Treatment Of Perihilar Cholangiocarcinoma Research Articles

Clinical features and prediction of long-term survival after surgery for perihilar cholangiocarcinoma.

The treatment of perihilar Cholangiocarcinoma (pCCA) poses specific challenges not only due to its high perioperative complication rates but also due its dismal long-term prognosis with only a few long-term survivors (LTS) among the patients. Therefore, in this analysis characteristics and predictors of LTS in pCCA patients are investigated. In this single center analysis, patients undergoing curative-intent liver resection for pCCA between 2010 and 2022 were categorized into long-term and short-term survivors (STS) excluding perioperative mortality. Binary logistic regression was used to determine key differences between the groups and to develop a prognostic composite variable. This composite variable was subsequently tested in the whole cohort of surgically treated pCCA patients using Cox Regression analysis for cancer-specific survival (CSS). Within a cohort of 209 individuals, 27 patients were identified as LTS (median CSS = 125 months) and 55 patients as STS (median CSS = 16 months). Multivariable analysis identified preoperative portal vein infiltration (OR = 5.85, p = 0.018) and intraoperative packed red blood cell (PRBC) transfusions (OR = 10.29, p = 0.002) as key differences between the groups. A prognostic composite variable based on these two features was created and transferred into a Cox regression model of the whole cohort. Here, the composite variable (HR = 0.35, p<0.001), lymph node metastases (HR = 2.15, p = 0.001) and postoperative complications (HR = 3.06, p<0.001) were identified as independent predictors of CSS. Long-term survival after surgery for pCCA is possible and is strongly negatively associated with preoperative portal vein infiltration and intraoperative PRBC transfusion. As these variables are part of preoperative staging or can be modulated by intraoperative technique, the proposed prognostic composite variable can easily be transferred into clinical management to predict the oncological outcome of patients undergoing surgery for pCCA.

Preoperative predictors for non-resectability in perihilar cholangiocarcinoma

IntroductionExplorative laparotomy without subsequent curative-intent liver resection remains a major clinical problem in the treatment of perihilar cholangiocarcinoma (pCCA). Thus, we aimed to identify preoperative risk factors for non-resectability of pCCA patients.Material and methodsPatients undergoing surgical exploration between 2010 and 2022 were eligible for the analysis. Separate binary logistic regressions analyses were used to determine risk factors for non-resectability after explorative laparotomy due to technical (tumor extent, vessel infiltration) and oncological (peritoneal carcinomatosis, distant nodal or liver metastases)/liver function reasons.ResultsThis monocentric cohort comprised 318 patients with 209 (65.7%) being surgically resected and 109 (34.3%) being surgically explored [explorative laparotomy: 87 (27.4%), laparoscopic exploration: 22 (6.9%)]. The median age in the cohort was 69 years (range 60–75) and a majority had significant comorbidities with ASA-Score ≥ 3 (202/318, 63.5%). Statistically significant (p < 0.05) risk factors for non-resectability were age above 70 years (HR = 3.76, p = 0.003), portal vein embolization (PVE, HR = 5.73, p = 0.007), and arterial infiltration > 180° (HR = 8.05 p < 0.001) for technical non-resectability and PVE (HR = 4.67, p = 0.018), arterial infiltration > 180° (HR = 3.24, p = 0.015), and elevated CA 19–9 (HR = 3.2, p = 0.009) for oncological/liver-functional non-resectability.ConclusionAdvanced age, PVE, arterial infiltration, and elevated CA19-9 are major risk factors for non-resectability in pCCA. Preoperative assessment of those factors is crucial for better therapeutical pathways. Diagnostic laparoscopy, especially in high-risk situations, should be used to reduce the amount of explorative laparotomies without subsequent liver resection.

Essential updates 2021/2022: Update in surgical strategy for perihilar cholangiocarcinoma.

Resection is the only potential curative treatment for perihilar cholangiocarcinoma (PHC); however, complete resection is often technically challenging due to the anatomical location. Various innovative approaches and procedures were invented to circumvent this limitation but the rates of postoperative morbidity (20%-78%) and mortality (2%-15%) are still high. In patients diagnosed with resectable PHC, deliberate and coordinated preoperative workup and optimization of the patient and future liver remnant are crucial. Biliary drainage is recommended to relieve obstructive jaundice and optimize the clinical condition before liver resection. Biliary drainage for PHC can be performed either by endoscopic biliary drainage or percutaneous transhepatic biliary drainage. To date there is no consensus about which method is preferred. The volumetric assessment of the future remnant liver volume and optimization mainly using portal vein embolization is the gold standard in the management of the risk to develop post hepatectomy liver failure. The improvement of systemic chemotherapy has contributed to prolong the survival not only in patients with unresectable PHC but also in patients undergoing curative surgery. In this article, we review the literature and discuss the current surgical treatment of PHC.

Diagnosis and Treatment of Perihilar Cholangiocarcinoma: A National Survey from the Korean Pancreatobiliary Association.

Based on their anatomy, cholangiocarcinomas (CCAs) are classified into intrahepatic, hilar, and distal CCAs. Although the diagnosis and treatment of each type of CCA are thought to be different, real-world data studies on the current practice are limited. Therefore, this study was designed to capture the current practice of diagnosing and treating perihilar CCA in Korea. We conducted a survey using an online platform. The questionnaire consisted of 18 questions designed to evaluate the current practice of diagnosing and treating perihilar CCA in Korea. The targets of this survey were biliary endoscopists who are members of the Korean Pancreatobiliary Association. In total, 119 biliary endoscopists completed the survey. Of the respondents, 89.9% thought that the use of the International Classification of Diseases, 11th Revision (ICD-11) system is necessary to classify CCA. Approximately half of the respondents would recommend surgery or chemotherapy until patients were 80 years of age. For the pathological diagnosis of CCA, endoscopic retrograde cholangiopancreatography with biopsy was the most preferred modality. Routine preoperative biliary drainage was performed by 44.5% of the respondents. For operable CCAs, 64.7% of the respondents preferred endoscopic biliary drainage using plastic stents. For palliative biliary drainage, 69.7% of the respondents used plastic stents. For palliative endoscopic biliary drainage using metal stents, 63% of the respondents preferred the stent-in-stent method. A new coding system using the ICD-11 is needed for classifying CCAs. Guidelines for diagnosing and treating CCA based on the clinical situation in Korea are needed.

Prognostic impact of preoperative skeletal muscle change from diagnosis to surgery in patients with perihilar cholangiocarcinoma.

Loss of skeletal muscle mass is a prognostic factor after surgery for gastrointestinal cancers. The treatment for perihilar cholangiocarcinoma (PHC) is a highly invasive surgery. Biliary drainage and portal vein embolization, which can prolong the preoperative waiting time (PWT), are often required before surgery. Assuming that the skeletal muscle mass can change during PWT, we investigated the clinical effect of skeletal muscle change on surgical outcomes of PHC. We retrospectively reviewed the medical records of 89 patients who underwent curative surgery for PHC from January 2013 to December 2019. We defined the psoas muscle area (PMA) at the third lumbar vertebra as the skeletal muscle mass. The PMA just before surgery was divided by that at the time of diagnosis, and we defined it as the rate of change of PMA (CPMA). Patients were divided into two groups according to CPMA: wasting (n=44, below the median CPMA) and no-change (n=45, above the median CPMA). The median PWT was 63 d, and CPMA was 96.1%. The median recurrence-free survival and overall survival were significantly shorter in the wasting group than in the no-change group (8.0 vs 33.2 mo, P =0.001 and 14.2 vs 48.7 mo, P <0.001, respectively). Multivariate analysis revealed that histological differentiation, R1 resection, lymph node metastasis, and preoperative skeletal muscle wasting were independent prognostic factors of PHC. This study suggests that preoperative skeletal muscle wasting in patients with PHC has a negative effect on survival outcomes.

Does Caudate Resection Improve Outcomes of Patients Undergoing Curative Resection for Perihilar Cholangiocarcinoma? A Systematic Review and Meta-Analysis

Margin-negative (R0) resection is the strongest positive prognostic factor in perihilar cholangiocarcinoma (PHC). Due to its anatomic location, the caudate lobe is frequently involved in PHC. This review aimed to examine the impact of caudate lobe resection (CLR) in addition to hepatectomy and bile duct resection for patients with PHC. The MEDLINE, EMBASE, and Cochrane databases were systematically reviewed from inception to October 2021 to identify studies comparing patients undergoing surgical resection with hepatectomy and bile duct resection with or without CLR for treatment of PHC. Outcomes included the proportion of patients achieving R0 resection, overall survival (OS), and perioperative morbidity. Altogether, 949 studies were screened. The review included eight observational studies reporting on 1137 patients. The patients who underwent CLR had a higher likelihood of R0 resection (odds ratio [OR], 5.85; 95% confidence interval [CI], 2.64-12.95) and a better OS (hazard ratio [HR], 0.65; 95% CI, 0.54-0.79) than those who did not. The use of CLR did not increase the risk of perioperative morbidity (OR, 1.03; 95% CI, 0.65-1.63). Given the higher likelihood of R0 resection, improved OS, and no apparent increase in perioperative morbidity, this review supports routine caudate lobectomy in the surgical management of PHC. These results should be interpreted with caution given the lack of high-quality prospective data and the high probability of selection bias.

Liver Resection for Type IV Perihilar Cholangiocarcinoma: Left or Right Trisectionectomy?

Simple SummarySurgical resection of perihilar cholangiocarcinoma (PHC), a rare malignant bile duct tumor arising in the hepatic hilum, requires either right- or left-sided liver resections depending on tumor-side predominance. Margin-free resection remains the only curative-intent treatment and extended liver resections (trisectionectomies) are needed for advanced (Bismuth type IV) PHC. However, the clinical outcomes of left (LTS) and right trisectionectomies (RTS) have so far not been compared for the resection of advanced PHC. In this retrospective study of consecutive cases of Bismuth type IV PHC, RTS (42 patients) and LTS (25 patients) were compared in terms of postoperative morbidity and patient survival. Although LTS was more frequently associated with arterial reconstructions, the postoperative liver failure rate was lower and overall survival was better as compared to RTS.How the side of an extended liver resection impacts the postoperative prognosis of advanced perihilar cholangiocarcinoma (PHC) is still controversial. We compared the outcomes of right (RTS) and left trisectionectomies (LTS) in Bismuth-Corlette (BC) type IV PHC resection. All patients undergoing RTS or LTS for BC type IV PHC in a single tertiary center between January 2012 and December 2019 were compared retrospectively. The endpoints were perioperative outcomes, long-term overall (OS), and disease-free survival (DFS). Among 67 hepatic resections for BC type IV PHC, 25 (37.3%) were LTS and 42 (63.7%) were RTS. Portal vein and artery resection rates were 40% and 52.4% (p = 0.29), and 24% and 0% (p < 0.001) in the LTS and RTS groups, respectively. The severe complication (Clavien–Dindo > IIIa) rate was comparable (36% vs. 21.5%, p = 0.357) while the postoperative liver failure (POLF) rate was lower in the LTS group (16% vs. 38%, p = 0.048). The R0 resection rate was similar between groups (81% vs. 92%; p = 0.154). The five-year OS rate was higher in the LTS group (66% vs. 30%, p = 0.009) while DFS was comparable (43% vs. 18%, p = 0.11). Based on multivariable analysis, the side of the trisectionectomy was an independent predictor of OS. Compared with RTS, LTS is associated with lower POLF and higher overall survival despite more frequent arterial reconstructions in type IV PHC. Although technically more demanding, LTS may be preferred in the treatment of advanced PHC.

Critical overview of resection for Bismuth-Corlette type IV perihilar cholangiocarcinoma

Background Current standard treatment for perihilar cholangiocarcinoma (pCCA) is surgical resection. Bismuth-Corlette (BC) type IV pCCA is accepted as an unresectable disease. In the present study, the results of non-transplant surgical approaches in patients with BC type IV pCCA were examined. Methods Medical records of consecutive patients with BC type IV pCCA between 2010 and 2021 were retrospectively reviewed. Patients were subdivided according to operation type. Postoperative survival rates were compared. Results Hemihepatectomy with caudate lobe and extrahepatic bile duct (EHBD) resection was performed in 15 patients and only EHBD resection was performed in 10 patients. Ten of the cases were found to be unresectable at the stage of laparotomy. Median follow-up was 41.3 (24.8–57.9) months. Overall survival rate for all 35 patients was 56.4% at 1 year, 32.2% at 2 years, and 16.1% at 3 years. When survivals were compared according to operation type, 1, 2, and 3-year survivals were 80%, 57.1% and 42.9% for the hepatectomy group; 55.6%, 44.4% and 11.1% for the EHBD resection group; 75%, 0% and 0% in laparotomy-only group, respectively (p = 0.13). The best survival rates were obtained in patients with pCCA who underwent hepatectomy and were lymph node negative, 100% for 1 year, 66.7 for 2 years and 50% for 3 years. Conclusion It is difficult to achieve high survival rates in BC type IV pCCA. However, these patients mostly benefit from resective treatments. Acceptable survival rates can be achieved, especially in the R0N0 patient group.

The pros and cons of the PCC staging system to guide surgical resectability and prognosis.

Perihilar cholangiocarcinoma (PCC) is a malignant mass originating from the bile ducts. There is currently no unified treatment plan, and there are various treatment methods applied in clinical practice, as well as several different staging and typing systems to guide resectability, prognosis and survival prediction. The choice of treatment for PCC is closely related to the stage of the tumor. Accurate preoperative staging is necessary for correct resectability assessment and the selection of a reasonable treatment plan and surgical method; similarly, accurate postoperative pathological staging is necessary to guide further treatment and judgment of the patient's prognosis. A universally accepted staging system facilitates the comparison of cases between different centers, but there is much debate about the classification and staging of PCC. At present, the existing staging systems include the Bismuth-Corlette classification, AJCC/UICC TNM staging, modified T staging, Gazzaniga staging, JSBS staging, and Mayo staging. Each system has advantages, but there is no comprehensive guide for tumor resectability, prognosis, and survival. In this paper, the pros and cons of the different systems for staging PCC in terms of resectability, prognosis and survival prediction are discussed.

Stereotactic Body Radiation Therapy after Chemotherapy for Unresectable Perihilar Cholangiocarcinoma: The STRONG Trial, a Phase I Safety and Feasibility Study.

Simple SummaryThe role of radiotherapy in the treatment of perihilar cholangiocarcinoma has not yet been properly defined. In this prospective study, we therefore explored the addition to first-line chemotherapy of stereotactic body radiation therapy (SBRT) delivered in 15 fractions. Patients eligible for the study had been diagnosed with unresectable perihilar cholangiocarcinoma, and then had no progressive disease after completing treatment with 6–8 cycles of cisplatin-gemcitabine. Primary endpoints were feasibility and safety. Secondary endpoints were local control, progression-free survival, overall survival, and quality of life. As each patient completed the SBRT successfully and no dose-limiting toxicity was found, we consider this treatment to be both feasible and safe. The local control rate and overall survival were promising. However, due to the small sample size of this study, we urge the analysis of this treatment in a larger series of patients.Background: In unresectable pCCA, the standard of care is palliative chemotherapy. We investigated the feasibility and safety of adding stereotactic body radiation therapy (SBRT) after chemotherapy. Methods: Patients with unresectable pCCA, stage T1-T4N0-N1M0, ECOG 0-1, having finished 6–8 cycles of cisplatin and gemcitabine without disease progression were eligible. SBRT was planned in 15 fractions of 3.0–4.5 Gy. The primary endpoints were feasibility (defined as completing SBRT as planned) and toxicity, evaluated within 3 months after SBRT (CTCAE v4.03). A conventional “3 + 3” design was used, corresponding to a sample size of 6 patients. Dose-limiting toxicity (DLT) was defined as grade ≥ 4 hepatobiliary or grade ≥ 3 gastrointestinal toxicity. The secondary endpoints, measured from the start of radiotherapy, were local control, progression-free survival, overall survival, and quality of life (QoL). ClinicalTrials.gov identifier: NCT03307538. Results: Six patients were enrolled between November 2017 and March 2020. SBRT was delivered as planned. All patients were treated with 60Gy (15 × 4.0Gy). No SBRT-related DLT was observed. The most common grade ≥ 3 toxicity was cholangitis (n = 5). The median follow-up was 14 months. The 12-month local control rate was 80%. We observed no substantial changes in QoL. Conclusion: In patients with unresectable pCCA with stable disease after palliative chemotherapy, adding SBRT is feasible and safe. The observed local control merits an additional evaluation of effectiveness.

Chronological analysis of surgical and oncological outcomes after the treatment of perihilar cholangiocarcinoma.

Backgrounds/AimsDespite advances in surgical techniques and perioperative supportive care, radical resection of hilar cholangiocarcinoma is the only modality that can achieve long-term survival. We chronologically investigated surgical and oncological outcomes of hilar cholangiocarcinoma and analyzed the factors affecting overall survival.MethodsWe retrospectively enrolled 165 patients with hilar cholangiocarcinoma who underwent liver resection with a curative intent. The patients were divided into groups based on the period when the surgery was performed: period I (2005-2011) and period II (2012-2018). The clinicopathological characteristics, perioperative outcomes, and survival outcomes were analyzed.ResultsThe patients’ age, serum CA19-9 levels, and serum bilirubin levels at diagnosis were significantly higher in the period I group. There were no differences in pathological characteristics such as tumor stage, histopathologic status, and resection status. However, perioperative outcomes, such as estimated blood loss (1528.8 vs. 1034.1 mL, p=0.020) and postoperative severe complication rate (51.3% vs. 26.4%, p=0.022), were significantly lower in the period II group. Regression analysis demonstrated that period I (hazard ratio [HR]=1.591; 95% confidence interval [CI]=1.049-2.414; p=0.029), preoperative serum bilirubin at diagnosis (HR=1.585; 95% CI=1.058-2.374; p=0.026), and tumor stage (III, IV) (HR=1.671; 95% CI: 1.133-2.464; p=0.010) were significantly associated with poor prognosis. The 5-year survival rate was better in the period II patients than in the period I patients (35.1% vs. 21.0%, p=0.0071).ConclusionsThe surgical and oncological outcomes were better in period II. Preoperative serum bilirubin and advanced tumor stage were associated with poor prognosis in patients with hilar cholangiocarcinoma.

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.

Stage I-laparoscopy partial ALPPS procedure for perihilar cholangiocarcinoma.

The treatment for perihilar cholangiocarcinoma (PHC) is a challenge for the surgeon requiring complex resections with a reported perioperative mortality rate between 15% and 48%. In PHC patients with future liver remnant (FLR) less than 30%, it is advised that hepatectomy can be safely performed after the FLR is modified. Associating Liver Partition and Portal vein ligation for Staged Hepatectomy (ALPPS) procedure is criticized heavily due to its high morbidity and mortality rate in this setting. Hereby, we are reporting a modification of ALPPS procedure for PHC. Clinical presentation, preoperative work-up as well as operation and postoperative course of two cases were described in detail. Both patients were jaundiced preoperatively, stage 1 partial-ALPPS procedures were performed laparoscopically, there was sufficient remnant hypertrophy during the interval stage and there was no posthepatectomy liver failure after the second stage (Supporting Information Video). We have followed patients with a mean follow up of 35 months without any recurrence. Here we describe the key technical aspects of this approach that are discussed in three parts: minimally invasive first stage, biliary drainage of both FLR, and deportalized liver at first stage and biliary reconstruction at the second stage. This technique, in selected patients, can extend the indication of ALPPS procedure for PHC with preoperative jaundice.

The surgeon's contribution to long term survival for peri-hilar cholangiocarcinoma

Background: Surgery for peri-hilar cholangiocarcinoma (PCC) is still demanding and long-term prognosis is still dismal. We sought to investigate the factors related to long term survival. Methods: Data regarding PCC patients who underwent surgical resection with radical intent from January 1990 to December 2017 were analysed from a prospectively maintained database. Clinicopathological characteristics were investigated to identify long-term survival predictors. Patients were staged according to the AJCC/UICC 8th ed. TNM staging system. Results: Among 162 patients submitted to surgical exploration, 123 who underwent radical intent surgery were included in this study. In this group of patients, 102 (82.9%) underwent major liver resections, portal vein resection was conducted in 17.1%, arterial resection in 4.1%, median number of lymph nodes retrieved was 8 [IQR 5-13]. Negative margin resection (R0) was achieved in 69,9% of cases and positive lymph nodes were observed in 45.5% of cases. Overall 3- and 5-year survival (OS) was 54.2% and 26.7% respectively, while 3- and 5-year disease free survival (DFS) were 32.5% and 22.1%, respectively. Multivariable Cox analysis for OS identified that pN stage 8th ed. (HR 1.62; P = 0.006), positive resection margins (HR 1.72; P = 0.027), portal vein resection (HR 1.95; P = 0.016) and number of lymph nodes retrieved ≥ 4 (HR 0.5; P = 0.027) are associated with OS. Interestingly, 5 years OS for R0 and pN0 patients was 40.3% compared to 24.4% for R1 and pN1-2 patients (P = 0.037). Conclusion: The surgeon’s contribution to long term survival in the treatment of PCC is still of great importance by means of oncological radicality and adequate lymph node dissection, which should be the current goal of treatment.

Surgical Removal of Inadvertent Portal Thrombosis by Rescue-ALPPS for Perihilar Cholangiocarcinoma

Introduction:Treatment of perihilar cholangiocarcinoma (PHC) usually requires extended resection after inducing hypertrophy of the future liver remnant (FLR). Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) can achieve rapid hypertrophy of the FLR. Though, due to significant morbidity and mortality, portal vein embolization (PVE) is considered gold standard. Despite remaining controversies, ALPPS might suit as reserve in patients who failed to achieve adequate hypertrophy of the FLR or suffered complications following PVE. We illustrate a rescue-ALPPS after inadvertent nontarget thrombosis of the FLR following PVE in a patient with PHC. Presentation of Case:A 67-year-old patient requiring right trisectionectomy for PHC Bismuth type IV suffered inadvertent nontarget portal thrombosis of the FLR following PVE. Subsequently, insufficient FLR hypertrophy prevented the planned surgical resection. ALPPS procedure with concomitant thrombectomy of the left portal vein was used as a rescue strategy for this patient. Discussion:Since ALPPS is associated with significant limitations, especially in patients with PHC, this approach remains controversial. However, surgery still remains the only curative option for patients with PHC and thus, in case of inadequate hypertrophy of the FLR or technical failure following PVE, these patients lack further treatment options. Recent technical refinements and methods of improved patient selection have the potential to emend outcomes of ALPPS in experienced centres. Conclusion:ALPPS should be considered as reasonable rescue strategy not only in case of insufficient hypertrophy of the FLR but also in the event of technical failure or complications following PVE, even in patients with PHC.

Progress in diagnosis and surgical treatment of perihilar cholangiocarcinoma

Progress in diagnosis and surgical treatment of perihilar cholangiocarcinoma

Role of A.L.P.P.S. in treatment of perihilar cholangiocarcinoma: experience of single centre

Background: We reported results of a mono-centric experience in the treatment of perihilar cholangiocarcinoma (PHCC) by Associated liver partition and portal vein ligation for staged hepatectomy (ALPPS). Methods: Since January 2013, 16 patients with primary or secondary tumors of the liver and biliary tract, whose future liver remnant (FLR) was considered too small to allow for a liver resection, were evaluated prospectively for ALPPS procedure. Procedure was completed in 13 patients. The indication for surgical resection was PHCC in 4 cases (30.8%). Results: The increase of the FLR between the two procedures was 80 ± 31% (p <0.001). By comparing the results of 4 patients underwent ALPPS for PHCC than the other 9 (No PHCC) emerge the following data: the average time between the first and second phase of the procedure was 8 ± 2 ( PHCC) vs 11.7 ± 2 days (No PHCC); The overall postoperative mortality was 7.69% with only 1 death from liver failure in a patient with PHCC and concomitant liver fibrosis, 25% (PHCC) vs 0% (No PHCC); The overall postoperative morbidity rate was 75% in PHCC patients vs 77.7% (No PHCC). Overall survival was 75% at 6, 12, 24, 30 months (PHCC) vs 100% in 6-12 months, 85% at 12, 24, 30 months (No PHCC). The recurrence-free survival was 100% in 6-12, 24, 30 months (PHCC) vs 100% at 6 months, 87.5% at 12 months, 75% at 24, 30 months (No PHCC). Conclusion: The ALPPS technique has effectively increased the resection of liver tumors otherwise inoperable as PHCC.

Role of A.L.P.P.S. in treatment of perihilar cholangiocarcinoma: experience of single centre

Background: We reported results of a mono-centric experience in the treatment of perihilar cholangiocarcinoma (PHCC) by Associated liver partition and portal vein ligation for staged hepatectomy (ALPPS). Methods: Since January 2013, 16 patients with primary or secondary tumors of the liver and biliary tract, whose future liver remnant (FLR) was considered too small to allow for a liver resection, were evaluated prospectively for ALPPS procedure. Procedure was completed in 13 patients. The indication for surgical resection was PHCC in 4 cases (30.8%). Results: The increase of the FLR between the two procedures was 80 ± 31% (p <0.001). By comparing the results of 4 patients underwent ALPPS for PHCC than the other 9 (No PHCC) emerge the following data: the average time between the first and second phase of the procedure was 8 ± 2 ( PHCC) vs 11.7 ± 2 days (No PHCC); The overall postoperative mortality was 7.69% with only 1 death from liver failure in a patient with PHCC and concomitant liver fibrosis, 25% (PHCC) vs 0% (No PHCC); The overall postoperative morbidity rate was 75% in PHCC patients vs 77.7% (No PHCC). Overall survival was 75% at 6, 12, 24, 30 months (PHCC) vs 100% in 6-12 months, 85% at 12, 24, 30 months (No PHCC). The recurrence-free survival was 100% in 6-12, 24, 30 months (PHCC) vs 100% at 6 months, 87.5% at 12 months, 75% at 24, 30 months (No PHCC). Conclusion: The ALPPS technique has effectively increased the resection of liver tumors otherwise inoperable as PHCC.

A vascular variant allows to resect "en bloc" cholangiocarcinoma Bismuth IV

Background: Curative hepatectomy with bile duct resection is the treatment for perihilar cholangiocarcinoma. When vessel involvement in imaging preoperative studies is found, the use of more aggressive aproach with bloc resection is the recommendation. Methods: A video of the surgical approach used in a case of Bismuth type IV Klatskin tumor resected with extended left hepatectomy. Results: A 67-year-old man who presented with epigastric pain and abnormal liver function was referred to our clinic for further examination. Serial examination resulted in diagnosis of Bismuth IV hilar cholangiocarcinoma, atrophying mainly the left hepatic lobe, and infiltrating right and left hepatic artery branches. Fortunately, the patient presented a SVI-VII artery arising from gastroduodenal artery no invaded, anatomical variant that allows tumor resection, keeping the arterial supply of the liver. The variant anatomical of the vessel was identified preoperatively. He underwent left hepatectomy with the main right hepatic artery, caudate lobectomy and extrahepatic bile duct resection without any complications. Pathological study of specimen showed a 4.9x1.2cms cholangiocarcinoma with free margins. No recurrence 1 year late. Conclusion: Aggressive approach with "en bloc" and extended liver resections in the treatment of Bismuth IV hilar cholangiocarcinoma could be feasible. It’s important a meticulous preoperative evaluation with images in this cases, because we can identify anatomical variations make surgery possible.

Surgical outcomes of left trisectionectomy combined with vascular reconstruction for perihilar cholangiocarcinoma

Introduction: Left risectionectomy for perihilar cholangiocarcinoma (PHC) is a complicated and extensive surgical procedure with high morbidity and mortality rates. Hence thorough regional extirpation including combined resection of adjacent vasculature is often required for curative surgical treatment of PHC. In the present study, we elucidate whether left trisectionectomy is efficacious in surgery for PHC. Method: Between April 1992 and December 2017, our department surgically treated 252 cases of PHC. These included 19 cases for which we performed left trisectionectomy (Tri) and 71 cases that underwent left hemihepatectomy (Hemi). Curative resection rates, incidences of Clavien-Dindo grade III or higher complications, in-hospital mortality rates, and long-term results were analyzed. Result: Preoperative patients’ background of the two group is almost similar except Bismuth type (Bismuth type IV; 94.7% in Tri, 22.5% in Hemi, p<0.001). Although PD was added 11.2% (8/71) in Hemi and only one patient in Tri (5.2%: 1/19) (p=0.730). Hepatic artery reconstruction was performed 39.4% (28/71) in Hemi and 73.6% (14/19) in Tri (p=0.007). Curative resection rates were almost same in both groups: 73.6% (14/19) in Tri and 80.2% (57/71) in Hemi (p=0.531). No Tri cases showed a positive bile duct surgical margin. Incidences of complications were similar in both groups, at 73.6% in Tri, and 54.9% in Hemi (p=0.140). In-hospital mortality rates in Tri were statistically higher than those in Hemi (26.3% (5/19) vs 8.4% (6/71), p=0.034). Five-year survival rates were 30.1% in Tri and 34.9% in Hemi. In Tri, the resection afforded good long-term results even with advanced cancers. Conclusion: Left trisectionectomy proved useful in securing the bile duct margin. However, as left trisectionectomy remains a challenging procedure with high in-hospital mortality rates, surgeons need to pay close attention to anatomical variations in order to perform left trisectionectomy safely and successfully.