Principles of surgical resection in hilar cholangiocarcinoma

Abstract

The aim of this article is to describe the surgical techniques for the treatment of hilar cholangiocarcinoma (HC). Resection with microscopically negative margin (R0) is the only way to cure patients with HC. Today, resection of the caudate lobe and part of segment IV, combined with a right or left hepatectomy, bile duct resection, lymphadenectomy of the hepatic hilum and sometimes vascular resection, is the standard surgical procedure for HC. Intraoperative frozen-section examination of proximal and distal biliary margins is necessary to confirm the suitability of resection. Although lymphadenectomy probably has little direct effect on survival, inaccurate staging information may influence post resection treatment recommendations. Aggressive venous and arterial resections should be undertaken in selected cases to achieve a R0 resection. The concept of “no-touch proposed” in 1999 by Neuhaus et al combine an extended right hepatectomy with systematic portal vein resection and caudate lobectomy avoiding hilar dissection and possible intraoperative microscopic dissemination of cancer cells. More recently minor liver resections have been proposed for treatment of HC. As the hilar bifurcation of the bile ducts is near to liver segments IV, V and I, adequate liver resection of these segments together with the bile ducts can result in cure.

Keywords: Cholangiocarcinoma, Surgery, Technique

Core tip: The aim of this article is to describe the surgical techniques for the treatment of hilar cholangiocarcinoma (HC). In recent years, parenchyma-preserving hepatic resections have been proposed to treat high risk surgical patients without vascular infiltration. This type of liver resection must include segments I, IVb and V. Radical surgery in patients with type I or II tumors should also include a right liver resection, except in the case of papillary HC and in high-risk surgical patients.