Management of hilar cholangiocarcinoma: comparison of an American and a Japanese experience

Hilar cholangiocarcinoma has remained a challenge to surgeons because of its propensity for local invasion and its proximity to the portal vein, hepatic arteries, and liver parenchyma. Locally advanced disease at diagnosis and surgical inaccessibility have resulted in low resectability and poor survival. Recent advances in interventional radiology and endoscopy have made possible nonsurgical palliation of this disease. Consequently, some clinicians recommend that palliative biliary stenting supplant surgical resection as the standard treatment for patients with hilar cholangiocarcinoma. Although some patients with advanced disease or prohibitive surgical risk factors are best served by nonoperative biliary stenting, we believe most should be evaluated for surgical resection. Recently, many institutions with expertise in the management of patients with hilar cholangiocarcinoma have reported higher resectability rates without increased surgical death rates. 1–12 Japanese surgeons 13–16 have reported resectability rates as high as 80% in patients treated by combined bile duct and liver resection with caudate lobectomy. Although surgical resection has gained acceptance during the past decade as the mainstay of therapy for hilar cholangiocarcinoma, the acceptance of combined liver resection with caudate lobectomy has been slow, especially by American surgeons. Moreover, the higher resectability and survival rates in Japanese reports have stirred debates as to whether the tumors in Japanese patients are of a more favorable histopathologic type or are detected at an earlier stage. The surgeons at Lahey Clinic and Nagoya University have a long shared an interest in the management of biliary malignancies and have gained from each other’s experience through the exchange of visiting surgeons. This study was prompted by one of these exchange visits. The aim of this study is to identify factors in our management approaches to hilar cholangiocarcinoma that might explain the reported differences in resectability and overall survival between American and Japanese patients.