Diagnostic and surgical features of Klatskin tumors

Klatskin tumors are rare and their prognosis is poor. Long term survival can be expected only after a surgical resection, the treatment of choice. The aim of this study is to report our single centre experience and, by literature analysis, to define the role of surgery in the treatment of hilar cholangiocarcinoma.

Between 1990 and 1998, 27 patients affected by Klatskin's tumor were observed. Eight women and seven men (mean age 59 years) underwent surgical resection. Thirteen patients (86%) had curative resection (7 hilar resection (HR), 4 HR combined with partial hepatectomy (PH) and 2 HR + PH with portal vein resection). Two patients (13%) had palliative biliary resection and surgical drainage.

One in-hospital death was recorded after a right hepatectomy with portal vein resection (6.6%). Postoperative morbidity rate was 40%. Patients were regularly followed up to date or to death. Ten patients died and 5 survived. The 1-, 2- and 3-year survival rate after curative resection was 84%, 54% and 34%. The median survival was 28.5 months. Lymph node involvement did not show a statistically significant difference on median survival between the positive group and the negative group (26.2 vs 29.8 months), nor did perineural invasion, because of the small number of patients. The 1-, 2-, 3- and 5-year survival rate after isolated hilar resection was 100%, 57.1%, 28.6% and 0. Four out of 6 patients who underwent hilar resection combined with partial hepatectomy are still alive 1, 23, 29, 38 months after resection. Hepatectomy increased mortality (16% vs 0). Palliative biliary resection and surgical drainage were successfully performed in 2 patients with satisfactory results.

Aggressive surgical treatment of Klatskin tumors can improve patients' survival. Careful preoperative management has to be carried out by a multidisciplinary approach including surgeons, gastroenterologists, radiologists and pathologists. Hepatic resection involving the caudate lobe is often performed in order to obtain microscopic tumor-free margins and curative resection (R0). Biliary drainage and treatment of cholangitis is mandatory before surgery in order to improve surgical outcome. Surgical treatment is characterized by high technical difficulties and better results can be achieved by hepatobiliary surgical teams.