Surgical treatment of hilar cholangiocarcinoma in the new era: the Asan experience

Abstract

Background/purpose Both curative resection and minimized in-hospital mortality offer the only chance of longterm survival in patients with hilar cholangiocarcinoma. The reported resectability rates for hilar cholangiocarcinoma have increased by virtue of combined major hepatectomy, but this procedure is technically demanding and still associated with a significant morbidity and mortality that must be carefully balanced against the chances of longterm survival. Methods Between January 2001 and December 2008, 350 patients with hilar cholangiocarcinoma underwent exploration for the purpose of potentially curative resection, of whom 302 (86.3%) were resected in the Department of Hepato-Biliary Surgery and Liver Transplantation, Asan Medical Center, University of Ulsan College of Medicine. Combined hepatectomy was carried out in 268 (88.7%) of 302 resected patients. Major hemihepatectomy and parenchyma-preserving hepatectomy were performed in 257 and 11 patients, respectively. Portal vein resection was associated in 40 (14.9%) of 268 hepatectomized patients.To control preoperative cholangitis and reduce risk of postoperative hepatic failure, biliary decompression through endoscopic and/or percutaneous transhepatic drainage and portal vein embolization were preoperatively applied in 329 (94.0%) of 350 explored patients and in 91 (54.2%) of 168 extended hepatectomized patients (154 right hemihepatectomy, 9 right trisectionectomy, 5 left trisectionectomy), respectively. Liver transplantation was not performed as primary treatment for hilar cholangiocarcinoma. Results There were 5 cases (1.7%) of in-hospital death after resection and 1 postoperative liver failure that was successfully treated with liver transplantation. Major complications were encountered in 23 patients (7.0%), and the overall morbidity rate was 43%. In 302 resections, 214 (70.9%) were curative resections (R0) and 88 (29.1%) were palliative resections (R1). The overall 1-, 3-and 5-year survival rates after resection, including in-hospital deaths, were 84.6, 50.7 and 47.3% in the R0 group and 69.9, 33.3 and 7.5% in the R1 group, respectively. The 5-year survival rate of extended hemihepatectomy of 36.4% was better than that of parenchyma-preserving hepatectomy at 10.5%. Two significant predictive factors adversely affecting survival after resection were lymph node metastasis and incurability of surgery (P \ 0.001). Two patients with vascular involvement who underwent concomitant hepatic artery and portal vein reconstruction are alive after more than 3 years. Conclusion Preoperative biliary decompression and portal vein embolization enabled us to reduce in-hospital deaths associated with extended hepatectomy for hilar cholangiocarcinoma. Major hemihepatectomy offers an increased survival because of the higher possibility of curative resection than bile duct resection alone and parenchyma-preserving hepatectomy, but it still carries a certain mortality. Less extensive procedures can be

Clinical practice guidelines for the management of biliary tract cancers 2015: the 2nd English edition

“…Several reports also showed that PVE enables surgical resection in cases that are initially considered as unresectable due to the shortage of future remnant liver volume [123]. However, the indication of PVE differs by institutions and no consensus exists [72,[123][124][125][126][127][128][129][130][131][132][133].…”

“…In many studies, the prognosis of patients who received combined PVR is poorer than that of patients who undergo surgical resection without PVR. However, the majority of these studies also show the prognosis of patients treated with combined PVR is significantly longer than the prognosis of unresected patients, especially in patients with hilar/upper bile duct carcinoma [71,72,74,116,155,156]. According to these reports, PVR is a safe procedure and may contribute to longer survival for patients with biliary tract cancers invading portal vein, although there is no prospective study for estimating the benefit of PVR.…”

Curative-intent Surgery for Perihilar Cholangiocarcinoma with and without Portal Vein Resection - A Comparative Analysis of Early and Late Outcomes

“…A negative resection margins surgery represents the most important determinant of survival in patients with PHC (5)(6)(7)(8). The curative-intent surgery for PHC has significantly changed over the years from simple bile duct resection (1,9,10) to more complex surgical procedures (5,8,11).…”

“…The curative-intent surgery for PHC has significantly changed over the years from simple bile duct resection (1,9,10) to more complex surgical procedures (5,8,11). Thus, nowadays, a curative-intent surgery for PHC includes bile duct resection, loco-regional lymph nodes dissection, caudate lobectomy and, usually, a major hepatectomy (3,5,8,11,12). These complex surgical procedures were associated with significantly improved long-term survival rates compared with simple bile duct resection (13), however, at the expense of increased morbidity rates and relatively high mortality rates (8).…”

“…A multidisciplinary approach in experienced surgical centers is mandatory to mitigate both morbidity and mortality rates and to obtain improved survivals in patients with PHC (3,5,8,11,14,15). A PHC should be preoperatively differentiated from a benign Klatskin-mimicking lesion to avoid unnecessary extensive resections, albeit the differentiation between the two entities remains challenging (16).…”