Radical surgery: vascular and pancreatic resection for cholangiocarcinoma.

Recent progress in vascular surgical techniques has made it possible to combine liver and portal vein and/or hepatic artery (HA) or retrohepatic inferior vena cava (IVC) resection and reconstruction in cases of locally advanced cholangiocarcinoma. Reports of the success of this difficult surgery have been published. Aggressive Japanese surgeons have applied hepatopancreatoduodenectomy (HPD) not just in cases of advanced gallbladder cancer, but also in locally advanced cholangiocarcinoma with or without superficial spread. The above extended surgeries were associated with high postoperative morbidity and mortality, but recent progress in perioperative management and surgical techniques has improved the outcome of these types of surgery. Combined portal vein and liver resection provides R0 resection and contributes to longer survival in resected patients with locally advanced cholangiocarcinoma than in unresected patients. Portal vein invasion is a strong prognostic factor of cholangiocarcinoma and the actual number of 5-year survivors is limited. The number of clinical cases of liver resection combined with IVC or HA resection and reconstruction is still limited, and therefore the long-term survival benefit from these procedures has not been clarified. HPD carried high morbidity and mortality rates in the 1990s, but the outcome has been improving and an increasing number of 5-year survivors has been reported. Although the clinical value of the above extended surgeries has not been evaluated prospectively, with the increasing number of retrospective studies it has been concluded that combined liver and portal vein and/or HA or IVC resection or HPD could be indicated for selected patients with locally advanced cholangiocarcinoma.