الفهرس 
Surgical AnatomyOnly 14 pages are availabe for public view
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Abstract
Perihilar cholangiocarcinoma includes extrahepatic and intrahepatic cholangiocarcinomas that involve the hepatic confluence of the bile duct. Although this intractable disease used to be difficult to resect as a result of complex anatomy of the hepatic hilum, diagnostic and surgical strategy has changed drastically over the past two decades. Hepatobiliary resection based on precise preoperative diagnosis of tumor extent has become a standard procedure to obtain curative resection. Despite the advance of preoperative diagnostic techniques, perihilar cholangio-carcinoma is typically diagnosed in an advanced stage at initial presentation. As only surgical resection can offer the superior survival probability, combined portal vein and liver resection and/or hepatopancreatoduodenectomy are aggressively performed at leading centers.
Most patients appear with obstructive jaundice. Even in patients without jaundice, serum alkaline phosphatase and/or g-glutamyltranspeptidase are usually elevated. Those symptoms result from bile congestion due to biliary stricture of the hepatic confluence involved by advanced cholangiocarcinoma. Ultrasonography is performed in those patients and reveals dilated intrahepatic bile ducts, the normal or atrophic gallbladder and sometimes a tumor itself, suggesting perihilar cholangiocarcinoma. Computed tomography (CT) or magnetic resonance imaging (MRI) is carried out for further examination. As CT or MRI usually indicate which lobe of the liver is predominantly involved, biliary drainage is applied to decompress the future remnant hepatic lobe.
Advanced perihilar cholangiocarcinoma thickens the bile duct wall, resulting in biliary stricture. Therefore, the extent of biliary stricture is evaluated carefully to diagnose tumor extent along the bile duct. For this purpose, direct cholangiography via the biliary drainage catheters remains the best modality and provides advanced resolution of the images.
As perihilar cholangiocarcicoma often requires major resection of a cholestatic liver to obtain curative resection, septic morbidity followed by liver failure is one of the serious postoperative complications and may result in a fatal condition. Therefore, preoperative liver function must be estimated carefully.
As only surgical resection can offer a chance of long-term survival in patients with perihilar cholangio-carcoinoma, aggressive surgery is recommended even for locally advanced perihilar cholangiocarcinoma. As R0 resection can rarely be obtained for bile duct resection without hepatectomy, segmental hepatectomy combined with caudate lobe resection, extrahepatic bile duct resection, and extended lymphadenectomy is the standard procedure. Type of hepatectomy should be determined according to cancer extent along the bile duct diagnosed by direct cholangiography. Surgical indication should not be determined based on Bismuth classification alone as surgical resection could be carried out in approximately 70% of patients with Bismuth type IV tumor.
Resection survival rates for patients with and without lymph node metastasis, and for patients with and without portal vein resection were 10%, 34%,, 11% and 27%, respectively. Five-year survival rate and median survival time for patients with R0 resection were 27% and 2.3 years, respectively. When R0 resection was performed in patients without M1 diseases, 5-year survival rates were 45% for patients without lymph node metastasis, and 50% for patients without lymph node metastasis nor portal vein resection.
The remarkable progress of living donor LT (LDLT) in the recent years has made the long waiting lists for transplantation redundant in centers actively engaged in LDLT. With improvements in surgical techniques and increased experience, morbidity and mortality for both donor and recipient can be minimized.LDLT thus can be a viable option for patients with hilar cholangiocarcinoma
Palliation of obstructive jaundice can be achieved successfully through three major routes: surgically, by the creation of a choledochojejunostomy or hepatico-jejunostomy; percutaneously, via percutaneous transhepatic cholangiography (PTC) and stent placement; and endoscopically via ERCP and stent placement. Photodynamic therapy and intraluminal brachytherapy delivered by either the percutaneous or endoscopic routemay be used in addition to stent placement.