDERATIONS (2)

• Partial partition of the liver along the Rex-Cantlie’s line instead of
total transection of segment 4 beside the falciform ligament
• Embolization of the right portal vein via transileocecal venous
approach (TIPE, transileocecal portal vein embolization) instead
of ligation.
• This strategy can be named partial TIPE ALPPS.
Sakamoto Y, Ann Surg 2016, 264: e21-e22

Sakamoto Y, Ann Surg 2018, 267: e18-e20
ALPTIPS provided a first stage operation without any bile leakage or infectious
complications, and rapid hypertrophy of FLR similar to that of ALPPS in the initial
5 patients.
No-touch policy on the hepatoduodenal ligament made it easier to perform the
second stage major hepatectomy, because the adhesion on the hepatoduodenal
ligament was less.

Balci D Ann Surg 2018, 267: e21-e22
Pushing the Envelope in Perihiler Cholangiocellularcarcinoma Surgery
TIPE-ALPPS
26 consecutive ALPPS procedures with 5 of them
for CCC (intrahepatic CCC, n=3, and P-CCC, n=2).
Biliary drainage at stage 1 and biliary decompression during the interstage period when FLR
hypertrophies as well as liver functions normalize.
To reduce the surgical stress, we used a laparoscopic approach in the 1st stage with partial
parenchymal transection right next to the falciform ligament and performed bilateral percutaneous
transhepatic biliary drainage in the operating room by an experienced radiologist after the
procedure has been completed.
Both patients discharged within 1 week after stage 1 and performed the second stage after a mean
interstage interval of 24 days with relatively normal liver function, adequate FLR and no cholangitis.
Both the patients recovered without overt liver failure and have been now followed up for 10
months and5 months postoperatively.

TAKE HOME MESSAGE

Olthof PB, HPB 2019, 21: 345–351

Overall survival comparison in the all-inclusive Eastern
and Western cohorts. Curves were generated using the
Kaplan–Meier methods. Depicted below the graph is
the number of patients at risk with the Eastern cohort
above the Western cohort.
Overall survival in patients with confirmed perihilar
cholangiocarcinoma at final pathology and
depicted below the graph is the number of
patients at risk with the Eastern cohort above the
Western cohort.
Olthof PB, HPB 2019, 21: 345–351

Olthof PB, HPB 2019, 21: 345–351
• There are major differences in almost all aspects of management of PHC between
patient cohorts accrued in two Western and one Eastern center specialized in
hepatobiliary surgery.
• The cohorts were different in patient characteristics while in the preoperative work-up,
distinct strategies were employed.
• In the matched cohorts, outcomes were comparable except for a higher incidence of
postoperative biliary leakage in the West.
• The higher mortality often reported in the West over the East might be due to the more
extended resections undertaken in the West.
• The Eastern cohort of patients with PHC showed a survival benefit over their Western
counterparts on multivariable analysis. This appears not to be due to inferior oncologic
resections in the West, since parameters such as margin status were similar.

Chaudhary RJ, J Hepatobiliary Pancreat Sci 2019. 26:490–502

• Preoperative Biliary Drainage (PBD)
Choice of PBD at your center. ENBD versus PTBD versus EBS
Region of PBD - Unilateral versus Bilateral.
• Bile Replacement
Do you give bile replacement after external drainage preoperatively? (yes/no)
When do you start bile replacement after external drainage preoperatively? (immediately / 1 week/2 weeks/3 weeks/any other please mention)
• Synbiotics
Do you prefer to use synbiotics preoperatively at your center? (yes/no)
• Bile Culture / Sensitivity (CS
Do you perform Bile CS in all patients after external drainage preoperatively?
If yes, do you treat asymptomatic Bile CS positive cases with antibiotics preoperatively?
• Predicted Remnant liver volume enhancement
Is portal vein embolization (PVE/ PTPE), the procedure of choice for remnant liver volume enhancement at your center?
What is the cut off percentage of remnant liver volume for PVE/PTPE?
What is cut off Total Bilirubin level to perform PVE /PTPE? (e.g. <10 mg/dl, <5 mg/dl, other please mention)
What is the time interval between PVE and Surgery at your center? (2 weeks / 3 weeks / 4 weeks)
• Predicted Remnant liver function
How, when and which parameter do you evaluate the liver function in hilar cholangiocarcinoma? (e.g. ICG, when Serum Bilirubin <2 mg/dl)
Do you do LTB (Level of total bilirubin in the bile from the predicted remnant liver)? What is your criteria for LTB?
What is the role of preoperative liver biopsy of the future remnant at your center? What are the indications?
• Imaging
What is the imaging of choice at your center for surgical planning in hilar cholangiocarcinoma? (3D MDCT cholangiography/MDCT/PET/MRCP/direct cholangiography)
• Nutrition
How do you build the nutrition of these patients preoperatively?
• Role of Inchinkoto (a herbal medicine recognized in Japan and China as a “magic bullet” for jaundice)
Do you use Inchinkoto preoperatively?
Survey of preoperative management protocol for perihilar cholangiocarcinoma at 10 Japanese high-volume
centers with a combined experience of 2,778 cases

1. Endoscopic nasobiliary drainage is the procedure of choice for preoperative biliary drainage.
2. Unilateral drainage, i.e. drainage of the future remnant liver should be done.
3. A bile replacement should be given, immediately within 2‐3 days of external biliary drainage.
4. Bile culture sensitivity should be performed in all cases and its result should be used as guide
for antibiotic usage in the perioperative period.
5. PVE should be performed for future remnant liver volume (FRLV) enhancement if the FRLV is
<40% and when the serum T.Bil is <4 mg/dl, and the interval between PVE and surgery should
be 3–4 weeks.
6. ICGR15, when serum T.Bil <2 mg/dl, is the most reliable test to predict postoperative liver
function.
7. MDCT and direct cholangiography can comprehensively help in surgical planning in PHC.
Survey of preoperative management protocol for perihilar cholangiocarcinoma at 10 Japanese high-volume
centers with a combined experience of 2,778 cases

Gian Luca Grazi
Hepato Biliary Pancreatic Surgery
National Cancer Institute “Regina Elena”, Rome, Italy
gianluca.grazi@ifo.gov.it
www.chirurgiadelfegato.it

Surgical technique. New tendencies in perihilar cholangiocarcinoma

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