AB009. S2-3. Surgical approach to hilar cholangiocarcinoma

Abstract: Hilar cholangiocarcinoma account for 50–70% of all biliary tract malignancies. While surgical resection is the mainstay of curative intent therapy for any cholangiocarcinoma, tumors in the hilar location present the most technically challenging because of the close relationship between biliary and vascular structures at this location. Patients who present with local disease can be treated with surgical therapy, either resection or transplant. Transplant is typically reserved for locally unresectable tumors often in the setting of underlying hepatic dysfunction. Retrospective data suggest that survival is similar between resection and transplant. Given the challenges with organ shortage and complex and often restrictive eligibility criteria, hilar cholangiocarcinoma should be treated the R0 resection when possible. Surgical resection for hilar cholangiocarcinoma results in 5-year survival rates range between 30–45%, with median survival ranging from 30–60 months. Favorable long-term outcome requires low perioperative complications and complete R0 resection, often best performed at high-volume specialty referral centers. Preoperative assessment, including high-quality imaging is important to determine local extent and determine risk factors for post-hepatectomy liver failure. Preoperative biliary decompression is often needed to correct hyperbilirubinemia and reduce postoperative morbidity. The operative approach necessitates surgical skills focused on determining resectability intraoperatively, performing a hemihepatectomy with en bloc resection of the extrahepatic bile duct, portal lymphadenectomy, and biliary reconstruction. Staging laparoscopy can be used selectively when there is concern for advanced disease on preoperative imaging. In some cases, main portal vein resection and reconstruction can be performed. Such cases can be associated with higher morbidity and should be done in high-volume centers with surgeons with experience in microsurgical vascular techniques. The role of adjuvant therapy for this disease has been controversial. High-risk patients such as those with positive margins or lymph node metastases may benefit from chemoradiation. More recently, randomized data support the use of adjuvant capecitabine.

Keywords: Hilar cholangiocarcinoma; Klatskin’s tumor; hepatectomy; bile duct cancer; biliary drainage