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From 1996, en bloc resection of the hepatoduodenal ligament (HDL) concomitant with the neighboring organs had been adapted for advanced biliary malignancy to achieve R0 (histological curative) resection. Preoperative indication for this drastic surgery is a locally advanced disease involving the portal trunk and bilateral hepatic arteries without the distant metastases. The portal vein was reconstructed by the autologous vein graft and the hepatic artery was reconstructed by the gastroduodenal or middle colic artery because the long segmental resections of the vessels were mandatory.
Patients: This study comprised of 12 patients with 5 gallbladder carcinomas (GBC) and 7 cholangiocarcinomas (CCC). Mean age of the patients was 62 years (range, 43 to 71); 7 females and 5 males. HLPD (hepato-ligamento-pancreatoduodenectomy) was applied for 5 GBC and 2 CCC, and HL (hepato-ligamentectomy) for 5 CCC. PD was added when massive HDL invasion was apparent. About the extent of hepatic resection, 1 right trisectionectomy, 4 right hepatectomies, and 2 left hepatectomies in HLPD; 1 right hepatectomy and 4 left hepatectomies in HL, and total caudate lobectomy was routinely performed. Surgical technique and outcome of the patients were investigated retrospectively.
Timing of vascular reconstruction: The portal vein resection and reconstruction was performed before the extirpation of the specimen, namely, just after the division of the hepatic ducts, and then the residual hepatic transection was followed. The right external iliac vein was always used for the graft. Contrary, the hepatic artery reconstruction was followed after the extirpation of the specimen.
Results: R0 resection was achieved in 9 out of 12 patients (75%). Positive margin was found in the hepatic duct in 2 patients and the common hepatic artery in 1, and perineural invasion was mostly recognized. The median operation time and blood loss were 554 min. (range, 438 to 1025) and 1392 ml (610 to 2900), respectively. Median graft length and reconstruction time were 3 cm (2 to 4) and 24 min. (19 to 30), respectively, and the hepatic artery reconstruction spent 28 min. (14 to 60). Morbidity occurred in 50% and 2 patients (1 HLPD and 1HL) died in hospital for liver abscess and MRSA septemia. Median and 5-year survivals of all patients were 24 months and 33.3% (2 patients survived over 5 years).
Conclusion: Despite the small number of the subjects, en bloc resection of HDL actually brought the favorable results for intractable diseases. This strategy can be justified for the rigorously selected patients.