Surgical Treatment Of Hilar And Intrahepatic Cholangiocarcinoma PdfBy Laercio M. In and pdf 31.03.2021 at 19:09 7 min read
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- Surgery for cholangiocarcinoma
- Intrahepatic cholangiocarcinoma: current perspectives
- Surgical Treatment of Hilar and Intrahepatic Cholangiocarcinoma
Peri-hilar cholangiocarcinoma PHC or hilar cholangiocarcinoma HCCA characterizes a critical effort to assess significantly sick patients.
Complete resection remains the only potentially curative therapy for biliary tract cancers BTC. Unfortunately, patients most commonly present with unresectable or metastatic disease, and recurrence rates remain high after complete resection. This review focuses on the current surgical strategies in the management of BTCs including gallbladder cancer, intrahepatic, and extrahepatic cholangiocarcinoma. Gallbladder cancer typically presents one of three ways: I suspicion of malignancy preoperatively; II malignancy suspected intra-operatively; and III malignancy diagnosed incidentally following cholecystectomy.
Surgery for cholangiocarcinoma
Metrics details. Radical resection is the only curative treatment for patients with hilar cholangiocarcinoma. While left-side hepatectomy LH may have an oncological disadvantage over right-side hepatectomy RH owing to the contiguous anatomical relationship between right hepatic inflow and biliary confluence, a small future liver remnant after RH could cause worse surgical morbidity and mortality. We retrospectively compared surgical morbidity and long-term outcome between RH and LH to determine the optimal surgical strategy for the treatment of hilar cholangiocarcinoma.
This study considered 83 patients who underwent surgical resection for hilar cholangiocarcinoma between and Among them, 57 patients undergoing curative-intent surgery including liver resection were enrolled for analysis—33 in the RH group and 27 in the LH group. Prospectively collected clinicopathologic characteristics, perioperative outcomes, and long-term survival were evaluated.
Portal vein embolization was more frequently performed in the RH group than in the LH group The proportion of R0 resection was comparable in both groups The 5-year overall and recurrence-free survival rates did not differ between the groups The side of liver resection did not affect long-term survival.
In multivariate analysis, transfusion odds ratio, 3. We recommend deciding the side of liver resection according to the possibility of achieving radical resection considering the anatomical differences between RH and LH.
Complete surgical resection with a negative margin is the only curative treatment for hilar cholangiocarcinoma [ 1 , 2 , 3 ]. However, R0 resection is always technically demanding owing to the complex contiguity of the hilar structures and longitudinal spread of the tumor.
Surgical morbidity and mortality are relatively high since surgical resection for hilar cholangiocarcinoma usually consists of extensive resection including major hepatectomy [ 4 , 5 ]. Regarding the extent of liver resection, inclusion of the caudate lobe has been a standard procedure as the bile ducts of the caudate lobe originate in the hilar bile ducts [ 6 , 7 ].
Right-side or left-side hepatectomy RH or LH, respectively is also mandatory to achieve a negative margin for hilar cholangiocarcinoma above Bismuth type II [ 1 , 8 ]. Which side of the liver to resect is determined according to the following considerations: 1 side and level of intrahepatic bile duct invaded by the tumor, 2 vascular invasion to the hepatic artery or portal vein, and 3 adequate future liver remnant FLR volume.
Tumors often invade the right hepatic artery because the right hepatic artery usually courses close behind the biliary confluence. When performing LH in such cases, aggressive vascular reconstruction is required to achieve radical resection [ 9 , 10 ].
Hence, some have argued that LH is considered to have an oncological disadvantage over RH [ 11 ]. There have been few studies about the comparative analysis between RH and LH in hilar cholangiocarcinoma, and the impact of the side of liver resection has not yet been fully determined [ 12 , 13 ].
Therefore, the aim of this study was to compare surgical morbidity and long-term outcomes between RH and LH in patients undergoing curative-intent resection for hilar cholangiocarcinoma. All 83 consecutive patients who underwent surgical resection for hilar cholangiocarcinoma between and were considered for this study.
The following exclusion criteria were applied: 1 non-curative-intent surgery such as bypass surgery, 2 surgery without liver resection, and 3 R2 resection macroscopic residual tumor. Prospectively collected data were retrospectively reviewed.
Contrast-enhanced multidetector computed tomography CT and magnetic resonance MR cholangiography were routinely performed to assess the tumor extent and resectability as well as anatomical variation. In addition, positron emission tomography PET -CT was performed to rule out potential distant metastases.
In patients with obstructive jaundice, preoperative biliary drainage, consisting of endoscopic nasobiliary drainage ENBD , through endoscopic retrograde cholangiopancreatography ERCP or percutaneous transhepatic biliary drainage PTBD were aggressively performed not only to obtain a histological diagnosis but also to decrease the bilirubin level. The indocyanine green ICG test was performed to assess the functional status of the liver after the total bilirubin level decreased to below 2.
Achievement of radical resection was the most important consideration in determining the surgical strategy. The longitudinal and radial extent of the tumor was assessed comprehensively through various imaging studies during an inter-department conference. The surgical procedures are detailed as follows. After making an upper midline incision, the entire abdominal cavity was explored to detect unexpected peritoneal seeding or metastasis.
If there was no obvious distant metastasis, a transverse extension to the right side was made to just below the right subcostal margin. A Kocher maneuver was routinely performed for resection of the aortocaval and retropancreatic lymph nodes. The hepatic artery and portal vein to the FLR were isolated to evaluate tumor resectability.
Thereafter, the distal common bile duct was isolated and divided at the level of the intrapancreatic portion to retain a negative distal resection margin, and the remainder was sent for frozen biopsy. Subsequently, skeletonization of the hepatoduodenal ligament was performed. The hepatic artery and portal vein of the side to be resected were suture-tied and divided, being careful not to disturb the vascular inflow to the FLR. If the tumor invaded the portal vein confluence, segmental resection and anastomosis were performed before liver transection.
After the liver was mobilized by dividing all ligamentous attachments, it was transected using a Cavitron Ultrasonic Surgical Aspirator Valleylab, Boulder, Colorado, USA along the demarcation line marked by the ischemic color change of the liver surface. The caudate lobe was involved in all cases. The left intrahepatic bile duct was resected at the origin of the umbilical portion in RH, while the right intrahepatic bile duct was resected at the highest achievable level in LH.
The hepatic vein was then resected. Multiple bile duct openings usually remained to be reconstructed after removal of the specimen from the abdominal cavity. The Roux limb was placed up in a retrocolic fashion, and hepaticojejunostomy was performed using a single-layer suture after making the bile duct openings contiguous whenever possible.
After completing the posterior wall suture, a trans-anastomotic internal plastic stent was inserted into each opening. Thereafter, jejunojejunostomy was performed. Two drainage catheters were placed around the resection plane of the liver and the hepaticojejunostomy.
Abdominal closure was performed after hemostasis was achieved. The follow-up visits comprised a physical exam, laboratory tests including tumor markers, and CT scan.
Postoperative adjuvant treatment was performed based on the final pathologic report. All patients who had lymph node metastasis were attempted to receive adjuvant chemotherapy with gemcitabine plus cisplatin, except for patients who refused. Patients with positive resection margin R1 resection received 5-FU-based concurrent chemoradiotherapy. No postoperative treatment was performed for patients who had no lymph node metastasis after R0 resection. The Bismuth—Corlette classification was used to categorize the type of hilar cholangiocarcinoma, as assessed by various imaging studies [ 14 ].
Preoperative cholangitis was defined as fever with increased bilirubin and white blood cell count with antibiotic administration. Continuous variables are presented as median and range and categorical variables as numbers with percentages. Overall and recurrence-free survival OS and RFS, respectively were calculated using Kaplan—Meier analysis and compared using log-rank tests.
Cox proportional hazards regression analysis was used to assess the prognostic significance of variables for survival. Baseline characteristics for all patients are shown in Table 1. These included 37 male and 20 female patients, with a median age of 66 42—83 years. The median follow-up was 19 1—97 months. Among patients who received preoperative biliary drainage, ENBD was performed for 20 patients Initial total bilirubin upon hospital referral was higher in the RH group than that in the LH group, with borderline significance 5.
However, there was no difference in total bilirubin prior to surgery 1. Six patients in the RH group underwent portal vein embolization because of a small FLR volume, compared to no patients in the LH group The baseline characteristics, besides portal vein embolization, did not differ between groups. With a combined intra-abdominal infection, hepatic failure progressed and the patient died at postoperative day Two patients in the RH group died due to pneumonia-induced sepsis.
One patient in the LH group developed a pseudoaneurysm of the hepatic artery after biliary leakage for which a stent graft was inserted successfully.
However, liver abscess and pneumonia-induced sepsis occurred subsequently. The 1-, 3-, and 5-year OS rates for all patients were The 1-, 3-, and 5-year OS rates of the RH group were RH, right-side hepatectomy; LH, left-side hepatectomy.
In univariate analysis, transfusion odds ratio, 3. Multivariate analysis revealed that transfusion 3. On the other hand, transfusion 2. Subgroup analysis was performed for 21 patients who had lymph node metastasis: 15 in the RH group and 6 in the LH group. Among them, 11 patients There were no significant differences in 5-year OS and RFS rates between adjuvant and non-adjuvant treatment group Considering its prognostic effects on the long-term outcome, radical resection plays a major role in the treatment of hilar cholangiocarcinoma [ 17 ].
Therefore, many surgeons have made considerable efforts to adopt an aggressive surgical approach, despite technical difficulty [ 9 , 18 ]. There are many considerations in determining which side of the liver to resect. The Bismuth—Corlette classification has been widely used to assess the hilar cholangiocarcinoma preoperatively [ 14 ].
It is a simple but useful method for classifying the type of tumor and deciding the surgical plan. However, surgeons must choose between RH and LH for tumors extending to both sides of the bile duct to a similar level or invading hepatic inflow to the FLR. Once a surgeon decides the surgical plan, it is hard to change during surgery.
Hence, clarifying the surgical outcome and long-term survival between RH and LH can be instrumental in deciding the surgical strategy for hilar cholangiocarcinoma. Few reports have compared RH and LH in hilar cholangiocarcinoma, and the impact of the side of the liver resection has not yet been established [ 12 , 13 ]. The tumor tends to invade the right hepatic artery or portal vein because biliary confluence leans to the right side of the vascular confluence [ 9 , 11 , 19 ].
This could lead surgeons performing LH to choose whether to stop further resection or to conduct aggressive vascular reconstruction. Various studies have demonstrated a high incidence of vascular invasion leading to reconstruction in LH [ 20 , 21 ].
Nagino et al. However, although combined portal vein resection and reconstruction are considered to be a certain option to increase resectability with acceptable morbidity [ 22 ], hepatic artery reconstruction could still be technically difficult and cause serious complications.
Furthermore, achieving a negative proximal ductal margin is another reason that makes R0 resection difficult. Some authors have asserted that a negative proximal ductal margin can be more easily achieved in RH because the left extrahepatic bile duct to the bifurcation is longer than that of the right liver and there is less variation in the segmental anatomy of the left liver [ 23 ].
Intrahepatic cholangiocarcinoma: current perspectives
Cholangiocarcinoma CCC is the most aggressive malignant tumor of the biliary tract. Besides its clinical presentation, a multimodal diagnostic approach should be carried on by a tertiary specialized center to avoid miss-diagnosis. Preoperative staging must consider the extent of liver resection to avoid post-surgical hepatic failure. During staging iter, magnetic resonance can obtain satisfactory cholangiographic images, while invasive techniques should be used if bile duct samples are needed. Consistently, to improve diagnostic potential, bile duct drainage is not necessary in jaundice, while it is indicated in refractory cholangitis or when liver hypertrophy is needed. Once resecability criteria are identified, the extent of liver resection is secondary to the longitudinal spread of CCC. While in the past type IV pCCC was not considered resectable, some authors reported good results after their treatment.
It seems that you're in Germany. We have a dedicated site for Germany. Cholangiocarcinoma is the second most frequent primary neoplasm of the liver and its incidence is increasing in Western countries. These neoplasms arise from the biliary tract and can be categorized according to their anatomical location as intrahepatic and extrahepatic cholangiocarcinomas. This book contains an up-to-date review of diagnostic and staging tools of cholangiocarcinoma, and of long-term outcome of surgery and liver transplantation. It also provides a guide to optimal selection of therapeutic modalities and a detailed description details of surgical techniques and principles for curative and palliative surgery.
Surgical Treatment of Hilar and Intrahepatic Cholangiocarcinoma
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Metrics details. Radical resection is the only curative treatment for patients with hilar cholangiocarcinoma. While left-side hepatectomy LH may have an oncological disadvantage over right-side hepatectomy RH owing to the contiguous anatomical relationship between right hepatic inflow and biliary confluence, a small future liver remnant after RH could cause worse surgical morbidity and mortality. We retrospectively compared surgical morbidity and long-term outcome between RH and LH to determine the optimal surgical strategy for the treatment of hilar cholangiocarcinoma. This study considered 83 patients who underwent surgical resection for hilar cholangiocarcinoma between and
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