3D Visualization Studies On The Operative Anatomy Of Hilar Cholangiocarcinoma

Objective: To explore the operative anatomical characteristics of hilar cholangiocarcinoma(HC),by the 3D visualization technique,and provide some proposals for the selection of surgical procedures.in addition,to show advantages and feasibility of mesohepatectomy on surgical anatomy.Methods: In this study,the lengths of resectable hepatic duct,portal vein,and the volumes of future liver remnant were measured based on the 3D visual models in 20 patients with hilar cholangicarcinoma(HC),and 17 patients with distal bile duct obstruction(NHC)。Results: Of the 37 patients,the portal vein variations were Cheng I type in 27,Cheng II type in 4 and Cheng III in 6.The biliary variations were Supraportal type in 34 and Infraportal type in 3.The lengths of resectable hepatic duct in left hemihepatectomies,left trisectionectomies,right hemihepatectomies,right trisectionectomies were 22.61±9.21,44.32±8.73,31.03±9.7,41.34 ±10.70 mm,respectively.Statistics determined that the lengths of the resectable hepatic ducts were(1)significantly longer in right hemihepatieectomies than in left hemi-hepatectoms(P<0.01),(2)similar in right and left trisectionectomies(P=0.57).In the patients with Cheng II/III type,the lengths of right hepatic duct and left portal vein were shorter than that in patients with Cheng I type(16.61±9.17 vs 7.30±8.18 mm,P=0.02,20.04±6.95 vs 27.58±8.60 mm,P=0.018),but the right posterior sectorial ducts were longer(26.89±9.45 vs 40.52±10.28 mm,P= 0.02).Th e lengths of resec table hepatic ducts in right hemihepatectomies and trisectionectomies were shorter than that in Cheng I type patients(22.25±8.98 vs 33.30±8.64 mm,P=0.05,31.51 ±10.08 vs 43.88±9.45 mm,P=0.05).In patients with Cheng II/III type,the lengths of resectable hepatic duct in left hemihepatectomies,left trisectionectomies,right hemihepatectomies,right trisectionectomies were 22.61±9.21,44.32±8.73,31.03±9.7,41.34 ±10.70 mm.Statistics determined that the lengths of the resectable hepatic ducts were(1)similar between right and l eft hemihepatectomies(P= 0.795),and(2)significantly longer in left trisectionectomies than in right trisectionectomies(P=0.016).The lengths of left portal vein,right portal vein and right posterior portal vein were 22.25±8.98,31.51 ±10.08,17.99±7.99,45.87±7.42 mm,respectively.Statistics determined that the lengths of left portal vein were longer than right portal vein(P=0.016),but shorter than right posterior portal vein(P=0.003).16 in 27 patients with a right portal vein longer than the left.The future liver remnants(FLRs)in left hemi-hepatectomies,left trisectionectomies,right hemihepatectomies,right trisectionectomies and mesohepatectomies combined with caudate lobectomies were 61.7 ± 6.9%,30.1 ± 7.3%,33.2 ± 6.6% and 18.4% ± 5.1 %,48.5 ± 6.8%,respectively.The numbers of cases t hat the FLR exceeded 40% in l eft hemi-hepatectomies,left trisectionectomies,right hemihepatectomies,right trisectionectomies,mesohepatectomies were 37(100%),3(8.1%),6(16.2%),0(0%),33(89.2%).The m ajority of pat ients could retain sufficient FLR i n mesohepatectomies.The lengths of ductal margins in left hemi-hepatectomies,left trisectionectomies,right hemihepatectomies,right trisectionectomies combined with caudate lobectomies were 8.41±9.61mm、9.90±9.60 mm,30.11±11.05 mm,20.21±10.35 mm,respectively。The numbers of cases that the length of ductal margin exceeded 10 mm in left hemi-hepatectomies,left trisectionectomies,right hemihepatectomies,right trisectionectomies,mesohepatectomies were 12(35.3%),12(35.3%),32(94.1%),31(91.2%)。Conclusion: Compared with left or ri ght hemi hepatectomy,mesohepatectomy can obtain longer resectable bile duct,which is beneficial to radical tumor resection.Compared with left trifoliate resection or right trifoliate resection,adequate functional liver volume can be retained to avoid a preoperative PVE.For HC with portal vein invasion,mesohepatectomy can also provide good resection and reconstruction conditions.For Starzl III/IV type HC,left / right hemi hepatectomy is hard to ensure safe m argins.The mesohepatectomy can obtain safe dutal margins while preserving enough FLR.The 3D visualization technique can display the three-dimensional structure of hepatic hilum,realized the quantification of surgeries,which should be applied routinely before the surgery of hilar cholangiocarcinoma.