Optimal perioperative care in peri-hilar cholangiocarcinoma resection
Eur Surg
Optimal perioperative care in peri-hilar cholangiocarcinoma resection
Leonard M. Quinn 0 1
Declan F. J. Dunne 0 1
Robert P. Jones 0 1
Graeme J. Poston 0 1
Hassan Z. Malik 0 1
Stephen W. Fenwick 0 1
0 L. M. Quinn ( ) ? D. F. J. Dunne, MD ? R. P. Jones, PhD ? G. J. Poston, MS ? H. Z. Malik, MD ? S. W. Fenwick , MD Liverpool Hepatobiliary Centre, Aintree University Hospital , Longmoor Lane, Liverpool, L9 7AL , UK
1 L. M. Quinn Institute of translational Medicine, University of Liverpool , Ashton Street, Liverpool, L69 3GE , UK
Summary Surgical resection remains the only proven curative treatment for peri-hilar cholangiocarcinoma. Despite recent advances in liver surgery techniques and perioperative care, resection for peri-hilar cholangiocarcinoma remains associated with significant morbidity and mortality. Considerable variation in the perioperative management of these patients exists. Optimal perioperative management has the potential to deliver improved outcomes. This article seeks to summarize the evidence underpinning best practice in the perioperative care of patients undergoing resection of peri-hilar cholangiocarcinoma. The authors also seek to identify areas where research efforts and future clinical trials should be targeted.
Cholangiocarcinoma; Peri-operative care; Pre-operative fitness assessment; Pre-habilitation; Enhanced Recovery
Introduction
Complete surgical resection represents the only
curative option in peri-hilar cholangiocarcinoma (pCCA);
however, the disease is often silent in the early stages
and many patients have advanced disease at
presentation. The majority of patients undergoing resection
do not achieve long-term disease control, but
radical curative resection can achieve a 5-year survival of
11 to 44% [
1
]. Surgical resection represents a major
K
undertaking, with mortality in western specialist
centres ranging from 13% [
2
] to 15% [
3
], and morbidity
of up to 40% [
4
]. Research to improve postoperative
outcomes through optimized perioperative
management is urgently needed to reduce this mortality and
morbidity burden and minimize management
variation. This article seeks to summarize the evidence
underpinning best practice in the perioperative care
of patients undergoing resection of peri-hilar
cholangiocarcinoma.
Cholangiocarcinoma
Cholangiocarcinoma represents a spectrum of biliary
tract adenocarcinomas. The disease encompasses
intra-hepatic (10%) and extra-hepatic cases, including
peri-hilar disease (50%) arising at or near the
confluence of the hepatic ducts, and distal disease (40%;
[
5
]).
Patients with surgically resectable disease enjoy the
most favourable prognosis, and this is a key
determinate in the staging of pCCA [
6
]. The most commonly
used staging system is the Union for International
Cancer Control/American Joint Committee on
Cancer (UICC/AJCC) 2010 revision of the tumour, node,
metastasis (TNM) classification, separating
cholangiocarcinoma into intra-hepatic, hilar and distal
disease, respectively [7, p. 201].
None of the staging systems accurately predict
survival. The most important staging and predictive issue
is surgical resectability. The AJCC system is based on
pathological outcome following resection.
Clinical preoperative staging systems for pCCA
include the Bismuth?Corlette and Memorial Sloan
Kettering Cancer Centre (MSKCC) systems.
Bismuth?Corlette classifies patients on the extent of
biliary involvement but does not incorporate
vascular involvement or lobar atrophy. As such, it cannot
Optimal perioperative care in peri-hilar cholangiocarcinoma resection 93
be used for predicting resectability. MSKCC builds
on Bismuth?Corlette and includes longitudinal and
radial extension of the tumour to more accurately
predict resectability. T staging includes local tumour
involvement, portal vein involvement and hepatic
lobar atrophy. This staging system has been externally
validated and accurately predicts resectability,
probability of metastatic disease and long-term survival in
the preoperative setting [
6
].
Resectability is ultimately determined at the time of
surgery, as these tumours often extend into the liver
and major vascular structures, with accurate
preoperative evaluation of these areas difficult. Therefore,
surgical exploration with or without trial dissection
is appropriate for potentially resectable disease based
on preoperative imaging [
8
].
For pCCA, bile duct resection alone results in high
local recurrence rates [
9
]. The addition of hepatic
resection improves R0 resection rate [
10
]. R0 resection
is the best management option for prolonged survival,
where technically feasible [
11
].
Neoadjuvant therapy and liver transplantation are
not considered standard of care at the current time.
The Mayo Clinic considers liver transplantation in
highly selected cases of early-stage local unresectable
peri-hilar CCA in patients who have completed
thorough staging, assessment and neoadjuvant
chemoradiothe (...truncated)