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Hilar cholangiocarcinoma The East Versus The West

Hilar cholangiocarcinoma The East Versus The West. WC Dai Department of Surgery Ruttonjee Hospital. Introduction. 3% of all gastrointestinal malignancies Intrahepatic (5-15 %) Extrahepatic perihilar (60-70%) distal segments (25%) Peak 50-70 years of age

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Hilar cholangiocarcinoma The East Versus The West

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  1. Hilar cholangiocarcinomaThe East Versus The West WC Dai Department of Surgery Ruttonjee Hospital

  2. Introduction • 3% of all gastrointestinal malignancies • Intrahepatic (5-15%) • Extrahepatic • perihilar (60-70%) • distal segments (25%) • Peak 50-70 years of age • Overall 5-year survival rate< 5% • Adenocarcinoma of the hepatic duct bifurcation Klatskin G. Am J Med 1965

  3. Clinical Biochemical Diagnosis Radiological Cytological

  4. Biochemical • Cancer antigen CA19.9 • Carcinoembryonic antigen (CEA) • Others

  5. Brush cytology • Notoriously difficult to diagnose cytologically • Sensitivity ranged from 35-70% • Specificity typically exceeded 90% Desa LAet al. Gut 1991 Mansfield JC et al. Gut 1997

  6. Cytological Benign VS Malignant • Necessity of establishing a tissue diagnosis • strictures of clinically indeterminate origin  • aggressive treatments  • characteristic findings of malignant hilar biliary obstruction  • unresectable cases  • clinical trials ?

  7. Radiological • Ideal imaging • Good imaging quality • Complete presentation of the biliary tract • Differentiation between malignant and benign lesions • Ultrasonography • Computed tomography • Magnetic resonance imaging

  8. Endoscopic retrograde cholangiopancreatography (ERCP) Percutaneous cholangiography (PTC) Cholangiography

  9. MRCP • Investigate different components • bile ducts, vessels and adjacent liver parenchyma • Comparable to ERCP and PTC • Understage disease in 20% Yeh TS et al. American Journal of Gastroenterology 2000 Zidi SH et al. Gut 2000

  10. Endoscopic USG • Primary tumourand regional lymph nodes • EUS-guided FNA have ahigher sensitivity than brushings or biopsies Fritscher-Ravens A et al. Gastrointestinal Endoscopy 2000

  11. Intraductal USG • Small caliber intraductal ultrasould miniprobes • Better image resolution than standard EUS • Evaluate the proximal biliary system and surrounding periductal tissue • Distinguish benign from malignant strictures Farrell RJ et al Gastrointestinal Endoscopy 2002 Dmoagk D et al. American Journal of Gastroenterology 2004

  12. PET scan • Detect nodular cholangiocarcinoma as small as 1cm • Alter surgical management in 30% of patients Anderson CD et al. Journal of Gastrointestinal Surgery 2004

  13. Management • Primary goal of surgery • complete resection with histological negative resection margins • Criteria for resectability • Tumour-free margins obtained in only 20-40% • Local failure being the first site of disease progression in 50-75% of cases

  14. Preoperative management • Preoperative biliary decompression • Controversial • Several prospective randomized trials failed to demonstrate a specific benefit of pre-operative biliary drainage Hatfield ARW et al. Lancet 1982 McPherson GAD et al. British Journal of Surgery 1984 Pitt HA et al. Annals of Surgery 1985 Lai ESC et al. British Journal of Surgery 1994

  15. Preoperative management • ‘Rapid hepatectomy’ • 20 patients with proximal duct carcinoma • No differences in liver failure (5 vs 0%) and mortality rates (5 vs 0%) • Post-operative liver function were comparable • Significant differences in postoperative complications Cherqui D et al. Achieves of Surgery 2000

  16. Pre-operative management Takada T. Journal of Hepatobiliary Pancreatic Surgery 2001

  17. Portal vein embolization • Devised by Makuuchi et al and Kinoshita et al • 25-30% remnant is the minimum essential volume • Permit a margin-negative resection • 240 consecutive patients • No significant procedure-related complications • Similar mortality and 5-years survival compared with those who underwent <50% resection Masato N et al. Annals of Surgery 2006

  18. Management Bismuth-Corlette classification • No universally accepted approach • Bile duct • Hepatic resection

  19. Hilar cholangiocarcinoma

  20. The East versus the West Tsao JI et al. Annals of Surgery 2000

  21. The East versus the West • Overall higher stage disease in the Japanese cohort • The criteria for resectability at Nagoya University Hospital were more liberal • Extensive preoperative staging investigations and interventions

  22. Aggressive approach • CT volumetric study • Indocyanine green test • Percutaneous transhepatic biliary drainage • Percutaneous transhepatic cholangioscopy • Selective celiac and superior mesenteric arteriography • Percutaneous transhepatic portography

  23. Portal vein resection • 160 patients with 52 portal vein resection • Similar surgical mortalities • No complications directly related to portal vein resection and reconstruction • Macroscopic portal vein invasion has a negative impact on survival Tomoki E et al. Annals of Surgery 2003

  24. Liver transplantation • Beavers KL et al • Median patient survival - 11.8 months • One-, three- and five-year survival rates - 63, 46 and 22% • Recurrence - 52% • Mayo clinic • Neoadjuvant chemoirradiation • Actuarial one- and five-year survival was 88% and 82% Rea DJ. Annals of Surgery 2005 • 50% remained disease free (2.8 to 14.5 years) Sudan et al. American Journal of Transplantation 2002

  25. Discussion • Increasing modalities of investigations • Pre-operative management • Controversies in the surgical management of hilar cholangiocarcinoma • Role of liver transplantation

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