Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Surgical resection of localized cholangiocarcinoma

Christopher D Anderson, MD, FACS
Section Editor
Stanley W Ashley, MD
Deputy Editors
Wenliang Chen, MD, PhD
Diane MF Savarese, MD


Cholangiocarcinomas are rare malignancies arising from the epithelial cells of the intrahepatic and extrahepatic bile ducts. Surgical resection can be offered to patients in whom disease appears to be localized and potentially resectable and is individualized according to the location of the tumor within the biliary tree: intrahepatic, perihilar, or distal. True resectability can often only be determined at the time of exploration.

Surgical resection of localized cholangiocarcinoma is reviewed here. The clinical evaluation, diagnosis, and treatment, including when to consider orthotopic liver transplantation, are discussed elsewhere. (See "Epidemiology, pathogenesis, and classification of cholangiocarcinoma" and "Clinical manifestations and diagnosis of cholangiocarcinoma" and "Treatment of localized cholangiocarcinoma: Adjuvant and neoadjuvant therapy and prognosis" and "Treatment options for locally advanced cholangiocarcinoma" and "Systemic therapy for advanced cholangiocarcinoma".)


Biliary tract cancers are classified according to their locations along the biliary tracts and the Tumor, Node, Metastasis (TNM) cancer staging system (figure 1 and table 1A-C). These are reviewed in detail elsewhere. (See "Epidemiology, pathogenesis, and classification of cholangiocarcinoma", section on 'Anatomy, tumor classification, and staging'.)

Unfortunately, neither the Bismuth-Corlette classification nor the American Joint Committee on Cancer (AJCC)'s TNM staging accurately assesses resectability, and true resectability may be ultimately determined only at surgical exploration. (See 'Surgical approach' below.)

A preoperative clinical staging system that accurately assesses resectability would be of value clinically. Such a classification, the Blumgart staging system, has been proposed that is based upon biliary tumor extent, the presence or absence of portal vein involvement, and the presence or absence of hepatic lobar hypertrophy [1,2]. In a series of 376 patients diagnosed with a perihilar cholangiocarcinoma whose disease could be adequately staged, this clinical T staging system accurately predicted resectability, metastatic disease, and the likelihood of a microscopically complete (R0) resection [3]. Independent confirmation of these results is needed.

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Nov 2017. | This topic last updated: Nov 15, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Burke EC, Jarnagin WR, Hochwald SN, et al. Hilar Cholangiocarcinoma: patterns of spread, the importance of hepatic resection for curative operation, and a presurgical clinical staging system. Ann Surg 1998; 228:385.
  2. Jarnagin WR, Fong Y, DeMatteo RP, et al. Staging, resectability, and outcome in 225 patients with hilar cholangiocarcinoma. Ann Surg 2001; 234:507.
  3. Matsuo K, Rocha FG, Ito K, et al. The Blumgart preoperative staging system for hilar cholangiocarcinoma: analysis of resectability and outcomes in 380 patients. J Am Coll Surg 2012; 215:343.
  4. Nakeeb A, Pitt HA, Sohn TA, et al. Cholangiocarcinoma. A spectrum of intrahepatic, perihilar, and distal tumors. Ann Surg 1996; 224:463.
  5. Sakamoto E, Nimura Y, Hayakawa N, et al. The pattern of infiltration at the proximal border of hilar bile duct carcinoma: a histologic analysis of 62 resected cases. Ann Surg 1998; 227:405.
  6. Nagino M, Ebata T, Yokoyama Y, et al. Evolution of surgical treatment for perihilar cholangiocarcinoma: a single-center 34-year review of 574 consecutive resections. Ann Surg 2013; 258:129.
  7. Tsao JI, Nimura Y, Kamiya J, et al. Management of hilar cholangiocarcinoma: comparison of an American and a Japanese experience. Ann Surg 2000; 232:166.
  8. Rajagopalan V, Daines WP, Grossbard ML, Kozuch P. Gallbladder and biliary tract carcinoma: A comprehensive update, Part 1. Oncology (Williston Park) 2004; 18:889.
  9. Ebata T, Nagino M, Kamiya J, et al. Hepatectomy with portal vein resection for hilar cholangiocarcinoma: audit of 52 consecutive cases. Ann Surg 2003; 238:720.
  10. Hemming AW, Reed AI, Fujita S, et al. Surgical management of hilar cholangiocarcinoma. Ann Surg 2005; 241:693.
  11. Chamberlain RS, Blumgart LH. Hilar cholangiocarcinoma: a review and commentary. Ann Surg Oncol 2000; 7:55.
  12. Aloia TA, Charnsangavej C, Faria S, et al. High-resolution computed tomography accurately predicts resectability in hilar cholangiocarcinoma. Am J Surg 2007; 193:702.
  13. Su CH, Tsay SH, Wu CC, et al. Factors influencing postoperative morbidity, mortality, and survival after resection for hilar cholangiocarcinoma. Ann Surg 1996; 223:384.
  14. American Joint Committee on Cancer Staging Manual, 7th, Edge SB, Byrd DR, Compton CC, et al (Eds), Springer, New York 2010. p.219.
  15. Laurent A, Tayar C, Cherqui D. Cholangiocarcinoma: preoperative biliary drainage (Con). HPB (Oxford) 2008; 10:126.
  16. Nimura Y. Preoperative biliary drainage before resection for cholangiocarcinoma (Pro). HPB (Oxford) 2008; 10:130.
  17. Walter T, Ho CS, Horgan AM, et al. Endoscopic or percutaneous biliary drainage for Klatskin tumors? J Vasc Interv Radiol 2013; 24:113.
  18. Paik WH, Loganathan N, Hwang JH. Preoperative biliary drainage in hilar cholangiocarcinoma: When and how? World J Gastrointest Endosc 2014; 6:68.
  19. Kloek JJ, van der Gaag NA, Aziz Y, et al. Endoscopic and percutaneous preoperative biliary drainage in patients with suspected hilar cholangiocarcinoma. J Gastrointest Surg 2010; 14:119.
  20. Kennedy TJ, Yopp A, Qin Y, et al. Role of preoperative biliary drainage of liver remnant prior to extended liver resection for hilar cholangiocarcinoma. HPB (Oxford) 2009; 11:445.
  21. Cherqui D, Benoist S, Malassagne B, et al. Major liver resection for carcinoma in jaundiced patients without preoperative biliary drainage. Arch Surg 2000; 135:302.
  22. Liu F, Li Y, Wei Y, Li B. Preoperative biliary drainage before resection for hilar cholangiocarcinoma: whether or not? A systematic review. Dig Dis Sci 2011; 56:663.
  23. Takahashi Y, Nagino M, Nishio H, et al. Percutaneous transhepatic biliary drainage catheter tract recurrence in cholangiocarcinoma. Br J Surg 2010; 97:1860.
  24. Sakata J, Shirai Y, Wakai T, et al. Catheter tract implantation metastases associated with percutaneous biliary drainage for extrahepatic cholangiocarcinoma. World J Gastroenterol 2005; 11:7024.
  25. Kang MJ, Choi YS, Jang JY, et al. Catheter tract recurrence after percutaneous biliary drainage for hilar cholangiocarcinoma. World J Surg 2013; 37:437.
  26. Hodul P, Creech S, Pickleman J, Aranha GV. The effect of preoperative biliary stenting on postoperative complications after pancreaticoduodenectomy. Am J Surg 2003; 186:420.
  27. Madoff DC, Hicks ME, Abdalla EK, et al. Portal vein embolization with polyvinyl alcohol particles and coils in preparation for major liver resection for hepatobiliary malignancy: safety and effectiveness--study in 26 patients. Radiology 2003; 227:251.
  28. Hemming AW, Reed AI, Howard RJ, et al. Preoperative portal vein embolization for extended hepatectomy. Ann Surg 2003; 237:686.
  29. Abdalla EK, Barnett CC, Doherty D, et al. Extended hepatectomy in patients with hepatobiliary malignancies with and without preoperative portal vein embolization. Arch Surg 2002; 137:675.
  30. Nimura Y, Kamiya J, Kondo S, et al. Aggressive preoperative management and extended surgery for hilar cholangiocarcinoma: Nagoya experience. J Hepatobiliary Pancreat Surg 2000; 7:155.
  31. Nagino M, Kamiya J, Nishio H, et al. Two hundred forty consecutive portal vein embolizations before extended hepatectomy for biliary cancer: surgical outcome and long-term follow-up. Ann Surg 2006; 243:364.
  32. Di Stefano DR, de Baere T, Denys A, et al. Preoperative percutaneous portal vein embolization: evaluation of adverse events in 188 patients. Radiology 2005; 234:625.
  33. Dodson RM, Weiss MJ, Cosgrove D, et al. Intrahepatic cholangiocarcinoma: management options and emerging therapies. J Am Coll Surg 2013; 217:736.
  34. DeOliveira ML, Cunningham SC, Cameron JL, et al. Cholangiocarcinoma: thirty-one-year experience with 564 patients at a single institution. Ann Surg 2007; 245:755.
  35. Razumilava N, Gores GJ. Cholangiocarcinoma. Lancet 2014; 383:2168.
  36. Spolverato G, Kim Y, Alexandrescu S, et al. Is Hepatic Resection for Large or Multifocal Intrahepatic Cholangiocarcinoma Justified? Results from a Multi-Institutional Collaboration. Ann Surg Oncol 2015; 22:2218.
  37. Ribero D, Pinna AD, Guglielmi A, et al. Surgical Approach for Long-term Survival of Patients With Intrahepatic Cholangiocarcinoma: A Multi-institutional Analysis of 434 Patients. Arch Surg 2012; 147:1107.
  38. Endo I, Gonen M, Yopp AC, et al. Intrahepatic cholangiocarcinoma: rising frequency, improved survival, and determinants of outcome after resection. Ann Surg 2008; 248:84.
  39. de Jong MC, Nathan H, Sotiropoulos GC, et al. Intrahepatic cholangiocarcinoma: an international multi-institutional analysis of prognostic factors and lymph node assessment. J Clin Oncol 2011; 29:3140.
  40. Farges O, Fuks D, Le Treut YP, et al. AJCC 7th edition of TNM staging accurately discriminates outcomes of patients with resectable intrahepatic cholangiocarcinoma: By the AFC-IHCC-2009 study group. Cancer 2011; 117:2170.
  41. Carpizo DR, D'Angelica M. Management and extent of resection for intrahepatic cholangiocarcinoma. Surg Oncol Clin N Am 2009; 18:289.
  42. Nimura Y, Kamiya J, Nagino M, et al. Aggressive surgical treatment of hilar cholangiocarcinoma. J Hepatobiliary Pancreat Surg 1998; 5:52.
  43. Miyazaki M, Ito H, Nakagawa K, et al. Aggressive surgical approaches to hilar cholangiocarcinoma: hepatic or local resection? Surgery 1998; 123:131.
  44. Lim JH, Choi GH, Choi SH, et al. Liver resection for Bismuth type I and Type II hilar cholangiocarcinoma. World J Surg 2013; 37:829.
  45. Tan JW, Hu BS, Chu YJ, et al. One-stage resection for Bismuth type IV hilar cholangiocarcinoma with high hilar resection and parenchyma-preserving strategies: a cohort study. World J Surg 2013; 37:614.
  46. Kosuge T, Yamamoto J, Shimada K, et al. Improved surgical results for hilar cholangiocarcinoma with procedures including major hepatic resection. Ann Surg 1999; 230:663.
  47. Cameron JL, Pitt HA, Zinner MJ, et al. Management of proximal cholangiocarcinomas by surgical resection and radiotherapy. Am J Surg 1990; 159:91.
  48. Iida S, Tsuzuki T, Ogata Y, et al. The long-term survival of patients with carcinoma of the main hepatic duct junction. Cancer 1987; 60:1612.
  49. Langer JC, Langer B, Taylor BR, et al. Carcinoma of the extrahepatic bile ducts: results of an aggressive surgical approach. Surgery 1985; 98:752.
  50. Fortner JG, Vitelli CE, Maclean BJ. Proximal extrahepatic bile duct tumors. Analysis of a series of 52 consecutive patients treated over a period of 13 years. Arch Surg 1989; 124:1275.
  51. Klempnauer J, Ridder GJ, Werner M, et al. What constitutes long-term survival after surgery for hilar cholangiocarcinoma? Cancer 1997; 79:26.
  52. Johnson SR, Kelly BS, Pennington LJ, Hanto DW. A single center experience with extrahepatic cholangiocarcinomas. Surgery 2001; 130:584.
  53. Hosokawa I, Shimizu H, Yoshidome H, et al. Surgical strategy for hilar cholangiocarcinoma of the left-side predominance: current role of left trisectionectomy. Ann Surg 2014; 259:1178.
  54. Matsumoto N, Ebata T, Yokoyama Y, et al. Role of anatomical right hepatic trisectionectomy for perihilar cholangiocarcinoma. Br J Surg 2014; 101:261.
  55. Esaki M, Shimada K, Nara S, et al. Left hepatic trisectionectomy for advanced perihilar cholangiocarcinoma. Br J Surg 2013; 100:801.
  56. Washburn WK, Lewis WD, Jenkins RL. Aggressive surgical resection for cholangiocarcinoma. Arch Surg 1995; 130:270.
  57. Nagino M, Nimura Y, Kamiya J, et al. Segmental liver resections for hilar cholangiocarcinoma. Hepatogastroenterology 1998; 45:7.
  58. Neuhaus P, Thelen A, Jonas S, et al. Oncological superiority of hilar en bloc resection for the treatment of hilar cholangiocarcinoma. Ann Surg Oncol 2012; 19:1602.
  59. Neuhaus P, Jonas S, Bechstein WO, et al. Extended resections for hilar cholangiocarcinoma. Ann Surg 1999; 230:808.
  60. Hemming AW, Mekeel K, Khanna A, et al. Portal vein resection in management of hilar cholangiocarcinoma. J Am Coll Surg 2011; 212:604.
  61. Hong SM, Pawlik TM, Cho H, et al. Depth of tumor invasion better predicts prognosis than the current American Joint Committee on Cancer T classification for distal bile duct carcinoma. Surgery 2009; 146:250.
  62. Ito K, Ito H, Allen PJ, et al. Adequate lymph node assessment for extrahepatic bile duct adenocarcinoma. Ann Surg 2010; 251:675.
  63. American Joint Committee on Cancer Staging Manual, Edge SB, Byrd DR, Compton CC, et al (Eds), Springer, New York 2010. p.227.
  64. Furusawa N, Kobayashi A, Yokoyama T, et al. Surgical treatment of 144 cases of hilar cholangiocarcinoma without liver-related mortality. World J Surg 2014; 38:1164.
  65. Loehrer AP, House MG, Nakeeb A, et al. Cholangiocarcinoma: are North American surgical outcomes optimal? J Am Coll Surg 2013; 216:192.
  66. Hasegawa S, Ikai I, Fujii H, et al. Surgical resection of hilar cholangiocarcinoma: analysis of survival and postoperative complications. World J Surg 2007; 31:1256.
  67. Jarnagin WR, Ruo L, Little SA, et al. Patterns of initial disease recurrence after resection of gallbladder carcinoma and hilar cholangiocarcinoma: implications for adjuvant therapeutic strategies. Cancer 2003; 98:1689.
  68. Spolverato G, Kim Y, Alexandrescu S, et al. Management and Outcomes of Patients with Recurrent Intrahepatic Cholangiocarcinoma Following Previous Curative-Intent Surgical Resection. Ann Surg Oncol 2016; 23:235.
  69. Groot Koerkamp B, Wiggers JK, Allen PJ, et al. Recurrence Rate and Pattern of Perihilar Cholangiocarcinoma after Curative Intent Resection. J Am Coll Surg 2015; 221:1041.