Ann Hepatobiliary Pancreat Surg.  2023 Aug;27(3):227-240. 10.14701/ahbps.23-028.

Surgical management of hilar cholangiocarcinoma: Controversies and recommendations

• Jena SS
• Mehta NN
• Nundy S

• KMID: 2545716
• DOI: http://doi.org/10.14701/ahbps.23-028

Abstract

Hilar cholangiocarcinomas are highly aggressive malignancies. They are usually at an advanced stage at initial presentation. Surgical resection with negative margins is the standard of management. It provides the only chance of cure. Liver transplantation has increased the number of ‘curative’ procedures for cases previously considered to be unresectable. Meticulous and thorough preoperative planning is required to prevent fatal post-operative complications. Extended resection procedures, including hepatic trisectionectomy for Bismuth type IV tumors, hepatopancreaticoduodenectomy for tumors with extensive longitudinal spread, and combined vascular resection with reconstruction for tumors involving hepatic vascular structures, are challenging procedures with surgical indications expanded. Liver transplantation after the standardization of a neoadjuvant protocol described by the Mayo Clinic has increased the number of patients who can undergo operation.

Keyword

Hilar cholangiocarcinoma; Associating Liver Partition and Portal Vein Ligation with Staged hepatectomy; Pancreatoduodenectomy; Associating Liver Partition and Portal Vein Ligation with Staged hepatectomy; Pancreatoduodenectomy

Figure

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  Fig. 1 (A) MRI showing duct separation, suggesting a hilar block. (B) Triphasic CT showing hilar cholangiocarcinoma near the portal vein.

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  Fig. 2 (A, B) Intra-operative picture showing hypertrophied left lobe with atrophied right lobe 2 weeks following portal vein embolization. This patient underwent right-trisectionectomy for type IIIa hilar cholangiocarcinoma (HC). (C) Post-right-trisectionectomy specimen showing HC grasped by the metal forceps.

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  Fig. 3 (A) Intra-operative picture showing removal of a self-expandable metallic stent (held with the metal instrument) in a patient with hilar cholangiocarcinoma who underwent left hepatectomy. (B) Removed self-expandable metallic stent.

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  Fig. 4 (A) Staging laparoscopy showing peritoneal deposits. (B) Same patient showing ascites. Further surgery was abandoned in this patient, thus avoiding a futile laparotomy.

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