title: Surgical strategy for bile duct cancer: Advances and current limitations.
abstract: The aim of this review is to describe recent advances and topics in the surgical management of bile duct cancer. Radical resection with a microscopically negative margin (R0) is the only way to cure cholangiocarcinoma and is associated with marked survival advantages compared to margin-positive resections. Complete resection of the tumor is the surgeon's ultimate aim, and several advances in the surgical treatment for bile duct cancer have been made within the last two decades. Multidetector row computed tomography has emerged as an indispensable diagnostic modality for the precise preoperative evaluation of bile duct cancer, in terms of both longitudinal and vertical tumor invasion. Many meticulous operative procedures have been established, especially extended hepatectomy for hilar cholangiocarcinoma, to achieve a negative resection margin, which is the only prognostic factor under the control of the surgeon. A complete caudate lobectomy and resection of the inferior part of Couinaud's segment IV coupled with right or left hemihepatectomy has become the standard surgical procedure for hilar cholangiocarcinoma, and pylorus-preserving pancreaticoduodenectomy is the first choice for distal bile duct cancer. Limited resection for middle bile duct cancer is indicated for only strictly selected cases. Preoperative treatments including biliary drainage and portal vein embolization are also indicated for only selected patients, especially jaundiced patients anticipating major hepatectomy. Liver transplantation seems ideal for complete resection of bile duct cancer, but the high recurrence rate and decreased patient survival after liver transplant preclude it from being considered standard treatment. Adjuvant chemotherapy and radiotherapy have a potentially crucial role in prolonging survival and controlling local recurrence, but no definite regimen has been established to date. Further evidence is needed to fully define the role of liver transplantation and adjuvant chemo-radiotherapy.
authors: Nobuhisa Akamatsu, Daijo Hashimoto, Department of Hepato-Biliary-Pancreatic Surgery, Saitama Medical Center, Saitama Medical University, 1981 Tsujido-cho, Kamoda, Kawagoe, Saitama 350-8550, Japan.
authors: Nobuhisa
authors: N
authors: Akamatsu
authors: Yasuhiko
authors: Y
authors: Sugawara
authors: Daijo
authors: D
authors: Hashimoto
references: Ann Surg. 1994 Mar;219(3):267-74
references: 8147607
references: J Am Coll Surg. 2002 Nov;195(5):641-7
references: 12437251
references: Cancer Treat Rev. 2009 Jun;35(4):322-7
references: 19147294
references: Ann Surg. 1997 May;225(5):472-81; discussion 481-3
references: 9193175
references: Gastrointest Endosc. 2005 Sep;62(3):374-82
references: 16111955
references: Ann Surg. 2004 Jul;240(1):95-101
references: 15213624
references: World J Gastroenterol. 2007 Mar 14;13(10):1505-15
references: 17461441
references: J Hepatobiliary Pancreat Surg. 2000;7(2):135-41
references: 10982605
references: Br J Surg. 2000 Mar;87(3):306-13
references: 10718799
references: Ann Surg. 2009 Aug;250(2):210-8
references: 19638920
references: Am J Surg. 2007 Jun;193(6):702-6
references: 17512280
references: AJR Am J Roentgenol. 2006 Jun;186(6):1580-6
references: 16714646
references: Ann Surg Oncol. 2008 Aug;15(8):2113-9
references: 18546046
references: J Hepatobiliary Pancreat Surg. 2002;9(2):237-41
references: 12140613
references: Hepatology. 1999 Apr;29(4):1099-105
references: 10094953
references: Br J Surg. 1996 Dec;83(12):1712-5
references: 9038548
references: Br J Surg. 1994 Aug;81(8):1195-8
references: 7741850
references: J Hepatobiliary Pancreat Surg. 1998;5(1):48-51
references: 9683754
references: Dig Surg. 2001;18(2):84-9
references: 11351150
references: Ann Surg. 2009 Mar;249(3):435-9
references: 19247031
references: J Hepatobiliary Pancreat Sci. 2010 Jul;17(4):463-9
references: 19941010
references: Am J Gastroenterol. 2004 Aug;99(8):1464-9
references: 15307861
references: Ann Surg. 2003 Feb;237(2):208-17
references: 12560779
references: Ann Surg. 2004 Feb;239(2):265-71
references: 14745336
references: J Hepatobiliary Pancreat Sci. 2010 Jul;17(4):470-5
references: 19936600
references: Ann Surg Oncol. 2008 Mar;15(3):807-14
references: 18181000
references: J Hepatobiliary Pancreat Sci. 2010 Jul;17(4):497-504
references: 19859651
references: World J Surg. 2003 Feb;27(2):173-9
references: 12616432
references: World J Gastroenterol. 2005 Nov 28;11(44):7024-7
references: 16437610
references: Eur J Surg Oncol. 2007 Mar;33(2):202-7
references: 17088040
references: Ann Surg. 2007 May;245(5):755-62
references: 17457168
references: AJR Am J Roentgenol. 2008 Feb;190(2):396-405
references: 18212225
references: J Am Coll Surg. 2007 Feb;204(2):250-60
references: 17254929
references: Ann Surg. 2003 Jul;238(1):84-92
references: 12832969
references: Surgery. 1994 Apr;115(4):445-51
references: 8165536
references: J Hepatobiliary Pancreat Surg. 2007;14(5):429-33
references: 17909709
references: Ann Surg. 2001 Mar;233(3):385-92
references: 11224627
references: Ann Surg Oncol. 2007 Nov;14(11):3202-9
references: 17705089
references: Ann Surg. 1999 Aug;230(2):131-42
references: 10450725
references: Ann Surg. 2006 Aug;244(2):240-7
references: 16858186
references: AJR Am J Roentgenol. 1997 Dec;169(6):1501-5
references: 9393153
references: Ann Surg Oncol. 2007 Mar;14(3):1212-9
references: 17176983
references: J Comput Assist Tomogr. 2007 Jan-Feb;31(1):72-8
references: 17259836
references: Surg Gynecol Obstet. 1975 Feb;140(2):170-8
references: 1079096
references: Am J Gastroenterol. 2004 Sep;99(9):1684-9
references: 15330902
references: Ann Surg. 2010 Apr;251(4):675-81
references: 20224368
references: World J Surg. 2003 Oct;27(10):1137-42
references: 12925900
references: J Hepatobiliary Pancreat Surg. 2009;16(1):1-7
references: 19110652
references: World J Surg. 2007 Feb;31(2):337-42; discussion 343-4
references: 17006609
references: Arch Surg. 2004 May;139(5):514-23; discussion 523-5
references: 15136352
references: Ann Surg. 1999 Jan;229(1):76-83
references: 9923803
references: Br J Surg. 2001 Jan;88(1):48-51
references: 11136309
references: Hepatology. 1997 Nov;26(5):1176-81
references: 9362359
references: Am J Clin Oncol. 2005 Feb;28(1):21-3
references: 15685030
references: World J Surg. 1988 Feb;12(1):2-10
references: 3344582
references: Ann Surg. 2002 Jul;236(1):17-27
references: 12131081
references: Radiology. 2001 Jul;220(1):90-6
references: 11425978
references: Ann Surg. 2010 Feb;251(2):281-6
references: 20054275
references: World J Surg. 1993 Jan-Feb;17(1):85-92; discussion 92-3
references: 8447147
references: Radiat Med. 2008 Aug;26(7):402-7
references: 18769997
references: J Gastrointest Surg. 2008 Jan;12(1):117-22
references: 17963015
references: Ann Oncol. 2001 Feb;12(2):183-6
references: 11300321
references: J Am Coll Surg. 2006 Jan;202(1):93-9
references: 16377502
references: Surgery. 1990 May;107(5):521-7
references: 2333592
references: Hepatogastroenterology. 1993 Feb;40(1):69-77
references: 8462933
references: Acta Radiol. 2005 Aug;46(5):462-70
references: 16224919
references: Ann Surg. 1999 Nov;230(5):663-71
references: 10561090
references: Ann Surg. 2005 May;241(5):693-9; discussion 699-702
references: 15849505
references: Gastroenterology. 2005 May;128(6):1655-67
references: 15887157
references: Semin Liver Dis. 2004 May;24(2):201-7
references: 15192792
references: J Hepatobiliary Pancreat Sci. 2010 Jul;17(4):455-62
references: 19820891
references: Int J Radiat Oncol Biol Phys. 2000 Feb 1;46(3):581-7
references: 10701737
references: Transplant Proc. 2009 Dec;41(10):4023-35
references: 20005336
references: Surgery. 2001 Jun;129(6):677-83
references: 11391365
references: Am Surg. 2006 Jul;72(7):599-604; discussion 604-5
references: 16875081
references: Hepatogastroenterology. 1995 Jul-Aug;42(4):332-7
references: 8586363
references: Eur Radiol. 2004 Jul;14(7):1174-87
references: 15106016
references: J Am Coll Surg. 1999 Mar;188(3):304-9
references: 10065820
references: Hepatogastroenterology. 2009 Mar-Apr;56(90):294-8
references: 19579585
references: Ann Surg. 2006 Mar;243(3):364-72
references: 16495702
references: J Gastrointest Surg. 2009 Aug;13(8):1470-9
references: 19421824
references: HPB (Oxford). 2008;10(5):341-6
references: 18982150
references: Am Surg. 2001 Sep;67(9):839-43; discussion 843-4
references: 11565760
references: Clin Radiol. 1999 Aug;54(8):513-20
references: 10484218
references: Hepatogastroenterology. 2000 May-Jun;47(33):650-7
references: 10919005
references: Am J Clin Oncol. 2000 Aug;23(4):425-8
references: 10955877
references: Br J Surg. 2005 May;92(5):547-56
references: 15800958
references: HPB (Oxford). 2009 Aug;11(5):445-51
references: 19768150
references: World J Surg. 1994 Sep-Oct;18(5):778-84
references: 7975700
references: J Hepatobiliary Pancreat Surg. 2007;14(2):131-5
references: 17384902
references: Surgery. 1999 May;125(5):514-21
references: 10330940
references: Ann Surg. 1992 Apr;215(4):344-9
references: 1558415
references: Am J Surg. 2010 Apr;199(4):447-52
references: 19596119
references: Ann Surg. 2003 Jul;238(1):73-83
references: 12832968
references: Ann Surg. 2008 Aug;248(2):273-9
references: 18650638
references: Abdom Imaging. 2004 Sep-Oct;29(5):540-7
references: 15383897
references: World J Surg. 2007 Jun;31(6):1256-63
references: 17453285
references: J Gastrointest Surg. 2005 Dec;9(9):1191-204; discussion 1204-6
references: 16332474
references: Ann Surg. 2003 Nov;238(5):720-7
references: 14578735
references: Surgery. 2009 Aug;146(2):250-7
references: 19628081
references: World J Gastroenterol. 2002 Oct;8(5):943-6
references: 12378647
references: J Comput Assist Tomogr. 2006 May-Jun;30(3):362-7
references: 16778607
references: Eur J Cancer. 1995 Sep;31A(10):1594-8
references: 7488407
references: Dig Surg. 2007;24(2):131-6
references: 17446708
references: Am J Surg. 1990 Jan;159(1):91-7; discussion 97-8
references: 1688486
references: Radiology. 2006 Apr;239(1):113-21
references: 16467211
references: Arch Surg. 2002 Jan;137(1):69-73
references: 11772220
references: J Hepatobiliary Pancreat Surg. 2006;13(2):94-9
references: 16547668
references: Am J Transplant. 2002 Sep;2(8):774-9
references: 12243499
references: Nat Clin Pract Gastroenterol Hepatol. 2006 Jan;3(1):33-42
references: 16397610
references: Arch Surg. 1999 Mar;134(3):261-6
references: 10088565
references: Surgery. 2000 Apr;127(4):395-404
references: 10776430
references: Ann Surg. 2002 Sep;236(3):355-66; discussion 366-8
references: 12192322
references: Surgery. 2007 May;141(5):581-8
references: 17462457
references: Am J Clin Oncol. 2003 Aug;26(4):422-8
references: 12902899
references: Radiology. 2006 Jan;238(1):300-8
references: 16304092
references: Int J Radiat Oncol Biol Phys. 2011 Mar 1;79(3):696-704
references: 20510541
references: Ann Surg. 2009 Feb;249(2):296-302
references: 19212185
references: Gastrointest Endosc. 2002 Jun;55(7):870-6
references: 12024143
references: World J Gastroenterol. 2009 Sep 14;15(34):4240-62
references: 19750567
references: Ann Surg Oncol. 2008 Aug;15(8):2104-12
references: 18543039
references: Ann Surg. 1985 May;201(5):545-53
references: 2986562
references: World J Surg. 2009 Jul;33(7):1459-67
references: 19381719
references: Ann Surg. 2006 Jan;243(1):28-32
references: 16371733
references: Transplantation. 2009 Aug 15;88(3):295-8
references: 19667927
references: J Hepatobiliary Pancreat Surg. 2000;7(2):155-62
references: 10982608
references: World J Gastroenterol. 2009 Mar 21;15(11):1353-8
references: 19294765
references: J Hepatobiliary Pancreat Surg. 2009;16(4):502-7
references: 19360368
references: J Gastrointest Surg. 2010 Feb;14(2):335-43
references: 19902311
references: Ann Surg. 2003 May;237(5):686-91; discussion 691-3
references: 12724635
references: J Gastroenterol Hepatol. 2010 Apr;25(4):731-7
references: 20074166
references: Eur J Cancer. 2005 Feb;41(3):398-403
references: 15691639
references: Ann Surg. 1999 Dec;230(6):808-18; discussion 819
references: 10615936
references: J Hepatobiliary Pancreat Surg. 2008;15(5):501-7
references: 18836804
references: HPB (Oxford). 2005;7(4):263-7
references: 18333204
references: J Hepatobiliary Pancreat Surg. 2009;16(2):216-22
references: 19214370
references: J Pathol. 1983 Feb;139(2):217-38
references: 6298394
references: J Hepatobiliary Pancreat Sci. 2010 Jul;17(4):449-54
references: 19806294
references: J Hepatobiliary Pancreat Surg. 2007;14(5):455-62
references: 17909713
references: Br J Surg. 2007 Nov;94(11):1386-94
references: 17583900
references: Transplantation. 2000 Apr 27;69(8):1633-7
references: 10836374
references: Br J Cancer. 2008 Sep 16;99(6):862-7
references: 19238628
references: World J Surg. 2005 Jun;29(6):723-7
references: 15880281
references: Surgery. 2010 Jan;147(1):49-56
references: 19767048
references: World J Surg. 2006 Apr;30(4):567-73; discussion 574-5
references: 16568228
references: Hepatogastroenterology. 1998 Jul-Aug;45(22):905-9
references: 9755978
references: Transpl Int. 2010 Jul;23(7):692-7
references: 20497401
references: Br J Cancer. 2005 May 9;92(9):1650-4
references: 15856037
references: Radiographics. 2002 Jan-Feb;22(1):173-87
references: 11796906
references: Ann Surg. 2004 Nov;240(5):738-45
references: 15492552
references: Radiat Oncol Investig. 1998;6(5):240-7
references: 9822171
references: Ann Oncol. 1999;10 Suppl 4:215-20
references: 10436826
references: Gut. 2002 Aug;51(2):240-4
references: 12117887
references: J Hepatobiliary Pancreat Sci. 2010 Jul;17(4):476-89
references: 19851704
references: Int J Radiat Oncol Biol Phys. 2002 Oct 1;54(2):414-9
references: 12243816
references: Ann Surg. 2005 Jan;241(1):77-84
references: 15621994
references: AJR Am J Roentgenol. 2005 May;184(5):1572-7
references: 15855117
references: Radiology. 2005 Jul;236(1):178-83
references: 15955859
references: Ann Surg. 2010 Jul;252(1):115-23
references: 20531001
references: Ann Surg. 1995 Jun;221(6):788-97; discussion 797-8
references: 7794082
references: Br J Cancer. 2007 Mar 26;96(6):896-902
references: 17325704
references: Hepatogastroenterology. 1997 Sep-Oct;44(17):1256-61
references: 9356836
references: Surgery. 2005 Apr;137(4):396-402
references: 15800484
references: Ann Surg. 1998 Mar;227(3):405-11
references: 9527064
references: Ann Surg. 2007 Feb;245(2):187-200
references: 17245171
references: Gastrointest Endosc. 2003 Dec;58(6):853-8
references: 14652552
references: J Surg Oncol. 1997 Mar;64(3):242-5
references: 9121157
references: World J Surg. 1990 Jul-Aug;14(4):535-43; discussion 544
references: 2166381
references: J Clin Oncol. 1997 Mar;15(3):947-54
references: 9060532
references: J Gastrointest Surg. 2009 Apr;13(4):814-20
references: 18726134
references: Cancer. 2002 Oct 15;95(8):1685-95
references: 12365016
references: Am J Med. 1965 Feb;38:241-56
references: 14256720
references: World J Surg. 2007 Sep;31(9):1788-1796
references: 17647056
references: J Hepatobiliary Pancreat Surg. 2007;14(5):447-54
references: 17909712
references: Surgery. 2002 Oct;132(4):555-63; discission 563-4
references: 12407338
references: J Comput Assist Tomogr. 2009 May-Jun;33(3):376-82
references: 19478630
references: Ann Oncol. 2004 Mar;15(3):478-83
references: 14998852
references: N Engl J Med. 1999 Oct 28;341(18):1368-78
references: 10536130
references: Br J Surg. 2002 Oct;89(10):1260-7
references: 12296893
references: J Hepatobiliary Pancreat Surg. 2007;14(5):434-40
references: 17909710
references: Int J Radiat Oncol Biol Phys. 2007 May 1;68(1):178-82
references: 17276614
references: Int J Radiat Oncol Biol Phys. 2009 Jan 1;73(1):148-53
references: 18805651
references: J Hepatobiliary Pancreat Surg. 2007;14(5):441-6
references: 17909711
references: Ann Surg Oncol. 2008 Nov;15(11):3147-56
references: 18754070
references: Ann Surg. 2001 Oct;234(4):507-17; discussion 517-9
references: 11573044
references: Hepatogastroenterology. 1998 Nov-Dec;45(24):2027-32
references: 9951858
references: Ann Surg. 2005 May;241(5):703-12; discussion 712-4
references: 15849506
references: Ann Surg Oncol. 2006 Jun;13(6):872-80
references: 16614876
references: Ann Surg. 1996 Apr;223(4):384-94
references: 8633917
references: Ann Surg. 2005 Sep;242(3):451-8; discussion 458-61
references: 16135931
references: Arch Surg. 2000 Mar;135(3):302-8
references: 10722032
references: J Gastrointest Surg. 2003 Mar-Apr;7(3):325-30
references: 12654556
references: Radiology. 2004 Oct;233(1):234-40
references: 15333766
references: Arch Surg. 1983 Oct;118(10):1147-51
references: 6615197
references: World J Surg. 1996 Jan;20(1):77-80
references: 8588418
references: World J Gastroenterol. 2009 Dec 21;15(47):5966-71
references: 20014461
references: Surgery. 2007 Nov;142(5):666-75
references: 17981186
references: Clin Oncol (R Coll Radiol). 2006 Nov;18(9):669-77
references: 17100152
references: Adv Surg. 2006;40:159-71
references: 17163100
references: Ann Surg. 2007 Dec;246(6):1052-7
references: 18043110