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UNUSUAL CASE
Year : 2021  |  Volume : 17  |  Issue : 3  |  Page : 369-372
 

Laparoscopic hepatopancreatoduodenectomy for locally advanced gall bladder cancer


Department of Surgical Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India

Date of Submission16-Aug-2020
Date of Decision26-Sep-2020
Date of Acceptance29-Sep-2020
Date of Web Publication03-Feb-2021

Correspondence Address:
Dr. Raja Kalayarasan
Department of Surgical Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry - 605 006
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmas.JMAS_179_20

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 ¤ Abstract 

Hepatopancreatoduodenectomy (HPD) can offer a survival advantage in selected patients with locally advanced gall bladder cancer (GBC). While the safety and feasibility of minimally invasive radical cholecystectomy have been recently documented, laparoscopic HPD for GBC has not been previously reported. A 73-year-old male with GBC infiltrating the bile duct underwent laparoscopic HPD to achieve R0 resection. The patient had an uneventful post-operative course except for delayed gastric emptying that improved with conservative management. The feasibility of laparoscopic HPD for locally advanced GBC reported in the present case needs to be documented in a large case series.


Keywords: Gall bladder cancer, hepatopancreatoduodenectomy, jaundice, laparoscopy


How to cite this article:
James M, Kalayarasan R, Gnanasekaran S, Pottakkat B. Laparoscopic hepatopancreatoduodenectomy for locally advanced gall bladder cancer. J Min Access Surg 2021;17:369-72

How to cite this URL:
James M, Kalayarasan R, Gnanasekaran S, Pottakkat B. Laparoscopic hepatopancreatoduodenectomy for locally advanced gall bladder cancer. J Min Access Surg [serial online] 2021 [cited 2021 Aug 4];17:369-72. Available from: https://www.journalofmas.com/text.asp?2021/17/3/369/308673



 ¤ Introduction Top


Gall bladder cancer (GBC) is an aggressive tumour with a propensity for early nodal and distant metastasis.[1] Despite advances in systemic therapy, radical resection remains the primary treatment modality. Extended surgical resection such as hepatopancreatoduodenectomy (HPD) can offer survival advantage in selected patients with locally advanced GBC.[2] The concept of minimally invasive radical surgery for GBC was initially vehemently opposed due to reports of tumour recurrence at port sites following laparoscopic cholecystectomy for unsuspected GBC.[3] However, with a better understanding of the mechanism of port-site recurrence and advancements in minimally invasive surgical technique, multiple series have reported the feasibility and safety of laparoscopic radical cholecystectomy for GBC.[4],[5],[6] As HPD is a complex procedure, minimally invasive approach was not commonly used. An extensive search of PubMed, Embase, Medline and Google Scholar with keywords such as laparoscopic surgery, GBC and HPD did not yield any previous report. The technique of laparoscopic HPD performed for a GBC patient with jaundice has been described in this report.


 ¤ Case Report Top


A 73-year-old male with Eastern Cooperative Oncology Group performance status 2 presented with a 2-month history of abdominal pain, intermittent vomiting and obstructive jaundice. He also had a significant loss of weight and appetite. An abdominal examination revealed a hard gall bladder (GB) mass in the right hypochondrium. His serum bilirubin at presentation was 15 mg/dl with elevated CA 19-9 level of 21,704 U/ml. Triple-phase contrast-enhanced computed tomography abdomen revealed a heterogeneously enhancing GB mass extending into the common bile duct (CBD) with bilateral intrahepatic biliary radical dilatation. Magnetic resonance cholangiopancreatography showed the proximal level of biliary obstruction below the level of hepatic duct confluence, and distally the tumour was extending up to the intrapancreatic portion of the bile duct. Because of raised bilirubin and cholangitis, the patient underwent endoscopic retrograde cholangiography and stenting. Bile cytology was positive for malignancy. Evaluation with whole-body positron emission tomography did not reveal any evidence of distant metastasis. After pre-operative optimisation and normalisation of serum bilirubin level, laparoscopic HPD was planned to achieve a negative bile duct margin.

The patient was placed supine with a split leg position, and a staging laparoscopy was performed with an umbilical and two pararectal ports.[7] As there was no evidence of distant metastasis, three additional working and assistant trocars were placed, as shown in [Figure 1]. Initially, the transverse colon appeared to be involved by the tumour. However, after the division of omental adhesions, the transverse colon could be separated from the GB mass [Figure 1]. The pulled-up duodenum adherent to the GB mass precluded access to the hepatoduodenal ligament (HDL). Hence, the stomach was transected proximal to the pylorus to gain access to the HDL. Lymph nodes along the hepatic artery were dissected. The right hepatic artery was divided as it was coursing through the tumour. Infiltration of the CBD by the tumour precluded complete HDL lymphadenectomy. Hence, HDL was looped for Pringle manoeuvre, and liver resection was started. The wedge of segments IVB and V was resected using the combination of ultrasonic shears and a bipolar energy device [Figure 2]. The Glissonean pedicles of segments IVb and V, along with hepatic vein branches from segments IVB and V to the middle hepatic vein, were securely ligated and divided. At the completion of the liver resection, the hepatic duct was divided at the level of confluence to have an adequate proximal resection margin [Figure 2]. This was followed by pancreatoduodenectomy (PD) [Figure 2]. The en bloc HPD specimen was placed in the specimen retrieval bag and parked in the right subdiaphragmatic region. Pancreatojejunostomy was done using the modified Blumgart technique. Hepaticojejunostomy was done using 4-0 polydioxanone continuous sutures in the posterior layer and interrupted sutures in the anterior layer. Antecolic anterior gastrojejunostomy was done using a 60-mm laparoscopic linear cutter, and the stapler entry site was closed with 3-0 polydioxanone sutures. Feeding jejunostomy was performed to initiate early enteral feeds, and the specimen was removed using a small periumbilical incision.
Figure 1: (a) Contrast-enhanced computed tomography abdomen showing gall bladder mass infiltrating the common bile duct. (b) Port position for laparoscopic hepatopancreatoduodenectomy. (c) Staging laparoscopy showing transverse colon close to the gall bladder mass. (d) After the division of omental adhesions, the transverse colon is away from the tumour, but the duodenum is pulled up towards the gall bladder mass

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Figure 2: (a) Wedge of segment IVb/V liver resection using ultrasonic shears. (b) Hepatic duct divided at the level of confluence. Right and left hepatic duct orifices can be seen (arrow). (c) Post-hepatopancreatoduodenectomy showing skeletonised hepatic artery and portal vein. Ligated right hepatic artery stump marked with arrow. (d) Completed pancreaticojejunostomy anastomosis. (e) Completed hepaticojejunostomy anastomosis. (f) En bloc laparoscopic hepatopancreatoduodenectomy specimen

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The total operation time was 610 min, and the estimated blood loss was 500 ml. The patient had a smooth post-operative course except for delayed gastric emptying that was managed conservatively and was discharged on the 12th post-operative day. Post-operative biopsy showed well-differentiated adenocarcinoma involving the entire GB invading through the muscle layer into the fibrous tissue on the side of the liver and extending into the CBD till its intrapancreatic portion. One out of 19 lymph nodes showed evidence of metastasis. All resection margins were free of tumour. The patient received adjuvant gemcitabine chemotherapy and doing well at 7-month follow-up without clinical evidence of recurrence.


 ¤ Discussion Top


The term Hepatopancreatoduodenectomy (HPD) refers to the surgical procedure in which hepatectomy is combined with PD. Since Takasaki et al. first reported the use of HPD in five patients with locally advanced GBC, many Japanese surgeons and a few surgeons in other parts of the world have performed this technically challenging procedure in locally advanced GBC.[8],[9] Current indications for HPD are GBC with extensive duodenopancreatic involvement, extensive peripancreatic lymphadenopathy that cannot be cleared without PD and diffuse biliary involvement.[2],[10] HPD is a morbid procedure with a 54% overall major complication rate.[9] Significant causes of morbidity and mortality are liver failure and pancreatic fistula. The strategies aimed to reduce the incidence of liver failure are avoidance of major hepatectomy whenever possible and routine portal vein embolisation in patients requiring major hepatectomy.[2],[10] In addition, patients who undergo HPD to achieve negative bile duct margin or secondary to direct infiltration of duodenum and pancreas have better survival than patients who undergo HPD for extensive peripancreatic lymph node metastasis.[10] Hence, HPD was planned in the present patient as the aim is to achieve a negative distal bile duct margin.

The safety and feasibility of minimally invasive radical cholecystectomy have been recently documented in multiple series.[4],[5],[6] Absence of port-site recurrence in all published series of minimally radical cholecystectomy with a median follow-up of at least 6 months, the critical period for the port-site recurrence is the colossal evidence that laparoscopic approach does not increase the incidence of port-site recurrence. Nonetheless, HPD was not commonly performed using a minimally invasive approach in view of the extensive dissection, complex anastomosis and want of advanced laparoscopic skills. A few case reports have recently reported the feasibility of minimally invasive HPD in hilar cholangiocarcinoma.[11],[12] However, laparoscopic HPD for locally advanced GBC has not been previously reported. In hilar cholangiocarcinoma, GB is usually collapsed. However, in locally advanced GBC, GB mass with infiltration of bile duct precludes complete access to HDL. Hence, liver resection should be performed in the initial stage; as the resection plane approaches close to the hilar plate, the hepatic duct should be divided to ensure R0 resection.

The right hepatic artery was divided in the present case as it was coursing through the tumour. Conventionally, right hepatic artery involvement in GBC has been considered a sign of advanced disease and an indication for major hepatectomy. We have previously reported that hepatic artery ligation without reconstruction could be safely performed in GBC patients who undergo parenchyma-preserving resection with bile duct excision if the roof of hepatic duct confluence can be preserved.[13] As the hilar collaterals were preserved in the present case, right hepatic artery reconstruction was not performed and the patient did not have any ischaemic or biliary complications in the post-operative period.

The technique of laparoscopic HPD described in the present report needs to be documented in a large case series. Furthermore, the term HPD for locally advanced biliary cancers is generally reserved for major hepatectomy (resection of three or more Couinaud's hepatic segments) combined with PD. In a recent systematic review of the safety and efficacy of HPD for bile duct and GBCs, minor hepatectomy, as described in the present report, was performed only in 18.7% of patients.[2] Neoadjuvant therapy has been recently proposed to improve outcomes in locally advanced GBC. While resectability rate and survival might be improved with neoadjuvant therapy, there are concerns about delay in the surgical resection and disease progression. In a recent systematic review of eight studies with 474 patients, 30.6% of the patients had progressive disease despite neoadjuvant therapy 17% of the patients who responded to chemotherapy did not proceed to surgery due to complications.[14] As the R0 rate for the whole cohort was 35.4%, the authors concluded that there is insufficient data to support the routine use of neoadjuvant therapy in locally advanced GBC. As the patient described in the present report primarily had bile duct infiltration without extensive nodal disease, the decision for upfront surgery was taken in the multidisciplinary tumour board meeting.

The feasibility of laparoscopic HPD for locally advanced GBC reported in the present case needs to be documented in a large case series. As it is a technically challenging procedure, cumulative experience in performing minimally invasive hepatectomy, PD and intracorporeal anastomosis is a sine qua non in the successful completion of the procedure.

Acknowledgement

The authors would like to express special thanks to Prof. Anil K Agarwal (Director and Head of Department of GI surgery, GIPMER) for sharing his experience in minimally invasive radical cholecystectomy for GBC.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
 ¤ References Top

1.
Sikora SS, Singh RK. Surgical strategies in patients with gallbladder cancer: Nihilism to optimism. J Surg Oncol 2006;93:670-81.  Back to cited text no. 1
    
2.
Zhou Y, Zhang Z, Wu L, Li B. A systematic review of safety and efficacy of hepatopancreatoduodenectomy for biliary and gallbladder cancers. HPB (Oxford) 2016;18:1-6.  Back to cited text no. 2
    
3.
Lundberg O, Kristoffersson A. Port site metastases from gallbladder cancer after laparoscopic cholecystectomy. Results of a Swedish survey and review of published reports. Eur J Surg 1999;165:215-22.  Back to cited text no. 3
    
4.
Agarwal AK, Javed A, Kalayarasan R, Sakhuja P. Minimally invasive versus the conventional open surgical approach of a radical cholecystectomy for gallbladder cancer: A retrospective comparative study. HPB (Oxford) 2015;17:536-41.  Back to cited text no. 4
    
5.
Yoon YS, Han HS, Cho JY, Choi Y, Lee W, Jang JY, et al. Is laparoscopy contraindicated for gallbladder cancer? A 10-year prospective cohort study. J Am Coll Surg 2015;221:847-53.  Back to cited text no. 5
    
6.
Han HS, Yoon YS, Agarwal AK, Belli G, Itano O, Gumbs AA, et al. Laparoscopic surgery for gallbladder cancer: An expert consensus statement. Dig Surg 2019;36:1-6.  Back to cited text no. 6
    
7.
Agarwal AK, Kalayarasan R, Javed A, Gupta N, Nag HH. The role of staging laparoscopy in primary gall bladder cancer-an analysis of 409 patients: A prospective study to evaluate the role of staging laparoscopy in the management of gallbladder cancer. Ann Surg 2013;258:318-23.  Back to cited text no. 7
    
8.
Takasaki K, Kobayashi S, Mutoh H, Akimoto S, Toda K, Asado S, et?al. Our experiences (5 cases) of extended right lobectomy combined with pancreato-duodenectomy for the carcinoma of the gall bladder (in Japanese). Tan Sui 1980;1:923-32.  Back to cited text no. 8
    
9.
Ogura Y, Mizumoto R, Isaji S, Kusuda T, Matsuda S, Tabata M. Radical operations for carcinoma of the gallbladder: Present status in Japan. World J Surg 1991;15:337-43.  Back to cited text no. 9
    
10.
Ebata T, Yokoyama Y, Igami T, Sugawara G, Mizuno T, Nagino M. Review of hepatopancreatoduodenectomy for biliary cancer: An extended radical approach of Japanese origin. J Hepatobiliary Pancreat Sci 2014;21:550-5.  Back to cited text no. 10
    
11.
Zhang CW, Liu J, Hong DF, Wang ZF, Hu ZM, Huang DS, et al. Pure laparoscopic radical resection for type IIIa hilar cholangiocarcinoma. Surg Endosc 2018;32:1581-2.  Back to cited text no. 11
    
12.
Chong EH, Choi SH. Hybrid laparoscopic and robotic hepatopancreaticoduodenectomy for cholangiocarcinoma. J Gastrointest Surg 2019;23:1947-8.  Back to cited text no. 12
    
13.
Kalayarasan R, Javed A, Agarwal AK. Gallbladder cancer with right hepatic artery involvement: Can the artery be ligated? HPB (Oxford) 2014;16:258-316.  Back to cited text no. 13
    
14.
Hakeem AR, Papoulas M, Menon KV. The role of neoadjuvant chemotherapy or chemoradiotherapy for advanced gallbladder cancer-A systematic review. Eur J Surg Oncol 2019;45:83-91.  Back to cited text no. 14
    


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