Palliative Surgical Treatment

Abstract

Tumors at the biliary confluence at the hilum of the liver (also called Klatskin tumors) comprise 40–60 % of all cholangiocarcinomas. The preoperative evaluation of a patient with suspected hilar cholangiocarcinoma is directed toward the following four primary objectives: (1) an assessment of the extent and level of biliary tract and vascular involvement including portal vein and hepatic artery involvement; (2) an assessment of the liver for evidence of lobar atrophy or concomitant liver pathology; (3) an assessment of the extent or presence of nodal disease and/or distant metastases; and (4) an assessment of the patients overall fitness for operation. The three primary goals in the surgical management of hilar cholangiocarcinoma are complete tumor excision with negative histological margins, relief of symptoms relating to biliary obstruction, and restoration of bilioenteric continuity [1, 2]. However, these are only achievable in the minority of patients (20∼30 %). When advanced local disease, or obvious extrahepatic metastases are identified preoperatively or at the time of laparotomy, therapeutic interventions are directed toward the relief of biliary obstruction and its associated symptoms and complications such as itching, cholangitis, and liver failure in order to improve the quality of life. Different modalities are currently available to drain the biliary system and include endoscopic, percutaneous, and surgical bypass. The best technique remains controversial. Endoscopic biliary drainage can be achieved by plastic (polyethylene) or metallic stents. However, endoscopic stenting for hilar malignancies is associated with a high failure rate. Percutaneous insertion of a biliary stent can be preferable for hilar cholangiocarcinoma as the stent placement is more predictable than with an endoscopic approach. Intrahepatic biliary-enteric bypass has an advantage in this regard since the anastomosis can be placed some distance from the primary tumor, but requires a major operative procedure with associated morbidity. Surgery is associated with greater early morbidity and mortality but greater long-term patency and a lower incidence of recurrent jaundice. Percutaneous transhepatic biliary drainage (PTBD) is the preferred method if unresectability is determined before surgery. If unresectability or the presence of metastatic disease is identified at laparotomy, palliative options include postoperative placement of transhepatic stents, operatively placed transtumoral stents, or the performance of an operative bilioenteric bypass. When deciding among these options, the general physical condition, age of the patient, and predicted life expectancy must be considered. Within the literature, there have been insufficient data to show whether a surgical or a non-surgical approach provides the more cost effective and better palliation [3, 4]. The lack of randomized data and the heterogeneity within studies makes any direct comparisons difficult. These studies need to be interpreted with caution also. The study population between the surgical and nonsurgical groups was dissimilar with the better risk patients receiving operative palliation and those with poor risk, advanced disease or severe co-morbidities referred for non-operative biliary drainage.