Cholangiocarcinomas arising at or near the confluence of the right and left hepatic ducts, commonly referred to as Klatskin tumors, are being diagnosed earlier and treated more promptly by palliative or curative surgical procedures. These may be termed hepatic duct bifurcation tumors or hilar tumors. 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 is 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 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 in planning when and if access to the biliary tree is necessary. The decision to instrument the obstructed biliary tree should be made only after treatment goals are defined. The jaundiced patient selected for biliary decompression should undergo percutaneous transhepatic cholangiography with appropriate prophylactic antibiotics given. These procedures should be undertaken by an experienced interventional radiologist. Following cholangiography, pigtail catheters may be placed bilaterally (although unilateral is usually sufficient), directed if possible through the obstructing lesion into the duodenum for 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 pigtail catheters. The catheters also serve as invaluable technical aids to the surgeon at the time of laparotomy.
High-resolution cross-sectional imaging is mandatory for evaluating hilar vasculature prior to any attempt at resection. MRI/MRCP with contrast enhancement and delayed imaging (i.e., cholangiocarcinoma protocol) is ideal at identifying occlusion of the hepatic artery or encasement of the main portal vein, either of which complicates and may contraindicate attempt at resection of the tumor. The vast majority 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.