Skip to main content
Log in

Oncological Superiority of Hilar En Bloc Resection for the Treatment of Hilar Cholangiocarcinoma

Annals of Surgical Oncology Aims and scope Submit manuscript

Abstract

Purpose

Long-term results after liver resection for hilar cholangiocarcinoma are still not satisfactory. Previously, we described a survival advantage of patients who undergo combined right trisectionectomy and portal vein resection, a procedure termed “hilar en bloc resection.” The present study was conducted to analyze its oncological effectiveness compared to conventional hepatectomy.

Patients

During hilar en bloc resection, the extrahepatic bile ducts were resected en bloc with the portal vein bifurcation, the right hepatic artery, and liver segments 1 and 4 to 8. With this “no-touch” technique, preparation of the hilar vessels in the vicinity of the tumor was avoided. The long-term outcome of 50 consecutive patients who underwent curative (R0) hilar en bloc resection between 1990 and 2004 was compared to that of 50 consecutive patients who received curative conventional major hepatectomy for hilar cholangiocarcinoma (perioperative deaths excluded).

Results

The 1-, 3-, and 5-year survival rates after hilar en bloc resection were 87%, 70%, and 58%, respectively, which was significantly higher than after conventional major hepatectomy. In the latter group, 1-, 3-, and 5-year survival rates were 79%, 40%, and 29%, respectively (P = 0.021). Tumor characteristics were comparable in both groups. A high number of pT3 and pT4 tumors and patients with positive regional lymph nodes were present in both groups. Multivariate analysis identified hilar en bloc resection as an independent prognostic factor for long-term survival (P = 0.036).

Conclusions

In patients with central bile duct carcinomas, hilar en bloc resection is oncologically superior to conventional major hepatectomy, providing a chance of long-term survival even in advanced tumors.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3

References

  1. Khan SA, Thomas HC, Davidson BR, Taylor-Robinson SD. Cholangiocarcinoma. Lancet. 2005;366:1303–14.

    Article  PubMed  Google Scholar 

  2. Jarnagin WR, Fong Y, DeMatteo RP, Goner M, Burke EC, Bodniewicz BS J, Youssef BA M, Klimstra D, Blumgart LH. Staging, resectability and outcome in 225 patients with hilar cholangiocarcinoma. Ann Surg. 2001;234:507–17.

    Article  PubMed  CAS  Google Scholar 

  3. Nimura Y, Kamiya J, Kondo S, Nagino M, Uesaka K, Oda K, Sano T, Yamamoto H, Hayakawa N. Aggressive preoperative management and extended surgery for hilar cholangiocarcinoma: Nagoya experience. J Hepatobiliary Pancreat Surg. 2000;7:155–62.

    Article  PubMed  CAS  Google Scholar 

  4. Nagino M, Nimura Y, Kamiya J, Kanai M, Uesaka K, Hayakawa N, Yamamoto H, Kondo S, Nishio H. Segmental liver resection for hilar cholangiocarcinoma. Hepatogastroenterology. 1998;45:7–13.

    PubMed  CAS  Google Scholar 

  5. Klempnauer J, Ridder GJ, von Wasielewski R, Werner M, Weimann A, Pichlmayr R. Resectional surgery of hilar cholangiocarcinoma: a multivariate analysis of prognostic factors. J Clin Oncol. 1997;15:947–54.

    PubMed  CAS  Google Scholar 

  6. Neuhaus P, Jonas S, Bechstein WO, Lohmann R, Radke C, Kling N, Wex C, Lobeck H, Hintze R. Extended resections for hilar cholangiocarcinoma. Ann Surg. 1999;230:808–19.

    Article  PubMed  CAS  Google Scholar 

  7. Bismuth H, Corlette MB. Intrahepatic cholangioenteric anastomosis in carcinoma of the hilus of the liver. Surg Gynecol Obstet. 1975;140:170–8.

    PubMed  CAS  Google Scholar 

  8. Wiley J and Sons, UICC. TNM classification of malignant tumors. 6th ed. New York: Springer; 2002.

  9. Blumgart LH, Benjamin IS. Liver resection for bile duct cancer. Surg Clin North Am. 1989;69:323–37.

    PubMed  CAS  Google Scholar 

  10. Beazley RM, Hadjis N, Benjamin IS. Clinicopathological subjects of high bile duct cancer: experience with resection and bypass surgical treatments. Ann Surg. 1984;199:623–36.

    Article  PubMed  CAS  Google Scholar 

  11. Mizumoto R, Kawarada Y, Suzuki H. Surgical treatment of hilar carcinoma of the bile duct. Surg Gynecol Obstet. 1986;162:153–8.

    PubMed  CAS  Google Scholar 

  12. Mittal B, Deutsch M, Iwatsuki S. Primary cancers of extrahepatic biliary passages. Int J Radiat Oncol Biol Phys. 1985;11:849–54.

    Article  PubMed  CAS  Google Scholar 

  13. Mizumoto R, Suzuki H. Surgical anatomy of the hepatic hilum with special reference to the caudate lobe. World J Surg. 1988;12:2–10.

    Article  PubMed  CAS  Google Scholar 

  14. Pichelmayr R, Ringe B, Lauchart W, Bechstein WO, Gubernatis G, Wagner E. Radical resection and liver grafting as the two main components of surgical strategy in the treatment of proximal bile duct cancer. World J Surg. 1988;12:88–98.

    Google Scholar 

  15. Bhuiya MR, Nimura Y, Kamiya J, Kondo S, Fukata S, Hayakawa N, Shionoya S. Clinicopathologic studies on perineural invasion of bile duct carcinoma. Ann Surg. 1992;215:344–9.

    Article  PubMed  CAS  Google Scholar 

  16. Ouchi K, Suzuki M, Hashimoto L, Sato T. Histologic findings and prognostic factors in carcinoma of the upper bile duct. Am J Surg. 1989;157:552–6.

    Article  PubMed  CAS  Google Scholar 

  17. Bismuth H, Nakache R, Diamond T. Management strategies in resection for hilar cholangiocarcinoma. Ann Surg. 1992;215:31–8.

    Article  PubMed  CAS  Google Scholar 

  18. Mimura H, Kim H, Ochiai Y, Takakura N, Hamazaki K, Tsuge H, Sakagami K, Orita K. Radical block resection of hepatoduodenal ligament for carcinoma of the bile duct with double catheter bypass for portal circulation. Surg Gynecol Obstet. 1988;167:527–9.

    PubMed  CAS  Google Scholar 

  19. Jarnagin WR, Shoup M. Surgical management of cholangiocarcinoma. Semin Liver Dis. 2004;24:189–99.

    Article  PubMed  Google Scholar 

  20. Sakamoto E, Nimura Y, Hayakawa N, Kamiya J, Kondo S, Nagino M, Kanai M, Miyachi M, Uesaka K. The pattern of infiltration at the proximal border of hilar bile duct carcinoma: a histologic analysis of 62 resected cases. Ann Surg. 1998;227:405–11.

    Article  PubMed  CAS  Google Scholar 

  21. Ito F, Agni R, Rettammel RJ, Been MJ, Cho CS, Mahvi DM, Rikkers LF, Weber SM. Resection of hilar cholangiocarcinoma: concomitant liver resection decreases hepatic recurrence. Ann Surg. 2008;248:273–9.

    Article  PubMed  Google Scholar 

  22. Jarnagin WR, Ruo L, Little SA, Klimstra D, D’Angelica M, DeMatteo RP, Wagman R, Blumgart LH, Fong Y. Patterns of initial recurrence after resection of gallbladder carcinoma and hilar cholangiocarcinoma: implications for adjuvant therapeutic strategies. Cancer. 2003;98:1689–700.

    Article  PubMed  Google Scholar 

  23. Jonas S, Steinmüller T, Neuhaus P. Surgical therapy of liver hilus tumors. Chirurg. 2001;72:775–83.

    Article  PubMed  CAS  Google Scholar 

  24. Bismuth H. Surgical anatomy and anatomical surgery of the liver. World J Surg. 1982;6:3–9.

    Article  PubMed  CAS  Google Scholar 

  25. Hirano S, Kondo S, Tanaka E, Shichinohe T, Tsuchikawa T, Kato K, Matsumoto J, Kawasaki R. Outcome of surgical treatment of hilar cholangiocarcinoma: a special reference to postoperative morbidity and mortality. J Hepatobiliary Pancreat Sci. 2010;17:455–62.

    Article  PubMed  Google Scholar 

  26. Miyazaki M, Kimura F, Shimizu H, Yoshidome H, Otuka M, Kato A, Yoshitomi H, Furukawa K, Takeuchi D, Takayashiki T, Suda K, Takano S. One hundred seven consecutive surgical resections for hilar cholangiocarcinoma of Bismuth types II, III, IV between 2001 and 2008. J Hepatobiliary Pancreat Sci. 2010;17:470–5.

    Article  PubMed  Google Scholar 

  27. van Gulik TM, Kloek JJ, Ruys AT, Busch OR, van Tienhoven GJ, Lameris JS, Rauws EA, Gouma DJ. Multidisciplinary management of hilar cholangiocarcinoma (Klatskin tumor): extended resection is associated with improved survival. Eur J Surg Oncol. 2011;37:65–71.

    Article  PubMed  Google Scholar 

  28. Sano T, Shimada K, Sakamoto Y, Yamamoto J, Yamasaki S, Kosuge T. One hundred two consecutive hepatobiliary resections for perihilar cholangiocarcinoma with zero mortality. Ann Surg. 2006;44:240–7.

    Article  Google Scholar 

  29. Lee SG, Song GW, Hwang S, Ha TY, Moon DB, Jung DH, Kim KH, Ahn CS, Kim MH, Lee SK, Sung KB, Ko GY. Surgical treatment of hilar cholangiocarcinoma in the new era: the Asan experience. J He Hepatobiliary Pancreat Sci. 2010;17:476–89.

    Article  Google Scholar 

  30. Nagino M, Nimura Y, Nishio H, Ebata T, Igami T, Matsushita M, Nishikimi N, Kamei Y. Hepatectomy with simultaneous resection of the portal vein and hepatic artery for advanced perihilar cholangiocarcinoma: an audit of 50 consecutive cases. Ann Surg. 2010;252:115–23.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Daniel Seehofer MD.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Neuhaus, P., Thelen, A., Jonas, S. et al. Oncological Superiority of Hilar En Bloc Resection for the Treatment of Hilar Cholangiocarcinoma. Ann Surg Oncol 19, 1602–1608 (2012). https://doi.org/10.1245/s10434-011-2077-5

Download citation

  • Received:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1245/s10434-011-2077-5

Keywords

Navigation