About Dr. Qian Xuefeng
Dr. Qian Xuefeng is a hepatobiliary surgeon at Eastern Hepatobiliary Surgery Hospital (东方肝胆外科医院), Naval Medical University — one of China's foremost specialist centres for liver, gallbladder, and biliary disease. He specialises in complex liver resections, biliary stricture reconstruction, and minimally invasive hepatobiliary surgery in high-risk patients. Dr. Qian is recognised for his precision surgical technique in ICG fluorescence-guided hepatectomy, vessel skeletonisation, and high-level hepaticojejunostomy, and his team's outcomes in laparoscopic management of combined hepatolithiasis and biliary malignancy are among the most documented in China.
Case Overview
A 62-year-old woman with a 5-year history of recurrent right upper quadrant pain and fever, and a 1-month history of progressive jaundice, was diagnosed with left intrahepatic cholangiocarcinoma (cT2N0M0) superimposed on complex hepatolithiasis and biliary stricture. Her background included prior open cholecystectomy (10 years earlier) and type 2 diabetes. Enhanced CT and MRI demonstrated left hepatic atrophy-hypertrophy complex, a 3.5 x 4.0 cm arterially enhancing mass at the B2/B3 bile duct confluence, and severe left hepatic duct stricture with upstream stone burden. CA19-9 was markedly elevated at 185 U/mL; total bilirubin 85 μmol/L. Following pre-operative biliary drainage (PTCD) to reduce bilirubin below 50 μmol/L, Dr. Qian Xuefeng performed fully laparoscopic extended left hepatectomy with ICG fluorescence navigation, vessel skeletonisation, and Roux-en-Y hepaticojejunostomy with intraluminal stent support. R0 resection was achieved; operative time 280 minutes; blood loss 200 mL with no transfusion. Pathology confirmed moderately differentiated intrahepatic cholangiocarcinoma with negative hepatic and biliary margins; 1 of 5 hilar lymph nodes showed micrometastasis (pN1). At 6-month follow-up, the patient was jaundice-free, weight-restored, and CA19-9 had normalised.
Patient Background
- Age / Sex: 62-year-old female
- Chief Complaint: Recurrent right upper quadrant pain with fever for 5 years; progressive jaundice for 1 month
- Surgical History: Open cholecystectomy for gallstone disease 10 years prior; dense adhesions anticipated at the hepatic hilum
- Medical History: Type 2 diabetes mellitus — adequately controlled
- Physical Examination: Moderate scleral and cutaneous jaundice; right upper quadrant tenderness; Murphy's sign negative; liver palpable 3 cm below the costal margin, firm in consistency
- Laboratory Results: CA19-9 185 U/mL (markedly elevated); CEA normal; total bilirubin 85 μmol/L; direct bilirubin 60 μmol/L; ALP and GGT significantly elevated
Imaging and Pre-operative Assessment
Enhanced CT / MRI
- Atrophy-hypertrophy complex: Left lateral lobe atrophy with compensatory right hepatic hypertrophy — consistent with chronic left biliary obstruction
- Mass lesion: Left intrahepatic bile duct (B2/B3 segments) — soft tissue mass approximately 3.5 x 4.0 cm; arterial phase enhancement with delayed washout — imaging characteristics consistent with intrahepatic cholangiocarcinoma (ICC)
- Biliary involvement: Left hepatic duct confluence stricture with upstream biliary dilatation and multiple intrahepatic stones
- Vascular relationship: Tumour in close proximity to the left portal vein branch and left hepatic artery — no definitive encasement identified; resectability confirmed
MRCP (Magnetic Resonance Cholangiopancreatography)
- Left hepatic duct cut-off sign clearly demonstrated
- Right hepatic duct system well-opacified; confluence stricture severe
- Findings confirmed the need for extended left hepatectomy with high-level biliary reconstruction
Pre-operative Diagnosis
- Primary: Left intrahepatic cholangiocarcinoma — clinical stage cT2N0M0
- Biliary: Left intrahepatic hepatolithiasis with biliary stricture
- Systemic: Obstructive jaundice
Clinical Decision Making and Surgical Planning
Three compounding surgical challenges defined this case:
- Re-operative field: Prior open cholecystectomy with anticipated dense adhesions at the hepatic hilum and between the liver and abdominal wall
- Obstructive jaundice and impaired hepatic reserve: Total bilirubin of 85 μmol/L substantially elevated operative mortality risk — direct surgery carried a high probability of post-operative liver failure
- High-level biliary reconstruction: Following tumour resection, the residual right hepatic duct orifice would be narrow, high, and anatomically challenging — tension-free, stricture-free anastomosis to a jejunal limb represented the critical technical endpoint
Dr. Qian Xuefeng's operative strategy: This patient is in obstructive jaundice. Direct surgery carries unacceptably high mortality. We must proceed in a staged approach. I have decided on fluorescence-guided laparoscopic extended left hepatectomy with bile duct exploration and Roux-en-Y hepaticojejunostomy. Our strategy: pre-operative biliary decompression via PTCD to bring bilirubin below 50 μmol/L before surgery; minimally invasive approach using laparoscopic magnification for precise dissection of the first, second, and third hepatic hila; ICG fluorescence imaging to demarcate the hepatic transection line in real time; vessel skeletonisation at the portal vein to ensure complete vascular clearance; and high-level bile duct plasty with intraluminal stent support to prevent anastomotic stricture.
Surgical Procedure
Approach: Fully laparoscopic extended left hepatectomy + hilar lymph node dissection + bile duct exploration + Roux-en-Y hepaticojejunostomy
Operative time: 280 minutes
Estimated blood loss: 200 mL (no transfusion required)
Step 1 — Adhesiolysis and Abdominal Exploration
Trocar placement was planned to avoid the prior midline scar. Pneumoperitoneum was established safely, and the laparoscope was used to systematically divide dense adhesions between the abdominal wall, liver surface, and hepatoduodenal ligament — with careful protection of the inferior epigastric vessels throughout.
Step 2 — ICG Fluorescence-Guided Hepatic Transection
Intravenous ICG (0.5 mg/kg) was administered intraoperatively. Under near-infrared fluorescence imaging, the demarcation line between the ischaemic left lobe and the perfused right lobe was clearly delineated in real time. Hepatic parenchymal transection was performed along the fluorescence boundary, with precise preservation of the right anterior sectoral portal blood supply.
Dr. Qian's operative note: Fluorescence imaging functions as intraoperative GPS — particularly in an atrophic lobe where anatomical landmarks are distorted. It allows us to navigate the transection plane with confidence, protecting the ductal and vascular architecture of the remnant liver.
Step 3 — Hilar Vascular Control
At the hepatoduodenal ligament, the left hepatic artery and left portal vein branch were individually dissected, ligated, and divided under laparoscopic magnification. Where tumour was found adherent to the portal vein trunk, a tunnel dissection technique using an ultrasonic scalpel and bipolar coagulation was employed — establishing a bloodless plane between the tumour and the portal vein wall, preserving portal vein integrity throughout.
Step 4 — Bile Duct Resection and Reconstruction (Critical Step)
The diseased left hepatic duct and tumour were resected en bloc. Intraoperative frozen section of the biliary margin was performed and confirmed negative. Biliary reconstruction proceeded as follows:
- A jejunal limb was divided 15 cm distal to the ligament of Treitz; the distal end was closed
- The jejunal limb was brought retrocolic to the hepatic hilum for a tension-free anastomosis
- Hepaticojejunostomy technique: Continuous suture with interrupted reinforcement — the high-level, narrow right hepatic duct orifice was first shaped by ductoplasty to create an adequate anastomotic circumference; three silicone stent tubes were placed intraluminally across the anastomosis to maintain patency and prevent post-operative stricture formation
Dr. Qian's operative note: Anastomotic stricture is the most feared long-term complication of hepaticojejunostomy. The solution lies in two principles: adequate jejunal limb mobilisation to eliminate tension, and high-level ductoplasty to create a wide, well-vascularised anastomotic orifice. Routine intraoperative choledochoscopy and stent placement are non-negotiable in our practice.
Pathology and Post-operative Recovery
Final Pathology Report
- Histology: Moderately differentiated intrahepatic cholangiocarcinoma; tumour size 4 cm
- Resection margins: Hepatic parenchymal margin and biliary margin both negative — R0 resection confirmed
- Lymph nodes: 1 of 5 hilar lymph nodes with micrometastasis — pN1 disease
Post-operative Course (ERAS Protocol)
- Day 1: Nasogastric tube removed; patient mobilised with assistance
- Day 2: Independent ambulation commenced
- Day 3: Liquid diet initiated
- Biliary complication: Grade B bile leak identified — managed conservatively via abdominal drain; resolved without re-intervention
- Week 1: Total bilirubin normalised
Follow-up
- 2-month CT: Right hepatic compensatory hypertrophy confirmed; no evidence of recurrence
- 6-month assessment: Patient jaundice-free; weight restored to pre-illness baseline; CA19-9 normalised
Extended Case: Iatrogenic Bile Duct Injury Repair
Dr. Qian Xuefeng's expertise in biliary reconstruction extends beyond oncological resection to the management of iatrogenic bile duct injuries — one of the most technically demanding scenarios in hepatobiliary surgery.
A 50-year-old woman sustained a common bile duct injury during laparoscopic cholecystectomy at an outside institution, resulting in bile leak and peritonitis. Dr. Qian's management strategy:
- Timing: Initial management with antibiotics and percutaneous drainage; definitive repair deferred 6 weeks until inflammation had fully resolved
- Operative approach: Laparoscopic end-to-end bile duct anastomosis or Roux-en-Y hepaticojejunostomy, selected based on intraoperative findings
- Technical challenge: Dense inflammatory scarring with loss of normal anatomical planes; intraoperative choledochoscopy used to confirm absence of intrahepatic stone burden and to guide wire placement for anastomotic orientation
- Outcome: Stent tubes removed at 3 months post-operatively; patient avoided long-term T-tube drainage; quality of life fully restored
Expert Commentary — Dr. Qian Xuefeng
1. Minimally Invasive Surgery: Precision Is the Goal, Not the Approach
For complex hepatolithiasis combined with biliary malignancy, laparoscopic surgery demands a high level of technical mastery. However, when three-dimensional anatomical visualisation and vessel skeletonisation techniques are applied correctly, minimally invasive hepatectomy consistently achieves lower blood loss and complication rates than open surgery — while preserving immune function in the immediate post-operative period and creating optimal conditions for adjuvant chemotherapy. The laparoscope is not a shortcut. It is a precision instrument that amplifies surgical judgment.
2. The Zero-Tension Principle in Biliary Reconstruction
Anastomotic stricture is the defining long-term complication of hepaticojejunostomy. Its prevention depends on two non-negotiable principles: sufficient jejunal limb length to eliminate anastomotic tension, and high-level ductoplasty to create a wide, well-vascularised orifice. Our team routinely employs intraoperative choledochoscopy and intraluminal stent placement as standard practice — not as salvage measures. The anastomosis must be built to last decades, not months.
3. Multimodal Treatment in Biliary Cancer
Surgical resection alone carries a high recurrence rate in intrahepatic cholangiocarcinoma. For this patient — with pN1 lymph node micrometastasis — we recommended adjuvant gemcitabine plus cisplatin (GC regimen) chemotherapy for 6 months following recovery. For patients with positive margins or nodal disease, our centre is actively enrolling in clinical trials evaluating PD-1 immune checkpoint inhibitors as adjuvant therapy, with the goal of improving long-term survival beyond what chemotherapy alone can achieve.
4. ERAS in Major Hepatobiliary Surgery
Through pre-operative nutritional optimisation, intraoperative normothermia, early post-operative mobilisation, and multimodal analgesia, our centre has reduced the mean hospital stay for major hepatobiliary procedures to 7–9 days. A decade ago, this was not considered achievable. ERAS is not a protocol — it is a philosophy of care that begins at the pre-operative consultation and ends only when the patient has returned to full functional independence.
How CMCS Shanghai Coordinated This Case
China Medical Concierge Shanghai (CMCS) supported this patient's care pathway from initial overseas inquiry through 6-month oncological follow-up. Our coordination included:
- Pre-arrival review of imaging, laboratory results, and prior operative records; specialist referral to Dr. Qian Xuefeng's hepatobiliary team at Eastern Hepatobiliary Surgery Hospital, Naval Medical University
- Arrangement of enhanced CT, MRI, and MRCP for complete pre-operative staging and biliary mapping
- Coordination of pre-operative PTCD biliary drainage: interventional radiology scheduling, drain management guidance, and serial bilirubin monitoring until surgical threshold was reached
- Bilingual interpretation during the surgical planning consultation, including detailed explanation of the staged approach rationale, ICG fluorescence technique, vessel skeletonisation, and Roux-en-Y reconstruction options
- Surgical admission logistics: hospital registration, operative suite scheduling, and accommodation support for accompanying family members
- On-site medical interpretation throughout the hospitalisation, including ERAS protocol guidance, drain management, and early mobilisation support
- Post-discharge coordination of CA19-9 and liver function surveillance, 2-month CT scheduling, and communication with the patient's home physician for ongoing monitoring
- Adjuvant chemotherapy coordination: oncology referral for GC regimen initiation, cycle scheduling, and toxicity monitoring liaison with Dr. Qian's team
- Stent tube removal coordination at 3 months: choledochoscopy scheduling and post-procedure biliary patency assessment
For international patients facing complex hepatobiliary disease — particularly those with combined biliary malignancy and stone burden, prior abdominal surgery, or iatrogenic bile duct injuries — the combination of ICG fluorescence navigation, vessel skeletonisation expertise, and high-level biliary reconstruction at Shanghai's leading hepatobiliary centres represents a standard of care that may not be available in their home country. CMCS exists to connect patients with that expertise: ensuring every staging option is explored, every surgical decision is explained in their language, and every step from pre-operative drainage to long-term oncological follow-up is coordinated with precision and care.
This case report is de-identified and published for educational purposes. All clinical details have been anonymized in accordance with patient privacy standards. CMCS Shanghai is a medical concierge service and does not provide direct medical care.
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