Liver resections for hilar cholangiocarcinoma

Hilar cholangiocarcinoma (HC) is a rare tumor which has to be distinguished by intrahepatic cholagiocarcinoma invading hepatic hilum because the former has better prognosis then the latter. Patients with HC are difficult to manage because many challenging issues remain in the treatment of this tumour regarding correct diagnosis and therapeutic strategy. HC is resectable in about 30% of cases, but operative risk is highly influenced by septic complications of preoperative biliary drainage and by the need of major liver resection associated with biliary resection. We report the results of 43 resected patients (28 M/15 F; mean age 60 years, range 33-78), accounting for 29% of 149 patients with HC. Symptomless jaundice was the most common clinical presentation (87%; 130 patients). Biliary stricture was classified according to the Bismuth-Corlette classification as type 1 in 3 patients (7%); type 2 in 12 patients (28%); type 3 in 28 patients (65%). Ten patients underwent preoperative right portal vein embolization. Main biliary confluence excision associated with major hepatectomy was performed in 40 patients (93%), with R0 resection rate by 77%. Postoperative mortality rate was 6.9% (3 patients). Morbidity rate was 52.5% (21 patients), being biliary fistula (38%) and liver failure (19%) the most frequent complications. Five-year overall and disease-free survival rate were 36.1% and 28.2, respectively. Surgical resection remains the only chance of cure for patients with HC. However, due to the complexity of surgery immediate results remain unsatisfactory with morbidity and mortality rates higher than those reported after liver resection for other malignancies. This is mainly related to septic complications, strictly linked to complications of preoperative biliary drainage. Selective biliary drainage, careful management of biliary drains, drainage of excluded ducts in case of cholangitis, bile culture guided antibiotic use and preoperative portal vein embolization are important factors to reduce the risk of cholangitis and of postoperative complications. Because of the significant perioperative risk, the demanding operative management and the rarity of this tumor, patients with HC should be referred to tertiary surgical centers.