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We report a rare case of hepatolithiasis, which was diagnosed as hilar cholangiocarcinoma and treated with hepatectomy and extrahepatic bile duct resection. A 59-year-old woman presented to a local hospital with liver dysfunction. Diagnostic imaging revealed a biliary stricture at the hepatic hilum and middle bile duct. Hilar cholangiocarcinoma was diagnosed, and she was referred to our hospital for definitive surgical treatment. She underwent left hepatic trisectionectomy, total caudate lobectomy, and extrahepatic bile duct resection. Gross examination of the resected specimen revealed intrahepatic stones firmly adherent to the bile duct wall. Pathological examination revealed no malignant lesions. The epithelium of the bile duct was absent underneath the stone, and the boundary between the stone and bile duct wall was ill defined. To our knowledge, this is the first case report of hepatolithiasis with a biliary stricture caused by peculiar stone formation, mimicking hilar cholangiocarcinoma.

Objective: The aim of this randomized controlled trial is to evaluate the effect on delayed gastric emptying (DGE) of using the greater omental flap to cover the cut surface of the liver after left-sided hepatobiliary resection., Methods: From June 2007 to December 2008, all eligible patients were randomly assigned to either the greater omental flap group (OF group) or the control group (non-OF group)., Results: A total of 40 patients remained for final analysis. The incidence of DGE after left-sided hepatobiliary resection was 25%. The incidence of DGE showed no statistically significant differences between the OF group (10%) and the non-OF group (40%) (p = 0.065). The assessment of DGE using radiopaque rings revealed that changes over time in the gastric emptying ratio (GER, percentage of rings excreted from stomach) did not differ in a significant manner between the two groups. There were significant differences in changes over time in GER (p = 0.044) between the patients with and without DGE. The patients with DGE also showed higher GER at 5 h (p = 0.042) and at 6 h (p = 0.034) than those without DGE., Conclusions: Using the greater omental flap to cover the cut surface of the liver may reduce the incidence of DGE after left-sided hepatobiliary resection. Assessment using radiopaque markers may be useful to evaluate DGE.

Background: The aim of the study was to clarify the incidence, risk factors and treatment of percutaneous transhepatic biliary drainage (PTBD) catheter tract recurrence in patients with resected cholangiocarcinoma., Methods: The medical records of 445 patients with perihilar and distal cholangiocarcinoma who underwent resection following PTBD were reviewed retrospectively., Results: PTBD catheter tract recurrence was detected in 23 patients (5.2 per cent). The mean(s.d.) interval between surgery and onset of the recurrence was 14.4(13.8) months. On multivariable analysis, duration of PTBD (60 days or more), multiple PTBD catheters and macroscopic papillary tumour type were identified as independent risk factors. In four patients with synchronous metastasis, the PTBD sinus tract was resected simultaneously, at the time of initial surgery. Of 19 patients with metachronous metastasis, 15 underwent surgical resection of the metastasis. Survival of the 23 patients with PTBD catheter tract recurrence was poorer than that of the 422 patients without recurrence (median 22.8 versus 27.3 months; P = 0.095). Even after surgical resection of PTBD catheter tract recurrence, survival was poor., Conclusion: PTBD catheter tract recurrence is not unusual. The prognosis for these patients is generally poor, even after resection. To prevent this troublesome complication, endoscopic biliary drainage is first recommended when drainage is indicated., (Copyright © 2010 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.)

Objective: To outline our experience with hepatectomy with simultaneous resection of the portal vein and hepatic artery for advanced perihilar cholangiocarcinoma, and to discuss the clinical significance of this challenging hepatectomy., Summary Background Data: Only a few authors reported negative results for this surgery in a very limited number of patients., Methods: We retrospectively reviewed medical records of 50 patients with advanced cholangiocarcinoma who underwent hepatectomy (left trisectionectomy in 26, left hepatectomy in 23, and right hepatectomy in 1) with simultaneous resection and reconstruction of the portal vein and hepatic artery, focusing on surgical outcome and survival., Results: The operative time was 776 +/- 191 minutes, and blood loss was 2593 +/- 1890 mL. Time of vessel resection and reconstruction was 25 +/- 19 minutes for the portal vein and 119 +/- 56 minutes for the hepatic artery. A total of 27 (54.0%) patients developed several kinds of complications, including intra-abdominal abscess (n = 13), wound infection (n = 9), bile leakage from liver stump (n = 9), and liver failure (n = 7). Relaparotomy was necessary in 5 (10.0%) patients. One (2.0%) patient died of a postoperative complication. Microscopic cancer invasion of the resected portal vein was found in 44 (88.0%) patients, while that of the resected hepatic artery was found in 27 (54.0%). The distal bile duct margin, proximal bile duct margin, and radial margin were positive for cancer in 2 (4.0%), 4 (8.0%), and 17 (34.0%) patients, respectively. Consequently, R0 resection was achieved in 33 (66.0%) patients. The 1-, 3-, and 5-year survival rates were 78.9%, 36.3%, and 30.3%, respectively. Survival for 30 patients with pM0 disease who underwent R0 resection was better, being 40.7% at the 3- and 5-year time points., Conclusion: Major hepatectomy with simultaneous resection and reconstruction of the portal vein and hepatic artery is technically demanding. However, this surgery can be performed with acceptable mortality by an experienced surgeon and offers a better chance of long-term survival in selected patients.

Objective: To review our surgical experience with hilar cholangiocarcinoma in the "new era.", Methods: The medical records of 428 patients with hilar cholangiocarcinoma who underwent treatment between 2001 and 2008 at the First Department of Surgery, the Nagoya University Hospital, were retrospectively reviewed., Results: Of the 428 patients, 298 (70%) underwent surgical resection (R0, n = 220; R1, n = 70; R2, n = 8). Portal vein resection was performed in 111 (37%) patients, and hepatic artery resection was performed in 53 (18%) patients. Several different types of postoperative complications occurred in a total of 129 (43%) patients and led to 6 (2%) deaths. Of the 298 resected tumors, 206 (69%) were extrahepatic type tumors, and the remaining 92 (31%) were intrahepatic type tumors. Using the Bismuth classification criteria, we identified 15 (5%) type I, 21 (7%) type II, 120 (40%) type III, and 142 (48%) type IV tumors. The overall 1-, 3-, and 5-year survival rates for all 298 patients were 77, 49, and 42%, respectively. The survival rates were highest among the 197 patients with pM0 disease who underwent R0 resection. Patients in this subgroup had a 5-year survival rate of 52%. The 5-year overall survival rate for the 55 patients with pM0 disease who underwent R1 resection was 32%. The survival rate for patients who had pM1 disease and/or underwent R2 resection was the worst of all the subgroups, but was nonetheless significantly better than that of patients with unresectable tumors. The survival rate for patients who underwent vascular resection and reconstruction was unexpectedly better, with 5-year survival of >20%., Conclusions: The surgical approach to hilar cholangiocarcinoma has become more challenging in the new era. Nevertheless, surgical outcomes have been improved, with decreased morbidity and mortality rates being observed. Long-term survival has also steadily improved. These findings indicate that biliary surgeons should use an aggressive surgical strategy to treat this intractable disease.

Background: Based on frozen section examination, additional resection of the proximal bile duct was performed to achieve a negative margin at the time of resection of hilar cholangiocarcinoma. The aim of this study was to determine whether additional resection of a margin-positive proximal duct can improve survival., Methods: The records of 303 resected patients with hilar cholangiocarcinoma were reviewed, focusing on the status of the proximal ductal margin., Results: Frozen section examination of the proximal ductal margin was carried out in 138 of the 303 patients included in this study. The histopathologic diagnosis was negative in 110 patients, positive with carcinoma in situ in 11, and positive with invasive cancer in 17. In the 17 patients with invasive cancer, additional resection was performed in 12. The length of resection was 5 mm in the proximal duct is difficult after maximal or near-maximal resection of the duct. Such limited resection of a margin-positive proximal duct does not improve survival, even when a negative margin can be achieved with additional resection., (Copyright (c) 2010 Mosby, Inc. All rights reserved.)

Background: The term perihilar cholangiocarcinoma has been used for all tumours involving or requiring resection of the hepatic confluence. However, it does not distinguish between intrahepatic and extrahepatic hilar tumours, and has no clinicopathological basis. This retrospective study examined whether the concept of perihilar cholangiocarcinoma is valid clinically., Methods: Some 250 patients with perihilar cholangiocarcinoma were divided into extrahepatic (EHC, 167 patients) and intrahepatic (IHC, 83) groups based on tumour location. Clinicopathological data were compared between these groups., Results: Liver, portal vein, venous and lymphatic invasion, and nodal metastasis were more common in IHCs than EHCs, whereas histological grade and incidence of perineural invasion were similar. IHCs were more advanced at the time of surgery; stage III or IV disease was found in 37.7 per cent of EHCs and 59 per cent of IHCs. Survival was marginally better for patients with EHCs than for those with IHCs (29.3 versus 20 per cent at 5 years; P = 0.057), but survival rates were similar for each tumour stage in the American Joint Committee on Cancer classification., Conclusion: Combining EHC and IHC under the term perihilar cholangiocarcinoma is valid, as these tumours have comparable biological behaviour, with similar clinical management depending on stage and invasion., (Copyright 2009 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.)

Background: A few authors have reported the value of multidetector row CT (MDCT) for evaluating the longitudinal extent of cholangiocarcinoma. They have not focused on CT attenuation of a tumor and actual tumor extent along the bile ducts. We designed the present study to analyze attenuation., Methods: Between January 2003 and July 2005, 113 consecutive patients with cholangiocarcinoma underwent a surgical resection following MDCT. Of these MDCT studies, 73 (perihilar cholangiocarcinoma, n = 62; middle and distal cholangiocarcinoma, n = 11) were suitable for analysis, and the patients were enrolled in the study. Patients were divided according to tumor hypoattenuation and hyperattenuation on MDCT. Histologic differentiation, desmoplastic reaction, and vascular density were microscopically compared with the tumor attenuation to differentiate the characteristics of the attenuation. The extent of cancer along the bile duct diagnosed by MDCT was compared with the actual extent determined by the microscopic findings., Results: Hyperattenuated tumor was observed in 40 patients. There was no difference in histologic differentiation, desmoplastic reaction, or vascular density between the hyperattenuated and hypoattenuated cholangiocarcinomas. Neither the proximal nor the distal borders between the normal and thickened bile duct wall could be determined in the 33 patients with hypoattenuated tumor; in contrast, an accurate assessment of extent of tumor was obtained in 76% of the proximal borders and 82% of the distal borders in the 40 patients with hyperattenuated tumor., Conclusions: Although the cause of the difference between the hyperattenuated and hypoattenuated cholangiocarcinoma still is unclear, MDCT can be an alternative to direct cholangiography in selected patients with hyperattenuated cholangiocarcinoma.

Objective: To review our experience with cholangiocarcinoma with superficial spread, to clarify its clinical features, and to discuss treatment strategies., Summary Background Data: Most of the previous reports on cholangiocarcinoma with superficial spread were case reports. Little is known about this type of cholangiocarcinoma., Methods: The medical records of 471 patients with cholangiocarcinoma who underwent resection (351 perihilar and 120 distal cancers) were retrospectively reviewed, focusing on superficial spread, which was defined as noninvasive cancer extension of more than 20 mm., Results: Superficial spread was found in 69 (14.6%) of 471 patients, and its length was 54 +/- 19 mm. Histologically, papillary and well differentiated adenocarcinomas were observed more frequently in cholangiocarcinomas with superficial spread (C(+SS)), compared with those without superficial spread (C(-SS)). Histologic indexes showing tumor aggressiveness, including lymphatic, venous, and perineural invasions, were lower in C(+SS), and all factors of tumor staging (pT, pN, and pM) were less advanced in C(+SS) than in C(-SS). Regarding surgical procedure, a combined hepatectomy and pancreatoduodenectomy was indicated in 26 (37.7%) of the 69 patients with C(+SS), but in only 25 (6.2%) of the 402 patients with C(-SS). Positivity of the proximal ductal margin was higher in C(+SS) than in C(-SS) (18.8% vs. 11.9%), although this was not statistically significant. All positive proximal ductal margins in C(+SS) were because of carcinoma in situ, whereas invasive cancer was the main reason for positivity in C(-SS). Survival (excluding 29 in-hospital deaths) was significantly better in the patients with C(+SS) than in those with C(-SS) (5- and 10-year survival rates; 48.8% and 19.6% vs. 26.8% and 16.6%, P = 0.0009). Survival was comparable between the patients with a negative ductal margin and those with a positive margin with carcinoma in situ. On multivariate analysis, the presence or absence of superficial spread was not identified as a prognostic factor., Conclusions: C(+SS) is associated with less advanced, slower growing tumors and better survival compared with C(-SS). In many cases of C(+SS), the survival does not depend on the complete resection of all the superficial spread but on the stage of the main lesion.

We report a case of small pancreatic carcinoma misdiagnosed as superficially spreading cholangiocarcinoma using percutaneous transhepatic cholangioscopy (PTCS). The patient was a 72-year-old man admitted to a local hospital with obstructive jaundice. The patient underwent percutaneous transhepatic biliary drainage and PTCS. He was referred to our hospital with a diagnosis of superficially spreading cholangiocarcinoma. Cholangiography revealed a stenosis of the common bile duct, and also revealed some irregularities from the common hepatic duct to the left hepatic duct, suggesting a superficial spread of cancer. No pancreatic tumor was identified by endoscopic retrograde pancreatography or by enhanced computed tomography. Cholangioscopy disclosed an elevated tumor with torsional vessels and granular mucosal lesions, which were extended to the left hepatic duct. Repeated cholangioscopic biopsies of the bile duct mucosa revealed adenocarcinoma. The patient was diagnosed with superficially spreading cholangiocarcinoma extending to the left hepatic duct and the right anterior hepatic duct. Left trisectionectomy combined with pancreatoduodenectomy was performed. The cut surface of the resected specimen showed a pancreatic head tumor that was 8 mm in diameter. Histological findings of the resected specimen revealed adenocarcinoma arising from the pancreatic head with invasion in the common bile duct. Additionally, extensive inflammatory granulation tissue was observed along the surface of the bile duct, without any evidence of carcinoma. This case implies to us that the results of PTCS, even after repeated biopsies, should be interpreted with great caution.

This report presents a case of a left hepatectomy and a caudate lobectomy combined resection of the ventral segment of the right anterior sector for hilar cholangiocarcinoma using percutaneous transhepatic portal vein embolization (PVE). The patient was a 44-year-old man admitted to a local hospital with obstructive jaundice. He was diagnosed to have hilar cholangiocarcinoma and was referred to the hospital for further treatment. Cholangiography revealed stenosis of the left hepatic duct and the hilar bile ducts. The dorsal branch of the right anterior sector joined the right posterior branch and the tumor did not invade to the confluence of these branches. Arteriography and portography reconstructed by multidetector-raw computed tomography revealed the ventral branches of the right anterior sector, which separately diverged from the other right anterior branches. It was therefore necessary to perform a left hepatectomy and caudate lobectomy combined resection of the ventral segment of the right anterior sector to completely remove the tumor. Portal vein embolization was thus performed on the left portal vein and the ventral branches of the right anterior sector. Intraoperatively, when the hepatic artery was temporally clamped, the demarcation between the ventral segment and the dorsal segment of the right anterior sector could be clearly visualized. The planned surgery was performed safely. This case demonstrates that the utilization of PVE is useful for a difficult and intricate hepatectomy, which requires an accurate identification of a hepatic subsegment.

Background: Perineural invasion is commonly observed in biliary tract cancer and is an independent prognostic factor. Since intrahepatic cholangiocarcinoma (ICC) develops from biliary epithelia in the liver, ICC may share the same characteristics in terms of the prognostic implications of perineural invasion. The aim of this study was to evaluate the clinical significance of perineural invasion in ICC., Methods: A total of 59 patients with ICC who underwent hepatectomy were retrospectively reviewed. The numbers of nerves with and without tumor involvement were counted. The perineural invasion index (PNI) was calculated as the number of involved nerves divided by the total number of nerves examined. Predictors for perineural invasion and prognostic factors were analyzed., Results: Perineural invasion was observed in 47 of 59 (80%) patients, and the median PNI was 0.082. The macroscopic tumor appearance and tumor location were significantly associated with perineural invasion (p = 0.013 and 0.032, respectively). Univariate and multivariate analyses (excluding seven in-hospital deaths) revealed that histologic grade, the presence of perineural invasion, nodal metastasis, and intrahepatic metastasis were independent prognostic factors. The survival rate of the patients with (n = 42) or without (n = 10) perineural invasion was 17 and 80% at 3 years; and 17 and 70% at 5 years, respectively (p = 0.001)., Conclusion: Perineural invasion is frequently found in patients with ICC and is an independent prognostic factor. ICC is an aggressive tumor similar to other biliary tract cancers. Because perineural invasion is a histologic marker of aggressiveness, it potentially has a role as a determinant of patient selection for adjuvant therapy.

Background: Although knowledge of cancer invasion of the portal bifurcation is vitally important in planning an operation for perihilar cholangiocarcinoma, the diagnostic capability of multidetector-row computed tomography (MDCT) for this purpose has not been assessed. We evaluated how well MDCT could identify cancer invasion of the portal bifurcation by perihilar cholangiocarcinoma., Methods: Between April 2003 and June 2005, perihilar cholangiocarcinoma was resected in 87 patients, 83 of whom underwent MDCT within 1 month before the surgery. Three-dimensional volume-rendered (3DVR) and multiplanar reformation (MPR) images were examined for evidence of portal vein invasion. Agreement with intraoperative and pathologic findings was assessed. Portal bifurcation findings by 3DVR and MPR were classified into no portal vein stenosis, unilateral stenosis, or more extensive stenosis, and also into tumor contact with the bifurcation in no, one of two, or two projections., Results: For macroscopic portal vein invasion, sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy were 81.5, 91.1, 81.5, 91.1, and 88.0% in 3D portography and 96.3, 92.6, 86.7, 98.1, and 94.0% in MPR, respectively. Findings by both 3DVR and MPR were significantly correlated with depth of cancer invasion (p < 0.001)., Conclusion: MDCT is useful in assessing cancer invasion of the portal vein bifurcation by perihilar cholangiocarcinoma.

Aim: To review the experience with hilar cholangiocarcinoma and to determine the results of a radical surgical approach in a UK centre., Methods: A 10-year review of all patients treated surgically for proximal bile duct carcinoma at a single surgical unit was conducted. Patient demographics, disease details and histopathology reports were reviewed. From January 1993 through December 2003, 106 patients were admitted with the diagnosis of hilar cholangiocarcinoma and 61 patients received surgical exploration., Results: Tumours were staged as follows (UICC 6th edition): stage IB, n=10 IIA, n=9; IIB, n=20; III, n=8; IV, n=14. Out of 61 patients, 44 had a resection (3 bile duct resection alone, 41 liver resection with bile duct resection), 5 were considered unresectable and 12 underwent liver transplantation (LT). The caudate lobe was excised in 34 of the patients and regional lymphadenectomy was systematically carried out. Para-aortic lymphadenectomy was performed in 17 cases. Portal vein resection was needed in 17 and hepatic artery resection was performed in 4 cases. Negative histologic margins (R0) were achieved in 20 patients and microscopic margin involvement (R1) was seen in 16. In the remaining 8 resected patients, localised metastasis were found (peritoneal deposits in 2, liver metastasis in 4 and positive para-aortic lymph nodes in 2); nevertheless the resection was performed and it was considered R2. Overall survival at 3 and 5 years for patients who underwent a resection was 43% and 28% including postoperative deaths. The 1-, 3- and 5-year actuarial survival rates for patients who underwent R0 resection were 78%, 64% and 45% respectively, including the postoperative deaths (n=3). The median survival time was 41.1 months. The 1-, 3- and 5-year actuarial survival rates for R1 resection and R2 were 60%, 26%, 26% and 25% and 0% respectively, while the median survival time for these groups was 15.4 and 6.8 months respectively. The actuarial survival rate at 1, 3 and 5 years for well-differentiated tumours (G1) was 73%, 54% and 40% (median 39.7 months). The figures for G2 were 60%, 48% and 0%. The figures for G3 (poorly differentiated) were 16% and 0% at three years (p=0.03).The overall survival at 3 and 5 years for those patients who had a liver transplant was 41% and 20% including early postoperative mortality. The tumour grading (presence of poorly differentiated tumour) was found to be the only independent factor affecting the survival time producing a hazard ratio of 4.3 (p=0.0034, 95% confidence interval 0.1007-6.342)., Conclusions: Radical surgical resection is the best treatment for hilar cholangiocarcinoma. R0 resection provides acceptable 5-year survival, but R1 resection may also provide acceptable palliation. In our experience TNM stage and tumour grade were the main determinants of long-term survival.

Objective: To clarify the optimal surgical strategy for Bismuth type I and II hilar cholangiocarcinomas., Summary Background Data: Local or hilar resections is often performed for Bismuth type I and II tumors; however, reported outcomes have been unsatisfactory with a high recurrence and low survival rate. To improve survival, some authors have recommended right hepatectomy. However, the clinical value of this approach has not been validated., Methods: Records of 54 consecutive patients who underwent resection of a Bismuth type I or II hilar cholangiocarcinoma were analyzed retrospectively. Through 1996, bile duct resection or the smallest necessary hepatic segmentectomy was performed. Beginning in 1997, choice of resection was based on the cholangiographic tumor type. For nodular or infiltrating tumor, right hepatectomy was indicated; for papillary tumor, bile duct resection with or without limited hepatectomy was chosen., Results: Right hepatectomy was performed in 5 (20.8%) of 24 patients through 1996 and was done in 22 (73.3%) of 30 patients from 1997 (P = 0.0003). In patients without pM1 disease, R0 resection was achieved more frequently in the later period than in the earlier period (23 of 24 = 95.8% vs. 13 of 21 = 61.9%, P = 0.0073), which lead to better survival (5-year survival, 44.3% vs. 25.0%, P = 0.0495). In the 31 patients with nodular or infiltrating tumor, who tolerated surgery and did not have pM1 disease, survival was better in the 18 patients who underwent right hepatectomy than in those who did not (5-year survival, 62.9% vs. 23.1%, P = 0.0030). In cases of papillary tumor, bile duct resection with or without limited hepatectomy was sufficient to improve long-term survival., Conclusions: The surgical approach to Bismuth type I and II hilar cholangiocarcinomas should be determined according to cholangiographic tumor type. For nodular and infiltrating tumors, right hepatectomy is essential; for papillary tumor, bile duct resection with or without limited hepatectomy is adequate.

Objective: We present our experiences with infraportal bile duct of the caudate lobe (B1) and discuss surgical implications of this rare variation., Summary Background Data: Although various authors have investigated biliary anatomy at the hepatic hilum, an infraportal B1 (joining the hepatic duct caudally to the transverse portion of the left portal vein) has not been reported., Methods: Between January 1981 and December 2005, 334 patients underwent hepatectomy combined with caudate lobectomy for perihilar cholangiocarcinoma. Four of them (1.2%) had infraportal B1 and were investigated clinicoanatomically., Results: All infraportal B1 were B1l, draining Spiegel's lobe; no infraportal B1r (draining the paracaval portion) or B1c ducts (draining the caudate process) were found. The infraportal B1l joined the common hepatic duct or the left hepatic duct. Three patients underwent right trisectionectomy with caudate lobectomy; for one, in whom preoperative diagnosis was possible, combined portal vein resection and reconstruction were performed before caudate lobectomy to resect the caudate lobe en bloc without division of infraportal B1. For the other 2 patients, the infraportal B1 was divided to preserve the portal vein, and then the caudate lobe was resected en bloc. The fourth patient underwent right hepatectomy with right caudate lobectomy; the cut end of the infraportal B1 showed no cancer by frozen section, so the bile duct was ligated and divided to preserve the left caudate lobe., Conclusion: Infraportal B1 can cause difficulties in performing right-sided hepatectomy with caudate lobectomy or harvesting the left side of the liver with the left caudate lobe for transplantation. Hepatobiliary and transplant surgeons should carefully evaluate biliary anatomy at the hepatic hilum, keeping this variation in mind.

Background: Distal bile duct cancer often invades the pancreas and/or duodenum. Invasion of the pancreas is defined as a T3 and that of the duodenum as a T4 tumor in the T classification of the American Joint Committee on Cancer (AJCC). The aim of this study was to assess whether this T classification is rational from the viewpoint of prognostic power., Method: Ninety-five patients with distal bile duct cancer were retrospectively analyzed according to the current T classification of the AJCC., Results: The main determinant of pT3 (n = 32) and pT4 (n = 30) was pancreatic and duodenal invasion, respectively, and the survival rates for patients with pT3 and pT4 are similar (p = 0.595). Duodenal invasion was present in 39% of the patients with pancreatic invasion, whereas pancreatic invasion was observed in 86% of those with duodenal invasion. The survival for patients with pancreatic invasion was not significantly different (p = 0.283) whether or not there was concomitant duodenal invasion (n = 19 and n = 37, respectively). Multivariate analysis identified venous invasion, distant metastasis, histologic grade, and pancreatic invasion as independent prognostic factors., Conclusion: Although duodenal invasion usually occurs after pancreatic invasion, it is not a significant prognostic factor while pancreatic invasion is. The current T classification should be revised since it expresses tumor extension but does not reflect a survival in distal bile duct cancer.

The clinical application of portal vein embolization (PVE) has contributed to improving the postoperative outcome of hilar cholangiocarcinoma. The enlarged nonembolized lobe after PVE protects the patient from postoperative hepatic failure, due to the increased functional reserve, and shortens the hospital stay. Although numerous reports have shown beneficial effects of PVE on postoperative outcome after extended hepatectomy, no randomized controlled study has been performed so far. It is urgent to establish a "gold standard" of PVE, because the indications, approach to the portal vein, types of embolic materials, and methods used to evaluate the function of the future liver remnant are variable among institutions. The indications and procedures of PVE for hilar cholangiocarcinoma may be different from those for hepatocellular carcinoma or colorectal metastasis, because, in many patients with hilar cholangiocarcinoma, biliary cancer is associated with biliary obstruction and cholangitis. This review article summarizes the contribution of PVE to the outcome of postoperative management in patients with hilar cholangiocarcinoma needing extended hepatectomy. We also describe our PVE procedure, which has been established from our experience of more than 240 cases of biliary cancer. Furthermore, the drawbacks of PVE, which may reduce the pool of candidates for surgery, are also discussed.

Background: Although intrahepatic cholangiojejunostomy is technically difficult, with recent improvements in surgery it should be possible to perform the anastomosis safely. The aim of this study was to evaluate the incidence of anastomotic leak after intrahepatic cholangiojejunostomy and to identify risk factors for such leakage., Methods: Intrahepatic cholangiojejunostomy was performed in 423 patients undergoing hepatobiliary resection between January 1991 and December 2005. Anastomotic leak was proven radiographically by leakage from the anastomosis of contrast medium introduced via a biliary drainage tube placed during surgery., Results: Anastomotic leak occurred in 27 patients (6.4 per cent), and was not related to the number of bile ducts reconstructed. The leak rate decreased significantly from 9.5 per cent (19 of 199) in the first 10 years to 3.6 per cent (eight of 224) in the last 5 years. Anastomotic leak was often followed by infections such as wound infection, intra-abdominal abscess and bacteraemia. Multivariable analysis identified age and intraoperative blood loss as independent risk factors for anastomotic leak. All leaks were treated by maintaining a prophylactically placed drain near the cholangiojejunostomy; neither repeat laparotomy nor percutaneous transhepatic biliary drainage was required., Conclusion: Although demanding, intrahepatic cholangiojejunostomy can be performed successfully with a relatively low failure rate. Routine use of prophylactic drains and anastomotic stenting allows safe management of anastomotic leak with conservative therapy., (Copyright 2006 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.)

Objectives: We set out to clarify the clinicopathologic characteristics of colorectal liver metastases with macroscopic intrabiliary tumor growth and to determine optimal surgical management., Methods: Over 15 years, 6 of 103 patients undergoing hepatectomy for colorectal liver metastases had macroscopic intrabiliary tumor growth and were analyzed retrospectively., Results: We performed 11 operations for the 6 patients, consisting of 10 hepatectomies (including 1 hepatopancreatoduodenectomy) and 1 pancreatoduodenectomy. Three patients survived more than 5 years: 1 died of pulmonary emphysema with no sign of recurrence 101 months after initial hepatectomy; the 2 others were alive with no sign of recurrence at 74 and 145 months after initial hepatectomy. Median survival time of all 6 patients was 87.5 months. Histologically, intrabiliary tumor growth had two components: intraluminal and intraepithelial extension. In the proximal direction, distance between these two components ranged from 4-10 mm., Conclusion: Aggressive surgical treatment can improve chances of long-term survival for patients with macroscopic intrabiliary growth of colorectal liver metastasis. Although nonanatomic limited resection is a common procedure for colorectal liver metastasis, anatomic hepatobiliary resection is recommended.

Background: Injury to the duct of Luschka is associated with biliary fistula from the gallbladder bed after cholecystectomy. However, few studies have reported on the detailed anatomy. We elucidated the anatomy and frequency of the duct of Luschka, Methods: A total of 128 specimens from patients who underwent right hepatectomy or more extensive right-sided liver resection between February 1992 and December 2003 were examined. Specimens were fixed in formalin, and serial sections were prepared to trace the course of the bile ducts from the subsegmental branch level., Results: The duct of Luschka was observed in 6 (4.6%) specimens. The sites of confluence were as follows: right anterior inferior dorsal branch (2 patients), right anterior branch (2 patients), right hepatic duct (1 patient), and common hepatic duct (1 patient). The upstream end was located in the liver parenchyma of the right anterior inferior dorsal subsegment (5b) and connective tissue of the gallbladder bed in 4 and 2 specimens, respectively., Conclusions: The duct of Luschka never crosses the segmental (5b) border. Therefore, its upstream region may not be injured by segmentectomy or more extensive liver resection. However, it is possible to injure the duct of Luschka at the common hepatic duct, even if right-sided hepatectomy is performed, as the sites of confluence included the common hepatic duct.

Objective: To assess clinical benefit of portal vein embolization (PVE) before extended, complex hepatectomy for biliary cancer., Summary Background Data: Many investigators have addressed clinical utility of PVE before simple hepatectomy for metastatic liver cancer or hepatocellular carcinoma, but few have reported PVE before hepatectomy for biliary cancer due to the limited number of surgical cases., Methods: This study involved 240 consecutive patients with biliary cancer (150 cholangiocarcinomas and 90 gallbladder cancers) who underwent PVE before an extended hepatectomy (right or left trisectionectomy or right hepatectomy). All PVEs were performed by the "ipsilateral approach" 2 to 3 weeks before surgery. Hepatic volume and function changes after PVE were analyzed, and the outcome also was reviewed., Results: There were no procedure-related complications requiring blood transfusion or interventions. Of the 240 patients, 47 (19.6%) did not undergo subsequent hepatectomy. The incidence of unresectability was higher in gallbladder cancer than in cholangiocarcinoma (32.2% versus 12.0%, P < 0.005). The remaining 193 patients (132 cholangiocarcinomas and 61 gallbladder cancers) underwent hepatectomy with resection of the caudate lobe and extrahepatic bile duct (n = 187), pancreatoduodenectomy (n = 42), and/or portal vein resection (n = 63). Seventeen (8.8%) patients died of postoperative complications: mortality was higher in gallbladder cancer than in cholangiocarcinoma (18.0% versus 4.5%, P < 0.05); and it was also higher in patients whose indocyanine green clearance (KICG) of the future liver remnant after PVE was <0.05 than those whose index was >or=0.05 (28.6% versus 5.5%, P < 0.001). The 3- and 5-year survival after hepatectomy was 41.7% and 26.8% in cholangiocarcinoma and 25.3% and 17.1% in gallbladder cancer, respectively (P = 0.011). In 136 other patients with cholangiocarcinoma who underwent a less than 50% resection of the liver without PVE, a mortality of 3.7% and a 5-year survival of 27.6% were observed, which was similar to the 132 patients with cholangiocarcinoma who underwent extended hepatectomy after PVE., Conclusions: PVE has the potential benefit for patients with advanced biliary cancer who are to undergo extended, complex hepatectomy. Along with the use of PVE, further improvements in surgical techniques and refinements in perioperative management are necessary to make difficult hepatobiliary resections safer.

Background: The techniques of right hepatic trisectionectomy are now standardized in patients with hepatocellular or metastatic carcinoma, but not in those with hilar cholangiocarcinoma., Methods: Under preoperative diagnosis of hilar cholangiocarcinoma, 8 patients underwent "anatomic" right hepatic trisectionectomy with en bloc resection of the caudate lobe and the extrahepatic bile duct, in which the bile ducts of the left lateral section were divided at the left side of the umbilical fissure following complete dissection of the umbilical plate., Results: Liver resection was successfully performed, and all patients were discharged from the hospital in good condition, giving a mortality of 0%. All patients were histologically diagnosed as having cholangiocarcinoma. The proximal resection margins were cancer-negative in 7 patients and cancer-positive in 1 patient. Four patients with multiple lymph node metastases died of cancer recurrence within 3 years after hepatectomy. One patient died of liver failure without recurrence 42 months after hepatectomy. The remaining 3 patients without lymph node metastasis are now alive after more than 5 years., Conclusions: Anatomic right hepatic trisectionectomy with caudate lobectomy can produce a longer proximal resection margin and can offer a better chance of long-term survival in some selected patients with advanced hilar cholangiocarcinoma.

Objective: To analyze results of 70 patients undergoing left hepatic trisectionectomy and to clarify its current role., Summary Background Data: Left hepatic trisectionectomy remains a complicated hepatectomy, and few reports have described the long-term results of the procedure., Methods: Short-term and long-term outcomes of 70 consecutive patients who underwent left hepatic trisectionectomy from January 1993 to February 2004 were analyzed., Results: Of the 70 patients, 36 had colorectal liver metastasis, 24 had cholangiocarcinoma, 4 had hepatocellular carcinoma, and the remaining 6 had other tumors. Overall morbidity, 30-day and 90-day mortality rates were 46%, 7%, and 9%, respectively. Multivariate analysis disclosed that preoperative jaundice and intraoperative blood transfusion were positive independent predictors for postoperative morbidity; however, there were no independent predictors for postoperative mortality. Postoperative morbidity (87% versus 35%, P < 0.001) and mortality (20% versus 5%, P = 0.108) were observed more frequently in patients with preoperative obstructive jaundice than in those without jaundice. Each survival according to tumor type was acceptable compared with reported survivals. Survival for patients with colorectal liver metastasis undergoing left hepatic trisectionectomy with concomitant partial resection of the remnant liver was similar to those without this concomitant procedure. This concomitant procedure was not associated with postoperative morbidity and mortality., Conclusions: Left hepatic trisectionectomy remains a challenging procedure. Preoperative obstructive jaundice considerably increases perioperative risk. Concomitant partial resection of the remaining liver appears to be safe and offers the potential for cure in patients with colorectal metastasis affecting all liver segments.

Background: A few investigators have evaluated the TNM classification for perihilar cholangiocarcinoma. The new sixth edition of the American Joint Committee on Cancer (AJCC)/Internal Union Against Cancer (UICC) staging system focuses on vascular invasion and regional lymph node metastasis., Methods: For 166 patients with perihilar cholangiocarcinoma undergoing R0 resection, survival curves stratified according to TNM classifications were compared between fifth and sixth editions., Results: The previous T3 now is divided into T3 and T4. Most new pT4 patients had invasion of the portal bifurcation; their survival was poorer than that for new pT3 patients. The 5-, 10-, and 15-year survival rates were worse in the previous stage III than in the previous stage IVA, although the difference fell short of significance. The previous stage IVA (T3 Any NM0) is divided into new stages: IIA (T3N0M0), IIB (T1-3N1M0), and III (T4 Any NM0). All patients in stage III had invasion of the portal bifurcation. Survival was similar between stages IA, IB, and IIA, while patients with T4N0M0 tumors survived longer than those with T4N1M0 tumors and similarly to those with stage IIB tumors., Conclusions: The sixth edition provided improved prediction of survival in patients with perihilar cholangiocarcinoma; for still better prediction, cancer invasion of the portal bifurcation and regional lymph node metastasis should be weighted equally.

Backgrounds/aims: Liver resection for hilar cholangiocarcinoma is now popular, and combined en bloc resection of the caudate lobe has become general practice, especially in Japan and some European countries. However, surgical procedure is not yet standardized, and many problems concerning surgical treatment of this disease still remain unsolved., Methodology: From April 1977 to December 1996, 173 patients with hilar cholangiocarcinoma were treated at The First Department of Surgery, Nagoya University Hospital. Of the 173 patients, 138 patients underwent surgical resection, including 124 liver resections and 14 bile duct resections., Results: Several kinds of hepatic segmentectomy with en bloc resection of the caudate lobe were performed in the 124 patients: 109 underwent hepatic lobectomy or more extensive resection including central bisegmentectomy; 15 received resection of one or less segment of the liver. Aggressive resections, including combined portal vein and liver resection (n = 41) and hepatopan-creatoduodenectomy (n = 16), were applied to advanced hilar cholangiocarcinoma. The hospital death rate in hepatectomized patients was 9.7% (12/124). The 3- and 5-year rates for the 97 patients with curative hepatectomy were 42.7%, and 25.8%, respectively., Conclusions: Aggressive liver resection improves survival of patients with hilar cholangiocarcinoma. Resection procedures should be designed based on a precise diagnosis of the extent of carcinoma.

Objectives: Our objective was to examine the usefulness of magnetic resonance cholangiography in hepatolithiasis., Methods: Ten patients with hepatolithiasis were studied by ultrasonography, computed tomography, direct cholangiography, and magnetic resonance cholangiography to detect stones and to determine the morphological features of the bile ducts. In nine patients who underwent surgery, dilation and stenosis of the bile ducts were confirmed by intraoperative cholangioscopy, pathology, or both., Results: Stones were demonstrated in seven patients by ultrasonography, in eight by computed tomography, in seven by direct cholangiography, and in all by magnetic resonance cholangiography. The locations of stones were identified in four patients by ultrasonography, in seven by computed tomography, in six by direct cholangiography, and in nine by magnetic resonance cholangiography. Among nine patients with dilation of the bile ducts, the dilation was shown by ultrasonography in seven, by computed tomography in eight, by direct cholangiography in six, and by magnetic resonance cholangiography in eight. Among seven patients with stenosis of the bile ducts, this stenosis was shown by direct cholangiography in four and by magnetic resonance cholangiography in six. Ultrasonography and computed tomography did not show the stenosis. Sensitivity for detection of biliary stenosis was significantly higher in magnetic resonance cholangiography., Conclusions: This study shows that magnetic resonance cholangiography not only detects stones, but can also delineate detailed information on the bile ducts, which is useful in the planning of treatment for hepatolithiasis.