Surgical management of hilar cholangiocarcinoma at Memorial Sloan Kettering Cancer Center

Abstract

Hilar cholangiocarcinoma, which represents approximately 60% of biliary tract malignancies, is increasing in incidence and presents an ongoing challenge for patients and hepatobiliary surgeons. Although the majority of patients present with advanced disease, the remaining minority of patients are best treated with surgical resection or transplant. Transplant is typically reserved for locally unresectable tumors often in the setting of underlying hepatic dysfunction and will not be discussed herein. This review, therefore, focuses on oncological resection and the strategies implemented for the treatment of hilar cholangiocarcinoma at a quaternary referral center, including preoperative considerations such as patient selection and optimization of the future liver remnant, nuances to the operative approach for these tumors such as resection under low central venous pressure and management of the bile duct, as well as postoperative management.

Keywords: complete surgical resection; hilar cholangiocarcinoma; portal vein embolization; preoperative biliary drainage.

Figure 1

Algorithm illustrating the general approach to patients with hilar cholangiocarcinoma. *Patients presenting with obstructive cholangitis must undergo biliary decompression. FLR, future liver remnant; PVE, portal vein embolization

Figure 2

Volumetric analysis before A, and after B, portal vein embolization (PVE)

Figure 3

A, Computed tomography and fluoroscopic images showing inappropriate placement of three endoscopic stents in the atrophic left liver (planned resection), without adequate drainage of the future liver remnant (FLR). B, Fluoroscopic image showing super‐selective percutaneous placement of transhepatic catheters into the right anterior and posterior divisions of the FLR