Vascular Resection in Perihilar Cholangiocarcinoma.

Alejandro Serrablo,Luis Tejedor,Leyre Serrablo,Ruslan Alikhanov

doi:10.3390/cancers13215278

Abstract

Simple SummaryIn perihilar cholangiocarcinoma with vascular involvement, vascular resection to achieve margin-free status is being performed with increasing frequency despite controversial results. Morbidity, mortality, and overall survival are widely variable throughout the world. Vascular resections can include the portal vein alone, the hepatic artery alone, or combined resections. In some cases of locally advance disease, extended resections, such as hepatopancreatoduodenectomy or liver transplant, may be performed to achieve R0 status or a change to cure. The neoadjuvant treatment could help to achieve it. This article reviews and updates all treatment options in this setting.Among the cholangiocarcinomas, the most common type is perihilar (phCC), accounting for approximately 60% of cases, after which are the distal and then intrahepatic forms. There is no staging system that allows for a comparison of all series and extraction of conclusions that increase the long-term survival rate of this dismal disease. The extension of the resection, which theoretically depends on the type of phCC, is not a closed subject. As surgery is the only known way to achieve a cure, many aggressive approaches have been adopted. Despite extended liver resections and even vascular resections, margins are positive in around one third of patients. In the past two decades, with advances in diagnostic and surgical techniques, surgical outcomes and survival rates have gradually improved, although variability is the rule, with morbidity and mortality rates ranging from 14% to 76% and from 0% to 19%, respectively. Extended hepatectomies and portal vein resection, or even right hepatic artery reconstruction for the left side tumors are frequently needed. Salvage procedures when arterial reconstruction is not feasible, as well as hepatopancreatoduodenectomy, are still under evaluation too. In this article, we discuss the aggressive surgical approach to phCC focused on vascular resection. Disparate results on the surgical treatment of phCC made it impossible to reach clear-cut conclusions.

Highlights

Altemeier in 1957 and Gerald Klatskin in 1965 were the first surgeons who described cholangiocarcinoma [1,2]
Between 50% and 70% of all cholangiocarcinomas are perihilar or Klatskin tumors [3,4,5,6]. phCC is a highly unresectable malignancy because, despite being a slow growing tumor, its proximity to hepatic hilar structures leads to early vascular involvement, complicating surgical resection
An aggressive surgical approach increases the number of resectable tumors that are initially regarded as unresectable [7], with 5-year survival rates (5-y SR) of 25–45% in

Summary

Introduction

Altemeier in 1957 and Gerald Klatskin in 1965 were the first surgeons who described cholangiocarcinoma [1,2]. PhCC is a highly unresectable malignancy because, despite being a slow growing tumor, its proximity to hepatic hilar structures leads to early vascular involvement, complicating surgical resection. The conventional surgical technique for the treatment of phCC is right or left hepatectomy, plus segment 1 resection, plus biliary duct resection, plus hilar lymphadenectomy. To this technique, a PV resection alone, a HA resection alone, both (HA resection may be followed or not by a HA reconstruction or a PV arterialization), or a pancreatoduodenectomy can be added. Thirty- and ninety-day mortality was more that four-fold higher in this group, compared with the non-vascular resected group [9]

Hepatic Artery Resection

Vascular Resection and Hepatopancreatoduodenectomy

Primary Procedure

Findings

Conclusions