Klatskin Tumour: Meticulous Preoperative Work-Up and Resection Rate

Zusammenfassung

Hintergrund: Operatives Vorgehen stellt die einzige potenziell kurative Therapie des hilären Cholangiokarzinoms (hilCC) dar. Höhere Resektionsraten in asiatischen Ländern lassen die Vermutung aufkommen, dass dies durch minutiöse präoperative Diagnostik bedingt ist. Methode: Alle Patienten, die sich zwischen 1998 und 2008 mit hilCC (n = 182) in unserer Einrichtung vorstellten, wurden unserer prospektiv geführten Datenbasis entnommen und in die Studie eingeschlossen. In 75 % dieser Patienten wurde eine präoperative perkutane transhepatische Cholangiografie durchgeführt. Ergebnisse: 123 (68 %) Patienten wurden reseziert. 91 % der Patienten hatten Bismuth-III- und -IV-Tumoren. En-bloc-Resektion von Tumor und entsprechendem Leberlappen war das Standardvorgehen (n = 109). Eine hiläre Resektion erfolgte bei 14 Patienten. Die Resektionsrate betrug 77 % bezogen auf explorierte Patienten. Die Hospitalletalität lag bei 5,7 %. Das 5-Jahres-Überleben nicht operierter Patienten war 0 %, nach Resektion 26 %. Patienten mit R 1-Resektion überlebten signifikant länger als nicht operierte Patienten (p < 0,001). Rechts- und Links-Resektionen wurden mit gleicher Häufigkeit und mit gleichem Überleben durchgeführt. Lymphknotenbefall war der einzige prognostische Prädiktor (p = 0,006). Schlussfolgerung: Eine Resektion sollte wann immer möglich erfolgen, da selbst nach palliativer Resektion eine substanzielle Lebensverlängerung im Vergleich zu nicht operierten Patienten zu erwarten ist. Eine detaillierte präoperative Diagnostik kann offenbar dazu beitragen, eine hohe Resektionsrate bei hilCC zu erreichen, indem zusätzliche Informationen gewonnen werden, die dem Chirurgen ein aggressiveres Vorgehen ermöglichen.

Abstract

Background: Surgery represents the only potentially curative treatment of hilar cholangiocarcinoma (hilCC). It may be suggested that meticulous preoperative work-up in Asian countries leads to higher resection rates. Method: One hundred and eighty-two patients treated in our department between 1998 and 2008 were included in an analysis based on our prospectively recorded database. Among them, 75 % had a percutaneous transhepatic cholangiography as part of their diagnostic work-up. A total of 160 patients underwent explorative surgery and 123 patients were resected (77 % of patients undergoing exploration, 68 % of all patients). Results: Ninety-one percent of the patients were diagnosed to have Bismuth III and IV tumours. En-bloc resection of the tumour and the adjacent liver including segment 1 was the standard procedure in 109 of these patients, while hilar resection was performed in 14 patients. Upon tumour resection, hospital mortality was 5.7 %. Five-year survival in patients without surgery or with mere exploration was 0 %, after resection it reached 26 %. Patients with R 1 resection experienced longer survival than patients without resection (p < 0.001). Right and left hemihepatectomies were performed with identical frequency resulting in identical survival. Lymph node involvement proved to be the only significant predictor of prognosis (p = 0.006). Conclusion: Resection should be performed whenever possible since even after palliative resection survival is substantially increased compared to patients without resection. Meticulous preoperative work-up may contribute to a high resection rate in patients with hilCC by providing additional information allowing the surgeon to perform more aggressive approaches.

Schlüsselwörter

Gallengang - hiläres Cholangiokarzinom - präoperative Diagnostik - Chirurgie - Klatskin-Tumor

Key words

bile ducts - hilar cholangiocarcinoma - diagnostic work-up - surgery - Klatskin tumour

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