Preoperative Management of Perihilar Cholangiocarcinoma

Abstract

Perihilar cholangiocarcinoma is a rare hepatobiliary malignancy that requires thoughtful, multidisciplinary evaluation in the preoperative setting to ensure optimal patient outcomes. Comprehensive preoperative imaging, including multiphase CT angiography and some form of cholangiographic assessment, is key to assessing resectability. While many staging systems exist, the Blumgart staging system provides the most useful combination of resectability assessment and prognostic information for use in the preoperative setting. Once resectability is confirmed, volumetric analysis should be performed. Upfront resection without biliary drainage or portal venous embolization may be considered in patients without cholangitis and an estimated functional liver remnant (FLR) > 40%. In patients with FLR < 40%, judicious use of biliary drainage is advised, with the goal of selective biliary drainage of the functional liver remnant. Percutaneous biliary drainage may avoid inadvertent contamination of the contralateral biliary tree and associated infectious complications, though the relative effectiveness of percutaneous and endoscopic techniques is an ongoing area of study and debate. Patients with low FLR also require intervention to induce hypertrophy, most commonly portal venous embolization, in an effort to reduce the rate of postoperative liver failure. Even with extensive preoperative workup, many patients will be found to have metastatic disease at exploration and diagnostic laparoscopy may reduce the rate of non-therapeutic laparotomy. Management of perihilar cholangiocarcinoma continues to evolve, with ongoing efforts to improve preoperative liver hypertrophy and to further define the role of transplantation in disease management.

Keywords: biliary drainage; cholangiocarcinoma; hepatectomy; hilar cholangiocarcinoma; preoperative management.

Figure 1

Lobar atrophy associated with perihilar cholangiocarcinoma. Preoperative ultrasonography (A) demonstrating perihilar biliary mass (white arrow) with resultant narrowing of the left portal vein (yellow arrow). MRI (B) demonstrated substantial left lobar atrophy (red arrow).

Figure 2

Repeat drainage following misplaced endoscopic biliary drain. Computed tomography showing perihilar tumor with involvement of right hepatic artery ((A), red arrow) with dilation of both left and right intrahepatic biliary trees (B). Repeat scan after placement of endoscopic biliary stent shows persistent arterial involvement ((C), red arrow) with inappropriate placement of the endoscopic stent into the right liver ((D), white arrow). The left liver (future liver remnant) remains undrained. Patient subsequently underwent selective percutaneous access of the left biliary tree (E) with placement of an internal-external biliary drain (F).

Figure 3

Algorithm for preoperative assessment and management of patients with perihilar cholangiocarcinoma.

Figure 4

Preoperative and postoperative volumetric analysis with interval portal vein embolization. Computed tomography-based volumetric analysis (TeraRecon Inc., Durham, NC, USA) with perihilar cholangiocarcinoma. Prior to portal vein embolization (panels (A,B)), functional liver remnant after planned right hepatectomy was calculated to be 31.9% (yellow). Patient underwent right portal vein embolization without embolization of Segment IV. After three weeks, repeat volumetry was performed (panels (C,D)). The newly calculated FLR (yellow) was 45.9%, yielding a KGR of 4.7%.