Surgical resection techniques for locally advanced hilar cholangiocarcinoma

Abstract

Advanced perihilar cholangiocarcinoma requires extended liver resection and often vascular resection, despite which the margin may be compromised in about one third of patients. Right sided tumours are likely to need right trisectionectomy and portal vein resection, best served by an en bloc hilar resection or Rex-recess approach. Left-sided tumours often involve contralateral blood vessels and require left trisegmentectomy with possible right portal vein or right hepatic artery reconstruction. These tumours are best tackled by hepatobiliary surgeons with experience in microvascular techniques. Salvage procedures when arterial reconstruction is not feasible are still under evaluation.

Percutaneous transhepatic biliary drainage may be the preferred preoperative drainage method in hilar cholangiocarcinoma

“…Resection of the hilar tumor with extended hepatectomy offers the best chance for cure. Although HC can be diagnosed at an early stage, the current reported R0 resection rate is less than 30 %, and a reported 5year postoperative survival rate ranges from 30 % to 40 % [6,7].…”

Lymphocyte to Monocyte Ratio Predicts Resectability and Early Recurrence of Bismuth-Corlette Type IV Hilar Cholangiocarcinoma

“…2,3 However, radicle resection for type IV HC is considered to be particularly challenging on account of the complexity of intact resection of locally advanced tumors. 4 Therefore, the resectability rate is poor and the postoperative recurrence is high, as a result of which the survival outcome for HC is unsatisfactory, with the 5-year overall survival rate of 11-40%. [5][6][7] To date, preoperative evaluation of the advancement and resectability of HC is mainly dependent on radiological examination.…”

Liver resection for perihilar cholangiocarcinoma – why left is sometimes right

“…One of the reasons why RLR is preferred over LLR 12 for PHC is the potential need for reconstruction of the RHA to achieve R0 resection status during the latter. 2 Not until Nagino 13 reported 50 patients who underwent combined arterial and portal vein resections for PHC with a 2% operative mortality and 30% 5-year survival, did LLR became more widely performed for Bismuth-Corlette Type IIIb and IV PHC.…”

“…Complete surgical resection provides the best chance of cure for perihilar cholangiocarcinoma (PHC). 1,2 Adequate surgery for this condition requires margin-free resection of the tumour, adjacent lymph nodes, the caudate lobe of liver and varying amounts of liver parenchyma. 2 Although logic dictates that rightsided tumours (Bismuth-Corlette Stage IIIa) should be best treated by right-sided liver resections (RLR), and left-sided tumours (Bismuth-Corlette Stage IIIb) by left-sided liver resections (LLR), the anatomy of the liver hilum causes many surgeons to prefer right hepatectomy or right trisectionectomy even for leftsided PHC whenever possible.…”

“…1,2 Adequate surgery for this condition requires margin-free resection of the tumour, adjacent lymph nodes, the caudate lobe of liver and varying amounts of liver parenchyma. 2 Although logic dictates that rightsided tumours (Bismuth-Corlette Stage IIIa) should be best treated by right-sided liver resections (RLR), and left-sided tumours (Bismuth-Corlette Stage IIIb) by left-sided liver resections (LLR), the anatomy of the liver hilum causes many surgeons to prefer right hepatectomy or right trisectionectomy even for leftsided PHC whenever possible. The long, extra-hepatic course of the left hepatic duct and the left portal vein make it easier to achieve tumour clearance on the hepatic duct and to perform portal vein resection respectively during right hepatectomy or right trisectionectomy.…”