JOINT HOSPITAL SURGICAL GRAND ROUND 17 th May 2008 Management of Cholangiocarcinoma – Before...

JOINT HOSPITAL SURGICAL GRAND ROUND 17th May 2008

Management of

Cholangiocarcino

ma – Before

Surgery

Charing ChongAlice Ho Miu Ling Nethersole Hospital /

North District Hospital


Background


Before Surgery . . . . . .


Diagnosis Resectability

Portal Vein Embolization

Liver Function Assessment

Pre-operative Biliary Drainage

Before Surgery . . . . . .


Diagnosis


DiagnosisCA 19-9• Increase in 50 – 70% of patients with biliary tract cancer

CEA• Increase in 40 - 70% of patients with biliary tract cancer

No specific and sensitive tumour markers for biliary tract cancer are available

Improved diagnostic ability can be achieved with a combination of tumour markers and other imaging

Patel AH, Harnois DM, Klee GG, at al. The utility of CA 19-9 in the diagnoses of cholangiocarcinoma in patients without primary sclerosing cholangitis. Am J Gastroenterol 2000;95:204–7.

Nichols JC, Gores GJ, LaRusso NF, et al. Diagnostic role of serum CA 19-9 for cholangiocarcinoma in patients with primary sclerosing cholangitis. Mayo Clin Proc 1993;68:874–9.

B l o o d T e s t s – T u m o u r M a r k e r s

Pasanen PA, Eskelinen M, Partanen K, et al. Clinical value of serum tumor markers CEA, CA50 and CA242 in the distinction between malignant versus benign diseases causing jaundice and cholestasis:

results from a prospective study. Anticancer Res 1992;12:1687–93.


DiagnosisMRCP• Site of bile duct stricture• Extension of invasion

• Sensitivity in differentiating benign and malignant stricture : 70-96%

I m a g i n g – c h o l a n g i o g r a m

Romagnuolo J, Bardou M, Rahme E,et al. Magnetic resonance cholangiopancreatography: a meta-analysis of test performance in suspected biliary disea

se. Ann Intern Med 2003;139:547–57.

Park MS, Kim TK, Kim KW, et al. Differentiation of extrahepatic bile duct cholangiocarcinoma frombenign stricture: fi ndings at MRCP versus ERCP.

Radiology 2004;233:234–40.

ERCP/PTC• Invasive• Therapeutic

• Cytologic diagnosis : accuracy 30%

• Increase by 40-70% by using brush biopsy

Romagnuolo J, Bardou M, Rahme E, et al. Magnetic resonance cholangiopancreatography: a meta-analysis of test performance in suspected biliary diseas

e. Ann Intern Med 2003;139:547–57.

Park MS, Kim TK, Kim KW, et al. Differentiation of extrahepatic bile duct cholangiocarcinoma frombenign stricture: findings at MRCP versus ERCP. Rad

iology 2004;233:234–40..


Resectability


Resectability

Poor General condition:– Major surgery is often needed– Functions of liver, heart, lung, kidney and performance

status

W h a t a r e t h e u n r e s e c t a b l e f a c t o r s ?

Weber SM, DeMatteo RP, Fong Y, Blumgart LH, Jarnagin WR. Staging laparoscopy in patients with extrahepatic biliary carcinoma:

analysis of 100 patients. Ann Surg 2002;235:392–9.

Presence of metastasis (liver, lung, peritoneum, distant lymph nodes):– Lymph node in hepatoduodenal ligament

(N1): resectable– Peripancreatic lymph node (N2): unresect

able– Para-aortic and exptraperitoneal lymph n

odes (Distant): unresectable


ResectabilityLocal extension of tumour:

– Encasement or occlusion of main portal vein

– Tumour extension to secondary biliary branches bilaterally

– More aggressive surgical approaches like resection and reconstruction of the portal vein and/or hepatic artery have been reported

W h a t a r e t h e u n r e s e c t a b l e f a c t o r s ?

Jarnagin WR, Fong Y, DeMatteo RP, Gonen M, Burke EC, Bodniewicz BS J, et al. Staging, resectability, and outcome in 225 patients with hilar cholangiocarcinoma. Ann Surg 2001;234: 507–17.

Roder JD, Stein HJ, Siewert JR. Carcinoma of the periampullary region: who benefi ts from portal vein resection? Am J Surg 1996;171:170–4.

Kondo S, Hirano S, Ambo Y, Tanaka E, Kubota T, Katoh H. Arterioportal shunting as an alternative to microvascular reconstruction after hepatic artery resection. Br J Surg 2004;91:248–51.

No consensus to date on local extension factors in u

nresectable cases


Assessment of Liver Function

GOOD

NO GOOD


Assessment of Liver FunctionA n y e f f e c t i v e m e a s u r e ?

• Liver failure is the main cause of mortality• The perioperative outcome of hepatic resectio

n has improved remarkably in recent years with improved surgical techniques and perioperative care

• As a result, the indications of hepatic resection have been extended to include patients with borderline liver function



CT Volumetry:• Measuring the ratio of the futur

e remnant liver volume to the total liver volume

• To assess effect of portal vein embolization

• Percentage of residual liver volume around 40-50% should be safe in cirrhotic liver

• 25% in normal liver

C T V o l u m e t r y

Zacharia et al. Assessment of future remnant liver regeneration after portal vein embolization using three-dimensional CT and MR volum

etric analyses. Australias Radiol. 2006 ;50: 543-8.

Tu R, Xia LP, Yu AL et al. Assessment of hepatic functional reserve by cirrhosis grading and liver volume measurement using CT.

World J Gastroenterol. 2007; 13: 2956 – 61.

Lee SG, Hwang S. How I do it: assessment of hepatic functional reserve for indication of hepatic resection. J Hepatobiliary Pa

ncreat Surg. 2005; 12: 38 – 43



Indocyanine green (ICG) clearance test:• Generally used in pre-operative assessment of hepatic

function reserve• Widely recognized as a predictor for post-operative de

ath and the development of liver failure in patients with liver cirrhosis

• Occurrence of cholangitis prior to resection have unfavourable impacts on post-operative results even in patients with good hepatic functional reserve

I C G c l e a r a n c e t e s t

Miyagawa S, Makuuchi M, Kawasaki S, Kakazu T. Criteria for safe hepatic resection. Am J Surg 1995;169:589–94.

Kanai M, Nimura Y, Kamiya J, Kondo S, Nagino M, Miyachi M, et al. Preoperative intrahepatic segmental cholangitis in patients with advanced carcinoma involving the hepatic hilus. Surgery 1

996;119:498–504.


Pre-operative Portal Vein Embolization


Pre-operative portal vein embolization

YES

• Portal vein embolization leads to right liver atrophy

• A significant increase in future liver remnant volume in 2 – 3 weeks

NO

• Even in patients without portal vein embolization, the liver remnant becomes larger after right hepatectomy

• Rate of hypertrophy unclear ? Similar as in portal vein embolization

I s I t u s e f u l ?


Pre-operative portal vein embolization I s I t u s e f u l ?

No randomized controlled trials on whether pre-operative portal vein embolization

contributes to a decreased incidence of post-operative morbidity and mortality in

cholangiocarcinoma



• Prospective cohort study:– No differences in the incidence of post-operativ

e complications in 55 patients with right hepatectomy for HCC and metastatic liver cancer

– Significantly lower incidence of post-operative complications in patients with chronic liver diseases


Farges O, Belghiti J, Kianmanesh R, Regimbeau JM, Santoro R, Vilgrain V, et al. Portal vein embolization before right hepatectomy: prospective clinical tria

l. Ann Surg 2003;237:208–17.



• Retrospective review:– 53 patients with hilar cholangiocarcinoma– Use of portal vein embolization as a routine pr

e-operative procedures for patients undergoing major hepatectomy

– Post-operative mortality was significantly lower in the group with hypertrophy of the future liver after embolization than the group without hypertrophy


Hemming AW, Reed AI, Fujita S, Foley DP, Howard RJ. Surgical management of hilar cholangiocarcinoma. Ann Surg 2005; 241:693–9.


Pre-op PVE may be considered in patients in whom right hepatectomy or more, or hepatectomy with a resection rate

exceeding 50-60% is planned, especially in jaundiced liver.

Kondo S et al. Guidelines for the management of biliary tract and ampullary carcinomas: surgical treatment. J Hepatobiliary Pancreat Surg. 2008;15(1):41-54.

Pre-operative portal vein embolization I s I t u s e f u l ?

Indications should be carefully considered especially in patients with normal liver or

those with planned left hepatectomy since PVE-related complications had been reported




Pre-operative biliary drainage

YES

• Jaundice affects liver, kidneys, gastric mucosa, coagulation, immune system

NO

• Risk of infection• Invasive procedure• No difference in

post-operative morbidity and mortality

I s I t n e c e s s a r y ?


Pre-operative biliary drainageI s I t n e c e s s a r y ?

• Randomized controlled trials :– No significant difference in post-operative morbidit

y and mortality between patients who received pre-operative biliary drainage and those who did not

– Included mostly bypass surgeries and palliative small resections, few major procedures like hepatectomy

– Improvement in drainage procedure technique and outcome

Hatfi eld AR, Tobias R, Terblanche J, Girdwood AH, Fataar S, Harries-Jones R, et al. Preoperative external biliary drainage in obstructive jaundice. Lancet 1982:896–9.

McPherson GAD, Benjamin IS, Hodgson HJF, Bowley NB, Allison DJ, Blumgart LH. Preoperative percutaneous biliary drainage:the results of a controlled trial. Br J Surg 1984;71: 371–5.

Pitt HA, Gomes AS, Lois JF, Mann LL, Deutsch LS, Longmire WP Jr. Does preoperative percutaneous biliary drainage reduce risk or increase hospital cost? Ann Surg 1985;201:545–52.



• Retrospective cohorts:– Pre-operative biliary drainage for all is

unnecessary– Except for patients with cholangitis or poor

hepatic function and before extended hepatectomy

– Since mortality after extended hepatectomy is high

– Cause of death is mainly hepatic failureSewnath ME, Birjmohun RS, Rauws EA, Huibregtse K, Obertop H, Gouma DJ. The effect of preoperative biliary drainage on postoperative complications after pancreatoduodenectomy. J Am Coll Surg 20

01;192:726–34.

Martignoni ME, Wagner M, Krahenbuhl L, Redaelli CA, Friesss H, Buchler MW. Effect of preoperative biliary drainage on surgical outcome after pancreatoduodenectomy. Am J Surg 2001;181: 52–9.

Pisters PW, Hudec WA, Hess KR, Lee JE, Vauthey JN, Lahoti S, et al. Effect of preoperative biliary decompression on pancreatoduodenectomy: associated morbidity in 300 consective patients. Ann Surg 2

001;234:47–55


Pre-operative biliary drainage is recommended for patients with cholangitis or patients

scheduled to undergo extended hepatectomy



Pre-operative biliary drainage• No RCTs compared percutaneous and e

ndoscopic drainage as the most appropriate pre-operative drainage method in cholangiocarcinoma

• Two RCTs on stent therapy for unresectable cases– Endoscopic procedure was superior to percu

taneous stents and bypass surgery• For hilar lesion, endoscopic drainage is

often difficult • Percutaneous drainage may be more eff

ective and recommended

H o w ?

Speer AG, Cotton PB, Russell RC, et al. Randomised trial of endoscopic versus percutaneous stent insertion in malignant obstructive jaundice. Lancet 1987;330:57–62.

Smith AC, Dowsett JF, Russell R,. Randomised trial of endoscopic stenting versus surgical bypass in malignant low bile duct obstruction. Lancet 1994;344:1655–60.


Pre-operative biliary drainageW h a t p r o c e d u r e s a r e a p p r o p r I a t e ?

Percutaneous transhepatic or endoscopic, drainage can be used.

The method that can be safely performed with the equipment and techniques availa

ble at each facility.


SummaryW h a t s h a l l w e d o ?

Diagnosis• Tumour markers• Cytology

Resectability• Poor general condition• Distant metastasis• Local extension


• Cholangitis• Extended hepatectomy• Percutaneous or

endoscopic drainage

Liver Function Assessment

• CT volumetry• ICG test

Portal Vein Embolization

• Right hepatectomy or more

• Hepatectomy with a resection rate exceeding 50-60%


Thank You

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JOINT HOSPITAL SURGICAL GRAND ROUND 17 th May 2008 Management of Cholangiocarcinoma – Before...

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