Hilar Cholangiocarcinoma: Preoperative Liver Optimization with Multidisciplinary Approach. Toward a Better Outcome.

Hepatobiliary Surgery Unit, General Surgery Department, Ospedale San Raffaele, Via Olgettina 60, Milano, Italy, .
World Journal of Surgery (Impact Factor: 2.35). 03/2013; DOI: 10.1007/s00268-013-1980-2
Source: PubMed

ABSTRACT INTRODUCTION: The diagnosis and treatment of hilar tumors requires a multidisciplinary approach based on the synergy of radiologists, surgeons, oncologists, and gastroenterologists. Klatskin tumor is a relatively rare disease with a poor prognosis. Currently, the only possible treatment is represented by the removal of the tumor associated with radical surgery, even though its results are still jeopardized by significant morbidity and mortality. A proper preoperative optimization of the patient, including staging laparoscopy, biliary drainage, and portal vein embolization, may improve short-term outcome. The purpose of this study was to evaluate the short- and long-term impact of preoperative optimization in patients affected by hilar cholangiocarcinoma. METHODS: From January 2004 to May 2012, 94 patients with preoperative diagnosis of Klastkin tumors were candidates for surgery at the Hepatobiliary Surgery Unit of the Hospital San Raffaele in Milan. The data of all patients were prospectively collected and retrospectively reviewed. The outcome was evaluated in terms of perioperative morbidity and mortality and overall and disease-free survival. Short-term outcome of patients undergoing preoperative optimization was compared with outcome of patients who did not undergo it in terms of intraoperative data, morbidity and mortality. RESULTS: Of 94 patients undergoing surgery, 80 underwent hepatic and biliary confluence resection. Fourteen patients were considered unresectable due to the presence of peritoneal carcinomatosis or advanced disease seen during staging laparoscopy or at laparotomy and therefore were excluded from the analysis. Seventy-five (93.7 %) patients underwent major liver resections: in 14 of these, surgery was performed at a distance of 30-40 days from PVE. In 55 patients, biliary drainage was preoperatively placed for palliation of obstructive jaundice. The postoperative morbidity rate was 51.2 % and mortality 6.2 %. The most frequent cause of death was postoperative liver failure. Five-year survival rate was 29 %. Patients undergoing preoperative optimization experienced a significant reduction of postoperative morbidity, especially in terms of infectious related events. CONCLUSIONS: Klatskin tumor remains a disease associated with poor prognosis, but a correct preoperative diagnostic and therapeutic management provides tools to perform this type of surgery with acceptable morbidity and mortality, thus improving long-term results.

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    ABSTRACT: Hilar cholangiocarcinoma is a tumor of the extrahepatic bile duct involving the left main hepatic duct, the right main hepatic duct, or their confluence. Biliary drainage in hilar cholangiocarcinoma is sometimes clinically challenging because of complexities associated with the level of biliary obstruction. This may result in some adverse events, especially acute cholangitis. Hence the decision on the indication and methods of biliary drainage in patients with hilar cholangiocarcinoma should be carefully evaluated. This review focuses on the optimal method and duration of preoperative biliary drainage (PBD) in resectable hilar cholangiocarcinoma. Under certain special indications such as right lobectomy for Bismuth type IIIA or IV hilar cholangiocarcinoma, or preoperative portal vein embolization with chemoradiation therapy, PBD should be strongly recommended. Generally, selective biliary drainage is enough before surgery, however, in the cases of development of cholangitis after unilateral drainage or slow resolving hyperbilirubinemia, total biliary drainage may be considered. Although the optimal preoperative bilirubin level is still a matter of debate, the shortest possible duration of PBD is recommended. Endoscopic nasobiliary drainage seems to be the most appropriate method of PBD in terms of minimizing the risks of tract seeding and inflammatory reactions.
    03/2014; 6(3):68-73. DOI:10.4253/wjge.v6.i3.68
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    ABSTRACT: PurposeExtended liver resection may provide long-term survival in selected patients with Bismuth type IV hilar cholangiocarcinoma (HCCA). The purpose of this study was to identify anatomical factors that predict curative-intended resection.MethodsThirty-three of 159 patients with Bismuth type IV HCCA underwent major hepato-biliary resection with curative intent (CIR) between 2000 and 2010. Disease extent and anatomical variations were analyzed as factors enabling CIR.ResultsCIR ratio with hilar trifurcation bile duct variation (13/16) was significantly higher than that with other bile duct variation types (18/25). Hilum to left second bile duct confluence and tumor infiltration over left second bile duct confluence lengths in right-sided CIR were significantly shorter than those lengths in left-sided CIR (10.8 ± 4.9 and 2.7 ± 0.8 mm vs. 16.5 ± 8.4 and 7.0 ± 5.3 mm, respectively). Left-sided CIR patients had a marginally higher proportion of tumors invading ≤5 mm over the right second confluence than that in right-sided CIR patients (13/17 vs. 6/16; P = 0.061). The 3-year survival rate after CIR (28%) was significantly higher than after non-CIR (6.1%).ConclusionWe recommend the criteria of CIR as bile duct variation type, length of hilum to contralateral second bile duct confluence, and extent of tumor infiltration over the second confluence for Bismuth type IV HCCA.
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    ABSTRACT: Das perihiläre Gallengangskarzinom (Klatskin-Tumor) ist ein seltener Tumor ausgehend von der extrahepatischen Gallengangsgabel. In Anbetracht der anatomisch engen Beziehung der Gallengangsgabel zu Leberparenchym, Pfortadergabel und auch Leberarterien bedeutet die Behandlung dieser Patienten eine große Herausforderung. Mit einer Inzidenz von 2 bis 4 Erkrankungen/100.000 Einwohner/Jahr ist eine Behandlung nur an Zentren sinnvoll, die über eine entsprechende Erfahrung verfügen. Histologisch liegt meist ein mäßig differenziertes Adenokarzinom vor, das diffus infiltrierend entlang der Gallenwege und Perineuralscheide nach proximal, aber auch nach distal wachsen kann. Als einzige kurative Option hat sich die radikale chirurgische Resektion von Gallenwegen, Gallengangsgabel en bloc mit Leberresektion und auch die Gefäßresektion durchgesetzt, dennoch ist das Erreichen eines proximalen und lateralen Sicherheitsabstands vom Tumor technisch problematisch.
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