Surgery, Gastroenterology and Oncology
Vol. 23, Nr. 4, Aug 2018
Need for Consensus Statement for Cholangiocarcinoma Diagnosis, Prognostication and Treatment: An IASGO Initiative
Nuh N. Rahbari, Dan G. Duda, Mitesh J. Borad, Ho-Seong Han
Article DOI: 10.21614/sgo-23-4-217
Read article While relatively infrequent, cholangiocarcinomas (CCAs) are liver cancers whose incidence is increasing worldwide.Unfortunately, the progress in medical, surgical and radiation oncology treatment of CCAhas made little strides in the survival of patients in most regions of the world over the past several decades.
As a result, CCA therapy remains a major challenge in medicine. There are multiple reasons for limited advances in CCA care. These include:
(1) the lack of standardized surgical approaches,
(2) the relatively difficulty of conducting clinical trials due to t....[more]
Basic Surgical Pathology of Perihilar Cholangiocarcinoma: Bridging Knowledge for Surgical Practice
Tomoki Ebata, Takashi Mizuno, Yukihiro Yokoyama, Tsuyoshi Igami, Junpei Yamaguchi, Shunsuke Onoe, Nobuyuki Watanabe, Masato Nagino
REVIEW, Aug 2018
Article DOI: 10.21614/sgo-23-4-219
Read article Perihilar cholangiocarcinoma (PCC) is a devastating disease with poor prognosis. Surgical resection remains a first-line therapy in patients with PCC, and the primary goal is to gain a tumor-free surgical margin.

However, surgical margins are sometimes involved after curative intent surgery even now, which is plausibly explained by the fact that there is a potential gap between the extent of radiologic tumor staging and that of histologic cancer invasion.
It is known that cancer cells of cholangiocarcinoma invade the surrounding area beyond the gross tumor border. The....[more]
Liver Transplantation for Perihilar Cholangiocarcinoma in the Era of Transplant Oncology: Urgent Need for a Common Definition of Res....
Keita Shimata, Hidekazu Yamamoto, Yasuhiko Sugawara, Taizo Hibi
REVIEW, Aug 2018
Article DOI: 10.21614/sgo-23-4-225
Read article The indications for liver transplantation in hepatobiliary malignancies have been carefully expanded, giving rise to a new era of Transplant Oncology, the fusion of transplantation medicine and oncology.
Curative resection is the only curative therapy for perihilar cholangiocarcinoma. Liver transplantation may achieve a complete resection with adequate negative margins in patients with locally advanced, unresectable disease due to bilateral invasion of second-order biliary radicals, portal vein and or hepatic artery involvement, or insufficient hepatic reserve.
An aggress....[more]
Surgical Strategies for the Management of Perihilar Cholangiocarcinoma
Mohamed Abdel Wahab, Ahmed Shehta, Mahmoud Ali
REVIEW, Aug 2018
Article DOI: 10.21614/sgo-23-4-230
Read article Cholangiocarcinoma is a fatal cancer arising from the biliary endothelium. Perihilar cholangiocarcinoma (pCCA) is the most common variant of cholangiocarcinoma, with increasing incidence worldwide.
Most pCCA patients present with unresectable disease at the time of diagnosis, and many patients are found to be unresectable after surgical exploration. pCCA carries a poor prognosis as more than 65% of the patients are presented with non-resectable disease at the time of diagnosis, and about 10% to 45% of patients are found to be unresectable after surgical exploration.
Preoperative Management of Patients Undergoing Liver Resection for Perihilar Cholangiocarcinoma
Mariano Cesare Giglio, Federico Tomassini, Sara Maritato, Giammauro Berardi, Nikdokht Rashidian, Roberto Montalti, Roberto Ivan Troisi
REVIEW, Aug 2018
Article DOI: 10.21614/sgo-23-4-241
Read article Surgical resection with negative margins is the standard treatment for perihilar cholangiocarcinoma whenever possible. Patient's frequent low performance status at presentation and need of extended resections require optimization of the patient's condition in the preoperative setting. Biliary drainage is mandatory in case of cholangitis, jaundice-related liver insufficiency, malnutrition or renal failure.

Drainage is also necessary in case of portal vein embolization (PVE), in order to improve regeneration of the future liver remnant (FLR). Unilateral drainage of the FLR sh....[more]
Minimal Invasive Surgery for Cholangiocarcinoma
Jai Young Cho, Ho-Seong Han, Young Rok Choi, Yoo-Seok Yoon, Woohyung Lee
REVIEW, Aug 2018
Article DOI: 10.21614/sgo-23-4-247
Read article Intrahepatic cholangiocarcinoma (IHCC) is a common primary hepatic tumor. However, its outcomes are usually worse than those of hepatocellular carcinoma owing to its non-specific presentation and detection at an advanced stage.
Surgery is the best treatment option that offers a chance of long-term survival. Minimal invasive procedures for IHCC were not well performed frequently due to necessity for major laparoscopic liver resection (LLR) with possible inclusion of caudate resection (for Klatskin tumor), laparoscopic lymphadenectomy, and laparoscopic biliary-enteric anastomosis....[more]
Surgical Margins and Lymphoid Infiltrate in Cholangiocarcinoma: When a Surgical Technique "Pushes" Tumor Biology to Provide Answer
Guido Torzilli, Luca Viganò
Article DOI: 10.21614/sgo-23-4-250
Read article Mass-forming cholangiocarcinoma (MFCCC) is a disease at increasing incidence (1,2). Liver resection (LR) is the standard treatment, while chemotherapy has a limited effectiveness (3,4).
Five-year survival rates after complete surgery range between 20 and 35% (5-9). Although surgery represents the unique curative treatment, the disease is characterized by low resectability and high post-surgical recurrences rates (1-4). To date, resectability is based on morphological features (number and size of lesions, vascular invasion), lymphnode metastases (N stage), and surgical radicalit....[more]
Radiotherapy of Cholangiocarcinoma
Thomas B. Brunner, Mathias Walke, Peter Hass
REVIEW, Aug 2018
Article DOI: 10.21614/sgo-23-4-254
Read article Unresectable cholangiocarcinoma represents a major therapeutic challenge and outcomes are still not satisfactory. However, there is the hope that recent developments in radiotherapy such as stereotactic body radiotherapy, proton therapy and brachytherapy are able to not only lead to better local control but also to prolong overall survival.

Specific bowel protection strategies such as simultaneous integrated protection are required to safely deliver the dose in situations where there is close proximity of the lesions to the bowel.
The integration of these techniques i....[more]
Novel Biomarkers in Cholangiocarcinoma
Dan G. Duda, Shuichi Aoki, Simona Dima, Irinel Popescu, Mitesh J. Borad
REVIEW, Aug 2018
Article DOI: 10.21614/sgo-23-4-259
Read article Cholangiocarcinoma (CCA) is the second most common type of primary liver cancer, after hepatocellular carcinoma, and accounts for 10-25% of primary liver cancers (1, 2). CCAs are classified as intrahepatic CCA (iCCA) and extrahepatic CCA (eCCA), according to their anatomical location (3).
CCA is more frequent in South Asia compared to Western countries, because of the increased prevalence of established risk factors, including fluke infections (2). In the USA, the incidence of CCA has increased over the past three decades (4). Surgical resection and transplantation are the only....[more]
Operative Management and Outcomes of 150 Patients with Curative-intent Surgery for Perihilar Cholangiocarcinomas: A Single Institute....
Traian Dumitrascu, Vladislav Brasoveanu, Cezar Stroescu, Mihnea Ionescu, Irinel Popescu
Article DOI: 10.21614/sgo-23-4-267
Read article Introduction: The knowledge of current approach and outcomes of curative-intent surgery for perihilar cholangiocarcinoma (PHC) has been highlighted in studies of the literature including mainly East Asian and Western patients.
Thus, papers presenting the curative-intent surgery in East Europe are scarce. The study aims to present the operative management and outcomes of curative-intent surgery for PHC in an East European institutional experience.

Patients and methods: The data of all patients with curative-intent surgery for PHC between 1996 and 2017 were ....[more]
Surgical Outcome of Extra-hepatic Cholangiocarcinoma
Michiaki Unno, Kei Nakagawa, Hiroki Hayashi, Koji Fukase, Fuyuhiko Motoi, Takashi Kamei, Takeshi Naitoh
Article DOI: 10.21614/sgo-23-4-278
Read article Extrahepatic cholangiocarcinoma is divided into two compartments, namely perihilar cholangiocarcinoma and distal cholangiocarcinoma. Hemihepatectomy and caudate lobectomy with resection of extrahepatic bile duct is usually performed for patients with perihilar cholangiocarcinoma, whereas pancreaticoduodenectomy is performed for distal cholangiocarcinoma.
As pancreaticoduodenectomy has been a well-established and more commonly performed operation, distal cholangiocarcinoma was thought to have better outcomes as compared to perihilar cholangiocarcinoma. However, both cholangiocarc....[more]
Perihilar Cholangiocarcinoma on Biliary Anatomical Variant. Case Report
Florin Botea, Diana Nicolaescu, Alexandru Barcu, Nausica Picu, Radu Dumitru, Ruxandra Fota, Vlad Herlea, Irinel Popescu
Images in Clinical Medicine, Aug 2018
Article DOI: 10.21614/sgo-23-4-284
Read article Background. Perihilar cholangiocarcinoma (PCC), defined as tumors involving or in close vicinity to the main bile duct confluence, is the most frequent type of cholangiocarcinoma (CC). Nevertheless, PCC occurring on biliary anatomical variant is a rare condition, difficult to diagnose and to establish the proper surgical approach.

Case presentation. A 59-year old male, with normal liver function, is incidentally diagnosed with PCC of the left hepatic duct (LHD), associated with a biliary anatomical variant consisting in right posterior hepatic duct (RPHD) enter....[more]
Slow-growing Intrahepatic Cholangiocarcinoma - Difficult Diagnosis, Prolong Survival
Sorin Alexandrescu, Razvan Grigorie, Mirela Boros, Vlad Herlea, Irinel Popescu
Images in Clinical Medicine, Aug 2018
Article DOI: 10.21614/sgo-23-4-290
Read article Intrahepatic cholangiocarcinoma (ICC) is usually diagnosed in advanced stages of disease, more than half of the patients being unresectable at the time of their diagnosis.
Moreover, the disease is very aggressive, almost half of untreated patients dying during the first 4 month after diagnosis. Even in patients who undergo curative-intent treatment, the prognosis is still modest, with median survival less than 30 months in most series.
Although this dismal prognosis is typical for ICC, some patients experience unusual long-term survival, even when poor clinico-pathologic pr....[more]

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