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Objective To investigate the clinical value of enhanced recovery after surgery (ERAS) in patients undergoing postoperative early enteral nutrition (EEN) with radical resection for hilar cholangiocarcinoma.Methods The clinical data of 48 patients with hilar cholangiocarcinoma who were admitted to the Drum Tower Clinical Medical College of Nanjing Medical University from July 2006 to September 2014 were retrospectively analyzed.All the 48 patients underwent radical resection for hilar cholangiocarcinoma,including 24 patients receiving postoperative EEN (EEN group) and 24 patients receiving total parenteral nutrition (TPN group).The serologic indices and liver function were detected regularly after operation.Ten percent of albumin (Alb) 10 g was administered by intravenous infusion when Alb ＜ 30 g/L.The indexes of all the 48 patients were compared in the 2 groups at postoperative day 3 and 7,including the serologic indices and liver function,the exhaust time,the volume of Alb infusion,the complications (incisional infection,abdominal infection,pleural effusion,peritoneal effusion and bile leakage) and the duration of hospital stay.The patients were followed up by outpatient examination and telephone interview till September 2014.The measurement data with normal distribution were presented as x ± s,comparison between groups and count data were analyzed using the t test and chi-squared test,respectively.Results Patients in the 2 groups were cured successfully and discharged,and no patient died perioperatively.Patients in the EEN group had a good tolerance for EEN and no occurrence of EEN-related complications was detected.The level of the GGT was (108 ± 73) U/L in the EEN group,which was significantly lower than (225 ± 121) U/L in the TPN group at postoperative day 3 (t =4.041,P ＜ 0.05).The level of the GGT was (142 ± 86) U/L in the EEN group,which was no significantly different from (183 ± 107)U/L in the TPN group at postoperative day 7 (t =1.477,P ＞ 0.05).The postoperative time to anal exsufflation and the duration of hospital stay were (73 ± 18) hours and (15 ± 4) days in the EEN group,which were significantly different from (97 ± 21) hours and (18 ± 4) days in the TPN group,and the volume of Alb infusion was (44 ± 29)g in the EEN group,which was significantly lower than (101 ± 92) g in the TPN group (t =4.295,2.615,2.916,P ＜ 0.05).All the 48 patients were followed up for 1 to 71 months (mediantime,10 months),no patients received reoperation or re-admitted to the hospital due to complications.Conclusion The application of postoperative EEN in enhanced recovery of patients undergoing radical resection for hilar cholangiocarcinoma is safe and effective,it could accelerate the recovery of enteral function,shorten the postoperative duration of hospital stay and reduce the supplement of extrinsic Alb,which is helpful for the fast recovery of patients.
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Extended liver resection may provide longterm survival in selected patients with hilar cholangiocarcinoma.In May 2013,a patient with hilar cholangiocarcinoma received right hemihepatectomy combined with caudate lobectomy under the guidance of precision hepatectomy technique.The porta hepatis was clamped in the operation for 3 times intermittently.The operation time was 8 hours,and the volume of intraoperative blood loss was 600 mL.The patient was discharged at postoperative day 14.The results of pathological examination confirmed that the patient had moderately-highly differentiated adenocarcinoma with full-thickness infiltration of the bile duct and tumorfree margins.No tumor recurrence was detected during the followup which was lasted for 6 months.The operation was carried out based on the three dimensional reconstruction,liver reserve function evaluation,intraoperative controlled low central venous pressure and precision hepatectomy technique,and the results were satisfactory.
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Hilar cholangiocarcinoma (HCCA) or Klatskin tumor is a scirrhous adenocarcinoma that arises from the conjunction of bile duct and hepatic ducts.Hepatic magnetic resonance imaging (MRI) and magnetic resonance cholangiopancreatography (MRCP) are important methods for the diagnosis of HCCA.In this article,the clinical data of 42 patients in the Changhai Hospital and 18 patients in the Eastern Hepatobiliary Surgery Hospital who received MRI and MRCP examination from October 2010 to October 2012 were retrospectively analyzed.According to the pathological features,HCCA could be divided into mass-forming type,infiltrating type and intraductal type.Based on the results of imaging examination and intra-and postoperative pathological examination,Bismuth-Corlette types were decided pre-and postoperatively.The coincidence rate of pre-and postoperative Bismuth-Corlette types was 89.7％ (35/39).Infiltration of liver parenchyma was both detected pre-and postoperatively in 19 patients (16 patients were detected by MRI preoperatively),and the sensitivity of MRI was 84.2％ ; vascular invasion was both detected pre-and postoperatively in 10 patients (12 patients were detected by MRI preoperatively),and the sensitivity of MRI was 83.3％ ; hilar and retroperitoneal lymph node metastasis was both detected pre-and postoperatively in 6 patients (4 patients were detected by MRI preoperatively),and the sensitivity of MRI was 66.7％.Combined application of different sequences and techniques of MRI is helpful in the diagnosis,staging and treatment of HCCA.
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Continuous progress of medicine and related areas are initiating and motivating a paradigm transformation of traditional surgery to precise surgery,which is characterized by precision in decision making and surgical intervention.The strategy of precise surgery is to seek a balance of maximized lesion removal,maximized organ sparing and minimal surgical invasiveness.Due to the special location and biological characteristics,the therapy of hilar cholangiocarcinoma is still challenging.To meet the demand of precise surgery,the knowledge of anatomy,biological characteristics and liver functional reserve is needed and the technical aspects of pre-surgical intervention,liver resection and reconstruction of vessels are also very important.
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Objective To investigate the effects of preoperative jaundice relieving on hemihepatectomy of hilar cholangiocarcinoma.Methods The clinical data of 18 patients who received preoperative percutaneous transhepatic cholangiography and drainage (PTCD) or endoscopic nasobiliary drainage (ENBD) before hemihepatectomy at the Tongji Hospital of Huazhong University of Science and Technology from January 2007 to January 2012 were retrospectively analyzed.The condition of the 18 patients (jaundice relieving group) was compared with that of 24 patients (non-jaundice relieving group) who did not receive PTCD or ENBD before hemihepatectomy.The differences in the pre-and postoperative blood loss,blood transfusion,operation time and postoperative incidence of complications between the 2 groups were analyzed.All data were analyzed using the t test or chi-square test.Results After PTCD or ENBD,the levels of total bilirubin (TBil),direct bilirubin (DBil),alanine aminotransferase (ALT) were (27 ± 5) μmol/L,(22 ± 6) μmol/L and (52 ± 42) U/L,which were significantly lower than (287 ± 120)μmol/L,(212 ± 86)μmol/L,and (267 ± 180)U/L before PTCD or ENBD in the jaundice relieving group (t =4.33,6.61,4.19,P ＜0.05).In the jaundice relieving group,left hemihepatectomy was performed on 14 patients,and right hemihepatectomy on 4 patients,and the radical resection rate was 16/18.In the nonjaundice relieving group,left hemihepatectomy was performed on 11 patients,and right hemihepatectomy on 13 patients,and the radical resection rate was 83.3％ (20/24).There was no significant difference in the radical resection rate between the 2 groups (x2 =1.09,P ＞ 0.05).The operation time,volume of intraoperative blood loss,volume of blood transfusion were (5.0 ± 0.8) hours,(562 ± 207) ml and (430 ± 317) ml in the jaundice relieving group,and (6.3 ± 1.5)hours,(815 ± 463)ml and (750 ± 146)ml in the non-jaundice relieving group,with significant differences between the 2 groups (t =4.77,7.80,4.65,P ＜ 0.05).The incidences of postoperative complications,bleeding and postoperative hepatic failure were 3/18,1/18 and 1/18 in the jaundice relieving group,and 75.0％ (18/24),33.3％ (8/24) and 33.3％ (8/24) in the non-jaundice relieving group,with significant differences between the 2 groups (x2=5.14,7.58,7.58,P ＜ 0.05).Conclusion Preoperative jaundice relieving could shorten the operation time and reduce the volume of intraoperative blood loss and the incidence of postoperative complications.
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Objective To investigate the efficacy of concomitant precise hemihepateetomy for the treatment of hilar cholangiocarcinoma.Methods The clinical data of 38 patients with hilar cholangiocarcinoma who received concomitant precise hemihepatectomy at the First Affiliated Hospital of Xi'an Jiaotong University from January 2009 to October 2012 were retrospectively analyzed.All patients were examined by B ultrasonography,computed tomography (CT),magnetic resonance cholangiopancreatography (MRCP) and CT angiography (CTA)preoperatively.The hepatic function was tested before operation.Of the 7 patients with obstructive jaundice,5 received percutaneous transhepatic cholangial drainage,and 2 received endoscopic nosalbiliary drainage.Surgical procedures were determined according to the results of imaging examination.The resection of hilar cholangiocarcinoma,postoperative histopathological examination,pre-and postoperative hepatic function and prognostic indicators were analyzed.The count data and measurement data were analyzed using the chi-square test and t test,respectively; the survival curve was drawn by Kaplan-Meier method,and the survival rate was analyzed using the Log-rank test.COX proportion hazards model was used for multivariate analysis.Results The positive rates of B ultrasonography,CT and MRCP were 65.8％ (25/38),71.1％ (27/38) and 89.5％ (34/38),respectively.The results of 5 patients who received CTA were positive.Concomitant left hemihepatectomy was performed on 28 patients,concomitant right hemihepatectomy on 10 patients; concomitant caudate lobectomy on 22 patients,concomitant resection and reconstruction of portal vein on 4 patients (including 1 patient who received left hepatic vein repair),concomitant hepatic artery resection on 12 patients (including 3 patients who received hepatic artery reconstruction).Of the 38 patients,R0 resection was performed on 32 patients,R1 resection on 4 patients,R2 resection on 2 patients.Hepatic function indicators including total bilirubin,direct bilirubin,alkaline phosphatase,gamma-glutamyl-transferase,alanine aminotransferase and aspartate aminotransferase were significantly decreased after operation (t =7.799,8.445,5.697,6.633,4.469,4.140,P ＜ 0.05).Two patients died perioperatively,with the mortality rate of 5.3％ (2/38).The main postoperative complications included bile leakage and hepatic function insufficiency,with the incidences of 28.9％ (11/38) and 21.1％ (8/38),respectively.Postoperative histopathological findings included 31 patients with invasive adenocarcinoma,5 patients with nodular adenocarcinoma,1 patient with mucinous adenocarcinoma and 1 patient with adenosquamous carcinoma.The overall 1-,2-,3-year survival rates were 66％,37％ and 21％,and the median survival time was 22.0 months.There were significant differences in the survival rates between patients who received R0 resection and those with R1/R2 resection,and between patients with N0 and N1/N2 stage (x2 =4.516,10.397,P ＜ 0.05).The results of multivariate analysis showed that positive margin and lymph node metastasis were prognostic indicators.Conclusions Concomitant precise hemihepatectomy has significantly improved the radical resection rate and the efficacy of treatment for hilar cholangiocarcinoma.Comprehensive preoperative imaging examination and hepatic function test are important for the assessment for resectability of hilar cholangiocarcinoma.Selective preoperative biliary drainage are key points to decrease postoperative morbidity and morality.
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Hilar cholangiocarcinoma (HCC) is a rare tumor with a poor prognosis.With the development of high definition imaging technology,improvement of surgical instruments,optimization of perioperative surgical strategies and accumulation of surgical experiences,the radical resection rate of HCC is significantly improved.Operation is the main method of treatment for HCC,and radical resection is important for a long-term survival of HCC patients.The clinical data of 66 patients with HCC who were admitted to the Beijing Youan Hospital from April 2004 to April 2012 were retrospectively analyzed.The key points in surgical procedure and prognosis of patients were investigated.
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Surgical resection is considered to be the most effective therapy for hilar cholangiocarcinoma.Inadequate excision range is the main reason for recurrence after surgery.Extended radical resection provides better long-term survival,however,it may also increase the risk of liver failure because of the extensive hepatic resection.In present study,we showed a new operation which could excise enough length of bile ducts and avoid large volume hepatic tissue resection.The excision extension includes:segment Ⅰ,Ⅳb and partial Ⅳ,left,right and furcation of hepatic duct,extrahepatic ducts,skeletonization of hilar vessels,and dissection of at least second station lymph nodes.As the tissue resected resembles a dumbbell,this surgical technique is named dumbbell type radical resection.The operative indications include:(1) hilar cholangiocarcinoma,Bithmuth Ⅱ and Bithmuth Ⅲ with tumor limited in left or right hepatic ducts ; (2) Without portal invasion; (3) Without third station lymph node metastasis; (4) Without liver or distant organ metastasis.Twenty-three patients had undergone this operation sucessfully.Most patients have high total bilirubin levels (more than 300 μmol/L) and have not received percutaneous transhepatic cholangial drainage or biliary drainage.The average operation time was 355 minutes,and average volume of blood loss during operation was 350 ml.The total survival rate was 65.2％.One-year tumour free survival rate was 95.7％ (22/23),and three-year tumor free survival rate was 7/15.The results indicated that dumbbell type radical resection was feasible for hilar cholangiocarcinoam of Bismuth Ⅱ and Bismuth Ⅲ with tumor limited in left or right hepatic ducts.
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Surgical resection offers hilar cholangiocarcinoma patients the only chance for cure and long-term survival.Hepatectomy,extrahepatic bile duct resection,regional lymphadenectomy and hepatojejunostomy are the current treatment of choice for most patients with hilar cholangiocarcinoma.Because of the aggressive nature of hilar cholangiocarcinoma and the absence of effective adjuvant therapy,surgical therapy still remains a challenge to hepatopancreatobiliary surgeons even in the precise surgery era.Controversies exist over preoperative assessment and staging,the use of preoperative biliary drainage,preoperative portal vein embolization,the range of hepatic resection,portal vein resection and construction,hepatic arteriectomy and the range of lymphadenectomy.This article reviews the surgical management of hilar cholangiocarcinoma with a focus on these controversies.
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Curative resection can offer a better chance for long-term survival than any other therapeutic modalities for hilar cholangiocarcinoma.This review highlights recent improvements in hilar cholangiocarcinoma management,with special attention to the new staging system for hilar cholangiocarcinoma,the perioperative management and the accurate dissection approach to achieve more adequate tumor-free resection margin.Overall,the precise surgical strategy and appropriate surgical techniques may provide an increased chance to cure patients with hilar cholangiocarcinoma.
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Hilar cholangiocarcinoma (HCCA) occurs at the confluence of the right and left hepatic bile ducts.Because of the unique anatomical position and the biological behaviour of HCCA,hepatic vessels,nerves,lymph nodes and adjacent tissues are easily invaded by HCCA.The operation for HCCA is difficult,and the prognosis of patients is poor.Extended hepatectomy guided by imaging techniques shed light on the management of HCCA,while controversies on extended hepatectomy exist at home and abroad,and a standard treatment is needed to be formulated.Therefore,the surgical management for HCCA should be standardized for improving the radical resection rate,reducing the incidence of complications and mortality.
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Objective To investigate the value of three-dimensional visualization system in the treatment of hilar cholangiocarcinoma.Methods The clinical data of 10 patients with hilar cholangiocarcinoma who were admitted to Chenggong Hospital of Xiamen University from January 2012 to September 2012 were retrospectively analyzed.The two-dimensional computed tomography images were converted to three-dimensional images with the three-dimensional visualization system,and then the volume of liver and tumor size,volume of liver to be resected,remnant liver volume were measured.Surgical procedure was planned based on the three-dimensional images,and the difference between the actual and planned surgical procedures was analyzed.The correlation between actual liver resection volume and predicted liver resection volume was analyzed by calculating the Pearson correlation coefficient.Results The mean liver volume,tumor size,predicted liver resection volume and remnant liver volume of the 10 patients detected by the three-dimensional visualization system were (1496 ± 162) ml,(67 ± 18) ml,(335 ± 241)ml and (1140 ± 197)ml,respectively.The average error rate of predicted liver resection volume was 6.4％.Surgical plan was made in accordance with the principle of curative hepatectomy,including 4 cases of left semihepatectomy,2 cases of right semihepatectomy,3 cases of partial liver resection and 1 case of palliative liver resection.The coincidence rate between the planned and actual surgical procedures was 9/10.R0 resection was performed on 7 patients,R1 resection on 1 patient and palliative resection on 2 patients.One patient received restrictive portal vein arterialization.Preoperative evaluation of the anatomy of blood vessels,bile ducts and tumors based on three-dimensional images was confirmed with operative findings.The accuracy of tumor typing by the three-dimensional visualization system was 8/10.The actual liver resection volume was (325 ± 258) ml,which was positively correlated with the predicted liver resection volume (r =0.902,P ＜ 0.05).Conclusion The three-dimensional visualization system is helpful in the treatment of hilar cholangiocarcinoma.
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Objective To summarize the experience in surgical management of hilar cholangiocarcinoma.Methods The clinical data of 88 patients with hilar cholangiocarcinoma who received surgical treatment at the First Affiliated Hospital of Harbin Medical University from January 2007 to December 2011 were retrospectively analyzed.All the patients were diagnosed by imaging examination.According to the severity of jaundice and predictive remnant liver volume,19 patients received percutaneous transhepatic cholangial drainage (PTCD) and 4 received portal vein embolization.The fundamental operation consisted of hilar cholangiocarcinoma resection,skeletonization of hepatoduodenum ligament and Roux-en-Y cholangiojejunostomy,and the transanastomotic stent was placed for 6 months.The count data were analyzed using the chi-square test; the survival rate was analysed using the Kaplan-Meier method; the survival was analyzed using the Log-rank test.Results Of the 88 patients,58 patients (including 11 patients who received PTCD) received hilar cholangiocarcinoma resection.Of the 58 patients,43 (including 4 patients who received portal vein embolization preoperatively) received R0 resection,and 15 received palliative resection.Thirty patients received internal and (or) external drainage.Commitant partial hepatectomy was performed on 22 patients (including 9 received left hemihepatectomy,2 received extended left hemihepatectomy,7 received left hemihepatectomy + caudate lobectomy,4 received right hemihepatectomy).Commitant pancreatico-duodenectomy was performed on 7 patients,commitant hepatic artery resection on 3 patients,and commitant portal vein resection on 2 patients.According to the modified Bismuth-Corlette classification,there were 17 patients with type Ⅰ,19 with type Ⅱ,21 with type Ⅲa,20 with type Ⅲb,and 11 with type Ⅳ.Of the 58 patients who received hilar cholangiocarcinoma resection,19 had postoperative complications,and 2 patients died within 30 days after operation.Seventy-three patients were followed up,and the overall 1-,3-,5-year survival rates were 68.5％,28.8％,11.0％,respectively.The 1-,3-,5-year survival rates of patients who received R0 resection were 94.6％,43.2％,18.9％,respectively,which were significantly higher than 78.6％,35.7％ and 7.1％ of patients who received palliative resection (x2=4.77,P ＜0.05).The 1-,3-,5-year survival rates of patients who received palliative resection were significantly higher than 18.2％,0,0 of patients who received biliary drainage (x2 =13.26,P ＜ 0.05).Conclusions R0 resection is the best choice for patients with hilar cholangiocarcinoma,and biliary drainage with no resection is the last choice.Sufficient preoperative treatment,optimized choice of surgical procedure and exquisite surgical techniques are important for the improvement of the prognosis.
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Hilar cholangiocarcinoma is a rare tumor with a poor prognosis.Due to advances in preoperative imaging and enhanced comprehension of tumor biological behavior,surgical management of hilar cholangiocarcinoma has evolved since its original description.Currently,it has been accepted that complete surgical resection provides the only possibility for cure or long-term survival,however,the surgical management of hilar cholangiocarcinoma is extremely challenging because of its anatomical location and vascular proximity.In order to achieve complete resection, several surgical approaches have been investigated and evaluated regarding major hepatic resection,lymph node dissection,vascular resection,extended resection and liver transplantation,however,there are still many disputations. Furthermore,many surgical technical difficulties exist in biliary reconstruction after resection owing to anatomical problems.Focusing on the disputes and problems mentioned above,we herein review and discuss surgical strategies in managing hilar cholangiocarcinoma.
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Objective To investigate the expression of DNA methyltransferases ( DNMTs) in hilar cholangiocarcinoma and its clinical significance.Methods A total of 150 samples of cholangetic tissues were collected from 111 patients with hilar cholangiocarcinoma ( cholangiocarcinoma group) and 39 patients with choledochocele ( control group) at the First Affiliated Hospital of Sun Yat-Sen University from April 1997 to March 2007.A tissue chip containing the samples of hilar cholangiocarcinoma and choledochocele was prepared.Expressions of DNMT1,DNMT3a and DNMT3b were detected by the immunohistochemical staining. Differences in the protein expressions of DNMTs in the cholangiocarcinoma group and the control group were compared,and the correlation between DNMTs protein expressions and clinicopathological features was analyzed.All data were analyzed by using the chi-square test or Fisher exact probability.The survival curve was drawn by using the Kaplan-Meier method and the survival rate was compared by using the Log-rank test.Results The rates of high protein expressions of DNMT1 and DNMT3b were 54.1％ (60/111) and 47.7％ (53/111) in the cholangiocarcinoma group, which were significantly higher than 28.2％ ( 11/39) and 23.1％ ( 9/39) in the control group ( x2 =7.740,7.240,P ＜0.05). The high protein expression of DNMT1 was correlated with-the Bismuth-Corlette classification and T staging of the tumor ( x2 =12.200, 17.800,P ＜0.05) ; there was no significant difference in the high protein expressions of DNMT3a in the cholangiocarcinoma group and the control group ( x2 =3.370.P ＞0.05 ) ; while the high protein expressions of DNMT3b was correlated with the Bismuth-Corlette classification (x2 =8.300,P ＜ 0.05 ),but not with the T staging. Sixty-six patients received hilar cholangiocarcinoma resection,and 42 of them were followed up.The median postoperative survival time of patients with low protein expression of DNMT1 was 23.9 months,which was significantly longer than 11.8 months of patients with high protein expression of DNMT1 (x2 =3.980,P ＜ 0.05).Conclusions DNMT1 and DNMT3b with high protein expression might play important roles in the carcinogenesis and development of hilar cholangiocarcinoma.There is an obvious relationship between the expression of DNMT1 and postoperative survival time of patients with hilar cholangiocarcinoma,and DNMT1 might be a valuable prognostic factor for hilar cholangiocarcinoma.
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Objective To detect the changes of hemodynamics in patients with portal vein embolization (PVE) before surgery for hilar cholangiocarcinoma, and analyze the relationship between hemodynamics and liver hypertrophy. Methods The clinical data of 21 patients with hilar cholangiocarcinoma who were admitted to the Eastern Hepatobiliary Surgery Hospital from April 2008 to December 2009 were retrospectively analyzed.Relevant hemodynamic variables were detected and analyzed before and 3, 7, 14 days after PVE. Data were processed using Student t test or linear correlation analysis. Results The main portal vein pressure after PVE was (25.9 ± 4.1 ) cm H2O ( 1 cm H2O = 0.098 kPa), which was ( 3.5 ± 2.5 ) cm H2O higher than that before PVE [( 22.4 ± 4.1 ) cm H2O] ( t = - 6. 504, P ＜ 0.05 ). The blood flow velocity in the non-embolized branch of portal vein increased after PVE, and reached peak [(26 ±9)cm/s] at the seventh day after PVE. A positive correlation was found between the hypertrophic rate of the non-embolized lobes and the ratio of embolized lobes to total liver volume ( r = 0. 593, P ＜ 0. 05 ). Conclusion Greater scope of the embolized vascular bed of portal vein induces higher hypertrophic rate of non-embolized liver.
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Since the 1980s, indications for resection of hilar cholangiocarcinoma have progressively improved. Operation is superior to any other therapeutic modalities with regard to survival rate and quality of life. Currently, hepatic lobectomy, extended hepatic lobectomy, extrahepatic bile duct resection, regional lymphadenectomy and Roux-en-Y hepatoenteric jejunos-tomy are recommended as the treatment of choice for most patients with hilar cholangiocarcinoma. However, controversy still remains regarding the diagnosis and treatment of hilar cholangiocarcinoma, including the assessment of longitudinal tumor extension, the evaluation of hepatic reserve function, the value of biliary drainage, the indication of portal vein emboliza-tion, the range of hepatic resection, the contribution of com-bined vascular resection, and the effectiveness of liver transplan-tation. This article summarizes these main issues requiring further investigation.
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Despite recent advances in preoperative diagnostic imaging and operative techniques for hilar cholangio-carcinoma, postoperative mid-or long-term survival has not improved. Moreover, it remains difficult to achieve curative resection with a negative resection margin for complicated hilar cholangiocarcinoma of Bismuth type ⅢorⅣ. Although it is questionable whether hepatic artery resection can improve the prognosis, combined vascular resection of the portal vein and hepatic artery for treatment of the tumor extending along the bile duct may be one of the key factors to achieve a negative resection margin. Further investigation is required to determine whether radical resection of the remaining liver parenchyma and limiting the amount of resection as much as possible, as well as the no-touch isolation technique, can improve the prognosis of patients.
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Currently, radical resection offers hilar cholangiocarcinoma patients the only chance for cure and long-term survival. Preoperative biliary drainage is necessary to reduce the risk of liver failure when total bilirubin levels are greater than 300 μmol/L, especially in patients who are about to receive hemihepatectomy or extended hemihepatectomy. Caudate lobectomy (segment I) should be performed as an elemental procedure for radical resection of hilar cholangiocarcinoma. For patients with Bismuth type Ⅲor Ⅳ, extended hemihepatectomy combined with caudate lobectomy, and if necessary, preoperative portal vein embolization, vascular resection and reconstruction, is needed to achieve tumor-free margins. Segment Ⅰ, Ⅳ,Ⅴ and Ⅷ resection is recommended to prevent postoperative liver dys-function if the volume of the remaining segments is insufficient. Resection of segment Ⅳ b and partial Ⅴ segment combined with segment Ⅰ can lessen the surgical trauma, and this is beneficial to most patients with Bismuth type Ⅱ and some Chinese patients with Bismuth type Ⅲor Ⅳ. Resection of lymph nodes 5, 6, 7, 8, 9, 12 and 13 is considered to be essential for radical resec-tion of hilar cholangiocarcinoma. Adjuvant chemotherapy and radiotherapy may prolong the long-time survival after resection.
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Hilar cholangiocarcinoma always presents with a mass, thickness of the bile duct wall or nodules in the bile duct. Computed tomography (CT) can demonstrate the above findings with high partial resolution as well as dilation of the intrahepatic bile duct. CT can show the field and the involvement of adjacent vessels on 3D reconstruction images for hilar cholangiocarcinoma spreading along the lumen of the bile duct. CT images can also demonstrate vessel involvement when evaluating the resectability. When combined with 3D reconstruc-tion, the sensitivity and specificity of CT imaging can reach 90.5% and 91.7% , respectively, for detecting vessel involve-ment.