Surgical Therapy for Perihilar Cholangiocarcinoma: State of the Art

Abstract

<b><i>Background:</i></b> Surgical therapy still offers the only chance of long-term survival for patients with perihilar cholangiocarcinoma (pCCA). The aim of this narrative review is to summarize the current standards and challenges in the surgical treatment of pCCA. <b><i>Summary:</i></b> After imaging and defining resectability, the first step towards optimal surgical treatment is optimizing biliary drainage and preventing cholangitis, followed by securing adequate future liver remnant volume and/or function. The main goal of resection for pCCA is achieving radical resection and ultimately long-term survival. In order to achieve radical resection, several points will be addressed (e.g., vascular resection and reconstruction, intraoperative frozen sections, right versus left hemihepatectomy, and the usefulness of preoperative [chemo]therapy). <b><i>Key Messages:</i></b> In order to optimize long-term outcomes for patients with pCCA, collaboration between leading centers should be increased. In addition, this collaboration is necessary to design large prospective randomized controlled trials, as the incidence of pCCA is low and the number of resectable patients is even lower. Currently, most results are based on small retrospective cohort studies resulting in low evidence. In order to properly investigate how to improve long-term survival, we need to set up trials to confirm the results of small series suggesting the positive effect of preoperative chemotherapy and extended lymph node resection.

Parenchyma-Preserving Hepatectomy in Perihilar Cholangiocarcinoma: A Chance for Critical Patients?

“…There are mainly two options to reduce the risk of PHLF. Deploying all available techniques to enhance FLR function by utilizing hypertrophy methods or adopting the extent of resection, hence minimizing sacrifice of liver parenchyma [25][26][27]. Both methods are extensively used in our centre.…”

National consensus on a new resectability classification for perihilar cholangiocarcinoma - A modified Delphi method

“…In the Netherlands, CT scans are the preferred modality as it comes to arterial involvement [30,31]. Currently the addition of 3D reconstruction of the most important vascular structures to clarify involvement is investigated [32]. Consensus was found on the following statement; If a short arterial segment is involved, a tumor could also be considered resectable as long as it was reconstructable without an interposition graft.…”

Timeline of FDA-Approved Targeted Therapy for Cholangiocarcinoma

“…In recent decades, several modes of treatments have been utilized to fight CCA. Depending on the type of CCA and the locality of the disease, surgical resection remains a treatment option with long-term survival [ 20 ]. This includes liver transplantation which has treated hepatobiliary malignancies with significantly improved outcomes [ 21 , 22 , 23 , 24 ].…”