Applying liver transplant techniques in complex liver resection for patients with hilar cholangiocarcinoma: in situ hypothermic portal perfusion without VV bypass.

backgroundBismuth-Corlette type IV hilar cholangiocarcinoma (HCCA) with invasion beyond the bifurcation of the anterior and posterior branches of the right portal vein, defined as the P-point, poses a significant challenge for radical resection due to its extensive involvement of the biliary ducts and vascular structures. However, radiotherapy and chemotherapy provide limited response rates for such HCCA patients. Based on the Mayo Clinic protocol, neoadjuvant chemotherapy combined with living donor liver transplantation has shown better prognosis in Bismuth-Corlette type IV HCCA, the shortage of donor livers and high costs are major obstacles. Radical resection remains crucial for Bismuth-Corlette type IV HCCA. Ex vivo liver resection and autotransplantation complicates vascular reconstruction for patients with portal vein invasion, while in situ hypothermic perfusion enables tumor resection with total blood flow occlusion, minimizing bleeding and aiding recovery. For patients needing liver vascular exclusion over 60 min, especially with chronic liver disease, hypothermic perfusion is recommended. Therefore, our team attempted to explore the feasibility of in situ hypothermic perfusion techniques in treating Bismuth-Corlette type IV HCCA with invasion beyond the P point of the portal vein. CASE PRESENTATION: We report a case of radical resection of Bismuth-Corlette type IV HCCA with invasion beyond the P point of the portal vein achieved through in situ hypothermic perfusion technique. Preoperative neoadjuvant therapy was administered with gemcitabine plus cisplatin for four cycles. Radical resection of the lesion and vessels took 10.5 h, with 90 min of liver ischemia. Postoperative pathology showed well-differentiated HCCA, 4.5 × 4.3 cm, negative microvascular invasion, margins > 5 mm, and no lymph node metastasis. The patient recovered well, had no major complications, was discharged after 14 days, and follow-up showed CA199 reduced to 136 U/mL. Chemotherapy started two months later with gemcitabine and oxaliplatin for four cycles. The patient has been monitored for two years without recurrence or complications.

conclusionThis case demonstrates that in situ hypothermic perfusion techniques can achieve radical resection of Bismuth-Corlette type IV HCCA with invasion beyond the P point of the portal vein. This surgical approach broadens the surgical treatment options for Bismuth-Corlette type IV HCCA and similar malignancies.