Surgical strategy for bile duct cancer: Advances and current limitations

Abstract

The aim of this review is to describe recent advances and topics in the surgical management of bile duct cancer. Radical resection with a microscopically negative margin (R0) is the only way to cure cholangiocarcinoma and is associated with marked survival advantages compared to margin-positive resections. Complete resection of the tumor is the surgeon's ultimate aim, and several advances in the surgical treatment for bile duct cancer have been made within the last two decades. Multidetector row computed tomography has emerged as an indispensable diagnostic modality for the precise preoperative evaluation of bile duct cancer, in terms of both longitudinal and vertical tumor invasion. Many meticulous operative procedures have been established, especially extended hepatectomy for hilar cholangiocarcinoma, to achieve a negative resection margin, which is the only prognostic factor under the control of the surgeon. A complete caudate lobectomy and resection of the inferior part of Couinaud's segment Ⅳ coupled with right or left hemihepatectomy has become the standard surgical procedure for hilar cholangiocarcinoma, and pyloruspreserving pancreaticoduodenectomy is the first choice for distal bile duct cancer. Limited resection for middle bile duct cancer is indicated for only strictly selected cases. Preoperative treatments including biliary drainage and portal vein embolization are also indicated for only selected patients, especially jaundiced patients anticipating major hepatectomy. Liver transplantation seems ideal for complete resection of bile duct cancer, but the high recurrence rate and decreased patient survival after liver transplant preclude it from being considered standard treatment. Adjuvant chemotherapy and radiotherapy have a potentially crucial role in prolonging survival and controlling local recurrence, but no definite regimen has been established to date. Further evidence is needed to fully define the role of liver transplantation and adjuvant chemo-radiotherapy.

Clinical Characteristics and Treatment Outcomes of Patients with Unresectable Cholangiocarcinoma in Thailand: Are there Differences Dependent on Stent Type?

“…13-16 months (Akamatsu et al, 2011;Aslanian and Jamidar, 2011;Anderson et al, 2012;Ruys et al, 2012). The number of patients in our study was not significantly different from those in retrospective studies by Nagino et al (2008) and Kawakami et al (2011), in which the overall median survival times were approximately 5-9 months.…”

“…In Western countries, approximately 60-70% of cases of CCA were reported to be hilar CCA, whereas distal and intrahepatic CCA comprised 20-30 and 5-10% of cases, respectively (Nagino et al, 2008;Akamatsu et al, 2011;Sangchan et al, 2012;Anderson et al, 2012). In Khonkaen, the region that reported the highest incidence of CCA, including Opisthorchis viverrini infestation in 15.7% of cases, intrahepatic and extrahepatic CCA comprised 40% and 60% of the cases, respectively.…”

“…Although advances in radical surgical treatment in resectable cases of this malignancy improved the clinical outcomes, the 5-year survival rate was only 25-43%. Chemotherapy is not effective for palliative treatment in advanced cases; therefore, the median survival of patients with unresectable CCA was only 3-13 months (Nagino et al, 2008;Akamatsu et al, 2011;Van der Gaag et al, 2012). Regarding the data of poor treatment outcomes for unresectable CCA despite adjuvant chemotherapy or radiation treatment (Shin et al, 2010;Aslanian and Jamidar, 2011;Sangchan et al, 2012;Ruys et al, 2012), many patients preferred only palliative treatment, particularly biliary drainage.…”

Spatial Distribution of the Population at Risk of Cholangiocarcinoma in Chum Phaung District, Nakhon Ratchasima Province of Thailand

“…In addition, CCA is considered to be an incurable and rapidly lethal disease unless all the tumors can be fully resected. Three-year survival rates of 35% to 50% are achieved only in a subset of patients who have negative histological margins at the time of surgery (Akamatsu et al, 2011). To e encourage patients to see health personnel at early stage is very important (Thunyaharn et al, 2013).…”

Laparoscopic Resection of Hilar Cholangiocarcinoma

“…Liver resection combined with complete extrahepatic bile duct resection, lymphadenectomy, and biliary reconstruction represent the current standard surgical treatment. [1][2][3][4][5] Laparoscopic liver resection is a feasible and safe technique and has been used to treat several types of liver neoplasms. However, technical limitations have limited the adoption of minimally invasive techniques for the treatment of hilar cholangiocarcinoma.…”