VB01 Video Biliary: Open Biliary Surgery 
Selection of Video Presentations from Abstract Submissions
VB01-02 Hepatopancreatoduodenectomy (HPD) with Portal Vein Resection for Cholangiocarcinoma
Poowanai Sarkhampee, Thailand

P. Sarkhampee, N. Lertsawatvicha, S. Chansitthichok, P. Wattanarath
Department of Surgery, Sunpasitthiprasong Hospital, Thailand

Introduction: Hepatopancreatoduodenectomy (HPD) is the combination of major hepatectomy and pancreatoduodenectomy (PD). This aggressive procedure is the curative treatment in cholangiocarcinoma with extensive horizontal tumor spreading from the hepatic hilum to the intrapancreatic bile duct. The peri-hilar cholangiocarcinoma often have portal vein (PV) invasion. To obtain negative resection margins, it may need HPD with PV resection.
Methods: The surgical procedure consists of PD, skeletonization of hepatoduodenal ligament (HDL), hepatectomy with hilar and PV resection, and reconstruction. After careful searching for intra- and extra-hepatic metastases, Kocherization was performed. Distal gastrectomy and small bowel resection were done. Pancreatic parenchyma was transected. Vascular structures in HDL were encircled and right hepatic artery was divided. After skeletonization of HDL, mobilisation of right lobe liver and liver parenchymal transection were performed. Left intra-hepatic bile duct was divided and then left PV and main PV were transected. Left PV was re-anastomosed to main PV. Right hepatic vein was divided and specimen was removed. The reconstruction was performed with pancreaticojejunostomy, hepatojejunostomy and gastrojejunostomy, respectively.
Results: HPD with PV resection was performed successfully without intra-operative complication. Operative time was 480 minutes and estimated blood loss was 1000 ml. Pathology showed cholangiocarcinoma with portal vein invasion. All resection margin uninvolved by tumor but there was lymph node metastases in 5/20 nodes. Patient was discharged on post-operative day 10 without peri-operative complications.
Conclusion: HPD with PV resection for extensive cholangiocarcinoma is feasible procedure and provide chance for achieving negative resection margin.
VB01-03 En Bloc Resection of Left-Sided Liver, Caudate Lobe, Right Portal Vein and Right Hepatic Artery for Peri-Hilar Cholangiocarcinoma with a Modified Reconstruction
Chao Liu, China

X.-D. Shi1, R. Zhang1, Q.-B. Tang1, H.-M. Li1, C. Liu2
1Biliary Pancreatic Surgery, Sun Yat-sen Memorial Hospital, China, 2Biliary Pancreatic Surgery, Sun Yat-Sen Memorial Hospital, China

Introduction: Locoregional recurrence following resection of type IIIB peri-hilar cholangiocarcinoma with contralateral vascular invasion could be caused by the microscopic dissemination of cancer cells during dissection of the right pedicle vascular from the involved bile duct at the hilar region.
Methods: The female, 59y-57kg-163cm, had jaundice of the skin and eyes for 20 days. At admission his serum TBIL and CA19-9 were 339umol/L and 353U/ml, respectively. The CT&MR showed that peri-hilar tumor invaded RHA, LPV and portal bifurcation. Preoperative diagnosis was peri-hilar cholangiocarcinoma (cT4N0M0/ⅢB).
Results: The patient's serum TBIL was 39.1umol/L after right-sided PTCD for 22 days. Residual liver volume(S5+6+7+8) was 79.6%. The surgical procedure included that anatomical left hemihepatectomy and caudate lobe resection, resection of the RPV, portal bifurcation and RHA, transection of RHD behind the P point. The modified reconstruction was that maintained blood flow in right liver throughout. RPV reconstruction was followed by RHA reconstruction, and transection of LHV was done finally. Pathological results showed that moderate differentiated cholangiocarcinoma was invasive type with nerve infiltration. Furthermore, the vascular adventitias of LPV and portal bifurcation, RHA were invaded. Surgical margins, including MPV, RPV, PHA and RHA, distant and proximal bile duct were all negative. None of lymph nodes was metastasis(0/16).
Conclusion: We describe the aggressive approach involving en bloc resection combined with PV and HA reconstruction for local advanced peri-hilar cholangiocarcinoma. The technique is based on anatomical and oncological principles, and has protective effects on the hepatic ischemia reperfusion injury.
VB01-04 Right Hepatectomy with Portal Vein Reconstruction for Hilar Cholangiocarcinoma
Li Xiangcheng, China

L. Xiangcheng1, Q. Feng2, C. Li3, X. Wu2, Z. Wu2, X. Wang2
1The First Affiliated Hospital of Nanjing Medical University, China, 2Jiangsu Province Hospital, Nanjing Medical University, China, 3Surgery, Jiangsu Province Hospital, Nanjing Medical University, China

Background: The most favorable long-term survival rate for hilar cholangiocarcinoma is achieved by a R0 resection. The right hepatectomy has always been the choice for IVa hilar cholangiocarcinoma. However, the feasibility of this technique may be relatively difficult when portal vein has been invaded. This video showed our experience in right hepatectomy and caudate lobectomy together with portal vein reconstruction.
Methods: A 67-year-old male patient with upper abdominal discomfort for 2months and jaundice for 1 months. CT scan demonstrated hilar mass with portal vein invasion. PTCD was performed 10 days ago. This patient was successfully treated with right hepatectomy and caudate lobectomy together with portal vein reconstruction. The portal vein invaded by the tumor was removed and end-to-end anastomosis was performed. Then, the biliary-enteric anastomosis was completed between the left hepatic duct and the jejunum in an end-to-side way.
Results: The hospital stayed is 18 days. This patient obtained rapid recovery without severe postoperative complications. Postoperative CT and laboratory examination were normal.
Conclusion: Right hepatectomy with portal vein reconstruction combined with caudate lobectomy for IVa hilar cholangiocarcinoma is difficult, but for an experienced surgeon. The consequence is acceptable and may be helpful in achieving long-term survival in selected patients.
VB01-05 Surgical Treatment of a Case of Hilar Cholangiocarcinoma
Zheng Lu, China

Z. Lu
Department of General surgery, The First Affiliated Hospital of Bengbu Medical College, Bengbu, China

A 54-year-old female was diagnosed with hilar cholangiocarcinoma (Bismuth-Corlette IV) before operation. After admission, the percutaneous transhepatic cholangial drainage (PTCD) was given to reduce jaundice, and the TBIL reduced from 108 to 28.5 umol/L, AST and ALT return back to normal before operation. The liver function reached Child-Pugh grade A. We made a three-dimensional reconstruction for these patients before operation routinely. For this patient, the extended right hemihepatectomy plus caudate lobectomy was proposed. But the residual liver volume was insufficient. The portal vein embolization (PVE) was performed. After 2 weeks, the residual liver volume reached to 48.7%. The enlarged right hemihepatectomy (include SIVb, SV, SVI, SVII and SVIII segment), and SI segment resection, hilar lymph node dissection, and choledochojejunostomy was performed. The operation lasted for 7 hours, and the intraoperative blood loss was 400ml. The postoperative showed pathology was bile duct adenocarcinoma, and the upper and down resection margin of the bile duct was free. He recovered unevenly and was discharged on the 10th day postoperative.
VB01-06 Intraductal Tubulopapillary Neoplasm of the Bile Duct
Morgan Bonds, United States

M. Bonds, F. Rocha
Virginia Mason Medical Center, United States

We present the resection of a hilar cholangiocarcinoma arising from an intraductal tubulopapillary neoplasm of the bile duct (ITPN). This relatively new entity is characterized by tubular growth in the lumen of the bile duct. Our patient presented with painless jaundice and was found to have a mass within the bile duct on cross sectional imaging. Brushings were positive for malignancy, staging revealed no extrahepatic disease. In preparation for an extended right hepatectomy plus caudate lobectomy, the patient underwent right portal vein embolization to increase the left lateral section volume from 19% to 29%. The video demonstrates the surgical technique for resecting a hilar cholangiocarcinoma arising from an intraductal tubulopapillary neoplasm. The oncologic principles of resecting a hilar cholangiocarcinoma are maintained. Cholangiocarcinoma arising from intraductal tubulopapillary neoplasms tend to present at an earlier stage due to biliary obstruction from the intraductal growth pattern. It is possible this results in a better prognosis compared to conventional cholangiocarcinomas but more study is needed in this area.