Radical Resection and Its Limits

Abstract

It has been difficult to make an accurate diagnosis of tumor extent and strategy for curative resection of hilar cholangiocarcinoma (HCCa) [1] even in this era of sophisticated imaging diagnostic modalities such as multidetector row computed tomography (MDCT) [2]. An increasing resection rate of HCCa has been achieved and the surgical procedures for HCCa are changing from hilar local resection or limited hepatectomy [3] to major or extensive hepatobiliary resection including caudate lobectomy [1], which remains technically demanding and calls for a high level of skill in biliary and hepatic surgeries. Although the histological curative resection with negative surgical margins (R0) offers the only chance for cure in patients with HCCa, the gold standard for the treatment strategy for HCCa has not yet been determined. To achieve a R0 resection, an extensive hepatectomy (hepatic trisectionectomy) with vascular resection and reconstruction [4, 5], or pancreatoduodenectomy (HPD) [6, 7] is essential in some patients with advanced or extensive disease. Since the majority of patients with HCCa have cholestatic liver damage due to bile duct obstruction, major hepatobiliary resection carries a considerable risk of serious postoperative morbidity and mortality [8]. The limitations for radical resection for HCCa are mainly determined in terms of two factors: whether R0 resection is possible or not against the local tumor extension and whether the functional reserve of the future remnant liver is adequate or not to tolerate the surgical stress. We have a dilemma as to whether extensive hepatobiliary resection is advisable to achieve a R0 resection, or whether less extensive resection is a prerequisite for patients with impaired functional reserve of the liver. Currently, we have adopted a management strategy for patients with HCCa, including preoperative biliary drainage, portal vein embolization (PVE) [9–12] and major hepatobiliary resection [13, 14].