Plate 104
###### Figure 5

Cholangiocarcinomas arising at or near the bifurcation of the common hepatic duct, commonly referred to as Klatskin tumors, are being diagnosed earlier and treated more promptly by palliative or curative surgical procedures. The majority of patients exhibit jaundice of increasing intensity and many have had recent biliary exploration, where the diagnosis was suggested by operative cholangiography. There is a wide patient age range and occasionally a preceding history of ulcerative colitis or sclerosing cholangitis. Although the number who can be cured may be limited, many patients are benefited by palliative procedures.

The seriousness of the lesion, the difficulty in determining the extent of involvement, and the necessity for avoiding infection from the required preoperative studies in an obstructed jaundiced patient requires meticulous preoperative evaluation. Early endoscopy of the common duct and consultation with an expert in interventional radiology are essential. The jaundiced patient should undergo transcutaneous transhepatic cholangiography with bile cultures taken and appropriate antibiotics given. These diagnostic procedures are usually performed by an interventional radiologist familiar with the technic. Following cholangiography, ring catheters may be placed bilaterally, directed if possible through the obstructing lesion into the duodenum with palliation of the jaundice (Figure 1). If there is cholangiographic evidence of tumor extending into the right or left hepatic ducts, the patient may eventually be explored to relieve the obstruction on the side of the involved duct. Palliation, however is usually possible with internal drainage into the duodenum through the ring catheters. The catheters also serve as invaluable technical aids to the surgeon at the time of laparotomy.

Hepatic arteriography or special imaging scans are also helpful in showing any occlusion of the hepatic artery as well as possible encasement of the main portal vein, either of which contraindicates a surgical attempt at resection of the tumor. About 20 percent of patients will show a stage of tumor involvement that makes attempts at surgical excision impossible.

Appropriate antibiotic therapy, intravenous alimentation, and vitamin K are given, and blood volume deficits are corrected.

The deeply jaundiced patient should be considered a poor surgical risk meriting special consideration by the anesthesiologist in planning the anesthesia.

The patient is placed on the table in a slightly reversed Trendelenburg position. Intravenous catheters should be placed in both arms. Catheter drainage of the bladder may be advisable as well as nasogastric suction.

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