Local resection of biliopancreatic cancer

Biliopancreatic tumors that are potentially amenable to local resection inc lude proximal bile duct tumors (Klatskin tumors), midcholedochal duct tumor s and tumors arising from the papilla of Vater. This paper reviews our expe rience in the AMC, with local resection of these conditions. From 1983-1997 , 112 patients underwent surgical resection of a carcinoma of the hepatic d uct confluence (Klatskin tumor). Local resection was undertaken in 80 patie nts (52 patients with type I and II tumors, and 28 patients with type III t umors) whereas in 32 patients with type III tumors, hilar resection was per formed with liver resection. Negative surgical margins were achieved in 10 patients after local resection of type I and II tumors (19.2%), in 1 patien t after local resection of a type IU tumor (3.6%), and in 5 patients after hilar resection and liver resection (15.6%). Middle-third carcinomas of the extra-hepatic biliary tract are less common than proximal or distal bile d uct tumors. From 1993-1998, 12 patients underwent resection of a midcholedo chal duct carcinoma. In 8 patients, local resection was performed and in 4 patients, subtotal pancreatoduodenectomy (PPPD) because of the close relati onship of the tumor and the pancreas. Four patients had negative surgical m argins, 2 after local resection (25%) and 2 after PPPD (50%). Although acce pted for villous adenomas located in the ampulla, local resection for ampul lary carcinoma is controversial. Nine patients underwent local resection of a presumed adenoma that proved to be an ampullary carcinoma. In 4 patients with T1 tumors, resection of the carcinoma was locally complete (44%). Add itional PPPD was performed in 6 patients, including the 4 patients with com plete local resections, showing no residual tumor at the previous site of e xcision, but, lymphnode metastases in two resection specimens (both of pati ents with presumed T1 tumors). Hence, local resection of a T1 ampullary car cinoma might result in tumor free margins, but does not deal with (usually retropancreatic) lymphnode metastases. In conclusion, local resection is ap plicable to Klatskin type I and TI tumors. Local resection may be considere d in the proximally located, mid-choledochal duct carcinomas but, when loca ted closer to the pancreas, PPPD is the preferred treatment. For ampullary adenomas, local resection is feasible unless frozen section examination rai ses suspicion on a malignancy. Local resection of even limited ampullary ca rcinomas is not advisable because of lymphatic dissemination of the tumor a nd consequently, inadequate clearance.