Il trattamento chirurgico del colangiocarcinoma - Gastrolearning®

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Il trattamento chirurgico del colangiocarcinoma
Prof. Gian Luca Grazi - Hepato-Biliary-Pancreatic Surgery National Cancer Institute Regina Elena, Roma

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Il trattamento chirurgico del colangiocarcinoma - Gastrolearning®

  1. 1. Gian Luca Grazi Hepato-Biliary-Pancreatic Surgery National Cancer Institute Regina Elena Rome Cholangiocarcinoma Treatment
  2. 2. Cholangiocarcinoma - Treatment Bridgewater J et al., J Hepatol 2014, in press
  3. 3. Cholangiocarcinoma - Treatment Bridgewater J et al., J Hepatol 2014, in press
  4. 4. Cholangiocarcinoma - Treatment Bridgewater J et al., J Hepatol 2014, in press
  5. 5. Cholangiocarcinoma - Treatment
  6. 6. Cholangiocarcinoma - Treatment Razumilava N, Lancet. 2014 Feb 25.
  7. 7. Cholangiocarcinoma - Treatment Assenza di problemi medici maggiori Anamnesi e visita medica Esami di laboratorio e di funzionalità Assenza di metastasi a distanza Studio del torace e dell’addome Altre indagini volte allo studio di sintomi Periferico – stadiazione locale Valutazione dei peduncoli glissoniani Valutazione delle vene sovraepatiche Coinvolgimento del parenchima Studio della via biliare Distale – stadiazione locale Valutazione della vena porta Valutazione della v. mesenterica superiore Valutazione delle vene sovraepatiche Valutazione dell’arteria epatica Studio della via biliare TAC con ricostruzione vascolare (laparoscopia?) TAC con ricostruzione vascolare ± Colangio RM (laparoscopia?) Colangio RM ERCP PTC TAC total body ± PET / laparoscopia
  8. 8. Cholangiocarcinoma - Treatment The major determinants of resectability are •the extent of tumor within the biliary tree, •the amount of hepatic parenchyma involved, •vascular invasion, •hepatic lobar atrophy, and •metastatic disease. Assessment of resectability
  9. 9. Cholangiocarcinoma - Treatment Patient to be resected •Non cirrhotic •No pre-op CHT Major resection planned Minor resection planned •Cirrhotic •Pre-op CHT Major resection planned Minor resection planned Maybe nothing IGR ?? Volumetry IGR ?? MELD IGR Useful MELD IGR Volumetry Biopsy ??
  10. 10. Cholangiocarcinoma - Treatment • Normal underlying liver FLR should be 20-25% of total liver volume (TLV) • Chemotherapy induced liver injury FLR should be >30% of TLV • Chronic liver disease (cirrhosis or severe fibrosis) FLR should be >40% Future Remnant Liver
  11. 11. Cholangiocarcinoma - Treatment Kondo S, J Hepatobiliary Pancreat Surg; 2008, 15 :41–54
  12. 12. Cholangiocarcinoma - Treatment
  13. 13. Cholangiocarcinoma - Treatment
  14. 14. Cholangiocarcinoma - Treatment Ercolani G, Ann Surg 2010, 252: 107-113
  15. 15. Cholangiocarcinoma - Treatment de Jong MC, J Clin Oncol 2011, 29: 3140-3145 • Although tumor size provides no prognostic information, tumor number, vascular invasion, and LN metastasis are associated with survival. • N1 status adversely affected overall survival and also influenced the relative effect of tumor number and vascular invasion on prognosis. • Lymphadenectomy should be strongly considered for ICC, because up to 30% of patients will have LN metastasis.
  16. 16. Cholangiocarcinoma - Treatment de Jong MC, J Clin Oncol 2011, 29: 3140-3145
  17. 17. Cholangiocarcinoma - Treatment de Jong MC, J Clin Oncol 2011, 29: 3140-3145
  18. 18. Cholangiocarcinoma - Treatment
  19. 19. Cholangiocarcinoma - Treatment
  20. 20. Cholangiocarcinoma - Treatment • The preoperative clinical T staging system as proposed by Jarnagin and Blumgart defines both the radial and longitudinal extension of hilar cholangiocarcinoma, which are critical factors in the determination of resectability. • This Memorial Sloan-Kettering Cancer Center (MSKCC) staging system incorporates 3 factors based on preoperative imaging studies: (1) location and extent of ductal involvement; (2) presence or absence of portal vein invasion, and; (3) presence or absence of hepatic lobar atrophy.
  21. 21. Cholangiocarcinoma - Treatment
  22. 22. Cholangiocarcinoma - Treatment 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
  23. 23. Cholangiocarcinoma - Treatment Razumilava N, Lancet. 2014 Feb 25.
  24. 24. Cholangiocarcinoma - Treatment
  25. 25. Cholangiocarcinoma - Treatment Seyama S, World J Gastroenterol 2007;13(10):1505-1515
  26. 26. Cholangiocarcinoma - Treatment Kondo S, J Hepatobiliary Pancreat Surg; 2008, 15 :41–54
  27. 27. Cholangiocarcinoma - Treatment Pro Cons PTBD provides precise preoperative staging of the disease Increases the risk of cholangitis Contributes to improved surgical outcome Possibly increases tumor seeding Definitive role when portal vein embolization is needed Could be omitted: •recent onset jaundice (<2-3 weeks), total bilirubin <200 μmol/l, •absence of sepsis, •future liver remnant 40%. It should not be performed systematically and specialized surgical evaluation should be performed before any type of direct cholangiography or PBD is performed. Consensus Conference on Cholangiocarcinoma, HPB, 2008; 10 Biliary stenting
  28. 28. Cholangiocarcinoma - Treatment
  29. 29. Cholangiocarcinoma - Treatment
  30. 30. Cholangiocarcinoma - Treatment Aljiffry M, J Am Coll Surg 2009; 208, 134-147 Schulick RD, HPB, 2008; 10: 122-125
  31. 31. Cholangiocarcinoma - Treatment
  32. 32. Cholangiocarcinoma - Treatment
  33. 33. Cholangiocarcinoma - Treatment Definition of Surgical Strategy Definition of the extention of the tumor in the left and in the right ducts Volumetry left lobe – S2+S3 left hemiliver – S2+S3+S4 right lobe – S5+S6+S7+S8 caudate lobe
  34. 34. Cholangiocarcinoma - Treatment  The Bismuth classification takes into account tumour extension into the right and left biliary system; but, tumour extension anteriorly to the quadrate lobe (segment 4) and posteriorly to the caudate lobe (segment 1) is equally important.  Surgical treatment, therefore, should include resection of segments 4 and 1 which in the case of right-sided tumours (type IIIa) comes down to extended right hemihepatectomy en bloc with segment 1.  In conjunction with any resection, complete lymphadenectomy of the hepatoduodenal ligament is carried out. Van Gulik TM, 2007; 26 (Suppl 2), 127–132
  35. 35. Cholangiocarcinoma - Treatment 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
  36. 36. Cholangiocarcinoma - Treatment Nagino M, Ann Surg 2013;258: 129–140
  37. 37. Cholangiocarcinoma - Treatment
  38. 38. Cholangiocarcinoma - Treatment Left Hepatectomy + caudate lobe Right Hepatectomy + caudate lobe Pro Cons Pro Cons Smaller procedure Greater procedure Greater liver remnant volume Smaller liver remnant volume No need for PVE Needs PVE Right duct shorter Left duct longer (usually available) Often double (triple) duct anastomosis Often one single duct anastomosis Quickly available Longer “evaluation to surgery” time
  39. 39. Cholangiocarcinoma - Treatment
  40. 40. Cholangiocarcinoma - Treatment
  41. 41. Cholangiocarcinoma - Treatment
  42. 42. Cholangiocarcinoma - Treatment
  43. 43. Cholangiocarcinoma - Treatment
  44. 44. Cholangiocarcinoma - Treatment
  45. 45. Cholangiocarcinoma - Treatment
  46. 46. Cholangiocarcinoma - Treatment
  47. 47. Cholangiocarcinoma - Treatment
  48. 48. Cholangiocarcinoma - Treatment
  49. 49. Cholangiocarcinoma - Treatment
  50. 50. Cholangiocarcinoma - Treatment
  51. 51. Cholangiocarcinoma - Treatment
  52. 52. Cholangiocarcinoma - Treatment
  53. 53. Cholangiocarcinoma - Treatment
  54. 54. The role of Portal Vein Embolization colangiocarcinomacolangiocarcinoma: 3 % tumori dell’apparato digerente età > 65 anni  2/3 dei casi > frequenza nei paesi asiatici COLECISTI 2/3 15% VB intraepatiche VB 1/3 60 % ilari (tumori di Klatskin) 25 % VB extraepatica
  55. 55. The role of Portal Vein Embolization - fattori di rischio: 2 volte più frequente nella donna correlazione con litiasi colecisti non dimostrata - stadio iniziale: reperto fortuito dopo colecistectomia per calcoli - stadio avanzato: massa epatica del IV-V segm, ittero, cattiva prognosi COLECISTI 2/3 15% VB intraepatiche VB 1/3 60 % ilari (tumori di Klatskin) 25 % VB extraepatica
  56. 56. The role of Portal Vein Embolization - fattori di rischio: leggera prevalenza nel maschio età > 50 anni, colangite sclerosante primitiva - clinica: ittero ostruttivoittero ostruttivo con epatomegalia, urine ipercromiche, feci ipocoliche, prurito, colecisti distesa (se tumore del coledoco), colangite (rara), calo PT (malassorbimento vit. K) COLECISTI 2/3 15% VB intraepatiche VB 1/3 60 % ilari (tumori di Klatskin) 25 % VB extraepatica
  57. 57. The role of Portal Vein Embolization
  58. 58. Gian Luca Grazi Hepato Biliary Pancreatic Surgery National Cancer Institute “Regina Elena”, Rome, Italy grazi@ifo.it www.chirurgiadelfegato.it Follow us on Twitter @Chirurgiafegato The role of Portal Vein Embolization

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