Surgical Treatment Of Perihilar Cholangiocarcinoma Research Articles

Surgical treatment of the perihilar cholangiocarcinoma with portal vein invasion

Background. Perichilar cholangiocarcinoma is a rare type of malignant neoplasm and is 3-7 cases per 100,000 population. Surgical method is the only radical method of treatment, allowing to improve long-term survival results. One of the important and characteristic features of perihilar cholangiocarcinoma is tumor invasion to the area of the portal vein bifurcation, which occurs in 30–45% of cases. Portal vein invasion is the one of the main causes of perihilar cholangiocarcinoma irresectability. However, innovative surgical technologies allow resection of the liver with resection and reconstruction of the portal vein with acceptable mortality.
 The aim. The aim of our study was to asses results of surgical treatment of perihilar cholangiocarcinoma with (Group 1) and without (Group 2) portal vein invasion.
 Materials and methods. From 2003 to January 2023 in the Department of Surgery and Liver Transplantation of the Ukrainian National Institute of Surgery and Transplantation, 208 patients with perihilar cholangiocarcinoma underwent major extended liver resections. We compared 93 (46%) patients who received extended liver resection with portal vein resection (Group 1) with 115 (54%) patients who underwent liver resections without vascular reconstructions (Group 2). The average Ca 19–9 in the group 1 was 288 (8 – 1000) U/ml, in the group 2 –262 (10 – 612) U/ml. The level of total bilirubin in patients of the group 1 was 312 (43 – 621) mcmol/l, in the group 2 – 267 (10 – 612) mcmol/l. In view of this, in the preoperative period, 190 (91,3%) patients underwent decompression of the bile ducts, using percutaneous transhepatic cholangiostomy (PTBD) or retrograde endobiliary stenting. For patients with small remnant liver volume less than 40 %, in 80(38,5%) cases we did preoperative PVE of a resected part of the liver. In 9 cases we made simultaneous PVE and PTBD. When choosing the volume of surgical intervention, we proceeded from the tumor type of Bismuth-Corlette classification, invasion into the portal vessels and the depth of the liver lesion. The portal vein reconstruction was in all cases performed in an “end-to-end”. In all cases we made extended lymphadenectomy.
 Results. All complications were classified according to the Dindo-Clavien classification. Postoperative mortality in the main group was 11.5%. The overall 1, 3, 5-year survival in the group 1 was 96%, 68,3%, 57,4%, respectively. 1, 3, 5-year survival rate in the comparison group 2 was 98,4%, 76,7%, 47,3%, respectively.
 Conclusions. Aggressive tactics of surgical treatment of perihilar cholangiocarcinoma provides maximum radicality, allows to increase resectability in case of tumor invasion of the portal vein with acceptable mortality and long-term survival.

Profiling the High-Risk Patient in Surgical Treatment of Perihilar Cholangiocarcinoma: A New Scoring-System for Oncological Outcomes

Background: Profiling the “high-risk patient” is fundamental to define the indication for further oncological therapies in patients with perihilar cholangiocarcinoma (PHC). Aim of the present study was to evaluate factors associated with oncological outcomes and to propose a scoring system to stratify patients according to their surgical and biological characteristics. Methods: Two hundred sixty-four patients underwent surgery with curative intent for PHC. The series was randomly split into a derivation set of two-thirds and a validation set of one-third. A PHC score was developed based on factors resulting significantly associated with prognosis. The accuracy of this score was validated by calculating the area under the ROC curve. Results: Factors associated with long-term outcome in multivariable analysis included Bismuth type, grade of differentiation, nodal status, side of hepatectomy and resection margins. One point was assigned to each variable and the total score was compared with the long-term outcome of each patient in the validation set. The PHC score accurately predicted survival, with an area under the ROC curve of 0.83 in the validation set. Conclusion: Use of PHC score could lead to substantial improvement in the definition of patients “risk-profile” and therefore the need for further adjuvant therapies.

Surgical treatment of perihilar cholangiocarcinoma

One of the important and characteristic features of perihilar cholangiocarcinoma is tumor invasion to the area of the portal vein bifurcation, which occurs in 30% to 45% of cases. The aim of our study was to asses results of surgical treatment of perihilar cholangiocarcinoma with (Group 1) and without (Group 2) portal vein invasion. From 2003 to January 2021 in the Department of Surgery and Liver Transplantation of the Ukrainian National Institute of Surgery and Transplantation, 170 patients with perihilar cholangiocarcinoma underwent major extended liver resections. We compared 79 (46.5%) patients who received extended liver resection with portal vein resection with 91 (53.5%) patients who underwent liver resections without vascular reconstructions. In the preoperative period, 150 (88.5%) patients underwent decompression of the bile ducts, using percutaneous transhepatic cholangiostomy (PTBD) or retrograde endobiliary stenting. For patients with small remnant liver volume less than 40 %, in 42 cases we did preoperative PVE of a resected part of the liver. In 9 cases we made simultaneous PVE and PTBD. When choosing the volume of surgical intervention, we proceeded from the tumor type of Bismuth-Corlette classification, invasion into the portal vessels and the depth of the liver lesion. The portal vein reconstruction was in all cases performed in an "end-to-end". In all cases we made extended lymphadenectomy. Histologically, the tumor in 7 (11.5%) cases was well differentiated, in 47 (77%) cases-moderate differentiated, in 7 (11.5%) cases-poor differentiated. Aggressive surgical treatment for perihilar cholangiocarcinoma with portal vein resection can be performed.

Extended Right-hemihepatectomy Is Preferred for Perihilar Cholangiocarcinoma.

Extended Right-hemihepatectomy Is Preferred for Perihilar Cholangiocarcinoma.

Single Center Experience of Surgical Treatment of Perihilar Cholangiocarcinoma with Portal Vein Invasion

Aim: The aim of our study was to asses results of surgical treatment of perihilar cholangiocarcinoma with (Group 1) and without (Group 2) portal vein invasion. Materials and Methods: From 2003 to January 2021 in the Department of Surgery and Liver Transplantation of the Ukrainian National Institute of Surgery and Transplantation, 166 patients with perihilar cholangiocarcinoma underwent major extended liver resections. We compared 78 (47%) patients who received extended liver resection with portal vein resection with 88 (53%) patients who underwent liver resections without vascular reconstructions. 103 (62%) patients were male, 63 (38%) patients were female. The average age of patients in the group 1 was 57 (37 – 81) years in the group 2 of 57.1 (26 – 74) years. The average Ca 19–9 in the group 1 was 288 (8 – 1000) U/ml, in the group 2 – (10 – 612) 262 U/ml. The level of total bilirubin in patients of the group 1 was 312 (43 – 621) mcmol/l, in the group 2 – 267 (10 – 612) mcmol/l. In view of this, in the preoperative period, 116 (88.5%) patients underwent decompression of the bile ducts, using percutaneous transhepatic cholangiostomy (PTBD) or retrograde endobiliary stenting. For patients with small remnant liver volume less than 40 %, in 58 cases we did preoperative PVE of a resected part of the liver. In 9 cases we made simultaneous PVE and PTBD. When choosing the volume of surgical intervention, we proceeded from the tumor type of Bismuth-Corlette classification, invasion into the portal vessels and the depth of the liver lesion. The portal vein reconstruction was in all cases performed in an “end-to-end”. In all cases we made extended lymphadenectomy. According to a histological study, metastatic lesion of 1-3 regional lymph nodes (N1) was detected in 9 (14.7%) patients, 4 or more (N2) – in 2 (3.3%) patients. All complications were classified according to the Dindo-Clavien classification. Postoperative mortality in the main group was 11.5%. The overall 1, 3, 5-year survival in the group 1 was 86.8%, 58%, 50%, respectively. 1, 3, 5-year survival rate in the comparison group was 85.6%, 56%, 42%, respectively. Conclusion: Aggressive surgical treatment for cholangiocarcinoma the confluence of bile duct with portal vein resection can be performed safely with acceptable lethality and long-term survival rate.

Differences in Clinicopathological Factors and Outcomes after Major Liver Resection and Bile Duct Resection for Biliary Tract Cancers

Purpose: The surgical treatment of perihilar cholangiocarcinoma (PHC), intrahepatic cholangiocarcinoma (ICC) and gallbladder cancer (GBC) can be similar in case of hilar tumor infiltration. The aim of the present study was to investigate short- and long-term outcomes between these cancers operated with a major liver resection (≥3 Couinaud’s segments) and extrahepatic bile duct resection. Methods: All patients subjected to a major liver resection and bile duct excision for PHC, ICC and GBC at a single center between 2012-2019 were included. Clinicopathological factors and survival were compared between groups. Results: In total, 81 patients were included (52 PHC, 9 ICC, 20 GBC). Tumor size was 30, 67 and 48 mm for PHC, ICC, and GBC (P<0.001). Percentage node positivity and peritoneal invasion were 52, 67 and 85% (P=0.033) and 31, 44 and 50% (P=0.046), for PHC, ICC, and GBC. Mortality within 90 days was 4, 0 and 35% for PHC, ICC, and GBC (P=0.002). Median survival and 5-year survival excluding perioperative mortality were 31, 21 and 18 months, and 42, 13 and 20% for PHC, ICC, and GBC, respectively (P=0.197). Conclusion: PHC, ICC and GBC necessitating a major liver resection and bile duct resection for tumor clearance display differences in pathological features. Survival for GBC was low.

Profiling the High-risk Patient in Surgical Treatment of Perihilar Cholangiocarcinoma: A New Scoring-system for Oncological Outcomes

Background: Profiling the “high-risk patient” is fundamental to define the indication for further oncological therapies in patients with perihilar cholangiocarcinoma (PHC). Aim of the present study was to evaluate factors associated with oncological outcomes and to propose a scoring system to stratify patients according to their surgical and biological characteristics.

Portal Vein Embolization is Associated with Reduced Liver Failure and Mortality in High-Risk Resections for Perihilar Cholangiocarcinoma

BackgroundPreoperative portal vein embolization (PVE) is frequently used to improve future liver remnant volume (FLRV) and to reduce the risk of liver failure after major liver resection.ObjectiveThis paper aimed to assess postoperative outcomes after PVE and resection for suspected perihilar cholangiocarcinoma (PHC) in an international, multicentric cohort.MethodsPatients undergoing resection for suspected PHC across 20 centers worldwide, from the year 2000, were included. Liver failure, biliary leakage, and hemorrhage were classified according to the respective International Study Group of Liver Surgery criteria. Using propensity scoring, two equal cohorts were generated using matching parameters, i.e. age, sex, American Society of Anesthesiologists classification, jaundice, type of biliary drainage, baseline FLRV, resection type, and portal vein resection.ResultsA total of 1667 patients were treated for suspected PHC during the study period. In 298 patients who underwent preoperative PVE, the overall incidence of liver failure and 90-day mortality was 27% and 18%, respectively, as opposed to 14% and 12%, respectively, in patients without PVE (p < 0.001 and p = 0.005). After propensity score matching, 98 patients were enrolled in each cohort, resulting in similar baseline and operative characteristics. Liver failure was lower in the PVE group (8% vs. 36%, p < 0.001), as was biliary leakage (10% vs. 35%, p < 0.01), intra-abdominal abscesses (19% vs. 34%, p = 0.01), and 90-day mortality (7% vs. 18%, p = 0.03).ConclusionPVE before major liver resection for PHC is associated with a lower incidence of liver failure, biliary leakage, abscess formation, and mortality. These results demonstrate the importance of PVE as an integral component in the surgical treatment of PHC.

Surgical treatment of perihilar cholangiocarcinoma with vascular invasion

Introduction: Vascular invasion is a main cause irresectability of perihilar cholangiocarcinoma. However innovative surgical technologies allow resecting involved portal vein with acceptable mortality. Invasion of the hepatic artery, often combined with invasion of portal vein, still remains the most serious obstacle in resection of this disease. Aim: The aim of our study was to asses Results of surgical treatment of perihilar cholangiocarcinoma with portal vein and hepatic artery invasion. Materials and Methods: We studied Results of surgical treatment 141 patients with Klatskin tumor period 2002-2018. T2a TNM stage had 3% patients, T2b – 8,4% patients, T3 – 71,8% patients, and T4 stage TNM had 16,8% patients. Bismuth type B2 had 4,6% patients, B3a – 37,4% patients, B3b – 46,6% patients, B4 – 11,4% patients. For patients with small remnant liver volume, less than 40 %, we did preoperative PV embolization of a resected part of the liver. RPV embolization we did in 71% right hemyhepatectomy, RPVE with Sg4 embolization – for 31,8% right trisectionectomy, LPVE and RAPVE for 25% left trisectionectomy. PV resection was made 61 (46,6%) patients, combined PV and HA resection and reconstruction we did for 8 cases, liver transplantation – 2 cases. In all cases we made extended lymphadenectomy. Mortality was 11,5% (15 patients). 1-, 3- and 5-years survival was higher in group with portal vein resection 86,8%, 58% and 50% respectively, for patients without portal vein resection– 85,6%, 56% and 42%. Conclusion: Aggressive surgical treatment for cholangiocarcinoma the confluence of bile duct with hepatic artery and portal vein resection can be performed safely with acceptable lethality and long-term survival rate.

Progress in diagnosis and surgical treatment of perihilar cholangiocarcinoma

Progress in diagnosis and surgical treatment of perihilar cholangiocarcinoma

Single center experience concerning surgical treatment for perihilar cholangiocarcinoma in 226 patients

Single center experience concerning surgical treatment for perihilar cholangiocarcinoma in 226 patients

Single Center Experience concerning Surgical Treatment for Perihilar Cholangiocarcinoma in 226 patients

Single Center Experience concerning Surgical Treatment for Perihilar Cholangiocarcinoma in 226 patients

Surgical treatment of perihilar cholangiocarcinoma with vascular invasion

Introduction: Vascular invasion is a main cause irresectability of perihilar cholangiocarcinoma. However innovative surgical technologies allow resecting involved portal vein with acceptable mortality. Invasion of the hepatic artery, often combined with invasion of portal vein, still remains the most serious obstacle in resection of this disease.The aim of our study was to assesresults of surgical treatment of perihilar cholangiocarcinoma with portal vein and hepatic artery invasion. Method: We studied results of surgical treatment 141 patients with Klatskin tumor period 2002-2018. T2a TNM stage had 3% patients, T2b – 8,4% patients, T3 – 71,8% patients, and T4 stage TNM had 16,8% patients. Bismuth type B2 had 4,6% patients, B3a – 37,4% patients, B3b – 46,6% patients, B4 – 11,4% patients. Result: For patients with small remnant liver volume, less than 40 %, we did preoperative PV embolization of a resected part of the liver. RPV embolization we did in 71% right hemyhepatectomy, RPVE with Sg4 embolization – for 31,8% right trisectionectomy, LPVE and RAPVE for 25% left trisectionectomy. PV resection was made 61 (46,6%) patients, combined PV and HA resection and reconstruction we did for 8 cases, liver transplantation – 2 cases. In all cases we made extended lymphadenectomy. Mortality was 11,5% (15 patients). 1-, 3- and 5-years survival was higher in group with portal vein resection 86,8%, 58% and 50% respectively, for patients without portal vein resection– 85,6%, 56% and 42%. Conclusion: Aggressive surgical treatment for cholangiocarcinoma the confluence of bile duct with hepatic artery and portal vein resection can be performed safely with acceptable lethality and long-term survival rate.

Resection of the portal vein in the treatment of perihilar cholangiocarcinoma

Background. Perichilar cholangiocarcinoma is a rare type of malignant neoplasm, and its incidence is 3–7 cases per 100,000 population. Surgery is the only radical method of treatment allowing to improve long-term survival results. The cases with tumor invasion of the portal vein are of particular complexity. The purpose of this research was to study the results of surgical treatment of patients with perihilar cholangiocarcinoma with invasion of the portal vein. Materials and methods. From 2003 to 2017, in the department of transplantation and surgery of the liver, extensive and advanced liver resections were preformed in 153 patients with perihilar cholangiocarcinoma. Results. To establish the nature of the lesion of the biliary tree, Bismuth-Corlette anatomical classification of the perihilar cholangiocarcinoma was used. Out of 153 patients, in 66 (43 %) cases, a portal vein resection was performed with subsequent reconstruction. One-, three- and five-year survival rate in the group of patients with portal vein resection was 81.8, 40.9 and 31.8 %, respectively. Conclusions. Aggressive surgical treatment of perihilar cholangiocarcinoma provides maximum radicality, allows to increase resectability in case of tumor invasion of the portal vein with acceptable mortality and long-term survival.

Application of the laparoscopic technique in perihilar cholangiocarcinoma surgery

IntroductionThe aim of this study is to investigate the feasibility of the application of the laparoscopic technique in perihilar cholangiocarcinoma. MethodsA total of nine cases of patients who received laparoscopic perihilar cholangiocarcinoma surgery from January 2007 to May 2014 were retrospectively analyzed. The Bismuth subtypes consisted of one case of type I, three cases of type II, two cases of type IIIb, and three cases type IV. ResultsRadical resection was conducted in six cases: two cases (type II) with the caudate lobe resection, and two cases (type IIIb) with the left hepatectomy and caudate lobe resection. The mean operation time was 7.3 h (5.5–8.5 h), the mean blood loss was 503 ml (150–850 ml). The pathological tests showed two cases of poorly differentiated adenocarcinoma, three cases of moderately differentiated adenocarcinoma, and four cases of highly differentiated adenocarcinoma. ConclusionLaparoscopic technology in the surgical treatment of perihilar cholangiocarcinoma is an option for the resection approach.

Profiling the high-risk patient in surgical treatment of perihilar cholangiocarcinoma: A new scoring-system for oncological outcomes

Profiling the high-risk patient in surgical treatment of perihilar cholangiocarcinoma: A new scoring-system for oncological outcomes

Surgical treatment for perihilar cholangiocarcinoma: the changing definition in the updated General Rules for Clinical and Pathological Studies on Cancer of the Biliary Tract

Surgical treatment for perihilar cholangiocarcinoma: the changing definition in the updated General Rules for Clinical and Pathological Studies on Cancer of the Biliary Tract

Perihilar cholangiocarcinoma: paradigms of surgical management

Cholangiocarcinoma is a lethal disease with increasing incidence worldwide. Perihilar cholangiocarcinoma represents the most common type of cholangiocarcinoma. Despite major development on surgical strategies over the past 20 years, the 5-year survival rate after surgery has remained below 40%, often in the vicinity of 20%. Most perihilar cholangiocarcinomas, however, are unresectable at the time of the diagnosis. The recent use of aggressive approaches based on better image modality, specific perioperative management, and a multidisciplinary approach have enabled to convert the use of palliative therapies to more radical surgery. This review focuses on the recent advances in surgical treatment for perihilar cholangiocarcinoma including liver transplantation with their respective impact on patient survival.

Assessment of nodal status for perihilar cholangiocarcinoma location, number, or ratio of involved nodes.

Surgical treatment of perihilar cholangiocarcinoma (PCC) is the treatment of choice that can achieve long term results. Unfortunately the presence of lymph node metastases is frequent and it is one of the major negative prognostic factors in patients submitted to surgery. In literature there are few data about the prognostic significance of location, number and ratio of involved nodes. Moreover guidelines about the extent of lymph node dissection are not available. In this commentary the data of literature about prognostic significance of lymph node involvement are described and analysed.

Evolution of Surgical Treatment for Perihilar Cholangiocarcinoma

To review our 34-year experience with 574 consecutive resections for perihilar cholangiocarcinoma and to evaluate the progress made in surgical treatment of this disease. Few studies have reported improved surgical outcomes for perihilar cholangiocarcinoma; therefore, it is still unclear whether surgical treatment of this intractable disease has progressed. Between April 1977 and December 2010, a total of 754 consecutive patients with perihilar cholangiocarcinoma were treated, of whom 574 (76.1%) underwent resection. The medical records of these resected patients were retrospectively reviewed. The incidence of major hepatectomies has increased, and limited resections, including central hepatectomies and bile duct resections, were rarely performed. Combined vascular resection was being used more often. Operative time has become shorter, and intraoperative blood loss has also decreased significantly. Because of refinements in surgical techniques and perioperative management, morbidity decreased significantly but was still high, with a rate of 43.1% in the last 5 years. Mortality rate has also decreased significantly (P < 0.001) from 11.1% (8/72) before 1990 to 1.4% (3/218) in the last 5 years. The ratio of advanced disease defined as pStage IVA and IVB has increased significantly from 49.4% before 2000 to 61.4% after 2001. The disease-specific survival for the 574 study patients (including all deaths) was 44.3% at year 3, 32.5% at year 5, and 19.9% at year 10. The survival was significantly better in the later period of 2001 to 2010 than in the earlier period of 1977 to 2000 (38.1% vs 23.1% at year 5, P < 0.001). For pM0, R0, and pN0 patients (n = 243), the survival in the later period was good with 67.1% at year 5, which was significantly better than that of the earlier period (P < 0.001). For pM0, R0, and pN1 patients (n = 142), however, the survival in the later period was similar to that of the earlier period (22.1% vs 14.6% at year 5, P = 0.647). Multivariate analysis revealed that lymph node metastasis was the strongest prognostic indicator. Surgical treatment of perihilar cholangiocarcinoma has been evolving steadily, with expanded surgical indication, decreased mortality, and increased survival. Survival for R0 and pN0 patients was satisfactory, whereas survival for pN1 patients was still poor, suggesting that establishment of effective adjuvant chemotherapy is needed.