Hilar cholangiocarcinoma- removing less liver without compromising radicality

A 50 year old gentleman from Villupuram presented with recent onset pruritus and weight loss. On evaluation, he was found to have stricture in hepatic hilum extending to right anterior duct. Blood investigations ruled out autoimmune and other rare benign causes. PET- CT scan was suggestive of malignancy. He underwent right anterior sectionectomy, extrahepatic biliary radical resection, radical lymphadenectomy, Roux en-Y right posterior and left hepaticojejunostomy. Patient had an uneventful postoperative outcome and was discharged on POD 6. Histopathology confirmed margin negtive moderately differentiated adenocarcinoma of bile duct (Perihilar cholangiocarcinoma, was staged pT2N0 with perineural invasion and was advised for adjuvant chemotherapy.

Why is hepatectomy done for peri hilar cholangiocarcinoma?

Lobar and sectoral bile ducts are like branches of a tree. When we need to remove a part of a branch, the corresponding leaves also falls down. Similarly, when the lobar bile duct needs to be removed, corresponding liver parenchyma has to be resected for R0 (margin negative) resection.

What is UNIQUE to this case?

Hilar cholagiocarcinoma extending to right sectoral ducts usually necessitates right or extended right hepatectomy. This patient had a small left lobe with volume of less than 400 ml and removal of entire right lobe would end up in liver insufficiency.

Fortunately, his biliary anatomy was favourable. He had long extrahepatic right posterior duct and left duct with malignancy extending into right anterior section ducts from CBD. So anatomical right anterior sectionectomy was done after ligating corresponding artery and portal vein individually. “Radicality was not compromised and adequate liver was preserved”.

Is it complex than right hepatectomy?

Right hepatectomy will have only one transaction surface and one hepaticojejunostomy. Whereas right anterior sectionectomy requires resection from left liver as well as right posterior section and two individual hepaticojejunostomy.