title: Right hepatectomy for a detoured left hepatic artery in hilar cholangiocarcinoma-report of a rare but rational resection.
abstract: BACKGROUND
  Curative hepatectomy with bile duct resection is the treatment for perihilar cholangiocarcinoma. A locally advanced tumor necessitates hepatectomy with simultaneous vascular resection, and reconstruction remains an obstacle for surgeons. Studies have focused on the variations of hepatic arteries. Nevertheless, the anatomical alignment of the portal veins, bile ducts, and hepatic arteries are equally critical in surgical planning of curative resection for advanced tumors. We have reported promising outcomes of hepatectomy with simultaneous resection and reconstruction of the hepatic artery. With respect to the type of surgery, most patients undergo left hepatectomy with right hepatic artery resection and reconstruction in contrast to right hepatectomy with left hepatic artery resection and reconstruction. We present two patients who showed detoured left hepatic arteries that were invaded by the perihilar tumors.
  
  
  METHODS
  A 78-year-old man who presented with epigastric pain and abnormal liver function was referred to our clinic for further examination. Serial examination resulted in the diagnosis of Bismuth type II hilar cholangiocarcinoma. The left hepatic artery ran a detoured course and was invaded by the tumor. The second patient was a 76-year-old woman who presented with jaundice and the Bismuth type II hilar cholangiocarcinoma. The left hepatic artery was along the right-lateral position of the left portal vein and was invaded by the tumor. The variant anatomical relationship of the vessel was identified preoperatively in both patients, and they underwent right hepatectomy with concomitant left hepatic artery resection and reconstruction without any major complications or recurrence.
  
  
  CONCLUSIONS
  The largely biased selection of patients is based on the following anatomical relationship: the left hepatic artery usually runs left lateral to the portal vein, which spares invasion by the perihilar cholangiocarcinoma. On the contrary, the right hepatic artery mostly runs behind the bile duct and is invaded by the tumor. This aforementioned anatomy is one of the reasons for the relatively rare left hepatic artery resections and reconstructions in right hepatectomies. By meticulous preoperative evaluation with images, we identify the anatomical variation and performed right hepatectomy with concomitant left hepatic artery resection and reconstruction without any major complications and mortalities.
authors.affiliation: Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan.
authors.forename: Chun-Yi
authors.initials: CY
authors.lastname: Tsai
authors.affiliation: Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan.
authors.forename: Nobuyuki
authors.initials: N
authors.lastname: Watanabe
authors.affiliation: Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan.
authors.forename: Tomoki
authors.initials: T
authors.lastname: Ebata
authors.affiliation: Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan.
authors.forename: Takashi
authors.initials: T
authors.lastname: Mizuno
authors.affiliation: Department of Plastic and Reconstructive Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan.
authors.forename: Yuzuru
authors.initials: Y
authors.lastname: Kamei
authors.affiliation: Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan. nagino@med.nagoya-u.ac.jp.
authors.forename: Masato
authors.initials: M
authors.lastname: Nagino
mesh_terms: D000368:Aged; D000714:Anastomosis, Surgical; D063405:Anatomic Variation; D001650:Bile Duct Neoplasms / Q000000981:diagnostic imaging / Q000601:surgery*; D001653:Bile Ducts, Intrahepatic / Q000000981:diagnostic imaging / Q000473:pathology / Q000601:surgery; D002758:Cholangiography; D000072226:Computed Tomography Angiography; D016099:Endoscopy, Gastrointestinal; D005260:Female; D006498:Hepatectomy / Q000379:methods*; D006499:Hepatic Artery / Q000033:anatomy & histology* / Q000000981:diagnostic imaging / Q000473:pathology / Q000601:surgery; D006801:Humans; D018285:Klatskin Tumor / Q000000981:diagnostic imaging / Q000601:surgery*; D008297:Male; D061330:Multidetector Computed Tomography; D011169:Portal Vein / Q000000981:diagnostic imaging / Q000601:surgery; D019651:Plastic Surgery Procedures
keywords: Hepatic artery resection; Perihilar cholangiocarcinoma; Simultaneous vascular resection; Variant hepatic artery