Integrated Surgical Treatment Of Hilar Cholangiocarcinoma

ObjectiveThe hilar cholangiocarcinoma is a kind of highly malignancy carcinoma. It was easily invasived to vascular, bile duct around hilar hepatic and liver parenchyma which coursed difficult for the surgery, what’s more the carcinoma was insensitive toradio-and chemo-therapy. HC radical resection is considered as to be the best treatment for hilar cholangiocarcinoma. To reduce surgical complications and improve long-term survival, we advocated the integration of surgical treatment, including:comprehensive preoperative management, accurate preoperative evaluation, surgical planning and rational aggressive surgical strategy.We analyzed the data of92patients in our surgical team with HC from Jul.2009to Feb.2014and discuss the experience of integration treatment for HC.MethodsWe made the retrospectively analyzing for the data of92patients with HC between Jul.2009to Feb.2014,15patients between Jul.2009to Jul.2010,17patients between Aug.2010to Aug.2011,25patients between Sep.2011to Sep.2012,35patients between Oct.2012to Feb.2014. The cases of HC we treated was increasing year by year. In the92patients with HC,84cases had performed PTCD and67cases reduce jaundice back to normal and detected ICG before surgery. In the35patients with HC between Oct.2012to Feb.2014, we also made the ICG test and3D evaluation which based on CT and MRCP to clear the relationship between the tumor with blood vessel and biliary tract. Then we did virtual operation plan to evaluated the resectablation for each patient. At last we compared to the actual situation during operation, recorded the surgical approach and outcome. Result1. In the92patients with HC,15patients between Jul.2009to Jul.2010,17patients between Aug.2010to Aug.2011,25patients between Sep.2011to Sep.2012,35patients between Oct.2012to Feb.2014. The cases of HC we treated was increasing year by year.And accroing to the Bismuth-Corlette classification,there were1case for type I,1case for type II,32cases for Ⅲa,44cases for Ⅲb,6cases for IVa and8cases for IVb.2.The TB of the92patients is (334.3±146.5) mmol/L while DB is (174.8±71.1) mmol/L when hospitalized.7patients whose bilirubin was in the normal range and1patient whose B-ultrasonic test showed no intrahepatic bile duct dilatation did not undergo PTCD drainage.84patients were performed PTCD under the guide of B ultrasound.27cases punctured on the bile duct of left lobe,39on the right and18cases on both sides. All the PTCD performents were successed. The whole process in the67cases whose TB was down to the normal reduced jaundice cost7to50days, with the average is15±5days and the bilirubin levels of the57patients with surgery showed a dramatic decrease with the TB was (24.3±9.2) mmol/L and DB was (8.1±4.9) mmol/L before operation.3. In the92patients,67patients detected ICG when the bilirubin were completely normal. The results were as follow:56cases ICGR15m were<10%(53cases with surgery,3cases without surgery),11cases ICGR15m>10%(4cases with surgery,7cases without surgery),25cases didn’t detected ICG, the results were as follow:11cases with surgery for their bilirubin cannot returned to normal,14cases refused to detect ICG(7cases with surgery,7cases without surgery).17cases forgo surgery.72patients were received combination of different types of liver resection.3patients did on-off surgery.4. In the92patients, through3D evaluation of35cases between Oct.2012to Feb.2014, there were1case for type I,1case for type II,7cases for Ⅲa,13cases for Ⅲb,6cases for IVa and7cases for IVb,3D evaluation of29cases was the same as actural, the accuracy of Bismuth-Corlette classification was90.6%. Anatomical classification of perihilar bile ducts as follow:29A type(82.9%),6B type(17.1%), no type C、D、E. Anatomical classification of right bile ducts as follow:27Supraportal type(77.1%),8Infraportal type(22.9%). Anatomical classification of left bile ducts as follow:8Type Ⅰ(22.8%),27Type Ⅱ(77.1%).The number of bile duct orifices in the cut end of the hilar plate was3.1. Anatomic variation rate of hepatic artery was14.3%. Hepatic artery infringement evaluation was87.5%. Anatomic variation rate of portal vein was5.7%. Portal vein infringement is84.4%, and resectable evaluation was93.8%. Virtual operation plans for32surgical patients were as follows:16cases were performed left liver resection,13cases were right half liver resection and3cases were third left liver resection. Only5cases had different surgery with virtual plans. So the accuracy was84.4%.5. In the92patients, after well preparation,58cases underwent radical operation;14cases underwent small scale hepatic resection, hilar bile duct plastic and bile duct intestinal anastomosis;3cases underwent on-off surgery.17patients gave up surgery. Among58patients who accepted radical operation,34cases underwent left liver resection,13combined resection of part of the caudate lobe,7combined resection of all the caudate lobe;20cases underwent right liver resection,9combined resection of part of the caudate lobe,3combined resection of all the caudate lobe; and4patients underwent third left liver resection,1combined resection of part of the caudate lobe,2combined resection of all the caudate lobe.3cases underwent Hepatopancreatoduodenectomy.2cases underwent right hepatic artery resection.4cases underwent portal vein resection. Pathologically confirmed:1case of gallbladder adenocarcinoma,18cases of adenocarcinoma, moderately differentiated adenocarcinoma in35cases,21cases of poorly differentiated adenocarcinoma.6. The operation time fluctuations in the310-580min and the mean was394±38min. Intraoperative blood loss around in180-1650ml and the mean was449±98ml, For intraoperative blood transfusion, red blood cells around400to1200ml, with an average of643±102ml, fresh frozen plasma around200to800ml, with an average of416ml±50ml.7. Postoperative complications:5cases of bile leakage,11cases of ascites,0cases of abdominal bleeding,0cases of abdominal infection Complication rate was21.3%;One case died for acute myocardial infarction died during hospitalization, perioperative mortality of1.3%.The mean postoperative hospital stay (18±3) days.8. Except for one case died in hospital The follow-up results for the other74cases as follows:15cases showed metastasis, Which is metastasis to the residual liver and the patient died7months after surgery,2cases occurred biliary tract infection,20patients were lost to follow37patients follow-up currently alive, we will keep to follow up.Conclusion1. The integration surgical treatment of hilar cholangiocarcinoma means radical resection based on a set of completely preoperative management system including PTCD, liver functional reserve estimation,3D evaluation, and so on. It can improve perioperative treatment of HC patients, increase the patient’s tolerance to surgery, help to predict resectable, and contribute to make surgical planning more accurate. Baesed on this treatment, performing radical surgery can reduce surgical complications and improve the long-term survival of patients with HC.2. Liver resection combined with portal vein (with or without hepatic artery) resection and rebuild made the HC operation became more challenging. At the same time, surgical curative effect and long-term survival rate of the patients is greatly improved. By the comprehensive management system, more aggressive operation strategy is suggested to in a large medical center.