Improved Outcome of Resection of Hilar Cholangiocarcinoma (Klatskin Tumor)

Surgical strategy for bile duct cancer: Advances and current limitations

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 pylorus-preserving 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.

Multidisciplinary management of hilar cholangiocarcinoma (Klatskin tumor): extended resection is associated with improved survival

BACKGROUND

Effective diagnosis and treatment of patients with hilar cholangiocarcinoma (HCCA) is based on the synergy of endoscopists, interventional radiologists, radiotherapists and surgeons. This report summarizes the multidisciplinary experience in management of HCCA over a period of two decades at the Academic Medical Center in Amsterdam, with emphasis on surgical outcome.

METHODS

From 1988 until 2003, 117 consecutive patients underwent resection on the suspicion of HCCA. Preoperative work-up included staging laparoscopy, preoperative biliary drainage, assessment of volume/function of future remnant liver and radiation therapy to prevent seeding metastases. More aggressive surgical approach combining hilar resection with extended liver resection was applied as of 1998. Outcomes of resection including actuarial 5-year survival were assessed.

RESULTS

Eighteen patients (15.3%) appeared to have a benign lesion on microscopical examination of the specimen, leaving 99 patients with histologically proven HCCA. These 99 patients were analysed according to three 5-year time periods of resection, i.e. period 1 (1988-1993, n=45), 2 (1993-1998, n=25) and 3 (1998-2003, n=29). The rate of R0 resections increased and actuarial five-year survival significantly improved from 20±5% for the periods 1 and 2, to 33±9% in period 3 (p<0.05). Postoperative morbidity and mortality in the last period were 68% and 10%, respectively.

CONCLUSION

Extended surgical resection resulted in increased rate of R0 resections and significantly improved survival. Candidates for resection should be considered by a specialized, multidisciplinary team.

Univariate and Multivariate Analysis of Prognostic Factors in the Surgical Treatment of Hilar Cholangiocarcinoma

Surgery is the only effective treatment able to improve survival of patients with hilar cholangiocarcinoma (CCA). However, the significance of prognostic factors on overall survival is still debated. We evaluated early and long-term outcomes of patients resected for hilar cholangiocarcinoma over a 3-year period to determine the role of prognostic factors and their effect on overall survival. Medical records of patients with hilar CCA who underwent resection between January 2001 and December 2004 were retrospectively reviewed. Univariate and multivariate analysis was performed to identify prognostic factors associated with survival. Thirty-two of 45 patients underwent surgical resection with curative intent. Morbidity was 24.4 per cent; perioperative mortality was 0 per cent. Overall median survival was 22.3 months. Well-differentiated tumor grading and R0 resection were independently associated with better survival at multivariate analysis. Aggressive surgery, including biliary resection combined with major hepatectomy, is a safe procedure with low morbidity and mortality in a tertiary referral hepatobiliary center. The main aim of an aggressive surgical approach is to obtain a microscopic margin-negative resection, which is associated with better prognosis. Another important prognostic factor is tumor grading, which is independently associated with survival.

A review of factors predicting perioperative death and early outcome in hepatopancreaticobiliary cancer surgery

OBJECTIVES

In the context of comparisons of surgical outcomes, risk adjustment is the retrospective adjustment of a provider's or a surgeon's results for case mix and/or hospital volume. It allows accurate, meaningful inter-provider comparison. It is therefore an essential component of any audit and quality improvement process. The aim of this study was to review the literature to identify those factors known to affect prognosis in hepatobiliary and pancreatic cancer surgery.

METHODS

PubMed was used to identify studies assessing risk in patients undergoing resection surgery, rather than bypass surgery, for hepatobiliary and pancreatic cancer.

RESULTS

In total, 63 and 68 papers, pertaining to 24 609 and 63 654 patients who underwent hepatic or pancreatic resection for malignancy, respectively, were identified. Overall, 22 generic preoperative factors predicting outcome on multivariate analysis, including demographics, blood results, preoperative biliary drainage and co-morbidities, were identified, with tumour characteristics proving disease-specific factors. Operative duration, transfusion, operative extent, vascular resection and additional intra-abdominal procedures were also found to be predictive of early outcome.

CONCLUSIONS

The development of a risk adjustment model will allow for the identification of those factors with most influence on early outcome and will thus identify potential targets for preoperative optimization and allow for the development of a multicentre risk prediction model.

Role of preoperative optimization of the liver for resection in patients with hilar cholangiocarcinoma type III

BACKGROUND

Long-term survival after complete resection of hilar cholangiocarcinoma remains disappointing. The aim of this retrospective study was to assess the impact of liver optimization on postoperative outcome of hilar cholangiocarcinoma type III.

MATERIALS AND METHODS

In a retrospective, single-center analysis, outcomes in patients with hilar cholangiocarcinoma type III who underwent resection after preoperative liver optimization (preoperative transhepatic biliary drainage [PTBD], bile replacement, and/or portal vein embolization [PVE]) were compared with nonoptimized controls.

RESULTS

Of 41 patients undergoing surgery, 38 patients undergoing curative intent procedures were identified, of whom 15 underwent preoperative optimization. After PTBD, direct bilirubin decreased from 218.0 ± 184.2 to 75.9 ± 42.7 μmol/L (P = 0.03), and there was a trend toward decreased AST and ALT levels. Overall, 3- and 5-year survival rates were 47.9 ± 9.1 and 41.9 ± 9.8%. The primary endpoint, 5-year survival after surgery, was not significantly different between groups. Preoperative jaundice was identified as an independent prognostic factor for poor outcome (hazard ratio [HR] 2.12, P = 0.02). Four patients (10.5%) without preoperative optimization died of liver failure within the first 30 days postsurgery, preceded in three cases by intra-abdominal abscesses. PTBD was associated with a lower rate of postoperative intra-abdominal abscesses; however this factor was not independently predictive of higher survival.

CONCLUSION

Preoperative optimization of the liver in hilar cholangiocarcinoma Type III reduced the incidence of intra-abdominal abscesses, but its impact on postoperative survival remains unclear.

Current surgical management of hilar and intrahepatic cholangiocarcinoma: the role of resection and orthotopic liver transplantation

Cholangiocarcinoma (CCA) is a rare but devastating malignancy that presents late, is notoriously difficult to diagnose, and is associated with a high mortality. Surgical resection is the only chance for cure or long-term survival. The treatment of CCA has remained challenging because of the lack of effective adjuvant therapy, aggressive nature of the disease, and critical location of the tumor in close proximity to vital structures such as the hepatic artery and the portal vein. Moreover, the operative approach is dictated by the location of the tumor and the presence of underlying liver disease. During the past 4 decades, the operative management of CCA has evolved from a treatment modality that primarily aimed at palliation to curative intent with an aggressive surgical approach to R0 resection and total hepatectomy followed by orthotopic liver transplantation.

Surgical Treatment of Intrahepatic Cholangiocarcinoma—A Single Center Experience

This study aimed to evaluate outcome after liver resection for intrahepatic cholangiocarcinoma (ICC). In a 72-month period a total of 25 patients operated on for ICC were followed-up with postoperatively. Eleven right hemihepatectomies (8 extended), seven left hemihepatectomies (3 extended), one segmental resection, two bisegmentectomies (II + III), and four nonanatomical resections were performed. Median observation period was 2.7 (range: 0.2-6.9) years. Analysis focused on age, gender, tumor-size, operating time, histologic resection margin, Tumor-Node-Metastasis-stage, reoperations, postoperative complications, tumor recurrence, survival rate and a putative relation between p53 accumulation, ki67 index, MUC1 positivity, and prognosis. Mean tumor size was 6.49 ± 3.93 cm. Eighteen patients (72%) underwent lymph node dissection. Major postoperative complications occurred in 10 patients. Seventeen patients (68%) showed tumor recurrence. Mean time to tumor recurrence was 6.7 (5.7-15.4) months. We found no correlation between p53 accumulation/ki67 index counts/Mucin 1 cell surface associated antibody (MUC1) positivity and ICC prognosis. A total of 13 patients died (52%) including one early and 12 late deaths. Mean time from surgery to death was 14.6 (7.4-30.9) months. Survival rate at 1 year was 84 per cent, at 3 years 57 per cent, and at 5 years 45 per cent. In our review only a small number of these 25 patients are indeed cured.

Does intrahepatic cholangiocarcinoma have better prognosis compared to perihilar cholangiocarcinoma?

BACKGROUND AND OBJECTIVES

Cholangiocarcinoma can be classified as intrahepatic (ICC) or perihilar (PCC). The objectives of this study is to evaluate the surgical outcomes of patients with PCC and ICC, identify the main prognostic factors related to survival and compare the outcome and the prognostic factors of PCC and ICC.

METHODS

Ninety-five out of 152 patients observed between January 1990 and December 2007 at Surgical Division of University of Verona Medical School underwent the resection of ICC (33 patients) or PCC (62 patients).

RESULTS

Overall median survival was 24 months with a 3- and 5-year survival rate of 45% and 23%, respectively. Prognostic factors for survival were macroscopic types of the tumor, the resection of extrahepatic bile duct, radical resection, lymph node metastases, and macro-vascular invasion. Survival was related with the macroscopic type of the tumors with a 5-year survival rate of 26% and 13% for ICC and PCC, respectively. Univariate analysis identified that negative clinico-pathological factors where significant more frequently found in PCC compared to ICC.

CONCLUSION

We identified that ICC have longer survival rate compared to PCC. PCC showed a higher frequency of negative clinico-pathological factors such as non-radical (R+) resection, perineural infiltration and macro-vascular invasion.

Changes in the surgical approach to hilar cholangiocarcinoma during an 18-year period in a Western single center

BACKGROUND

Liver resection is the only potential curative treatment for hilar cholangiocarcinoma. In this article, we evaluate mortality, survival, prognostic factors, and changes in surgical approach during the last two decades at a Western hepato-biliary center.

METHODS

Fifty-one patients undergoing liver resections constitute the study population. Patients undergoing palliative procedures were considered as a control group for comparison to the resected group. After 1997, a more aggressive surgical approach was applied that is based on the experience of Japanese surgeons.

RESULTS

Curative resections were achieved in 37 (72.5%) patients, and R1 resections were performed in 14 (27.5%). The overall 3- and 5-year survival rates were 47.3 and 34.1%, respectively. The 3- and 5-year survival rates were 38 and 19% in the R1 resection group, and 15% and 0 in the non-resected group, respectively. Univariate analysis revealed that lymph node and perineural invasion, R1 resection, and a bilirubin level >10 mg/dl affected long-term survival. Multivariate analysis showed that only perineural invasion was significant in affecting long-term survival. Univariate analysis showed that the mean preoperative bilirubin levels and mean blood transfusion were related to the mortality rate. The resectability rate significantly increased from 25 to 75.6% after 1997 following implementation of the new surgical approach.

CONCLUSIONS

An aggressive surgical approach increases the resectability rate and may improve long-term survival even after R1 resection. Severe hyperbilirubinemia should be preoperatively drained, possibly by the percutaneous approach.

Major hepatectomy for perihilar cholangiocarcinoma

BACKGROUND/PURPOSE

Hilar cholangiocarcinoma and intrahepatic cholangiocarcinoma involving the hepatic hilus are defined as "perihilar cholangiocarcinoma". The principle of surgical treatment is hemi-hepatectomy or trisectionectomy of the liver, caudate lobectomy, and resection of the extrahepatic bile duct for complete resection of the tumor. The aim of this study was to review the outcomes of major hepatectomy for perihilar cholangiocarcinoma.

METHODS

Using the Kaplan-Meier method and the Cox proportional hazards model, we analyzed the results in 125 patients with perihilar cholangiocarcinoma who had undergone major hepatectomy.

RESULTS

Right hepatectomy, right trisectionectomy, left hepatectomy, and left trisectionectomy were performed in 66, 8, 49, and 2 patients, respectively. Curative resection was achieved in 79 patients (63.2%). Mortality and morbidity rates were 8.0 and 48.7%, respectively. The overall 1-, 3-, and 5-year survival rates of all patients were 73.2, 36.7, and 34.7%, respectively. The median survival was 26.8 months. Multivariate analysis showed that the independent prognostic factors for overall survival were gender, histopathological grading, curative resection, and American Joint Committee on Cancer (AJCC)/International Union Against Cancer (UICC) pT.

CONCLUSIONS

Major hepatectomy for perihilar cholangiocarcinoma was acceptable and showed satisfactory outcomes. For long-term survival in these patients, the surgeon should aim for complete resection of the tumor with negative margins.

Extent of liver resection for hilar cholangiocarcinoma

BACKGROUND

The extent of liver resection for hilar cholangiocarcinoma (HC) remains controversial despite extensive studies. The aim of this study was to determine the safety and efficacy of minor and major hepatectomy, selected by predetermined criteria in patients with HC.

METHODS

From 2000 to 2007, 187 patients with HC were studied prospectively; 138 patients underwent resection with curative intent. Minor hepatectomy was performed in 93 patients with Bismuth-Corlette type I, II or III HC without hepatic arterial or portal venous invasion, and major hepatectomy in 45 patients with type III HC with hepatic arterial or portal venous invasion, or type IV HC.

RESULTS

Overall mortality and morbidity rates were 0 and 29.7 per cent respectively, and the bile leak rate was 1.4 per cent. Actuarial 1-, 3- and 5-year survival rates were 87, 54 and 34 per cent respectively in the minor liver resection group, and 80, 42 and 27 per cent for major resection (P = 0.300).

CONCLUSION

Minor liver resection for HC, selected by predetermined criteria, had good results. Major liver resection, which had a higher operative morbidity rate than minor resection, should be reserved for Bismuth-Corlette type III HC with vascular invasion, or type IV HC.

Surgical treatment of hilar cholangiocarcinoma in a new era: comparison among leading Eastern and Western centers, Leeds

OBJECTIVE

Surgery for hilar cholangiocarcinoma (HCCA) remains challenging, with radical procedures thought to offer the best chance of long-term survival. Here we present our data for surgical resection of HCCA for the period 2001-2008.

METHODS

A prospectively maintained database was interrogated to identify all resections. Clinico-pathological data were analyzed and assessed for impact on survival.

RESULTS

51 patients were identified. Almost three-quarters required hepatic trisectionectomy. Overall survival was 76% at 1 year, 36% at 3 years and 20% at 5 years. When R0 resection was achieved, the 5-year survival was 40%. Portal vein resection, perineural invasion and T-stage were predictive of overall survival on univariate analysis. Only T-stage remained significant on multivariate analysis. Lymph node status predicted disease-free survival.

CONCLUSION

Radical surgery continues to offer the prospect of long-term survival for patients with HCCA. Earlier detection and referral to tertiary centers may allow more patients to have potentially curative surgical resections.

Clinical value of additional resection of a margin-positive proximal bile duct in hilar cholangiocarcinoma

BACKGROUND

Based on frozen section examination, additional resection of the proximal bile duct was performed to achieve a negative margin at the time of resection of hilar cholangiocarcinoma. The aim of this study was to determine whether additional resection of a margin-positive proximal duct can improve survival.

METHODS

The records of 303 resected patients with hilar cholangiocarcinoma were reviewed, focusing on the status of the proximal ductal margin.

RESULTS

Frozen section examination of the proximal ductal margin was carried out in 138 of the 303 patients included in this study. The histopathologic diagnosis was negative in 110 patients, positive with carcinoma in situ in 11, and positive with invasive cancer in 17. In the 17 patients with invasive cancer, additional resection was performed in 12. The length of resection was <or=5 mm in all patients. With additional resection, a negative margin was achieved in 8 patients. The survival rate for patients in whom a negative margin was achieved after additional resection (n=8) was worse than that for patients with a negative margin or a positive with carcinoma in situ margin (n=275) and was similar to that for patients with a positive margin with invasive cancer (n=20).

CONCLUSION

Additional resection of >5 mm in the proximal duct is difficult after maximal or near-maximal resection of the duct. Such limited resection of a margin-positive proximal duct does not improve survival, even when a negative margin can be achieved with additional resection.

Advances in diagnosis, treatment and palliation of cholangiocarcinoma: 1990-2009

Several advances in diagnosis, treatment and palliation of cholangiocarcinoma (CC) have occurred in the last decades. A multidisciplinary approach to this disease is therefore recommended. CC is a relatively rare tumor and the main risk factors are: chronic inflammation, genetic predisposition and congenital abnormalities of the biliary tree. While the incidence of intra-hepatic CC is increasing, the incidence of extra-hepatic CC is trending down. The only curative treatment for CC is surgical resection with negative margins. Liver transplantation has been proposed only for selected patients with hilar CC that cannot be resected who have no metastatic disease after a period of neoadjuvant chemo-radiation therapy. Magnetic resonance imaging/magnetic resonance cholangiopancreatography, positron emission tomography scan, endoscopic ultrasound and computed tomography scans are the most frequently used modalities for diagnosis and tumor staging. Adjuvant therapy, palliative chemotherapy and radiotherapy have been relatively ineffective for inoperable CC. For most of these patients biliary stenting provides effective palliation. Photodynamic therapy is an emerging palliative treatment that seems to provide pain relief, improve biliary patency and increase survival. The clinical utility of other emerging therapies such as transarterial chemoembolization, hepatic arterial chemoinfusion and high intensity intraductal ultrasound needs further study.

Hilar cholangiocarcinoma: current management

OBJECTIVE

To review the literature with regard to outcome of surgical management for hilar cholangiocarcinoma (Klatskin tumor).

BACKGROUND

Hilar cholangiocarcinoma is a rare tumor with a poor prognosis. Surgical resection provides the only possibility for cure. Advances in hepatobiliary imaging and surgical strategies to treat this disease have resulted in improved postoperative outcomes.

METHODS

We performed a review of the English literature on hilar cholangiocarcinoma from 1990 to 2007. This review included preoperative evaluation, surgical techniques, issues and controversies in management, prognostic variables, and considerations for future directions.

RESULTS

Complete resection remains the most effective and only potentially curative therapy for hilar cholangiocarcinoma. Negative resection margins are associated with improved outcomes, and major hepatic resections have enhanced the likelihood of R0 resection. Portal vein embolization may be indicated in selected patients before extensive hepatic resection. Staging laparoscopy should be considered to detect occult metastatic disease. Orthotopic liver transplantation might be applicable for a highly selected subgroup.

CONCLUSIONS

Surgical resection including major hepatic resection remains the mainstay of treatment of hilar cholangiocarcinoma. Additional evidence is needed to fully define the role of orthotopic liver transplantation. Improvements in adjuvant therapy are essential for improving long-term outcome.

The costs of postoperative liver failure and the economic impact of liver function capacity after extended liver resection--a single-center experience

PURPOSE

Postoperative liver failure (PLF) is a relatively frequent and life-threatening complication after extended liver resection. This study describes the economic burden of PLF from the hospitals' perspective and explores the role of liver function capacity.

MATERIALS AND METHODS

Economic data of total costs and cost distribution were analyzed for 48 patients who had participated in a prospective study with the LiMAx test, a novel test for liver function capacity. For this population, detailed individual data were available. The economic data were analyzed and adjusted for relevant covariates. In addition, economic data of 916 patients who had undergone liver resection during 2005-2007 were retrieved from the hospitals' medical controlling office for comparison.

RESULTS

A significant difference between the costs of patients with regular recovery (25,980 Euro [95% confidence interval (95%CI) = 9,559 to 42,401]) versus patients developing PLF (82,199 Euro [95%CI = 42,812 to 121,586]; p = 0.013) was observed. The mean additional costs of PLF were 56,219 Euro. An equivalent cost difference of mortality was obtained from the analysis of 916 patients. Patients developing PLF had a decreased LiMAx of 61 microg/kg/h compared to the regular group 122 microg/kg/h (p < 0.001) after surgery. Initial postoperative LiMAx and total costs revealed a linear correlation coefficient of r = -0.340 (p = 0.018).

CONCLUSIONS

PLF is a very relevant medical and economic problem. Liver function capacity does not only predict PLF but also correlates with total costs in general.

Addition of hepatectomy decreases liver recurrence and leads to long survival in hilar cholangiocarcinoma

AIM: To evaluate hepatic recurrence and prognostic factors for survival in patients with surgically resected hilar cholangiocarcinoma in a single institution over the last 13 years.

METHODS: From 1994 to 2007, all patients with hilar cholangiocarcinoma referred to a surgical clinic were evaluated. Demographic data, tumor characteristics, and outcome were analyzed retrospectively. Outcome was compared in patients who underwent additional liver resection with resection of the tumor.

RESULTS: Of the 69 patients submitted to laparotomy for tumor resection, curative resection (R₀ resection) was performed in 40 patients, and palliative resection in 29. Thirty-one patients had only duct resection, and 38 patients had combined duct resection with liver resection including 34 total or part caudate lobes. Curative rates with the combined hepatectomy were significantly improved compared with those without additional hepatectomy (27/38 vs 13/31; χ² = 5.94, P < 0.05). Concomitant liver resection was associated with a decreased incidence of initial recurrence in liver one year after surgery (11/38 vs 23/31; χ² = 13.98, P < 0.01). The 3-year survival rate after R₀ resection was 30.7% and was 10.5% for palliative resection. R₀ resection improved the 3-year survival rate (30.7% vs 10.5%; χ² = 12.47, P < 0.01).

CONCLUSION: Hepatectomy, especially including the caudate lobe combined with bile duct resection should be considered standard treatment to cure hilar cholangiocarcinoma.

Development and controversy of surgical therapy for hilar cholangiocarcinoma

Hilar cholangiocarcinoma has always been the focus attracting the attention of surgeons because of its special anatomic location and poor prognosis. At the present time, complete tumor resection has been recognized as the most effective therapy for hilar cholangiocarcinoma. However, the risk of operation is very high, and there also are many technical difficulties and exploratory progress in attempting to remove the tumor. This article will analyze and discuss the perioperative management and the development and controversy of surgical skills in the treatment of hilar cholangiocarcinom in order to help clinical surgeons take an active part in improving their practice skills.

Differentiation of malignant and benign proximal bile duct strictures: The diagnostic dilemma

AIM: To identify the criteria for the differentiation of hilar cholangiocarcinoma (HCCA) from benign strictures.

METHODS: A total of 68 patients underwent resection of lesions suspicious for HCCA between 1998 and 2006. The results of laboratory investigations, imaging studies and brush cytology were collected. These findings were analyzed to obtain the final diagnosis.

RESULTS: Histological examination of the resected specimens confirmed HCCA in 58 patients (85%, group I) whereas 10 patients (15%, group II) were diagnosed to have benign strictures. The most common presenting symptom was obstructive jaundice in 77% patients (79% group I vs 60% group II, P = 0.23). Laboratory findings showed greater elevation of transaminase levels in group I compared to group II. The various imaging modalities showed vascular involvement exclusively in the malignant group (36%, P < 0.05). Brush cytology was positive for malignant cells in only 50% patients in group I whereas none in group II showed malignant cells.

CONCLUSION: Despite improvements in imaging techniques, 10 patients (15%) with a presumptive diagnosis of HCCA were ultimately found to have benign strictures. Except for vascular involvement which was associated significantly with malignancy, there were no conclusive features of malignancy on regular imaging modalities. This uncertainty should be taken into account when patients with a suspicious lesion at the liver hilum are considered for resection.

Resection of hilar cholangiocarcinoma: concomitant liver resection decreases hepatic recurrence

BACKGROUND

Hilar cholangiocarcinoma is an uncommon tumor with a poor prognosis. We sought to evaluate recurrence patterns and prognostic factors for disease-specific and disease-free survival in patients with surgically resected hilar cholangiocarcinoma in a single institution over the last 21 years.

METHODS

From 1985 to 2006, all patients with hilar cholangiocarcinoma referred to a tertiary surgical clinic were evaluated. Demographic data, tumor characteristics, and outcome were analyzed retrospectively. Outcome was compared in patients treated in a recent era (1995-2006) compared with an earlier era (1985-1994).

RESULTS

Of 91 patients evaluated, 22 patients (24%) had unresectable disease at presentation. Of the 69 patients submitted to laparotomy, resection was possible in 55% and the curative (R0) resection rate was 63%. In patients submitted to exploration, the operative (60 day) morbidity and mortality rates were 26% and 3%. Median disease-specific (DSS) and disease-free survival (DFS) were 29 and 20 months, respectively (median FU, 29 months.). In patients undergoing R0 resection, the median survival was prolonged (65 months). In the more recent era, resectability rates improved (69% vs. 17%; P = 0.0002), and this was associated with an improvement in median survival (30 vs. 4 months; P < 0.001). Factors predictive of improved disease-specific and disease-free survival included negative histologic margins, concomitant hepatic lobectomy, lack of nodal disease, well-differentiated histology, and an earlier tumor stage (P < 0.05). Concomitant liver resection was associated with a higher R0 resection rate (P = 0.006) and improved DSS and DFS (P = 0.005). In addition, concomitant liver resection was associated with a decreased incidence of initial recurrence in liver (P = 0.031).

CONCLUSIONS

In patients with hilar cholangiocarcinoma, concomitant hepatic resection is associated with improved DFS, DSS, and decreased hepatic recurrence. Therefore, hepatectomy combined with bile duct resection should be considered standard treatment.

[Radical resection of a hilar cholangiocarcinoma. Indications and results]

OBJECTIVE

The objective of the study is to review our experience in the surgical treatment of Klatskin tumours, after the systematic application of the current concepts of radicalism. Sixty-one patients resected using these criteria are presented.

PATIENTS AND METHOD

We have studied 154 patients. Surgery was ruled out in 59 (41%) of them, and a liver transplant was performed on 9; of the 86 patients operated on, 25 were resectable. Resectability was 71% (of the 86 patients operated on) and was 39% of the total patients. The results during two periods are compared, 1989-1998 (pre-99) and 1999-2007 (post-99).

RESULTS

On comparing the two periods, resectability increased from 26% to 53% (p = 0.01), the percentage of exploratory laparotomies decreasing (pre: 45% vs post: 22%; p = 0.04). Hepatectomy was performed in 53 cases (87%), being most frequent post-99 (pre: 66% vs post: 91%; p = 0.02). Resection of the caudate was performed in 48 cases (90%), being most frequent in the post-99 period (pre: 40% vs pos: 89%; p = 0.005). Post-operative morbidity was 77%, with 28% the patients being re-operated on, and the post-operative mortality was 16.4%, with no significant differences between the periods. Actuarial survival at 5 years increases in the post-99 period (pre: 26% vs post: 51%; p = 0.06).

CONCLUSIONS

Adequate staging, associated with an aggressive surgical strategy can achieve a greater than 50% resectability rate. The post-operative morbidity and mortality of this strategy is high, but the survival that it achieves justifies this.

Surgical management and prognostic factors of hilar cholangiocarcinoma: experience with 115 cases in China

BACKGROUND

Hilar cholangiocarcinoma (or Klatskin tumor) is a rare condition, accounting for less than 1% of all cancers. This study was designed to assess the surgical and postsurgical management of affected patients, including the postoperative chemotherapy, and an analysis to determine prognostic factors for postoperative morbidity and mortality.

METHODS

A retrospective review of 115 consecutive cases treated with resection between January 1990 and January 2004 at a single university medical center in southern China was carried out. Clinicopathological data were analyzed and univariate and multivariate analyses against outcome was employed to determine the prognostic significance of a variety of factors including excision margin characteristics, status of metastases, tumor type, histological differentiation, lymph node characteristics, and postoperative therapy.

RESULTS

Median survival time of patients treated with resection and anastomosis with postoperative chemotherapy was 41 months compared with 36 months for patients who did not receive chemotherapy postoperatively. Factors correlating with shorter survival were positive excision margin, metastasis, adenoacanthoma-type tumor, poor or unknown histological differentiation, and positive lymph nodes. In addition, postoperative chemotherapy improved survival. Patients treated with chemotherapy postoperatively had a survival of 43.15 +/- 21.02 months, which was significantly longer than the survival of patients who received no postoperatively chemotherapy (36.97 +/- 15.99 months; P < 0.05).

CONCLUSION

Resection with anastomosis and postoperative chemotherapy results in longer survival time compared with no chemotherapy postoperatively. Positive excision margins, metastases, adenoacanthoma-type tumor, poor or unknown histological differentiation, and positive lymph nodes correlate with shorter survival.

Surgery for extrahepatic cholangiocarcinoma: predictors of survival

The incidence of extrahepatic cholangiocarcinoma is increasing worldwide and is often in an advanced stage at diagnosis and difficult to treat. The TNM (tumor node metastasis) cancer staging system predicts survival on the basis of tumor histopathology and the presence of distant metastases. However, numerous prognostic factors have been described that are not included in the TNM system. This review focuses on the prognostic significance of clinical, surgical, and histopathological factors as reported in the literature. Overall, the most important independent prognostic factors for long-term survival are negative surgical margins, lymph node status, and differentiation grade of the tumor. Further improvement of staging systems and identification of prognostic factors are crucial if we are to better select patients for surgical and adjuvant therapy and, hence, increase the rate of curative resections.

Local surgical resection of hilar cholangiocarcinoma: is there still a place?

In recent decades, surgical treatment of hilar cholangiocarcinoma has moved toward liver surgery in association with biliary resection in order to increase radicality and to achieve better survival. Results of local resection compared with hepatectomy associated with bile duct resection and its actual indications have to be clarified. A systematic review of relevant studies published before December 2007 was performed. Original published studies comparing the results of isolated local excision with those of hepatectomy associated with bile duct resection were identified and the reported results were synthesized. The pathologic data suggest that isolated bile duct resection cannot be adequate: required wide surgical margins; neoplastic extension along perineural sheaths; Segment 1 neoplastic invasion. Considering postoperative outcomes, in the 1990s, local resection had significantly lower mortality rates than liver resection. In recent years, the short-term results of liver surgery have improved significantly, while mortality rates have decreased. The R0 resection rate is significantly higher after associated liver resection. Comparison of survival results between local resection and associated liver surgery is difficult because, in the majority of series, the treatment was planned according to tumor extension. Better long-term outcomes have been reported after liver resection than after isolated bile duct resection, even for Bismuth-Corlette type I-II cholangiocarcinoma. Long-term survivors after local resection have been reported in a few selected patients with Bismuth-Corlette type I Tis-T1 or papillary neoplasm.

A new technique of biliary reconstruction after "high hilar resection" of hilar cholangiocarcinoma with tumor extension to secondary and tertiary biliary radicals

BACKGROUND

Radical operation for hilar cholangiocellular carcinoma, including extended hepatic resection, seems to improve prognosis by increasing the surgical curability rate. Nevertheless, high postoperative morbidity and mortality have been reported in patients with obstructive jaundice. We describe the technique of "high hilar resection" and a modification of bilioenteric anastomosis for drainage of the multiple secondary or tertiary biliary radicals.

METHODS

Ten patients with advanced hilar cholangiocellular carcinoma underwent a high hilar resection with complete parenchymal preservation, and the biliary drainage was reconstructed by a sheath-to-enteric hepaticojejunostomy. Because of the technical difficulty caused by anastomosis line in the range of the biliary sheath, a modification was performed by dividing the biliary apertures of segments 5 and 4b.

RESULTS

A high hilar resection was successfully performed, and all patients were discharged from the hospital in good condition. No patient died postoperatively. The proximal resection margin was tumor-free in all patients. One patient died after 29 months of peritoneal carcinomatosis. None of the patients developed local recurrence around the hepaticojejunostomy. The remaining nine patients are alive after a mean follow-up of 28.8 months after surgery without any signs of recurrence.

CONCLUSION

In highly selected patients with advanced hilar cholangiocellular carcinoma, a high hilar resection is technically safe and oncologically justifiable. In combination with our new technique of sheath-to-enteric anastomosis, the patients considerably benefit from the preservation of liver parenchyma with low postoperative morbidity and very short in-hospital stay.

Immunoglobulin G4-related sclerosing cholangitis in patients resected for presumed malignant bile duct strictures

Background

Immunoglobulin (Ig) G4-related lymphoplasmacytic sclerosing pancreatitis has been described in the context of autoimmune pancreatitis mimicking distal cholangiocarcinoma. The aim of this study was to assess the occurrence of this entity in benign bile duct strictures in patients resected for presumed hilar cholangiocarcinoma.

Methods

Of 185 patients who had undergone resection of proximal bile ducts on suspicion of hilar cholangiocarcinoma between January 1984 and June 2005, 32 (17·3 per cent) had a benign bile duct stricture on histopathological examination. After re-evaluation, further immunohistochemical analysis was performed on specimens from patients with features of autoimmune-like disease.

Results

The periductal stroma in 15 patients showed features of autoimmune-like disease (diffuse, moderate to severe lymphoplasmacytic infiltration with marked fibrosis). Abundant IgG4-positive plasma cell infiltration around the bile duct lesions was seen in two of these. Although not significant, patients with features of autoimmune-like disease on histological changes showed a higher incidence of recurrent biliary complications than those without (P = 0·250).

Conclusion

Features of autoimmune-like bile duct disease were seen in almost half (15 of 32) of patients with benign hilar strictures resected for presumed hilar cholangiocarcinoma. Frank IgG4-related sclerosing disease was found in only two of the 15 patients with autoimmune-like bile duct disease.

Original article: New surgical approaches to the Klatskin tumour

BACKGROUND

Surgical treatment of hilar cholangiocarcinoma (Klatskin tumours) is difficult because of its central location in the liver hilum. Recent developments in surgical techniques have improved the outcome after resection.

AIM

To describe the surgical approaches currently applied in our centre and the impact of these strategies on outcome and criteria for resection.

METHODS

From 1988 to 2003, 99 consecutive patients underwent resection for hilar cholangiocarcinoma. Patients were analysed for rate of R0 resections in relation with Bismuth classification. Morbidity, mortality and survival were assessed.

RESULTS

The rate of hilar resections in combination with (extended) liver resections for type III and IV tumours increased from 24% to 95% in the last 5 years of the study period. Eight patients (8%) had Bismuth type IV tumours. Four of these patients underwent palliative local excisions of the hepatic duct confluence whereas the other four patients underwent hilar resection in combination with partial liver resection, resulting in microscopically radical resections. There was no mortality in this group. Overall postoperative morbidity and mortality were 68% and 10%, respectively.

CONCLUSIONS

An aggressive surgical approach consisting of hilar resections combined with partial liver resections including segments 1 and 4, resulted in a higher rate of R0 resections. Even Bismuth type IV tumours may be resectable depending on the biliary anatomy of the hepatic duct confluence.

[Management of hilar cholangiocarcinoma]

Hilar cholangiocarcinoma is a rare disease departing from the biliary convergence. It is primarily revealed by the onset of retention jaundice. Only 20%-30% of patients can undergo resection at diagnosis. The only chance for survival for these patients is R0 resection, which requires hepatectomy associated with resection of the common bile duct and pedicle lymph node removal, whatever the classification of the cholangiocarcinoma. No adjuvant treatment has been shown to be effective to date. Palliative treatment is most often based on implanting a biliary stent. Dynamic phototherapy may be beneficial in these situations. Improvements in survival for selected N0 hilar cholangiocarcinoma may be obtained with neoadjuvant treatment with radiochemotherapy followed by liver transplantation.

Radicalidad en la cirugía del colangiocarcinoma hiliar (tumor de Klatskin)

In patients with hilar cholangiocarcinoma, long-term survival critically depends on complete tumor resection. Indeed, there are no long-term survivors with positive resection margins. Furthermore, hilar cholangiocarcinoma seems to have a low propensity for distant metastases and adjuvant therapy after surgery has not been shown to have clear clinical benefits. This evidence should be regarded as arguments for extended resections. The question remains of how to achieve an R0 resection. In the last few years greater use of major hepatectomy has increased resectability and has improved long-term results. Concomitant resection of the caudate lobe is recommended as this site is a prime area of local recurrence. Frozen sections should be routinely used to assess the remnant proximal and distal ductal stumps. However, if the proximal remnant is positive, additional ductal resection at the separating limits is not always feasible. Gross portal vein invasion has a negative impact on survival, but should not be a contraindication to resection. Hepatectomy with portal vein resection can offer long-term survival in some patients with advanced hilar cholangiocarcinoma. The incidence of nodal involvement in resected specimens has been reported to range from 30% to more than 50% and there is a correlation between primary tumor extension and nodal involvement. Lymphatic metastases from hilar cholangiocarcinoma appear to spread first to pericholedochal nodes in the hepatoduodenal ligament and then to spread widely toward the posteriorsuperior area around the pancreatic head, portal vein and common hepatic artery. Routine lymphadenectomy should include all these areas. The only factors precluding resection are involvement of celiac, superior mesenteric or para-aortic tumoral nodes. Survival is closely associated with the extent of nodal involvement. The no-touch technique including right trisegmentectomy combined with portal vein resection has been proposed as the surgical procedure of choice for a more radical approach, and as a measure to prevent dissemination of tumor cells during surgery.

Cholangiocarcinoma: thirty-one-year experience with 564 patients at a single institution

OBJECTIVE

To assess long-term survival and prognostic factors in a large series of patients with bile duct cancer.

SUMMARY BACKGROUND DATA

The incidence of bile duct cancer is low but increasing. Determinants of survival vary in the literature, due to a lack of sufficient numbers of patients in most series.

METHODS

We studied 564 consecutive patients with bile duct cancer operated upon between 1973 and 2004. Patients were divided into intrahepatic, perihilar, and distal groups. Principle outcome measures were complications, 30-day mortality, and survival.

RESULTS

Of the 564 patients, 44 (8%) had intrahepatic, 281 (50%) had perihilar, and 239 (42%) had distal tumors. Approximately half (294, 52%) were treated before 1995, while 270 (48%) were treated thereafter. The perioperative mortality rate was 4%. In log-rank analyses, survival was higher in the later time period (P = 0.002), in patients with intrahepatic disease (P = 0.001), with negative resection margins (P < 0.001), with well/moderately differentiated tumors (P < 0.001), and those with negative lymph nodal status (P < 0.001). In multivariate analysis, negative margins (P < 0.001), tumor differentiation (P < 0.001), and negative nodal status (P < 0.001), but not tumor diameter, were significant independent prognostic factors. In R0-resected patients, lymph node status (P < 0.001), but not tumor diameter, histology, or differentiation, further predicted survival. The median survivals for R0-resected intrahepatic, perihilar, and distal tumors were 80, 30, and 25 months, respectively, and the 5-year survivals were 63%, 30%, and 27%, respectively.

CONCLUSION

R0 resection remains the best chance for long-term survival, and lymph node status is the most important prognostic factor following R0 resection.

Cholangiocarcinoma: thirty-one-year experience with 564 patients at a single institution

OBJECTIVE

To assess long-term survival and prognostic factors in a large series of patients with bile duct cancer.

SUMMARY BACKGROUND DATA

The incidence of bile duct cancer is low but increasing. Determinants of survival vary in the literature, due to a lack of sufficient numbers of patients in most series.

METHODS

We studied 564 consecutive patients with bile duct cancer operated upon between 1973 and 2004. Patients were divided into intrahepatic, perihilar, and distal groups. Principle outcome measures were complications, 30-day mortality, and survival.

RESULTS

Of the 564 patients, 44 (8%) had intrahepatic, 281 (50%) had perihilar, and 239 (42%) had distal tumors. Approximately half (294, 52%) were treated before 1995, while 270 (48%) were treated thereafter. The perioperative mortality rate was 4%. In log-rank analyses, survival was higher in the later time period (P = 0.002), in patients with intrahepatic disease (P = 0.001), with negative resection margins (P < 0.001), with well/moderately differentiated tumors (P < 0.001), and those with negative lymph nodal status (P < 0.001). In multivariate analysis, negative margins (P < 0.001), tumor differentiation (P < 0.001), and negative nodal status (P < 0.001), but not tumor diameter, were significant independent prognostic factors. In R0-resected patients, lymph node status (P < 0.001), but not tumor diameter, histology, or differentiation, further predicted survival. The median survivals for R0-resected intrahepatic, perihilar, and distal tumors were 80, 30, and 25 months, respectively, and the 5-year survivals were 63%, 30%, and 27%, respectively.

CONCLUSION

R0 resection remains the best chance for long-term survival, and lymph node status is the most important prognostic factor following R0 resection.

Hepaticojejunostomy--analysis of risk factors for postoperative bile leaks and surgical complications

Anastomoses between the jejunum and the bile duct are an important component of many surgical procedures; however, risk factors for clinically relevant bile leaks have not yet been adequately defined. The objective of this study was to describe the incidence of bile leaks after hepaticojejunostomy and to define predictive factors associated with this risk and with surgical morbidity. Between October 2001 and April 2004, hepaticojejunostomies were performed in 519 patients in a standardized way. Patient- and treatment-related data were documented prospectively. A bile leak was defined as bilirubin concentration in the drains exceeding serum bilirubin with a consecutive change of clinical management or occurrence of a bilioma necessitating drainage. Surgical morbidity occurred in 15% of patients, the incidence of a bile leak was 5.6%. Multivariate analysis confirmed preoperative radiochemotherapy, preoperative low cholinesterase levels, biliary complications after liver transplantation necessitating a hepaticojejunostomy, and simultaneous liver resection as risk factors for bile leakages, whereas biliary complications after liver transplantation necessitating hepaticojejunostomy, simultaneous liver resection, and diabetes mellitus were significantly associated with postoperative surgical morbidity. Our results demonstrate that hepaticojejunostomy is a safe procedure if performed in a standardized fashion. The above found factors may help to better predict the risk for complications after hepaticojejunostomy.

Cholangiocarcinoma: emerging approaches to a challenging cancer

PURPOSE OF REVIEW

Cholangiocarcinomas are malignancies arising from biliary tract epithelia that are associated with a poor prognosis. The diagnosis, evaluation and management of these tumors continue to be clinically challenging. In this review, we will discuss recent information that may influence the approach to the diagnosis and management of this devastating tumor.

RECENT FINDINGS

Epidemiological studies are defining patient groups at increased risk of cancer in regions of low prevalence. Emerging approaches that may improve evaluation and management include the potential use of genomic and proteomic markers, cytogenetic and digital image analysis, endoscopic ultrasound with fine needle aspiration, and cholangioscopy. Adoption of aggressive surgical approaches along with the use of preoperative portal vein embolization, hepatic and caudate lobe resection and preoperative laparoscopy may improve survival.

SUMMARY

Recent conceptual and technical advances will impact the clinical approach to cholangiocarcinoma and offer the promise of improving outcomes from this difficult tumor.