Surgical Technique and Feasibility of Pancreaticoduodenectomy after Surgery for Perihilar Cholangiocarcinoma.

Abstract

Background: Standard treatment for perihilar cholangiocarcinoma (PHCC) involves major hepatectomy with caudate lobectomy and biliary-enteric reconstruction (Ann Surg. 258:129-140; Ann Surg Oncol. 29:6759-6771). Some patients may develop recurrence or second primary malignancies involving the intrapancreatic bile duct (J Am Coll Surg. 221:1041-1049; Surgery. 163:732-738). In selected cases, re-resection including pancreaticoduodenectomy (PD) may offer a valuable treatment option (Ann Surg. 262:121-129). However, reports of PD following prior PHCC surgery are extremely limited, and the technical aspects have not been systematically described (J Gastrointest Surg. 2015:19(12):2138-2145; J Med Case Rep. 2016:10(1):299).

Methods: Between January 2012 and May 2025, five patients underwent PD after previous PHCC surgery. Operative videos and records were reviewed to assess characteristic technical elements, including adhesiolysis around the hepaticojejunostomy, mesenteric dissection with preservation of the jejunal limb blood supply, and complex reconstruction strategies. Postoperative outcomes were collected from medical records. Based on these data, we evaluated the technical feasibility of PD in this setting and proposed a classification of reconstruction patterns.

Results: PD was successfully completed in all five cases. The median operative time was 463 minutes, and the median blood loss was 1155 mL. No complications of Clavien-Dindo grade III or higher occurred. The original hepaticojejunostomy was preserved in all cases. In four cases, the existing afferent limb was used for pancreaticojejunostomy (Child or Whipple type). In the remaining case, a new elevated jejunal limb was created for double-tract reconstruction.

Conclusion: PD after prior PHCC surgery is technically feasible and can be safely performed. The proposed classification, along with the surgical video, may provide practical guidance for preoperative planning and intraoperative decision-making (see supplementary Figure 1).