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We report a case of successful right hepatectomy plus pancreatoduodenectomy (Rt-HPD) with arterial reconstruction for extrahepatic bile duct carcinoma with obstruction of the celiac axis in a 76-year-old man. Obstruction of the celiac axis resulted in arterial blood supply to the upper abdominal organs coming from the pancreatic head arcade. The patient underwent arterial reconstruction before the Rt-HPD to maintain the blood supply from the pancreatic head arcade for as long as possible. His postoperative course was uneventful and he was well with no sign of recurrence when last seen, 64 months after surgery. To our knowledge, this is the first description of this modified HPD with arterial reconstruction. Thus, rational surgical planning based on careful preoperative assessment would expand the indications for HPD, even for patients with celiac axis obstruction requiring arterial reconstruction.

Purpose: The hepatic vein (HV) can be removed during hepatectomy if there is an effective intrahepatic veno-venous shunt (vv-shunt). We evaluated the efficacy of vv-shunt detection by three-dimensional (3D) venography reconstructed from multidetector-row computed tomography (MDCT) during angiography., Methods: 3D venography was reconstructed using computer software in 88 patients with intrahepatic tumors., Results: We found that 12 patients had one shunt [4 right hepatic vein (RHV)-middle hepatic vein (MHV) and 12 RHV- inferior right hepatic vein (IRHV)] and 1 patient had 2 shunts (RHV-MHV and -IRHV), confirming a clinically efficient vv-shunt in 14.8% of the patients. In one patient with an RHV-IRHV shunt, the preserved RHV-IRHV shunt worked well and prevented congestion of the postero-caudal subsegment after central bisegmentectomy with partial resection of the RHV ventral trunk for huge hepatocellular carcinoma (HCC)., Conclusions: Although the vv-shunt detection rate by 3D venography is low, a visualized vv-shunt proved to be efficient. Thus, invasive occlusion venography is avoidable if a vv-shunt is seen on 3D venography.

A 70-year-old man presented with a mass-forming perihilar cholangiocarcinoma in his left liver, and both the portal trunk and proper hepatic artery were involved by the tumor. We performed a hepato-ligamento-pancreatoduodenectomy (HLPD), including an extended left lobectomy with a caudate lobectomy, and the external iliac vein graft was harvested for portal vein reconstruction while the right middle colic artery was anastomosed to the right posterior hepatic artery. Vascular involvement (portal vein and hepatic artery) and peripancreatic lymph node metastases were proven histologically. Although the liver abscess and pancreatic fistula both occurred postoperatively, the patient is now healthy and still alive 3 years 9 months after surgery without recurrence. We consider that the absence of para-aortic lymph node metastases and hepatic invasion which is not involved beyond the second order of the hepatic ducts in the future remnant liver might therefore have contributed to the satisfactory outcome after performing HLPD in this case.