Annals of Surgical Oncology

, Volume 13, Issue 6, pp 872–880 | Cite as

Improved Outcome of Resection of Hilar Cholangiocarcinoma (Klatskin Tumor)

  • Sander Dinant
  • Michael F. Gerhards
  • E. A. J. Rauws
  • Olivier R. C. Busch
  • Dirk J. Gouma
  • Thomas M. van Gulik



Treatment of hilar cholangiocarcinoma (Klatskin tumors) has changed in many aspects. A more extensive surgical approach, as proposed by Japanese surgeons, has been applied in our center over the last 5 years; it combines hilar resection with partial hepatectomy for most tumors. The aim of this study was to assess the outcome of a 15-year evolution in the surgical treatment of Klatskin tumors.


A total of 99 consecutive patients underwent resection for hilar cholangiocarcinoma in three 5-year time periods: periods 1 (1988–1993; n = 45), 2 (1993–1998; n = 25), and 3 (1998–2003; n = 29). Outcome was evaluated by assessment of completeness of resection, postoperative morbidity and mortality, and survival.


The proportion of margin negative resections increased significantly from 13% in period 1 to 59% in period 3 (P < .05). Two-year survival increased significantly from 33% ± 7% and 39% ± 10% in periods 1 and 2 to 60% ± 11% in period 3 (P < .05). Postoperative morbidity and mortality were considerable but did not increase with this changed surgical strategy (68% and 10%, respectively, in period 3). Lymph node metastasis was, next to period of resection, also associated with survival in univariate analysis.


Mainly in the last 5-year period (1998–2003), when the Japanese surgical approach was followed, more hilar resections were combined with partial liver resections that included segments 1 and 4, thus leading to more R0 resections. This, together with a decrease in lymph node metastases, resulted in improved survival without significantly affecting postoperative morbidity or mortality.


Hilar cholangiocarcinoma Hepatectomy Liver Surgery Mortality Survival 



The authors thank Professor Y. Nimura (Division of Surgical Oncology, Nagoya University Hospital) for his collaboration during the last 5 years. They also thank Professor H. Obertop (Department of Surgery, Academic Medical Center) for his contributions to this study.


  1. 1.
    Klatskin G. Adenocarcinoma of the hepatic duct at its bifurcation within the porta hepatis. Am J Med 1965; 38:241–56CrossRefPubMedGoogle Scholar
  2. 2.
    Burke EC, Jarnagin WR, Hochwald SN, Pisters PWT, Fong Y, Blumgart LH. Hilar cholangiocarcinoma: patterns of spread, the importance of hepatic resection for curative operation, and a presurgical clinical staging system. Ann Surg 1998; 228:385–94CrossRefPubMedGoogle Scholar
  3. 3.
    Hadjis NS, Blenkharn JI, Alexander N, Benjamin IS, Blumgart LH. Outcome of radical surgery in hilar cholangiocarcinoma. Surgery 1990; 107:597–604PubMedGoogle Scholar
  4. 4.
    Pichlmayr R, Weimann A, Klempnauer J, et al. Surgical treatment in proximal bile duct cancer. A single-center experience. Ann Surg 1996; 224:628–38CrossRefPubMedGoogle Scholar
  5. 5.
    Beazley RM, Hadjis N, Benjamin IS, Blumgart LH. Clinicopathological aspects of high bile duct cancer. Experience with resection and bypass surgical treatments. Ann Surg 1984; 199:623–36PubMedGoogle Scholar
  6. 6.
    Blumgart LH, Hadjis NS, Benjamin IS, Beazley R. Surgical approaches to cholangiocarcinoma at confluence of hepatic ducts. Lancet 1984; 1:66–70CrossRefPubMedGoogle Scholar
  7. 7.
    Launois B, Campion JP, Brissot P, Gosselin M. Carcinoma of the hepatic hilus. Surgical management and the case for resection. Ann Surg 1979; 190:151–7PubMedGoogle Scholar
  8. 8.
    Washburn WK, Lewis WD, Jenkins RL. Aggressive surgical resection for cholangiocarcinoma. Arch Surg 1995; 130:270–6PubMedGoogle Scholar
  9. 9.
    Baer HU, Stain SC, Dennison AR, Eggers B, Blumgart LH. Improvements in survival by aggressive resections of hilar cholangiocarcinoma. Ann Surg 1993; 217:20–7PubMedGoogle Scholar
  10. 10.
    Nimura Y, Kamiya J, Kondo S, et al. Aggressive preoperative management and extended surgery for hilar cholangiocarcinoma: Nagoya experience. J Hepatobiliary Pancreat Surg 2000; 7:155–62CrossRefPubMedGoogle Scholar
  11. 11.
    Gerhards MF, Van Gulik TM, Bosma A, et al. Long-term survival after resection of proximal bile duct carcinoma (Klatskin tumors). World J Surg 1999; 23:91–6CrossRefPubMedGoogle Scholar
  12. 12.
    Kawasaki S, Makuuchi M, Miyagawa S, Kakazu T. Radical operation after portal embolization for tumor of hilar bile duct. J Am Coll Surg 1994; 178:480–6PubMedGoogle Scholar
  13. 13.
    Klempnauer J, Ridder GJ, Van Wasielewski R, Werner M, Weimann A, Pichlmayr R. Resectional surgery of hilar cholangiocarcinoma: a multivariate analysis of prognostic factors. J Clin Oncol 1997; 15:947–54PubMedGoogle Scholar
  14. 14.
    Kawasaki S, Imamura H, Kobayashi A, Noike T, Miwa S, Miyagawa S. Results of surgical resection for patients with hilar bile duct cancer: application of extended hepatectomy after biliary drainage and hemihepatic portal vein embolization. Ann Surg 2003; 238:84–92CrossRefPubMedGoogle Scholar
  15. 15.
    Seyama Y, Kubota K, Sano K, et al. Long-term outcome of extended hemihepatectomy for hilar bile duct cancer with no mortality and high survival rate. Ann Surg 2003; 238:73–83CrossRefPubMedGoogle Scholar
  16. 16.
    Jarnagin WR, Fong Y, DeMatteo RP, et al. Staging, resectability, and outcome in 225 patients with hilar cholangiocarcinoma. Ann Surg 2001; 234:507–17CrossRefPubMedGoogle Scholar
  17. 17.
    Tsao JI, Nimura Y, Kamiya J, et al. Management of hilar cholangiocarcinoma. Comparison of an American and a Japanese experience. Ann Surg 2000; 232:166–74CrossRefPubMedGoogle Scholar
  18. 18.
    Nimura Y, Hayakawa N, Kamiya J, Kondo S, Shionoya S. Hepatic segmentectomy with caudate lobe resection for bile duct carcinoma of the hepatic hilus. World J Surg 1990; 14:535–43CrossRefPubMedGoogle Scholar
  19. 19.
    Ogura Y, Kawarada Y. Surgical strategies for carcinoma of the hepatic duct confluence. Br J Surg 1998; 85:20–4CrossRefPubMedGoogle Scholar
  20. 20.
    Kosuge T, Yamamoto J, Shimada K, Yamasaki S, Makuuchi M. Improved surgical results for hilar cholangiocarcinoma with procedures including major hepatic resection. Ann Surg 1999; 230:663–71CrossRefPubMedGoogle Scholar
  21. 21.
    Gerhards MF, Van Gulik TM, de Wit LT, Obertop H, Gouma DJ. Evaluation of morbidity and mortality after resection for hilar cholangiocarcinoma—a single center experience. Surgery 2000; 127:395–404CrossRefPubMedGoogle Scholar
  22. 22.
    Tio TL, Reeders WA, Sie LH, et al. Endosonography in the clinical staging of Klatskin tumor. Endoscopy 1993; 25:81–5PubMedCrossRefGoogle Scholar
  23. 23.
    Van Delden OM, de Wit LT, van Nieveen Dijkum EJ, Smits MJ, Gouma DJ, Reeders JW. Value of laparoscopic ultrasonography in staging of proximal bile duct tumors. J Ultrasound Med 1997; 16:7–12PubMedGoogle Scholar
  24. 24.
    Tilleman EHBM, de Castro SMM, Busch ORC, et al. Diagnostic laparoscopy and laparoscopic ultrasound for staging of patients with malignant proximal bile duct obstruction. J Gastrointest Surg 2002; 6:426–30CrossRefPubMedGoogle Scholar
  25. 25.
    Bismuth H, Corlette MB. Intrahepatic cholangioenteric anastomosis in carcinoma of the hilus of the liver. Surg Gynecol Obstet 1975; 140:170–8PubMedGoogle Scholar
  26. 26.
    Gerhards MF, Gonzales DG, ten Hoopen-Neumann H, van Gulik TM, de Wit LT, Gouma DJ. Prevention of implantation metastases after resection of proximal bile duct tumours with pre-operative low dose radiation therapy. Eur J Surg Oncol 2000; 26:480–5CrossRefPubMedGoogle Scholar
  27. 27.
    Gerhards MF, van Gulik TM, Gonzalez GD, Rauws EA, Gouma DJ. Results of postoperative radiotherapy for resectable hilar cholangiocarcinoma. World J Surg 2003; 27:173–9PubMedGoogle Scholar
  28. 28.
    Neuhaus P, Jonas S, Settmacher U, et al. Surgical management of proximal bile duct cancer: extended right lobe resection increases resectability and radicality. Langenbecks Arch Surg 2003; 388:194–200CrossRefPubMedGoogle Scholar
  29. 29.
    Heron DE, Stein DE, Eschelman DJ, et al. Cholangiocarcinoma: the impact of tumor location and treatment strategy on outcome. Am J Clin Oncol 2003; 26:422–8CrossRefPubMedGoogle Scholar
  30. 30.
    Figueras J, Llado L, Valls C, et al. Changing strategies in diagnosis and management of hilar cholangiocarcinoma. Liver Transpl 2000; 6:786–94PubMedGoogle Scholar
  31. 31.
    Sewnath ME, Karsten TM, Prins MH, Rauws EAJ, Obertop H, Gouma DJ. A meta-analysis on the efficacy of preoperative biliary drainage for tumors causing obstructive jaundice. Ann Surg 2002; 236:17–27CrossRefPubMedGoogle Scholar
  32. 32.
    Ebata T, Nagino M, Kamiya J, Uesaka K, Nagasaka T, Nimura Y. Hepatectomy with portal vein resection for hilar cholangiocarcinoma. Audit of 52 consecutive cases. Ann Surg 2003; 238:720–7CrossRefPubMedGoogle Scholar
  33. 33.
    Capussotti L, Muratore A, Polastri R, Ferrero A, Massucco P. Liver resection for hilar cholangiocarcinoma: in hospital mortality and longterm survival. J Am Coll Surg 2002; 195:641–7CrossRefPubMedGoogle Scholar
  34. 34.
    Nagino M, Kamiya J, Uesaka K, et al. Complications of hepatectomy for hilar cholangiocarcinoma. World J Surg 2001; 25:1277–83CrossRefPubMedGoogle Scholar
  35. 35.
    Abdalla EK, Hicks ME, Vautney JN. Portal vein embolization: rationale, technique and future prospects. Br J Surg 2001; 88:165–75CrossRefPubMedGoogle Scholar

Copyright information

© The Society of Surgical Oncology, Inc. 2006

Authors and Affiliations

  • Sander Dinant
    • 1
  • Michael F. Gerhards
    • 1
  • E. A. J. Rauws
    • 2
  • Olivier R. C. Busch
    • 1
  • Dirk J. Gouma
    • 1
  • Thomas M. van Gulik
    • 1
  1. 1.Department of SurgeryAcademic Medical CenterAmsterdamThe Netherlands
  2. 2.Department of GastroenterologyAcademic Medical CenterAmsterdamThe Netherlands

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