セッション情報 The 4th International Forum

II Challenge to the pancreatic and biliary cancers 4. Biliary cancer―Challenge to the better prognosis

タイトル IFII-4-1:

Surgery of hilar and extrahepatic cholangiocarcinoma

演者 Neuhaus Peter(Department of General-, Visceral- and Transplantation- Surgery, Charit? -Universit?tsmedizin Berlin Campus Virchow Klinikum, Germany)
共同演者 Seehofer Daniel(Department of General-, Visceral- and Transplantation- Surgery, Charit? -Universit?tsmedizin Berlin Campus Virchow Klinikum, Germany)
抄録 Liver resections for hilar cholangiocarcinoma are technically demanding and associated with a high postoperative morbidity.
Surgery is the only potentially curative treatment for hilar cholangiocarcinoma. However, its characteristic growth pattern with periductal infiltration makes curative tumor resection difficult and requires appropriate safety margins. This requires a radical surgical strategy and isloated resection of the extrahepatic bile ducts is considered as palliative procedure, since recurrence rates are close to 100%. Extended hepatectomies have evolved as the standard of curative treatment in hilar cholangiocarcinoma - adequate liver function provided. If permitted by local tumor extension and volume of the future liver remnant, a right sided hepatectomy is the procedure of choice, because of its higher oncological radicality compared to left hemihepatectomies. Due to the biliary anatomy, a R0 resection is more liekly in(extended)right hemihepatectomies, since the biliary confluence is located on the right side of the hepatoduodenal ligament and therefore the left hepatic duct has a longer extrahepatic course until it traverses the left portal vein within the umbilical fissure and ramifies to the segments 2 and 3 branches. Also another critical step with potential tumor dissemination, the dissection of the right hepatic artery running dorsally close to the tumor region, can be avoided. Major drawback of right trisectionectomy is the relatively low remnant liver volume, leading to an elevated perioperative risk. Therefore, an optimal conditioning of the liver prior to surgery is mandatory. This includes reversal of cholestasis, embolisation of the right liver lobe and treatment of cholangitis where appropriate. All together, this has markedly increased the safety of this procedure. The final decision if an extended right hepatectomy or a right trisectionectomy is feasible is based in our own practice on liver function tests. We routinely rely on the LiMAx(maximum liver function capacity)liver function test which is used before all extended hepatectomies.
However, in about one third of cases the left hepatic lobe is severely atrophic due to long-standing cholestasis or occlusion of the left portal branch, making an extended right hemihepatectomy impossible. For extrahepatic bile duct tumors below the junction of the cystic duct(distal bile duct tumors)surgery consist of partial pancreato-duodenectomy. In case of infiltration of the distal bile duct and the hilar bifurcation a combined hepatectomy and pancreatic head resection might be considered in selected cases.
Depending on tumor characteristics and surgical methods 5 year survival rates of 20 to 50 % have been reported after R0 resection by major liver resection.
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