Surgical treatment of cholangiocarcinoma

1. Gian Luca Grazi
Hepato-Biliary-Pancreatic Surgery
National Cancer Institute Regina Elena
Rome
Surgical Treatment of
Cholangiocarcinoma

2. Surgical Treatment of Cholangiocarcinoma

3. Surgical Treatment of Cholangiocarcinoma

4. Surgical Treatment of Cholangiocarcinoma

5. Surgical Treatment of Cholangiocarcinoma
Doussot A, J Am Coll Surg 2015: 221: 452-461

6. Surgical Treatment of Cholangiocarcinoma
Doussot A, J Am Coll Surg 2015: 221: 452-461

7. Surgical Treatment of Cholangiocarcinoma
Doussot A, J Am Coll Surg 2015: 221: 452-461

8. Surgical Treatment of Cholangiocarcinoma
Doussot A, J Am Coll Surg 2015: 221: 452-461
 Both nomograms can be useful for patient prognosis estimation
and recommendation for adjuvant therapy after liver resection
for ICC.
 The nomogram proposed by Wang and colleagues appeared to
have the best overall prognostic accuracy, but requires routine
portal LN dissection and preoperative tumor markers (CEA and
CA 19-9), in addition to the variables necessary for the AJCC
staging system, for optimal performance.
 By contrast, the Fudan score and AJCC staging system were of
limited utility.
 Additional investigations are needed in wider series to define
the most appropriate prognostic nomogram for clinical practice.

9. Surgical Treatment of Cholangiocarcinoma
Spolverato G, Cancer 2015: 121: 3998-4006

10. Surgical Treatment of Cholangiocarcinoma
Spolverato G, Cancer 2015: 121: 3998-4006

11. Surgical Treatment of Cholangiocarcinoma
Spolverato G, Cancer 2015: 121: 3998-4006

12. Surgical Treatment of Cholangiocarcinoma
Spolverato G, Cancer 2015: 121: 3998-4006

13. Surgical Treatment of Cholangiocarcinoma
Spolverato G, Cancer 2015: 121: 3998-4006

14. Surgical Treatment of Cholangiocarcinoma
Cillo U, World J Surg 2015: 39: 2500-2509

15. Surgical Treatment of Cholangiocarcinoma
Cillo U, World J Surg 2015: 39: 2500-2509

16. Surgical Treatment of Cholangiocarcinoma
Cillo U, World J Surg 2015: 39: 2500-2509

17. Surgical Treatment of Cholangiocarcinoma
Cillo U, World J Surg 2015: 39: 2500-2509

18. Surgical Treatment of Cholangiocarcinoma
Cillo U, World J Surg 2015: 39: 2500-2509
• In patients with large ([6 cm) ICC who may be at risk of R1
resection, and in patients with ICC and vascular invasion,
HR appeared to be associated with a greater NHB and be
more cost-effective than sCT.
• In contrast, in patients with multi-focal ICC HR had a
negative NHB, and therefore they should be treated with
sCT rather than HR.

19. Tompkins RK, Ann Surg 1981: 194: 447-455
Surgical Treatment of Cholangiocarcinoma

20. Altemeier WA, Arch Surg. 1957; 75: 450-461
Surgical Treatment of Cholangiocarcinoma

21. Surgical Treatment of Cholangiocarcinoma

22. • Gerald Klatskin (1910-1986) was born in New York City to a family
of Russian descent.
• In Yale in 1946, he established a laboratory that became a
renowned Liver Study Unit.
• In 1965 he described the unique features of cholangiocarcinoma at
the bifurcation of the main intrahepatic bile ducts, which came to
be called the Klatskin tumor.
• It was his dream to create a histological atlas of diseases of the
liver, an ambition brought to fruition in 1993 by Harold Conn, his
first fellow and longtime collaborator at Yale.
• Known by some of his many students as “Great Bear” because of
his seemingly burly mien, Klatskin was, in fact, a kindly and
unpretentious mentor.
Surgical Treatment of Cholangiocarcinoma

23. Surgical Treatment of Cholangiocarcinoma

24. Surgical Treatment of Cholangiocarcinoma

25. Surgical Treatment of Cholangiocarcinoma

26. Changes in pre-, intra-, and postoperative management over the course of the study
period. ENBD indicates endoscopic naso-biliary drainage; MDCT,multidetector-row
computed tomography; PTBD, percutaneous transhepatic biliary drainage; PTCS,
percutaneous transhepatic cholangioscopy.
Nagino M, Ann Surg 2013;258: 129–140
Surgical Treatment of Cholangiocarcinoma

27. Bhardwaj N, World J Surg 2015: 39: 2748-2756
Surgical Treatment of Cholangiocarcinoma

28. Bhardwaj N, World J Surg 2015: 39: 2748-2756
Surgical Treatment of Cholangiocarcinoma

29. Bhardwaj N, World J Surg 2015: 39: 2748-2756
Surgical Treatment of Cholangiocarcinoma

30. Bhardwaj N, World J Surg 2015: 39: 2748-2756
Surgical Treatment of Cholangiocarcinoma

31. Bhardwaj N, World J Surg 2015: 39: 2748-2756
Surgical Treatment of Cholangiocarcinoma

32. Bhardwaj N, World J Surg 2015: 39: 2748-2756
Surgical Treatment of Cholangiocarcinoma

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34. Surgical Treatment of Cholangiocarcinoma
Mizuno T, Surg Today 2017: 47: 182-192

35. Surgical Treatment of Cholangiocarcinoma
Mizuno T, Surg Today 2017: 47: 182-192

36. Surgical Treatment of Cholangiocarcinoma

37. Loehrer AP, J Am Coll Surg 2013; 216: 192-200
Surgical Treatment of Cholangiocarcinoma

38. • The observed morbidity and mortality particularly for resections
involving hepatectomy remain considerably higher than would
be expected after risk adjustment.
• Patients receiving a BEA in addition to a hepatectomy are at
particularly high risk of 30-day mortality.
• More than half of all patients with perihilar lesions are likely
failing to receive optimal oncologic resections that should
include at least a partial hepatectomy.
• The decision by some surgeons to avoid a hepatectomy for
perihilar tumors might have been due to concerns about
increased risk of this procedure.
Loehrer AP, J Am Coll Surg 2013; 216: 192-200
Surgical Treatment of Cholangiocarcinoma

39. 440 patients from 17 centers
(From January 1, 1992, through December 31, 2007)
16 years
5/17 centers (29.4%) reported 40 or more patients who
underwent resection and accounted for 317 patients (72.0%)
5 High volume centers
317 procedures
63.4 procedures/center
3.9 procedures/year
12 Low volume centers
123 procedures
10.2 procedures/center
0.6 procedures/year
Nuzzo G, Arch Surg 2012; 147: 26-34
Surgical Treatment of Cholangiocarcinoma

40. Surgical Treatment of Cholangiocarcinoma

41. Surgical Treatment of Cholangiocarcinoma

42. Surgical Treatment of Cholangiocarcinoma