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Despite current acceptance that combined biliary hepatic resection provides improved survival over isolated ductal resection, several controversies remain. These refer to the concept of inadequate residual hepatic reserve, and the extent of resection required to provide negative margins. The most controversial issue has concerned the extent of resection required to obtain tumour-free surgical margins. Several authors have described portal vein resection with reconstruction. En bloc vascular resection avoids the dissection of tumour-bearing planes, which gives this technique a theoretical advantage.

Our group has also selectively utilized the technique of portal vein resection to achieve negative margins. Several groups have demonstrated success using these techniques without an increase in associated morbidity or mortality. Significant emphasis has been placed on the risk for liver failure associated with an inadequate liver remnant post-resection.

This becomes even more significant when the cholangiocarcinoma is associated with primary sclerosing cholangitis with fibrosis or cirrhosis. To avoid inadequate reserve and the risk of liver insufficiency, our group advocates ensuring a calculated remnant based on a preoperative triphasic CT scan and a preoperative liver biopsy to evaluate the hepatic substance for any evidence of fibrosis or cirrhosis. This figure is based on the transplant experience of the senior author, which implies that ml is considered to represent the minimal graft volume able to provide sufficient hepatic function.

However, this number is only a rough approximation and the decision on what constitutes adequate hepatic parenchyma must be tailored to each patient based on his or her level of hepatic functioning.

We also advocate the use of sealant glues over coil embolization in response to concerns over stapler misfire. Imperative to adequate embolization is the understanding of segment IV collateral flow, and the need for selective embolization of this segment to provide adequate contralateral growth.

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An adequate period of observation, generally of 4—6 weeks, is also required to allow the fullest extent of hepatic hypertrophy. Five patients in the second-era group underwent PVE and four of them went on to receive bile duct excision with concurrent lobectomy and hepaticojejunostomy. In the first era of our study period, these patients would not have been deemed surgical candidates based on inadequate future liver remnant. In the future, PVE is certain to play an increasingly important role in the preoperative preparation of patients with Klatskin's tumour. The final controversy refers to preoperative biliary instrumentation.

Several studies have cautioned that the use of preoperative biliary drainage is associated with an increase in the incidence of postoperative infection, whereas other reports have indicated improvement in the post-resection liver remnant.

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Early in the series, it was our policy to continue biliary drainage for 6—8 weeks. In more recent patients, we have limited the period of drainage to 1—2 weeks preoperatively. In regard to a technical aspect, stenting also provides a clear plane for dissection and leads to localized fibrosis in the stented biliary radicle.

In the present series, stenting represents another factor contributing to the higher resection rates achieved in the second-era patient group. Furthermore, fibrosis of the duct provides better purchase for a subsequent biliary enteric anastamosis. Renewed attempts at liver transplantation in hilar cholangiocarcinoma have been met with newfound enthusiasm.

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Unfortunately, although numerous patients are screened, only a minority are actually eligible for transplantation. Despite the role of chemotherapy in the neoadjuvant protocol for transplantation, no solid clinical evidence exists for the postoperative administration of chemotherapy in patients undergoing resection for hilar cholangiocarcinoma. Some series have demonstrated modest improvements in survival, 46 , 47 but this benefit has never been demonstrated clearly in a large prospective trial.

Over the last two decades, the treatment of hilar cholangiocarcinoma has continued to rest firmly on the same cornerstone: Clear benefit has been observed with the use of an aggressive approach to surgical resection, including concomitant hepatectomy. More uncertain is the use of portal vein resection or pancreatoduodenectomy to achieve tumour-free margins. Advances in interventional radiology, and in percutaneous transhepatic biliary drainage, PVE, anaesthesia and critical care techniques have made the achievement of a higher percentage of R0 resections feasible.

However, even when negative margins cannot be achieved, there is still a survival benefit to patients who undergo surgical resection of all gross disease.

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Despite the renewed hope that other modalities such as transplantation and adjuvant chemoradiotherapy or chemophotodynamic therapy will prove feasible, aggressive resection remains the principal treatment for hilar cholangiocarcinoma. The major limitations of this study refer to its retrospective nature and the fact that it was confined to patients who had been referred for surgical evaluation.

The number of patients who are not referred for surgery is substantial and probably constitutes the majority of patients with hilar cholangiocarcinoma. Including these patients would provide a better estimate of the true resectability rate. Furthermore, it is possible that changes in referral patterns may play a role in the increased rate of resectability seen in the more recent era of the study. National Center for Biotechnology Information , U.

Author information Article notes Copyright and License information Disclaimer. Received Jul 25; Accepted Oct This article has been cited by other articles in PMC. Abstract Objectives In hilar cholangiocarcinoma, resection provides the only opportunity for longterm survival. Methods We conducted a retrospective analysis of consecutive hilar cholangiocarcinoma patients presenting over an year period.

Results Of the patients in the cohort, Conclusions Although R0 resection can be achieved in only a minority of patients, these patients have a reasonable chance of longterm survival. Introduction Early experiences with hilar cholangiocarcinoma, or Klatskin's tumour, were often discouraging. Materials and methods From January to December , consecutive patients with hilar cholangiocarcinoma underwent surgical exploration at the University of Louisville or the University of Cincinnati.

Results Patient presentation Of the consecutive patients evaluated for hilar cholangiocarcinoma, the majority were White males. Table 1 Patient characteristics and comparison by era. Open in a separate window. Diagnostic imaging and preoperative staging Of the patients in whom preoperative brushings were performed, cytology was positive in 39 Operative morbidity and mortality A total of patients were explored for potential resection. Resection and operative margins Univariate analysis revealed era first vs. Table 2 Univariate analysis of factors affecting resection.

Table 3 Univariate analysis of factors affecting the ability to achieve margin-negative resection. R1 R0 P -value Age, years, median range 63 21—88 64 27—88 0. Survival Rates of 1-, 3- and 5-year survival in the first 55 patients were Table 4 Survival rates over 1, 3 and 5 years and median survival. Survival P -value 1-year 3-year 5-year Median, months All patients Table 5 Multivariate Cox proportional hazards analysis of survival. Discussion Historically, hilar cholangiocarcinoma has been considered as a uniformly lethal disease in which expectations for 5-year survival are low.

Conclusions Over the last two decades, the treatment of hilar cholangiocarcinoma has continued to rest firmly on the same cornerstone: Conflicts of interest None declared. Adenocarcinoma of the hepatic duct at its bifurcation within the porta hepatis. An unusual tumour with distinctive clinical and pathological features. Sclerosing carcinoma of the major intrahepatic bile ducts.

Carcinoma of the extrahepatic biliary tract. Carcinoma of the hepatic hilus. Surgical management and the case for resection. Surgical management of carcinoma of the junction of the main hepatic ducts. Jarnagin WR, Shoup M. Surgical management of cholangiocarcinoma. Survival and an overview of decision-making in patients with cholangiocarcinoma. Hepatobiliary Pancreat Dis Int. Proximal bile duct cancer. Aggressive surgical resection for hilar cholangiocarcinoma: Audit of a single centre's experience.

Melanie Tomlin

Surgical management of hilar cholangiocarcinoma: HPB Oxford ; 7: Resection of hilar cholangiocarcinoma: Forty consecutive resections of hilar cholangiocarcinoma with no postoperative mortality and no positive ductal margins: Aggressive surgical approaches to hilar cholangiocarcinoma: Management of hilar cholangiocarcinoma: Treatment of hilar cholangiocarcinoma Klatskin tumours with hepatic resection or transplantation. J Am Coll Surg. Surgery for hilar cholangiocarcinoma: Eur J Surg Oncol. Management of hilar cholangiocarcinoma in the north of England: Proximal bile duct cancer: Longterm survival after resection of proximal bile duct carcinoma Klatskin tumours World J Surg.

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Liver resection for hilar cholangiocarcinoma: Extended resections for hilar cholangiocarcinoma. Major hepatectomy for hilar cholangiocarcinoma type 3 and 4: Improved outcome of resection of hilar cholangiocarcinoma Klatskin tumour Ann Surg Oncol. Olnes MJ, Erlich R. A review and update on cholangiocarcinoma. Surgical management of hilar cholangiocarcinoma. Staging, resectability, and outcome in patients with hilar cholangiocarcinoma. Improved surgical results for hilar cholangiocarcinoma with procedures including major hepatic resection.

Major hepatic resection for hilar cholangiocarcinoma: Longterm outcome of extended hemihepatectomy for hilar bile duct cancer with no mortality and high survival rate. Preoperative portal vein embolization for extended hepatectomy.

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