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16 Digital Diagnosis andManagement ofCholangiocarcinoma
387
hg
Fig. 16.17 (continued)
Type B (RB): The right posterior bile duct enters the left
hepatic duct.
Type C (RC): The right posterior lobe hepatic duct, the
right anterior lobe hepatic duct, and the left hepatic duct constitute a trigeminal bile duct that joins the common bile duct.
(lower segment of the left lateral lobe) converge into B4 (bile
duct of hepatic segment IV) to form the left hepatic bile duct.
Type B: B2, B3, and B4 form a trigeminal type.
Type C: B3 and B4 work together and conuent with B2.
D: Other types.
Type D (RD): The right posterior bile duct enters the right
anterior bile duct below the portal vein.
Type E (RE): The right posterior lobe bile duct enters the
common bile duct below the portal vein.
Type F-J shape (RF): Other types.
• Caudate lobe (C) bile duct was divided into four
groups: Right branch, left superior branch, left inferior
branch, and caudate process branch; the right branch
and the left superior branch above the right hepatic
duct, the right posterior bile duct, the left hepatic duct,
• Left (L) bile duct of the liver is classied into 4 types.
and the left lateral bile duct; the left inferior branch
below the left hepatic duct; and the caudate process
Type A (LA): The bile duct (B2) of hepatic segment II
(upper left lateral lobe) and the bile duct (B3) of segment III
branch below or behind the right hepatic duct
(Figs.16.19 and 16.20).
388
F. Shen et al.
a
b
c
Fig. 16.18 Right (R) hepatic duct typing. (a) Type B (RB); (b) Type C (RC); (c) Type E (RE)
Fig. 16.19 Bile duct typing guided by 3D visualization
Fig. 16.20 Bile duct typing guided by 3D visualization
16 Digital Diagnosis andManagement ofCholangiocarcinoma
389
3D visualization of bile duct typing was established
according to Kitami’ s CT classication method. Under normal conditions, intrahepatic bile duct was not dilated, and
bile uid dynamics were in a state of low pressure, so it was
challenging to construct a three-dimensional visualization
model of the bile duct by thin-layer CT data. Patients with
hilar cholangiocarcinoma are associated with obstructive
jaundice and biliary hypertension. The high-quality thinslice CT scan data of the biliary tract required to construct a
complete three-dimensional model, can only be obtained
through the communication between doctors and CT technicians and the cooperation of patients. For some patients with
percutaneous transhepatic cholangial drainage (PTCD) or
endoscopic nasobiliary drainage (ENBD) placed preoperatively, satisfactory 3D reconstruction of the bile duct can be
achieved by clamped PTCD and ENBD tubes for 6–8h, and
the patient’s biliary tract model can also be obtained by
MRCP image.
3D Visualization ofIndividualized Liver
Segmentation forHilar Cholangiocarcinoma
3D visualization of liver segmentation can be performed
according to the blood ow topography, that is, the hepatic
segment of each functional area is determined by the independent portal vein blood supply and hepatic vein reux.
According to the characteristics of the hepatic vein and portal vein of the patients, each hepatic segment has an indepen-
dent blood supply and blood drainage this is adopted as the
guiding principle. Individualized segmentation was performed according to the Couinaud segment classication,
which divides the liver into eight segments. Each segment of
the liver has an independent blood supply and reux system,
which can be regarded as a functional unit. In case of variation of the right posterior hepatic vein, rst divide the right
liver into 4 segments corresponding to the right hepatic vein
and the right portal vein branch, and then take a right posterior vein as the segment boundary. If the right posterior vein
is located above the right portal vein branch plane, the right
liver will be divided into 6 segments, and the liver can be
divided into 10 segments; if segment IV of hepatic vein
appears, the left inner lobe is divided into two segments, and
the liver is divided into nine segments with the segment IV of
hepatic vein as the boundary. Each liver segment was divided
into different colors for comparison and differentiation to
locate the tumors accurately.
Liver segmentation under the guidance of 3D visualization originates from the living donor’s liver, and the reconstructed liver structure can be individually segmented at will.
Each segment can be labeled with different colors, and the
spatial structure can be 360° rotated arbitrarily. The shape
and size of each segment and its relationship with the posi-
tion of the intrahepatic vessel were observed dynamically
(Figs. 16.21 and 16.22). Due to the individualized differences in liver morphology, the portal vein has a high rate of
variation, and because of its various intrahepatic course, the
size and shape of each liver segment are also different
(Figs. 16.23 and 16.24). Through preoperative 3D reconstruction, individualized 3D segmental and volume calculation of hepatic vein and portal vein can be carried out, thereby
achieving accurate localization of the tumor, which is of
practical guiding signicance for accurate preoperative surgical planning.
Fig. 16.21 Preoperative 3D visualization of liver segmentation
Fig. 16.22 Preoperative volume calculation and surgical simulation
390
Fig. 16.23 Preoperative surgical simulation. MHV middle hepatic vein
Fig. 16.24 The point P of portal vein variation are clearly shown prior
to surgery. MHV middle hepatic vein, LBD left bile duct
Volume Calculation ofIndividualized Hepatic
Segments Through 3D Visualization forHilar
Cholangiocarcinoma
See Sect. 12.6.
16.3.3 Simulation Surgery Guided by 3D
Visualization
The condition of patients with hilar cholangiocarcinoma is
complex, and there are many uncertain factors affecting the
success of the surgery. It is suggested that individual preoperative virtual surgery should be performed according to the
F. Shen et al.
specic conditions such as the variability of each hepatic
duct, the relationship between the location of the tumor and
the intrahepatic duct, and the volume of the liver. Especially
in the case of intrahepatic duct variation, preoperative virtual
surgery can be performed repeatedly to verify the feasibility
of surgical planning formulated based on 3D visualization,
and if necessary, to adjust the surgical scheme, so that surgeons can have a comprehensive preoperative understanding. Thus, optimal surgical planning can be selected, and the
safety of operation can be improved.
16.3.4 Surgical Planning Guided by 3D Visualization
The 3D visualization technique can display the anatomy of
each segment of the liver, the course, and variation of the
intrahepatic duct system, as well as the location and size of
the liver lesions more intuitively, clearly, and at any angle.
Utilizing the analysis function of the software, the anatomy
of intrahepatic vessels, tumors, and whole liver can be
observed individually or in combination, as well as any anatomical variation. In order to improve the accuracy and
reliability of hepatic hilar tumor location, the software was
used to locate the anatomic position of the hilar tumor accurately. It provides individual information for surgeons to
develop accurate surgical procedures.
A case of type III b hilar cholangiocarcinoma was taken as
an example. The variation of the portal vein was analyzed by
3D visualization. In type II, the right anterior portal vein, right
posterior portal vein, and left portal vein were triplicated. The
hepatic artery was normal. Following preoperative assessment, radical resection was performed. Due to the variation of
the portal vein, the position of P point moved forward to the
rst hilum. During the left half hepatectomy, the liver section
was very close to the right anterior branch of the portal vein,
so it was vital to avoid injury to it during the operation; otherwise, it would result in segments V and VIII ischemia and the
need to perform extended left trisectionectomy.
The intraoperative condition was consistent with the preoperative 3D reconstruction and 3D printed model. The right
anterior branch and the right posterior branch of the portal
vein were protected after extrahepatic separation. The left
branch was further dissected to the left, and the sagittal split
was placed. On examination of the left branch of the portal
vein, it was found that the color of the left half of the liver
was signicantly darker, and the right half of the liver was
normal. The portal vein and hepatic artery were ligated and
cut before performing hemihepatectomy in combination
with caudate lobectomy skeletonization of hepatoduodenal
ligament, right hepatic duct plasty, and Roux-Y jejunostomy.
Pathological diagnosis: cholangiocarcinoma with negative
liver margin.
ab
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16 Digital Diagnosis andManagement ofCholangiocarcinoma
391
16.3.5 Clinical Classication ofHilar
Cholangiocarcinoma Using 3D
Visualization Technology
3D visualization of the liver can be used to perform transparent staining for each segment of the liver, to conceal the
intrahepatic portal vein system, hepatic artery system,
hepatic vein system, to observe the location of bile duct
tumors by means of amplication, reduction, and rotation,
and to understand the situation of vascular invasion through
the classication and observation methods of the intrahepatic
vascular system mentioned-above. Given this, the clinical
classication of 3D visualized hilar cholangiocarcinoma can
be established based on the above clinical classication. It is
mainly divided into 5 types (Fig.16.25).
• Type-I: The tumor invades the common biliary duct, and
does not invade the conuence part of the right hepatic
duct and left hepatic duct, hepatic artery, and portal vein;
there is no liver segment or sector atrophy.
• Type-II: The tumor invades the conuence of right hepatic
duct and left hepatic duct, with/without invasion of
hepatic artery and/or portal vein, without liver segment or
sector atrophy.
• Type-IIIa: The tumor invades the conuence of right
hepatic duct and left hepatic duct, mainly the right hepatic
duct, with invasion of right hepatic artery or right branch
of portal vein, with/without right-sided liver sector and/or
liver segment atrophy.
• Type-IIIb: The tumor invades the conuence of right
hepatic duct and left hepatic duct, mainly the left hepatic
duct, with invasion of left hepatic artery or left branch of
portal vein, with/without left-sided liver sector and/or
liver segment atrophy.
• Type-IVa: The tumor invades the conuence of right
hepatic duct and left hepatic duct, the right-sided second-
Fig. 16.25 Three-dimensional visualization clinical classication for hilar cholangiocarcinoma. (a) Type I; (b) Type II; (c) Type IIIa; (d) Type
IIIb; (e) Type IVa; (f) Type IVb; (g) Type V
392
F. Shen et al.
e
g
f
Fig. 16.25 (continued)
grade biliary duct is involved, with right hepatic artery or
right branch of portal vein invasion; tumor has not spread
beyond the P point, with right-sided liver segment or liver
sector atrophy.
• Type-IVb: The tumor invades the conuence of right
hepatic duct and left hepatic duct, the left-side secondgrade biliary duct is involved, with left hepatic artery or
left branch of portal vein invasion; the tumor has not
spread beyond the U point, with left-sided liver segment
or liver sector atrophy.
• Type-V: The extent of tumor invasion spreads beyond
bilateral resection limitation points; right and left hepatic
arteries, and left branch and right branch of portal vein are
involved, with/without total liver atrophy.
According to the key points of clinical classication such
as Bismuth-Corlette classication and AJCC type, the clinical classication of hilar cholangiocarcinoma by 3D visualization technology can be divided into 5 types, based on the
location of tumor invasion of the bile duct and blood vessel,
as well as the three-dimensional imaging characteristics of
lymph node metastasis.
16.3.6 Accurate Surgical Management ofHilar
Cholangiocarcinoma Guided by 3D
Visualization
16.3.6.1 Therapeutic Schedules Based
ontheClinical Typing of3D
Visualization ofHilar
Cholangiocarcinoma
Type I
Local excision of tumor, Roux-en-Y anastomosis; Lymph
nodes of hepatoduodenal ligament should be dissected. If the
result of frozen section is positive, second-station nodes
should be further dissected.
16 Digital Diagnosis andManagement ofCholangiocarcinoma
393
Type II
Resection of segments IVb, V, and I; lymph nodes of hepatoduodenal ligament should be dissected. If the result of frozen
section is positive, second-station nodes should be further
dissected.
Type IIIa
Right hepatectomy or extended right hepatectomy, resection
of segment I, skeletonization of hepatic hilum, and lymph
node dissection.
Type IIIb
Left hepatectomy or extended left hepatectomy, resection of
segment I, skeletonization of hepatic hilum, and lymph node
dissection.
Type IVa
Adequate Residual Liver Volume Right hemihepatectomy
or even extended right hemihepatectomy.
Inadequate Residual Liver Volume
• Resection of segment IVb, the scope of right hepatic
resection should be determined according to the right
hepatic artery, portal vein involvement; reconstruction of
right hepatic artery and portal vein; resection of segment
I.Otherwise, palliative surgery should be performed.
• Unilateral hepatic artery resection does not require anastomosis and bilateral invasion requires anastomosis of
unilateral hepatic artery; skeletonization of hepatic hilum
and lymph node dissection.
Type IVb
Adequate Residual Liver Volume Left hemihepatectomy
or even extended left hemihepatectomy.
Inadequate Residual Liver Volume Left hemihepatec-
tomy, resection of segments V and I. Skeletonization of
hepatic hilum and lymph node dissection.
Type V
PTC/PTBD biliary drainage or conservative medical treatment is recommended.
Currently, types III and IV hilar cholangiocarcinoma are
common in clinical practice, which requires hemihepatectomy. 3D visualization has obvious guiding value for regular
liver segment resection because it can display various intrahepatic pipeline structures:
• Before operation, the variation of intrahepatic ducts can
be clearly displayed, so that the surgeon can have a better
understanding of it; moreover, the surgeon repeatedly
“rehearses” different surgical schemes by using 3D visu-
alization virtual surgery technology. By comparing the
advantages and disadvantages of different surgical methods or surgical paths, the optimal scheme can be selected.
• Accurately dening the scope of hepatectomy. When the
shape of liver is signicantly changed due to lobar atrophy and hilar transposition in hilar cholangiocarcinoma,
the importance of 3D visualization should be strongly
emphasized.
• Accurately assessing the volume of residual liver.
• Protecting the blood ow of residual liver and bile
drainage.
Regular hepatectomy should not only completely remove
the diseased bile duct tree and the drained liver area, but also
protect the blood ow and bile drainage of the residual adjacent liver segments simultaneously.
Type I-IV are recommended for surgical treatment,
among which for type I–III we strive to achieve R0 resection
in clinic; type IV relates to the above treatment principles
(the basic treatment plans are set based on the 3D visualization clinical classication characteristics of hilar cholangiocarcinoma), type V is recommended for reducing bilirubin
levels or conservative medical management.
16.3.6.2 Typical Case
Case 1
The patient, male, 65years old, was admitted to the hospital
due to “abdominal distension pain for half a month and yellow scleral skin for 10 days.” Admission examination: total
serum bilirubin and conjugated bilirubin were 155.0 and
109.3 μmol/L, respectively; tumor marker: carbohydrate
antigen 19-9 (CA19-9) was 224.5U/mL, which was signicantly increased, and both alpha-fetoprotein and carcinoembryonic antigen were negative. Enhanced CT in the upper
abdomen suggested hilar cholangiocarcinoma and multiple
hilar lymph nodes. It was diagnosed as obstructive jaundice
and hilar bile duct space-occupying lesions. Percutaneous
liver puncture biliary drainage of the right liver was performed on the patient immediately after admission, but the
effect of drainage was not good. The daily biliary drainage
volume was 100–200ml, and the drainage time was 13days.
The preoperative total serum bilirubin increased to
183.6μmol/L.
Imaging Assessment
Enhanced CT showed signicant
thickening of the bile duct wall in the hilum of the liver,
involving the conuence of the left and right hepatic ducts,
the common hepatic duct, and the upper common bile duct.
Mild enhancement was observed in the arterial phase, and
further enhancement in the venous phase. In the venous
394
F. Shen et al.
phase, the wall of the bile duct opening in segment IV of the
liver was thickened and markedly strengthened; the volume
of gallbladder increased, the wall of gallbladder became
thicker and was slightly enhanced. The portal vein and
hepatic artery were not invaded (Figs. 16.26 and 16.27).
Cholangiography showed complete obstruction between left
and right hepatic ducts and common hepatic ducts. The
tumors were Bismuth-Corlette type IIIb and were planned to
undergo combined left hemihepatectomy + total caudate
lobectomy.
The Outcome of 3D Reconstruction The left side of the
tumor involved the secondary bile duct, while the right side
involved the right hepatic duct, and the adjacent hepatic
artery and portal vein were not invaded. Fine right posterior
inferior hepatic veins could be seen. The software simulated
a 10-mm surgical margin, and the left side had exceeded the
cut limit point of the bile duct system. The volume of the
whole liver was 1525 cm3, and that of the right half was
1032cm 3 (67% of the total volume). Measured by 3D reconstruction software. Left hemihepatectomy + total caudate
lobectomy can be safely performed (Figs.16.28, 16.29, and
16.30).
Surgery and Pathology After surgical exploration, it was
found that there were visible hard masses in the hilum of the
liver with extensive involvement on both sides and enlarged
lymph nodes in the hilum of the liver with a hard texture.
Combined with preoperative images, considering that the
main body of the tumor deviated to the left, the resectability
was determined after further exploration. The pancreatic
head and duodenum were freed through Kochel incision. No
Fig. 16.26 CT arterial phase: Hilar enhanced mass (white arrow) with signicant dilation of intrahepatic bile duct; The right hepatic artery (red
arrow) was not invaded by the tumor
Fig. 16.27 CT portal venous phase: The wall of the opening of the bile
duct in segment IV is thickened and markedly enhanced (black arrow),
and the possibility of tumor invasion is considered; the portal vein (blue
arrow) is not invaded by tumor; The upper part of the common bile duct
and the opening of the cystic duct are enhanced and the tube wall is
thickened (white arrow), and the possibility of tumor invasion is
considered
16 Digital Diagnosis andManagement ofCholangiocarcinoma
395
enlarged lymph nodes were found beside the abdominal
aorta when the abdominal aorta was exposed. The gallbladder was removed, the sheath of the common hepatic artery
was cut, and the enlarged lymph nodes around the common
hepatic artery were resected. The gastroduodenal artery, the
proper hepatic artery, the left hepatic artery, the right hepatic
artery, and the middle hepatic artery were dissected from the
proximal end in turn. Meanwhile, the peripheral connective
tissue was dissected from the main portal vein to the hepatic
portal (Fig.16.31). The distal part of the common bile duct
was cut close to the pancreas, ligated proximally, and closed
Fig. 16.28 EDDA IQQA-Liver 3D reconstruction: the tumor (yellow
mass) involves the secondary bile duct on the left and the right hepatic
duct on the right. The adjacent hepatic artery and portal vein are not
involved, and a small right posterior inferior hepatic vein is visible
(white arrow)
with 5-0 PDS continuous suture at the distal part. The traction bile duct was separated from the porta hepatis. It was
found that the main tumor of the porta hepatis was located in
the left hepatic duct, which invaded the origin of the left
branch of the portal vein, and there was no invasion of the
bifurcation of the portal vein and the right branch of the portal vein. After careful separation of the right hepatic artery,
the secondary branch of the right hepatic artery (right anterior and right posterior hepatic artery) is closely related to
the tumor. The secondary branch of the right hepatic artery
was carefully explored and peeled off, and it was found that
the secondary branch of the right hepatic artery was not
invaded by the tumor. We decided to perform left hemihepatectomy plus total caudate lobectomy. The veins and bile
ducts were separated in the hepatic parenchyma with striation forceps, and the left hepatic veins were cut off with a
blood vessel occluder. The right hepatic duct was amputated,
and two bile duct openings were observed at the end of the
amputation, which was right anterior and right posterior bile
duct openings, respectively. Roux-en-Y cholangiojejunostomy was performed to restore bile duct continuity after
plastic surgery.
Anatomical examination of the resected specimens
showed that the tumor had invaded the opening of the segment IV of the hepatic bile duct, which was consistent with
the preoperative imaging evaluation (Fig. 16.32).
Postoperative pathological diagnosis: adenocarcinoma of the
bile duct, grade II-III, tumor inltrated the whole layer of
hepatobiliary duct, involving the surrounding brous connective adipose tissue, and the tumor invaded nerve; no cancer was involved in the incised margin of the liver; gallbladder
tumors were involved; no cancer metastasis was found in the
lymph nodes of group 12 (0/4).
Fig. 16.29 EDDA IQQALiver software simulation:
10mm is set to simulate the
surgical margin, indicating
that the left biliary tract
system is far from the limit
point on the left (U point),
while the tumor is far from
the limit point on the right (P
point)
396
Fig. 16.30 EDDA IQQALiver accurately measures the
volume of each liver segment
F. Shen et al.
Fig. 16.31 Skeletonization of the hepatoduodenal ligament. Note: 1.
Middle hepatic artery; 2. Left hepatic artery; 3. Proper hepatic artery; 4.
Common hepatic artery; 5. Gastroduodenal artery; 6. Main portal vein;
7. Right hepatic artery
Case 2
A 59-year-old woman was admitted to the hospital because
of “upper abdominal distension and pain for more than 20
days, skin and sclera yellowing for one week.” The patient
underwent right knee arthroplasty in 2009. Admission examination: total serum bilirubin and conjugated bilirubin were
168.9μmol/L and 120.6μmol/L, respectively. Tumor marker:
CA19-9 was 127.1U/L, alpha-fetoprotein, and ROR1 were
both negative. Enhanced CT of the upper abdomen suggested
the soft tissue density shadow of the left lobe near the hilum
of the liver, considering the possibility of bile duct carcinoma, accompanied by intrahepatic bile duct dilatation, and
Fig. 16.32 Gross anatomy of a surgically resected specimen. Note: 1.
Right hepatic duct; 2.Common bile duct; 3. Left hepatic duct; 4. IV
segmental bile duct
thickening of the wall of the upper segment of the common
bile duct. It was diagnosed as obstructive jaundice and an
intrahepatic bile duct space-occupying lesion.
Imaging Assessment
Cross-sectional CT images showed
that the main body of the tumor tilted to the left, the left bile
duct system was extensively involved, and tumors invaded
the conuence of the right anterior and right posterior bile
duct; the left portal vein was invaded, and the right portal
vein was stenosed in the initial segment. Tumor invasion was