Total Laparoscopic Radical Resection of S1 + S4 for Bismuth-Corlette Type IV Hilar Cholangiocarcinoma (With Video).

BACKGROUND: The management of Bismuth-Corlette type IV hilar cholangiocarcinoma typically necessitates extensive hepatectomy, resection of the extrahepatic bile ducts, regional lymph node dissection, and reconstruction of the biliary tract; however, there is a high incidence of postoperative liver dysfunction and failure. METHODS: A 64-year-old male patient was admitted to our department after 1 month of escalating jaundice and abdominal discomfort. Upon admission, his total bilirubin was 334 µmol/L and his direct bilirubin was 221 µmol/L. His carbohydrate antigen 19-9 was > 1200.00 U/mL, his carcinoembryonic antigen was 98.90 U/mL, and his α-fetoprotein was normal. Enhanced computed tomography (CT) and magnetic resonance imaging scans revealed a thickened and enlarged biliary tree extending from the common hepatic duct to the orifices of the left and right hepatic ducts. RESULTS: The patient underwent total laparoscopic radical resection of S1 + S4, accompanied by radical lymphadenectomy with skeletonization and biliary reconstruction. The surgery was successfully conducted within 450 min, with a minimal blood loss of 200 mL. The histological grading was T2bN1M0 (stage III). CT on postoperative day 5 showed satisfactory postoperative recovery. The patient was discharged from the hospital on postoperative day 10 without complications, following which the patient underwent a regimen of single-agent capecitabine chemotherapy. Over a 20-month follow-up period, no recurrence was observed. CONCLUSIONS: Resection of hepatic segments S1 + S4 is a viable surgical option for hilar carcinoma in cases with poor liver function or when the carcinoma is confined to both hepatic ducts without invasion of the hepatic artery and portal vein.

Portal supply of segment IV of the liver based on CT-scan.

BACKGROUND: The portal vascularization of segment IV (S4) of the liver has not been well described. Knowledge of the portal supply to S4 is of great interest for liver surgery and for interventional radiological procedures. This study aimed to analyse the distribution of portal vein branches supplying S4. METHODS: We retrospectively analysed data from patients operated on for liver tumours between 2007 and 2016. Patients with involvement of S4 branches or the left portal vein, previous liver surgery or poor quality imaging were excluded. Branches originating from the right portal vein and/or from the transverse part of the left portal vein (TPLPV) and/or from the umbilical part of the portal vein (UPLPV) were identified. RESULTS: In 102 patients who underwent a right hepatectomy, S4 was vascularized by 2-8 branches of the left portal vein, with 84.3 % of patients having 3-6 branches. Only eleven patients (10.8 %) had portal branches originating from the TPLPV, with no impact on the number of branches coming from the UPLPV. Three patients (2.9 %) had one branch from the right portal vein. In patients with only two or three branches supplying S4, the branches had a larger diameter and typically arose from a short common trunk which divided further within its first centimetres. CONCLUSIONS: Portal vascularization of S4 varies widely (2-8 branches) between patients and originates predominantly from the junction between the left portal vein and the round ligament. There is no anatomical rationale to divide S4 into S4a and S4b.

Improving graft survival by understanding the mechanism of segment 4 complications after split liver transplantation.

BACKGROUND: This study was designed to assess the actual mechanism of segment 4 (S4)-related complications after split liver transplantation (SLT) and their impact on graft and overall survival with reference to those of left lateral sectionectomy for pediatric living donor liver transplantation (LLSLD). METHODS: Clinical data from 53 SLT recipients and 62 LLSLD patients were assessed to determine the mechanism of S4-related complications. The postoperative parameters of SLT and their impact on graft and overall survival were also evaluated. RESULTS: Although two biliary leakages were noted (3.2%), no necrosis of S4 developed after LLSLD. S4-related complications were seen in 15 (28.3%) patients after SLT. Radiological volumetry of S4 and the ischemic area after SLT showed no significant difference between those with and without S4-related complications. There were no significant differences between the patients with and without S4-related complications regarding both overall and graft survival rates. Significant better overall and graft survival rates were observed in patients treated during the later period. CONCLUSIONS: S4-related complications after SLT are totally independent of the S4 volume, and biliary leakage is inherently an actual mechanism. Adequate intervention with early identification leads to better graft and overall survival, which validates SLT as a treatment option.

Surgical and Oncological Outcomes of Wedge Resection Versus Segment 4b + 5 Resection for T2 and T3 Gallbladder Cancer: a Meta-Analysis.

BACKGROUND: Liver resection is the standard operative procedure for patients with T2 and T3 gallbladder cancers (GBC). However, the optimal extent of hepatectomy remains unclear. METHODS: We conducted a systematic literature search and meta-analysis to assess the safety and long-term outcomes of wedge resection (WR) vs. segment 4b + 5 resection (SR) in patients with T2 and T3 GBC. We reviewed surgical outcomes (i.e., postoperative complications and bile leak) and oncological outcomes (i.e., liver metastasis, disease-free survival (DFS), and overall survival (OS)). RESULTS: The initial search yielded 1178 records. Seven studies reported assessments of the above-mentioned outcomes in 1795 patients. WR had significantly fewer postoperative complications than SR, with an odds ratio of 0.40 (95% confidence interval, 0.26 - 0.60; p < 0.001), although there were no significant differences in bile leak between WR and SR. There were no significant differences in oncological outcomes such as liver metastases, 5-year DFS, and OS. CONCLUSIONS: For patients with both T2 and T3 GBC, WR was superior to SR in terms of surgical outcome and comparable to SR in terms of oncological outcomes. WR that achieves margin-negative resection may be a suitable procedure for patients with both T2 and T3 GBC.

Portal vein embolization failure: Current strategies and future perspectives to improve liver hypertrophy before major oncological liver resection.

Portal vein embolization (PVE) is currently considered the standard of care to improve the volume of an inadequate future remnant liver (FRL) and decrease the risk of post-hepatectomy liver failure (PHLF). PHLF remains a significant limitation in performing major liver surgery and is the main cause of mortality after resection. The degree of hypertrophy obtained after PVE is variable and depends on multiple factors. Up to 20% of patients fail to undergo the planned surgery because of either an inadequate FRL growth or tumor progression after the PVE procedure (usually 6-8 wk are needed before surgery). The management of PVE failure is still debated, with a lack of consensus regarding the best clinical strategy. Different additional techniques have been proposed, such as sequential transarterial chemoembolization followed by PVE, segment 4 PVE, intra-portal administration of stem cells, dietary supplementation, and hepatic vein embolization. The aim of this review is to summarize the up-to-date strategies to overcome such difficult situations and discuss future perspectives on improving FRL hypertrophy.

Segment 4 occlusion in portal vein embolization increase future liver remnant hypertrophy - A Scandinavian cohort study.

BACKGROUND: The additional value of including segment 4 (S4) portal branches in right portal vein embolization (rPVE) is debated. The aim of the study was to explore this in a large multicenter cohort. MATERIAL AND METHODS: A retrospective cohort study consisting of all patients subjected to rPVE from August 2012 to May 2017 at six Scandinavian university hospitals. PVE technique was essentially the same in all centers, except for the selection of main embolizing agent (particles or glue). All centers used coils or particles to embolize S4 branches. A subgroup analysis was performed after excluding patients with parts of or whole S4 included in the future liver remnant (FLR). RESULTS: 232 patients were included in the study, of which 36 received embolization of the portal branches to S4 in addition to rPVE. The two groups (rPVE vs rPVE + S4) were similar (gender, age, co-morbidity, diagnosis, neoadjuvant chemotherapy, bilirubin levels prior to PVE and embolizing material), except for diabetes mellitus which was more frequent in the rPVE + S4 group (p = 0.02). Pre-PVE FLR was smaller in the S4 group (333 vs 380 ml, p = 0.01). rPVE + S4 resulted in a greater percentage increase of the FLR size compared to rPVE alone (47 vs 38%, p = 0.02). A subgroup analysis, excluding all patients with S4 included in the FLR, was done. There was no longer a difference in pre-PVE FLR between groups (333 vs 325 ml, p = 0.9), but still a greater percentage increase and also absolute increase of the FLR in the rPVE + S4 group (48 vs 38% and 155 vs 112 ml, p = 0.01 and 0.02). CONCLUSION: In this large multicenter cohort study, additional embolization of S4 did demonstrate superior growth of the FLR compared to standard right PVE.

Evaluation of segment 4 portal vein embolization added to right portal vein for right hepatic trisectionectomy: A retrospective propensity score-matched study.

BACKGROUND: Adding segment 4 (S4) portal vein embolization (PVE) to right PVE before right hepatic trisectionectomy is controversial. We retrospectively examined the effect of S4 PVE on segments 2 and 3 (S2 + 3) hypertrophy. METHODS: We reviewed patients with biliary carcinoma who underwent right PVE with (R3PVE) or without (R2PVE) S4 PVE using gelatin sponge particles and coils (2010-2019). Propensity score matching balanced the cohort for baseline characteristics, including total liver volume and S2 + 3 volume before PVE. We compared the groups regarding the S2 + 3 volume changes after PVE. RESULTS: Of 178 enrolled patients, 38 underwent R3PVE for right hepatic trisectionectomy and 140 underwent R2PVE for right hepatectomy. Twenty-eight patients from each group were respectively matched. The median absolute volume increase in (146 cm3 vs 70 cm3 ), hypertrophy rate of (52.4% vs 32.3%), and kinetic growth rate of (3.1%/wk vs 2.0%/wk) S2 + 3 were significantly higher in the R3PVE group than in the R2PVE group. In the pre-matched cohort, the rate of posthepatectomy liver failure and postoperative hospital stay did not significantly differ between the patients who underwent right hepatic trisectionectomy and right hepatectomy. CONCLUSION: R3PVE increased the S2 + 3 volume more effectively than R2PVE in patients with biliary carcinoma.

Computed Tomography Evaluation of the Arterial Supply to Segment 4 of the Liver.

INTRODUCTION: In a setting of living-donor liver transplant and patients undergoing extended hepatic resections for both primary and metastatic liver tumors, preoperative assessment of hepatic arterial anatomy is very important because of the risk of ischemic complications in the event of inadvertent injury to the arterial supply. Anatomical variations in hepatic arterial supply to the liver are very common and seen in nearly half the population. Identifying anomalous origin of segment 4 hepatic artery is vital since this vessel can cross the transection plane and can result in liver ischemia and liver failure. The purpose of our study is to study the variations in hepatic arterial anatomy to segment 4 of the liver in the Indian population. MATERIALS AND METHODS: A retrospective evaluation of 637 consecutive computed tomography (CT) angiograms over a period of 1 year was performed, and we analyzed the arterial supply to segment 4 of the liver. RESULTS: We found that the arterial supply to segment 4 of the liver originated from left hepatic artery (LHA) in majority of cases, 76.3%. LHA along with the accessory LHA supplied this segment in 6.4%, whereas the accessory LHA solely supplied this segment in 0.4%. The right hepatic artery (RHA) was seen to supply this segment in 10.2%. Dual supply with branches from the RHA and LHA was seen in 6.6% of patients. CONCLUSION: Preoperative mapping of segment 4 hepatic arterial supply using CT angiography will act as a roadmap to surgeons as they attempt to carefully dissect and preserve this segments' arterial supply. Depending on the anatomical variation, surgical techniques will vary to ensure safety of segment 4 arterial supply.