Transparenchymal glissonean approach: a novel surgical technique for advanced perihilar bile duct cancer.

Abstract

PURPOSE:

To increase the surgical opportunities for locally advanced perihilar bile duct cancers that require left-sided hepatectomies, we developed the transparenchymal glissonean approach (TGA); it comprises intra-hepatic exposure and dissection of the Glisson's sheath to gain access to the hepatic artery and portal vein for reconstruction.

METHODS:

Following skeletonization of the hepatoduodenal ligament, the proximal portions of invaded vessels are exposed. If extra-hepatic attempts to access the distal portions of the invaded vessels fail, TGA can be used. The distal portion of the invaded right or right posterior Glisson's sheath is exposed following liver transection. The anterior portion of the wall of bile duct is cut and transected circumferentially including the fibrous plate tissue. The non-invaded portal vein and hepatic artery are isolated and dissected towards the hepatic hilum until the invaded distal portion of the vessels, and vascular reconstructions are performed.

RESULTS:

TGA was performed in 9 patients; 5 patients underwent left hemihepatectomy and 4 underwent left tri-sectionectomy. Eight patients needed vascular reconstruction. Clavien-Dindo classification (CDC) grades IIIa and IIIb were recorded in 6 and 1 patients, respectively. No patients had CDC grades IV and V disease. Pathologically, all cases were pT4; 3 cases were R0, 5 were R1 with microscopic positive margin, and 2 were R1 with microscopic metastasis. The overall median survival time was 25.0 months.

CONCLUSIONS:

TGA is feasible with acceptable prognosis and expands the surgical opportunities.

• Authors: Hirofumi Kamachi, Toshiya Kamiyama, Yousuke Tsuruga, Tatsuya Orimo, Kenji Wakayama, Shingo Shimada, Tatsuhiko Kakisaka, Hideki Yokoo, Kenichiro Yamashita, Akinobu Taketomi
• Journal: Langenbeck's archives of surgery (Langenbecks Arch Surg) Vol. 403 Issue 3 Pg. 387-394 (May 2018) ISSN: 1435-2451 [Electronic] Germany
• PMID: 29063245 (Publication Type: Journal Article)

Topics

• Aged
• Bile Duct Neoplasms (diagnostic imaging, mortality, pathology, surgery)
• Biliary Tract Surgical Procedures (methods)
• Cohort Studies
• Combined Modality Therapy
• Disease-Free Survival
• Female
• Hepatectomy (methods)
• Hepatic Artery (pathology, surgery)
• Hepatic Veins (pathology, surgery)
• Hospitals, University
• Humans
• Japan
• Klatskin Tumor (diagnostic imaging, mortality, pathology, surgery)
• Male
• Middle Aged
• Neoplasm Invasiveness (pathology)
• Neoplasm Staging
• Parenchymal Tissue (surgery)
• Prognosis
• Retrospective Studies
• Risk Assessment
• Survival Analysis
• Treatment Outcome