Gastrolearning II modulo/8a lezione Il trattamento chirurgico del colangiocarcinoma Prof. Gian Luca Grazi - Hepato-Biliary-Pancreatic Surgery National Cancer Institute Regina Elena, Roma

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

2. Cholangiocarcinoma - Treatment
Bridgewater J et al., J Hepatol 2014, in press

3. Cholangiocarcinoma - Treatment
Bridgewater J et al., J Hepatol 2014, in press

4. Cholangiocarcinoma - Treatment
Bridgewater J et al., J Hepatol 2014, in press

5. Cholangiocarcinoma - Treatment

6. Cholangiocarcinoma - Treatment
Razumilava N, Lancet. 2014 Feb 25.

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. 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. 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. 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. Cholangiocarcinoma - Treatment
Kondo S, J Hepatobiliary Pancreat Surg; 2008, 15 :41–54

12. Cholangiocarcinoma - Treatment

13. Cholangiocarcinoma - Treatment

14. Cholangiocarcinoma - Treatment
Ercolani G, Ann Surg 2010, 252: 107-113

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. Cholangiocarcinoma - Treatment
de Jong MC, J Clin Oncol 2011, 29: 3140-3145

17. Cholangiocarcinoma - Treatment
de Jong MC, J Clin Oncol 2011, 29: 3140-3145

18. Cholangiocarcinoma - Treatment

19. Cholangiocarcinoma - Treatment

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. Cholangiocarcinoma - Treatment

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. Cholangiocarcinoma - Treatment
Razumilava N, Lancet. 2014 Feb 25.

24. Cholangiocarcinoma - Treatment

25. Cholangiocarcinoma - Treatment
Seyama S, World J Gastroenterol 2007;13(10):1505-1515

26. Cholangiocarcinoma - Treatment
Kondo S, J Hepatobiliary Pancreat Surg; 2008, 15 :41–54

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. Cholangiocarcinoma - Treatment

29. Cholangiocarcinoma - Treatment

30. Cholangiocarcinoma - Treatment
Aljiffry M,
J Am Coll Surg 2009; 208, 134-147
Schulick RD,
HPB, 2008; 10: 122-125

31. Cholangiocarcinoma - Treatment

32. Cholangiocarcinoma - Treatment

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. 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. 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. Cholangiocarcinoma - Treatment
Nagino M, Ann Surg 2013;258: 129–140

37. Cholangiocarcinoma - Treatment

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

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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. 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. 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. The role of Portal Vein Embolization

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