Surgical treatment of hilar and intrahepatic cholangiocarcinoma

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  1. 1. Updates in Surgery
  2. 2. Alfredo Guglielmi Andrea Ruzzenente Calogero Iacono Surgical Treatment of Hilar and Intrahepatic Cholangiocarcinoma In cooperation with Luigi Marchiori Silvia Pachera Luca Bortolasi Riccardo Manfredi Paola Capelli 13
  3. 3. Alfredo Guglielmi Andrea Ruzzenente Calogero Iacono General Surgery A, Department of Surgery and Gastroenterology University Hospital G.B. Rossi Verona, Italy in cooperation with Luigi Marchiori, Silvia Pachera, Luca Bortolasi General Surgery A, Department of Surgery and Gastroenterology University Hospital G.B. Rossi Verona, Italy Riccardo Manfredi Department of Radiology University Hospital G.B. Rossi Verona, Italy Paola Capelli Department of Pathology University Hospital G.B. Rossi Verona, Italy The publication and the distribution of this volume have been supported by the Italian Society of Surgery Library of Congress Control Number: 2007931745 ISBN 978-88-470-0728-4 Milan Heidelberg New York e-ISBN 978-88-470-0729-1 Springer is a part of Springer Science+Business Media springer.com Springer-Verlag Italia 2008 This work is subject to copyright. All rights are reserved, whether the whole or part of the mate- rial is concerned, specifically the rights of translation, reprinting, re-use of illustrations, recitation, broadcasting, reproduction on microfilms or in other ways, and storage in data banks. Duplication of this publication or parts thereof is only permitted under the provisions of the Italian Copyright Law in its current version, and permission for use must always be obtained from Springer. Violations are liable for prosecution under the Italian Copyright Law. The use of general descriptive names, registered names, trademarks, etc., in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the rele- vant protective laws and regulations and therefore free for general use. Product liability: The publisher cannot guarantee the accuracy of any information about dosage and application contained in this book. In every individual case the user must check such infor- mation by consulting the relevant literature. Cover design: Simona Colombo, Milan, Italy Typesetting: Graphostudio, Milan, Italy Printing and binding: Arti Grafiche Nidasio, Assago, Italy Printed in Italy Springer-Verlag Italia S.r.l. Via Decembrio 28 I-20137 Milan
  4. 4. Foreword In the 10 years since the presentation of Gazzanigas excellent monograph on extra- hepatic biliary tumours at the SIC Congress in 1997, interesting developments in the field have pressed upon us an undoubted need to reassess the complex topic of hepatobiliary surgery. It is therefore with great pleasure that, at the proposal of the Steering Committee of the Italian Society of Surgery (SIC), we present to Italian surgeons this monograph on the treatment of hilar and intrahepatic cholangiocarci- noma, prepared by Alfredo Guglielmi, professor and chairman of Surgical Department A at the University School of Medicine of Verona, and his colleagues. The volume is divided into two parts. The first relates to hilar cholangiocarci- nomas, about which there are a number of complex and still controversial issues; the second relates to intrahepatic cholangiocarcinomas, which are frequently treat- ed like other primary tumours of the liver. The monograph includes preliminary information about molecular biology, and diagnostic and treatment methods are extensively examined in relation to type of neoplastic spread. In our opinion the most interesting part of the book concerns the treatment of these tumours with both interventional radiology and surgery, which can range from simple hepatectomies to liver transplantation. We would like to point out that Professor Guglielmi carried out the first liver transplantation in the University of Verona surgical department. The monograph is aimed at those in clinical practice, and is written by a col- league for whom the most important objective of his work is to perform the best surgery in the light of the most recent developments and to achieve results in the interests of his patients. Just as usually happens in clinical practice, pathologists and radiologists have participated in the making of this book. This type of disease management team improves the quality and results of surgery. Over the last 20 years, Alfredo Guglielmi has followed with enthusiasm and intelligence the progress made in hepatobiliary surgery. He has connections with European, American and Japanese surgical institutes; he performed an in-depth study of the surgical treatment of cholangiocarcinoma at the University of Nagoya under the guidance ofYuji Nimura, a pioneer in this field. The mutuality of this pro- fessional relationship and sincere friendship is attested to by several visits of Yuji Nimura to the surgical department of the University School of Medicine of Verona.
  5. 5. It is for all these reasons that we are proud to present to Italian surgeons this monograph, which conveys the most recent orientations of the SIC. For the first time it is being published in English by a publishing house with an international presence. We think that this is the best way to share our experiences with colleagues from other countries. We also feel that this volume will be an excellent instrument for the achievement of the aims of the SIC Steering Committee. We hope it will achieve wide circulation and great success. Verona, October 2007 Claudio Cordiano Past President, Italian Society of Surgery Rome, October 2007 Roberto Tersigni President, Italian Society of Surgery ForewordVI
  6. 6. Preface I would like to thank the Steering Committee of the Italian Society of Surgery (SIC) for giving me the opportunity of writing this book. I accepted the task enthusiasti- cally, because the surgery of cholangiocarcinoma is a fascinating and complex part of hepatobiliary surgery that has undergone numerous changes over recent decades. My aim has been to provide an update on the diagnosis, staging, preoperative man- agement and treatment of hilar and intrahepatic cholangiocarcinoma, and to pro- vide a critical review of diagnostic and therapeutic tools in the light of the published literature and personal experience. Cholangiocarcinoma is a rare neoplasm, but its incidence is increasing in Western and Eastern countries. It was described in rare reports before the 1950s, and only in 1965 did Klatskin collect 13 cases and describe the clinical and patho- logical characteristics of the disease. Classically, cholangiocarcinoma is cate- gorised into intrahepatic and extrahepatic types according to the location of the tumour along the biliary tract. However, the frequently mixed type of growth of these tumours often makes this type of classification difficult to apply. This mono- graph has therefore been divided into two parts to analyse the differences between the two types of cholangiocarcinoma, emphasising that the treatment of these two neoplasms often requires combined hepatic and bile duct resection. The modern era of surgery of hilar cholangiocarcinoma began in 1954 when Brown performed the first bile duct resection for hilar cholangiocarcinoma. The first experiences of bile duct resection associated with liver resection were pub- lished during the 1960s. From the 1970s onwards, Longmire, Fortner and Launois reported the first surgical series with good survival results but with a high rate of mortality and complications. After the 1980s, the clinico-anatomical study of the hepatic hilum and the segmental biliary drainage proposed by Nimura led to further progress in precise preoperative diagnosis of tumour extent and surgical planning. More recently, progress in non-invasive diagnostic tools has further improved the preoperative evaluation, with a reduction in invasive diagnostic techniques. During the past decade, improvements in surgical techniques and preoperative opti- misation of liver function (preoperative biliary drainage and portal vein embolisa- tion) have made it possible to perform extended liver resection combined with vas-
  7. 7. cular resection and reconstruction with low mortality and morbidity. The higher curative resection rate of this type of surgical approach has also improved long- term results. The surgery of cholangiocarcinoma is still changing today, and several contro- versies in preoperative and surgical management remain. These open issues provide stimulus for further research and new ideas on the treatment of this tumour. I am extremely grateful to Professor Claudio Cordiano, who in his surgical department stimulated and supported me in the development of hepatobiliary sur- gery. I owe a debt of thanks to my maestro. I also thank Professor Yuji Nimura for all the teachings he gave me, with great willingness and undisputed expertise, over the last 15 years. His thoughts are present in many places in the pages of this book. Thanks also go to all the colleagues who helped me during the writing of the book, of whom I asked dedication and diligence, and into whom I hope I have instilled my passion for this challenging branch of surgery. Finally, thank you to Giovanni Paolo Pianegonda for his wonderful drawings. Alfredo Guglielmi PrefaceVIII
  8. 8. Contents Part 1: Hilar Cholangiocarcinoma Reporting Cholangiocarcinoma: Pathological Aspects . . . . . . . . . . . . . . . . . . 3 Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Clinical Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Intraoperative Consultation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Macroscopic Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Pathology Findings in Non-Neoplastic Liver