Optimal perioperative care in peri-hilar cholangiocarcinoma resection

European Surgery, May 2018

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.

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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)


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Leonard M. Quinn, Declan F. J. Dunne, Robert P. Jones, Graeme J. Poston, Hassan Z. Malik, Stephen W. Fenwick. Optimal perioperative care in peri-hilar cholangiocarcinoma resection, European Surgery, 2018, pp. 93-99, Volume 50, Issue 3, DOI: 10.1007/s10353-018-0529-x