Proximal bile duct cancer: High resectability rate and 5-year survival

Objective To review and update the authors' experience with resectional surgery for p roximal bile duct carcinoma (Klatskin tumor) and assess the role of liver r esection over the past 25 years. Background Until recently, resection of proximal bile duct carcinoma was uncommon, wit h most patients undergoing palliative procedures. The authors adopted a rad ical surgical approach aimed at definitive cure in 1974. Recent reports sug gest that resection improves outcome. Methods The records of 40 of 94 patients (23 men, 17 women, age range 34-81 years) diagnosed with proximal bile duct carcinoma who underwent resection between 1968 and 1993 were reviewed. According to the Bismuth classification, ther e were five type I, four type II, 25 type III, and six type IV lesions; 11 patients underwent tumor resection alone, and 25 patients had combined tumo r and liver resection (seven of these also underwent an associated regional vascular resection). In 3 patients, venous allografts were harvested from cadaveric donors and used to reconstruct the portal vein. Four patients und erwent liver transplantation; in two, organ cluster-type resections includi ng the liver with porta hepatitis and pancreas were performed. Results The resectability rate in the more recent period of the study was 49.4%. Mo st type I, three (of four) type II, T in situ, T1a, T1b, and all stage 0 tu mors were resected without hepatectomy. In the other subgroups of tumors. t he main surgical procedure was hepatectomy. Thirty-day mortality was 12.5%. After tumor resection alone, survival at 1, 3, and 5 years was 81.8%, 45.5 %, and 27.3%, respectively. After tumor resection and hepatectomy without v ascular resection, 1-, 3-, and 5-year survival was 66.7%, 16.7%, and 6%, re spectively. With vascular resection, survival rates were similar: 64%, 20%, and 4%, respectively. Conclusion The type of surgery required to achieve cure is closely related to tumor lo cation, TNM classification, and staging. Increasing resectability through t he use of hepatectomy improves survival and offers a chance of cure in pati ents with more advanced disease.