Hilar Cholangiocarcinoma: Preoperative Liver Optimization with Multidisciplinary Approach. Toward a Better Outcome

• Published in: World journal of surgery Vol. 37; no. 6; pp. 1388 - 1396
• Main Authors: Ratti, Francesca, Cipriani, Federica, Ferla, Fabio, Catena, Marco, Paganelli, Michele, Aldrighetti, Luca A. M.
• Format: Journal Article
• Language: English
• Published: New York Springer-Verlag 01.06.2013; Springer‐Verlag; Springer Nature B.V
• Subjects: Abdominal Surgery; Adult; Aged; Aged, 80 and over; Bile Duct Neoplasms - diagnostic imaging; Bile Duct Neoplasms - pathology; Bile Duct Neoplasms - surgery; Biliary Drainage; Cardiac Surgery; Female; Future Liver Remnant; General Surgery; Hepatic Duct, Common; Hilar Cholangiocarcinoma; Humans; Klatskin Tumor - diagnostic imaging; Klatskin Tumor - pathology; Klatskin Tumor - surgery; Laparoscopy; Male; Medicine; Medicine & Public Health; Middle Aged; Neoplasm Staging; Patient Selection; Percutaneous Transhepatic Biliary Drainage; Portal Vein Embolization; Prognosis; Prospective Studies; Surgery; Thoracic Surgery; Tomography, X-Ray Computed; Treatment Outcome; Vascular Surgery; Future Liver Remnant; Hilar Cholangiocarcinoma; Biliary Drainage; Percutaneous Transhepatic Biliary Drainage; Portal Vein Embolization
• DOI: 10.1007/s00268-013-1980-2
• ISSN: 0364-2313

Introduction The diagnosis and treatment of hilar tumors requires a multidisciplinary approach based on the synergy of radiologists, surgeons, oncologists, and gastroenterologists. Klatskin tumor is a relatively rare disease with a poor prognosis. Currently, the only possible treatment is represented by the removal of the tumor associated with radical surgery, even though its results are still jeopardized by significant morbidity and mortality. A proper preoperative optimization of the patient, including staging laparoscopy, biliary drainage, and portal vein embolization, may improve short-term outcome. The purpose of this study was to evaluate the short- and long-term impact of preoperative optimization in patients affected by hilar cholangiocarcinoma. Methods From January 2004 to May 2012, 94 patients with preoperative diagnosis of Klastkin tumors were candidates for surgery at the Hepatobiliary Surgery Unit of the Hospital San Raffaele in Milan. The data of all patients were prospectively collected and retrospectively reviewed. The outcome was evaluated in terms of perioperative morbidity and mortality and overall and disease-free survival. Short-term outcome of patients undergoing preoperative optimization was compared with outcome of patients who did not undergo it in terms of intraoperative data, morbidity and mortality. Results Of 94 patients undergoing surgery, 80 underwent hepatic and biliary confluence resection. Fourteen patients were considered unresectable due to the presence of peritoneal carcinomatosis or advanced disease seen during staging laparoscopy or at laparotomy and therefore were excluded from the analysis. Seventy-five (93.7 %) patients underwent major liver resections: in 14 of these, surgery was performed at a distance of 30–40 days from PVE. In 55 patients, biliary drainage was preoperatively placed for palliation of obstructive jaundice. The postoperative morbidity rate was 51.2 % and mortality 6.2 %. The most frequent cause of death was postoperative liver failure. Five-year survival rate was 29 %. Patients undergoing preoperative optimization experienced a significant reduction of postoperative morbidity, especially in terms of infectious related events. Conclusions Klatskin tumor remains a disease associated with poor prognosis, but a correct preoperative diagnostic and therapeutic management provides tools to perform this type of surgery with acceptable morbidity and mortality, thus improving long-term results.