Vascular Involvements in Cholangiocarcinoma: Tips and Tricks

Abstract

Cholangiocarcinoma (CCA) is an aggressive malignancy of the biliary tract. To date, surgical treatment remains the only hope for definitive cure of CCA patients. Involvement of major vascular structures was traditionally considered a contraindication for resection. Nowadays, selected cases of CCA with vascular involvement can be successfully approached. Intrahepatic CCA often involves the major hepatic veins or the inferior vena cava and might necessitate complete vascular exclusion, in situ hypothermic perfusion, ex situ surgery and reconstruction with autologous, heterologous or synthetic grafts. Hilar CCA more frequently involves the portal vein and hepatic artery. Resection and reconstruction of the portal vein is now considered a relatively safe and beneficial technique, and it is accepted as a standard option either with direct anastomosis or jump grafts. However, hepatic artery resection remains controversial; despite accumulating positive reports, the procedure remains technically challenging with increased rates of morbidity. When arterial reconstruction is not possible, arterio-portal shunting may offer salvage, while sometimes an efficient collateral system could bypass the need for arterial reconstructions. Keys to achieve success are represented by accurate selection of patients in high-volume referral centres, adequate technical skills and eclectic knowledge of the various possibilities for vascular reconstruction.

Liver Resection for Type IV Perihilar Cholangiocarcinoma: Left or Right Trisectionectomy?

“…Current advances in complex liver and vascular surgical techniques have led to more aggressive approaches with acceptable outcomes, low complication rates and substantial survival benefits compared with non-surgical strategies [ 9 , 28 , 29 , 30 ]. Even though the type of vascular reconstruction (portal, arterial or both) may influence postoperative outcomes it appears beneficial in terms of long-term survival as recently reported by Angelico et al in a recent systematic review [ 31 ]. These encouraging results has led to an increase in the popularity of LTS, especially among Asian surgical teams.…”

A narrative review of intrahepatic cholangiocarcinoma: a surgical curative option

“…When major hepatic veins or inferior cava vein are involved, it may be required a complete vascular exclusion such as hypothermic perfusion, ex situ surgery or autologous, heterologous, or synthetic grafts reconstruction. However, this aggressive surgery doesn't decrease tumour recurrence rate and the long-term disease-free survival remain worse (28).…”

Rescue Liver Transplantation for Posthepatectomy Liver Failure: A Systematic Review and Survey of an International Experience

“…A recent systematic review and pooled analysis of rescue LT after PHLF was published (8 studies, published between 2003 and 2021, 29 patients). 61 Our study analyzed 40 cases (including our unpublished experience of 5 cases) published in 11 series from 2000 to 2021. Paradoxically, this recent review concluded that excellent LT short-term outcomes with no mortality at the 6-mo follow-up can be obtained.…”