Hepatocellular Carcinoma With Bile Duct Tumor Thrombus: Extrahepatic Bile Duct Preserving or Not? Reply

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To the Editor:
We would like to thank Xu et al for their comments on our article1 describing the operative techniques for hepatocellular carcinoma (HCC) with a bile duct tumor thrombus (BDTT) and their usefulness. Four major points were raised in this letter.
First, Xu et al points out that the recurrence rate of 67% was too high. According to a previous report,2 however, the 3-year recurrence rate, in general, after surgical resection for HCC is more than 70%, regardless of the presence or absence of BDTT. In our opinion, 67% was not so high as compared with the reported average. In fact, Xu et al have also reported a recurrence rate of 56.8%,3 which is almost similar to our results. As BDTT is regarded as one of the phenotypes of vascular invasion suggestive of an advanced tumor status and is associated with a very high risk of recurrence, it is difficult to conclude that our policy of bile duct preservation may have increased the rate of tumor recurrence.
Second, Xu et al has raised a concern about the possibility of direct invasion of the bile duct wall. We fully agree that sharp detachment of a BDTT from the bile duct wall should be avoided at the point of direct invasion. However, the tip of the BDTT and the point of division of the bile duct were distant from the area of direct invasion in our cases, which is theoretically acceptable.
Third, Xu et al has raised a question about the risks of local recurrence and development of another BDTT potentially arising from remnant tumor cells in the bile duct. We understand the possibility of intraluminal tumor seeding; however, there was no case with this type of recurrence in any of the cases in our series, as we have mentioned in our report. In all cases, we thoroughly washed the bile duct lumen by normal saline infused via a catheter placed in the common bile duct via the cystic duct, which is also described in our report. We consider that this procedure is effective to prevent local recurrence and development of another BDTT.
Finally, Xu et al has opined that repeat resection would be more effective than our policy of bile duct preservation. We would like to emphasize that the purpose of bile duct preservation favored by us is not to prevent repeat liver resection. In fact, quite the contrary, we have been aggressively performing repeat liver resection for recurrent HCC4 and repeat liver resection may be technically easier after bile duct-preserving surgery than that after bilioenteric anastomosis, because of the fewer postoperative adhesions. Actually, we performed repeat resection in 3 of the 10 cases with recurrence in this series.1 However, with the high risk of development of unresectable recurrence in these cases, because BDTT is generally indicative of advanced malignancy, it is important to keep the possibility open for as many potentially effective second-line therapeutic options as possible, such as radiofrequency ablation and transcatheter hepatic arterial chemoembolization, by preserving the bile duct. We would therefore like to reassert that our peeling-off technique would be useful to obtain noninferior short-term outcomes and offer the patients a better chance for effective second line treatment options.

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