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Liver parenchymal sparing surgery for locally advanced gallbladder cancer with extracapsular lymph node invasion.

Narita M, Matsusue R, Hata H, Yamaguchi T, Otani T, Ikai I - World J Surg Oncol (2014)

Bottom Line: Herein, we report a case of a locally advanced gallbladder cancer invading the right hepatic artery (RHA), common hepatic duct, and transverse colon.This patient was successfully treated with parenchymal sparing surgery without major hepatectomy and achieved R0 resection by means of extended cholecystectomy combined with resection of the transverse colon, extrahepatic bile duct, and RHA.Intrahepatic arterial flow was preserved without reconstruction of the RHA, and the postoperative course was favorable.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Surgery, National Hospital Organization, Kyoto Medical Center, 1-1 Mukaihata-cho, Fukakusa, Fushimi-ku, Kyoto 612-8555, Japan. narinari@kuhp.kyoto-u.ac.jp.

ABSTRACT
A complete R0 resection is the standard treatment in patients with gallbladder cancer and the only potentially definitive curative therapy. Major hepatectomy, including right or extended right hepatectomy with extrahepatic bile duct resection, would be an option in patients with locally advanced gallbladder cancer, while morbidity and mortality rate are still high. Herein, we report a case of a locally advanced gallbladder cancer invading the right hepatic artery (RHA), common hepatic duct, and transverse colon. This patient was successfully treated with parenchymal sparing surgery without major hepatectomy and achieved R0 resection by means of extended cholecystectomy combined with resection of the transverse colon, extrahepatic bile duct, and RHA. Intrahepatic arterial flow was preserved without reconstruction of the RHA, and the postoperative course was favorable. Liver parenchymal sparing surgery might be an alternative procedure in patients with gallbladder cancer, to minimize the risk of severe morbidity, if R0 resection is possible.

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Postoperative imaging studies using contrast-enhanced CT at (A) postoperative day 1 and (B) 5 months after operation. (A) Arrowhead and arrow indicate anterior and posterior sectorial branch of the right hepatic artery, respectively.
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Figure 3: Postoperative imaging studies using contrast-enhanced CT at (A) postoperative day 1 and (B) 5 months after operation. (A) Arrowhead and arrow indicate anterior and posterior sectorial branch of the right hepatic artery, respectively.

Mentions: A 55-year-old woman presented with a painful and large palpable mass at the right upper quadrant of the abdomen. She reported that she had had this for 2 months prior to admission. This patient had no previous history of similar problems or any prior medical or surgical conditions. On physical examination, a right upper quadrant mass with tenderness was palpable. The laboratory examination revealed that the results of liver and renal function tests, urinary analysis, and complete blood count tests were within the normal ranges. Tumor marker levels, carcinoembryonic antigen (CEA:11.8 ng/ml) and carbohydrate antigen 19-9 (CA19-9:1521 U/ml), were elevated. Contrast-enhanced computed tomography (CT) showed a tumor in the fundus and body of the gallbladder, 6 × 4 cm in size, with a peripheral wall enhancement (Figure 1A,B). This tumor extended to the liver (Figure 1A) and transverse colon (Figure 1B). An enlarged lymph node with a diameter of 23 mm was detected in the area of the cystic duct (Figure 1C). The RHA from the proper hepatic artery runs close to this lymph node (Figure 1D), suggesting extracapsular invasion into the RHA. The estimated volume ratio of the left hepatic lobe to the whole liver was 0.3. Endoscopic retrograde cholangiography showed a stricture of the common hepatic duct and deficit of the cystic duct (Figure 1E). Fluorodeoxyglucose positron emission tomography showed high fluorodeoxyglucose uptake (accumulation) in the gallbladder tumor and cystic duct lymph node (Figure 1F), while there was no evidence of distant metastasis. Taken together with these examinations, this patient was diagnosed with locally advanced gallbladder cancer extending to the liver parenchyma and the transverse colon with lymph node metastasis in the area of the cystic duct, invading the RHA and common hepatic duct. We planned surgical intervention for curative intent since there was no evidence of distant metastasis.At laparotomy, neither peritoneal dissemination nor distant metastasis was detected. The transverse colon invaded by the tumor was partially resected. The lower common bile duct was dissected after its ligation as low as possible in the pancreas. The enlarged lymph node was involved in the RHA and tightly adhered to the common hepatic duct. This finding strongly indicated extracapsular invasion of the lymph node, extending to the RHA and the common hepatic duct. Intraoperative Doppler ultrasonography showed sufficient right intrahepatic arterial flow despite the clamp of the RHA. We speculated that the right intrahepatic arterial flow would be preserved by the interlobar hepatic artery at the hepatic hilum, perfused from the left hepatic artery. The patient underwent extended cholecystectomy with a 2-cm wedge resection of the liver parenchyma as a safety margin combined with regional lymph node dissection. The RHA was dissected at both the distal and proximal side, as much as possible, and divided without reconstruction. The right and left hepatic ducts were carefully dissected and divided with a preservation of the communication across the hilar plate to avoid injury of the interlobar hepatic artery (Figure 2A). After this procedure, a specimen of the tumor substance was removed. The right intrahepatic arterial flow was detected by Doppler ultrasonography. Separate orifices of the right and left hepatic ducts were joined to form a single orifice and biliary reconstruction was performed using a Roux-en-Y hepaticojejunostomy. The duration of operation was 485 minutes and the amount of blood loss was 380 g without blood transfusion.Pathological examination revealed moderately differentiated adenocarcinoma situated mainly in the body and fundus of gallbladder, invading the transverse colon, liver parenchyma, and lymph node in the area of the cystic duct (Figure 2B). The neck of the gallbladder was intact. There was no evidence of lymph node involvement in the hepatoduodenal ligament, behind the pancreatic head or in the common hepatic artery region. Extracapsular invasion of the lymph node extended to the common hepatic duct and periadventitial tissue of the RHA, while there was no evidence of invasion of the adventitia of the RHA (Figure 2C). R0 resection was achieved. According to the International Union Against Cancer (UICC) classification system, pathological staging was pT3N1(1/16)M0, Stage IIB.At postoperative day 1, the bilirubin concentration in the drain fluid was 17.3 mg/dl, indicating leakage of the bilioenteric anastomosis. Contrast-enhanced CT was performed on the same day and revealed that there was no evidence of intra-abdominal fluid collection. Intrahepatic arterial flow was preserved in the right liver lobe, although parenchymal enhancement was delayed (Figure 3). Postoperative changes in serum biochemistry included a rapid increase of transaminase (aspartate transaminase, 830 U/l; alanine transaminase 495 U/l), lactate dehydrogenase (949 u/l), and total bilirubin (3.1 mg/dl) on postoperative day 1, while they decreased gradually after postoperative day 2. The leakage of the bilioenteric anastomosis was treated conservatively with continuous drainage, since the patient’s general condition was stable. This patient was discharged at postoperative day 45 and the drainage tube was removed at postoperative day 60.


Liver parenchymal sparing surgery for locally advanced gallbladder cancer with extracapsular lymph node invasion.

Narita M, Matsusue R, Hata H, Yamaguchi T, Otani T, Ikai I - World J Surg Oncol (2014)

Postoperative imaging studies using contrast-enhanced CT at (A) postoperative day 1 and (B) 5 months after operation. (A) Arrowhead and arrow indicate anterior and posterior sectorial branch of the right hepatic artery, respectively.
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4061770&req=5

Figure 3: Postoperative imaging studies using contrast-enhanced CT at (A) postoperative day 1 and (B) 5 months after operation. (A) Arrowhead and arrow indicate anterior and posterior sectorial branch of the right hepatic artery, respectively.
Mentions: A 55-year-old woman presented with a painful and large palpable mass at the right upper quadrant of the abdomen. She reported that she had had this for 2 months prior to admission. This patient had no previous history of similar problems or any prior medical or surgical conditions. On physical examination, a right upper quadrant mass with tenderness was palpable. The laboratory examination revealed that the results of liver and renal function tests, urinary analysis, and complete blood count tests were within the normal ranges. Tumor marker levels, carcinoembryonic antigen (CEA:11.8 ng/ml) and carbohydrate antigen 19-9 (CA19-9:1521 U/ml), were elevated. Contrast-enhanced computed tomography (CT) showed a tumor in the fundus and body of the gallbladder, 6 × 4 cm in size, with a peripheral wall enhancement (Figure 1A,B). This tumor extended to the liver (Figure 1A) and transverse colon (Figure 1B). An enlarged lymph node with a diameter of 23 mm was detected in the area of the cystic duct (Figure 1C). The RHA from the proper hepatic artery runs close to this lymph node (Figure 1D), suggesting extracapsular invasion into the RHA. The estimated volume ratio of the left hepatic lobe to the whole liver was 0.3. Endoscopic retrograde cholangiography showed a stricture of the common hepatic duct and deficit of the cystic duct (Figure 1E). Fluorodeoxyglucose positron emission tomography showed high fluorodeoxyglucose uptake (accumulation) in the gallbladder tumor and cystic duct lymph node (Figure 1F), while there was no evidence of distant metastasis. Taken together with these examinations, this patient was diagnosed with locally advanced gallbladder cancer extending to the liver parenchyma and the transverse colon with lymph node metastasis in the area of the cystic duct, invading the RHA and common hepatic duct. We planned surgical intervention for curative intent since there was no evidence of distant metastasis.At laparotomy, neither peritoneal dissemination nor distant metastasis was detected. The transverse colon invaded by the tumor was partially resected. The lower common bile duct was dissected after its ligation as low as possible in the pancreas. The enlarged lymph node was involved in the RHA and tightly adhered to the common hepatic duct. This finding strongly indicated extracapsular invasion of the lymph node, extending to the RHA and the common hepatic duct. Intraoperative Doppler ultrasonography showed sufficient right intrahepatic arterial flow despite the clamp of the RHA. We speculated that the right intrahepatic arterial flow would be preserved by the interlobar hepatic artery at the hepatic hilum, perfused from the left hepatic artery. The patient underwent extended cholecystectomy with a 2-cm wedge resection of the liver parenchyma as a safety margin combined with regional lymph node dissection. The RHA was dissected at both the distal and proximal side, as much as possible, and divided without reconstruction. The right and left hepatic ducts were carefully dissected and divided with a preservation of the communication across the hilar plate to avoid injury of the interlobar hepatic artery (Figure 2A). After this procedure, a specimen of the tumor substance was removed. The right intrahepatic arterial flow was detected by Doppler ultrasonography. Separate orifices of the right and left hepatic ducts were joined to form a single orifice and biliary reconstruction was performed using a Roux-en-Y hepaticojejunostomy. The duration of operation was 485 minutes and the amount of blood loss was 380 g without blood transfusion.Pathological examination revealed moderately differentiated adenocarcinoma situated mainly in the body and fundus of gallbladder, invading the transverse colon, liver parenchyma, and lymph node in the area of the cystic duct (Figure 2B). The neck of the gallbladder was intact. There was no evidence of lymph node involvement in the hepatoduodenal ligament, behind the pancreatic head or in the common hepatic artery region. Extracapsular invasion of the lymph node extended to the common hepatic duct and periadventitial tissue of the RHA, while there was no evidence of invasion of the adventitia of the RHA (Figure 2C). R0 resection was achieved. According to the International Union Against Cancer (UICC) classification system, pathological staging was pT3N1(1/16)M0, Stage IIB.At postoperative day 1, the bilirubin concentration in the drain fluid was 17.3 mg/dl, indicating leakage of the bilioenteric anastomosis. Contrast-enhanced CT was performed on the same day and revealed that there was no evidence of intra-abdominal fluid collection. Intrahepatic arterial flow was preserved in the right liver lobe, although parenchymal enhancement was delayed (Figure 3). Postoperative changes in serum biochemistry included a rapid increase of transaminase (aspartate transaminase, 830 U/l; alanine transaminase 495 U/l), lactate dehydrogenase (949 u/l), and total bilirubin (3.1 mg/dl) on postoperative day 1, while they decreased gradually after postoperative day 2. The leakage of the bilioenteric anastomosis was treated conservatively with continuous drainage, since the patient’s general condition was stable. This patient was discharged at postoperative day 45 and the drainage tube was removed at postoperative day 60.

Bottom Line: Herein, we report a case of a locally advanced gallbladder cancer invading the right hepatic artery (RHA), common hepatic duct, and transverse colon.This patient was successfully treated with parenchymal sparing surgery without major hepatectomy and achieved R0 resection by means of extended cholecystectomy combined with resection of the transverse colon, extrahepatic bile duct, and RHA.Intrahepatic arterial flow was preserved without reconstruction of the RHA, and the postoperative course was favorable.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Surgery, National Hospital Organization, Kyoto Medical Center, 1-1 Mukaihata-cho, Fukakusa, Fushimi-ku, Kyoto 612-8555, Japan. narinari@kuhp.kyoto-u.ac.jp.

ABSTRACT
A complete R0 resection is the standard treatment in patients with gallbladder cancer and the only potentially definitive curative therapy. Major hepatectomy, including right or extended right hepatectomy with extrahepatic bile duct resection, would be an option in patients with locally advanced gallbladder cancer, while morbidity and mortality rate are still high. Herein, we report a case of a locally advanced gallbladder cancer invading the right hepatic artery (RHA), common hepatic duct, and transverse colon. This patient was successfully treated with parenchymal sparing surgery without major hepatectomy and achieved R0 resection by means of extended cholecystectomy combined with resection of the transverse colon, extrahepatic bile duct, and RHA. Intrahepatic arterial flow was preserved without reconstruction of the RHA, and the postoperative course was favorable. Liver parenchymal sparing surgery might be an alternative procedure in patients with gallbladder cancer, to minimize the risk of severe morbidity, if R0 resection is possible.

Show MeSH
Related in: MedlinePlus