First results of radical and conditionally radical resections for Klatskin tumors

Relevance: Hilar cholangiocarcinoma is the most common malignant tumor of the bile ducts.

Aim: analysis of the first experience of radical and conditionally radical operations performed in MCSC during one year.

Materials and methods: Extended hepatectomies combined with resection of bile ducts and first segment performed in 18 patients with Klatskin tumor. Right hemihepatectomy performed in 8 patients, resection with caudal lobectomy – in 8 patients. The preoperative percutaneous right-sided selective portal embolisation using Celonova microspheres was performed in 5 patients. One patient with type II tumor according to Bismuth-Corlette classification underwent hemihepatectomy with a left caudal lobectomy and resection of the extrahepatic bile ducts using laparoscopic approach and DaVinci robotic system.

Results: The average volume of intraoperative blood loss was 705±616 ml (range 200 to 2000 ml). Postoperative III and IV grade complications according to Clavien-Dindo classification occurred in 13 patients (72%). Two patients (11%) died postoperatively. The cause of death in both observations was severe sepsis. Patients with R1 and R2-resections undergo adjuvant chemotherapy with no objective signs of progression. Patients with R0-resection are under observation with no signs of progression.

Conclusion: Late diagnosis, a high risk of postoperative complications requires a multidisciplinary approach at each stage of the treatment of Klatskin tumor.

1. DeOliveira M.L., Cunningham S. C., Cameron J. L., Kamangar F., Winter J. M., Lillemoe K. D., et al. Cholangiocarcinoma: thirty one year experience with 564 patients at a single institution. AnnSurg 2007; 245: 755–62.

2. Hamilton S. R., Aaltonen L. A. Pathology and genetics of tumours of the digestive system. In: Wo rldHealthClassificationofTumors. Lyon: IARCPress; 2000.

3. Altemeier W. A., Gall E. A., Zinninger M. M., Hoxworth P. I. Sclerosing Carcinoma of the Major Intrahepatic Bile DuctsAMA Arch Surg. 1957;75 (3): 450–461.

4. Klatskin G. Adenocarcinoma of the hepatic duct at its bifurcation within the porta hepatis: An unusual tumor with distinctive clinical and pathological features. Am J Med. 1965 Feb;38:241–56.

5. De Martel C., Plummer M., Franceschi S. Cholangiocarcinoma: descriptive epidemiology and risk factors.GastroenterolClin Biol. 2010 Mar;34 (3):173–80.

6. Статистика злокачественных новообразований в России и странах СНГ в 2012 г. Под редакцией М. И. Давыдова и Е. М. Аксель. Москва. 2012. с. 77.

7. Вишневский В. А., Ефанов М. Г., Икрамов Р. З., Назаренко Н. А., Шевченко Т. В., Ионкин Д. А., Чжао А. В. Отдаленные результаты радикальных и условно радикальных резекций при воротной холангиокарциноме. Анналы хирургической гепатологии. 2013, том 18, № 2. с. 9–20.

8. Neuhaus P., Jonas S., Bechstein W. O., Lohmann R., Radke C., Kling N., Wex C., Lobeck H., Hintze R. Extended Resections for HilarCholangiocarcinoma. Ann Surg. 1999; 230 (6): 808–819.

9. Neuhaus P., Thelen A., Jonas S., Puhl G., Denecke T., Veltzke-Schlieker W., Seehofer D. Oncological superiority of hilaren bloc resection for the treatment of hilarcholangiocarcinoma. Ann SurgOncol. 2012; 19 (5): 1602–1608.

10. Nagino M., Ebata T., Yokoyama Y., Igami T., Sugawara G., Takahashi Y., Nimura Y. Evolution of Surgical Treatment for PerihilarCholangiocarcinoma: A Single-Center 34-Year Review of 574 Consecutive Resections. Ann Surg2012;00: 1–12.

11. Kawarada Y., Das B. C., Taoka H. Anatomy of the hepatic hilar area: the plate system. J Hepatobiliary Pancreat Surg. 2000; 7: 580–586.

12. Nimura Y. Preoperative biliary drainage before resection for cholangiocarcinoma (Pro). HPB, 2008; 10: 130–133.

13. Palavecino M, Abdalla EK, Madoff DC, Vauthey JN. Portal vein embolization in hilarcholangiocarcinoma. SurgOncolClinNAm. 2009 Apr;18 (2):257–67.

14. Yi B, Xu AM, Lai EC, Qu ZQ, Cheng QB, Liu C, Luo XJ, Yu Y, Qiu YH, Wang XY, Cheng HY, Zhang BH, Shen F, Lau WY, Wu MC, Jiang XQ Preoperative portal vein embolization for hilarcholangiocarcinoma — a comparative study. Hepatogastroenterology. 2010 Nov-Dec; 57 (104):1341–6.

15. Nagino M, Kamiya J, Nishio H, Ebata T, Arai T, Nimura Y. Two Hundred Forty Consecutive Portal Vein EmbolizationsBefore Extended Hepatectomy for Biliary Cancer. Surgical Outcome and Long-term Follow-Up. Ann Surg. 2006 Mar;243 (3):364–72.

16. Giulianotti P. C., Sbrana F., Bianco F. M., Addeo P. Robot-assisted laparoscopic extended right hepatectomy with biliary reconstraction. J LaparoendoscAdvSurg Tech A. 2010 Mar;20 (2):159–63.

17. Liu Q. D., Chen J. Z., Xu X. Y., Zhang T., Zhou N. X. Incidence of port-site metastasis after undergoing robotic surgery for biliary malignancies. World J Gastroenterol. 2012 Oct 28;18 (40):5695–701.

18. Itano O.,, Oshima G., Maeda S., Chiba N., Aikou S., Kitagawa Y. Laparoscopy-Assisted Right Hepatectomy and Caudate Lobectomy with Portal Reconstruction for HilarCholangiocarcinoma. Journal of Laparoendoscopic& Advanced Surgical Techniques Part B, Videoscopy. Dec 2011, Vol. 21, No. 6.

19. Hughes M. A., Frassica D. A., Yeo C. J., Riall T. S., Lillemoe K. D., Cameron J. L., Donehower R. C., Laheru D. A., Hruban R. H., Abrams R. A. Adjuvant concurrent chemoradiation for adenocarcinoma of the distal common bile duct. Int J RadiatOncolBiol Phys. 2007 May 1;68 (1):178–82.

20. Nelson J. W., Ghafoori A. P., Willett C. G., Tyler D. S., Pappas T. N., Clary B. M., Hurwitz H. I., Bendell J. C., Morse M. A., Clough R. W., Czito B. G. Concurrent chemoradiotherapy in resected extrahepaticcholangiocarcinoma. Int J RadiatOncolBiol Phys. 2009 Jan 1;73 (1):148–53.

21. Lim K. H., Oh D. Y., Chie E. K., Jang J. Y., Im S. A., Kim T. Y., Kim S. W., Ha S. W., Bang Y. J. Adjuvant concurrent chemoradiation therapy (CCRT) alone versus CCRT followed by adjuvant chemotherapy: which is better in patients with radically resected extrahepatic biliary tract cancer?: a non-randomized, single center study. BMCCancer. 2009 Sep. 27;9:345.

22. Borghero Y., Crane C. H., Szklaruk J., Oyarzo M., Curley S., Pisters P. W., Evans D., Abdalla E. K., Thomas M. B., Das P., Wistuba I. I., Krishnan S., Vauthey J. N. Extrahepatic bile duct adenocarcinoma: patients at high-risk for local recurrence treated with surgery and adjuvant chemoradiation have an equivalent overall survival to patients with standard-risk treated with surgery alone. Ann SurgOncol. 2008 Nov;15 (11):3147–56.

23. Park J. H., Choi E. K., Ahn S. D., Lee S. W., Song S. Y., Yoon S. M., Kim Y. S., Lee Y. S., Lee S. G., Hwang S., Lee Y. J., Park K. M., Kim T. W., Chang H. M., Lee J. L., Kim J. H. Postoperative chemoradiotherapy for extrahepatic bile duct cancer. Int J RadiatOncolBiol Phys. 2011 Mar 1;79 (3):696–704.

24. Das P., Wolff R. A., Abbruzzese J. L., Varadhachary G. R., Evans D. B., Vauthey J. N., Baschnagel A., Delclos M. E., Krishnan S., Janjan N. A., Crane C. H. Concurrent capecitabine and upper abdominal radiation therapy is well tolerated. RadiatOncol. 2006 Oct24;1:41.

25. Lin L. L., Picus J., Drebin J. A., Linehan D. C., Solis J., Strasberg S. M., Tan B., Thorstad W. L., Myerson R.A phase II study of alternating cycles of split course radiation therapy and gemcitabine chemotherapy for inoperable pancreatic or biliary tract carcinoma. Am J ClinOncol. 2005 Jun;28 (3):234–41.