Clinical Implications of Biliary Confluence Pattern for Bismuth-Corlette Type IV Hilar Cholangiocarcinoma Applied to Hemihepatectomy.
Since biliary variations are commonly seen, our aims are to clarify these insidious variations and discuss their surgicopathologic implications for Bismuth-Corlette (BC) type IV hilar cholangiocarcinoma (HC) applied to hemihepatectomy.



Three-dimensional images of patients with distal bile duct obstruction (n = 97) and advanced HC (n = 79) were reconstructed and analyzed retrospectively. Normal biliary confluence pattern was defined as the peripheral segment IV duct (B4) joining the common trunk of segment II (B2) and segment III (B3) ducts to form the left hepatic duct (LHD) that then joined the right hepatic duct (RHD). The lengths from left and right secondary biliary ramifications to the right side of the umbilical portion of the left portal vein (Rl-L) and the cranio-ventral side of the right portal vein (Rr-R) were measured, respectively, and compared with the resectable bile duct length in HCs. Surgicopathologic findings were compared between different BC types.



The resectable bile duct length in right hemihepatectomy for eradication of type IV tumors was significantly longer than the Rl-L length in normal biliary configuration (17.4 ± 1.8 and 10.3 ± 3.4 mm, respectively, p < 0.001), and type III variation (B2 joining the common trunk of B3 and B4) was the predominant configuration (53.8%). The resectable length in left hemihepatectomy for eradication of type IV tumors was comparable with the Rr-R length in RHD absent cases (15.2 ± 2.5 and 16.4 ± 2.6 mm, respectively, p = 0.177) but significantly longer than that in normal configuration (p < 0.001). The estimated length was 8.5 ± 2.0 mm in unresectable cases. There was no significant difference between type III and IV tumors, except for the rate of nodal metastasis (29.7 and 76.0%, respectively, p < 0.001).



Hemihepatectomy might be selected for curative-intent resection of BC type IV tumors considering the advantageous biliary variations, whereas anatomical trisegmentectomy is recommended for the resectable bile duct length less than 10 mm. Biliary variations might result in excessive classification of BC type IV but require validation on further study.
Key Laboratory on Living Donor Liver Transplantation, Ministry of Health, Department of Liver Surgery, First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, People's Republic of China.
Gu-Wei
GW
Ji
Department of Radiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, People's Republic of China.
Fei-Peng
FP
Zhu
Key Laboratory on Living Donor Liver Transplantation, Ministry of Health, Department of Liver Surgery, First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, People's Republic of China.
Ke
K
Wang
Key Laboratory on Living Donor Liver Transplantation, Ministry of Health, Department of Liver Surgery, First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, People's Republic of China.
Chen-Yu
CY
Jiao
Key Laboratory on Living Donor Liver Transplantation, Ministry of Health, Department of Liver Surgery, First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, People's Republic of China.
Zi-Cheng
ZC
Shao
Key Laboratory on Living Donor Liver Transplantation, Ministry of Health, Department of Liver Surgery, First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, People's Republic of China. drxcli@njmu.edu.cn.
Xiang-Cheng
XC
Li
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D059925:Anatomic Landmarks; D001650:Bile Duct Neoplasms / Q000000981:diagnostic imaging / Q000473:pathology / Q000601:surgery*; D001653:Bile Ducts, Intrahepatic / Q000033:anatomy & histology* / Q000000981:diagnostic imaging / Q000601:surgery*; D001729:Bismuth; D002779:Cholestasis / Q000000981:diagnostic imaging / Q000601:surgery; D005260:Female; D006498:Hepatectomy / Q000379:methods; D006500:Hepatic Duct, Common / Q000033:anatomy & histology / Q000000981:diagnostic imaging; D006801:Humans; D021621:Imaging, Three-Dimensional; D018285:Klatskin Tumor / Q000000981:diagnostic imaging / Q000556:secondary / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D009929:Organ Size; D011169:Portal Vein / Q000033:anatomy & histology / Q000000981:diagnostic imaging; D012189:Retrospective Studies
D001729:Bismuth
Biliary variation; Bismuth-Corlette type IV; Hemihepatectomy; Hilar cholangiocarcinoma