بسم الله الرحمن بسم الله الرحمن الرحيمالرحيم

MManagement ofanagement of

ccholangiocarcinomaholangiocarcinoma

Mansoura Experience EgyptMansoura Experience Egypt

Prof. Mohamed Abd ElwahabProf. Mohamed Abd ElwahabGastroenterology Surgical Center Gastroenterology Surgical Center

Mansoura UniversityMansoura University

CHOLANGIOCARCINOMACHOLANGIOCARCINOMACHOLANGIOCARCINOMACHOLANGIOCARCINOMA

Is the second most frequent malignant Is the second most frequent malignant tumor of the liver after hepatocelular tumor of the liver after hepatocelular carcinoma, with incidence at autopsy carcinoma, with incidence at autopsy ranges from 0.01 to 0.05%ranges from 0.01 to 0.05%

Is the second most frequent malignant Is the second most frequent malignant tumor of the liver after hepatocelular tumor of the liver after hepatocelular carcinoma, with incidence at autopsy carcinoma, with incidence at autopsy ranges from 0.01 to 0.05%ranges from 0.01 to 0.05%

This neoplasm tends to grow slowly and to This neoplasm tends to grow slowly and to infiltrate the surrounding structures such as infiltrate the surrounding structures such as liver parenchyma, intra hepatic ducts and liver parenchyma, intra hepatic ducts and hepatic pedicle.hepatic pedicle.

The clinical course of this tumor remains poor The clinical course of this tumor remains poor despite recent progress in diagnostic and despite recent progress in diagnostic and therapeutic modalities.therapeutic modalities.

This neoplasm tends to grow slowly and to This neoplasm tends to grow slowly and to infiltrate the surrounding structures such as infiltrate the surrounding structures such as liver parenchyma, intra hepatic ducts and liver parenchyma, intra hepatic ducts and hepatic pedicle.hepatic pedicle.

The clinical course of this tumor remains poor The clinical course of this tumor remains poor despite recent progress in diagnostic and despite recent progress in diagnostic and therapeutic modalities.therapeutic modalities.

EPIDEMIOLOGICAL AND RISK EPIDEMIOLOGICAL AND RISK FACTORFACTOR

EPIDEMIOLOGICAL AND RISK EPIDEMIOLOGICAL AND RISK FACTORFACTOR

The age of presentation varies with peak at The age of presentation varies with peak at sixth decade.sixth decade.

Very Common in Asian countries where Very Common in Asian countries where parasitic infestation with liver flukes is parasitic infestation with liver flukes is endemic.endemic.

The age of presentation varies with peak at The age of presentation varies with peak at sixth decade.sixth decade.

Very Common in Asian countries where Very Common in Asian countries where parasitic infestation with liver flukes is parasitic infestation with liver flukes is endemic.endemic.

The etiology of cholangio The etiology of cholangio carcinoma is unknown. But carcinoma is unknown. But there are some risk factors.there are some risk factors.

1- Biliary stone1- Biliary stone2- chronic typhoid carries2- chronic typhoid carries3- Ulcerative colitis3- Ulcerative colitis4- Sclerosing cholangitis4- Sclerosing cholangitis5- Cystic disease of the biliary system5- Cystic disease of the biliary system6- Parastic infestation of the biliary tract.6- Parastic infestation of the biliary tract.

The etiology of cholangio The etiology of cholangio carcinoma is unknown. But carcinoma is unknown. But there are some risk factors.there are some risk factors.

1- Biliary stone1- Biliary stone2- chronic typhoid carries2- chronic typhoid carries3- Ulcerative colitis3- Ulcerative colitis4- Sclerosing cholangitis4- Sclerosing cholangitis5- Cystic disease of the biliary system5- Cystic disease of the biliary system6- Parastic infestation of the biliary tract.6- Parastic infestation of the biliary tract.

CLASSIFICATION OF CLASSIFICATION OF CHOLANGIOCARCINOMACHOLANGIOCARCINOMA

CLASSIFICATION OF CLASSIFICATION OF CHOLANGIOCARCINOMACHOLANGIOCARCINOMA

Peripheral type:-Peripheral type:- intra-hepatic intra-hepatic ((from the small from the small hepatic ducts).hepatic ducts).

Central type :-Central type :- (klatskin) from-right, leftt hepatic (klatskin) from-right, leftt hepatic duct, hilar confluence and proximal ductduct, hilar confluence and proximal duct

Middle :-Middle :- form the distal common hepatic duct, form the distal common hepatic duct, cystic duct and its confluence with common bile ductcystic duct and its confluence with common bile duct

Distal :-Distal :- from the distal common bile ducts from the distal common bile ducts (ampullary and periampullary regions).(ampullary and periampullary regions).

Hilar ccc classified into 4 TypesHilar ccc classified into 4 Types

Type I :Type I : below the confluence of the below the confluence of the right and left hepatic ductsright and left hepatic ducts

Type IIType II : present in the confluence and : present in the confluence and interrupt the communication of both interrupt the communication of both ducts without extension to any of them.ducts without extension to any of them.

Type III:Type III: extend to either left or right extend to either left or right ducts up to its bifurcation.ducts up to its bifurcation.

Type IV:Type IV: Involving both right and left Involving both right and left hepatic ducts up to their bifurcation.hepatic ducts up to their bifurcation.

(Bismuth 1975)

Lygidakis 1989

MANAGMENTMANAGMENTMANAGMENTMANAGMENT

Maximal/surgical resection remains the Maximal/surgical resection remains the mainstay of management providing there is no mainstay of management providing there is no contra indcation to resection.contra indcation to resection.

NowNow the trends with extensive surgical the trends with extensive surgical resection that may be accompanied with resection that may be accompanied with hepatic resection, vascular reconstruction or hepatic resection, vascular reconstruction or even hepatic transplantation.even hepatic transplantation.

Maximal/surgical resection remains the Maximal/surgical resection remains the mainstay of management providing there is no mainstay of management providing there is no contra indcation to resection.contra indcation to resection.

NowNow the trends with extensive surgical the trends with extensive surgical resection that may be accompanied with resection that may be accompanied with hepatic resection, vascular reconstruction or hepatic resection, vascular reconstruction or even hepatic transplantation.even hepatic transplantation.

Several endoscopic methods have Several endoscopic methods have potential value in the management potential value in the management of patients with biliary obstruction of patients with biliary obstruction due to malignant diseasedue to malignant disease

Jaundice can be relieved either as Jaundice can be relieved either as definitive palliation or as preparation definitive palliation or as preparation for surgery by endoscopic placement for surgery by endoscopic placement of indwelling prothesis. of indwelling prothesis.

Several endoscopic methods have Several endoscopic methods have potential value in the management potential value in the management of patients with biliary obstruction of patients with biliary obstruction due to malignant diseasedue to malignant disease

Jaundice can be relieved either as Jaundice can be relieved either as definitive palliation or as preparation definitive palliation or as preparation for surgery by endoscopic placement for surgery by endoscopic placement of indwelling prothesis. of indwelling prothesis.

Surgical strategy for bile duct Surgical strategy for bile duct carcinoma is different, carcinoma is different, depending of the tumor site.depending of the tumor site.

1-In the lower and middle third bile duct 1-In the lower and middle third bile duct carcinoma pancreatico duodenectomy or bile carcinoma pancreatico duodenectomy or bile duct resection is the treatment of choice.duct resection is the treatment of choice.

2-Additional hepatic resection may be 2-Additional hepatic resection may be considered for upper bile duct carcinomaconsidered for upper bile duct carcinoma

Surgical strategy for bile duct Surgical strategy for bile duct carcinoma is different, carcinoma is different, depending of the tumor site.depending of the tumor site.

1-In the lower and middle third bile duct 1-In the lower and middle third bile duct carcinoma pancreatico duodenectomy or bile carcinoma pancreatico duodenectomy or bile duct resection is the treatment of choice.duct resection is the treatment of choice.

2-Additional hepatic resection may be 2-Additional hepatic resection may be considered for upper bile duct carcinomaconsidered for upper bile duct carcinoma

Left hepatectomy, segment one Left hepatectomy, segment one resectionresection

Portal. VPortal. V..

I.V.CI.V.C..

R.hepatic AR.hepatic A..

CCC supra duodenal dissectionCCC supra duodenal dissection

The post operative outcome of patient with The post operative outcome of patient with

lower or middle bile duct carcinoma is better lower or middle bile duct carcinoma is better

than those with upper bile duct carcinoma.than those with upper bile duct carcinoma.

Because the upper bile duct is located close to Because the upper bile duct is located close to

portal vein and common hepatic artery.portal vein and common hepatic artery.

The post operative outcome of patient with The post operative outcome of patient with

lower or middle bile duct carcinoma is better lower or middle bile duct carcinoma is better

than those with upper bile duct carcinoma.than those with upper bile duct carcinoma.

Because the upper bile duct is located close to Because the upper bile duct is located close to

portal vein and common hepatic artery.portal vein and common hepatic artery.

Recent progress inRecent progress in1- Diagnostic methods1- Diagnostic methods

2- Preoperative management2- Preoperative management

3- Surgical technique3- Surgical technique

4- Intensive care4- Intensive care Has led to improved outcomes for aggressive Has led to improved outcomes for aggressive

liver and bile duct resection Which, however liver and bile duct resection Which, however still show considerable morbidity and mortalitystill show considerable morbidity and mortality..

Recent progress inRecent progress in1- Diagnostic methods1- Diagnostic methods

2- Preoperative management2- Preoperative management

3- Surgical technique3- Surgical technique

4- Intensive care4- Intensive care Has led to improved outcomes for aggressive Has led to improved outcomes for aggressive

liver and bile duct resection Which, however liver and bile duct resection Which, however still show considerable morbidity and mortalitystill show considerable morbidity and mortality..

Mansoura Experience (Mansoura Experience (EEGGYYPPT)T)Gastroenterology CenterGastroenterology Center

Mansoura Experience (Mansoura Experience (EEGGYYPPT)T)Gastroenterology CenterGastroenterology Center

385385 patients patients with cholangio with cholangio carcinoma were managed carcinoma were managed

between 1995-2002between 1995-2002 Central cholangio carcinomaCentral cholangio carcinoma 216216 56.5%56.5% Distal cholangio carcinomaDistal cholangio carcinoma 148148 38%38% Middle thirdMiddle third 1616 4%4% Intra hepaticIntra hepatic 55 1.5%1.5%

385385 patients patients with cholangio with cholangio carcinoma were managed carcinoma were managed

between 1995-2002between 1995-2002 Central cholangio carcinomaCentral cholangio carcinoma 216216 56.5%56.5% Distal cholangio carcinomaDistal cholangio carcinoma 148148 38%38% Middle thirdMiddle third 1616 4%4% Intra hepaticIntra hepatic 55 1.5%1.5%

PRESENTATIONPRESENTATION

385385PRESENTATIONPRESENTATION

385385AgeAge 50 ± 12.3 year50 ± 12.3 year

Gender Gender M/FM/F 277/108 (72-28%)277/108 (72-28%)

Jaundice Jaundice 385 385 100)100)

PainPain 292292 76%76%

FeverFever 7777 20%20%

Loss of weightLoss of weight 127127 33%33%

VomitingVomiting 8080 21%21%

AgeAge 50 ± 12.3 year50 ± 12.3 year

Gender Gender M/FM/F 277/108 (72-28%)277/108 (72-28%)

Jaundice Jaundice 385 385 100)100)

PainPain 292292 76%76%

FeverFever 7777 20%20%

Loss of weightLoss of weight 127127 33%33%

VomitingVomiting 8080 21%21%

EVALUATIONEVALUATIONEVALUATIONEVALUATION

1- Sonography1- Sonography

2- M.R.C.P.2- M.R.C.P.

3- CT3- CT

4- ERCP4- ERCP

5-P.T.C 5-P.T.C

6-Angiography6-Angiography

7- Biopsy7- Biopsy

1- Sonography1- Sonography

2- M.R.C.P.2- M.R.C.P.

3- CT3- CT

4- ERCP4- ERCP

5-P.T.C 5-P.T.C

6-Angiography6-Angiography

7- Biopsy7- Biopsy

Cholangio carcinomaCholangio carcinoma

MRCP of young patients with MRCP of young patients with C.C.CC.C.C

MRCP. Shows Hilar chalangio MRCP. Shows Hilar chalangio carcinomacarcinoma

CCC

ResectabilityResectabilityResectabilityResectability

Total Total ResectableResectable Non Non resectableresectable

- Central cholangio- Central cholangio 216 216 46 (21%)46 (21%) 170 (79%)170 (79%)

carcinomacarcinoma

- Distal cholangio- Distal cholangio 148 148 35 (24%)35 (24%) 113(76%)113(76%)

carcinomacarcinoma

- Middle third- Middle third 16 16 5 (31%)5 (31%) 11 (69%)11 (69%)

- Intrahepatic - Intrahepatic 5 5 3 (60%)3 (60%) 2 (40%)2 (40%)

Total Total ResectableResectable Non Non resectableresectable

- Central cholangio- Central cholangio 216 216 46 (21%)46 (21%) 170 (79%)170 (79%)

carcinomacarcinoma

- Distal cholangio- Distal cholangio 148 148 35 (24%)35 (24%) 113(76%)113(76%)

carcinomacarcinoma

- Middle third- Middle third 16 16 5 (31%)5 (31%) 11 (69%)11 (69%)

- Intrahepatic - Intrahepatic 5 5 3 (60%)3 (60%) 2 (40%)2 (40%)

CENTRAL CHOLANGIOCARCINOMACENTRAL CHOLANGIOCARCINOMA

216 216

ResectableResectable 46 46 (21%)(21%)

NonresectableNonresectable 170170 (79%) (79%)

Operative photo : stent inside the Operative photo : stent inside the common hepatic duct of C.C.Ccommon hepatic duct of C.C.C

1- General condition.1- General condition.

2- Advanced liver cirrhosis.2- Advanced liver cirrhosis.

3- Bilateral involvement of the bile duct up to the 3- Bilateral involvement of the bile duct up to the secondary branches.secondary branches.

4- Involvement of the biliary tract of one side and 4- Involvement of the biliary tract of one side and vascular encasement of the other side.vascular encasement of the other side.

5- Peritoneal metastasis.5- Peritoneal metastasis.

6- Liver metastasis.6- Liver metastasis.

1- General condition.1- General condition.

2- Advanced liver cirrhosis.2- Advanced liver cirrhosis.

3- Bilateral involvement of the bile duct up to the 3- Bilateral involvement of the bile duct up to the secondary branches.secondary branches.

4- Involvement of the biliary tract of one side and 4- Involvement of the biliary tract of one side and vascular encasement of the other side.vascular encasement of the other side.

5- Peritoneal metastasis.5- Peritoneal metastasis.

6- Liver metastasis.6- Liver metastasis.

CRITERIA FOR CRITERIA FOR UNRESECTABILTYUNRESECTABILTY

CRITERIA FOR CRITERIA FOR UNRESECTABILTYUNRESECTABILTY

Cholangio carcinoma in cirrhotic Cholangio carcinoma in cirrhotic

liverliver

WHAT ABOUT NON WHAT ABOUT NON RESECTABLE C.C.C. 170 RESECTABLE C.C.C. 170

PATIENTSPATIENTS

WHAT ABOUT NON WHAT ABOUT NON RESECTABLE C.C.C. 170 RESECTABLE C.C.C. 170

PATIENTSPATIENTSCausesCauses

1- Advanced liver cirrhosis1- Advanced liver cirrhosis 42 (27%)42 (27%)

2- Bilateral tumor2- Bilateral tumor 32 (18%)32 (18%)

3- Hepatorenal failure3- Hepatorenal failure 25 (15%)25 (15%)

4- Malnutrition and bad general condition4- Malnutrition and bad general condition 25 (15%)25 (15%)

5- Vascular invasion in both side5- Vascular invasion in both side 21 (12%)21 (12%)

6- Hepatic cell failure6- Hepatic cell failure 15 (9%)15 (9%)

7- Peritoneal deposite7- Peritoneal deposite 10 (6%)10 (6%)

CausesCauses

1- Advanced liver cirrhosis1- Advanced liver cirrhosis 42 (27%)42 (27%)

2- Bilateral tumor2- Bilateral tumor 32 (18%)32 (18%)

3- Hepatorenal failure3- Hepatorenal failure 25 (15%)25 (15%)

4- Malnutrition and bad general condition4- Malnutrition and bad general condition 25 (15%)25 (15%)

5- Vascular invasion in both side5- Vascular invasion in both side 21 (12%)21 (12%)

6- Hepatic cell failure6- Hepatic cell failure 15 (9%)15 (9%)

7- Peritoneal deposite7- Peritoneal deposite 10 (6%)10 (6%)

Treatment of NON Treatment of NON RESECTABLE C.C.C. RESECTABLE C.C.C. (170 (170

PATIENTSPATIENTS))

Treatment of NON Treatment of NON RESECTABLE C.C.C. RESECTABLE C.C.C. (170 (170

PATIENTSPATIENTS))

1- Operative drainage1- Operative drainage 1212 7%7%

2- Percutanous drainage2- Percutanous drainage 5858 34%34%

3- Endoscopic3- Endoscopic 4545 26.4%26.4%

4- No treatment4- No treatment 5555 32%32%

With mean survival 5.8 ± 43 With mean survival 5.8 ± 43 monthsmonths

1- Operative drainage1- Operative drainage 1212 7%7%

2- Percutanous drainage2- Percutanous drainage 5858 34%34%

3- Endoscopic3- Endoscopic 4545 26.4%26.4%

4- No treatment4- No treatment 5555 32%32%

With mean survival 5.8 ± 43 With mean survival 5.8 ± 43 monthsmonths

SURGICAL TREATMENTSURGICAL TREATMENT (46(46 patients with C.C.C.)patients with C.C.C.)

SURGICAL TREATMENTSURGICAL TREATMENT (46(46 patients with C.C.C.)patients with C.C.C.)

Types of resectionTypes of resection No.No. % %

1- Bile duct resection (BDR)1- Bile duct resection (BDR) 66 13 13

2- B.D.R. + Segment IV2- B.D.R. + Segment IV 14 14 30.5 30.5

3- B.D.R. + left Hepatectomy 3- B.D.R. + left Hepatectomy 1212 26 26

+ segment I+ segment I

4- B.D.R. + Right Hepatectomy 4- B.D.R. + Right Hepatectomy 1414 30.5 30.5

Types of resectionTypes of resection No.No. % %

1- Bile duct resection (BDR)1- Bile duct resection (BDR) 66 13 13

2- B.D.R. + Segment IV2- B.D.R. + Segment IV 14 14 30.5 30.5

3- B.D.R. + left Hepatectomy 3- B.D.R. + left Hepatectomy 1212 26 26

+ segment I+ segment I

4- B.D.R. + Right Hepatectomy 4- B.D.R. + Right Hepatectomy 1414 30.5 30.5

INDICATION LOCALIZED INDICATION LOCALIZED RESECTIONRESECTION

INDICATION LOCALIZED INDICATION LOCALIZED RESECTIONRESECTION

1- Confluent tumor in cirrhotic liver.1- Confluent tumor in cirrhotic liver.

2- Confluent tumor in border liver function.2- Confluent tumor in border liver function.

3- Upper 1/3 tumor (Bismuth type I).3- Upper 1/3 tumor (Bismuth type I).

4- Positive lymph nodes.4- Positive lymph nodes.

1- Confluent tumor in cirrhotic liver.1- Confluent tumor in cirrhotic liver.

2- Confluent tumor in border liver function.2- Confluent tumor in border liver function.

3- Upper 1/3 tumor (Bismuth type I).3- Upper 1/3 tumor (Bismuth type I).

4- Positive lymph nodes.4- Positive lymph nodes.

Operative photo loclaised Operative photo loclaised resection in cirrhotic liver resection in cirrhotic liver

RARP LD

CHD

GB

Localized resection of C.C.CLocalized resection of C.C.C

Post operativ cholangiography after resection of central cholangiocarcinoma double

hapaticojejunostomy(arrows)

INDICATION OF L. INDICATION OF L. HEPATECTOMYHEPATECTOMY

INDICATION OF L. INDICATION OF L. HEPATECTOMYHEPATECTOMY

1- Atrophy of left lob.1- Atrophy of left lob.

2- Invasion of the left Portal vein .2- Invasion of the left Portal vein .

3- Tumor involvement of the left duct up to the 3- Tumor involvement of the left duct up to the

liver parenchyma. liver parenchyma.

1- Atrophy of left lob.1- Atrophy of left lob.

2- Invasion of the left Portal vein .2- Invasion of the left Portal vein .

3- Tumor involvement of the left duct up to the 3- Tumor involvement of the left duct up to the

liver parenchyma. liver parenchyma.

Operative photo of C.C.C Operative photo of C.C.C (atrophic left lob)(atrophic left lob)

Portography (obstruction of the left Portography (obstruction of the left portal vein)portal vein)

Operative Operative cholangiogramcholangiogram

CCC supra duodenal dissectionCCC supra duodenal dissection

Segment 1 abscessSegment 1 abscess

CCC portahepatis dissectionCCC portahepatis dissection

Left hepatectomy, segment one resectionLeft hepatectomy, segment one resectionCut surface after left hepatectomy (catheters inside 3 ducts)Cut surface after left hepatectomy (catheters inside 3 ducts)

1 2

3 4

Papillematosis of the left Papillematosis of the left

hepatic ducthepatic duct

Left hepatectomy + segment Left hepatectomy + segment I for C.C.CI for C.C.C

Left hepatectomy for C.C.C in Left hepatectomy for C.C.C in cirrhotic liver cirrhotic liver

Post operative cholangiogram Post operative cholangiogram right hepatico jujnostomy after right hepatico jujnostomy after

left hepatectomy for C.C.Cleft hepatectomy for C.C.C

Post operative Post operative cholangiogram after left cholangiogram after left

hepatectomyhepatectomy

Cholangogram after left hepatectomy for Cholangogram after left hepatectomy for hillar chalongio carcinoma Right hepatico hillar chalongio carcinoma Right hepatico

jejunostomy (arrow) jejunostomy (arrow)

CCCCCC

INDICATION OF RIGHT INDICATION OF RIGHT HEPATICTOMYHEPATICTOMY

INDICATION OF RIGHT INDICATION OF RIGHT HEPATICTOMYHEPATICTOMY

1- Vascular infiltration of the right side1- Vascular infiltration of the right side

2- Tumor involvement of the right side2- Tumor involvement of the right side

3- Confluent tumor.3- Confluent tumor.

1- Vascular infiltration of the right side1- Vascular infiltration of the right side

2- Tumor involvement of the right side2- Tumor involvement of the right side

3- Confluent tumor.3- Confluent tumor.

RIGHT HEPATECTOMYRIGHT HEPATECTOMY

Portahepatis Portahepatis DessectionDessection

Rt.hepati c Rt.hepati c arteryartery

Rt.hepati c Rt.hepati c vei nvei n

C.DC.D.DD

Porta Hepatis DessectionPorta Hepatis Dessection

RT PVRT PV

5S

Stump of RT H A

LT H ALT H A

HemivascularHemivascular OcclusionOcclusion

7S

Hepatic Vein Dissection

Dessection of Rt Hepatic VeinDessection of Rt Hepatic Vein

Rt H V OcclusionRt H V Occlusion15 S

1

2

3

4

One week . Postoperative Chalangiogrphy ( left One week . Postoperative Chalangiogrphy ( left hepaticojejunostomy)hepaticojejunostomy)

Post operative cholangiogram after Post operative cholangiogram after right hepatectomy for C.C.Cright hepatectomy for C.C.C

Postoperative ComplicationPostoperative Complication

Total % BDR.% Total % BDR.% (20)(20) BDR+L.R %. BDR+L.R %.(26)(26)

Liver cell F.Liver cell F. 7 (15)7 (15) 1 (5)1 (5) 6 (23)6 (23)

Biliary leakageBiliary leakage 8 (17)8 (17) 2 (10)2 (10) 6 (23)6 (23)

Abdominal infectionAbdominal infection 5 (11)5 (11) 2 (10) 2 (10) 3 (11.5)3 (11.5)

Gastro intestinal bleedingGastro intestinal bleeding 3 (6.5)3 (6.5) 1 (5)1 (5) 2 (7.6)2 (7.6)

Total % BDR.% Total % BDR.% (20)(20) BDR+L.R %. BDR+L.R %.(26)(26)

Liver cell F.Liver cell F. 7 (15)7 (15) 1 (5)1 (5) 6 (23)6 (23)

Biliary leakageBiliary leakage 8 (17)8 (17) 2 (10)2 (10) 6 (23)6 (23)

Abdominal infectionAbdominal infection 5 (11)5 (11) 2 (10) 2 (10) 3 (11.5)3 (11.5)

Gastro intestinal bleedingGastro intestinal bleeding 3 (6.5)3 (6.5) 1 (5)1 (5) 2 (7.6)2 (7.6)

postoperative complicationpostoperative complication

Total Total BDR. BDR. (20)(20) BDR+L.R . BDR+L.R .(26)(26)

Internal haemonhageInternal haemonhage 22 -- 2 (4.3)2 (4.3)

Wound infectionWound infection 44 2 (10)2 (10) 2 (7.6)2 (7.6)

Multiple organfailureMultiple organfailure 11 -- 1 (3.8)1 (3.8)

Pulmonary infarctionPulmonary infarction 11 1 (5)1 (5) --

Total No. with comp.Total No. with comp. 13 13 4 (20)4 (20) 9 (34.6)9 (34.6)

Total Total BDR. BDR. (20)(20) BDR+L.R . BDR+L.R .(26)(26)

Internal haemonhageInternal haemonhage 22 -- 2 (4.3)2 (4.3)

Wound infectionWound infection 44 2 (10)2 (10) 2 (7.6)2 (7.6)

Multiple organfailureMultiple organfailure 11 -- 1 (3.8)1 (3.8)

Pulmonary infarctionPulmonary infarction 11 1 (5)1 (5) --

Total No. with comp.Total No. with comp. 13 13 4 (20)4 (20) 9 (34.6)9 (34.6)

continuecontinue

Hospital Mortality 5 (10.8)Hospital Mortality 5 (10.8)Hospital Mortality 5 (10.8)Hospital Mortality 5 (10.8)

CausesCauses No. No. %%

Hepatic cell failureHepatic cell failure 33 6.6 6.6

Gastro intestinal bleedingGastro intestinal bleeding 11 2.12.1

Multple organ failureMultple organ failure 11 2.12.1

CausesCauses No. No. %%

Hepatic cell failureHepatic cell failure 33 6.6 6.6

Gastro intestinal bleedingGastro intestinal bleeding 11 2.12.1

Multple organ failureMultple organ failure 11 2.12.1

LATE COMPLICATIONLATE COMPLICATION LATE COMPLICATIONLATE COMPLICATION

No.No. %%

RecurrenceRecurrence 1919 46%46%

CholangitisCholangitis 88 17%17%

Hepatic cell failureHepatic cell failure 44 86%86%

Gastro intestinal bleedingGastro intestinal bleeding 22 4.3%4.3%

Malignant plural effusionMalignant plural effusion 11 2%2%

No.No. %%

RecurrenceRecurrence 1919 46%46%

CholangitisCholangitis 88 17%17%

Hepatic cell failureHepatic cell failure 44 86%86%

Gastro intestinal bleedingGastro intestinal bleeding 22 4.3%4.3%

Malignant plural effusionMalignant plural effusion 11 2%2%

RECURRENCERECURRENCERECURRENCERECURRENCE

NoNo %%

Number Number 1919 45.345.3 SiteSite

AnastomosisAnastomosis 0909 47.447.4LiverLiver 0707 36.936.9Abdominal L.N.Abdominal L.N. 0303 15.815.8

OutcomeOutcomeMortalityMortality 1616 84.284.2SurvivalSurvival 0303 15.815.8

NoNo %%

Number Number 1919 45.345.3 SiteSite

AnastomosisAnastomosis 0909 47.447.4LiverLiver 0707 36.936.9Abdominal L.N.Abdominal L.N. 0303 15.815.8

OutcomeOutcomeMortalityMortality 1616 84.284.2SurvivalSurvival 0303 15.815.8

Female patient 32 years .Female patient 32 years . Presented 18 months after left hepatectomy for Presented 18 months after left hepatectomy for

central cholangiocarcinoma with local recurrence, central cholangiocarcinoma with local recurrence, obstructive jaundice and pregnancy 5 month .obstructive jaundice and pregnancy 5 month .

Reaxploreation revealed local recurrence at the Reaxploreation revealed local recurrence at the anastomotic site.anastomotic site.

Resection of part of the right lobe and reanastomosis.Resection of part of the right lobe and reanastomosis.

Surgery for recurrent CCCSurgery for recurrent CCCanastomoticanastomotic

Surgery for recurrent Surgery for recurrent CCCCCC

CCC

15 months after resection of C.C.C15 months after resection of C.C.C

Recurrent stricture (1), Balloon inside stric.(2), Recurrent stricture (1), Balloon inside stric.(2), After dilatation(3)After dilatation(3)

1 2 3

LATE MORTALITYLATE MORTALITY

24 (57.2%)24 (57.2%)LATE MORTALITYLATE MORTALITY

24 (57.2%)24 (57.2%)

CausesCauses NoNo %%

RecurrenceRecurrence 1616 3838 Liver cell failureLiver cell failure 0606 1414 UnknownUnknown 0202 0505

Mean follow up 18 Mean follow up 18 monthmonth

CausesCauses NoNo %%

RecurrenceRecurrence 1616 3838 Liver cell failureLiver cell failure 0606 1414 UnknownUnknown 0202 0505

Mean follow up 18 Mean follow up 18 monthmonth

SURVIVALSURVIVALSURVIVALSURVIVAL

• 19 patient survived 19 patient survived 46% with 46% with mean follow up 18.6 ± 9 month.mean follow up 18.6 ± 9 month.

• 6 month.6 month. 92%92%• 12 month.12 month. 82%82%• 18 month.18 month. 52%52%• 24 month.24 month. 25%25%• 30 month.30 month. 18%18%

• 19 patient survived 19 patient survived 46% with 46% with mean follow up 18.6 ± 9 month.mean follow up 18.6 ± 9 month.

• 6 month.6 month. 92%92%• 12 month.12 month. 82%82%• 18 month.18 month. 52%52%• 24 month.24 month. 25%25%• 30 month.30 month. 18%18%

INTRA HEPATIC CHOLANGIOCARCINOMAINTRA HEPATIC CHOLANGIOCARCINOMA

In some litretures It represent 10% of liver In some litretures It represent 10% of liver tumor.tumor.

The etiology and pathogenesis remain unclear The etiology and pathogenesis remain unclear in a great majority of cases.in a great majority of cases.

In some litretures It represent 10% of liver In some litretures It represent 10% of liver tumor.tumor.

The etiology and pathogenesis remain unclear The etiology and pathogenesis remain unclear in a great majority of cases.in a great majority of cases.

In east countries porticulary in In east countries porticulary in AsiaAsia where the where the hepatolithiasis and liver fluke infestation are endemic. hepatolithiasis and liver fluke infestation are endemic. Intra hepatic cholangiocarcinoma are usually Intra hepatic cholangiocarcinoma are usually associated with this types of pathology.associated with this types of pathology.

Due to:-Due to:- Chronic cholangitis.Chronic cholangitis. Long standing inflamation.Long standing inflamation. Chronic injury to bile ducts.Chronic injury to bile ducts. Hyperplasia of the biliary epithelium.Hyperplasia of the biliary epithelium.

In east countries porticulary in In east countries porticulary in AsiaAsia where the where the hepatolithiasis and liver fluke infestation are endemic. hepatolithiasis and liver fluke infestation are endemic. Intra hepatic cholangiocarcinoma are usually Intra hepatic cholangiocarcinoma are usually associated with this types of pathology.associated with this types of pathology.

Due to:-Due to:- Chronic cholangitis.Chronic cholangitis. Long standing inflamation.Long standing inflamation. Chronic injury to bile ducts.Chronic injury to bile ducts. Hyperplasia of the biliary epithelium.Hyperplasia of the biliary epithelium.

Peripheral cholangiocarcinomaPeripheral cholangiocarcinoma

MRCPMRCP

PTC for pripheral cholangiocarcinoma

0

0.2

0.4

0.6

0.8

1

1.2

0 2 4 6 8 10 12 14 16 18 20 22 24 26

Time of surv.

Time of survival (months)Time of survival (months)

Surv

ival pro

bab

ility

Surv

ival pro

bab

ility

0

0.2

0.4

0.6

0.8

1

1.2

0 2 4 6 8 10 12 14 16 18 20 22 24 26

Radical Palliative

Time of survival (months)Time of survival (months)

((P= 0.017)P= 0.017)

Surv

ival pro

bab

ility

Surv

ival pro

bab

ility

0

0.2

0.4

0.6

0.8

1

1.2

0 2 4 6 8 10 12 14 16 18 20 22 24 26

LN No LN

Time of survival (months)Time of survival (months)

(P= 0.041)(P= 0.041)

Surv

ival

Surv

ival p

robabili

typro

babili

ty

0

0.2

0.4

0.6

0.8

1

1.2

0 2 4 6 8 10 12 14 16 18 20 22 24 26

Differ. Moderate Undiffer.

Time of survival (months)Time of survival (months)

((P= 0.049P= 0.049))

Surv

ival

Surv

ival p

robabili

typro

babili

ty

0

0.2

0.4

0.6

0.8

1

1.2

0 2 4 6 8 10 12 14 16 18 20 22 24 26

Bilir. <10mg Bilir. >10mg

Surv

ival

Surv

ival p

robabili

typro

babili

ty

Time of survival (months)Time of survival (months)

((P= 0.25)P= 0.25)

Thank youThank you