Langenbeck's Archives of Surgery

, Volume 388, Issue 3, pp 194–200

Surgical management of proximal bile duct cancer: extended right lobe resection increases resectability and radicality

  • Peter Neuhaus
  • Sven Jonas
  • Utz Settmacher
  • Armin Thelen
  • Christoph Benckert
  • Enrique Lopez-Hänninen
  • Rainer E. Hintze
New Surgical Horizons


Background: Surgical resection provides the only chance of cure for patients suffering from hilar cholangiocarcinoma. Although appropriate procedures are not agreed upon, an increase in radicality has been observed during the past 20 years.

Methods: The literature as well as our own experience after 133 resections of hilar cholangiocarcinomas were reviewed.

Results: Tumor-free margins represent the most important prognostic parameter. Hilar resections as least radical resective procedure will generate rates of formally curative resections of less than 50%. Even after these formally curative resections, long-term survival cannot be achieved. Only additional liver resections will increase the number of long-term survivors to significant figures. In our series, the best 5-year survival rate of 72% was achieved after right trisegmentectomy with concomitant resection of the portal vein bifurcation.

Conclusion: Right trisegmentectomy and combined portal vein resection represent the best way to comply with basic rules of surgical oncology for hilar cholangiocarcinoma. This procedure will provide the most pronounced benefit among various types of liver resection, whereas local resections of the extrahepatic bile duct must be considered as an oncologically inefficient procedure.


Bile duct cancer Klatskin tumor Central bile duct resection Extended surgery for biliary cancer 


  1. 1.
    Okuda K, Kubo Y, Okazaki N, Arishima T, Hashimoto M (1977) Clinical aspects of intrahepatic bile duct carcinoma including hilar carcinoma: a study of 57 autopsy-proven cases. Cancer 39:232–246PubMedGoogle Scholar
  2. 2.
    Bhuiya M-R, Nimura Y, Kamiya J, Kondo S, Fukata S, Hayakawa N, Shionoya S (1992) Clinicopathologic studies on perineural invasion of bile duct carcinoma. Ann Surg 215:344–349PubMedGoogle Scholar
  3. 3.
    Weinbren K, Mutum S-S (1983) Pathological aspects of cholangiocarcinoma. J Pathol 139:217–238PubMedGoogle Scholar
  4. 4.
    Born P, Rosch T, Willkomm G, Sandschin W, Fitz N, Weigert N, Ott R, Frimberger E, Allescher H, Classen M (1999) Initial experience with a new Yamakawa-type prosthesis for long-term percutaneous transhepatic drainage. Endoscopy 31:748–750CrossRefPubMedGoogle Scholar
  5. 5.
    Kaufman S-L (1995) Percutaneous palliation of unresectable pancreatic cancer. Surg Clin North Am 75:989–999PubMedGoogle Scholar
  6. 6.
    Schlitt H-J, Weimann A, Klempnauer J, Oldhafer K-J, Nashan B, Raab R, Pichlmayr R (1999) Peripheral hepatojejunostomy as palliative treatment for irresectable malignant tumors of the liver hilum. Ann Surg 229:181–186CrossRefPubMedGoogle Scholar
  7. 7.
    Jarnagin W-R, Fong Y, DeMatteo R-P, Gonen M, Burke E-C, Bodniewicz BSJ, Youssef BAM, Klimstra D, Blumgart L-H (2001) Staging, resectability, and outcome in 225 patients with hilar cholangiocarcinoma. Ann Surg 234:507–517CrossRefPubMedGoogle Scholar
  8. 8.
    Miyazaki M, Ito H, Nakagawa K, Ambiru S, Shimizu H, Shimizu Y, Kato A, Nakamura S, Omoto H, Nakajima N, Kimura F, Suwa T (1998) Aggressive surgical approaches to hilar cholangiocarcinoma: hepatic or local resection? Surgery 123:131–136Google Scholar
  9. 9.
    Nimura Y, Kamiya J, Kondo S, Nagino M, Uesaka K, Oda K, Sano T, Yamamoto H, Hayakawa N (2000) Aggressive preoperative management and extended surgery for hilar cholangiocarcinoma: Nagoya experience. J Hepatobiliary Pancreat Surg 7:155–162PubMedGoogle Scholar
  10. 10.
    Mittal B, Deutsch M, Iwatsuki S (1985) Primary cancers of the extrahepatic biliary passages. Int J Radiat Oncol Biol Phys 11:849–855PubMedGoogle Scholar
  11. 11.
    Kawarada Y, Isaji S, Taoka H, Tabata M, Das B-C, Yokoi H (1999) S4a+S5 with caudate lobe (S1) resection using the Taj Mahal liver parenchymal resection for carcinoma of the biliary tract. J Gastrointest Surg 3:369–373CrossRefPubMedGoogle Scholar
  12. 12.
    Bismuth H (1982) Surgical anatomy and anatomical surgery of the liver. World J Surg 6:3–9PubMedGoogle Scholar
  13. 13.
    Neuhaus P, Jonas S, Bechstein W-O, Lohmann R, Radke C, Kling N, Wex C, Lobeck H, Hintze R (1999) Extended resections for hilar cholangiocarcinoma. Ann Surg 230:808–818PubMedGoogle Scholar
  14. 14.
    Scheele J, Altendorf-Hofmann A, Stangl R, Schmidt K (1996) Surgical resection of colorectal liver metastases: Gold standard for solitary and radically resectable lesions. Swiss Surg (Suppl) 4:4–17Google Scholar
  15. 15.
    Iwasaki Y, Okamura T, Ozaki A, Todoroki T, Takase Y, Ohara K, Nishimura A, Otsu H (1986) Surgical treatment for carcinoma at the confluence of the major hepatic ducts. Surg Gynecol Obstet 162:457–464PubMedGoogle Scholar
  16. 16.
    Mizumoto R, Kawarada Y, Suzuki H (1986) Surgical treatment of hilar carcinoma of the bile duct. Surg Gynecol Obstet 162:153–158PubMedGoogle Scholar
  17. 17.
    Makuuchi M, Thai BL, Takayasu K, et al (1990) Preoperative portal embolization to increase safety of major hepatectomy for hilar bile duct carcinoma: a preliminary report. Surgery 107:521–527PubMedGoogle Scholar
  18. 18.
    Hatfield ARW, Tobias R, Terblanche J, et al (1982) Preoperative external biliary drainage in obstructive jaundice: a prospective controlled clinical trial. Lancet 2:896–899PubMedGoogle Scholar
  19. 19.
    Hintze R-E, Abou-Rebyeh H, Adler A, Veltzke-Schlieker W, Felix R, Wiedenmann B (2001) Magnetic resonance cholangiopancreatography-guided unilateral endoscopic stent placement for Klatskin tumors. Gastrointest Endosc 53:40–46CrossRefPubMedGoogle Scholar
  20. 20.
    Vogl T-J, Balzer J-O, Dette K, Hintze R, Pegios W, Maurer J, Keck H, Neuhaus P, Felix R (1998) Initially unresectable hilar cholangiocarcinoma: hepatic regeneration after transarterial embolization. Radiology 208:217–222PubMedGoogle Scholar
  21. 21.
    Bismuth H, Nakache R, Diamond T (1992) Management strategies in resection for hilar cholangiocarcinoma. Ann Surg 215:31–38PubMedGoogle Scholar
  22. 22.
    Kosuge T, Yamamoto J, Shimada K, Yamasaki S, Makuuchi M (1999) Improved surgical results for hilar cholangiocarcinoma with procedures including major hepatic resection. Ann Surg 230:663–671CrossRefPubMedGoogle Scholar
  23. 23.
    Kitagawa Y, Nagino M, Kamiya J, Uesaka K, Sano T, Yamamoto H, Hayakawa N, Nimura Y (2001) Lymph node metastasis from hilar cholangiocarcinoma: audit of 110 patients who underwent regional and paraaortic node dissection. Ann Surg 233:385–392PubMedGoogle Scholar
  24. 24.
    Tojima Y, Nagino M, Ebata T, Uesaka K, Kamiya J, Nimura Y (2003) Immunohistochemically demonstrated lymph node micrometastasis and prognosis in patients with otherwise node-negative hilar cholangiocarcinoma. Ann Surg 237:201–207CrossRefPubMedGoogle Scholar
  25. 25.
    Izbicki J-R, Hosch S-B, Pichlmeier U, Rehders A, Busch C, Niendorf A, Passlick B, Broelsch C-E, Pantel K (1997) Prognostic value of immunohistochemically identifiable tumor cells in lymph nodes of patients with completely resected esophageal cancer. N Engl J Med 337:1188–1194Google Scholar

Copyright information

© Springer-Verlag 2003

Authors and Affiliations

  • Peter Neuhaus
    • 1
  • Sven Jonas
    • 1
  • Utz Settmacher
    • 1
  • Armin Thelen
    • 1
  • Christoph Benckert
    • 1
  • Enrique Lopez-Hänninen
    • 2
  • Rainer E. Hintze
    • 3
  1. 1.Klinik für Allgemein-Viszeral und Transplantationschirurgie, Charité, Campus Virchow Klinikum, Humboldt University BerlinBerlinGermany
  2. 2.Strahlenklinik und PoliklinikCharité, Campus Virchow Klinikum, Humboldt University BerlinBerlinGermany
  3. 3.Zentrale Interdisziplinäre Endoskopie/Medizinische Klinik mit Schwerpunkt Hepatologie und GastroenterologieCharité, Campus Virchow Klinikum, Humboldt University BerlinBerlinGermany

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