白袍恐懼症

The treatment of klatskin tumor

1.      operation: 唯一提高存活率的方法

Criteria for respectability

a.      Absence of retropancreatic and paraceliac nodal metastases or distant liver metastases

b.      Absence of invasion of the portal vein or main hepatic artery (although some centers support en bloc resection with vascular reconstruction

c.       Absence of extrahepatic adjacent organ invasion

d.      Absence of disseminated disease

2.      Preoperative biliary decompression

a.    方法: endoscope or PTCD

b.    目前做法: serum bilirubin level over 10 mg/dL=> perform nonoperative biliary drainage；until bilirubin levels are under 3 mg/dL才operation

c.    目前研究: no significant differences in mortality or the incidence of postoperative liver failure, but postoperative morbidity rates were significantly higher in the jaundiced patients

3.      Preoperative portal vein embolization

PVE may permit a margin-negative resection in patients who otherwise would be considered unresectable because of concerns about insufficient postoperative residual liver volume.

4.      Prognostic factors

margin (+/-)和lymph node

5.      Surgical treatment

a.      Distal cholangiocarcinoma: prognosis best, Five-year survival rates range from 23 to 50 percent. Treated with pancreaticoduodenectomy (Whipple procedure). Lymph node involvement and depth of tumor invasion are important prognostic indicators

b.      Intrahepatic cholangiocarcinoma : treated by hepatic resection to achieve negative resection margins. Lymph node involvement is an important prognostic factor.

c.       Perihilar cholangiocarcinoma:

I.            type I and II : en bloc resection of the extrahepatic bile ducts and gallbladder with 5 to 10 mm bile duct margins and a regional lymphadenectomy with Roux-en-Y hepaticojejunostomy.

II.          type II and III lesions often involve the ducts of the caudate lobe, many surgeons recommend routine caudate lobectomy

III.        type III : hepatic lobectomy

6.        將jejunum 切開，將遠端接到common hepatic ，此段jejunum取代CBD的功能，使bile排出，並可避免食物和胃酸進入liver造成破壞，然後再將近端jejunum切口接到jejunum上，形成Y型的jejunal-jejunostomy.

7.      NCCN guidelines

a.   Extrahepatic cholangiocarcinoma 

For patients with resected, margin-negative extrahepatic cholangiocarcinoma with negative regional nodes, observation or fluoropyrimidine-based chemoradiotherapy are acceptable options.

For patients with positive regional lymph nodes, carcinoma in situ at the margins, or positive margins with invasive disease, fluoropyrimidine-based chemoradiotherapy should be considered.

b.   Intrahepatic cholangiocarcinoma 

For no residual local disease, no adjuvant therapy recommendations are made.
For patients with positive margins, options include reresection, ablation, or fluoropyrimidine or chemoradiotherapy.