Combined portal vein resection for hilar cholangiocarcinoma: a meta-analysis of comparative studies

A case of endovascular treatment for acute portal vein thrombosis following portal vein resection and hepatectomy for hilar cholangiocarcinoma

Currently, portal vein (PV) resection is performed in 10%-40% of liver resections performed for hilar cholangiocarcinoma (HC). The defect is generally repaired with a patch of an autologous vein graft or end-to-end anastomosis after complete separation of the main PV trunk and the left PV. Postoperative PV thrombosis is a severe complication occurring in 2%-9% of patients requiring PV reconstruction. Here in, we presented a 55-year-old man with abdominal pain without hyperbilirubinaemia who was diagnosed with HC. The patient underwent right hepatectomy, extrahepatic biliary resection, and PV resection. The PV defect was repaired with autologous umbilical vein graft. Following the operation, acute PV thrombosis was encountered postoperative day 1. We conducted the treatment of the early acute PV thrombosis by intraportal tPA and PV stenting with endovascular approach.

Surgical management of hilar cholangiocarcinoma: Controversies and recommendations

Hilar cholangiocarcinomas are highly aggressive malignancies. They are usually at an advanced stage at initial presentation. Surgical resection with negative margins is the standard of management. It provides the only chance of cure. Liver transplantation has increased the number of 'curative' procedures for cases previously considered to be unresectable. Meticulous and thorough preoperative planning is required to prevent fatal post-operative complications. Extended resection procedures, including hepatic trisectionectomy for Bismuth type IV tumors, hepatopancreaticoduodenectomy for tumors with extensive longitudinal spread, and combined vascular resection with reconstruction for tumors involving hepatic vascular structures, are challenging procedures with surgical indications expanded. Liver transplantation after the standardization of a neoadjuvant protocol described by the Mayo Clinic has increased the number of patients who can undergo operation.

Application of mesohepatectomy with caudate lobectomy for the treatment of type III-IV hilar cholangiocarcinoma: a single-center retrospective study

BACKGROUND

The main surgical procedure for Bismuth‒Corlette III-IV hilar cholangiocarcinoma (HCCA) is hemihepatectomy/extended hemihepatectomy. However, many patients have no opportunity for surgery due to having an insufficient remnant liver volume. Preservation of more liver volume on the premise of ensuring R0 resection is the goal. Mesohepatectomy with caudate lobectomy may be a new method to meet these requirements.

METHODS

The clinical data of 41 patients with Bismuth‒Corlette III-IV HCCA, including 18 patients who underwent mesohepatectomy with caudate lobectomy (the mesohepatectomy group) and 23 patients who underwent hemihepatectomy or extended hemihepatectomy (the hemihepatectomy group), were analyzed retrospectively. The perioperative indicators and prognostic survival time between the two groups were analyzed.

RESULTS

The mesohepatectomy group was compared with the hemihepatectomy group, and the operation time was 7.95 ± 1.2 vs. 7.15 ± 1.5 h (P > 0.05); the intraoperative blood loss was 600.0 ± 153.4 vs. 846.1 ± 366.8 mL (P < 0.05); the postoperative hospital stay was 9.9 ± 2.2 vs. 13.8 ± 3.0 days (P < 0.05); and the R0 resection rate was 100% vs. 87.0% (P > 0.05). The postoperative complications of the two groups included bile leakage (22.2% vs. 21.7%), pleural effusion (11.1% vs. 8.7%), and fever (16.7% vs. 8.7%), with no significant differences in the incidences (P > 0.05). The 1-, 3-, and 5-year survival rates of the two groups were 87.5%, 55.7%, 27.8% and 83.5%, 56.1%, 24.5%, respectively, with no significant differences (P > 0.05).

CONCLUSIONS

Mesohepatectomy with caudate lobectomy can preserve more functional liver volume while ensuring the bile duct margin. It can be applied as the surgical treatment of Bismuth‒Corlette III-IV HCCA.

Effects of portal vein resection and hepatic artery resection on long-term survival in Klatskin tumor: a meta-analysis

BACKGROUND

Surgical treatment is currently the only way to achieve the clinical cure for Klatskin tumor. However, whether combined vascular resection should be combined during surgeries is still controversial. The aim of this article was to analyze the effect of portal vein resection (PVR) and hepatic artery resection (HAR) on the long-term survival after surgery for Klatskin tumor.

METHODS

Articles about Klatskin tumor with PVR and HAR, which were published from 2000 to 2020, were searched using PubMed, Embase, and EBSCO. HR with a 95% CI of overall survival, recurrence-free survival, disease-free survival, 3- and 5-year survival rate, and median survival time were reported to evaluate prognosis.

RESULTS

A total of 17 articles were included. The total case number of these studies was 3150 (685 in the PVR group, 345 in the HAR group, and 2120 in the control group). Survival analyses showed that both vascular resection types were poor prognostic factors (PVR: HR = 1.50, 95% CI = 1.24-1.81, P < 0.001; HAR: HR = 1.68, 95% CI = 1.26-2.24, P < 0.001; the pooled effect size of the two groups: HR = 1.55, 95% CI = 1.32-1.82, P < 0.001). In general, the analyses of 3- and 5-year survival and median survival time showed that both vascular resection types tended to be poor prognostic factors, but most of recent researches showed that the PVR did not lead to a poor prognosis.

CONCLUSION

PVR should be used when necessary to achieve R0 resection of Klatskin tumor and improve the long-term survival of patients. Whether HAR should be performed or not is still need to be evaluated.

Impact of Combined Vascular Resection and Reconstruction in Patients with Advanced Perihilar Cholangiocarcinoma

BACKGROUND

Perihilar cholangiocarcinoma often involves the adjacent vasculature, including the portal vein and hepatic artery. Combined vascular resection and reconstruction of the portal vein is more common than vascular resection and reconstruction of the hepatic artery. Herein, we aimed to elucidate the long-term outcomes in patients who underwent vascular resection and reconstruction for perihilar cholangiocarcinoma.

METHODS

Between January 2004 and December 2020, 106 patients with perihilar cholangiocarcinoma were grouped into the no resection (n = 58), resection-portal vein (n = 31), and resection-hepatic artery with or without that of portal vein (n = 17) groups.

RESULTS

There were no significant differences in morbidity and mortality between the three groups. The resection-portal vein and resection-hepatic artery groups had a significantly higher number of advanced tumors than the no resection group, but no significant differences were detected in the rates of lymph node metastasis and R0 resection between the three groups. The 5-year disease-specific survival in the resection-portal vein (37.6%) and resection-hepatic artery (26.9%) groups were poorer than that in the no resection group (47.8%), although the former groups had a significantly better prognosis than the latter group (7.0%). Multivariate analysis identified high preoperative carcinoembryonic antigen level (>5.7 ng/mL), intrahepatic metastasis, and non-R0 resection as independent poor prognostic factors.

CONCLUSION

Although the perioperative course in the resection-portal vein and hepatic artery groups was similar to that in the no resection group, the long-term prognoses were poor in the resection-portal vein and hepatic artery groups. Pre- and postoperative multidisciplinary therapy is required for patients with vascular resection and reconstruction.

Portal vein wedge resection and patch venoplasty using autologous and homologous vein grafts during surgery for hepatobiliary malignancies

Obtaining tumor-free resection margins is one of the most important factors for achieving favorable prognosis of patients undergoing resection for hepatobiliary malignancies. In this study, we present our experience of portal vein (PV) wedge resection and patch venoplasty using autologous or homologous vessel grafts for resecting perihilar cholangiocarcinoma, hepatocellular carcinoma, and distal bile duct cancer. Case 1 was 68-year-old male patient with type IV perihilar cholangiocarcinoma who underwent central bisectionectomy with caudate lobectomy and bile duct resection, and PV wedge resection and patch venoplasty with a cryopreserved iliac vein allograft patch. This patient survived 14 months after surgery. Case 2 was 77-year-old male patient with type IIIA perihilar cholangiocarcinoma who underwent left medial sectionectomy with caudate lobectomy, bile duct resection, and PV wedge resection and patch venoplasty with a cryopreserved iliac vein allograft patch. This patient survived 17 months after surgery. Case 3 was 54-year-old male patient with hepatitis B virus-associated liver cirrhosis and hepatocellular carcinoma with PV tumor thrombus who underwent left hepatectomy. The PV wall defect was repaired with an autologous greater saphenous vein patch. This patient survived 11 months after surgery. Case 4 was 65-year-old female patient with distal bile duct cancer who underwent pylorus-preserving pancreaticoduodenectomy, and main PV wedge resection and patch venoplasty with a cryopreserved iliac artery allograft patch. This patient survived 21 months after surgery. In conclusion, PV wedge resection and patch venoplasty can be used to facilitate complete tumor resection in patients undergoing various extents of surgical resection for hepatobiliary malignancies.

Vascular surgery in liver resection

Vascular surgery in liver resection is a standard part of liver transplantation, but is also used in oncological liver surgery. Malignant liver tumors with vascular involvement have a poor prognosis without resection. Surgery is currently the only treatment to provide long-term survival in advanced hepatic malignancy. Even though extended liver resections are increasingly performed, vascular involvement with need of vascular reconstruction is still considered a contraindication for surgery in many institutions. However, vascular resection and reconstruction in liver surgery-despite being complex procedures-are safely performed in specialized centers. The improvements of the postoperative results with reduced postoperative morbidity and mortality are a result of rising surgical and anesthesiological experience and advancements in multimodal treatment concepts with preconditioning measures regarding liver function and systemic treatment options. This review focuses on vascular surgery in oncological liver resections. Even though many surgical techniques were developed and are also used during liver transplantation, this special procedure is not particularly covered within this review article. We provide a summary of vascular reconstruction techniques in oncological liver surgery according to the literature and present also our own experience. We aim to outline the current advances and standards in extended surgical procedures for liver tumors with vascular involvement established in specialized centers, since curative resection improves long-term survival and shifts palliative concepts to curative therapy.

Effect of vascular resection for perihilar cholangiocarcinoma: a systematic review and meta-analysis

OBJECTIVE

To evaluate the effect of vascular resection (VR), including portal vein resection (PVR) and hepatic artery resection (HAR), on short- and long-term outcomes in patients with perihilar cholangiocarcinoma (PHC).

BACKGROUND

Resection surgery and transplantation are the main treatment methods for PHC that provide a chance of long-term survival. However, the efficacy and safety of VR, including PVR and HAR, for treating PHC remain controversial.

METHODS

This study was registered at the International Prospective Register of Systematic Reviews (CRD42020223330). The EMBASE, PubMed, and Cochrane Library databases were used to search for eligible studies published through November 28, 2020. Studies comparing short- and long-term outcomes between patients who underwent hepatectomy with or without PVR and/or HAR were included. Random- and fixed-effects models were applied to assess the outcomes, including morbidity, mortality, and R0 resection rate, as well as the impact of PVR and HAR on long-term survival.

RESULTS

Twenty-two studies including 4,091 patients were deemed eligible and included in this study. The meta-analysis showed that PVR did not increase the postoperative morbidity rate (odds ratio (OR): 1.03, 95% confidenceinterval (CI): [0.74-1.42], P = 0.88) and slightly increased the postoperative mortality rate (OR: 1.61, 95% CI [1.02-2.54], P = 0.04). HAR did not increase the postoperative morbidity rate (OR: 1.32, 95% CI [0.83-2.11], P = 0.24) and significantly increased the postoperative mortality rate (OR: 4.20, 95% CI [1.88-9.39], P = 0.0005). Neither PVR nor HAR improved the R0 resection rate (OR: 0.70, 95% CI [0.47-1.03], P = 0.07; OR: 0.77, 95% CI [0.37-1.61], P = 0.49, respectively) or long-term survival (OR: 0.52, 95% CI [0.35-0.76], P = 0.0008; OR: 0.43, 95% CI [0.32-0.57], P < 0.00001, respectively).

CONCLUSIONS

PVR is relatively safe and might benefit certain patients with advanced PHC in terms of long-term survival, but it is not routinely recommended. HAR results in a higher mortality rate and lower overall survival rate, with no proven benefit.

Major hepatectomy with combined vascular resection for perihilar cholangiocarcinoma

Background

Hepatectomy with vascular resection (VR) for perihilar cholangiocarcinoma (PHCC) is a challenging procedure. However, only a few reports on this procedure have been published and its clinical significance has not been fully evaluated.

Methods

Patients undergoing surgical resection for PHCC from 2002–2017 were studied. The surgical outcomes of VR and non-VR groups were compared.

Results

Some 238 patients were included. VR was performed in 85 patients. The resected vessels were hepatic artery alone (31 patients), portal vein alone (37 patients) or both (17 patients). The morbidity rates were almost the same in the VR (49.4 per cent) and non-VR (43.8 per cent) groups (P = 0.404). The mortality rates of VR (3.5 per cent) and non-VR (3.3 per cent) were also comparable (P > 0.999). The median survival time (MST) was 45 months in the non-VR group and 36 months in VR group (P = 0.124). Among patients in whom tumour involvement was suspected on preoperative imaging and whose carbohydrate antigen 19-9 (CA19-9) value was 37 U/ml or less, MST in the VR group was significantly longer than that in the non-VR group (50 versus 34 months, P = 0.017). In contrast, when the CA19-9 value was greater than 37 U/ml, MST of the VR and non-VR groups was comparable (28 versus 29 months, P = 0.520).

Conclusion

Hepatectomy with VR for PHCC can be performed in a highly specialized hepatobiliary centre with equivalent short- and long-term outcomes to hepatectomy without VR.

Vascular Involvements in Cholangiocarcinoma: Tips and Tricks

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.

Hilar portal vein wedge resection and patch venoplasty in patients undergoing bile duct resection for hepatobiliary malignancy: A report of two cases

Margin-free resection is one of the most important factors for favorable prognosis in patients undergoing resection for hepatobiliary malignancies. Herein, we present two cases of hepatobiliary malignancies in patients who underwent bile duct resection combined with hilar portal vein (PV) resection and vein allograft patch plasty. The first case was a 51-year-old female patient with gallbladder cancer, in whom we performed extended cholecystectomy, bile duct resection and extensive lymph node dissection. The tumor-invaded PV wall was meticulously excised and the defect was repaired with a cryopreserved iliac vein allograft patch. The extent of the tumor was pT4N2M0 (stage IVB), thus concurrent chemoradiation therapy and adjuvant chemotherapy were performed. This patient is currently alive for 7 years after surgery without any evidence of tumor recurrence. The second case was a 79-year-old male patient with perihilar cholangiocarcinoma of type I and gallbladder cancer, in whom extended bile duct resection and extensive lymph node dissection were performed. The extent of the bile duct tumor was pT4N1M0 (stage IVA) and that of gallbladder tumor was pT2N0M0 (stage II). No additional treatment was provided because of old age and poor general condition. This patient passed away 11 months after surgery due to rapid progression of tumor recurrence. In conclusion, hilar PV wedge resection and roofing patch venoplasty is a useful option to facilitate complete tumor resection in patients undergoing bile duct resection for hepatobiliary malignancy.

Italian Clinical Practice Guidelines on Cholangiocarcinoma - Part II: Treatment

Currently, the only curative treatment for cholangiocarcinoma (CCA) is surgical resection, though this treatment is possible in less than 40% of patients. However, recent improvements in preoperative management have led to a higher number of patients who are candidates for this procedure. For unresectable patients, progress is ongoing in terms of locoregional and chemoradiation treatments and target therapies, especially in the definition of patient selection criteria. This is the second part of the Italian CCA guidelines, dealing with CCA treatment, that have been formulated in accordance with Italian National Institute of Health indications and developed according to the GRADE method and related advancements.

Management Strategies for Patients with Hilar Cholangiocarcinomas: Challenges and Solutions

Advances in imaging, pathology and therapy have resulted in major improvements in the management of cholangiocarcinomas; the mortality has come down and with it there has been an improved 5-year survival. Surgical resection remains the treatment of choice and reports from high volume centres have shown an increase in resectability rates, R0 resection, a decrease in mortality and an improvement in 5-year survival; however, the operative morbidity remains high, pointing towards the complexity of the management of these difficult lesions. Complete excision is also often limited by the locally advanced nature of the disease at the time of diagnosis and a proportion of patients who were earlier deemed resectable on imaging are found to have unresectable disease at the time of operation. Neoadjuvant therapy has had only a limited impact on survival. Liver transplantation is also an option in a few patients following strict criteria for selection. Since the large majority of patients are only diagnosed at the late stages of the disease palliation (endoscopic or surgical) is an important part of treatment. Portal vein embolisation and pre-operative biliary drainage have had a major impact on outcomes. Major liver resection with caudate lobe removal remains the standard operation and procedures like routine vascular resection and liver transplant should only be carried out in experienced centres. Improvements in both neo as well as adjuvant therapy may lead to a standardized protocol in the future, as well as an improvement in survival.

Surgical Outcomes for Perihilar Cholangiocarcinoma with Vascular Invasion

PURPOSE

To investigate short- and long-term surgical outcomes for patients with perihilar cholangiocarcinoma and vascular invasion.

METHODS

Data from 249 patients who underwent perihilar cholangiocarcinoma surgery between 2000 and 2016 were retrospectively analyzed. Patient evaluations included short-term surgical outcomes following vascular resection and long-term outcomes in cases with histopathological vascular invasion.

RESULTS

Mortality was 3.6% overall; 16% for hepatic artery resections, 5.4% for portal vein resections, and 1.7% in the absence of vascular resection (p = 0.029). No between-group differences were observed in the incidence of Clavien-Dindo grade ≥ 3 complications. The factors related to perioperative mortality were hepatic artery resection (odds ratio [OR] = 25.5), right trisectionectomy (OR = 13.0), and central bisectionectomy (OR = 13.8). Multivariate analysis for overall survival identified several prognostic factors: carcinoembryonic antigen level ≥ 5 ng/mL (hazard ratio [HR] = 1.68), poor differentiation (HR = 2.39), distant metastasis (HR = 1.97), and R1 invasive resection (HR = 2.13). Five-year overall survival for patients with portal vein invasion and M0R0/1cis was 35.6%, significantly worse than the 53.4% for patients with no portal vein invasion and M0R/1cis but better than the 0% for patients with portal vein invasion and M1 or R1. Those with hepatic arterial invasion and M0R0/1cis were 24.7%, significantly worse than the 53.4% for patients with no hepatic arterial invasion and M0R0/1cis but significantly better than the 0% for patients with hepatic arterial invasion and M1 or R1.

CONCLUSION

Short-term outcomes for patients with perihilar cholangiocarcinoma and undergoing vascular resection were poor compared to those without vascular resection. Long-term survival in R0M0 disease was more favorable; aggressive surgery is recommended.

Our Rationale of Initiating Neoadjuvant Chemotherapy for Hilar Cholangiocarcinoma: A Proposal of Criteria for "Borderline Resectable" in the Field of Surgery for Hilar Cholangiocarcinoma

BACKGROUND

The concept of "borderline resectable" was recently introduced to the field of surgery for pancreatic cancer, and surgical outcomes for this disease with extremely dismal prognosis have improved since the introduction of this concept. However, no such concept has yet been introduced to the field of surgery for hilar cholangiocarcinoma (HCca).

AIM

To determine a definition and criteria for "borderline resectable" in the field of surgery for HCca.

PATIENTS AND METHODS

Retrospective analysis of 88 patients undergoing curative-intent surgery for HCca at our institution between May 1992 and December 2008 to clarify independent prognostic factors.

RESULTS

Survival outcomes were obtained for these 88 patients, with a 5-year overall survival rate of 31.8%. Independent factors predictive of cancer death were determined by multivariate analysis to be the presence of regional lymph node metastasis (LNM) and pathological confirmed vascular invasion (VI). Cumulative survival rates of 23 patients with both LNM and VI who underwent surgery were significantly worse than those of the remaining 65 surgically treated patients and similar to those of 26 patients who were considered to have unresectable disease and treated with non-surgical multidisciplinary treatment during the same study period.

CONCLUSION

Outcomes of surgery for cases of HCca showing regional LNM and VI were no better than those of non-surgical treatment for unresectable disease. Coexistence of these two factors indicates oncologically dismal condition and thus such cases should be considered "borderline resectable." Treatments additional to surgery are required for "borderline resectable" cases to obtain better outcomes.

Progress in diagnosis and surgical treatment of perihilar cholangiocarcinoma

Cholangiocarcinomas are heterogeneous biliary tract tumors that cause devastating disease. Perihilar cholangiocarcinoma (PHC) is the most common type of biliary tract cancer and are associated with a high mortality. Diagnoses of PHC depend on the results of its clinical presentation, serum biomarkers and imaging techniques. Pre-operative managements including pre-operative biliary drainage (PBD) and portal vein embolization (PVE) could reduce mortality. The best chance of long-term survival and potential cure is surgical resection with negative surgical margin. Lymph node metastasis over N2 nodes precludes long-term survival. The benefit of concomitant vascular resection remains uncertain. Liver transplantation combined with neoadjuvant chemotherapy with radiotherapy is a promising option in highly selected patients with unresectable tumors. Herein, an overview is provided of developments in diagnosis, peri-operative management and surgical treatment among patients with PHCs.

A retrospective review of correlative radiological assessment and surgical exploration for hilar cholangiocarcinoma

Backgrounds/Aims

Hilar cholangiocarcinomas (HCCAs) are tumors that involve the biliary confluence; at present, radical surgery offers the only chance of long-term survival, but this can be challenging given the complexity of the hilar anatomy. Blumgart and Jarnagin described a preoperative staging system that incorporates the effect of local tumor extent and its impact on adjacent structures and that has been demonstrated to correlate better with actual surgical resectability. The primary aim of this study is to describe the correlation between preoperative Blumgart-Jarnagin staging and its correlation with surgical resectability.

Methods

Patients who underwent surgical resection for hilar cholangiocarcinoma at Singapore General Hospital between January 1, 2002, and January 1, 2013, were identified from a prospectively maintained institutional database. All patients were staged based on the criteria described by Blumgart and Jarnagin. Correlation with surgical resectability was then determined.

Results

A total of 19 patients were identified. Overall resectability was 57.8% (n=11). Patients with Blumgart-Jarnagin stage T1 had the highest rates of resectability at 80%; patients with stage T2 and T3 disease had resectability rates of 25% and 40% respectively. Median overall survival was 13.6 months.

Conclusions

The Blumgart-Jarnagin staging system is useful for predicting tumor resectability in HCCA.

Hepatic Artery Resection for Bismuth Type III and IV Hilar Cholangiocarcinoma: Is Reconstruction Always Required?

OBJECTIVE

The objective of the study is to examine the feasibility of hepatic artery resection (HAR) without subsequent reconstruction (RCS) in specified patients of Bismuth type III and IV hilar cholangiocarcinoma.

METHODS

We retrospectively reviewed 63 patients who underwent hepatic artery resection for Bismuth type III and IV hilar cholangiocarcinoma. These patients were subsequently enrolled into two groups based on whether the artery reconstruction was conducted. Postoperative morbidity and mortality, and long-term survival outcome were compared between the two groups.

RESULTS

There were 29 patients in HAR group and 34 patients in the HAR + RCS group. Patients with hepatic artery reconstruction tended to have longer operative time (545.6 ± 143.1 min vs. 656.3 ± 192.8 min; P = 0.013) and smaller tumor size (3.0 ± 1.1 cm vs. 2.5 ± 0.9 cm; P = 0.036). The R0 resection margin was comparable between the HAR group and HAR + RCS group (86.2 vs. 85.3%; P > 0.05). Twelve patients (41.4%) with 24 complications in HAR group and 13 patients (38.2%) with 25 complications in HAR + RCS group were recorded (P = 0.799). The postoperative hepatic failure rate (13.8 vs. 5.9%) and postoperative mortality rate (3.4% vs. 2.9%) were also comparable between the two groups. In the HAR group, the overall 1-, 3-, and 5-year survival rates were 72, 41, and 19%, respectively; while in the HAR + RCS group, the overall 1-, 3-, and 5-year survival rates were 79, 45, and 25%, respectively (P = 0.928).

CONCLUSIONS

Hepatic artery resection without reconstruction is also a safe and feasible surgical procedure for highly selected cases of Bismuth type III and IV hilar cholangiocarcinoma.

Current controversies in cholangiocarcinoma

Cholangiocarcinoma represents 10% of primary liver malignancies and accounts for less than 3% of all gastrointestinal malignant tumors, with an enormous geographical variation. This neoplasia can arise from the biliary tract epithelium or hepatic progenitor cells. Depending on the anatomic localization, it is classified into three subtypes: intrahepatic, perihilar and distal. This fact is one of the main difficulties, because there are many studies that indistinctly include the results in the management of these different types of cholangiocarcinoma, without differentiating its location and even including gallbladder cancer. There are many controversial points in epidemiology, liver transplantation as a treatment, limitations of different results by group and type of treatment, histological testing and chemotherapy. This is a narrative review about topics in cholangiocarcinoma. This article is part of a Special Issue entitled: Cholangiocytes in Health and Disease edited by Jesus Banales, Marco Marzioni, Nicholas LaRusso and Peter Jansen.

Diagnosis and Management of Intrahepatic and Extrahepatic Cholangiocarcinoma

Cholangiocarcinomas (CC) are rare tumors which usually present late and are often difficult to diagnose and treat. CCs are categorized as intrahepatic, hilar, or extrahepatic. Epidemiologic studies suggest that the incidence of intrahepatic CCs may be increasing worldwide. In this chapter, we review the risk factors, clinical presentation, and management of cholangiocarcinoma.

MDCT assessment of resectability in hilar cholangiocarcinoma

PURPOSE

The purpose of this study is to investigate the value of multidetector computed tomography (MDCT) assessment of resectability in hilar cholangiocarcinoma, and to identify the factors associated with unresectability and accurate evaluation of resectability.

METHODS

From January 2007 to June 2015, a total of 77 consecutive patients were included. All patients had preoperative MDCT (with MPR and MinIP) and surgical treatment, and were pathologically proven with hilar cholangiocarcinoma. The MDCT images were reviewed retrospectively by two senior radiologists and one hepatobiliary surgeon. The surgical findings and pathologic results were considered to be the gold standard. The Chi square test was used to identify factors associated with unresectability and accurate evaluation of resectability.

RESULTS

The sensitivity, specificity, and overall accuracy of MDCT assessment were 83.3 %, 75.9 %, and 80.5 %, respectively. The main causes of inaccuracy were incorrect evaluation of N2 lymph node metastasis (4/15) and distant metastasis (4/15). Bismuth type IV tumor, main or bilateral hepatic artery involvement, and main or bilateral portal vein involvement were highly associated with unresectability (P < 0.001). Patients without biliary drainage had higher accuracy of MDCT evaluation of resectability compared to those with biliary drainage (P < 0.001).

CONCLUSION

MDCT is reliable for preoperative assessment of resectability in hilar cholangiocarcinoma. Bismuth type IV tumor and main or bilateral vascular involvement highly suggest the unresectability of hilar cholangiocarcinoma. Patients without biliary drainage have a more accurate MDCT evaluation of resectability. We suggest MDCT should be performed before biliary drainage to achieve an accurate evaluation of resectability in hilar cholangiocarcinoma.

Transhepatic Hilar Approach for Perihilar Cholangiocarcinoma: Significance of Early Judgment of Resectability and Safe Vascular Reconstruction

In the most common surgical procedure for perihilar cholangiocarcinoma, the margin status of the proximal bile duct is determined at the final step. Our procedure, the transhepatic hilar approach, confirms a cancer-negative margin status of the proximal bile duct first. We first performed a partial hepatic parenchymal transection to expose the hilar plate, and then transected the proximal bile duct to confirm margin status. Then, divisions of the hepatic artery and portal vein of the future resected liver are performed, followed by the residual hepatic parenchymal transection. The transhepatic hilar approach offers a wide surgical field for safe resection and reconstruction of the portal vein in the middle of the hepatectomy. We reviewed 23 patients with perihilar cholangiocarcinoma who underwent major hepatectomy using our procedure from 2011 to 2015. A combined vascular resection and reconstruction was carried out in 14 patients (60.9%). R0 resection was achieved in 17 patients (73.9%), and the overall 3-year survival rate was 52.9% (median survival time 52.4 months). The transhepatic hilar approach is useful and practicable regardless of local tumor extension, enabling us to determine tumor resectability and perform safe resection and reconstruction of the portal vein early in the operation.

GUIDELINE FOR THE MANAGEMENT OF BILE DUCT CANCERS BY THE BRAZILIAN GASTROINTESTINAL TUMOR GROUP

The Brazilian Gastrointestinal Tumor Group developed guidelines for the surgical and clinical management of patients with billiary cancers. The multidisciplinary panel was composed of experts in the field of radiology, medical oncology, surgical oncology, radiotherapy, endoscopy and pathology. The panel utilized the most recent literature to develop a series of evidence-based recommendations on different treatment and diagnostic strategies for cholangiocarcinomas and gallbladder cancers.

Significance of Vascular Resection and Reconstruction in Surgery for Hilar Cholangiocarcinoma: With Special Reference to Hepatic Arterial Resection and Reconstruction

PURPOSE

The aim of this study was to assess the efficacy of combined resection and reconstruction (CRR) of the hepatic artery (HA) in surgery for hilar cholangiocarcinoma (HC).

MATERIALS AND METHOD

Among 172 patients who underwent surgical resection for HC, the following three groups were defined according to the type of vascular reconstruction: VR(-) group, in which neither CRR of the portal vein (PV) nor HA was performed (n = 74); VR-PV group, in which only CRR of the PV was required (n = 54); and VR-A group, in which CRR of the HA was performed either with or without CRR of the PV (n = 44). Clinicopathological variables and clinical outcomes were compared among the three groups.

RESULTS

Although the VR-A group showed significantly more advanced disease than other groups, the R0 resection rate was comparable among the three groups (VR(-), 74 %; VR-PV, 80 %; VR-A, 80 %). The 5-year disease-specific survival rate was also comparable among the three groups (VR(-), 45.6 %; VR-PV, 51.2 %; VR-A, 22.3 %), but tended to be worse in the VR-A group than in the other groups. A similar trend was observed in morbidity rate. Lymph node metastasis was more frequent in the VR-A group (59 %) than in the other groups (VR(-), 33.8 %; VR-PV, 50 %). In the VR-A group, lymph node metastasis (p = 0.004) and adjuvant chemotherapy (p = 0.006) were determined to represent independent prognostic factors for survival according to multivariate analysis.

CONCLUSION

CRR of the HA was considered efficacious in selected patients; however, long-term outcomes of the VR-A group seem unsatisfactory. Treatments additional to surgery may be necessary in cases requiring CRR of the HA.

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

BACKGROUND

Resection of the bile duct is required for the treatment of cholangiocarcinoma and is sometimes indicated in resections of liver and gallbladder malignancies. The goal of this retrospective review was to characterize surgical outcomes in patients submitted to bile duct resection for malignancy when additional procedures, specifically hepatic or vascular resections, were performed.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was searched to identify a total of 747 patients who underwent: (i) biliary-enteric anastomosis (BEA) only (Group 1, n = 266); (ii) BEA with hepatic resection (Group 2, n = 439), or (iii) BEA with hepatic and vascular resection (Group 3, n = 42). Postoperative outcomes were compared and regression-adjusted risk factors were analysed to produce observed and expected (O/E) morbidity and mortality ratios.

RESULTS

The performance of hepatic and vascular resections significantly increased rates of overall morbidity (P < 0.001) and mortality (P = 0.021). Risk-adjusted O/E mortality ratios in Groups 1, 2 and 3 were 1.44 [95% confidence interval (CI) 0.84-2.30], 2.16 (95% CI 1.51-2.98) and 5.92 (95% CI 2.54-11.66), respectively. Multivariate analysis identified Group 2 (P < 0.001) and Group 3 (P = 0.001) status as independent predictors of morbidity, and Group 3 status (P = 0.008) as independently associated with mortality. More than 30% of deaths were associated with pulmonary complications and septic shock.

CONCLUSIONS

The addition of hepatic and vascular resections to bile duct resection significantly increased morbidity and mortality. The high O/E mortality ratios for patients in Groups 2 and 3 suggest these outcomes can be improved.

Perioperative Management of Hilar Cholangiocarcinoma

BACKGROUND

Cholangiocarcinoma is the most common primary tumor of the biliary tract although it accounts for only 2 % of all human malignancies. We herein review hilar cholangiocarcinoma including its risk factors, the main classification systems for tumors, current surgical management of the disease, and the role chemotherapy and liver transplantation may play in selected patients.

METHODS

We performed a comprehensive literature search using PubMed, Medline, and the Cochrane library for the period 1980-2015 using the following MeSH terms: "hilar cholangiocarcinoma", "biliary cancer", and "cholangiocarcinoma". Only recent studies that were published in English and in peer reviewed journals were included.

FINDINGS

Hilar cholangiocarcinoma is a disease of advanced age with an unclear etiology, most frequently found in Southeast Asia and relatively rare in Western countries. The best chance of long-term survival and potential cure is surgical resection with negative surgical margins, but many patients are unresectable due to locally advanced or metastatic disease at diagnosis. As a result of recent efforts, new methods of management have been identified for these patients, including preoperative portal vein embolism and biliary drainage, neoadjuvant chemotherapy with subsequent transplantation, and chemoradiation therapy.

CONCLUSION

Current management of hilar cholangiocarcinoma depends on extent of the tumor at presentation and includes surgical resection, liver transplantation, portal vein embolization, and chemoradiation therapy. Our understanding of hilar cholangiocarcinoma has improved in recent years and further research offers hope to improve the outcome in patients with these rare tumors.

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

BACKGROUND

Hilar 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.

METHODS

The 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.

RESULTS

Complete 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.

CONCLUSION

The curative treatment of hilar cholangiocarcinoma remains challenging. Advances in hepatobiliary techniques have improved the perioperative and long-term survival outcomes of this tumor.

Curative-intent surgery for hilar cholangiocarcinoma: prognostic factors for clinical decision making

BACKGROUND

The surgical approach for hilar cholangiocarcinoma (HC) has largely evolved, and increased resectability rates are reported. Large series of patients with resections for HC were published in the last years, and potential predictors for survival were explored. However, the usefulness of these predictors in clinical decision making is controversial.

PURPOSE

The aim of the present review is to explore the main prognostic factors after curative-intent surgery for HC, as emerged from the current literature. Furthermore, the impact of these predictors on clinical decision making is assessed.

CONCLUSION

An aggressive surgical approach has improved the survival rates in patients with HC and implies bile duct resection associated with liver resection and loco-regional lymph node dissection. The AJCC staging system remains the main tool to assess the prognosis after resection of HC. Margin-negative resections and absence of lymph node metastases are the main prognostic factor after curative-intent surgery for HC. Response to chemotherapy is also a prognostic factor. Markers of systemic inflammatory response might predict prognosis of patients with HC, but their usefulness in clinical decision making remains unclear.

Multimodal treatment strategies for advanced hilar cholangiocarcinoma

Cholangiocarcinoma (CCA) is the second most common primary malignancy of the liver arising from malignant transformation and growth of biliary ductal epithelium. Approximately 50-70 % of CCAs arise at the hilar plate of the biliary tree, which are termed hilar cholangiocarcinoma (HC). Various staging systems are currently employed to classify HCs and determine resectability. Depending on the pre-operative staging, the mainstays of treatment include surgery, chemotherapy, radiation therapy, and photodynamic therapy. Surgical resection offers the only chance for cure of HC and achieving an R0 resection has demonstrated improved overall survival. However, obtaining longitudinal and radial surgical margins that are free of tumor can be difficult and frequently requires extensive resections, particularly for advanced HCs. Pre-operative interventions may be necessary to prepare patients for major hepatic resections, including endoscopic retrograde cholangiopancreatography, percutaneous transhepatic cholangiography, and portal vein embolization. Multimodal therapy that combines chemotherapy with external beam radiation, stereotactic body radiation therapy, bile duct brachytherapy, and/or photodynamic therapy are all possible strategies for advanced HC prior to resection. Orthotopic liver transplantation is another therapeutic option that can achieve complete extirpation of locally advanced HC in judiciously selected patients following standardized neoadjuvant protocols.

Hilar cholangiocarcinoma: diagnosis, treatment options, and management

Hilar cholangiocarcinoma (HC) is a rare disease with a poor prognosis which typically presents in the 6(th) decade of life. Of the 3,000 cases seen annually in the United States, less than one half of these tumors are resectable. A variety of risk factors have been associated with HC, most notably primary sclerosing cholangitis (PSC), biliary stone disease and parasitic liver disease. Patients typically present with abdominal pain, pruritis, weight loss, and jaundice. Computed topography (CT), magnetic resonance imaging (MRI), and ultrasound (US) are used to characterize biliary lesions. Endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic cholangiography (PTC) assess local ductal extent of the tumor while allowing for therapeutic biliary drainage. MRCP has demonstrated similar efficacies to PTC and ERCP in identifying anatomic extension of tumors with less complications. Treatment consists of surgery, radiation, chemotherapy and photodynamic therapy. Biliary drainage of the future liver remnant should be performed to decrease bilirubin levels thereby facilitating future liver hypertrophy. Standard therapy consists of surgical margin-negative (R0) resection with extrahepatic bile duct resection, hepatectomy and en bloc lymphadenectomy. Local resection should not be undertaken. Lymph node invasion, tumor grade and negative margins are important prognostic indicators. In instances where curative resection is not possible, liver transplantation has demonstrated acceptable outcomes in highly selected patients. Despite the limited data, chemotherapy is indicated for patients with unresectable tumors and adequate functional status. Five-year survival after surgical resection of HC ranges from 10% to 40% however, recurrence can be as high as 50-70% even after R0 resection. Due to the complexity of this disease, a multi-disciplinary approach with multimodal treatment is recommended for this complex disease.

Surgical technique of hepatectomy combined with simultaneous resection of hepatic artery and portal vein for perihilar cholangiocarcinoma (with video)

Perihilar cholangiocarcinomas often involve the bifurcation of the portal vein and the hepatic artery at initial presentation. Previously, vascular invasion was a major obstacle for R0 resection; therefore, such tumors were regarded as locally advanced, unresectable disease. Recently, in leading centers, these tumors have been resected using a specific technique, vascular resection and reconstruction. Vascular resection is classified into three types: portal vein resection alone, hepatic artery resection alone, and simultaneous resection of both the portal vein and hepatic artery. Of these, portal vein resection is widely performed, whereas hepatic artery resection remains controversial. Therefore, hepatectomy combined with simultaneous resection of the portal vein and hepatic artery represents one of the most complicated and challenging procedures in hepatobiliary surgery. The survival benefit of this extended procedure remains unproven, and there is only a single study reporting an unexpectedly favorable outcome in 50 patients. Considering the dismal survival in patients with unresectable disease, hepatic artery resection and/or portal vein resection may be a promising option of choice. However, the technique is highly demanding and has not been standardized. Therefore, this extended surgery may be allowed only in selected hepatobiliary centers.