Hilar cholangiocarcinoma: Controversies on the extent of surgical resection aiming at cure

Abstract

BackgroundHilar cholangiocarcinoma is the most common malignant tumor affecting the extrahepatic bile duct. Surgical treatment offers the only possibility of cure, and it requires removal of all tumoral tissues with adequate resection margins. The aims of this review are to summarize the findings and to discuss the controversies on the extent of surgical resection aiming at cure for hilar cholangiocarcinoma.MethodsThe English medical literatures on hilar cholangiocarcinoma were studied to review on the relevance of adequate resection margins, routine caudate lobe resection, extent of liver resection, and combined vascular resection on perioperative and long-term survival outcomes of patients with resectable hilar cholangiocarcinoma.ResultsComplete resection of tumor represents the most important prognostic factor of long-term survival for hilar cholangiocarcinoma. The primary aim of surgery is to achieve R0 resection. When R1 resection is shown intraoperatively, further resection is recommended. Combined hepatic resection is now generally accepted as a standard procedure even for Bismuth type I/II tumors. Routine caudate lobe resection is also advocated for cure. The extent of hepatic resection remains controversial. Most surgeons recommend major hepatic resection. However, minor hepatic resection has also been advocated in most patients. The decision to carry out right- or left-sided hepatectomy is made according to the predominant site of the lesion. Portal vein resection should be considered when its involvement by tumor is suspected.ConclusionThe curative treatment of hilar cholangiocarcinoma remains challenging. Advances in hepatobiliary techniques have improved the perioperative and long-term survival outcomes of this tumor.

Is intraoperative frozen section analysis of the proximal bile ducts in hilar cholangiocarcinoma of limited value?

“…Even though the intraoperative assessment of bile duct margin clearance is a useless prognostic marker for patients undergoing resection for HCCA in few reports, frozen section analysis of bile duct margins is the most used method to guide the extent of surgical resection for HCCA. The accuracy, sensitivity, and specificity of 89, 68, and 97%, respectively, of intraoperative FS in this study are higher than those of 56.5, 75.0, and 46.7% reported by Okazaki et al. except sensitivity.…”

“…Even though the intraoperative assessment of bile duct margin clearance is a useless prognostic marker for patients undergoing resection for HCCA in few reports, frozen section analysis of bile duct margins is the most used method to guide the extent of surgical resection for HCCA. [2] The accuracy, sensitivity, and specificity of 89, 68, and 97%, respectively, of intraoperative FS in this study are higher than those of 56.5, 75.0, and 46.7% reported by Okazaki et al [3] except sensitivity. It suggests us that these are unlikely to be totally objective, besides the specific pathologic features of the tumor, these are determined by different Abstract Mantel et al showed that the use of intraoperative frozen section analysis of the proximal bile ducts has a limited contribution in obtaining secondary R0 resections and final resection status had no impact on recurrence rate in hilar cholangiocarcinoma.…”

“…However, it has been demonstrated that tumor‐free resection margin (R0) is the most prognostic factor for survival, as well as the only factor that can be modified by the surgeons . For patient who can be further resected, 54 to 83% can achieve R0 resection . The reason of additional resection does not improve the survival probably lies in the limited additional resection of a margin‐positive proximal bile duct <5 mm .…”

Bile duct surgery in the treatment of hepatobiliary and gallbladder malignancies: effects of hepatic and vascular resection on outcomes

“…Over the last two decades, several studies have demonstrated improved survival in patients with hilar cholangiocarcinoma treated with bile duct resection and major hepatic resection as a result of increased R0 resection rates . A recent analysis of hilar cholangiocarcinoma resected with combined major hepatic resection demonstrated a positive correlation with the tumour‐free resection margin rate . Reported rates of postoperative morbidity and mortality ranged from 6% to 52% and from 2% to 12%, respectively .…”

Comprehensive management of cholangiocarcinoma: Part II. Treatment

“…A recent meta-analysis found mortality after hepatectomy for PCC of 3.7%. 81,82 The 5-year survival, although longer, has not been significantly different in R0 and R1 resections. 83,84 Achievement of R0 and R1 surgical margins in non-metastatic disease has been associated with median survival of 40-74 months and 9-24 months respectively in some studies.…”