Symposium on hilar cholangiocarcinoma

Abstract

Hilar cholangiocarcinoma has been a subject of major interest in the IHPBA ever since its founding, with many members who have emerged as leading experts in the management of this difficult tumour. This thematic issue of HPB addresses some of the current issues in the surgical treatment of hilar cholangiocarcinoma. The first contribution, from New York, deals with preoperative evaluation and assessment of resectability of hilar cholangiocarcinoma. The Bismuth–Corlette classification is based on proximal extent of the tumour into the biliary tree, but does not take into account vascular involvement. The authors therefore propose an alternative, clinical staging system based on biliary ductal involvement, vascular involvement and lobar atrophy. The paper from Paris points out the need for optimal preoperative preparation of patients with hilar cholangiocarcinoma considered for resection. Although preoperative biliary decompression is controversial, it probably is important in patients with hilar cholangiocarcinoma requiring extended liver resection in order to allow postoperative or preoperative regeneration of the liver, the latter in the setting of preoperative portal vein embolization to induce hypertrophy of the future liver remnant. Resectional strategies in the treatment of hilar cholangiocarcinoma are discussed in the contribution from Houston. Resection of the portal vein bifurcation in conjunction with hilar resection potentially increases the rate of margin‐negative resections, but as the authors emphasize, is not routinely recommended in the absence of signs of portal vein invasion. The authors from Nagoya, who pioneered resection of hilar cholangiocarcinoma with extended liver resections three decades ago, show that in recent years, these major resections have been performed with a mortality rate of <5% and a 5‐year survival rate of 27% (in R0 resections). They also show that patients resected with regional lymph node metastases still have a better survival than unresected patients. In a study from Amsterdam, it is shown that complete excision of segment 1 with resection of hilar cholangiocarcinoma leads to a higher rate of R0 resections and improves survival without increasing morbidity or mortality. The current status of liver transplantation in the treatment of hilar cholangiocarcinoma is reviewed in the paper from Essen. The place of liver transplantation needs to be reconsidered in the light of recent, promising results of neoadjuvant therapies in selected patients. Surgical palliative treatment of hilar cholangiocarcinoma is addressed in the contribution from Edinburgh. Relief of pruritus or cholangitis is the main indication for biliary drainage, and most experience to date concerns segment III cholangio‐jejunostomy as a biliary bypass procedure. Although favourable results have been reported for intrahepatic ductal bypass, it remains to be seen whether these procedures can compete with percutaneous stenting techniques. A review from Indianapolis addresses the role of radiation and chemotherapy in hilar cholangiocarcinoma. Whereas the benefit of radiation or chemotherapy alone is questionable, chemoradiation seems the way to go but awaits further clinical assessment in controlled trials. It gives the editors of HPB great pleasure to present in this issue a true update on the surgical management of hilar cholangiocarcinoma, at the same time showing the vast experience with this tumour shared in the IHPBA.